RESUMO
PURPOSE: To assess the learning curve of Thulium Fiber Laser Enucleation of prostate (ThuFLEP) of a single surgeon inexperienced in laser endoscopic enucleation of prostate (EEP). METHODS: We retrospectively analyzed all patients with benign prostate hyperplasia undergoing ThuFLEP at our center between January 2022 and August 2023 by one surgeon. Inclusion criteria were International Prostate Symptom Score > 7, prostate volume < 200 g, and maximal urinary flow rate < 15 mL/s. The surgeon was inexperienced in laser EEP and trained by watching educational videos of ThuFLEP before starting to perform the procedure under mentoring during the first 4 cases. Procedural data (enucleation and morcellation efficiency, complications) and functional results up to 3 months were evaluated. Patients were divided into 4 cohorts of 20 consecutive cases to evaluate outcomes evolution throughout time. RESULTS: The mean age of the patients was 69.9 years (SD 7.8) and mean prostate volume was 89.9 g (SD 25.8). Preoperative functional parameters were comparable between the groups. Mean enucleation efficiency (EE) ratio and morcellation efficiency (ME) ratio reached respectively 0.78 g/min (SD 0.55) and 2.49 g/min (SD 1.03) and both variables significantly increased from group 1 to group 3 (p < 0,001). Perioperative complications remained low throughout the caseload with similar significant 3-month functional improvements between all groups. CONCLUSION: This is the first study to evaluate ThuFLEP learning curve for a single surgeon inexperienced in laser EEP with limited mentoring. Under these real-world conditions, nearly 60 cases were needed to complete the learning curve with a complications rate remaining low throughout the training process.
Assuntos
Terapia a Laser , Curva de Aprendizado , Prostatectomia , Hiperplasia Prostática , Túlio , Humanos , Masculino , Estudos Retrospectivos , Hiperplasia Prostática/cirurgia , Idoso , Terapia a Laser/métodos , Túlio/uso terapêutico , Pessoa de Meia-Idade , Prostatectomia/métodos , Prostatectomia/educação , Competência Clínica , Lasers de Estado Sólido/uso terapêuticoRESUMO
PURPOSE: Convective water vapor thermal therapy or "Rezum™" treatment for lower urinary tract symptoms in men with benign prostate hypertrophy require postoperative catheterization to avoid acute urinary retention. Unsuccessful catheter removal is still unpredictable. We, therefore, aimed to identify the risk factors of failed initial trial without catheter (TWOC) after Rezum™ therapy inside a large cohort of patients. METHODS: A retrospective study was conducted on patients who underwent Rezum™ therapy by three referent urologists across two academic hospitals between January 2022 and January 2023. A Foley catheter was systematically placed after therapy for 7 days in all patients before TWOC. Patients characteristics [age, imagery, maximum urinary flow rate (Qmax), postvoid residual (PVR)], and treatment outcomes (International Prostate Symptom Score (IPSS), quality of life (QoL), adverse events) were analyzed at baseline and 3 months from procedure. Failed initial TWOC was defined as the incapacity to pass urine or measured PVR > 300 mL. After univariate selection, the risk factors for TWOC failure were identified using multivariate logistic regression analysis. RESULTS: 216 patients qualified for analysis with 23 (10.6%) failing the first TWOC after 7 days of catheterization. After multivariate logistic regression, only preoperative PVR predicted TWOC failure (OR 1.01; p = 0.007). The cut-off of preoperative PVR increasing this risk was 120 mL (p = 0, 02). CONCLUSION: Over 10% of men undergoing Rezum™ therapy for LUTS/BPH will experience TWOC failure and AUR after 7 days of catheterization. Preoperative PVR seems to be the only independent risk factor of unsuccessful catheter removal.
Assuntos
Hiperplasia Prostática , Retenção Urinária , Masculino , Humanos , Qualidade de Vida , Estudos Retrospectivos , Hiperplasia Prostática/cirurgia , Retenção Urinária/etiologia , Retenção Urinária/terapia , Resultado do Tratamento , Fatores de Risco , Catéteres/efeitos adversosRESUMO
Primary urethral carcinoma (PUC) is a rare disease with frequent nodal metastasis at the time of diagnosis. Few risk factors have been established and overall prognosis remains poor. As of now, no clear therapeutic guidelines are established and management of advanced PUC often involves surgery which can have negative functional and psychological outcomes for the patient. Few authors have already reported the use of chemoradiotherapy alone to avoid surgery with some good short-term results. We report the case of a 48-year-old woman with advanced high-grade urothelial carcinoma of distal urethra associated to bilateral inguinal nodal metastasis. She was similarly and successfully treated using chemoradiotherapy exclusively without significant adverse effects. This experience reinforces benefits of a surgery-sparing management, when possible, as recommended in current guidelines.
RESUMO
Renal artery pseudoaneurysm may develop after laser flexible ureteroscopy stone lithotripsy (FURSL). Typical symptoms include flank pain, persistent hematuria, delayed refractory anemia, or hemorrhagic shock in case of pseudoaneurysm rupture. This complication of laser FURSL is very rare with only five cases reported in the literature as of April 2023, of which one involved Thulium laser. We report the case of a 65-year-old man with recurrent renal lithiasis who underwent FURSL using Thulium fibered laser (TFL) for 8 mm stone of left kidney upper pole. Persistent hematuria developed postoperatively, secondary to a pseudoaneurysm from a segmental branch of the left renal artery. It was diagnosed on arteriography performed for sudden hemorrhagic shock 27 days after surgery. Selective embolization with metallic micro-coils resolved hematuria. Although laser FURSL is often uncomplicated and TFL is regarded as safe, this complication should be suspected when refractory hematuria or hemodynamic instability follows the procedure. We report this case to add support to the current literature and outline procedural risk factors and useful precautions during the procedure.
RESUMO
BACKGROUND: Prostate biopsy is a rather frequent procedure, mostly performed in outpatient settings. Bleeding complications following this procedure require precise and delicate management of pre-, peri- and post-procedure anti-coagulation treatments. New oral anti-coagulation drugs (NOACs) are increasingly used. However, the management of such treatments is feared and not yet well known to urologists. A protocol for prostate biopsy management of NOACs seems mandatory. MATERIALS AND METHODS: A review of the literature, using Pubmed and Cochrane databases, together with analysis of several medical associations' recommendations in urology, anaesthesiology, cardiology, oncology and drug safety agency, was performed. RESULTS: There are no recommendations about NOAC management for prostate biopsy available from scientific societies. There is also a lack of specific urological studies. However, several panels of expert recommendations could be helpful in establishing standardized protocols adapted from surgery to prostate biopsy. With the growing use of NOACs, recommendations have shifted to continue anti-coagulant treatment without bridging NOACs for low bleeding risk procedures such as prostate biopsy, in carefully selected groups of patients. CONCLUSION: Extensive indications coupled with the ease of use of NOACs contribute significantly to the widespread replacement of traditional vitamin K antagonist. Knowing that heparin bridging leads to more bleeding, and in the pursuit of more autonomy and safety, urologists should be able to propose dedicated anti-coagulant management using NOACs adapted to carefully selected patients before the prostate biopsy procedure. Further studies and guidelines specific to the concept of non-bridging for anti-coagulant-requiring patients are mandatory for this routine procedure.