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Journal of Endourology Sep 2023The effect of prophylactic bladder neck incision (BNI) at time of holmium laser enucleation of the prostate (HoLEP) is unknown. The aim of our study was to examine...
The effect of prophylactic bladder neck incision (BNI) at time of holmium laser enucleation of the prostate (HoLEP) is unknown. The aim of our study was to examine HoLEP outcomes with a specific focus on rates of bladder neck contractures (BNCs), with and without utilizing prophylactic BNI. We performed a retrospective review of HoLEP patients from January 2021 until January 2022. Outcomes of patients who underwent BNI at time of HoLEP were compared with those who underwent standard HoLEP alone. Student's -tests, chi-square tests, and logistic regressions were performed using SAS Studio. In total, 421 patients underwent HoLEP. BNI was concurrently performed in 74 (17.6%) HoLEP patients. BNI patients were younger (67.5 ± 9.0 years 71.1 ± 8.2 years, = 0.00007) and had smaller prostates (60.7 ± 30.3 cc 133.2 ± 64.5 cc, < 0.0001). Procedure, enucleation, and morcellation times were shorter in the BNI group (all < 0.0001). There was no statistical difference in same-day discharge rates (90.4% 87.7%, = 0.5), short-term functional outcomes, emergency department (ED) visits, or readmission rates between the two groups. At 14 months mean follow-up, two BNCs occurred in patients in the control group (0.6%), and no BNCs occurred in patients who underwent BNI (0.0%, = 0.5). BNI at time of HoLEP did not decrease the ability to achieve same-day discharge or increase 90-day complications, ED visits, or readmission rates. No BNCs occurred in patients who underwent prophylactic BNI (0.0%) despite a smaller gland size and lower specimen weight in this cohort. Further prospective studies are required to conclude if concurrent BNI at time of HoLEP is protective against BNC.
Topics: Male; Humans; Prostate; Urinary Bladder; Lasers, Solid-State; Prostatic Hyperplasia; Transurethral Resection of Prostate; Holmium; Laser Therapy; Retrospective Studies; Treatment Outcome
PubMed: 37276153
DOI: 10.1089/end.2022.0816 -
BMJ Open Sep 2023Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has already proven its non-inferiority to conventional abdominal laparoscopy (CAL) for hysterectomy...
Assessment of women's sexual quality of life after benign adnexal surgery using vNOTES approach in comparison to conventional laparoscopy: protocol for a randomised controlled trial.
INTRODUCTION
Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has already proven its non-inferiority to conventional abdominal laparoscopy (CAL) for hysterectomy without conversion. The results in terms of efficacy and safety are promising. However, we note a lack of medical literature and no specific randomised controlled trial assessing women's sexual function after vNOTES for benign adnexal surgery. The aim of this RCT is to confirm the non-inferiority of the vNOTES approach for benign adnexal pathology compared with CAL on women's sexual function. Secondary outcomes will evaluate vNOTES's efficiency, morbidity and postoperative complications compared with CAL for benign adnexal surgery. The relationship between adnexal mass morcellation and the quality of the histological analysis will also be evaluated as secondary outcome.
METHODS AND ANALYSIS
Women aged 18-70 years undergoing a benign adnexal surgery at the Geneva University Hospitals will be eligible and randomised with a 1:1 ratio to the CAL arm or the vNOTES arm, if inclusion criteria are met. Participants will complete the Female Sexual Function Index, the Couple Satisfaction Index-16 and a self-reported questionnaire on dyspareunia within 4 weeks prior to randomisation and at 3+6 months after surgery. General and clinical data will be collected when the patient is enrolled in the study, during hospitalisation and at 1 month postoperative to assess secondary outcomes.An absence of impairment on sexual function will be confirmed with a stability or an improvement of the evaluated scores in each group at 3 and 6 months postoperative compared with the preoperative scores. We expect to have no statistically significant difference in sexuality questionnaires scores between the two groups.
ETHICS AND DISSEMINATION
Protocol of this study was validated by the Cantonal Research Ethics Commission of Geneva, Switzerland, on 9 August 2022. We aim to publish the study's results in peer-reviewed journals within 3 years.
TRIAL REGISTRATION NUMBER
NCT05761275.
Topics: Female; Humans; Quality of Life; Laparoscopy; Sexual Behavior; Sexuality; Dyspareunia; Randomized Controlled Trials as Topic
PubMed: 37678943
DOI: 10.1136/bmjopen-2023-073691 -
Facts, Views & Vision in ObGyn Mar 2024Regardless of the technique used, extraction of the uterus is a crucial step in hysterectomy. There is currently no scoring system to predict its feasibility.
BACKGROUND
Regardless of the technique used, extraction of the uterus is a crucial step in hysterectomy. There is currently no scoring system to predict its feasibility.
OBJECTIVES
Our main objective was to determine a predictive score of uterine extraction feasibility to optimise surgical planning of total hysterectomy. As secondary objectives, we examined the correlation between uterine volume predicted by preoperative ultrasound and the final weight of the surgical specimen and analysed the impact of the uterine extraction modality on operative and hospitalisation times.
MATERIALS AND METHODS
We defined a Uterine Extraction Score (UES) based on the ratio between uterine sizes and vaginal access. This score was retrospectively applied to a cohort of 178 patients who were hysterectomised for benign conditions between January 2019 and December 2022.
MAIN OUTCOME MEASURES
The UES allows identification of three groups of decreasing feasibility of vaginal extraction, symbolised by traffic light colours: green - vaginal extraction without morcellation, orange -vaginal extraction with morcellation, red - abdominal morcellation by mini-laparotomy or primary laparotomy.
RESULTS
The results show that the UES--predicted, and the observed routes of extraction concord in 92% of cases. There is a strong correlation between estimated volume and final uterine weight. Uterine morcellation lengthens the operative time and the hospital stay.
CONCLUSIONS
The UES seems to be a reliable tool to predict the route of uterine extraction in total hysterectomy.
WHAT IS NEW?
The development of a new scoring system empowers surgeons with decisive information to enhance perioperative outcomes.
PubMed: 38551477
DOI: 10.52054/FVVO.16.1.009 -
International Journal of Gynaecology... Mar 2024To compare contained and free manual vaginal morcellation of large uteruses after total laparoscopic hysterectomy (TLH) in women at low risk of uterine malignancy in...
OBJECTIVE
To compare contained and free manual vaginal morcellation of large uteruses after total laparoscopic hysterectomy (TLH) in women at low risk of uterine malignancy in terms of feasibility and safety.
METHODS
A single-center, observational, retrospective, cohort study was carried out including all patients undergoing TLH requiring manual vaginal morcellation for specimen extraction of large uteruses from January 2015 to August 2021 at the Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy. Patients were divided into two groups according to the type of manual vaginal morcellation (contained or free), and compared in terms of demographic, clinical, and perioperative data.
RESULTS
In all, 271 patients were included: 186 (68.6%) in the contained morcellation group and 85 (31.4%) in the free morcellation group. The mean operative time was significantly lower in the contained morcellation group compared with the free morcellation group (median [interquartile range] 130 [45] vs. 155 [60] min; P < 0.001). No significant difference was found in complications related to the morcellation step, overall, intraoperative and postoperative complications, estimated blood loss, length of hospital stays, uterine weight, and rate of occult malignancy between the two groups.
CONCLUSION
Contained vaginal manual morcellation of the uterus after total laparoscopic hysterectomy using a specimen retrieval bag appears to be a safe procedure with significantly lower operative time than free vaginal manual morcellation.
Topics: Female; Humans; Morcellation; Retrospective Studies; Cohort Studies; Laparoscopy; Uterus; Hysterectomy; Uterine Neoplasms; Treatment Outcome; Hysterectomy, Vaginal; Urogenital Abnormalities
PubMed: 37937384
DOI: 10.1002/ijgo.15224 -
Arab Journal of Urology 2024Anatomical endoscopic enucleation of the prostate (AEEP) provides durable management for patients with lower urinary tract symptoms (LUTS) secondary to large-sized...
INTRODUCTION AND OBJECTIVES
Anatomical endoscopic enucleation of the prostate (AEEP) provides durable management for patients with lower urinary tract symptoms (LUTS) secondary to large-sized prostate over other surgical modalities. We aimed to assess the early outcomes of Collins knife-assisted bipolar enucleation (BipolEP) versus Thulium-Yag enucleation (ThuLEP) in a group of patients with LUTS secondary to a prostate larger than 80 grams.
METHODS
We included patients with benign prostatic hyperplasia (BPH) having a prostate volume > 80 grams, international prostate symptom score (IPSS) >7, urine flow (Q-max) <15, and post-void residual (PVR)>150 ml. We excluded those with a history of previous prostatic surgery, stone, or neurogenic bladder. Bipolar enucleation with early apical release was performed using Collins knife at an 80/100-watt setting (Lamidey Noury), while ThuLEP was conducted using 550- micron fiber and 40/15-watt energy (Lisa Laser). Patients were evaluated before then 2 weeks and 3, 6,12 months postoperatively for changes in IPSS, Q- max, PVR, and the incidence of stress incontinence.
RESULT
One hundred and twenty patients were equally randomized with a mean prostate size of 104 ± 25 gram. The mean IPSS score was 25 ± 6, Qmax 7.6 ± 1.3 mL/S, and PVR 225 ± 39. There was no significant difference regarding enucleation time, morcellation time, and enucleated tissue volume. Irrigation volume and post-operative hemoglobin drop were significantly lower in the bipolar group ( = 0.008, = 0.0002), respectively. At the third-month follow-up, IPSS, Q-max, and PVR were comparable across both groups, with stress incontinence at 3.3% in the bipolar group versus 1.6% in the thulium group, showing an insignificant difference ( = 0.5)."
CONCLUSION
Both BipolEP and ThuLEP, with early apical release, provide a safe and effective management of large-size prostate resulting in significant decrease in post-operative stress incontinence incidence during early follow-up. Intraoperative irrigation saline volume, and post-operative hemoglobin drop favored the bipolar group.
PubMed: 38818261
DOI: 10.1080/20905998.2024.2321737 -
International Neurourology Journal Sep 2023We aimed to identify the risk factors for salvage procedure (SP) required for refractory adenomatous tissue resistant to morcellation during holmium laser enucleation of...
PURPOSE
We aimed to identify the risk factors for salvage procedure (SP) required for refractory adenomatous tissue resistant to morcellation during holmium laser enucleation of the prostate (HoLEP).
METHODS
Patients who underwent HoLEP between January 2010 and April 2020 at Seoul National University Hospital were analyzed. SPs were defined as cases of conversion to resection of the prostatic tissue using an electrosurgical loop after morcellation or secondary morcellation a few days after surgery or conversion to open cystotomy.
RESULTS
Among a total of 2,427 patients, 260 were identified as having SP (SP group) (transurethral resection-nodule [n = 250, 96.1%], secondary morcellation a few days after surgery [n = 9, 3.5%], and conversion to open cystotomy [n = 1, 0.4%]). Patients in the SP group were older and had higher 5-α reductase inhibitors use, higher prostate-specific antigen, larger total prostate volume, and larger transition zone volume (TZV) than those in the non-SP group. In the multivariable logistic regression analysis, only age and TZV were associated with SP. Compared to 40s and 50s, the odds ratios (ORs) were 3.84 in 60s (95% confidence interval [CI] 1.37-10.78, P = 0.011), 4.53 in 70s (95% CI, 1.62-12.62, P = 0.004), and 6.59 in 80s or older (95% CI, 2.23-19.46, P = 0.001). The ORs of the SP were analyzed per TZV quartile. Compared to TZV ≤ 20.3 mL, the OR was 3.75 in 32.0 mL < TZV ≤ 50.4 mL (95% CI, 2.00-7.04, P < 0.001) and 8.25 in 50.4 mL < TZV (95% CI, 4.06-16.77, P < 0.001).
CONCLUSION
The risk of refractory morcellation increased in patients aged > 60 years or those with TZV > 32 mL. In order to more efficiently remove these resistant adenomas, it is necessary to develop more efficient morcellators in the future.
PubMed: 37798887
DOI: 10.5213/inj.2346076.038 -
Prostate International Mar 2024Endoscopic enucleation of the prostate (EEP) has gained acceptance as an equitable alternative to transurethral resection of the prostate for benign prostate hyperplasia...
High-power holmium laser versus thulium fiber laser for endoscopic enucleation of the prostate in patients with glands larger than 80 ml: Results from the Prostate Endoscopic EnucLeation study group.
BACKGROUND
Endoscopic enucleation of the prostate (EEP) has gained acceptance as an equitable alternative to transurethral resection of the prostate for benign prostate hyperplasia (BPH). Our primary aim is to compare peri-operative outcomes of EEP using thulium fiber laser (TFL) against high-power holmium laser (HPHL) in hands of experienced surgeons for large prostates (≥80 ml in volume). Secondary outcomes were assess complications within 1 year of follow up.
MATERIALS AND METHODS
We retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with TFL or HPHL in 13 centers (January 2019-January 2023). Patients with prostate volume ≥80 ml were included, while those with concomitant prostate cancer, previous prostate/urethral surgery, and pelvic radiotherapy were excluded.
RESULTS
Of 1,929 included patients, HPHL was utilized in 1,459 and TFL in 470. After propensity score matching (PSM) for baseline characteristics, 247 patients from each group were analyzed. Overall operative time (90 [70, 120] vs. 52.5 [39, 93] min, < 0.001) and enucleation time (90 [70, 105] vs. 38 [25, 70] min, < 0.001) were longer in the TFL group, with comparable morcellation time (13 [10, 19.5] vs. 13 [10, 16.5] min, = 0.914). In terms of postoperative outcomes, there were no differences in 30-day complications such as acute urinary retention, urinary tract infection or sepsis. In the PSM cohort, univariable analyses showed that higher age, lower preoperative Qmax, higher preoperative PVRU, and longer operation time were associated with higher odds of postoperative incontinence, while 2-lobe enucleation had lower odds of incontinence compared to 3-lobe enucleation.
CONCLUSIONS
This real-world study reaffirms that HPHL and TFL in large prostates are equally efficacious in terms of 30-day complications. TFL with the en-bloc technique has a shorter operative time which significantly improves short- and medium-term functional outcomes.
PubMed: 38523902
DOI: 10.1016/j.prnil.2023.12.001 -
International Journal of Surgical... Aug 2023Uterus-like mass is a rare form of endometriosis, which shows striking structural similarity to the normal uterus. Formation of a mass lesion raises clinical concern for...
Uterus-like mass is a rare form of endometriosis, which shows striking structural similarity to the normal uterus. Formation of a mass lesion raises clinical concern for malignancy, and pathologic examination is necessary for accurate diagnosis. We describe herein, a middle aged woman who presented with a mesenteric mass six years post hysterectomy, which was initially suspected to be a gastrointestinal stromal tumor. The resected was specimen was grossly pear shaped with microscopy showing a central endometrial glands and stroma lined cavity, surrounded by a thick muscular wall reminiscent of uterine myometrium. Histogenesis of this entity is unclear, and several theories are proposed regarding the etiology, including congenital anomaly theory, metaplasia and heterotopia theories. Our clinical scenario developed a few years after uterine morcellation, indicating a possibility of another "iatrogenic implantation" theory behind the pathogenesis of this rare lesion.
Topics: Middle Aged; Female; Humans; Morcellation; Uterus; Hysterectomy; Uterine Neoplasms; Laparoscopy; Iatrogenic Disease
PubMed: 36325720
DOI: 10.1177/10668969221133350 -
World Journal of Urology Apr 2024To assess the learning curve of Thulium laser enucleation of the prostate (ThuLEP) of a single surgeon.
PURPOSE
To assess the learning curve of Thulium laser enucleation of the prostate (ThuLEP) of a single surgeon.
METHODS
Hundred patients suffering from benign prostatic hyperplasia were treated by the same surgeon. In all cases, a well-trained urologist was present in the operating room. Patients urinary function was assessed preoperatively using the International Prostate Symptoms Score (IPSS), maximum flow rate and Post-Void Residual volume. Preoperative prostate volume was recorded. Enucleation and morcellation efficiency and complication rate were evaluated. Patients were divided into 5 cohorts of 20 consecutive cases to assess changes in outcomes through time.
RESULTS
Mean age of patients was 73.1 years (SD 17.5) and mean prostate volume was 89.7 ml (SD 55.1). Overall, mean enucleation and morcellation efficiency were 1.7 (SD 2.9) and 5.1 (SD 2.7) g/min. A statistically significant increase in enucleation efficiency was observed when comparing cohort 1 vs 2 (0.9 vs 1.3 g/min, p = 0.03) and cohort 2 vs 3 (1.3 vs 1.7 g/min, p = 0.02). A statistically significant increase in morcellation efficiency was observed when comparing cohort 1 vs 2 (2.8 vs 3.7 g/min, p = 0.02) and cohort 2 vs 3 (3.7 vs 4.9 g/min, p = 0.03). In both cases, no significant differences were observed when comparing the following cohorts. Complication rate showed no significant differences throughout the caseload.
CONCLUSIONS
In our single-surgeon experience, we observed a learning curve of nearly 60 cases for the ThuLEP procedure in presence of a well-trained surgeon. Complication rate was low from the beginning of surgical experience.
Topics: Male; Humans; Aged; Prostate; Thulium; Learning Curve; Treatment Outcome; Laser Therapy; Prostatic Hyperplasia; Lasers, Solid-State
PubMed: 38643250
DOI: 10.1007/s00345-024-04958-7 -
World Journal of Urology Mar 2024To clinically and histologically characterize prostatic nodules resistant to morcellation ("beach balls," BBs).
PURPOSE
To clinically and histologically characterize prostatic nodules resistant to morcellation ("beach balls," BBs).
PATIENTS AND METHODS
We reviewed a consecutive cohort of 559 holmium laser enucleation of the prostate (HoLEP) procedures performed between January 2020 and November 2023. The BBs group comprised 55 men (10%) and the control group comprised 504 men (90%). The clinical, intraoperative, outcome, and histologic data were statistically processed for the prediction of the presence of BBs and their influence on the perioperative course and outcome.
RESULTS
The BBs group in comparison to the controls was older (75 vs 73 years, respectively, p = 0.009) and had higher rates of chronic retention (51 vs 29%, p = 0.001), larger prostates on preoperative abdominal ultrasound (AUS) (140 vs 80 cc, p = 0.006), longer operating time (120 vs 80 min, p = 0.001), higher weights of removed tissue (101 vs 60 gr, p = 0.008), higher complication rates (5 vs 1%, p = 0.03), and longer hospitalization (p = 0.014). A multivariate analysis revealed that larger prostates on preoperative AUS and older age independently predicted the presence of BBs which would prolong operating time. ROC analyses revealed that a threshold of 103 cc on AUS predicted BBs with 94% sensitivity and 84% specificity. BBs were mostly characterized histologically by stromal component (p = 0.005).
CONCLUSIONS
BBs are expected in older patients and cases of chronic retention. Prostatic volume is the most reliable predictor of their presence. They contribute to prolonged operating time and increased risk of complications. The predominantly stromal composition of the BBs apparently confers their resistance to morcellation.
Topics: Aged; Humans; Male; Holmium; Laser Therapy; Lasers, Solid-State; Prostate; Prostatectomy; Prostatic Hyperplasia; Retrospective Studies; Transurethral Resection of Prostate; Treatment Outcome
PubMed: 38546885
DOI: 10.1007/s00345-024-04902-9