Trans-urethral bladder suture in female patients: Not a tour de force but a quick and realistic answer to complex situations.

INTRODUCTION: Trans-urethral bladder surgery has gained popularity in the fields of electro-resection and laser lithotripsy, with endoscopic suturing being overlooked. Bladder defect closure using a pure trans-urethral suturing technique can provide a quick and effective solution in situations where conventional management options are not feasible. METHODS: Here we describe this innovative novel technique developed by our group that was used to treat two different cases with bladder perforation at two different institutions. We used a 5 mm laparoscopic port with gas insufflation and a laparoscopic needle holder trans-urethrally to achieve defect closure with a monofilament 2/0 monocryl mattress suture on a small 22 mm needle. RESULTS: The defects were successfully closed without any intraoperative complications. Average operative time for the technique was 18 min with minimal blood loss. Bladder closure was sustained at a median follow-up of 2 years for one of these cases. CONCLUSIONS: We claim that transurethral bladder suturing is quick, safe in expert hands and provides an effective option where the clinical condition/situation of the patient warrants a minimally invasive surgery approach.

Robotic assisted laparoscopic radical prostatectomy following open trans-vesical adenomectomy: A single centre experience and review of the literature.

INTRODUCTION: Robotic assisted laparoscopic radical prostatectomy (RALRP) following endoscopic resection of the prostate is known to be feasible with good outcomes. However, the literature evidence is limited on the feasibility and outcomes of RALRP following open prostatic surgery. In this study, our aim was to report our experience with RALRP in patients who had undergone trans-vesical adenomectomy of the prostate in the past. PATIENTS AND METHODS: We reviewed our prospectively maintained database of men treated with RALRP at our institution to identify patients with previous history of open suprapubic trans-vesical adenomectomy, between 2016 and 2020. Data were collected on demographic information, interventions, oncological outcomes and follow-up. RESULTS: Out of 362 patients, four individuals were identified that had previous open suprapubic trans-vesical adenomectomy. The mean age was 71 years with a mean pre-operative prostate specific antigen (PSA) of 11.35 ng/ml, and an average of 10 years after their trans-vesical adenomectomy. The mean console time was 119 min with an average estimated blood loss of 137.5 ml and 75% underwent lymphadenectomy. Post-operatively, all patients were discharged after 1 day with their urinary catheters removed at 7 days post-op. For one of the patients, a urine leak was identified, and his pelvic drain was removed at 5 days instead of 1 day as for the other three patients. No other complications were noted within 30 days. The average prostate weight was 54.7 g with all specimens being T3a R0. At 6 weeks follow-up, PSA was undetectable, three patients reported full continence and 1 was using two pads/day. CONCLUSION: RALRP following previous open trans-vesical prostatectomy is feasible and safe with excellent oncological outcomes. They are, however, more challenging and cumbersome with increased console time.

Eroded Tape: A Case of an Early Vesicoscopy Rather Than Laser Melting.

OBJECTIVE: To report our experience on vesicoscopic excision of eroded foreign material in the bladder. MATERIALS AND METHODS: The use of xenografts in female urology is becoming more prevalent and so are their complications. Erosion of foreign material into the bladder often goes unrecognized for a long time and patients are troubled by irritative urinary symptoms, recurrent infections, and stone formation. The treatment of such erosions is traditionally reported through the transurethral route using laser or electrocautery to cut the foreign material. Such methods have a high rate of incomplete material removal and as a result a high recurrence rate. Leaving a urothelial defect results in prolonged time to symptom resolution. Between 2012 and 2015, 5 patients with eroded tapes were referred for tertiary care to King's College Hospital and Ygia Polyclinic; all patients had undergone a variety of endoscopic, vaginal, and/or open attempts for mesh removal that failed. We offered vesicoscopic excision of the eroded portion of the tape. RESULTS: We here report 5 cases with tape erosions referred to our team that were treated with vesicoscopic excision of the material and primary closure of the urothelial defect. The foreign material was completely removed in all cases and there is no recurrence at a median follow-up of 30 months. CONCLUSION: Vesicoscopic excision of bladder-eroded foreign material is feasible and efficient. We recommend this technique to be considered as a primary approach to tapes eroding into the bladder.

When Physical Examination Signs Point to Sinister Causes.

A 55-year-old male presented with mild abdominal discomfort. On physical examination, a right upper quadrant abdominal mass was palpable and an obstructed right varicocele was evident. Ultrasonography and computed tomography revealed a 15 cm right renal tumor with a 2 cm aortocaval lymph node. The patient underwent an uneventful laparoscopic transperitoneal radical nephrectomy and lymphadenectomy and was discharged after 2 days. No complications or recurrence were noted at 6 months follow-up. This report signifies the importance of physical examination and attention to cardinal clinical signs and also the feasibility of laparoscopy in large renal tumor in expert hands.

Combined vaginal and vesicoscopic collaborative repair of complex vesicovaginal fistulae.

INTRODUCTION: This study aimed to describe and demonstrate the feasibility of a minimally invasive surgical technique for the repair of complex vesicovaginal fistulae that may not be amenable to vaginal repair. TECHNICAL CONSIDERATIONS: Nine cases of vesicovaginal fistulae, which were repaired laparoscopically at King's College Hospital, London and Ygia Polyclinic Private Hospital, Limassol between 2011 and 2013, were identified. The repair was carried out by direct placement of the ports into the urinary bladder (vesicoscopy). Preoperative, intraoperative, and postoperative data were collected from a prospective database. All 9 operations were completed without any conversion to open surgery. Four ureteric reimplantations were necessary for ureteric involvement. There were no intraoperative complications but some intraoperative technical difficulties. No early postoperative complications were documented, and the hospital stay varied from 2 to 8 days. The fistula repair success rate was 89% at a median follow-up of 30 months. CONCLUSION: This surgical technique is feasible and offers an alternative approach to the classical open or laparoscopic transperitoneal approach. It supplements the vaginal approach for fistulae that are not suitable for pure vaginal approach, allowing close collaboration between the laparoscopic urologist and the vaginal surgeon.

Giant benign prostatic hyperplasia in a young adult male.

A 27-year-old Caucasian male presented with lower urinary tract symptoms and hemospermia. Magnetic resonance imaging revealed a prostate of 180 mL. The patient underwent open transvesical prostatic enucleation with preoperative and postoperative histopathologic examinations consistent with benign prostatic hyperplasia. Benign prostatic hyperplasia is a very rare condition at this age group, with this patient being the youngest non-Asian confirmed case in the literature.

Prostate specific antigen through the years.

PSA was first identified in the 1960s. Some controversy exist as to who should be credited with its discovery as different groups, simultaneously, isolated the same protein but gave it a different name. PSA was firstly approved by FDA in 1986 as a test to aid the management of patients diagnosed with prostate cancer. In 1994, it was approved by the FDA as a diagnostic tool and up to date its beneficial role as a screening test is largely unknown. The results of the PLCO and ERSPC trials are awaited. Increasing interest is also emerging on the use of PSA as a tool in the management of BPH. Recently some embryonic data on the use of other novel markers such as EPCA and prostasomes is emerging and the data on PCA3 as a diagnostic tool for prostate cancer is maturing.

Simultaneous transurethral resection of bladder tumour and prostate: is it safe?

OBJECTIVES: This study aims to review and assess the safety of carrying out transurethral resection of prostate (TURP) and transurethral resection of bladder tumour (TURBT) simultaneously, in men who require TURP for bladder outflow obstruction and are incidentally found to have a transitional cell carcinoma of the bladder. METHODS: A detailed Medline search between 1966 and 2005 identified only five published papers in the English literature addressing this subject. These were retrospective studies of small numbers and were analysed together in order to quantify the risk of bladder cancer recurrence that could be attributed to TURP. The anatomical area of interest for tumour recurrence was hence the bladder neck and prostatic urethra. RESULTS: 424 patients had simultaneous TURBT and TURP, whereas 350 had TURBT alone. The rate of recurrence of bladder tumour in these two groups of patients was 58 and 63%, respectively. The recurrence rate at the bladder neck and prostatic urethra was equally comparable. Tumour grade and multiplicity do not appear to influence the tumour recurrence rate when TURP is carried out at the same time as TURBT. CONCLUSIONS: There is paucity of clinical evidence to support the theoretical risk of tumour cell implantation at the bladder neck and prostatic urethra when TURP is carried out at the time of TURBT.

The 12-year outcome analysis of an endourethral wallstent for treating benign prostatic hyperplasia.

OBJECTIVE: To evaluate the long-term results of using the Urolume(TM) endourethral prosthesis (American Medical Systems, Minnetonka, MN, USA) for managing benign prostatic hyperplasia (BPH), an alternative minimally invasive option. PATIENTS AND METHODS: Sixty-two patients with moderate/severe lower urinary tract symptoms secondary to BPH were treated with the Urolume stent by one surgeon (J.H.P.). They were followed up at 12 weeks, 6 months and then yearly. Data recorded before and after treatment included symptom scoring, peak urinary flow rate (PFR) and postvoid residual volume (PVR). A one-way anova was used to compare baseline and the 5- and 12-year follow-up data. RESULT: Twenty-two and 11 patients completed the 5- and 12-year follow-up, respectively. Twenty-one (34%) patients died with the stent in situ from causes unrelated to BPH and Urolume insertion. Twenty-nine (47%) stents were removed; 18 in the first 2 years, seven at 3-5 years and four at 9-10 years. Early stent explantation was primarily a result of poor case selection, or stent malposition/migration. Four stents were removed because the patient was dissatisfied. Late stent explantation was for symptom progression. At 5 years, the symptom score and PFR were 6.82 an 11.7 mL/s, respectively, compared with 20.4 and 9 mL/s at basleine (P < 0.05); at 12 years, the symptom score, PFR and PVR were 10.82, 11.5 mL/s and 80 mL, respectively. The mean quality of life score was 2 and no patient opted for any further treatment. CONCLUSION: The Urolume wallstent is a safe treatment for BPH, in selected patients. Careful case selection and experience is mandatory. This stent can provide the urologist with an alternative along with other minimally invasive treatments for men with BPH at high risk of requiring transurethral resection.