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Archivos Espanoles de Urologia Oct 2020Prostate enucleation is becoming more relevant within BPH treatment. Nowadays is probably the gold standard for enucleation. Several studies have shown holmium laser as... (Review)
Review
OBJECTIVE
Prostate enucleation is becoming more relevant within BPH treatment. Nowadays is probably the gold standard for enucleation. Several studies have shown holmium laser as the most frequently used safe and efficient energy source. The long learning curve remains as its major drawback. The current review aims to describe step to step technique at our institutionand describing the rational for its use.
METHODS
A detailed description on our step-to-step Holep technique is provided. We focused on the main differences with other techniques already described highlighting the largest experience reported.
RESULTS
None of the published series has shown better results in terms of functional, safety and less complications outcomes on the short and long term. No differences are shown in terms of intraoperative/postoperative blood loss, reoperations, capsular perforations or urethral strictures. Our techniques provides shorter surgical length and improved efficiency than blocking and trilobular techniques. The rates of early continence are 4% vs5-40%. Lastly, improvement in morcellator devices delivered no complications related to that part of the surgery.
CONCLUSIONS
Holep is the gold standard technique for prostate enucleation. It provides improved functional and safety outcomes than with other techniques. A standardized and optimized technique is mandatory.
Topics: Humans; Laser Therapy; Lasers, Solid-State; Male; Prostatic Hyperplasia; Urethral Stricture
PubMed: 33025915
DOI: No ID Found -
Frontiers in Surgery 2022
PubMed: 36406373
DOI: 10.3389/fsurg.2022.1060503 -
Turkish Journal of Urology Mar 2021This study aimed to assess the perioperative and the 12-month efficacy and safety of 140 W high-powered holmium laser for enucleation of the prostate (HP-HoLEP) for the...
OBJECTIVE
This study aimed to assess the perioperative and the 12-month efficacy and safety of 140 W high-powered holmium laser for enucleation of the prostate (HP-HoLEP) for the treatment of benign prostatic obstruction.
MATERIAL AND METHODS
The data of 540 patients who underwent HoLEP by a single surgeon were analyzed retrospectively. Preoperative evaluation included a physical examination with a digital rectal examination, measurement of maximum urinary flow rate (Q), postvoid residual volume (PVR) and prostate volume by transabdominal ultrasonography, serum prostate-specific antigen (PSA), international prostate symptom score (I-PSS) and international index of erectile function-5 (IIEF-5) questionnaires, and urine analysis. Morcellation, enucleation, and operation efficiencies were calculated with the resected weight divided by morcellation, enucleation, and operative times, respectively. The patients were reassessed at 1, 3, 6, and 12 months after surgery by I-PSS, IIEF-5, Q, PSA, and the occurrence of complications.
RESULTS
The mean operative time was 65.2±20.9 minutes. The mean enucleation time and efficiency were 53±15.1 minutes and 1.72±0.4 g/min, respectively. The mean morcellation time and efficiency were 12.3±15.1 minutes and 7.4±3.2 g/min respectively. Clavien grade 1 complications were observed in 102 (18.9%) patients, Clavien grade 2 complications in 20 (3.7%) patients, and Clavien grade 3b complications in 23 (5.4%) patients. I-PSS, Q, and IIEF-5 at postoperative 1, 3, 6, and 12 months were significantly better than baseline results.
CONCLUSION
Our study demonstrated that 140 W HP-HoLEP can be performed with high enucleation efficiency, low perioperative and postoperative complication rates, and excellent functional results.
PubMed: 33819443
DOI: 10.5152/tud.2021.20558 -
Fertility and Sterility Aug 2022To describe a novel, minimally invasive technique for performing myomectomy, a fertility-sparing procedure.
OBJECTIVE
To describe a novel, minimally invasive technique for performing myomectomy, a fertility-sparing procedure.
DESIGN
This technique was developed based on similar techniques for other surgeries that showed a benefit. Liu et al. (1) described vaginal natural orifice transluminal endoscopic surgery (vNOTES) for myomectomy, in which a 6-cm myoma was resected transvaginally. An anterior colpotomy was made, and single-site surgical skills were used to perform the entire myomectomy without an abdominal incision and with minimal blood loss (1). Another study showed that this technique was also feasible in 8 patients with type 3-7 myomas, and the patients were discharged within a day (2). Robotic vNOTES surgery has been performed for various gynecologic procedures, including hysterectomy, sacrocolpopexy, and the resection of endometriosis (3-6). One study showed that robotic vNOTES was a viable alternative to traditional vNOTES for hysterectomy, with no differences in operative time, the length of hospital stay, postoperative pain levels, or conversions (3). This study in fact proposed that robotic vNOTES was beneficial because of the opportunity to use wristed instruments to increase an otherwise limited range of motion. Another study showed that if surgeons already have significant experience with laparoscopic single-site and abdominal robotic surgeries, only 10 cases of robotic vNOTES and 10-20 port placements with robotic docking are needed to become proficient in robotic vNOTES (7). Another study showed that robotic vNOTES was a safe and feasible approach for the treatment of endometriosis with hysterectomy and the resection of endometriosis, which may be technically challenging because of distorted anatomy or scar tissue due to endometriosis (4). This video demonstrates a robotic vNOTES for myomectomy, a novel, minimally invasive technique for performing myomectomy. Vaginal surgery is the preferred route for hysterectomy compared with other techniques, and this parallel can also be made for other gynecologic procedures, including myomectomy (8). The vaginal approach is preferred for hysterectomy because it is associated with shorter hospital stays and operative time as well as faster recovery. Given these factors, the vaginal approach is preferred over the more traditional umbilical or abdominal laparoscopy. However, visualization and fine movement can be difficult in vaginal surgery, given the lack of space. Robotic techniques in place of traditional or vaginal laparoscopy do not require the surgeon to have a large amount of space to make fine movements because the camera and small robotic instruments are docked close to the tissue. This allows for precision while suturing and performing more layers in the myometrium after myomectomy. This is more difficult to achieve with traditional umbilical laparoscopy and may potentially reduce the risk of uterine rupture in future pregnancies. Given the advantages of the robotic and vaginal approaches, the robotic vNOTES route was pursued for this procedure because it combines the benefits of robotic and vaginal surgeries and can be considered as a feasible alternative to open, vaginal, or laparoscopic techniques.
SETTING
Academic-center hospital.
PATIENT(S)
A 28-year-old presented with heavy periods and pelvic pain. Imaging showed a large, 8-cm posterior fibroid, and the patient strongly desired a fertility-sparing approach.
INTERVENTION(S)
Robotic vNOTES for myomectomy for the 8-cm posterior uterine fibroid.
MAIN OUTCOME MEASURE(S)
Feasibility and safety of using this technique for myomectomy.
RESULT(S)
Robotic vNOTES is a feasible option for performing minimally invasive myomectomy. In this technique, a posterior horizontal colpotomy was made and a gel port was placed through the incision. The DaVinci Robot was docked, and myomectomy was performed using single-incision surgical techniques. The uterine serosa was closed with the V-Loc suture, and an interceed adhesion barrier was placed over the incision. The surgeon should take care to notice that the entire surgery is essentially performed "upside down" compared with the traditional abdominal laparoscopic approach. With this change in perspective, the surgeon should have a very good understanding of the vaginal anatomy and the expected location of the uterine artery, ureter, and rectum to avoid any damage to surrounding structures (the uterus) or increased blood loss. The fibroid was morcellated out of the vagina using The Extracorporeal C-Incision Tissue Extraction technique, and the posterior colpotomy was closed (9). The patient was discharged for home on the same day, with minimal blood loss. A prelabor cesarean section was recommended for all future pregnancies to reduce the risk of uterine rupture. The rate of uterine rupture after myomectomy is approximately 0.6% (10). However, the rate of uterine rupture after classical cesarean section is approximately 1%-12% (11). Given that the incision made was similar to the classical incision, except on the posterior uterus, prelabor cesarean section was recommended, although the uterine cavity was not entered.
CONCLUSION(S)
In this video, we demonstrate a myomectomy performed using the robotic vNOTES technique. The traditional vNOTES technique for myomectomy has been previously described (1); however, this technique can be very burdensome for suturing and does not allow for precision, and performing multiple layers is challenging. However, the robotic vNOTES approach solves this issue and can allow the surgeon to perform very precise suturing. While choosing the ideal patient for this procedure, the preoperative considerations include the desire for future fertility, the size and location of the fibroid, ideally 1 large posterior fibroid, and adequate space for vaginal port placement. This technique combines the advantages of both vaginal and robotic surgeries while maintaining low blood loss, and patients may be discharged for home on the same day.
Topics: Adult; Cesarean Section; Endometriosis; Female; Humans; Laparoscopy; Leiomyoma; Natural Orifice Endoscopic Surgery; Pregnancy; Robotic Surgical Procedures; Robotics; Uterine Myomectomy; Uterine Rupture
PubMed: 35691722
DOI: 10.1016/j.fertnstert.2022.05.009 -
The World Journal of Men's Health Oct 2023To evaluate the safety, efficiency, and size-dependency of the 'Inverted omega (Ʊ)' holmium laser enucleation of the prostate (HoLEP) in benign prostate hyperplasia...
The Efficacy and Safety of 'Inverted Omega ' Holmium Laser Enucleation of the Prostate (HoLEP) for Benign Prostatic Hyperplasia: A Size-Independent Technique for the Surgical Treatment of LUTS.
PURPOSE
To evaluate the safety, efficiency, and size-dependency of the 'Inverted omega (Ʊ)' holmium laser enucleation of the prostate (HoLEP) in benign prostate hyperplasia (BPH) with lower urinary tract symptoms.
MATERIALS AND METHODS
A retrospective analysis of 716 consecutive patients who underwent HoLEP under the care of a single surgeon from 2014-2021. These patients were treated using the 'Inverted omega ' HoLEP technique for BPH. The patients were divided into 3 groups: Group 1 (<40 mL, n=328), Group 2 (40-60 mL, n=221), and Group 3 (≤60 mL, n=167). Perioperative parameters, safety, and functional outcomes were assessed and analyzed.
RESULTS
The perioperative parameters, like enucleation time (45.8±26.9 min), morcellation time (13.2±47.5 min), and catheterization duration (1.6±1.2 d) significantly differed to favor smaller prostate sizes (p<0.01). Significant improvements in the IPSS (total, voiding, storage, and quality of life), post-void residual urine, and maximum flow rate were observed 3 months post-HoLEP and continued during the 1-year follow-up period in all groups (p<0.01). The postoperative complications included urethral stricture in 11 patients (1.5%), bladder neck contracture in 12 (1.7%), urinary incontinence in 14 (2.0%), and bladder injuries in 4 (0.6%). Bladder neck contractures occurred only in Group 1. The postoperative surgical management for complications included urethral sounding (n=9, 1.3%), endoscopic internal urethrotomy (n=2, 0.3%), and re-HoLEP for bladder neck contractures in (n=12, 1.7%). The rate of re-HoLEP for regrowing adenomas was 15 (2.1%). Postoperative medications exceeding 6 months were α-blocker (n=22, 3.1%), cholinergics (n=16, 2.2%), anticholinergics (n=58, 8.1%), antidiuretics (n=18, 2.5%), and daily PDE5 inhibitor (n=38, 5.3%). Thirty-four patients (4.7%) had postoperative incidental prostate cancer.
CONCLUSIONS
The inverted omega HoLEP technique is safe and effective for the treatment of BPH. Moreover, 'Inverted omega ' HoLEP is a size-independent and effective method for all prostate sizes.
PubMed: 37118958
DOI: 10.5534/wjmh.220225 -
Annals of Translational Medicine Jan 2022This study sought to analyze the risk of morcellation in patients who underwent surgery for leiomyoma and had a final pathological diagnosis of uterine leiomyosarcoma...
BACKGROUND
This study sought to analyze the risk of morcellation in patients who underwent surgery for leiomyoma and had a final pathological diagnosis of uterine leiomyosarcoma (uLMS), and evaluate the survival benefits of second-look surgery and chemotherapy in patients with stage I occult uLMS.
METHODS
A retrospective analysis of the data of patients with occult stage I uLMS in the Peking Union Medical College Hospital database between 2005 and 2018 was conducted. The recurrence rate and progression-free survival (PFS) were compared between patients who underwent morcellation or not. Univariate analyses were used to evaluate the survival impact of lymphadenectomy, oophorectomy and adjuvant chemotherapy. Propensity-score matching methods were used to evaluate the effect of morcellation on recurrence while adjusting for baseline confounding factors using Poisson regression fitted by inverse probability weighting (IPW) estimation.
RESULTS
A total of 96 patients with uLMS were identified among the 31,679 surgeries performed for leiomyomas (incidence: 0.303%). Hysterectomy was performed in 60 patients, and myomectomy was performed in 36 patients (power morcellation n=20). There were 36 (37.5%) patients underwent lymphadenectomy, and 76 (79.2%) patients underwent oophorectomy. Among them, 47 (52.8%) patients received postoperative chemotherapy. The median follow-up time was 40 months (range, 12-146 months), and there were 43 cases of recurrence (44.7%). No differences in recurrence were found between the hysterectomy and myomectomy groups (hazard ratio 0.839, P=0.701). The 3-year PFS rates for patients with hysterectomy, power morcellation, and non-power morcellation were 64.3%, 53.8%, and 59.8%, respectively. No survival differences were identified between patients with/without lymphadenectomy [PFS: P=0.513; overall survival (OS): P=0.413] and oophorectomy (PFS: P=0.162; OS: P=0.815). Postoperative chemotherapy was associated with better PFS (P=0.047), but not OS (P=0.36).
CONCLUSIONS
No survival differences were observed among the initial surgical procedures in stage I patients with occult uLMS. No survival benefits were observed between lymphadenectomy and oophorectomy patients. Compared to continued observation, postoperative chemotherapy was associated with improved PFS, but not OS.
PubMed: 35282058
DOI: 10.21037/atm-21-6424 -
The Australian & New Zealand Journal of... Dec 2022To evaluate morcellation practices among Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG).
AIMS
To evaluate morcellation practices among Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG).
MATERIALS AND METHODS
RANZCOG Fellows were invited to complete an online survey. This anonymous, cross-sectional survey consisted of 29 questions regarding demographics and morcellation practices.
RESULTS
Four hundred and thirty eight (19.04%) of 2300 RANZCOG Fellows responded, and of these 258 (11.22%) completed the entire survey; analysis was undertaken on data from the latter respondents. Respondents were broadly representative of all RANZCOG Fellows regarding gender, age, and location. Of the respondents, 53.10% considered themselves advanced laparoscopic surgeons. Of respondents who had worked as gynaecology consultants prior to 2014, 39.39% used uncontained power morcellation prior to 2014, compared to 17.58% since (a decrease of 44.63%). The most common reasons for utilising uncontained power morcellation less often were the 2014 Food and Drug Administration warnings (40.31%), risk of adverse outcomes (33.72%), and recommendations from colleges such as RANZCOG (27.13%). When undertaking an operation that required specimen extraction, the most common methods used were: employing an open approach from the get-go (utilised by respondents in 31.01% of such cases); contained manual morcellation (28.90%); and conversion to intra-operative laparotomy (10.10%).
CONCLUSIONS
There has been a strong trend away from uncontained power morcellation since 2014, with a 36.00% increase in clinicians who never use uncontained power morcellation, and an 80.65% decrease in clinicians who always use this method of specimen extraction. The most common reason cited for employing uncontained power morcellation less often was the 2014 Food and Drug Administration's warnings.
Topics: Humans; Cross-Sectional Studies; New Zealand; Australia; Morcellation; Surveys and Questionnaires
PubMed: 36225109
DOI: 10.1111/ajo.13618 -
Facts, Views & Vision in ObGyn Mar 2022A possible solution to the problem of cell dissemination through laparoscopic uncontained morcellation during laparoscopic supracervical hysterectomy (LASH) is the use...
Total surgical time in laparoscopic supracervical hysterectomy with laparoscopic in-bag-morcellation compared to laparoscopic supracervical hysterectomy with uncontained morcellation.
BACKGROUND
A possible solution to the problem of cell dissemination through laparoscopic uncontained morcellation during laparoscopic supracervical hysterectomy (LASH) is the use of laparoscopic in-bag morcellation. One criticism regarding the use of in-bag morcellation is the additional surgical time associated with this procedure.
OBJECTIVES
In this retrospective study we compared the total surgical time in LASH with laparoscopic in-bag morcellation (107 cases from 2016-2018) and LASH with uncontained morcellation (47 cases from 2015-2017).
MATERIALS AND METHODS
All surgeries were performed in the same department of minimally invasive gynaecological surgery by a total of three experienced surgeons for the indication of bleeding disorder and / or dysmenorrhea.
MAIN OUTCOME MEASURE
We measured and compared total surgical time, surgical outcome, blood loss and complications in LASH with in-bag morcellation and with uncontained morcellation.
RESULTS
Total surgical time in both procedures do not show a significant difference. Considering the learning curve in laparoscopic bag use, the total surgical time in LASH with laparoscopic in-bag morcellation is shorter than total surgical time in LASH with uncontained morcellation. Laparoscopic in-bag morcellation consumes time for bag use and handling, but saves time as it eliminates the need for meticulous sampling of lost tissue fragments and the complex lavage of the peritoneal cavity after morcellation. There is no difference between both groups in terms of blood loss, complications and surgical results.
CONCLUSION / WHAT IS NEW?
We conclude that LASH with in-bag morcellation is not related to additional surgical time when compared to LASH with uncontained morcellation.
PubMed: 35373549
DOI: 10.52054/FVVO.14.1.006 -
Medicine Oct 2020Leiomyomatosis peritonealis disseminata (LPD) is a rare benign lesion primarily consisting of smooth muscle cells, which mostly affects premenopausal females. Here, we...
RATIONALE
Leiomyomatosis peritonealis disseminata (LPD) is a rare benign lesion primarily consisting of smooth muscle cells, which mostly affects premenopausal females. Here, we reported 3 females with LPD (age, 40-48 years) admitted for pelvic masses.
PATIENT CONCERNS
All 3 LPD cases received laparoscopic uterine fibroid morcellation at 3, 8, and 14 years ago, respectively. Two cases were admitted for pelvic masses. One case was admitted for recurrent fibroids with pollakiuria.
DIAGNOSES
LPD was considered in 2 cases preoperation according to imaging examination, and one of them received ultrasound-guided biopsy of the lesion in the right lobe of the liver. One case was considered as recurrent fibroids preoperation. After surgery, all cases were pathologically diagnosed as LPD consisting of benign smooth muscle cells.
INTERVENTIONS
A total abdominal hysterectomy, salpingo-oophorectomy, and debulking was performed for all 3 cases. Intraoperative exploration revealed that the fibroids distributed in the mesentery (3 cases), broad ligament (1 case), omentum (1 case), liver (1 case), and rectus abdominis (1 case).
OUTCOMES
No recurrence was found during postoperative following-up (5-12 months).
LESIONS
Preoperative diagnosis of LPD is presented as a challenge due to unspecific clinical manifestations. Its diagnosis mainly depends on histopathologic evaluation. Surgery still is the primary treatment for LPD. For patients without reproductive desire, total abdominal hysterectomy, salpingo-oophorectomy, and debulking can be performed, and the affected tissue should be removed as much as possible based on the risk assessment.
Topics: Abdominal Cavity; Adult; Female; Humans; Laparoscopy; Leiomyomatosis; Middle Aged; Morcellation; Pelvis; Postoperative Complications; Ultrasonography
PubMed: 33031323
DOI: 10.1097/MD.0000000000022633 -
American Journal of Obstetrics and... Jun 2021Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically...
BACKGROUND
Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically requires morcellation to remove the corpus uteri while preserving the cervix. Hospitals might vary in how they respond to safety warnings and altered hysterectomy procedures to avoid use of power morcellation. However, there has been little data on how hospitals differ in their practice changes.
OBJECTIVE
This study aimed to examine whether hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation and compare the risk of surgical complications at hospitals that had different response trajectories in use of laparoscopic supracervical hysterectomy.
STUDY DESIGN
This was a retrospective analysis of data from the New York Statewide Planning and Research Cooperative System and the State Inpatient Databases and State Ambulatory Surgery and Services Databases from 14 other states. We identified women aged ≥18 years undergoing hysterectomy for benign indications in the hospital inpatient and outpatient settings from October 1, 2013 to September 30, 2015. We calculated a risk-adjusted utilization rate of laparoscopic supracervical hysterectomy for each hospital in each calendar quarter after accounting for patient clinical risk factors. Applying a growth mixture modeling approach, we identified distinct groups of hospitals that exhibited different trajectories of using laparoscopic supracervical hysterectomy over time. Within each trajectory group, we compared patients' risk of surgical complications in the prewarning (2013Q4-2014Q1), transition (2014Q2-2014Q4), and postwarning (2015Q1-2015Q3) period using multivariable regressions.
RESULTS
Among 212,146 women undergoing benign hysterectomy at 511 hospitals, the use of laparoscopic supracervical hysterectomy decreased from 15.1% in 2013Q4 to 6.2% in 2015Q3. The use of laparoscopic supracervical hysterectomy at these 511 hospitals exhibited 4 distinct trajectory patterns: persistent low use (mean risk-adjusted utilization rate of laparoscopic supracervical hysterectomy changed from 2.8% in 2013Q4 to 0.6% in 2015Q3), decreased medium use (17.0% to 6.9%), decreased high use (51.4% to 24.2%), and rapid abandonment (30.5% to 0.8%). In the meantime, use of open abdominal hysterectomy increased by 2.1, 4.1, 7.8, and 11.8 percentage points between the prewarning and postwarning periods in these 4 trajectory groups, respectively. Compared with the prewarning period, the risk of major complications in the postwarning period decreased among patients at "persistent low use" hospitals (adjusted odds ratio, 0.88; 95% confidence interval, 0.81-0.94). In contrast, the risk of major complications increased among patients at "rapid abandonment" hospitals (adjusted odds ratio, 1.48; 95% confidence interval, 1.11-1.98), and the risk of minor complications increased among patients at "decreased high use" hospitals (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.72).
CONCLUSION
Hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation. Complication risk increased at hospitals that shifted considerably toward open abdominal hysterectomy.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Female; Guideline Adherence; Healthcare Disparities; Hospitals; Humans; Hysterectomy; Intraoperative Complications; Laparoscopy; Logistic Models; Middle Aged; Morcellation; Outcome Assessment, Health Care; Patient Safety; Postoperative Complications; Practice Guidelines as Topic; Practice Patterns, Physicians'; Retrospective Studies; Risk Assessment; United States; Young Adult
PubMed: 33359176
DOI: 10.1016/j.ajog.2020.12.1207