How I do it: Aquablation in very large prostates (> 150 mL).

Aquablation has been well-studied in prostates sizes up to 150 mL. Recently, American Urological Association guidelines distinguish surgical interventions for men with large prostates (80 mL-150 mL) and now very large prostates (> 150 mL). Readers will gain an understanding of how to use Aquablation in the very large prostate size category.

Men with lower urinary tract symptoms secondary to BPH undergoing Aquablation with very large prostates (> 150 mL).

INTRODUCTION: The AUA guidelines for benign prostatic hyperplasia distinguish treatments based upon prostate volume (PV), particularly for very large prostates (> 150 mL). While the clinical outcomes and benefits of Aquablation have been studied for men with average and large prostates, it is unknown whether this technology can be used for very large prostates. MATERIALS AND METHODS: Men with PV > 150 mL undergoing Aquablation were identified retrospectively from four North American hospitals. The surgical times and clinical outcomes of men with very large prostates (> 150 mL) were compared to data from men with average PV ≤ 80 mL (WATER study) and large PV 80 mL-150 mL (WATER II study). RESULTS: The average PV of men who underwent Aquablation with very large prostates was 209 mL ± 56 (n = 34, range 151-362 mL), large PV 107 mL ± 20 (n = 101, range 80-150 mL) and average PV 54 mL ± 16 (n = 116, range 30-80 mL). For men with PV > 150 mL, baseline IPSS was 19 ± 6. With a mean follow up of 7 ± 9 months, the IPSS improved to 7 ± 5 (p < 0.001). Peak urinary flow rate, Qmax, improved from 7 ± 4 mL/s to 19 ± 5 mL/s (p<0.001). Compared to the two other PV groups, there were no differences in terms of improvements in IPSS, quality of life, or uroflowmetry. There were no reports of transfusions (0%) in the cohort of men with very large prostates. CONCLUSIONS: In the present study, we demonstrate that Aquablation is effective and safe in prostates greater than 150 mL while showing consistent outcomes compared to average and large prostates sizes.

Familiarity and self-reported compliance with American Urological Association best practice recommendations for use of thromboembolic prophylaxis among American Urological Association members.

PURPOSE: Thromboprophylaxis with subcutaneous heparin or low molecular weight heparin is now an integral part of national surgical quality and safety assessment efforts, and has been incorporated into the current AUA Best Practice Statement. We evaluated familiarity and compliance with the AUA Best Practice Statement, assessed practice patterns in terms of perioperative thromboprophylaxis and specifically examined self-reported compliance in high risk patients undergoing radical cystectomy. MATERIALS AND METHODS: An electronic survey was sent to AUA members with valid e-mail addresses (10,966). Associations between AUA Best Practice Statement adherence and factors such as urological specialty, graduation year and guideline familiarity were assessed using chi-square analyses and generalized estimating equations. RESULTS: With 1,210 survey responses the largest group of respondents was urological oncologists and/or laparoscopic/robotic specialists (26.0%). This group was more likely to use thromboprophylaxis than nonurological oncologists and/or laparoscopic/robotic specialists in high risk patients (OR 1.3, CI 1.1-1.5). Respondents aware of the AUA Best Practice Statement guidelines (50.7%) were more likely to use thromboprophylaxis (OR 1.4, CI 1.2-1.6). Although 18.1% of urological oncologists and/or laparoscopic/robotic specialists and 34.2% of nonurological oncologists and/or laparoscopic/robotic specialists avoided routine thromboprophylaxis in patients undergoing radical cystectomy, the former were more likely to use thromboprophylaxis (p <0.0001) than other respondents. Urologists graduating after the year 2000 used thromboprophylaxis in high risk patients undergoing radical cystectomy more often than did earlier graduates (79.2% vs 63.4%, p <0.0001). CONCLUSIONS: Although younger age and self-reported urological oncologist and/or laparoscopic/robotic specialist status correlated strongly with thromboprophylaxis use, self-reported adherence to AUA Best Practice Statement was low, even in high risk cases with clear AUA Best Practice Statement recommendations such as radical cystectomy. These data identify opportunities for quality improvement in patients undergoing major urological surgery.

Prolonged natural progression from localized to symptomatic renal cell carcinoma.

Surgical excision is the gold standard therapy for clinically localized renal masses. Nevertheless, prognostication of the natural history of untreated renal cell carcinoma (RCC) remains a clinical challenge. While active surveillance (AS) has emerged as a viable treatment option in select patients with localized tumors and significant competing mortality risks, long term follow up data to assess the risk of disease progression are limited. We present a case of a localized, clinical stage T2 renal mass progressing to regional and systemic disease over 6 years, demonstrating that kinetics of disease progression may be prolonged and are yet to be fully understood.