High-power potassium-titanyl-phosphate laser photoselective vaporization prostatectomy for symptomatic benign prostatic hyperplasia.

BACKGROUND AND PURPOSE: Potassium-titanyl-phosphate (KTP) laser photoselective vaporization prostatectomy (PVP) is a relatively new technology for the management of lower urinary-tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). We review our initial experience. PATIENTS AND METHODS: We prospectively evaluated our initial 12-month experience with 80 W KTP laser PVP. All had American Urological Association symptom score (AUASS), American Society of Anesthesiologists (ASA) risk score, serum prostate-specific antigen (PSA), maximum flow rate (Qmax), and postvoid residual (PVR) determinations and transrectal ultrasonography. RESULTS: There were 160 consecutive patients identified, with a mean age of 69.7 years (range 34-88 yrs) and a mean ASA score of 2.4 (range 1-4). The mean prostate volume was 72.3 cm(3) (range 20.3-261 cm(3)), with a mean PSA level of 2.2 ng/mL (range 0.1-17.9 ng/mL). Mean laser time and energy usage were 33.4 minutes (range 4-165 min) and 99.0 kJ (range 11.3-524 kJ), respectively. All were outpatient procedures with 96 (60%) patients catheter-free at discharge. Twenty-eight patients need catheter drainage for 1 week. Urinary-tract infections developed in 13 patients. Fourteen patients had clinically insignificant hematuria for more than 1 week. Bladder neck contractures that necessitated intervention developed in three patients. Three patients had persistent urinary retention. No urethral strictures or urinary incontinence were noted. Mean AUASS decreased significantly from 23 to 13, 9, 8, 7, and 6 (P < 0.05) at 1, 4, 12, 24, and 52 weeks, respectively. Qmax and PVR values also showed statistically significant improvement. CONCLUSION: Our initial results demonstrate that KTP laser PVP is safe and effective for the management of LUTS secondary to BPH.

Decreased efficiency of potassium-titanyl-phosphate laser photoselective vaporization prostatectomy with long-term 5 alpha-reductase inhibition therapy: is it true?

OBJECTIVES: 5 Alpha-reductase inhibitors (5ARIs) reduce angiogenesis in benign prostatic tissue. This has been postulated to affect the efficiency of the potassium-titanyl-phosphate (KTP) laser during photoselective vaporization prostatectomy (PVP), which has hemoglobin as its primary chromophore. We evaluate KTP laser PVP as treatment for benign prostatic hyperplasia (BPH) in patients on long-term 5ARIs. METHODS: We prospectively evaluated our initial 12 month KTP laser PVP experience with patients without or with 5ARIs. Transurethral PVP was performed with the use of an 80W KTP side-firing laser system. Voiding trials were performed 2 hours after surgery. International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and postvoid residual (PVR) were measured preoperatively and at 1, 4, 12, 24, and 52 weeks after surgery. RESULTS: One hundred sixty consecutive patients were identified, of which 117 were not on a 5ARI and 43 were on either finasteride or dutasteride for at least 6 months. Mean prostate volumes were 72.8 +/- 49.5 cm3 and 70.8 +/- 49.1 cm3 (P = 0.39), respectively. There were no significant differences in the parameters of laser time (32.0 +/- 27.6 minutes and 37.0 +/- 36.2 minutes) and energy usage (97.4 +/- 91.6 kJ and 103.3 +/- 86.0 kJ). All were outpatient procedures with the majority of patients catheter-free at discharge. All patients were able to discontinue their prostate medications after surgery. IPSS, Qmax, and PVR values showed significant improvement within each group, but the degree of improvement between the 2 groups did not show statistical significance. CONCLUSIONS: Our experience suggests that 5ARIs do not have a detrimental effect on the efficiency and efficacy of KTP laser PVP.

Percutaneous cystolithotomy of large urinary-diversion calculi using a combination of laparoscopic and endourologic techniques.

BACKGROUND AND PURPOSE: Patients with urinary diversions are at higher risk for bladder urolithiasis. Often, the stone burden is large, necessitating open stone removal. We describe our technique for removing such stones using a combination of laparoscopic and endourologic instrumentation. PATIENTS AND METHODS: With the patient in the dorsal lithotomy position or supine, cystoscopy is performed via the native urethra or catheterizable stoma, respectively. With the urinary reservoir distended with normal saline, percutaneous access is obtained under direct vision with a 10-mm trocar introduced through the scar of the previous suprapubic cystostomy. A laparoscopic entrapment bag is introduced through the trocar, into which the calculi are manipulated. The bag is delivered percutaneously through the trocar site with subsequent removal of the trocar. A 30F Amplatz renal dilator sheath (Cook Urological, Spencer, IN) is introduced directly into the bag. An ultrasonic lithotrite passed through a nephroscope is utilized to fragment and evacuate the calculi. Closure of the neocystotomy is not performed. A drainage catheter is left in for 7 days. RESULTS: This procedure has been successful in eight consecutive patients, six with bladder augmentations, one with a bladder reconstruction with appendicovesicostomy, and one with an Indiana pouch. All calculi were radiopaque, having a mean linear size of 4.1 cm (range 1.5-7.0) cm. Several patients had multiple stones. The mean operating room time was 123 minutes (range 48-228 minutes). Two patients had concomitant ureteroscopy with laser lithotripsy for ureteral calculi. All were rendered stone free with one procedure and were discharged within 23 hours after surgery. There were no immediate or delayed complications. CONCLUSIONS: Our technique of percutaneous cystolithotomy utilizing laparoscopic and endourologic instrumentation is safe and effective for the removal of large calculi from urinary diversions. It is well tolerated, allows complete stone removal in a single sitting, and obviates an open procedure.

Pediatric laparoscopic pyeloplasty: 4-year experience.

BACKGROUND AND OBJECTIVE: Laparoscopic dismembered pyeloplasty for correction of ureteropelvic junction obstruction (UPJO) in the pediatric population is comparable to open dismembered pyeloplasty in success rates. Experience with this procedure however remains limited. We review our experience with this technique. PATIENTS AND METHODS: The hospital records of consecutive patients undergoing surgery for UPJO between May 2001 and May 2005 were reviewed. Only those who underwent laparoscopic pyeloplasty for single system UPJO were included in the study. Indications for surgical correction were T(1/2) > or = 20 minutes by diethylene triamine pentaacetic acid Lasix renography or symptomatology with hydronephrosis seen on renal ultrasonography (US). RESULTS: Fifty-nine patients were identified, all of whom were treated surgically for salvageable UPJO. Four underwent percutaneous endopyelotomy for concomitant urolithiasis, 27 underwent open dismembered pyeloplasty (parent choice or under 18 months of age), and 28 underwent laparoscopic dismembered pyeloplasty. One patient had bilateral laparoscopic repairs at different times, resulting in 29 renal units that were reconstructed laparoscopically. Of these, 28 were completed. Eighteen procedures were performed on boys and 11 on girls. The mean age was 8.1 (1.6-18.9) years. The mean operating room time was 255 (157-396) minutes. Estimated blood loss was <10 mL in every patient. One patient required hospitalization longer than 23 hours because of postoperative ileus. A retroperitoneal urinoma developed in another patient, despite having a ureteral stent; it resolved with urethral catheter drainage. The first laparoscopic pyeloplasty resulted in open conversion because of failure of progression of the ureteropelvic anastomosis. At a mean follow-up of 27.9 (7.6-58.0) months, all patients demonstrated improvement of symptoms and drainage on nuclear renography or a decrease in the grade of hydronephrosis on renal US. CONCLUSION: Our series of patients undergoing laparoscopic pyeloplasty had excellent results with low morbidity. We consider this our primary technique for surgical correction of UPJO in patients older than 18 months.

Tumor recurrence incidence following hand-assisted laparoscopic nephroureterectomy.

BACKGROUND AND OBJECTIVES: We evaluated the incidence of tumor recurrence following hand-assisted laparoscopic nephroureterectomy (HALNU) for the treatment of upper tract urothelial carcinoma. METHODS: The medical records of consecutive patients who underwent HALNU by a single surgeon (CW) between October 2001 and May 2005 were reviewed. The ureter was clipped before kidney dissection to prevent distal migration of tumor. Following liberation of the kidney, the bladder cuff and intramural ureter were excised by using a Collings knife under cystoscopic guidance. RESULTS: Ten patients were identified. The primary location of disease was confined to the intrarenal collecting system. Eight high-grade (HG) and 2 low-grade (LG) tumors were removed, with pT3 (6), pT2 (1), pT1 (1), and pTa (2) disease. The patient having a LG pTa urothelial carcinoma developed pulmonary metastasis 20 months following surgery and survived an additional 26 months. Two patients, each having a HG pT3 tumor, developed a urothelial carcinoma in the bladder contralateral to the site of ureteral excision. At a mean follow-up of 41 months, there has been no evidence of tumor recurrence in the pelvis. CONCLUSION: Our technique of HALNU does not appear to harbor an increased risk for urothelial carcinoma recurrence.

Laparoscopic transabdominal transvesical vesicovaginal fistula repair.

BACKGROUND AND PURPOSE: Transabdominal transvesical repair has been the standard treatment for difficult vesicovaginal fistulae. We describe a laparoscopic transvesical technique that minimizes operative morbidity while adhering to the principles of transabdominal repair as described by O'Conner. TECHNIQUE: The patient is placed in the lithotomy position using Allen stirrups, and bilateral 5F open-ended ureteral catheters are placed cystoscopically. Using four laparoscopic ports, the prevesical space is accessed. The bladder is bivalved down to the fistula, and stay sutures are placed at the bladder edges for exposure. The fistulous tract and adjacent fibrotic tissue are excised, and the bladder and vagina are closed separately with single layers of full-thickness interrupted 2-0 Vicryl sutures. An omental flap is interposed between suture lines in the bladder and vagina. The ureteral catheters are sequentially removed on the first and second postoperative days. A gravity cystogram is performed 3 weeks postoperatively; if it is normal, the urethral catheter is removed. RESULTS: This procedure has been performed on two consecutive patients who had failed prior Latzko repairs. Both patients were discharged 2 days postoperatively without complications. At a follow-up of 41 months in the first patient and 39 months in the second, no fistula recurrence has been seen. CONCLUSIONS: Laparoscopic transvesical vesicovaginal fistula repair appears to be a safe and effective procedure that adheres to the principles of a transabdominal transvesical fistula repair while decreasing morbidity and improving cosmesis. Continued follow-up is required to determine its long-term efficacy compared with the accepted open transabdominal and transvaginal approaches.

2-stage repair in infancy for severe hypospadias with chordee: long-term results after puberty.

PURPOSE: Urinary and sexual functions were assessed in post-pubescent boys who had undergone 2-stage hypospadias repair in infancy for severe hypospadias with chordee. MATERIALS AND METHODS: A total of 44 boys who had undergone 2-stage hypospadias repair from 1985 to 1993 and who were at least 13 years old were contacted. Of the 44 boys 27 (61%) with an average age of 15.4 years (range 13 to 21) responded. Meatal locations were midshaft in 14 cases, penoscrotal in 9 and perineal in 4. Four boys had bifid scrotum and 5 had intersex disorders. Intramuscular testosterone was administered preoperatively to 15 (56%) boys. A Nesbit procedure was performed in 18 boys (67%). Average patient age at stage 2 repair was 2.3 years. Mean followup was 12.7 years (range 10.7 to 17.2). Additional surgery was performed for diverticuli in 5 cases, fistula in 3 and minor strictures in 4. Of the 27 patients 25 presented for examination and 2 responded to questionnaire only. RESULTS: All patients had normal meatal position, normal glanular anatomy, a well-defined coronal sulcus, normal cylindrical shafts without extra skin and well-defined penoscrotal junctions. Ten boys (40%) had minor spraying of stream, all stood to void and 10 (40%) milked the urethra after voiding. None had chordee. Twenty patients were able to ejaculate and 9 (42.9%) had to milk the ejaculate. Two patients (7.7%) had minor pain with erection. All subjects were satisfied with urinary, erectile and ejaculatory functions, and 23 (92%) were pleased with appearance. CONCLUSIONS: The 2-stage approach for severe hypospadias results in excellent function, cosmesis and patient satisfaction after puberty, with no chordee. Minor voiding and ejaculatory problems are to be expected. Late complications are rare. The use of extragenital skin to either primarily repair or salvage a "cripple" has not been necessary.