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Dean NS, Lee MS, Assmus MA, Guo J, Xu P, McDonald A, Fadl-Alla A, Helin J, Krambeck AE. Does Resectoscope Sheath Size Influence Holmium Laser Enucleation of the Prostate Outcomes? A Prospective Randomized Controlled Trial. J Endourol 2023; 37:1261-1269. [PMID: 37786336 DOI: 10.1089/end.2023.0383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Introduction: Holmium laser enucleation of the prostate (HoLEP) is routinely performed with a 24F, 26F, or a 28F scope. Proponents of the larger scopes propose that a bigger sheath size allows for superior flow and visibility leading to a more efficient operation and better hemostasis. Those utilizing the smaller scopes suggest that the smaller sheath is less traumatic, resulting in lower stricture rates and temporary incontinence. We sought to compare outcomes of ambulatory HoLEP using the 24F and 28F laser scope. Materials and Methods: From May 2022 to March 2023, we randomized patients undergoing HoLEP (<200 cm3 in size) 1:1 to either a 24F or 28F scope. The primary outcome was differences in surgical duration between groups (minutes). Secondary outcomes included surgeon scope evaluation and postoperative patient results. Results: There was no difference in patient characteristics in those randomized to 28F (n = 76) vs 24F (n = 76) (p > 0.05) scopes. Procedural duration and efficiencies were not different between groups (all p > 0.05). The 28F scope was associated with improved surgeon-graded irrigation flow and visibility (p < 0.001). Patients treated with the 28F scope were more likely to achieve effective same-day trial of void (SDTOV) (28F 94.3% vs 24F 82.1%, p = 0.048) and have a shorter length of stay (LOS) (28F 7.0 vs 24F 11.9 hours, p = 0.014), however, rates of same-day discharge (SDD) were not statistically different (28F 87.8% vs 24F 78.4%, p = 0.126). There was no difference between the cohorts in rates of 90-day emergency room presentations, re-admissions, complications, or functional ouctomes (p > 0.05). Conclusions: We identified no clear advantage of scope size with regard to intraoperative or postoperative outcomes at 3-month follow-up due to scope size. However, if SDD is part of your postoperative pathway, the 28F scope may shorten LOS and increase rates of effective SDTOV. Clinicaltrials.gov: NCT05308017.
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Affiliation(s)
- Nicholas S Dean
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew S Lee
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Urology, Ohio State University, Columbus, Ohio, USA
| | - Mark A Assmus
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Urology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Jenny Guo
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Perry Xu
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alyssa McDonald
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alla Fadl-Alla
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jessica Helin
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Amy E Krambeck
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Spinos T, Tatanis V, Liatsikos E, Kallidonis P. Same-day catheter removal after holmium laser enucleation of the prostate (HoLEP): a systematic review. World J Urol 2023; 41:3503-3510. [PMID: 37878061 DOI: 10.1007/s00345-023-04655-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/22/2023] [Indexed: 10/26/2023] Open
Abstract
PURPOSE To summarize all existing evidence regarding the feasibility, safety, and efficacy of same-day trial of void and catheter removal after Holmium Laser Enucleation of the Prostate (HoLEP). Although there have been many reports of the safety and efficacy of same-day discharge from the hospital for selected patients undergoing HoLEP, in most of these reports, patients return to the hospital, usually on postoperative day one, to undergo a trial of void and catheter removal. METHODS PubMed®, Scopus®, and Cochrane® primary databases were systematically screened, from inception to 17 January 2023. The search strategy used the PICO (Patient, Intervention, Comparison, Outcomes) Framework. We followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS Six studies met all the predefined criteria and were included in the final qualitative synthesis. Four studies were retrospective and two were prospective. Four studies were non-comparative, while two were comparative ones. The same-day catheter removal success rate ranged from 85.5 to 90% among studies, while only one grade-IIIb Clavien-Dindo complication was reported, which was unrelated to surgery. CONCLUSION Same-day catheter removal is a feasible, safe, and efficient approach for selected patients undergoing HoLEP. Certain factors, such as intraoperative furosemide administration, were found to improve same-day catheter-free rates, while preoperative PVR and urinary retention were independent predictive factors of same-day trial of void failure.
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Affiliation(s)
- Theodoros Spinos
- Department of Urology, University of Patras Hospital, 26504, Patras, Greece
| | - Vasileios Tatanis
- Department of Urology, University of Patras Hospital, 26504, Patras, Greece
| | - Evangelos Liatsikos
- Department of Urology, University of Patras Hospital, 26504, Patras, Greece
- Department of Urology, Medical University of Vienna, 1090, Vienna, Austria
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Porto JG, Blachman-Braun R, Delgado C, Zarli M, Chen R, Ajami T, Marcovich R, Shah HN. Is Holmium Laser Enucleation of the Prostate Truly Size-Independent? A Critical Evaluation at the Extreme Ends of the Spectrum. Urology 2023; 182:204-210. [PMID: 37716456 DOI: 10.1016/j.urology.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVE To assess the outcomes of holmium laser enucleation of the prostate (HoLEP) at the extremes of the size spectrum, comparing whether the results are consistent for very large and small prostates. METHODS A retrospective review of 402 patient charts was conducted to compare the outcomes of HoLEP in patients with prostate size ≤40 g (group 1), 41-200 g (group 2), and >200 g (group 3). Various preoperative, perioperative, and postoperative variables were collected. RESULTS HoLEP showed comparable voiding outcomes among all 3 groups, although patients with small prostates had a higher International Prostate Symptom Score during follow-up (P = .022). We noted a higher rate of perioperative blood transfusion in patients with very large prostates (P = .019) and a higher rate of transient acute urinary retention (AUR) in group 1 when compared to group 3 (P = .048). Patients with smaller prostates had a higher rate of bladder neck stenosis and urethral strictures, but the differences were not found to be statistically significant. The incidence of other complications, length of hospital stay, and catheterization duration did not differ significantly among the groups. CONCLUSION HoLEP has consistent and safe outcomes across a wide range of prostate sizes. Although, the risk of blood transfusion is higher in patients with very large prostates and the risk of transient AUR is greater in patients with small glands, the overall efficacy and safety of HoLEP are not significantly influenced by prostate size.
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Affiliation(s)
- Joao G Porto
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Ruben Blachman-Braun
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Carlos Delgado
- School of Medicine and Health Sciences, Tecnologico de Monterrey, Monterrey, Mexico
| | - Mohamadhusni Zarli
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL
| | - Ryan Chen
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Tarek Ajami
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Robert Marcovich
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Hemendra N Shah
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL.
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Yilmaz M, Karaaslan M, Polat ME, Tonyali S, Aybal HÇ, Şirin ME, Toprak T, Tunç L, Gratzke C, Miernik A. Is day-case surgery feasible for laser endoscopic enucleation of the prostate? A systematic review. World J Urol 2023; 41:2949-2958. [PMID: 37689604 PMCID: PMC10632304 DOI: 10.1007/s00345-023-04594-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 08/23/2023] [Indexed: 09/11/2023] Open
Abstract
PURPOSE Laser endoscopic enucleation of the prostate (EEP) for benign prostatic obstruction has become increasingly prevalent worldwide. Considering the medical cost-savings and concomitantly fewer nosocomial infections, the feasibility of same-day postoperative discharge of patients who have undergone laser EEP in terms of its safety and effectiveness has become a subject matter of growing interest. We aimed to review those studies focussing on day-case surgery (DCS) in patients undergoing laser EEP. METHODS A systematic search was conducted using PubMed-MEDLINE and Web of Science databases until October 2022 with the following search terms: "same day discharge AND laser enucleation of the prostate", "day-case AND laser enucleation of the prostate", "same day surgery AND laser enucleation of the prostate" and "one day surgery AND laser enucleation of the prostate" by combining PICO (population, intervention, comparison, outcome) terms. We identified 15 eligible studies. RESULTS While 14 of the studies focussed on holmium laser EEP, one focused on thulium laser vapoenucleation of the prostate. We observed an improvement in functional parameters in all studies we reviewed, and DCS success and readmission rates ranged between 35.3-100% and 0-17.8%, respectively. The complication rates varied between 0 and 36.7%, most of the complicatons were Clavien-Dindo (CD) I and II. CD ≥ III complications did not significantly differ between same day discharge (SDD) and non-SDD groups in the studies. CONCLUSION Laser EEP is feasible and promising DCS treatment option delivering improved functional parameters compared to baseline values, and lower perioperative complication and readmission rates in certain patients.
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Affiliation(s)
- Mehmet Yilmaz
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
| | | | - Muhammed Emin Polat
- Department of Urology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Senol Tonyali
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Urology, Istanbul University Istanbul School of Medicine, Istanbul, Turkey
| | | | - Mehmet Emin Şirin
- Department of Urology, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Tuncay Toprak
- Department of Urology, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Lütfi Tunç
- Faculty of Medicine, Department of Urology, Gazi University, Ankara, Turkey
| | - Christian Gratzke
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Arkadiusz Miernik
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany.
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Palacios DA, Kaouk J, Abou Zeinab M, Ferguson EL, Abramczyk E, Wright HC, Pramod N, De S. Holmium Laser Enucleation of the Prostate vs Transvesical Single-port Robotic Simple Prostatectomy for Large Prostatic Glands. Urology 2023; 181:98-104. [PMID: 37517682 DOI: 10.1016/j.urology.2023.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/11/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To compare the perioperative outcomes of transvesical single-port robotic simple prostatectomy (SP-RASP) and holmium laser enucleation of the prostate (HoLEP). MATERIALS AND METHODS A retrospective review was performed of patients undergoing SP-RASP and HoLEP from 2019 to 2022 with preoperative prostatic volume (PPV) >80 cm3. Percent of prostate adenoma removed (%PAR) was estimated by specimen weight normalized by PPV. Univariate analysis was performed using chi-square, Fisher exact, and Wilcoxon rank-sum tests. A subgroup analysis with 1:1 matching for PPV was also performed. RESULTS A total of 50 SP-RASP and 90 HoLEP cases were analyzed. The median (interquartile range) PPV was 169 (128-244)cm3 for SP-RASP and 129 (100-150)cm3 for HoLEP, (P < .01). The median (interquartile range) %PAR was 57(44-68) for SP-RASP vs 51(42-62) for HoLEP (P = .10). Overall, 11(12%) HoLEP and 5(10%) SP-RASP patients experienced complications (P = .51). Same-day discharge occurred in 24(48%) SP-RASP vs 7(8%) HoLEP patients (P < .01). Median foley catheter duration was longer in SP-RASP (6 vs 1 day, P < .01) and trial of void was successful at first attempt in >94% (P = .68). Transient de novo incontinence was reported in 24(28%) HoLEP vs 2(5%) SP-RASP (P < .01). No differences in voiding parameters were observed at latest follow up. Subgroup postmatched analysis revealed analogous findings. CONCLUSION SP-RASP and HoLEP have similar favorable perioperative outcomes for management of large prostatic adenomas. SP-RASP may be considered in patients unwilling to accept the risk of transient incontinence and in those with unfavorable urethral access, large bladder stone burden, or diverticula.
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Affiliation(s)
| | - Jihad Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH.
| | - Mahmoud Abou Zeinab
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Ethan L Ferguson
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Emily Abramczyk
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Henry C Wright
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH; Northwestern Medicine, Algonquin, IL
| | - Nikhil Pramod
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Smita De
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH
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Diana P, Baboudjian M, Saita A, Uleri A, Gallioli A, Casale P, Buffi N, Pradere B, Misrai V, Gondran-Tellier B, Boissier R, Schwartzmann I, Breda A, Del Dago PJ. Same-day discharge for endoscopic enucleation of the prostate: a systematic review and meta-analysis. World J Urol 2023; 41:2099-2106. [PMID: 37395755 DOI: 10.1007/s00345-023-04471-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
PURPOSE To systematically review studies focused on the feasibility and outcomes of outpatient endoscopic enucleation of the prostate for benign prostatic obstruction. METHODS A literature search was conducted through December 2022 using PubMed/Medline, Web of Science, and Embase databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. Risk of bias assessment was performed according to the Newcastle-Ottawa Scale for case control studies. RESULTS Of 773 studies, ten were included in the systematic review (n = 1942 patients) and four in the meta-analysis (n = 1228 patients). The pooled incidence of successful same-day discharge was 84% (95% CI 0.72-0.91). Unplanned readmission was recorded in 3% (95% CI 0.02-0.06) of ambulatory cases. In the reported criteria-selected patients submitted to SDD surgery, the forest plot suggested a lower rate of postoperative readmission (OR 0.56, 95% CI 0.34-0.91, p = 0.02) and complications (OR 0.69, 95% CI 0.48-1, p < 0.05) rates compared to standard protocols. CONCLUSION We provide the first systematic review and meta-analysis on SDD for endoscopic prostate enucleation. Despite the lack of randomized controlled trials, we confirm the feasibility and safety of the protocol with no increase in complications or readmission rate in well-selected patients.
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Affiliation(s)
- Pietro Diana
- Department of Urology, Fundació Puigvert, Autonoma University of Barcelona, Cartagena 340-350, 08025, Barcelona, Spain.
- Department of Urology, Humanitas Clinical and Research Institute IRCCS, Rozzano, Italy.
- Department of Urology, Hospitales Universitarios San Roque, Las Palmas de Gran Canaria, Spain.
- GUA Gabinete de Urología y Andrología, Las Palmas de Gran Canaria, Spain.
| | - Michael Baboudjian
- Department of Urology, North Hospital, Aix-Marseille University, APHM, Marseille, France
- Department of Urology and Renal Transplantation, La Conception University Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Alberto Saita
- Department of Urology, Humanitas Clinical and Research Institute IRCCS, Rozzano, Italy
| | - Alessandro Uleri
- Department of Urology, Fundació Puigvert, Autonoma University of Barcelona, Cartagena 340-350, 08025, Barcelona, Spain
- Department of Urology, Humanitas Clinical and Research Institute IRCCS, Rozzano, Italy
| | - Andrea Gallioli
- Department of Urology, Fundació Puigvert, Autonoma University of Barcelona, Cartagena 340-350, 08025, Barcelona, Spain
| | - Paolo Casale
- Department of Urology, Humanitas Clinical and Research Institute IRCCS, Rozzano, Italy
| | - Nicolomaria Buffi
- Department of Urology, Humanitas Clinical and Research Institute IRCCS, Rozzano, Italy
| | - Benjamin Pradere
- Department of Urology, La Croix du Sud Hospital, 31130, Quint Fonsegrives, France
| | - Vincent Misrai
- Department of Urology, Clinique Pasteur, Toulouse, France
| | - Bastien Gondran-Tellier
- Department of Urology and Renal Transplantation, La Conception University Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Romain Boissier
- Department of Urology and Renal Transplantation, La Conception University Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Ivan Schwartzmann
- Department of Urology, Fundació Puigvert, Autonoma University of Barcelona, Cartagena 340-350, 08025, Barcelona, Spain
| | - Alberto Breda
- Department of Urology, Fundació Puigvert, Autonoma University of Barcelona, Cartagena 340-350, 08025, Barcelona, Spain
| | - Pablo Juarez Del Dago
- Department of Urology, Hospitales Universitarios San Roque, Las Palmas de Gran Canaria, Spain
- GUA Gabinete de Urología y Andrología, Las Palmas de Gran Canaria, Spain
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Huang MM, Dean NS, Assmus MA, Lee MS, Guo JN, Krambeck AE. Intradetrusor OnabotulinumtoxinA Injections at the Time of Holmium Laser Enucleation of the Prostate for Men with Severe Storage Symptoms. J Endourol 2023; 37:801-806. [PMID: 37053094 DOI: 10.1089/end.2023.0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
Introduction: Intradetrusor onabotulinumtoxinA (OTA) injection is a well-established treatment option for refractory overactive bladder; however, its use at the time of holmium laser enucleation of the prostate (HoLEP) for men with bladder outlet obstruction (BOO) and severe storage symptoms has not been previously reported. Materials and Methods: We retrospectively identified men with BOO and severe storage symptoms who underwent treatment with 200 U of intradetrusor OTA (Botox®) at the time of HoLEP. Patients were propensity score matched to a cohort of HoLEP-only patients based on age, Michigan Incontinence Symptom Index (M-ISI) score, preoperative urinary retention, urge incontinence, and prostate size. Perioperative, postoperative, and patient-reported outcomes were examined between groups. Results: We identified 82 men who underwent HoLEP, including 41 patients in the OTA group and 41 patients in the control group. There was no difference in operative times (59 minutes OTA vs 55 minutes control, p = 0.2), rates of same-day trial of void (TOV) (92% OTA vs 94% control, p = 0.7), or rates of same-day discharge (88% OTA vs 85% control, p = 0.6) between groups. There was no difference in temporary postoperative urinary retention (7% OTA vs 2% control, p = 0.3) between groups. Patients who received OTA injections had a significant reduction in their incontinence scores at 3-month follow-up (M-ISI -8, interquartile range [IQR]: -13 to 0, p < 0.001), whereas control patients did not (M-ISI -5, IQR: -8 to -1, p = 0.2). There was no difference in rates of 90-day complications between groups (OTA 10% vs control 5%, p = 0.7). Conclusions: Intradetrusor OTA at the time of HoLEP is safe and is associated with improved urinary incontinence scores and AUA Symptom Score. Rates of same-day discharge and same-day TOV after HoLEP were not affected by OTA. These findings support the role of OTA as an adjunct to surgical intervention in men with incontinence in the presence of BOO.
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Affiliation(s)
- Mitchell M Huang
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nicholas S Dean
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mark A Assmus
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Urology, University of Calgary, Calgary, Canada
| | - Matthew S Lee
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Urology, Ohio State University, Columbus, Ohio, USA
| | - Jenny N Guo
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Amy E Krambeck
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Badreddine J, Sun H, Tay K, Rhodes S, Chen D, Zell M, Jaeger I, Nevo A. The outcomes of same-day discharge following holmium laser enucleation of the prostate (HoLEP) surgeries: our experience during the COVID-19 pandemic. World J Urol 2023:10.1007/s00345-023-04410-2. [PMID: 37160451 PMCID: PMC10169120 DOI: 10.1007/s00345-023-04410-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/11/2023] [Indexed: 05/11/2023] Open
Abstract
OBJECTIVE To describe the outcomes of Same-Day Discharge (SDD) following Holmium Laser Enucleation of the Prostate (HoLEP) in patients during the COVID-19 pandemic. METHODS A retrospective review of HoLEP surgeries at a single institution between January 2021 and March 2022 was performed. Patient demographic and operative data were collected, and postoperative outcomes were evaluated in terms of safety and efficacy and compared in both groups using a t-test and chi-square test. Logistic regression was also performed to identify factors that correlate with the failure of SDD. RESULTS A total of 155 patients were identified; 135 patients were successfully discharged on the same day and 20 were admitted (87% SDD rate). Admitted HoLEP patients had a significantly higher median prostate-specific antigen (5.7 vs 3.9 ng/dL, P < 0.001), prostate volume (152.3 vs 100.6 mL, P < 0.001), and enucleated tissue weight (90.3 vs 56.9 g, P = 0.04) compared to the SDD group. The SDD group had a 2.9% (n = 4) readmission rate and a 5.2% (n = 7) Emergency Department (ED) visit rate. There was no significant difference in the rate of postoperative ED visits (P = 0.64), readmissions (P = 0.98), complications, and catheterization time (P = 0.98) between both groups. Preoperative predictors of SDD failure included prostate gland volume > 150 mL (OR = 7.17; CI 2.01-25.67; P < 0.01) and history of antiplatelet/anticoagulation use (OR = 6.59; CI 2.00-21.67; P < 0.01). CONCLUSION Same-day discharge following HoLEP is a safe and effective approach that can be performed in most patients using a liberal discharge criteria and relying on postoperative findings only.
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Affiliation(s)
- Jad Badreddine
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Helen Sun
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Kimberly Tay
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Stephen Rhodes
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Daniel Chen
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Michael Zell
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Irina Jaeger
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Amihay Nevo
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
- Department of Urology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Assmus MA, Krambeck AE. Moses Laser Enucleation of the Prostate (MoLEP): Use of Pulse Modulated Holmium Laser Technology for Prostate Enucleation. Curr Bladder Dysfunct Rep 2023. [DOI: 10.1007/s11884-023-00698-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
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Wood A, Jivanji D, Kaplan-Marans E, Katlowitz E, Lubin M, Teper E, Silver D, Schulman A. Same-Day Discharge After Robot-Assisted Partial Nephrectomy: Is It Worth It? J Endourol 2023; 37:297-303. [PMID: 36463427 DOI: 10.1089/end.2022.0510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Introduction and Objective: Robot-assisted partial nephrectomy (RAPN) has traditionally been performed as an inpatient procedure; however, recent studies have suggested the feasibility of same-day discharge (SDD) after RAPN. We aimed to evaluate the safety and cost-effectiveness of SDD for RAPN. Methods: A retrospective analysis was conducted on patients undergoing RAPN between January 2015 and July 2021. Comparison before and after the implementation of an SDD protocol was assessed through differences in postanesthesia care unit (PACU) time, length of stay, 30-day readmission rate, 30-day return to emergency department (ED) rates, unplanned office visits (OVs), and need for secondary procedures. A cost-efficacy model was generated to estimate the difference in expenditure between SDD and inpatient RAPN. Results: In total, 192 patients underwent RAPN with 74 being SDD and 118 being admitted postoperatively. After SDD protocol implementation, the percentage of patients discharged from the PACU increased from 0% to 76%. The safety profile of SDD was similar to the inpatient group, with no differences in readmission rates (1.4% vs 5.1%, p = 0.18) or return to ED (5.4% vs 9.3%, p = 0.33). Compared with inpatient RAPN, SDD was associated with increased time in PACU (375 vs 251 minutes, p < 0.001), resulting in an additional expenditure of $1,622 per patient. SDD patients were more likely to return for one or more unplanned OVs (17.6% vs 6.8%, p = 0.02). Overall, the total cost of SDD was significantly lower than inpatient RAPN ($5,222 per patient vs $8,425, p < 0.001). Conclusion: Despite a shorter postoperative monitoring period, SDD appears safe, with equivalent readmission rates, return to ED, and secondary procedures. SDD for RAPN saves ∼$3,000 per patient. In implementing an SDD protocol, clinicians should be cognizant of increased demands on PACU infrastructure and be willing to provide additional support in the office setting.
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Affiliation(s)
- Andrew Wood
- Department of Surgery, Division of Urology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Dhaval Jivanji
- Department of Surgery, Division of Urology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Elie Kaplan-Marans
- Department of Surgery, Division of Urology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Eitan Katlowitz
- Department of Surgery, Division of Urology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Marc Lubin
- Department of Surgery, Division of Urology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Ervin Teper
- Department of Surgery, Division of Urology, Maimonides Medical Center, Brooklyn, New York, USA
| | - David Silver
- Department of Surgery, Division of Urology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Ariel Schulman
- Department of Surgery, Division of Urology, Maimonides Medical Center, Brooklyn, New York, USA
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Riveros C, Di Valerio E, Bacchus M, Chalfant V, Leelani N, Thomas D, Jazayeri SB, Costa J. Predictors of readmission and impact of same-day discharge in holmium laser enucleation of the prostate. Prostate Int 2023; 11:20-26. [PMID: 36910904 PMCID: PMC9995658 DOI: 10.1016/j.prnil.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/22/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022] Open
Abstract
Background Holmium enucleation of the prostate (HoLEP) is becoming the gold standard for the treatment of benign prostatic hyperplasia (BPH). Our objective was to identify predictors of 30-day readmission and the impact of same-day discharge after HoLEP. Methods Using NSQIP data from 2011 to 2019, we identified men who underwent HoLEP for the treatment of BPH. We compared patients based on time of discharge and readmission status. We used multivariable logistic regression analysis (MLRA) to identify independent factors associated with 30-day readmission. Results A total of 3,489 patients met inclusion criteria with 833 (23.88%) being discharged within 24 hours and 2,656 (76.12%) discharged after 24 hours. There were 158 (4.53%) 30-day readmissions, mostly due to hematuria and urinary tract infection. Patients being readmitted were older (72 vs. 70 years old, P = 0.001), were more likely to have preoperative anemia (36.7% vs. 23.1%; P < 0.001), chronic kidney disease (29.7% vs. 19.7%; P < 0.001), bleeding disorder (10.8% vs. 2.8%; P < 0.001), higher American Society of Anesthesiologists (ASA) scores (≥3: 70.3% vs. 46.7%; P < 0.001) and a higher frailty burden (5-item modified frailty index [5i-mFI] ≥ 2: 36.1% vs. 19.1%; P < 0.001) compared to their counterparts. Factors independently associated with 30-day readmission were bleeding disorder (OR 2.89; 95% CI 1.63-5.11; P < 0.001), 5i-mFI ≥ 2 (OR 1.67; 95% CI 1.03-2.71; P = 0.038) and an ASA score ≥3 (OR 1.80; 95% CI 1.21-2.70; P = 0.004); however, same-day discharge was not found to be a significant predictor of 30-day readmissions. Conclusion The overall readmission rate after HoLEP is low. Patients discharged within 24 hours have similar rates of readmission compared to patients discharged after 24 hours. We found bleeding disorder, frailty burden, and ASA score to be independent predictors of 30-day readmission.
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Affiliation(s)
- Carlos Riveros
- Department of Urology, University of Florida, Jacksonville, FL, USA
| | | | - Michael Bacchus
- Department of Urology, University of Florida, Gainesville FL, USA
| | - Victor Chalfant
- Department of Urology, University of Florida, Jacksonville, FL, USA
| | - Navid Leelani
- Department of Urology, University of Florida, Jacksonville, FL, USA
| | - Devon Thomas
- Department of Urology, University of Florida, Jacksonville, FL, USA
| | | | - Joseph Costa
- Department of Urology, University of Florida, Jacksonville, FL, USA
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12
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Shelton TM, Drake C, Vasquez R, Rivera M. Comparison of Contemporary Surgical Outcomes Between Holmium Laser Enucleation of the Prostate and Robotic-Assisted Simple Prostatectomy. Curr Urol Rep 2023; 24:221-229. [PMID: 36800115 PMCID: PMC9936114 DOI: 10.1007/s11934-023-01146-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE OF REVIEW This study reviews contemporary literature on RASP and HoLEP to evaluate perioperative outcomes, common complications, cost analytics, and future directions of both procedures. RECENT FINDINGS RASP is indicated for prostates > 80 mL, while HoLEP is size-independent. No notable differences were found in operative time, PSA nadir (surrogate for enucleation volume), re-catheterization rates, or long-term durability. Prolonged incontinence and bladder neck contracture rates are low for both surgeries. Patients experience similar satisfaction outcomes and improvements in uroflowmetry and post-void residual volumes. HoLEP demonstrates shorter hospitalizations, lower transfusion rates, lower costs, and higher rates of same-day discharge. RASP offers a shorter learning curve and lower rates of early postoperative urinary incontinence. HoLEP is a size-independent surgery that offers advantages for patients seeking a minimally invasive procedure with the potential for catheter-free same-day discharge. Future directions with single-port simple prostatectomy may offer parity in same-day discharge, but further research is needed to determine broader feasibility.
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Affiliation(s)
- T Max Shelton
- Department of Urology, Indiana University School of Medicine, 1801 North Senate Blvd., Indianapolis, IN, 46202, USA
| | - Connor Drake
- Department of Urology, Indiana University School of Medicine, 1801 North Senate Blvd., Indianapolis, IN, 46202, USA
- Indiana University School of Medicine, Indianapolis, USA
| | - Ruben Vasquez
- Department of Urology, Indiana University School of Medicine, 1801 North Senate Blvd., Indianapolis, IN, 46202, USA
| | - Marcelino Rivera
- Department of Urology, Indiana University School of Medicine, 1801 North Senate Blvd., Indianapolis, IN, 46202, USA.
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Socarrás MR, Del Álamo JF, Espósito F, Elbers JR, Monsalve DC, Rivas JG, Greco I, González LLL, Rivera VC, Sancha FG. En Bloc enucleation with early apical release technique using MOSES (En Bloc MoLEP) vs. classic En Bloc HoLEP: a single arm study comparing intra- and postoperative outcomes. World J Urol 2023; 41:159-165. [PMID: 36335245 DOI: 10.1007/s00345-022-04205-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/28/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND AND PURPOSE We aimed to describe the technique and outcomes of En-Bloc MOSES laser enucleation of the prostate (En-Bloc MoLEP) with early apical release comparing it to En-Bloc HoLEP (non-MOSES). PATIENTS AND METHODS This is a single-arm prospective study, using a historical control. n = 80 patients were enrolled to the En Bloc MoLEP group and compared to a retrospective group of n = 137 patients treated by En Bloc HoLEP (non-MOSES), in total n = 217 patients. RESULTS En-Bloc MoLEP, showed to significantly improve the surgical time by 32% compared to non-MOSES HoLEP (32.16 ± 14.46 min, 47.58 ± 21.32, respectively; P = 0.003). Enucleation time, ablation rate and hemostasis time were also significantly improved (P < 0.001, for all three parameters). Enucleation time was 22.10 ± 9.27 min and 31.46 ± 14.85 min (P < 0.001), ablation rate 4.11 ± 2.41 and 2.54 ± 1.31 gr/min (P < 0.001), Hemostasis time 3.01 ± 2.50 and 8.35 ± 5.38 min (P < 0.001), for En Bloc MoLEP and En Bloc HoLEP, respectively. Q-max, PVR, PSA and IPSS showed significant improvement, however, at 12 months no significant differences were observed comparing both groups. CONCLUSIONS En-Bloc MoLEP was significantly better than En-Bloc HoLEP in terms of surgical time, enucleation time, ablation rate and hemostasis time. However, large comparative RCT with long-term follow-up are needed.
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Affiliation(s)
| | | | - Fabio Espósito
- Instituto de Cirugía Urológica Avanzada (ICUA), Clínica Cemtro, Madrid, Spain
| | | | | | - Juan Gómez Rivas
- Instituto de Cirugía Urológica Avanzada (ICUA), Clínica Cemtro, Madrid, Spain
| | - Isabella Greco
- Instituto de Cirugía Urológica Avanzada (ICUA), Clínica Cemtro, Madrid, Spain
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Cooley LF, Assmus M, Ganesh M, Lee M, Helon J, Krambeck AE. Predictors of Failed Same-Day Catheter Removal After Holmium Laser Enucleation of the Prostate. Urology 2022; 170:168-173. [PMID: 35963396 DOI: 10.1016/j.urology.2022.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/01/2022] [Accepted: 07/28/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To determine factors associated with failure of same-day trial of void (SDTOV) following holmium laser enucleation of the prostate (HoLEP). BACKGROUND HoLEP is increasingly utilized for patients with benign prostatic hyperplasia. Advancements in technology have improved operative efficiency and hemostasis making same-day, catheter-free discharge possible. METHODS We conducted a retrospective review on 190 patients undergoing HoLEP from July, 2021 to January, 2022 by a single center. We assessed pre- and intra-operative variables associated with our primary outcome: failure of same-day catheter removal. Post-operative complications and outcomes at a ≤7 days and 3-month follow up were examined. Continuous and categorical variables were analyzed using unpaired t-tests (Mann Whitney) and chi-square, respectively. Univariate and multivariable logistic regression models were fitted to examine the associations of failed SDTOV. RESULTS Of 190 candidates for a SDTOV, 90% (171/190) were successful. We found no difference between SDTOV success and failures with regards to age, comorbidities, presence of pre-operative urinary retention, anesthesia factors, operative time, volume resected, enucleation time, and morcellation time (all P>0.05). Pre-operatively, 26.3% (50/190) were on antiplatelet and 6.3% (12/190) were on anticoagulation. While pre-operative antiplatelet therapy was not associated with SDTOV failure (P=0.78), pre-operative anticoagulation use was (4.7% vs. 21.1%, P=0.021). Patients who continued anticoagulation through surgery had the highest rate of SDTOV failure (2.3% (4/171) vs. 15.8% (3/19), P=0.023). For those with successful SDTOV, 4.1% (7/171) required catheterization following discharge. At 3 months, no patient required catheterization. CONCLUSION On the day of surgery, patients eligible for SDTOV successfully voided 90% of the time. History of preop anticoagulation, whether continued or held, increased SDTOV failure.
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Affiliation(s)
- Lauren Folgosa Cooley
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mark Assmus
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Meera Ganesh
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Matthew Lee
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jessica Helon
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Amy E Krambeck
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL.
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15
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Savin Z, Dekalo S, Herzberg H, Ben-David R, Bar-Yosef Y, Beri A, Yossepowitch O, Sofer M. Improving Prostatic Preoperative Volume Estimation and Planning before Laser Enucleation. J Pers Med 2022; 12:jpm12111761. [PMID: 36573723 PMCID: PMC9696623 DOI: 10.3390/jpm12111761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 12/30/2022] Open
Abstract
We aimed to validate a formula for improving the estimation of prostatic volume by abdominal ultrasound (AUS) prior to transurethral laser enucleation. A total of 293 patients treated for benign prostate hyperplasia (BPH) by laser enucleation from 2019−2022 were included. The preoperative AUS volume was adjusted by the formula 1.082 × Age + 0.523 × AUS − 53.845, which was based on specimens retrieved by suprapubic prostatectomy. The results were compared to the weight of the tissue removed by laser enucleation as determined by the intraclass correlation coefficient test (ICC). The potential impact of preoperative planning on operating time was calculated. The ICC between the adjusted volumes and the enucleated tissue weights was 0.86 (p < 0.001). The adjusted volume was more accurate than the AUS volume (weight-to-volume ratio of 0.84 vs. 0.7, p < 0.001) and even more precise for prostates weighing >80 g. The median operating time was 90 min. The adjusted volume estimation resulted in an overall shorter expected preoperative operating time by a median of 21 min (24%) and by a median of 40 min in prostates weighing >80 g. The adjustment formula accurately predicts prostate volume before laser enucleation procedures and may significantly improve preoperative planning, the matching of a surgeon’s level of expertise, and the management of patients’ expectations.
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Affiliation(s)
- Ziv Savin
- The Department of Urology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 6423906, Israel
- Correspondence: ; Tel.: +972-528-361-123
| | - Snir Dekalo
- The Department of Urology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 6423906, Israel
| | - Haim Herzberg
- The Department of Urology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 6423906, Israel
| | - Reuben Ben-David
- The Department of Urology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 6423906, Israel
| | - Yuval Bar-Yosef
- The Department of Urology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 6423906, Israel
| | - Avi Beri
- The Department of Urology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 6423906, Israel
| | - Ofer Yossepowitch
- The Department of Urology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 6423906, Israel
| | - Mario Sofer
- The Department of Urology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 6423906, Israel
- The Endourology Unit, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
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Yilmaz M, Karaaslan M, Aybal HC, Ferry von Bargen M, Tonyali S, Toprak T, Gratzke C, Miernik A. Laser enucleation of the prostate in men with very large glands ≥175 ml: A systematic review. Ann Med Surg (Lond) 2022; 80:104279. [PMID: 36045851 PMCID: PMC9422289 DOI: 10.1016/j.amsu.2022.104279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022] Open
Abstract
Background Surgical treatment options for lower urinary tract symptoms can differ according to prostate size. There are few studies on the efficacy and safety of endoscopic enucleation of prostate (EEP) in patients with very large prostates focusing on laser as energy source. In this systematic review, we aimed to examine the efficacy and safety of laser-based EEP on prostate glands ≥150 ml. Methods A systematic search was conducted using Web of Science, PubMed-MEDLINE, Wiley Online Library and Cochrane Library databases with the following search terms solely or in combination: "large prostate", "laser enucleation", "laser prostatectomy"by combining PICO (population, intervention, comparison, and outcome) terms. Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed. Results We retrieved 6 studies included 375 patients with prostate sizes ≥175 ml treated with laser-based EEP for symptomatic benign prostatic obstruction. Three studies examined Holmium laser enucleation of prostate (HoLEP) outcomes with a prostate volume (PV) >200 ml, one evaluated HoLEP outcomes with a PV of 200–299 and ≥ 300 ml, two studies evaluated HoLEP outcomes with a PV > 175 ml. We observed improvement in postoperative functional outcomes in patients with a PV > 175, >200 and >300 ml. The retreatment rate was 0–1.3% in all studies involving prostate size ≥175 ml. Most of the complications were Clavien-Dindo I (%0–9) and II (%12.7–16.6). Conclusions Laser-based EEP is an efficient, safe and feasible procedure even in very large prostates with good functional outcomes, low perioperative complication and retreatment rates. We observed better postoperative functional outcomes in prostates with a volume of ≥175, >200 and >300 ml in the present study. The retreatment rate was 0–1.3% in all studies involving prostate size ≥175 ml. Laser-based- endoscopic enucleation of the prostate is an efficient, safe and feasible procedure even in very large glands.
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Assmus MA, Lee MS, Krambeck AE. EDITORIAL COMMENT. Urology 2022; 164:202-203. [PMID: 35710170 DOI: 10.1016/j.urology.2021.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 12/06/2021] [Indexed: 10/18/2022]
Affiliation(s)
- Mark A Assmus
- Department of Urology, Northwestern University, Chicago, IL
| | - Matthew S Lee
- Department of Urology, Northwestern University, Chicago, IL
| | - Amy E Krambeck
- Department of Urology, Northwestern University, Chicago, IL
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18
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Assmus MA, Lee MS, Krambeck AE. Moses laser enucleation of the prostate (MoLEP). Urology Video Journal 2022. [DOI: 10.1016/j.urolvj.2021.100123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Assmus MA, Lee MS, Sivaguru M, Agarwal DK, Large T, Fouke BW, Krambeck AE. Laser fiber degradation following holmium laser enucleation of the prostate utilizing Moses technology versus regular mode. World J Urol 2022; 40:1203-1209. [PMID: 35166893 DOI: 10.1007/s00345-022-03951-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/27/2022] [Indexed: 01/08/2023] Open
Abstract
PURPOSE We sought to objectively compare laser fiber degradation for holmium laser enucleation of the prostate (HoLEP) cases performed with 550 μm standard fibers versus 550 μm Moses 2.0 fiber in BPH mode on a macroscopic and microscopic level. METHODS We prospectively collected outcomes for 50 standardized HoLEP cases using 550 μm Moses fiber with 2.0 BPH mode compared to our historical cohort of 50 patients using 550 μm standard fibers on regular mode. Macroscopic degradation length was the difference in length of exposed fiber at the start and end of each case. Five consecutive 550 μm standard fibers, five 550 μm Moses fibers and their respective controls underwent novel utilization of three objective corroborating imaging techniques: Brightfield high resolution microscopy, high resolution 3-D microCT and Confocal Reflection Surface Analysis. Mann-Whitney U, 2-tailed T tests and Chi-squared tests were used. RESULTS Standard fibers demonstrated greater degradation than the Moses fibers with 2.0 BPH mode [2.9 cm (IQR 1.7-4.3 cm) vs 0.2 cm (IQR 0.1-0.4 cm), p < 0.01]. This difference remained significant when comparing degradation per energy used, per minute enucleation and per gram enucleated (all p < 0.05). None of the cases with Moses fiber and 2.0 BPH mode required intraoperative interruption to re-strip the fiber. Objective fiber degradation by three microscopic techniques confirmed more damage to the standard fibers with regular mode. CONCLUSION Overall, use of the 550 μm Moses fiber with 2.0 BPH mode resulted in less fiber degradation compared to a standard 550 μm fiber with regular mode as confirmed using 4 corroborating macroscopic and microscopic techniques.
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Affiliation(s)
- Mark A Assmus
- Department of Urology, Northwestern University, Chicago, USA.
| | - Matthew S Lee
- Department of Urology, Northwestern University, Chicago, USA
| | - Mayandi Sivaguru
- Carver Biotechnology Center, University of Illinois at Urbana-Champaign, Urbana-Champaign, Champaign, USA.,Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana-Champaign, Champaign, USA
| | - Deepak K Agarwal
- Department of Urology, Indiana University, Indianapolis, IN, USA
| | - Tim Large
- Department of Urology, Indiana University, Indianapolis, IN, USA
| | - Bruce W Fouke
- Carver Biotechnology Center, University of Illinois at Urbana-Champaign, Urbana-Champaign, Champaign, USA.,Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana-Champaign, Champaign, USA
| | - Amy E Krambeck
- Department of Urology, Northwestern University, Chicago, USA
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Garden EB, Ravivarapu KT, Levy M, Chin CP, Omidele O, Tomer N, Al-Alao O, Araya JS, Small AC, Palese MA. The utilization and safety of same-day discharge after transurethral benign prostatic hyperplasia surgery: a case-control, matched analysis of a national cohort. Urology 2022; 165:59-66. [DOI: 10.1016/j.urology.2022.01.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/20/2022] [Accepted: 01/26/2022] [Indexed: 12/21/2022]
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21
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Guo J, Lee MS, Assmus M, Krambeck AE. Barriers to Implementation of a Same-Day Discharge Pathway for Holmium Laser Enucleation of the Prostate. Urology 2021:S0090-4295(21)01184-5. [PMID: 34973241 DOI: 10.1016/j.urology.2021.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate perceived barriers to successful same-day discharge (SDD) after holmium laser enucleation of the prostate (HoLEP) from the perspective of surgical and nursing staff members. METHODS A 17-question survey was administered to intraoperative and postoperative surgical staff in June 2021 after a six-month period of implementing a SDD HoLEP pathway with same-day catheter removal. McNemar's and Stuart-Maxwell tests were performed for statistical analysis. RESULTS Surveys were completed by 30 respondents. The majority of respondents had less than 5 years of surgical experience (63%). Almost all respondents (96%) felt that HoLEP patients could be discharged safely on day of surgery. Overall, 60% felt that HoLEP had a lower risk of post-operative bleeding compared to other transurethral surgeries. There was a significant decrease in number of respondents that felt apprehensive when comparing initiation of SDD HoLEP pathway to 6-months post-implementation (43% vs 7%, P = .003). The most common factors causing apprehension both pre- and post-implementation included: degree of hematuria (43% vs 40%, P = .56), risk of failure of trial of void (40% vs 30%, P = .26), and risk of readmission or unplanned emergency department (ED) visit (33% vs 30%, P = .48). There was a significant decrease in the number of respondents who were apprehensive about lack of experience with SDD after HoLEP comparing pre- and post-implementation (20% vs 0%, P = .01). CONCLUSION While staff report initial apprehension regarding implementation of a SDD HoLEP pathway, adequate support to intraoperative and postoperative teams helps build experience that alleviates these concerns.
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22
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Assmus MA, Ganesh MB, Lee MS, Large T, Krambeck AE. Contemporary Outcomes for Patients Undergoing Concurrent Surgeries at the Time of Holmium Laser Enucleation of the Prostate Before and After Moses 2.0 BPH Mode. J Endourol 2021; 35:S8-S13. [PMID: 34910607 DOI: 10.1089/end.2021.0531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Outcomes of holmium laser enucleation of the prostate (HoLEP) for benign prostatic hyperplasia has been well studied. As comfort with the procedure has improved, the number of concurrent surgeries performed with HoLEP has increased. Technology and technique optimization have safely transitioned HoLEP toward same-day catheter removal and discharge. We aim to assess the success and safety of transitioning toward a same-day care pathway for patients undergoing concurrent surgeries with HoLEP. Materials and Methods: With institutional review board approvals, we queried the electronic medical record and retrospective clinical registry to examine perioperative characteristics and outcomes of patients who underwent HoLEP performed by two endourologists at two centers between July 1, 2016, and June 1, 2021, in which ≥1 concurrent surgical procedure was performed. Results: There were 188 patients with an average age of 72.3 years, who underwent HoLEP with ≥1 concurrent surgical procedure within the study period. In total, 221 non-HoLEP procedures were performed with 30/188 (16.0%) undergoing ≥3 total procedures in a single operation. The four-most common concurrent procedures were cystolitholapaxy 86/221 (38.9%), ureteroscopy 57/221 (25.8%), transurethral resection of bladder tumor 14/221 (6.3%), and percutaneous nephrolithotomy 14/221 (6.3%). Postoperatively, 3 (1.6%) patients required transfusion. After transitioning to a same-day care path, the proportion of patients who had successful same-day catheter removal and same-day discharge increased (all p < 0.05). Median length of stay decreased (from 23 hours 11 minutes to 3 hours 49 minutes, p = 0.008). Our 90-day readmission rate for urology complication was 7.9%, and only 3.6% of patients undergoing concurrent stone surgery required an additional stone surgery within 90 days. The overall Clavien-Dindo ≥3b rate was 4.8% (9-3b, 0-4, 0-5). Conclusions: Advances in HoLEP technique and technology allow for safe same-day discharge for concurrent surgery performed at the time of HoLEP. Few patients were readmitted within 90 days and no patients experienced Clavien-Dindo ≥4 complications.
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Affiliation(s)
- Mark A Assmus
- Department of Urology, Northwestern University, Chicago, Illinois, USA
| | - Meera B Ganesh
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Matthew S Lee
- Department of Urology, Northwestern University, Chicago, Illinois, USA
| | - Tim Large
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Amy E Krambeck
- Department of Urology, Northwestern University, Chicago, Illinois, USA
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Lee MS, Assmus M, Cooley LF, Li E, Large T, Krambeck A. Ex Vivo Comparison of Efficiency, Safety, and Surgeon Satisfaction in Four Commercial Morcellators. J Endourol 2021; 36:514-521. [PMID: 34779660 DOI: 10.1089/end.2021.0573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Introduction: Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for the management of benign prostatic hypertrophy. Although advancements in laser technology have led to clinical improvements in the enucleation portion of HoLEP, the morcellation aspect of HoLEP is often the rate-limiting step. We sought to compare efficiency and surgeon satisfaction in four commercial morcellators. Methods: This was an ex vivo study comparing four commercial morcellators: the Wolf Piranha™, the Lumenis VersaCut™, the JenaSurgical MultiCut Solo™, and the Hawk™ Morcellator. Four surgeons with significant experience performing HoLEPs participated. Surgeons tested each device to morcellate two different prostate models (1) morcellating as much microwave-cooked chicken breast in 10 minutes and (2) timed morcellation of bull testicles. Surgeons completed subjective surveys after each morcellator trial. Objective outcomes included the following: morcellation efficiency (g/min morcellated) and aspiration power (time to aspirate 1 L of saline). Means of continuous variables were compared using analysis of variance. Categorical variables were compared using chi-square tests. Statistical analyses were performed using SAS 9.4 (2019). Results: Comparing subjective outcomes, the Piranha™ was chosen as the safest morcellator (p = 0.0058). The least safe morcellator was thought to be the MultiCut by 75% of surgeons (p = 0.046). The Piranha™ was chosen as the most effective morcellator by 75% of surgeons (p = 0.046). Comparing objective parameters between the morcellators, the Piranha™ had the fastest aspiration time (43.50 ± 10.34 seconds, p = 0.0116). There were no significant differences in morcellation efficiency when using chicken breast (p = 0.3096). However, when comparing the morcellation efficiency using bull testicles, the Piranha™ had the highest efficiency at 39.68 ± 3.57 g/min (p = 0.0268). Conclusion: In this ex vivo study comparing four different commercially available morcellators, the Piranha™ had the highest aspiration power. No significant differences were found in morcellation efficiency using microwave-cooked chicken breast. The Piranha™ was felt to be the safest and most effective morcellator.
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Affiliation(s)
- Matthew S Lee
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Mark Assmus
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Lauren F Cooley
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Eric Li
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Tim Large
- Department of Urology, Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Amy Krambeck
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Assmus MA, Large T, Krambeck A. Holmium Laser Enucleation of the Prostate Efficiency by Prostate Gland Size: Is There a Sweet Spot? Uro 2021; 1:202-8. [DOI: 10.3390/uro1040022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Holmium laser enucleation of the prostate (HoLEP) is one of only two AUA guideline-recommended prostate size-independent surgeries for benign prostate hyperplasia (BPH). The significant variation in gland size treated results in a wide range of enucleation and morcellation times. We sought to understand the effect of prostate size on HoLEP efficiency to better educate patients and improve operative room utilization. After IRB approval, we identified patients from 1 July 2016 to 1 January 2020 who underwent HoLEP by two endourologists. Our primary objectives were to assess the effects of increasing increments (25 g) of mean enucleated prostate tissue weight on enucleation and morcellation efficiency (g/min). One-way Kruskal–Wallis ANOVA with Dunn’s post hoc test was used, with significant p < 0.05. We included 675 HoLEPs with all comers mean tissue weight resected of 72.1 g (Range 1–448 g), energy used 110.00 kJ (10.73–340 kJ), enucleation time 48.6 min (5–151 min), and morcellation time 10.1 min (0.5–113 min). Average enucleation efficiency increased with increasing prostate size categories (e.g., <25 g–0.48 g/min, >325 g–3.91 g/min) (K-W ANOVA p = 0.004, Dunn’s post hoc p = 0.004). The combined average enucleation and morcellation efficiency was ≥5 g/min between 55 and 271 g. Inefficiency for cases <55 g was driven by enucleation, while >271 g case inefficiency was driven by morcellation. Increasing tissue weight at the time of HoLEP is associated with a linear relationship of increasing enucleation and decreasing morcellation efficiencies.
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Abstract
PURPOSE OF REVIEW This review aims to give a brief description of the latest minimally invasive surgical techniques (MISTs) for the treatment of benign prostatic obstruction (BPO). RECENT FINDINGS In recent years technological advances have made the implementation of MISTs in the armamentarium of BPO surgery possible and in many cases could replace standard procedures.These techniques offer many advantages -short recovery time, rapid symptomatic relief, few adverse effects, lower risk of sexual/ejaculatory dysfunction, acceptable durability and most can be performed as an outpatient procedure.Many of the newer MISTs can be performed outside the operating room under local anesthesia, hence the term office-based MIST. SUMMARY A tailored BPO surgical treatment should not only take into account the prostate volume, but also many other factors including possible adverse events and the patient's expectations.Further studies and long-term data are necessary to standardize methods for evaluating the outcomes of these new procedures and to see which will pass the test of time and end-up replacing the gold standard procedures.
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Affiliation(s)
- Enrique Rijo
- Department of Urology, Hospital Quiron Barcelona, Barcelona, Spain
| | - Richard Hindley
- Department of Urology, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | | | - Thorsten Bach
- Department of Urology, Asklepios Western Hospital Hamburg, Hamburg, Germany
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Pallauf M, Herrmann T, Oswald D, Törzsök P, Deininger S, Lusuardi L. Electrosurgery or laser for benign prostatic enlargement: trumpcard or pitfalls. Curr Opin Urol 2021; 31:444-450. [PMID: 34265843 PMCID: PMC8373441 DOI: 10.1097/mou.0000000000000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To summarize and comment on publications of the last 2 years in the field of endoscopic surgery for benign prostatic enlargement, focusing on similarities and differences of laser and electrosurgery. RECENT FINDINGS Because of good hemostasis and safety, invasive endoscopic surgery has evolved to a choice of treatment for vulnerable patients with ongoing antithrombotic medication and in same-day surgery. Recent publications show a good perioperative course and no deterioration in the postoperative outcome. Furthermore, alterations to the original surgical techniques of resection, enucleation, and vaporization have increased the preservation rate for antegrade ejaculation, advancing them to an appealing choice of treatment for sexually active men. Favorable outcomes can be achieved in both laser and electrosurgery. Only the choice of the surgical technique determines the outcome. SUMMARY Various invasive endoscopic surgical techniques are available, offering different advantages and disadvantages for the patient. All of them can be performed with laser and electrosurgery. Therefore, focusing on the proper choice of surgical technique instead of the energy source will guarantee the patient to benefit most.
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Affiliation(s)
- Maximilian Pallauf
- Department of Urology, University Hospital Salzburg, Paracelsus Medical University, Austria
| | - Thomas Herrmann
- Department of Urology, Spital Thurgau AG, Frauenfeld, Switzerland
| | - David Oswald
- Department of Urology, University Hospital Salzburg, Paracelsus Medical University, Austria
| | - Peter Törzsök
- Department of Urology, University Hospital Salzburg, Paracelsus Medical University, Austria
| | - Susanne Deininger
- Department of Urology, University Hospital Salzburg, Paracelsus Medical University, Austria
| | - Lukas Lusuardi
- Department of Urology, University Hospital Salzburg, Paracelsus Medical University, Austria
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