Comparison of Holmium Laser Prostate Enucleation Outcomes in Patients with or without Preoperative Urinary Retention.

PURPOSE: We determine whether outcomes of holmium laser enucleation of the prostate are similar in patients with and those without preoperative urinary retention. MATERIALS AND METHODS: From May 2008 to July 2014, 231 patients underwent holmium laser prostate enucleation for symptomatic benign prostatic hyperplasia. Retrospective analysis was performed to evaluate for differences in postoperative outcomes for patients with and those without preoperative urinary retention. RESULTS: Overall 95 patients (41%) had urinary retention before holmium laser prostate enucleation while 136 (59%) did not. Mean followup for all patients was 15.3 months. Patients with retention tended to be older, have larger prostates, and have higher scores on the AUA SS and bother questionnaires (all p <0.05). Postoperatively there was no difference in rates of complications, including urinary retention. Both groups showed significant improvement in AUA SS and bother score after the procedure at all postoperative points. Median post-void residual was less than 60 ml and median maximum flow rate on uninstrumented uroflow was greater than 18 ml per second at all postoperative points for all patients regardless of preoperative retention status. No patients required long-term catheterization and rates of postoperative complications did not differ significantly during the followup period. CONCLUSIONS: This study represents the first direct comparison to our knowledge of holmium laser prostate enucleation outcomes in patients with or without urinary retention. There was no increased risk of postoperative urinary retention in patients with preoperative retention, and both groups demonstrated significant postoperative improvement in subjective and objective voiding measures.

A pilot ex vivo evaluation of a telerobotic system for transurethral intervention and surveillance.

INTRODUCTION: Transurethral resection of bladder tumor (TURBT) and pathological staging are both standard surgical therapies for nonmuscle-invasive bladder cancer and integral parts of the diagnostic evaluation and progression monitoring of all bladder tumors. We developed and tested a dexterous robot that can fit through a standard resectoscope for evaluation for possible en bloc resection of bladder tumors, especially tumors along the dome and anterior wall of the bladder. MATERIALS AND METHODS: Our dexterous robot uses a continuum (snake-like) mechanical architecture with three working channels through which a fiberscope, biopsy graspers, and a holmium laser were placed. The continuum robot has two segments. Using indigo carmine, injections were performed through the detrusor muscle into the mucosa of the ex vivo bovine bladders at a total of 11 positions throughout all quadrants of the bladder. The snake robot was used in conjunction with the holmium laser to ablate nine of the lesions; two additional lesions were resected en bloc using the grasper and the laser down through the muscle layer. RESULTS: Both experiments showed that the robotic system was able to directly visualize all 11 targets. In both the bladders, we were able to resect en bloc two tumors using the grasper and 200 µm holmium laser fiber down to the muscle layer indicating a good resection. All of the other targets were completely ablated using the holmium laser. CONCLUSION: The dexterous robot allowed for visualization as well as provided adequate ablation and en bloc resection of bladder lesions throughout the entire bladder.

Robotic-assisted sacrocolpopexy for pelvic organ prolapse.

The demand for surgical correction of pelvic organ prolapse is expected to grow as the aging population remains active and focused on quality of life. Definitive correction of pelvic organ prolapse can be accomplished through both vaginal and abdominal approaches. This article provides a contemporary reference source that specifically addresses the historical framework, diagnostic algorithm, and therapeutic options for the treatment of female pelvic organ prolapse. Particular emphasis is placed on the role and technique of abdominal-based reconstruction using robotic technology and the evolving controversy regarding the use of synthetic vaginal mesh.

Adequate or not? A comparison of 24-hour urine studies for renal stone prevention by creatinine to weight ratio.

PURPOSE: The intent of this study was to compare urine parameters between kidney stone formers with low, expected, and high creatinine to weight ratio (Cr/kg) and to discuss implications for treatment. PATIENTS AND METHODS: In this retrospective study, 381 stone formers (205 females and 176 males) with urine collections for nephrolithiasis evaluation were included. Using the first collected sample, patients were grouped into low, expected, and high Cr/kg using sex appropriate reference ranges (15.0-20.0 mg/kg for females and 18.0-24.0 mg/kg for males) and evaluated. RESULTS: Of initial collections, 50.7% were outside the Cr/kg reference range. Median age increased as Cr/kg decreased with 13 years age difference between low (56) and high (43) groups. Body mass index and weight also increased significantly with decreased ratio. No significant difference between groups was found for urine volume, total oxalate, oxalate concentration, pH, and supersaturations of calcium oxalate and uric acid. Total calcium, sodium, citrate, calcium concentration, supersaturation of calcium phosphate, and other parameters significantly increased with increased Cr/kg for the cohort. CONCLUSIONS: To our knowledge, this is the first study to thoroughly evaluate the impact of Cr/kg on urine parameters. Clinicians should be cognizant of limitations of Cr/kg for evaluating collection adequacy. It is especially important to consider Cr/kg when there is potential for undertreatment or overtreatment of patients with abnormal Cr/kg. Studies demonstrating hypercalciuria and high Cr/kg may need to be repeated before starting thiazide diuretics. Further studies are needed to determine how to better interpret urine components that vary with Cr/kg ratio.

LESS and NOTES: rationale and terminology.

Laparoendoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) are emerging platforms to further reduce the invasive profile of surgery. As feasibility of an increasing array of procedures in both platforms is being demonstrated, with out comes comparable to multiport laparoscopy, there has been a parallel proliferation of concepts, terminology and technology. In this article, we describe the rationale behind the evolving paradigm shift towards truly "scarless" surgery and address the terminology associated with these surgical approaches.

Single incision mid-urethral sling for treatment of female stress urinary incontinence.

OBJECTIVES: To present the longitudinal outcomes in an observational cohort of patients who had undergone treatment of stress urinary incontinence with a single incision mid-urethral sling (MUS). METHODS: A prospective, observational study of all female patients who had undergone surgical intervention with the MiniArc MUS was performed. The surgical candidates underwent history and physical examination and urodynamic testing, as indicated. Quality of life questionnaires (Urogenital Distress Inventory [UDI-6] and Incontinence Impact Questionnaire [IIQ-7]) were administered preoperatively. The salient operative data were recorded. The patients were followed up postoperatively for evidence of treatment success and adverse events. The patients completed the UDI-6, IIQ-7, and Female Sexual Function Index questionnaires at 1 and 12 months after treatment. RESULTS: From September 2007 to October 2008, 120 patients underwent placement of the MiniArc MUS for the treatment of stress urinary incontinence. The mean patient age was 58.4 years. The mean body mass index was 27.2 kg/m(2). The mean preoperative daily pad use was 2.4. The mean preoperative IIQ-7 and UDI-6 score was 86.58 and 62.5, respectively. Of the 120 patients, 108 (90%) completed a minimum follow-up period of 12 months. Of these 108 patients, 101 (94%) were cured/dry. The mean postoperative pad use was 0.2 (P < .001). The mean IIQ-7 and UDI-6 score was 13.32 (P < .001) and 12.5 (P < .001), respectively. The Female Sexual Function Index results demonstrated no discomfort with intercourse in 49%, occasional discomfort in 9%, and frequent discomfort in 2%. The remaining 40% of our patients were not sexually active. CONCLUSIONS: Our results have shown that the MiniArc MUS offers excellent outcomes that are durable at 1 year after treatment.

Short-term efficacy of botulinum toxin a for refractory overactive bladder in the elderly population.

PURPOSE: We determined the efficacy of intravesical botulinum toxin A injection for refractory overactive bladder in elderly patients. MATERIALS AND METHODS: Patients 75 years or older with refractory urinary urgency were prospectively evaluated and offered treatment of symptoms with botulinum toxin A. A voiding log was obtained and urodynamics were performed before treatment. Patients underwent injection of 200 U botulinum toxin A (Botox(R)) into the detrusor muscle at 20 sites under cystoscopic guidance. Patients were followed postoperatively for evidence and duration of success, and treatment related complications. RESULTS: From January 2006 to June 2007, 18 females and 3 males with a mean age of 81.2 years (range 75 to 92) in whom detrusor overactivity was confirmed on urodynamics and who were refractory to or intolerant of antimuscarinics were treated with intravesical botulinum toxin A. Preoperatively the mean +/- SD number of daily voids was 11.4 +/- 1.67 and the mean number of pads per day was 4.0 +/- 0.89. One month after treatment 16 of the 21 patients (76%) reported greater than 50% improvement in symptoms after 1 injection. Specifically there was a significant improvement in the mean number of voids per day (5.19 +/- 0.83, p <0.001) and in the number of pads used daily (1.3 +/- 0.60, p <0.001). Two of the remaining 5 patients demonstrated greater than 50% improvement following repeat injection, while 3 did not show improvement after 2 injections. Mean time to deterioration was 7.12 months. There were no treatment related complications. CONCLUSIONS: Intravesical botulinum toxin A for detrusor overactivity in the elderly population appears to be efficacious and durable. Given its low incidence of adverse events, it should be considered a viable treatment option in this population.