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International Braz J Urol : Official... 2023The En-bloc Resection of Bladder Tumors (ERBT) is a method that offers more benefits compared to the traditional Transurethral Resection of Bladder Tumor (TURBT) (1, 2)....
INTRODUCTION
The En-bloc Resection of Bladder Tumors (ERBT) is a method that offers more benefits compared to the traditional Transurethral Resection of Bladder Tumor (TURBT) (1, 2). Recent studies have shown that ERBT offers better pathological analysis and oncological outcomes (3-6). Thulium and holmium are the most frequently used lasers for this procedure, with the hybrid laser being a new addition that combines thulium and diode to improve hemostatic properties (5, 7-9).
OBJECTIVE
This report aims to discuss the use of two types of lasers, hybrid and holmium, for ERBT.
MATERIAL AND METHODS
Two case studies were conducted. The first case featured a 68-year-old male with two tumors measuring 1.5cm and 2cm. The hybrid laser was used for the procedure. The second case involved a 70-year-old female with a 5cm tumor on the posterior bladder wall, and holmium laser was used with morcellation of the tumor. The quality of histopathological analysis was evaluated. The perioperative data and the entire procedure of the two cases were documented in a step-by-step video.
RESULTS
Both lasers demonstrated excellent results without technical difficulties. There was no bleeding, and both patients were discharged with one day of hospitalization. The detrusor muscle was present without artifacts, and the morcellation did not affect the analysis. The first case showed a pT1G3, and the second case showed a pT2 urothelial carcinoma. The hybrid laser exhibited superior hemostatic capacity compared to the holmium laser.
CONCLUSION
ERBT can use hybrid or holmium lasers without affecting histopathological analysis, even with morcellation.
Topics: Male; Female; Humans; Aged; Urinary Bladder Neoplasms; Carcinoma, Transitional Cell; Lasers, Solid-State; Thulium; Holmium; Cystectomy; Hemostatics
PubMed: 37624663
DOI: 10.1590/S1677-5538.IBJU.2023.0231 -
Actas Urologicas Espanolas Mar 2024Patients treated with HoLEP are frequently treated with previous treatments, including 5-alpha-reductase inhibitors (5-ARIs). We investigated the impact of pretreatment...
INTRODUCTION AND AIM
Patients treated with HoLEP are frequently treated with previous treatments, including 5-alpha-reductase inhibitors (5-ARIs). We investigated the impact of pretreatment with 5-ARIs on perioperative and immediate postoperative parameters in patients treated with HoLEP.
MATERIAL AND METHODS
A retrospective study was performed using a prospectively collected database including all patients treated with HoLEP at our center between January 2017 and January 2023. The resected tissue weight, enucleation and morcellation efficiency (enucleation weight/time and morcellation weight/ time), postoperative complications, hospital stay and hemoglobin drop have been analyzed.
RESULTS
A total of 327 patients were included. Of these, 173 (52.9%) were treated with 5-ARIs. No differences were found among the perioperative parameters investigated to determine efficiency. No differences were observed in peri- or postoperative complications, hospital stay or hemoglobin drop.
CONCLUSIONS
Therapy with 5-ARIs had no impact on the immediate postoperative outcomes of patients treated with HoLEP. In our cohort, we observed that the use of 5-ARIs did not affect surgical efficiency, enucleation or morcellation. Further multicenter studies will be necessary to validate these findings.
Topics: Male; Humans; 5-alpha Reductase Inhibitors; Prostate; Prostatic Hyperplasia; Retrospective Studies; Lasers, Solid-State; Laser Therapy; Postoperative Complications; Hemoglobins
PubMed: 37604401
DOI: 10.1016/j.acuroe.2023.08.008 -
BMC Surgery Jul 2023Laparoscopic surgery has been a milestone for minimally invasive surgeries. But safe removal of large uterine tissue is a challenge for minimally invasive procedures,...
BACKGROUND
Laparoscopic surgery has been a milestone for minimally invasive surgeries. But safe removal of large uterine tissue is a challenge for minimally invasive procedures, and there still exists concern about the dissemination of benign or occult malignant uterine tissue during the use of the morcellator. Different tissue containment systems have been used in laparoscopic power morcellation. However, a risk of leakage still exists in clinical practice. In this study, we aimed to evaluate leakage and tissue dissemination associated with a new detachable multi-hard-port containment system for tissue removal during laparoscopic myomectomy morcellation.
METHODS
Beef tongue specimens were stained with methylene blue solution and morcellated in a plastic trainer box under laparoscopic guidance. The morcellation test in vitro conditions comprised two different containment systems to simulate laparoscopic power morcellation, specifically a polyurethane bag with two pipes (control group) and a detachable multi-hard-port containment system (experimental group). Insufflation pressure was set at 14 mmHg. Three methods are used to detect the leakage The procedure times were recorded. Thirty trials were performed using a multi-port approach and the two tissue containment systems.
RESULTS
The leakage rate was 0.03% (n = 30) for the experimental group and 26.6% (n = 30) for the control group (p < 0.005). Morcellation time was significantly shorter in the experimental group than in the control group (p < 0.001). Median bag introduction time was shorter in the experimental group than in the control group; however, removal time differences were not significant.
CONCLUSIONS
This study quantified the low leakage rate during morcellation and the improved convenience of operation provided by a new tissue containment system.
Topics: Animals; Cattle; Female; Humans; Leiomyoma; Uterine Neoplasms; Morcellation; Laparoscopy; Uterine Myomectomy; Hysterectomy
PubMed: 37525186
DOI: 10.1186/s12893-023-02124-1 -
World Journal of Urology Nov 2023To compare Holmium laser with MOSES technology (MoLEP) and Thulium fiber laser enucleation of the prostate (ThuFLEP) in terms of surgical and functional outcomes.
Holmium laser with MOSES technology (MoLEP) vs Thulium fiber laser enucleation of the prostate (ThuFLEP) in a real-world setting. Mid-term outcomes from a multicenter propensity score analysis.
PURPOSE
To compare Holmium laser with MOSES technology (MoLEP) and Thulium fiber laser enucleation of the prostate (ThuFLEP) in terms of surgical and functional outcomes.
METHODS
We performed a retrospective analysis of all patients who underwent either procedure in five centers (January 2020-January 2022).
EXCLUSION CRITERIA
previous urethral/prostatic surgery, radiotherapy, concomitant surgery. Propensity score matching (PSM) analysis was performed to adjust for the bias inherent to the different characteristics at baseline. Differences between procedures were estimated using Firth Penalized Likelihood regression for International prostate symptom score (IPSS), quality of life (QL), maximum flow rate (Qmax).
RESULTS
PSM retrieved 118 patients in each group. Baseline characteristics were similar except for PSA and number of men on indwelling catheter (higher in MoLEP group). Median surgical time was significantly longer in the MoLEP group despite the enucleation and morcellation times being similar. Median catheter dwelling time and postoperative length of stay were similar. Most of the early complications were Clavien ≤ 2 grade. There were only two Clavien grade 3 complications (one for each group), one grade 4 in MoLEP group. Rate and type of early and persistent incontinence (> 3 months) were similar. At 12-month, proportion of patients reaching a decrease (Δ) of IPSS ≥ 18 from baseline was significantly larger in MoLEP group, with no significant difference in ΔQmax > 12 ml/sec and ΔQL ≥ -3.
CONCLUSION
MoLEP and ThuFLEP were safe and efficacious procedures with similar short-term operative and functional outcomes. At 1-year, MoLEP patients had a sustained reduction of IPPS score.
Topics: Male; Humans; Prostate; Lasers, Solid-State; Thulium; Prostatic Hyperplasia; Quality of Life; Retrospective Studies; Propensity Score; Treatment Outcome; Laser Therapy
PubMed: 37515650
DOI: 10.1007/s00345-023-04524-7 -
Minimally Invasive Therapy & Allied... Dec 2023Proposing hysteroscopic morcellation (HM) as a surgical-therapeutic approach in the treatment of retained products of conception (RPOC) to prevent intrauterine adhesions...
OBJECTIVE
Proposing hysteroscopic morcellation (HM) as a surgical-therapeutic approach in the treatment of retained products of conception (RPOC) to prevent intrauterine adhesions (IUAs).
DESIGN
Prospective analysis.
SETTING
A teaching and university hospital.
PATIENTS
Women with RPOC.
INTERVENTIONS
Office -HM with 'Truclear 5 C'.
MATERIAL AND METHODS
Twenty-two consecutive patients presenting with trophoblastic residue retention after miscarriage and interruption of pregnancy or placenta remnants after cesarean section or delivery were enrolled. These women underwent office-HM with 'Truclear 5 C'. Primary outcomes were median time and rate of hospitalization. The quality of the specimen was also analyzed. A hysteroscopic second look for IUAs was performed.
RESULTS
Mean procedure time was six minutes ( ± 5). Tissue samples had a mean collection size 2.5 cm+0.9. 38% of the samples had spotting or abnormal vaginal discharge. Dilatation of the cervical canal was not performed in any case. Second-look hysteroscopy did not show any IUAs in any of the enrolled patients.
CONCLUSIONS
In the hysteroscopic treatment of RPOC, HM is a valid choice in an office setting without the use of cervical dilatation. Removal of RPOC was uneventful in all cases, simple and carried out faster without any adverse outcomes.
Topics: Pregnancy; Humans; Female; Cesarean Section; Morcellation; Pregnancy Complications; Uterine Diseases; Hysteroscopy; Retrospective Studies
PubMed: 37493491
DOI: 10.1080/13645706.2023.2227694 -
International Urogynecology Journal Nov 2023Robotics-assisted laparoscopic supracervical hysterectomy (RALSH) with concomitant apical robotics-assisted POP repair provides advantages of minimally invasive...
INTRODUCTION AND HYPOTHESIS
Robotics-assisted laparoscopic supracervical hysterectomy (RALSH) with concomitant apical robotics-assisted POP repair provides advantages of minimally invasive procedures; however specimen removal without intraperitoneal spillage of potential pathology remains challenging. The primary aim of our study is to determine the factors affecting contained manual morcellation (CMM) of specimens during RALSH for POP surgery. The secondary aim of the study is to report complications associated with CMM and on specimen pathology.
METHODS
A total of 67 sequential patients underwent RALSH with concomitant robotics-assisted sacrocolpopexy or uterosacral vaginal suspension. Factors analyzed to affect CMM were specimen weight, length of skin and fascia incisions, patient age, body mass index (BMI), and estimated blood loss (EBL).
RESULTS
Median CMM time was 11 min (1 to 46) and specimen weight 62 g (19 to 711). Median patient age was 56 years (36 to 83), and patient BMI was 28 (18 to 44). Median EBL was 50 ml (10 to 150). Median skin and fascial incision lengths were 3 cm (1.5 to 7), and 3.5 cm (1.5 to 8). CMM time was significantly dependent on specimen weight (p < 0.0001) and length of rectus fascia incision (p < 0.0126). There was no gross tissue spillage or bag ruptures. Uterine pathology revealed normal tissue (26%), leiomyoma (47%), adenomyosis (49%), and endometriosis (14%). 4.5% of specimens had evidence of microscopic neoplasm, and 5 years after surgery patients were cancer free.
CONCLUSION
Contained manual extraction of the uterus and/or adnexae at the time of RALSH for POP surgery is a viable, safe, and efficient method of specimen removal.
Topics: Female; Humans; Middle Aged; Morcellation; Laparoscopy; Hysterectomy; Uterus; Pelvic Organ Prolapse; Uterine Neoplasms
PubMed: 37490062
DOI: 10.1007/s00192-023-05586-2 -
Fertility and Sterility Oct 2023To review important diagnostic considerations for accurate identification of a prolapsing submucosal myoma and to highlight surgical techniques for minimally invasive... (Review)
Review
OBJECTIVE
To review important diagnostic considerations for accurate identification of a prolapsing submucosal myoma and to highlight surgical techniques for minimally invasive and uterine-sparing combined vaginal and hysteroscopic myomectomy. Submucosal myomas can present with various symptoms, including vaginal bleeding, pelvic pain, and abnormal discharge, and can also contribute to infertility. This type of myoma has the potential to prolapse through the cervical canal, and prompt identification and management are essential to avoid serious sequelae, including hemorrhage, infection, and sepsis.
DESIGN
A case report. Patient consent was received to publish. This publication received an exemption from institutional review board approval from the institution as this was a case report. The investigators have no conflicts of interest.
SETTING
Academic medical center.
PATIENTS
We present a 33-year-old G5P2032 patient with pelvic pain and vaginal bleeding. Her clinical course involved multiple encounters with inaccurate diagnoses, leading to worsening symptoms. She was found ultimately to have a large, prolapsing submucosal myoma. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, and others), and other applicable sites.
INTERVENTION(S)
Given the severity of her symptoms and her desire for uterine preservation for future fertility, the patient was counseled on the need for surgical intervention and elected to proceed with a combined vaginal and hysteroscopic myomectomy.
MAIN OUTCOME MEASURE(S)
Preoperative considerations discussed in this video include common mimics of this condition, the importance of a thorough pelvic examination and preoperative imaging, as well as recommendations for surgical management.
RESULT(S)
We reviewed the following surgical techniques: (1) adequate exposure; (2) clamping of the myoma stalk; (3) morcellation "cone" technique; (4) use of intracervical vasopressin; (5) hysteroscopic evaluation; and (6) insertion of an intrauterine balloon.
CONCLUSION(S)
Prolapsing submucosal myomas can present as common gynecologic complaints but can lead to serious sequelae when timely diagnosis and treatment are not performed. Appropriate evaluation, accurate diagnosis, preoperative imaging, and knowledge of surgical techniques are critical for optimizing patient outcomes and avoiding complications in patients with a prolapsed myoma.
Topics: Humans; Female; Adult; Pregnancy; Leiomyoma; Uterine Neoplasms; Uterine Myomectomy; Myoma; Uterine Hemorrhage; Pelvic Pain; Hysteroscopy
PubMed: 37487820
DOI: 10.1016/j.fertnstert.2023.07.009 -
Journal of Minimally Invasive Gynecology Nov 2023To investigate the incidence of venous thromboembolism (VTE) in patients undergoing large specimen hysterectomy for benign indications. To evaluate the impact of route...
STUDY OBJECTIVE
To investigate the incidence of venous thromboembolism (VTE) in patients undergoing large specimen hysterectomy for benign indications. To evaluate the impact of route of surgery and operative time in the development of VTE in this population.
DESIGN
Retrospective cohort study (Canadian Task Force Classification II2) of targeted hysterectomy data prospectively collected from the American College of Surgeons National Surgical Quality Improvement Program involving over 500 hospitals across the United States.
SETTING
National Surgical Quality Improvement Program Database.
PATIENTS
Women aged 18 years or older undergoing hysterectomy for benign indications between 2014 and 2019. Patients were further classified into 4 groups according to uterine weight: <100 g, 100-249 g, 250 g-499 g, and specimens ≥500 g.
INTERVENTIONS
Current Procedural Terminology codes were used to identify cases. Variables including age, ethnicity, body mass index, smoking status, diabetes, hypertension, blood transfusion, and American Society of Anesthesiologists classification system scores were collected. Cases were stratified by route of surgery, operative time, and uterine weight.
MEASUREMENTS AND MAIN RESULTS
A total of 122,418 hysterectomies occurring between 2014 and 2019 were included in our study, of which 28,407 (23.2%) patients underwent abdominal, 75,490 (61.7%) laparoscopic, and 18,521 (15.1%) vaginal hysterectomy. The overall rate of VTE in patients with large specimen hysterectomies (≥500 g) was 0.64%. After multivariable adjustment, there was no significant difference in the odds of VTE between uterine weight groups. Only 30% of the surgeries with uterine weight above 500 g were performed with minimally invasive surgical routes. Patients who underwent minimally invasive hysterectomy had lower odds of VTE via laparoscopic (adjusted odds ratio [aOR] 0.62; confidence interval [CI]: 0.48-0.81) and vaginal (aOR 0.46; CI: 0.31-0.69) routes compared to laparotomy. Prolonged operative time (>120 min) was associated with increased odds of VTE (aOR 1.86; CI:1.51-2.29).
CONCLUSION
The occurrence of VTE after a benign large specimen hysterectomy is rare. The odds of VTE is higher with longer operative times and lower with minimally invasive approaches, even for markedly enlarged uteri.
Topics: Humans; Female; United States; Venous Thromboembolism; Retrospective Studies; Postoperative Complications; Hysterectomy; Hysterectomy, Vaginal
PubMed: 37422052
DOI: 10.1016/j.jmig.2023.06.017 -
European Urology Focus Jan 2024Different lasers have been developed for treatment of benign prostatic hyperplasia, with no definitively superior technique identified to date.
Comparison Between Thulium Fiber Laser and High-power Holmium Laser for Anatomic Endoscopic Enucleation of the Prostate: A Propensity Score-matched Analysis from the REAP Registry.
BACKGROUND
Different lasers have been developed for treatment of benign prostatic hyperplasia, with no definitively superior technique identified to date.
OBJECTIVE
To compare surgical and functional enucleation outcomes in real-world multicentre practice using high-power holmium laser (HP-HoLEP) and thulium fiber laser enucleation of the prostate (ThuFLEP) for different prostate sizes.
DESIGN, SETTING, AND PARTICIPANTS
The study included 4216 patients who underwent HP-HoLEP or ThuFLEP at eight centers in seven countries between 2020 and 2022. Exclusion criteria were previous urethral or prostatic surgery, radiotherapy, or concomitant surgery.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
To adjust for the bias arising from different characteristics at baseline, propensity score matching (PSM) was used to identify 563 matched patients in each cohort. Outcomes included the incidence of postoperative incontinence, early complications (30-d), and delayed complications, and results for the International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and postvoid residual volume (PVR).
RESULTS AND LIMITATIONS
After PSM, 563 patients in each arm were included. Total operative time was similar between the arms, but enucleation and morcellation times were significantly longer for ThuFLEP. The rate of postoperative acute urinary retention was higher in the ThuFLEP arm (3.6% vs 0.9%; p = 0.005), but the 30-d readmission rate was higher in the HP-HoLEP arm (22% vs 8%; p = 0.016). There was no difference in postoperative incontinence rates (HP-HoLEP:19.7%, ThuFLEP:16.0%; p = 0.120). Rates of other early and delayed complications were low and comparable between the arms. The ThuFLEP group had higher Qmax (p < 0.001) and lower PVR (p < 0.001) than the HP-HoLEP group at 1-yr follow-up. The study is limited by its retrospective nature.
CONCLUSIONS
This real-world study shows that early and delayed outcomes of enucleation with ThuFLEP are comparable to those with HP-HoLEP, with similar improvements in micturition parameters and IPSS.
PATIENT SUMMARY
As lasers become readily available for the treatment of enlarged prostates causing urinary bother, urologists should focus on performing good anatomic removal of prostate tissue, with the choice of laser not as important for good outcomes. Patients should be counseled about long-term complications, even when the procedure is being performed by an experienced surgeon.
Topics: Male; Humans; Prostate; Lasers, Solid-State; Thulium; Quality of Life; Prostatectomy; Retrospective Studies; Propensity Score; Treatment Outcome; Prostatic Hyperplasia; Postoperative Complications; Registries
PubMed: 37414615
DOI: 10.1016/j.euf.2023.06.009 -
European Journal of Obstetrics,... Aug 2023This review aims to provide a comprehensive description of surgical approaches for the management of uterine sarcomas. Uterine sarcomas are rare uterine neoplasms.... (Review)
Review
This review aims to provide a comprehensive description of surgical approaches for the management of uterine sarcomas. Uterine sarcomas are rare uterine neoplasms. Frequently, diagnosis is made after hysterectomy or myomectomy scheduled for presumed benign leiomyomas. The gold standard for surgical treatment of uterine sarcomas is hysterectomy with bilateral salpingo-oophorectomy. It is possible to adopt a fertility-sparing approach for those patients who wish to maintain their fertility. The role of pelvic lymphadenectomy is controversial; in fact, removal of lymph nodes is only recommended in the case of radiological suspicion of nodal involvement. Use of a morcellator is associated with increased risk of total recurrence, intra-abdominal recurrence and death. Advanced disease management should be customized based on the patient's performance status given the uncertain role of adjuvant chemotherapy. Treatment of advanced or recurrent disease remains a subject of debate, but surgery is the best approach in terms of morbidity and mortality. There are few options for management of these uterine tumours, and further studies are needed to clarify the diagnostic and therapeutic pathways of patients with a first diagnosis of uterine sarcoma and patients with relapse of uterine sarcoma. No specific evidence supports the adoption of adjuvant therapy in uterine-confined disease, and molecular/genomic profiling may be useful to identify patients at risk of recurrence.
Topics: Female; Humans; Neoplasm Recurrence, Local; Sarcoma; Uterine Neoplasms; Leiomyoma; Pelvic Neoplasms; Hysterectomy
PubMed: 37348383
DOI: 10.1016/j.ejogrb.2023.06.016