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1.
Can Urol Assoc J ; 2024 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-38587977

RESUMO

INTRODUCTION: We aimed to compare holmium laser enucleation of the prostate (HoLEP) outcomes in patients with and without neurologic diseases (ND). METHODS: A prospectively maintained database of patients undergoing HoLEP from January 2021 to April 2022 was reviewed. The following NDs were included: diabetes-related neuropathy/neurogenic bladder, Parkinson's disease, dementia, cerebrovascular accident, multiple sclerosis, traumatic brain injury, transient ischemic attack, brain/spinal tumors, myasthenia gravis, spinal cord injury, and other. Statistical analysis was performed using t-tests, Chi-squared, and binomial tests (p<0.05). RESULTS: A total of 118 ND patients were identified with 135 different neurologic diseases. ND patients were more likely to have indwelling catheters (57% vs. 39%, p=0.012) and urinary tract infections (UTIs) preoperatively (32% vs. 19%, p=0.002). Postoperatively, ND patients were more likely to fail initial trial of void (20% vs. 8.1%, p<0.001) and experience an episode of acute urinary retention (16% vs. 8.5%, p=0.024). Within 90 days postoperative, the overall complication rate was higher in the ND group (26% vs. 13%, p=0.001). Within the ND group, 30/118 (25%) had ≥1 UTI within 90 days preoperative, which decreased to 10/118 (8.7%) 90 days postoperative (p<0.001). At last followup (mean 6.7 months [ND] vs. 5.4 months [non-ND], p=0.03), four patients (4.4%) in the ND group required persistent catheter/clean intermittent catheterization compared to none in the non-ND group (p=0.002). CONCLUSIONS: Patients with ND undergoing HoLEP are more likely to experience postoperative retention and higher complication rates compared to non-ND patients. While UTI rates are higher in this population, HoLEP significantly reduced three-month UTI and catheterization rates.

2.
J Endourol ; 37(12): 1261-1269, 2023 12.
Artigo em Inglês | MEDLINE | ID: mdl-37786336

RESUMO

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.


Assuntos
Terapia a Laser , Lasers de Estado Sólido , Hiperplasia Prostática , Ressecção Transuretral da Próstata , Masculino , Humanos , Próstata/cirurgia , Hiperplasia Prostática/cirurgia , Hiperplasia Prostática/complicações , Lasers de Estado Sólido/uso terapêutico , Estudos Prospectivos , Resultado do Tratamento , Hólmio , Ressecção Transuretral da Próstata/métodos , Terapia a Laser/métodos
3.
J Endourol ; 37(10): 1123-1128, 2023 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-37503627

RESUMO

Introduction: Holmium laser enucleation of the prostate (HoLEP) has evidenced-based advantages in treating benign prostatic hyperplasia (BPH) relative to other interventions. Unfortunately, the adoption of HoLEP has remained relatively low in Medicare and the National Surgical Quality Improvement Program populations. HoLEPs role as an inpatient surgical intervention is changing as advancements in the technique and systems have demonstrated the feasibility of same-day discharge. Thus, our objective was to evaluate national HoLEP trends in ambulatory surgery settings from 2016 to 2019. Materials and Methods: The Nationwide Ambulatory Surgery Sample (NASS) is the largest national all-payer database of ambulatory surgical encounters, managed by the Agency for Healthcare Research and Quality. A cross-sectional retrospective analysis of the 2016 and 2019 NASS was performed. Rates of BPH surgeries were calculated and stratified by age, census region, and primary payer to compare across time points for trends. Chi-squared tests and two-sample t-tests were completed for categorical and continuous variables, respectively. Results: The total number of ambulatory BPH surgeries fell 20% between 2016 (n = 124,538) and 2019 (n = 100,593). In 2016, HoLEP lagged behind photoselective vaporization of the prostate (PVP) and transurethral resection of prostate (TURP) with 4.7% of surgeries but rose to the second most common procedure in 2019 with 8.3% of total surgeries. TURP was the most common intervention (62.6% in 2016, 90.7% in 2019). Simple prostatectomy was the most expensive intervention. By U.S. census region, more HoLEPs were carried out in the South (43.1% in 2016, 37.5% in 2019) and Midwest (26.8% in 2016, 31.7% in 2019). Conclusions: Overall, HoLEP uptake is increasing. HoLEP has replaced greenlight PVP as the second most frequently used intervention. The rate of ambulatory HoLEPs has nearly doubled despite a general decrease in the number of surgeries.

4.
J Endourol ; 37(9): 1037-1042, 2023 09.
Artigo em Inglês | MEDLINE | ID: mdl-37276153

RESUMO

Introduction: The effect of prophylactic bladder neck incision (BNI) at time of holmium laser enucleation of the prostate (HoLEP) is unknown. The aim of our study was to examine HoLEP outcomes with a specific focus on rates of bladder neck contractures (BNCs), with and without utilizing prophylactic BNI. Materials and Methods: We performed a retrospective review of HoLEP patients from January 2021 until January 2022. Outcomes of patients who underwent BNI at time of HoLEP were compared with those who underwent standard HoLEP alone. Student's t-tests, chi-square tests, and logistic regressions were performed using SAS Studio. Results: In total, 421 patients underwent HoLEP. BNI was concurrently performed in 74 (17.6%) HoLEP patients. BNI patients were younger (67.5 ± 9.0 years vs 71.1 ± 8.2 years, p = 0.00007) and had smaller prostates (60.7 ± 30.3 cc vs 133.2 ± 64.5 cc, p < 0.0001). Procedure, enucleation, and morcellation times were shorter in the BNI group (all p < 0.0001). There was no statistical difference in same-day discharge rates (90.4% vs 87.7%, p = 0.5), short-term functional outcomes, emergency department (ED) visits, or readmission rates between the two groups. At 14 months mean follow-up, two BNCs occurred in patients in the control group (0.6%), and no BNCs occurred in patients who underwent BNI (0.0%, p = 0.5). Conclusions: BNI at time of HoLEP did not decrease the ability to achieve same-day discharge or increase 90-day complications, ED visits, or readmission rates. No BNCs occurred in patients who underwent prophylactic BNI (0.0%) despite a smaller gland size and lower specimen weight in this cohort. Further prospective studies are required to conclude if concurrent BNI at time of HoLEP is protective against BNC.


Assuntos
Terapia a Laser , Lasers de Estado Sólido , Hiperplasia Prostática , Ressecção Transuretral da Próstata , Masculino , Humanos , Próstata/cirurgia , Bexiga Urinária/cirurgia , Hiperplasia Prostática/cirurgia , Hólmio , Estudos Retrospectivos , Resultado do Tratamento
5.
J Endourol ; 37(7): 801-806, 2023 07.
Artigo em Inglês | MEDLINE | ID: mdl-37053094

RESUMO

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.


Assuntos
Toxinas Botulínicas Tipo A , Terapia a Laser , Lasers de Estado Sólido , Hiperplasia Prostática , Obstrução do Colo da Bexiga Urinária , Incontinência Urinária , Retenção Urinária , Masculino , Humanos , Próstata/cirurgia , Toxinas Botulínicas Tipo A/uso terapêutico , Retenção Urinária/cirurgia , Lasers de Estado Sólido/uso terapêutico , Estudos Retrospectivos , Hiperplasia Prostática/complicações , Hiperplasia Prostática/tratamento farmacológico , Hiperplasia Prostática/cirurgia , Resultado do Tratamento , Terapia a Laser/efeitos adversos , Incontinência Urinária/cirurgia , Obstrução do Colo da Bexiga Urinária/tratamento farmacológico , Obstrução do Colo da Bexiga Urinária/etiologia , Obstrução do Colo da Bexiga Urinária/cirurgia , Hólmio , Qualidade de Vida
6.
Urology ; 173: 180-186, 2023 03.
Artigo em Inglês | MEDLINE | ID: mdl-36586427

RESUMO

OBJECTIVE: To compare perioperative outcomes between Holmium laser enucleation of the prostate (HoLEP), open simple prostatectomy (OSP), and robotic simple prostatectomy (RSP) for large prostates (> 80 cc). MATERIALS AND METHODS: A retrospective study of 340 patients who underwent HoLEP (n = 209), OSP (n = 66), or RSP (n = 65) at a large academic medical center between January 2013 - September 2021 was performed. Length of stay (LOS), operative time, catheter duration, estimated blood loss (EBL), blood transfusion, and 30-day ED visits and readmissions were compared between the three groups. Univariate analyses consisted of ANOVA with Tukey's corrections and Chi-square tests. Linear and multivariate logistic regression was also performed. All tests were two-sided and a p-value <0.05 was pre-determined to be statistically significant. Analyses were performed with SAS v9.4. RESULTS: HoLEP was found to have the shortest: operative time (1.4 vs 2.7 vs 3.8h), LOS (0.65 vs 4.2 vs 2.6d), and catheter duration (0.38 vs 9.9 vs 11.2d) compared to OSP and RSP, respectively (all P <.0001). HoLEP also had the lowest EBL (66 vs 795 vs 326 mL, P <.0001). HoLEP and RSP had a lower risk of blood transfusion compared to OSP (P <.0001). These associations remained significant on multivariable analyses. CONCLUSION: HoLEP is a minimally invasive treatment option for large prostates that was found to have shorter operative time, LOS, and catheter duration as well as lower EBL compared to OSP and RSP.


Assuntos
Terapia a Laser , Lasers de Estado Sólido , Hiperplasia Prostática , Procedimentos Cirúrgicos Robóticos , Masculino , Humanos , Próstata/cirurgia , Hiperplasia Prostática/cirurgia , Lasers de Estado Sólido/uso terapêutico , Estudos Retrospectivos , Prostatectomia , Hólmio , Resultado do Tratamento
7.
Nat Rev Urol ; 20(4): 226-240, 2023 04.
Artigo em Inglês | MEDLINE | ID: mdl-36418491

RESUMO

Holmium laser enucleation of the prostate (HoLEP) is a size-independent surgical option for treating benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) with excellent, durable functional outcomes. The prevalence of LUTS secondary to BPH and prostate cancer both increase with age, although the two diseases develop independently. Urologists often face a diagnostic dilemma, as men with LUTS secondary to BPH might also present with an elevated PSA and, therefore, need a diagnostic work-up to exclude prostate cancer. Nevertheless, ~15% of men with a negative elevated PSA work-up will undergo HoLEP and will be diagnosed with incidental prostate cancer at the time of HoLEP. Indeed, prostate cancer is often found in men undergoing HoLEP, and this situation can be challenging to manage. Variables associated with the detection of incidental prostate cancer, strategies to reduce incidental prostate cancer, as well as the natural history and management of this condition have been extensively studied, but further work in this area is still needed.


Assuntos
Terapia a Laser , Lasers de Estado Sólido , Sintomas do Trato Urinário Inferior , Hiperplasia Prostática , Neoplasias da Próstata , Ressecção Transuretral da Próstata , Masculino , Humanos , Próstata/cirurgia , Hiperplasia Prostática/diagnóstico , Hiperplasia Prostática/cirurgia , Antígeno Prostático Específico , Lasers de Estado Sólido/uso terapêutico , Resultado do Tratamento , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/cirurgia , Neoplasias da Próstata/complicações , Sintomas do Trato Urinário Inferior/diagnóstico , Sintomas do Trato Urinário Inferior/etiologia , Sintomas do Trato Urinário Inferior/cirurgia , Estudos Retrospectivos
8.
J Endourol ; 37(2): 171-178, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36222618

RESUMO

Introduction: Tranexamic acid (TXA) is a clot promoting agent utilized during orthopedic procedures to decrease bleeding. Urologists have demonstrated the benefits of TXA in percutaneous surgery. Our objective was to assess the safety and efficacy of single-dose TXA on same-day holmium laser enucleation of the prostate (HoLEP) outcomes. Methods: From September 2021 to January 2022, we prospectively randomized 110 patients undergoing HoLEP to either 1 g of TXA after induction or no treatment. Institutional Review Board (IRB) approval (STU00215134) and registry with ClinicalTrials.gov (NCT05082142) were obtained before enrollment. Primary outcome was the rate of effective same-day discharge (SDD). Secondary outcomes included transfusion rate, same-day catheter removal, length of stay (LOS), and 90-day complications. Power analysis determined that 110 patients should be enrolled to detect a 25% difference in SDD rate. Results: There was no difference in patient demographic and prostate features between the control (n = 55) and TXA groups (n = 55; all p > 0.05). The overall rate of effective SDD was not different between the control and TXA groups (49/55 [89%] vs 51/55 [93%], p = 0.74). Median LOS (hh:mm) was not different between groups (03:07 vs 02:50, p = 0.23) with only 3/110 (2.7%) having an LOS >24 hours. Effective same-day catheter removal occurred in 99/110 (90%) patients with no difference between groups (49/55 vs 50/55, p = 0.99). There was no difference in operative parameters (time, energy, specimen weight) and postoperative complications between groups (all p > 0.05). No patients required transfusions and there were no major 90-day complications related to surgery (Clavien-Dindo ≥IIIb). Conclusion: TXA administration is safe but did not impact SDD after HoLEP.


Assuntos
Terapia a Laser , Lasers de Estado Sólido , Hiperplasia Prostática , Ácido Tranexâmico , Masculino , Humanos , Próstata/cirurgia , Ácido Tranexâmico/uso terapêutico , Lasers de Estado Sólido/uso terapêutico , Estudos Prospectivos , Hiperplasia Prostática/cirurgia , Hólmio , Terapia a Laser/métodos , Resultado do Tratamento
9.
World J Urol ; 40(11): 2675-2681, 2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-36136130

RESUMO

PURPOSE: To identify a threshold for intrarenal pressure (IRP), that if exceeded, will result in renal parenchymal damage. Herein, we attempt to identify an IRP threshold by subjecting in vivo porcine kidneys to various levels of extreme pressurized irrigation. Our objective was not to simulate ureteroscopy treatment, but to attempt identify a threshold of IRP injury. METHODS: Ten female pigs were intubated and sedated. The abdomen was opened; the ureters were isolated and incised. A LithoVue™ (Boston Scientific) ureteroscope was inserted. A 0-silk tie was then used to tie the ureter around the scope to create a closed system (to achieve a constant level of pressure). Real-time IRPs were measured using the Comet™ Pressure guidewire (Boston Scientific). Kidneys were exposed to pressurized, saline for 36 min (at control, 50, 100, 150 mmHg and higher pressures). Kidneys were then immediately harvested. Two expert histologists independently analyzed kidney slides to identify areas of renal damage. RESULTS: The two kidneys exposed to IRPs > 185 mmHg resulted in forniceal rupture and large areas of hematoma. The other IRP groups (control, 50, 100, and 150 mmHg) had no identifiable gross or histologic renal parenchymal damage. CONCLUSIONS: No differences in renal parenchymal morphology were identified between pressure groups of control, 50, 100, or 150 mmHg. However, IRPs > 185 mmHg did result in forniceal rupture in this closed-system in vivo porcine model. Further study is required to elucidate the damage threshold.


Assuntos
Ureteroscópios , Ureteroscopia , Feminino , Suínos , Animais , Ureteroscopia/métodos , Pelve Renal , Pressão , Rim
10.
Urology ; 170: 168-173, 2022 12.
Artigo em Inglês | MEDLINE | ID: mdl-35963396

RESUMO

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.


Assuntos
Terapia a Laser , Lasers de Estado Sólido , Hiperplasia Prostática , Ressecção Transuretral da Próstata , Masculino , Humanos , Lasers de Estado Sólido/uso terapêutico , Próstata/cirurgia , Hiperplasia Prostática/cirurgia , Hiperplasia Prostática/complicações , Estudos Retrospectivos , Anticoagulantes , Hólmio , Resultado do Tratamento
11.
Eur Urol Focus ; 8(6): 1673-1682, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-35760722

RESUMO

BACKGROUND: Patient factors associated with urinary tract cancer can be used to risk stratify patients referred with haematuria, prioritising those with a higher risk of cancer for prompt investigation. OBJECTIVE: To develop a prediction model for urinary tract cancer in patients referred with haematuria. DESIGN, SETTING, AND PARTICIPANTS: A prospective observational study was conducted in 10 282 patients from 110 hospitals across 26 countries, aged ≥16 yr and referred to secondary care with haematuria. Patients with a known or previous urological malignancy were excluded. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcomes were the presence or absence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC], and renal cancer). Mixed-effect multivariable logistic regression was performed with site and country as random effects and clinically important patient-level candidate predictors, chosen a priori, as fixed effects. Predictors were selected primarily using clinical reasoning, in addition to backward stepwise selection. Calibration and discrimination were calculated, and bootstrap validation was performed to calculate optimism. RESULTS AND LIMITATIONS: The unadjusted prevalence was 17.2% (n = 1763) for bladder cancer, 1.20% (n = 123) for UTUC, and 1.00% (n = 103) for renal cancer. The final model included predictors of increased risk (visible haematuria, age, smoking history, male sex, and family history) and reduced risk (previous haematuria investigations, urinary tract infection, dysuria/suprapubic pain, anticoagulation, catheter use, and previous pelvic radiotherapy). The area under the receiver operating characteristic curve of the final model was 0.86 (95% confidence interval 0.85-0.87). The model is limited to patients without previous urological malignancy. CONCLUSIONS: This cancer prediction model is the first to consider established and novel urinary tract cancer diagnostic markers. It can be used in secondary care for risk stratifying patients and aid the clinician's decision-making process in prioritising patients for investigation. PATIENT SUMMARY: We have developed a tool that uses a person's characteristics to determine the risk of cancer if that person develops blood in the urine (haematuria). This can be used to help prioritise patients for further investigation.


Assuntos
Neoplasias Renais , Neoplasias da Bexiga Urinária , Neoplasias Urológicas , Humanos , Masculino , Neoplasias Urológicas/complicações , Neoplasias Urológicas/diagnóstico , Neoplasias Urológicas/epidemiologia , Neoplasias da Bexiga Urinária/complicações , Neoplasias da Bexiga Urinária/diagnóstico , Neoplasias da Bexiga Urinária/epidemiologia
12.
Can Urol Assoc J ; 16(11): E533-E538, 2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-35704929

RESUMO

INTRODUCTION: To improve surgeon-patient communication of postoperative expectations, a multidisciplinary team created and evaluated a holmium laser enucleation of the prostate (HoLEP) expectations handout. Although an effective benign prostatic hyperplasia (BPH) surgery, it is crucial that patients understand the HoLEP recovery. A quality assessment previously performed at our center revealed 11% of patients were not aware of potential ejaculate volume changes. METHODS: Patients presenting for consultation prior to HoLEP were assessed with post-procedure patient-reported outcomes (PRO) questionnaires before (n=50) and after (n=50) the implementation of a surgeon-patient expectations handout. Patient demographics and perioperative course were examined in the context of responses. Comparisons were made with a Chi-squared test (p<0.05). RESULTS: We observed a response rate of 96% (pre-handout: 46/50 vs. post-handout: 50/50). Overall, 89/96 (93%) patients felt they had a reasonable understanding of HoLEP expectations, with no difference between cohorts (45/46 vs. 48/50, p=0.71). There was no difference in reporting an understanding of post-HoLEP hematuria (p=0.12) or urinary incontinence (UI) (p=0.99). The implementation of the handout improved understanding of retrograde ejaculation (pre-handout: 41/46 vs. post-handout: 50/50, p=0.022) and dysuria (pre-handout: 35/46 vs. post-handout: 46/50, p=0.048). Fifty-five patients experienced any dysuria postoperatively, with 89% reporting less than or equal to what they expected. Close to 30% (28/94) of respondents offering ways to improve communication suggested an educational website. CONCLUSIONS: The implementation of a surgeon-patient handout during HoLEP consultation improved understanding of postoperative retrograde ejaculation and dysuria at our center. We identified areas for future technology-aided improvements in post-HoLEP communication.

13.
Urology ; 167: 61-66, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-35772484

RESUMO

OBJECTIVE: To evaluate cost-effectiveness and user satisfaction of a single-use flexible cystoscope at a tertiary care center we conducted a 90-day trial. Single-use flexible cystoscope advancements have introduced alternative options to reusable scopes. However, there is a paucity of cost-effectiveness and provider satisfaction studies examining the implementation of a hospital-based transition to single-use cystoscopes. METHODS: Following institutional device-approval we initiated a 90-day trial period (November 1, 2020-January 29, 2021) where all flexible, transurethral, and percutaneous, urologic care was provided with a disposable AMBU aScope. We performed a micro-costing analysis examining payor per case cost of the reusable flexible cystoscope (including servicing and processing) to the disposable units. Provider surveys assessed visual quality, deflection, ease of working channel and overall satisfaction on a 10-point Likert scale. RESULTS: Over the 90-day period, we encountered 84 cases (78 operative, 5 inpatient, 1 emergency department) where flexible cystoscopy was required. One disposable flexible cystoscope was successfully used in 78 of 84 (93%) cases. Of the 6 failures, 2 were due to an inability to access a disposable scope/monitor. Per use cost of the reusable flexible cystoscope at our center was $272.41 versus $185.00 for the single use. Extrapolating our average case volume and conservative failure rate (3 single use failures/month, requiring reusable), transitioning to predominately single use scopes results in $39,142.84 annual cost savings. CONCLUSIONS: This single center 90-day trial of disposable flexible cystoscopy identified per-use costs to be less when a single-use flexible cystoscope was utilized at a high-volume tertiary care center.


Assuntos
Cistoscópios , Cistoscopia , Análise Custo-Benefício , Cistoscopia/métodos , Desenho de Equipamento , Humanos , Satisfação Pessoal
14.
World J Urol ; 40(7): 1763-1767, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35622115

RESUMO

PURPOSE: Patients presenting with multiple same-sided ureteric stones (MSSUS) are a unique population with nuanced prognostic and treatment considerations, which have yet to be characterized in the literature. Therefore, our purpose was to examine outcomes of patients with MSSUS vs those with single ureteric stones (SUS). METHODS: A retrospective review of prospectively collected patients included adults (> 18yo) with [Formula: see text] 2 ipsilateral ureteral stones without prior treatment for their current stone burden. A historical comparison group was used as a control population. Univariate logistic regression analyses and descriptive statistics were performed with SPSS® 20.0 (p < 0.05). RESULTS: Seventy-nine MSSUS patients were compared to 101 SUS patients. MSSUS patients had 2.21 [Formula: see text] 0.66 ureteric stones and had significantly smaller lead stones (MSSUS 6.4 mm vs SUS 7.2 mm, p = 0.03). MSSUS patients were more likely to have had prior stones (66 vs 42%) and 5.9 times more likely to have had prior stone procedures. Conservative management was successful in 30% MSSUS vs 19% SUS (p = 0.073), and there were no differences in resolution time (p = 0.44). For patients proceeding to intervention, (MSSUS n = 52, SUS n = 78), ureteroscopy was performed on 58% MSSUS vs 51% SUS patients (p = 0.302), and shockwave lithotripsy in 10% MSSUS vs 26% SUS (p = 0.01). MSSUS were more likely to spontaneously pass a stone prior to planned intervention (OR = 41.1; 95% CI = 12.0-140.7; p = 0.0001). CONCLUSION: MSSUS patients are more likely recurrent stone formers with extensive stone histories and current stone burdens. Conservative management appears as successful between groups, with no difference in resolution time. When employed, ureteroscopy outcomes do not different between cohorts.


Assuntos
Litotripsia , Ureter , Cálculos Ureterais , Adulto , Humanos , Litotripsia/métodos , Estudos Retrospectivos , Resultado do Tratamento , Cálculos Ureterais/terapia , Ureteroscopia/métodos
15.
World J Urol ; 40(5): 1203-1209, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35166893

RESUMO

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.


Assuntos
Terapia a Laser , Lasers de Estado Sólido , Hiperplasia Prostática , Ressecção Transuretral da Próstata , Hólmio , Humanos , Terapia a Laser/métodos , Lasers de Estado Sólido/uso terapêutico , Masculino , Próstata/cirurgia , Hiperplasia Prostática/cirurgia , Tecnologia , Resultado do Tratamento
16.
Ther Adv Urol ; 14: 17562872211072637, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35096145

RESUMO

Herein, we describe a case of a patient diagnosed with prostate cancer (PCa) who presented with lower urinary tract symptoms (LUTS) and elevated Prostate Specific Antigen (PSA). He underwent Holmium Laser Enucleation of the Prostate (HoLEP) for his severe LUTS with concurrent placement of SpaceOAR gel and gold fiducials in preparation for radiation therapy (RT). After a successful operation, the patient underwent same-day discharge and catheter removal. He regained continence at 2 weeks and started RT at 9 weeks post-HoLEP. We present that concurrent placement of fiducials and SpaceOAR during HoLEP appears to be feasible, well tolerated and effective for PCa patients who elect RT.

17.
Urology ; 161: 105-110, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-34973241

RESUMO

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.


Assuntos
Terapia a Laser , Lasers de Estado Sólido , Hiperplasia Prostática , Ressecção Transuretral da Próstata , Hólmio , Humanos , Lasers de Estado Sólido/uso terapêutico , Masculino , Alta do Paciente , Próstata/cirurgia , Hiperplasia Prostática/cirurgia , Resultado do Tratamento
18.
Urology ; 161: 25-30, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-34848277

RESUMO

OBJECTIVE: To define risk factors and perioperative outcomes for matrix stones and compare these outcomes with struvite and calcium stone cohorts. METHODS: A retrospective cohort study comparing matrix stones (n=32), struvite stones (n=23) and a matched, calcium stone control group (n=32) was performed. Two-way ANOVA was used to compare the groups for continuous variables. Chi-square tests were used to compare categorical variables. Significance was set at P <.05. All statistical tests were performed using R (v1.73). RESULTS: We identified no differences in age, gender, or BMI between the three groups. Matrix and struvite stones were more likely to have a history of prior stone surgery and recurrent UTIs compared to calcium stones (P=.027 and P <.001, respectively). Struvite stones were more likely to present as staghorn calculi compared to matrix or calcium stones (56.5% vs 21.7% vs 18.8%, P=.006). There were no significant differences in postoperative stone free rates (P=.378). No significant differences in postoperative infectious complications were identified. Matrix stones were more likely to have Candida on stone culture compared to the struvite or calcium stones (P <.0001). CONCLUSION: Matrix and struvite stones were more likely have a history of stone surgery and preoperative recurrent UTIs. Struvite stones were more likely to present as staghorn calculi. Matrix stones were more likely to have Candida present in stone cultures. However, no difference in postoperative infectious outcomes or stone free rates were identified. Further study with larger cohorts is necessary to distinguish matrix stone postoperative outcomes from struvite and calcium stones.


Assuntos
Cálculos Renais , Cálculos Coraliformes , Cálcio , Feminino , Humanos , Cálculos Renais/cirurgia , Masculino , Fosfatos , Complicações Pós-Operatórias , Estudos Retrospectivos , Cálculos Coraliformes/cirurgia , Estruvita , Ácido Úrico
19.
Can Urol Assoc J ; 16(1): E25-E31, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34464254

RESUMO

INTRODUCTION: Although holmium laser enucleation of the prostate (HoLEP) is a highly effective surgery, there is a variable recovery period where patients may experience hematuria, dysuria, or urinary incontinence (UI). Despite preoperative consultation, there is a paucity of literature examining the effectiveness of physician-patient communication in preparing the patient for the postoperative recovery period. We sought to examine recovery expectations as a patient-reported outcome (PRO) metric for HoLEP. METHODS: With institutional review board approval, we queried our electronic medical record and retrospective clinical registry to identify 50 consecutive patients that underwent HoLEP from November 2019 to March 2020 by two endourologists. Patients were provided questionnaires via Twistle© ≥6 months postoperatively. Patient demographics and perioperative course was examined in the context of responses. Our primary objective was determining whether patients felt they had a reasonable understanding of the recovery process. RESULTS: We observed a 92% (46/50) response rate, with an average patient age of 69.4 years (range 55-88). Overall, 91.3% (42/46) felt they had a reasonable understanding of the recovery. Additionally, 97.8% (45/46) were aware of temporary UI, with 87% having ≥1 episodes of UI after catheter removal. We found 47.8% (22/46) of patients expected UI to resolve within 30 days, while 8.6% expected >90 days of UI. All patients were aware of the risk of hematuria, with 93.5% (43/46) expecting resolution within 30 days (<7 days: 47.8%; 7-14 days: 28.3%; 15-30 days: 17.4%). CONCLUSIONS: Although surgical technique continues to improve HoLEP, ensuring adequate physician-patient communication to optimize expectations is crucial. We report patient understanding of HoLEP recovery and areas for future improvement.

20.
J Endourol ; 36(4): 514-521, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-34779660

RESUMO

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.


Assuntos
Terapia a Laser , Lasers de Estado Sólido , Morcelação , Hiperplasia Prostática , Cirurgiões , Ressecção Transuretral da Próstata , Animais , Bovinos , Humanos , Terapia a Laser/métodos , Lasers de Estado Sólido/uso terapêutico , Masculino , Satisfação Pessoal , Hiperplasia Prostática/cirurgia , Resultado do Tratamento
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