Feasibility of outpatient daycase local anaesthestic Rezum™ without sedation.

BACKGROUND: Rezum™ is a relatively new bladder outflow obstruction (BOO) procedure that uses thermal energy through water vapour to cause necrosis of prostatic tissue. The standard delivery of this treatment is in an operating theatre under a general or spinal anaesthetic, or under local anaesthetic with sedation that requires patient monitoring. METHODS: We propose an outpatient daycase method of delivering Rezum™ under local anaesthetic without sedation, using a prostatic local anaesthetic block and cold local anaesthetic gel instillation into the urethra. RESULTS: Preliminary results of our first thirteen patients demonstrate the feasibility of this new technique, with a mean pain score of 2.1 out of 10 on a visual analogue scale, a successful trial without catheter in all 13 patients (one patient voided successfully on second trial), a reduction in mean International Prostate Symptom Score (IPSS) from 20.6 to 5.4, and improvement in maximum flow from 8.8 ml/s to 14.4 ml/s. The complications were minor (Clavien-Dindo less than III) and included a UTI, minor bleeding not requiring admission, and retrograde ejaculation. CONCLUSIONS: We demonstrate that an outpatient local anaesthetic daycase service without sedation is feasible. This can be delivered in a clinic setting, reduce waiting times for BOO surgery, and increase availability of operating theatre for other general anaesthetic urological procedures.

Unveiling prostatic inflammation to optimize management of lower urinary tract symptoms: a discussion with experts.

Benign prostatic obstruction (BPO) and associated lower urinary tract symptoms (LUTS) are common conditions in men, which increase in frequency and severity with age, and have a significant impact on quality of life. Chronic prostatic inflammation is increasingly being recognized as a key component of BPO. This may lead to new targets for the management of BPO/LUTS. This podcast is based on presentations from a symposium titled 'Unveiling prostatic inflammation to optimize LUTS management' held at the European Association of Urology 2023 Congress. The presenters outline evidence of a role for prostatic inflammation in the development and progression of BPO/LUTS, approaches to the identification of biomarkers of inflammation, and the implications of prostatic inflammation for the optimal management of BPO/LUTS.

The impact of surgical duration on complications after transurethral resection of the prostate: an analysis of NSQIP data.

BACKGROUND: Transurethral resection of the prostate is the most commonly performed procedure for the management of benign prostatic obstruction. However, little is known about the effect surgical duration has on complications. We assess the relationship between operative time and TURP complications using a modern national surgical registry. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2006 to 2016 for patients undergoing TURP. Patients were separated into five groups based on operative time: 0-30 min, 30.1-60 min, 60.1-90 min, 90.1-120 min, and greater than 120 min. Standard statistical analysis, including multivariate regression, was performed to determine factors associated with complications. RESULTS: 31,813 patients who underwent TURP were included. The overall complication rate was 9.0% and increased significantly with longer surgical duration (p < 0.001). Longer operative time was associated with a greater risk of postoperative sepsis or shock, transfusion, reoperation, and deep vein thrombus or pulmonary embolism. Longer surgical duration was associated with increased odds of any complication and, specifically, blood transfusion after controlling for age, race, comorbidities, American Society of Anesthesia (ASA) class, type of anesthesia administered, and trainee involvement. The adjusted risk of each of the above complications remained significantly increased for surgeries lasting longer than 120 min. CONCLUSIONS: As surgical duration increases, there is a significant increase in the rate of complications after TURP. These data demonstrate that this procedure is safest when performed in under 90 min.

Transurethral ablation of a prostatic utricle cyst with the use of a holmium laser.

OBJECTIVE: To demonstrate a safe and effective approach to the treatment of obstructing midline prostate utricle cyst with the use of a holmium laser. DESIGN: Video presentation. SETTING: University hospital. PATIENT(S): A 33-year-old man presented with chronic pelvic pain, pain with ejaculation, and infertility. Semen analysis demonstrated oligoasthenospermia with poor viability and computerized tomographic scan identified the presence of a midline 2-3-cm prostatic cyst with dilated seminal vesicles bilaterally. Transrectal ultrasound in the office confirmed the diagnosis of midline obstructing prostatic utricle cyst and estimated the distance from the urethra. INTERVENTION(S): Transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser. MAIN OUTCOME MEASURE(S): Intraoperative technique highlighting the main steps for a transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser. RESULT(S): This video highlights the technique for transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser to unroof the cyst. Retrograde vesiculography was performed to confirm patency of the ejaculatory ducts. Outpatient surgery was tolerated well and the patient was discharged. After surgery at 4 weeks, his symptoms had abated and semen analysis revealed normozoospermia. CONCLUSION(S): We demonstrate safe and effective transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser. Preoperative transrectal ultrasound or cross-sectional imaging can be useful for operative planning. When the orifices of the ejaculatory ducts can be identified, vesiculography can be performed to confirm patency of the ducts and seminal vesicles after relief of the obstructing cyst.

Treatment of Renal Fungal Ball with Fluconazole Instillation Through a Nephrostomy Tube: Case Report and Literature Review.

BACKGROUND Urinary tract candida infection can be due either to hematogenous dissemination of the organism or a retrograde infection. In debilitated or immunosuppressed septic patients, who have upper urinary tract obstruction with renal filling defect, fungal infection should be considered. We report on a patient with sepsis and renal fungal ball who was treated with percutaneous nephrostomy and intravenous antifungal agent, but the patient did not respond so instillation of fluconazole through nephrostomy was given. CASE REPORT A 60-year-old male patient with a known case of diabetes mellitus with refractory urine retention underwent transurethral resection of the prostate. Postoperatively, the patient developed recurrent high-grade fever with left loin pain, and elevated septic parameters; urine and blood culture were positive for Candida albicans. Computed tomography urography showed left hydronephrosis with filling defect in the left renal pelvis with suspected renal fungal ball. Left percutaneous nephrostomy was performed and intravenous fluconazole started but the fever did not subside, therefore, the treatment was changed to anidulafungin. The patient improved but urine from both the bladder and the nephrostomy remained positive for candida. Instillation of fluconazole at 300 mg in 500 mL normal saline was applied through the nephrostomy tube over 12 hours at 40 mL/hour for 7 days. CONCLUSIONS Renal fungal ball is rare but can be serious, especially in immunocompromised patients. Management options for renal fungal ball include intravenous antifungal agents and percutaneous nephrostomy with antifungal instillation of antifungal agents. The objective of this case report was to document treatment success with the use of fluconazole instillation through a nephrostomy tube.

[Clinical research of chronic pelvic cavity pain syndrome treated with acupoint catgut embedding therapy].

OBJECTIVE: To explore the clinical efficacy of acupoint catgut embedding therapy on chronic pelvic cavity pain syndrome differentiated as kidney deficiency and stagnation of damp heat, and explore the impacts on plasma P substance (SP), plasma beta-endorphin (ß-EP). METHODS: One hundred and eighty cases were randomly divided into a catgut embedding group (90 cases) and a western medication group (90 cases). In the western medication group, tamsulosin capsules 0. 2 mg were prescribed for oral administration, once a day; indometacin sustained release tablets, 25 mg, three times a day. Totally, the oral administration for 8 weeks was required. In the catgut embedding group, the acupoint catgut embedding therapy was applied to Qugu (CV 2), Shenshu (BL 23), Zhibian (BL 54), Huiyin (CV 1) and Sanyinjiao (SP 6), once every two weeks; the treatment of 4 weeks made one session, and two sessions were required. Before and after treatment, TCM symptom score, NIH-CPSI (the National Institute of Health Chronic Prostatitis Symptom Index) score, lecithin body numbers in prostatic fluid, score in SAS (self-rating anxiety scale), score in SDS (self-rating depression scale), the levels of SP and ß-EP, etc. were observed in the two groups, and the clinical efficacy was assessed in the two groups. RESULTS: (1) Ten cases were dropped in either group. The total effective rate was 91. 25% (73/80) in the catgut embedding group, higher than 78. 75% (63/80) in the western medication group (P<0. 05). (2) After treatment, TCM symptom score, total score in NIH-CPSI, pain score and the scores in SAS and SDS were all reduced as compared with those before treatment in the two groups (all P<0. 05). After treatment, TCM symptom score, total score and pain score in NIH-CPSI, and the scores in SAS and SDS in the catgut embedding group were both lower than those in the western medication group (all P<0. 05). (3) After treatment, the lecithin body numbers were both increased as compared with those before treatment in the two groups (both P<0. 05), and the result in the catgut embedding group was higher than that in the western medication group (P<0. 05). (4)After treatment, the SP level was lower than that before treatment in the two groups (both P<0. 05); the level of p-EP was increased as compared with that before treatment (both P<0. 05). The SP level in the catgut embedding group was lower than that in the western medication group (P<0. 05); the level of ß-EP was higher than that in the western medication group (P<0. 05). CONCLUSION: The acupoint catgut embedding therapy apparently relieves the clinical symptoms of chronic pelvic cavity pain syndrome differentiated as kidney deficiency and stagnation of damp heat as well as the condition of anxiety and depression, increases lecithin body numbers in prostatic fluid and ß-EP level and reduces SP level.

Ultrasound-guided spinal anesthesia in an obese patient.

We describe the case of 62-year-old man with a body mass index of 53, hypertension, diabetes mellitus and obstructive sleep apnea that was proposed for transurethral resection of prostate under spinal anesthesia. The surface landmark-guided approach was difficult and was abandoned after many unsuccessful attempts. Spinal anesthesia was achieved in one attempt with ultrasound guidance using the midline approach at the identified level. The trajectory was determined from the transducer angle.

TURP in the young man: is it possible to preserve the anterograde ejaculation?

INTRODUCTION: LUTS are fairly common in young men. BPO and intra-prostatic cyst localized near the bladder neck can determine a BOO in men younger than 50 years too. TURP remains the gold standard treatment, but the retrograde ejaculation or the decreased ejaculate volume after TURP was associated with considerable bother. In our study we have evaluated the possibility of obtaining a prostatic disobstruction without affecting the patient's sexual function and, specifically, the retrograde ejaculation, evaluating the sexual function after a 1-year follow-up. MATERIALS AND METHODS: 18 patients were enrolled in the study. Mean age of the patients at time of surgery was 41 years. Erectile and sexual functions have been evaluated according to the self-administered IIEF and MSHQ. Endoscopic procedure was performed with a resection of the bladder neck at 6 o'clock position followed by a resection at the 12 o'clock position. The same questionnaires were administered at 6 months and 1 year after endoscopic surgery. RESULTS: The mean baseline prostate volume was 36 mL, with a mean operative time of 22 minutes. No statistical differences were reported in IIEF and MSHQ domains at baseline and after 1 year. Qmax increased from 7.4 mL/s preoperatively to 23.6 mL/s at 1-year follow-up. CONCLUSION: In young and selected patients with prostatic obstruction, it is possible to perform a mini-invasive surgery: "Minimally Invasive Nonexpensive TURP", an effective and safe procedure, not affecting sexual function, and particularly, retrograde ejaculation.

Disorders of bladder depletion in a young man because of a prostatic cyst: a case report.

Symptomatic prostatic cysts presenting with recurrent urinary tract infections and urinary obstructive disorders in young men may be misdiagnosed as benign prostatic hyperplasia, urethral stenosis or neuropathic bladder. We report a case of a 28 year old young man with obstructive and irritative voiding disorders caused by a prostatic cyst, located in the anterior and left lateral lobe of the prostate gland. The cyst appeared to obstruct the bladder outlet by a "ball-valve" mechanism. The prostatic cyst was incised and marsupialized by transurethral resection. At post-operative follow up we observed an increase in Qmax with no residual urine and negative urine culture. The patient showed no retrograde ejaculation nor erectile dysfunction.

[Prostatic retention cyst around the bladder neck: a case report].

We report a case of a prostatic retention cyst around the bladder neck causing prostatitis-like symptoms. A 34-year-old man was referred to our hospital for treatment of a cystic lesion in his prostate and prostatitis-like symptoms such as pollakisuria, dysuria and pain on urination. Blood examination and urinalysis showed neither systemic inflammation nor urinary tract infection. Transrectal ultrasonography (TRUS), magnetic resonance imaging (MRI) and cystoscope revealed a projecting prostatic cyst which occupied the bladder outlet and seemed to cause the prostatitis-like symptoms. Transurethral resection of the cyst was performed and the symptoms were markedly improved. Histopathologically, the cyst was retention cyst of the prostate.

[Ejaculatory duct obstruction]. / Obstrucción de conductos eyaculadores.

BACKGROUND: Prostatic cysts are rare lesions with a reported incidence from 1 to 7.9%. They have been associated with primary infertility. The main characteristic is the benign course and positive prognosis after correct surgical management. CLINICAL CASES: We present three clinical cases, two with primary infertility and another with a history of primary infertility who presented with recurrent hemospermia and refractory medical treatment. All patients had hypospermia and alteration of the seminal parameters represented by moderate oligospermia (MOS), asteno- and teratozoospermia, in addition to hemospermia in two patients. Diagnosis was confirmed by transrectal ultrasound. Transurethral resection (TUR) of the cyst was performed in two cases and resection of the veru montanum in one, obtaining improvement in the seminal parameters after 1 month of follow-up and acceptable parameters for spontaneous conception at 6 months. CONCLUSIONS: Infertility associated with partially obstructed ejaculatory ducts may be suspected clinically by hypospermia. Transrectal ultrasound is essential to confirm the diagnosis. TUR of this lesion reestablishes the free passage of semen in almost all patients, with potential recovery of fertility 6 months after treatment.

Obstrucción de conductos eyaculadores / Ejaculatory duct obstruction

BACKGROUND: Prostatic cysts are rare lesions with a reported incidence from 1 to 7.9%. They have been associated with primary infertility. The main characteristic is the benign course and positive prognosis after correct surgical management. CLINICAL CASES: We present three clinical cases, two with primary infertility and another with a history of primary infertility who presented with recurrent hemospermia and refractory medical treatment. All patients had hypospermia and alteration of the seminal parameters represented by moderate oligospermia (MOS), asteno- and teratozoospermia, in addition to hemospermia in two patients. Diagnosis was confirmed by transrectal ultrasound. Transurethral resection (TUR) of the cyst was performed in two cases and resection of the veru montanum in one, obtaining improvement in the seminal parameters after 1 month of follow-up and acceptable parameters for spontaneous conception at 6 months. CONCLUSIONS: Infertility associated with partially obstructed ejaculatory ducts may be suspected clinically by hypospermia. Transrectal ultrasound is essential to confirm the diagnosis. TUR of this lesion reestablishes the free passage of semen in almost all patients, with potential recovery of fertility 6 months after treatment.

[Effect of Goshajinkigan on storage symptoms in prostatic disease--fundamental researches of Chinese herbal medicine for voiding dysfunction and its future aspects].

At present, patients with lower urinary tract symptoms, including storage symptoms, caused by prostatic disease are predominantly treated with alpha1-adrenoceptor antagonist and anticholinergic agents. However, some patients are not improved by this treatment. We investigated the efficacy of Goshajinkigan in 25 patients with prostatic disease in whom pollakisuria was not improved by treatment with drugs for lower urinary tract symptoms. The urinary frequency was significantly improved both in the daytime and at night. The parameters of uroflowmetry, the residual urine volume, the international prostate symptom score and QOL score were also improved after therapy. It was considered that the pollakisuria was improved by Goshajinkigan induced activation of spinal kappa-opioid receptors, which inhibited the micturition reflex via blunting of bladder sensation. The inhibition of C-fiber and the down regulation of Fos protein in the pontine micturition center were also suggested to be related with improvement ofpollakisuria. Chinese herbal medicine therapy is different in various aspects from Western medicine. Clarification of the mechanisms of Chinese herbal medicine and Sho (patient status in Chinese herbal medicine) is awaited.

Comparación de complicaciones por sangrado en resección transuretral de próstata con y sin participación de residentes / Comparison of complications for bleeding in transurethral resection of prostate with and without participation of residents

Introduction: transurethral resection of the prostate (TURP) is still the gold standard treatment of prostatic obstruction. The objective of the present study is to compare the bleeding complications of TURP with and without the participation of residents. Material and methods: The data was obtained from a prospective protocol that included 200 patients submitted to TURP. Eleven patients were excluded from the study (5,5 percent). No patient was lost from follow-up. Results: Were viewed 189 surgeries, 46 with resident participation (24,3 percent). The operations performed by residents were more prolonged, and required more days with bladder drainage. The following bleeding complications were observed: 1) Bladder catheter washing to solve obstruction by clots: 11,6 percent, 2) Endoscopic revision in severe hematuria: 2,6 percent, 3) Readmission to the hospital in complete urinary retention secondary to clots: 2,1 percent and 4) Blood transfusion: 2,1 percent. The transfusion rate was significantly higher in resident surgeries (6,5 percent versus 0,7 percent, p=0,045), without differences in the other bleeding complications. Conclusion: The rate of bleeding complications is comparable to that recently published. Applying strict criterion for blood transfusion, no difference was observed between the groups. At our institution, the process of teaching and learning TURP does not increase significantly the risk of bleeding complications.

[The efficacy of Gosyajinkigan for pollakisuria].

We investigated the efficacy of Gosyajinkigan in 20 patients with prostatic disease, in whom pollakisuria was not improved by treatment with drugs for lower urinary tract symptoms. Four and 8 weeks after treatment, the urinary frequency was significantly improved during both daytime and night. The efficacy rates for diurnal frequency and nocturia were 45% and 65%, respectively. The International Prostate Symptom Score (IPSS) was decreased 4 weeks after treatment, and the parameters of uroflowmetry, the residual urine volume and quality of life score were improved 8 weeks after therapy. It was concluded that Goshajinkigan was effective for pollakisuria with prostatic disease, and the administration of the agent for 8 weeks or longer was needed to improve lower urinary tract symptoms.

Intraurethral prostatic cyst: a rare cause of infravesical obstruction.

A case is reported here of symptomatic intraurethral anterior midline prostatic cyst in a 52-year-old man whom transurethral resection of the cyst was performed successfully establishing the resolution of voiding symptoms.

Thick vs thin loop transurethral resection of the prostate: a double-blind prospective trial of early morbidity.

OBJECTIVE: To compare blood loss, irrigation requirements and hospital stay between standard transurethral resection of the prostate (TURP) and resection incorporating vaporization, i.e. transurethral vaporization resection (TUVRP). PATIENTS AND METHODS: Seventy patients were prospectively randomized in a blinded fashion between TURP with a standard resection loop (thin loop) or resection with a roller cutting electrode (thick loop). The outcome was assessed as the change in haemoglobin at 30 min and 24 h after the resection finished. Secondary outcome measures were irrigation requirements, length of catheterization, hospital stay, changes in serum sodium, and complications. The nursing staff and surgical registrar managing the patients after surgery were unaware of the resection technique used. RESULTS: Data were available for 65 patients (36 thin loop and 29 thick loop resections). The mean decrease in haemoglobin after TURP was 14.8 g/L at 30 min and 11.8 g/L at 24 h; for TUVRP the corresponding values were 14.6 and 14.2 g/L (P = 0.69). In addition, there was no difference in irrigation requirements, changes in serum sodium, length of catheterization, hospital stay or bleeding complications. CONCLUSION: The use of a thick loop at higher cutting current settings during TUVRP offers no advantage over standard thin-loop TURP.

Transurethral microwave thermotherapy of nonbacterial prostatitis and prostatodynia: initial experience.

OBJECTIVES: To report our early experience using transurethral microwave thermotherapy (TUMT) to treat patients with nonbacterial prostatitis (NBP) and prostatodynia. METHODS: Nineteen patients with NBP (symptoms, negative cultures, no response to antibiotics, leukocytosis in expressed prostatitic fluid) and 5 patients with prostatodynia (symptoms, negative cultures, no response to antibiotics, no leukocytosis in expressed prostatitic fluid) were treated with TUMT at interstitial temperatures of 45 degrees to 60 degrees C for 1 hour. Response was assessed by a consistent symptom severity index and global assessment of symptoms. RESULTS: A marked and significant early (3 months) favorable response was noted in nearly one half of the NBP group but little benefit was found in the prostatodynia group. The treatment was associated with few adverse experiences. CONCLUSIONS: TUMT appears to be a potentially effective therapy for NBP, but its real efficacy as well as the durability of the response needs to be confirmed with a randomized double-blind sham-controlled trial.

Norfloxacin in the treatment of urinary tract infections in men with and without identifiable urologic complications.

A retrospective analysis of data from the treatment of 95 men with nonbacteremic urinary tract infections (UTIs) (clean-catch urinary bacterial count greater than or equal to 10(5) colony-forming units/ml) who received norfloxacin (400 mg orally twice daily) was performed. Treatment duration ranged from a required minimum of seven days to a maximum of 30 days. If an underlying anatomic or functional condition existed that might decrease the likelihood of a favorable medical response and/or require prolonged treatment, the patient's UTI was considered "complicated." In addition to eight patients with polymicrobic UTIs (usually involving enterococci or Pseudomonas aeruginosa), 48 men (i.e., 51 percent of the total population) had an identifiable complication. Complications included benign prostatic hypertrophy in 13 patients; prostatic cancer in four; urethral stricture in four; quadriplegia/paraplegia with indwelling urinary catheter in four; prostatism in three; and other conditions commonly recognized as altering the response to antibiotic treatment. Among the 95 patients treated, 76 (80 percent) were considered to have had a cure and five (5 percent) showed improvement. Fourteen patients (15 percent) failed to show a response to treatment. Of the 48 patients with UTI and defined complications, 36 (75 percent) had a cure, three (6 percent) showed improvement, and therapy failed in nine (19 percent). Ninety-seven percent (105 of 108) of the pretreatment bacterial isolates were susceptible to norfloxacin. In addition to the three resistant organisms that were present prior to therapy, three organisms (two P. aeruginosa and one Enterobacter) persisted and acquired resistance during therapy. Five adverse clinical experiences and six adverse laboratory experiences were noted. Only one of the former (mild heartburn) was thought to be drug related, and no adverse experience was considered serious or required discontinuation of treatment. Gastrointestinal tolerability of oral norfloxacin was good.