Safety and feasibility of the prostatic urethral lift: a novel, minimally invasive treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

OBJECTIVES: • To investigate the Prostatic Urethral Lift (PUL) procedure, a novel, minimally invasive treatment for symptomatic benign prostatic hyperplasia (BPH), which aims to mechanically open the prostatic urethra without ablation or resection. • To demonstrate the safety and feasibility of this procedure and to make an initial assessment of effectiveness. PATIENTS AND METHODS: • The PULprocedure was performed on 19 men in Australia. • Small suture-based implants were implanted transurethrally under cystoscopic visualisation to separate encroaching lateral prostatic lobes. • Patients were evaluated at 2 weeks and 3, 6, and 12 months after PUL. RESULTS: • All cases were successfully completed with no serious or unexpected adverse events (AEs). • Between two and five sutures were delivered in each patient and the prostatic urethral lumen was visually increased in all patients. • Reported postoperative AEs were typically mild and transient and included dysuria and haematuria. • Follow-up cystoscopy at 6 months in a subset of patients showed no calcification. Histological findings from two of three patients who progressed to transurethral resection of the prostate for return of symptoms showed no evidence of inflammation related to the implanted materials. • The mean International Prostate Symptom Score was reduced by 37% at 2 weeks and 39% at 1 year after PUL as compared with baseline. CONCLUSIONS: • We demonstrated in this initial experience that the PUL procedure is safe and feasible. • The safety profile of the PUL procedure appears favourable; most patients reported sustained symptom relief to 12 months with minimal morbidity • PUL therefore warrants further study as a new option for the many patients who seek an alternative to current therapies.

Successful use of steroids and ureteric stents in 24 patients with idiopathic retroperitoneal fibrosis: a retrospective study.

BACKGROUND/AIMS: Retroperitoneal fibrosis (RPF) is a chronic inflammatory disorder causing obstructive nephropathy and renal failure. We reviewed our management of this condition. METHOD: All patients with RPF treated at a single center over a 15-year period were identified. A full review of notes and computer records was undertaken. RESULTS: Data was available on 27 patients, 3 of which were excluded from later analysis. Diagnosis was based on clinical history and cross-sectional imaging. Retroperitoneal biopsy was undertaken in 3 patients. 96% had significant renal impairment at presentation with a mean serum creatinine of 688 micromol/l. 46% required emergency hemodialysis. All patients were treated with a combination of ureteric stents and/or steroids with an excellent clinical response. The mean best creatinine reached by the cohort was 136 micromol/l, and renal function remained stable in the long term. No patients required chronic dialysis. Ureteric stents were removed within 12 months and low-dose steroids were continued for a mean of 34 months. Recurrent disease was observed in 25% of patients, who all responded well to further steroid therapy. Mean duration of follow-up was 76 months. CONCLUSIONS: RPF is very effectively treated by a combination of ureteric stents and steroids, with excellent long-term results using this approach. Continued follow-up is advised because of the possibility of recurrent disease.

Drug treatments for lower urinary tract symptoms secondary to bladder outflow obstruction: focus on quality of life.

Benign prostatic hyperplasia (BPH), now referred to as lower urinary tract symptoms suggestive of bladder outflow obstruction (LUTS/BOO), is a significant cause of morbidity in ageing men. Surgery has virtually eliminated BPH-related mortality, and so the focus for men and their urologist is improvement in urinary symptoms and quality of life. Numerous tools have been developed to quantify symptoms and impact on quality of life--the most commonly used is the International Prostate Symptom Score. Sexual function and the avoidance of BPH-related complications such as acute urinary retention and surgery are also important to men--tools are available to assess sexual function but the benefits of complication avoidance are difficult to quantify. Approximately one million men in the UK have brought their symptoms to the attention of their doctor and been given a diagnosis of BPH, but extrapolation from community based studies suggests that many more (up to 2.5 million men) may have significant symptoms without seeking attention. Histopathological BPH, diminishing peak urinary flow rate, worsening lower urinary tract symptoms and increasing impact on quality of life all become more common as men age. Two groups of drugs are commonly used to treat LUTS/BOO--alpha-adrenoreceptor antagonists and 5alpha-reductase inhibitors. Both groups have been shown to improve quality of life measures in randomised, placebo-controlled trials--usually by approximately twice as much as placebo.

Minimally invasive prostatic urethral lift: surgical technique and multinational experience.

BACKGROUND: Many men with benign prostatic hyperplasia (BPH) are dissatisfied with current treatment options. Although transurethral resection of the prostate (TURP) remains the gold standard, many patients seek a less invasive alternative. OBJECTIVE: We describe the surgical technique and results of a novel minimally invasive implant procedure that offers symptom relief and improved voiding flow in an international series of patients. DESIGN, SETTING, AND PARTICIPANTS: A total of 102 men with symptomatic BPH were consecutively treated at seven centers across five countries. Patients were evaluated up to a median follow-up of 1 yr postprocedure. Average age, prostate size, and International Prostate Symptom Score (IPSS) were 68 yr, 48 cm(3), and 23, respectively. SURGICAL PROCEDURE: The prostatic urethral lift mechanically opens the prostatic urethra with UroLift implants that are placed transurethrally under cystoscopic visualization, thereby separating the encroaching prostatic lobes. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patients were evaluated pre- and postoperatively by the IPSS, Quality-of-Life (QOL) scale, Benign Prostatic Hyperplasia Impact Index, maximum flow rate (Qmax), and adverse event reports including sexual function. RESULTS AND LIMITATIONS: All procedures were completed successfully with a mean of 4.5 implants without serious adverse effects. Patients experienced symptom relief by 2 wk that was sustained to 12 mo. Mean IPSS, QOL, and Qmax improved 36%, 39%, and 38% by 2 wk, and 52%, 53%, and 51% at 12 mo (p<0.001), respectively. Adverse events were mild and transient. There were no reports of loss of antegrade ejaculation. A total of 6.5% of patients progressed to TURP without complication. Study limitations include the retrospective single-arm nature and the modest patient number. CONCLUSIONS: Prostatic urethral lift has promise for BPH. It is minimally invasive, can be done under local anesthesia, does not appear to cause retrograde ejaculation, and improves symptoms and voiding flow. This study corroborates prior published results. Larger series with randomisation, comparator treatments, and longer follow-up are underway.

Developing a robotic prostatectomy service and a robotic fellowship programme - defining the learning curve.

INTRODUCTION: Robotic radical prostatectomy (RRP) is an established treatment for prostate cancer in selected centres with appropriate expertise. We studied our single-centre experience of developing a RRP service and subsequent training of 2 additional surgeons by the initial surgeon and the introduction of United Kingdom's first nationally accredited robotic fellowship training programme. We assessed the learning curve of the 3 surgeons with regard to peri-operative outcomes and oncological results. PATIENTS AND METHODS: Three hundred consecutive patients underwent RRP between November 2008 and August 2012. Patients were divided into 3 equal groups (Group 1, case 1-100; Group 2, case 101-200; and Group 3, case 201-300). Age, ASA score, preoperative co-morbidities and indications for laparoscopic radical prostatectomy were comparable for all 3 patient groups. Peri-operative and oncological outcomes were compared across all 3 groups to assess the impact of the learning curve for laparoscopic radical prostatectomy. All surgical complications were classified using the Clavien-Dindo system. RESULTS: The mean age was 60.7 years (range 41-74). There was a significant reduction in the mean console time (p < 0.001), operating time (p < 0.001), mean length of hospital stay (p < 0.001) and duration of catheter (p < 0.001) between the 3 groups as the series progressed. The two most important factors predictive of positive surgical margins (PSM) at RRP were the initial prostate specific antigen (PSA) and tumor stage at diagnosis. The overall PSM rate was 26.7%. For T2/T3 tumors the incidence of PSM reduced as the series progressed (Group 1-22%, Group 2-32% and Group 3-26%). The incidence of major complications i.e. grade Clavien-Dindo system score ≤ III was 2% (6/300). CONCLUSION: RRP is a safe procedure with low morbidity. As surgeons progress through the learning curve peri-operative parameters and oncological outcomes improve. This learning curve is not affected by the introduction of a fellowship-training programme. Using a carefully structured mentored approach, RRP can be safely introduced as a new procedure without compromising patient outcomes.

Complications of vasectomy.

INTRODUCTION: Vasectomy is a common method of sterilisation. However, it is less popular than tubal ligation world-wide. It is also a frequent cause of litigation relating to its complications. This article reviews the early and late risks associated with the procedure. PATIENTS AND METHODS: Data collection was done using the internet to search Medline for obtaining evidence-based medicine reviews. Cross-references were obtained from key articles. Websites of government bodies and medical associations were searched for guidelines relating to vasectomy. DISCUSSION: Early complications include haematoma, wound and genito-urinary infections, and traumatic fistulae. Vasectomy failure occurs in 0-2% of patients. Late recanalisation causes failure in 0.2% of vasectomies. Significant chronic orchalgia may occur in up to 15% of men after vasectomy, and may require epididyectomy or vasectomy reversal. Antisperm antibodies develop in a significant proportion of men post-vasectomy, but do not increase the risk of immune-complex or atherosclerotic heart disease. Similarly, vasectomy does not enhance risk of testicular or prostate cancer. Vasectomy has a lower mortality as compared to tubal occlusion, but is still significantly high in non-industrialised countries because of infections. CONCLUSIONS: Vasectomy, though safe and relatively simple, requires a high level of expertise to minimise complications. Adequate pre-operative counselling is essential to increase patient acceptability of this method of permanent contraception.