RESUMEN
OBJECTIVE: The aim of the study was to compare procedural efficacy, early and late functional outcomes in holmium laser enucleation of the prostate (HoLEP) under spinal anesthesia (SA) versus general anesthesia (GA). METHODS: We retrospectively reviewed patients undergoing HoLEP at our institution between 2012 and 2017. Standard pre-, peri-, and postoperative characteristics were compared according to anesthetic technique. Multivariable logistic regression analyses (MVAs) were employed to study the impact of SA on procedural efficacy and postoperative complications. RESULTS: Our study cohort consisted of 1,159 patients, of whom 374 (32%) underwent HoLEP under SA. While a medical history of any anticoagulation/antiplatelet therapy except low-dose acetylsalicylic acid was significantly more common among patients undergoing GA (16% vs. 10%, p = 0.001), no other significant differences in preoperative characteristics were noted including age, body mass index, American Society of Anesthesiologists Classification (ASA), prostate size, or International Prostate Symptom Score (IPSS), and quality of life scores. Patients under SA exhibited shorter times of enucleation 42 min (interquartile range [IQR]:27-59 vs. 45 min [IQR: 31-68], p = 0.002), and combined time of enucleation/morcellation/coagulation (57 min [IQR: 38-85] vs. 64 min [IQR: 43-93], p = 0.002), as well as fewer complications (Clavien-Dindo ≥3) (12 [3.2%] vs. 55 [7%], p = 0.013). These associations were confirmed in MVA. Patients did not differ significantly with regard to early micturition including post-void residual volume and maximum flow-rate improvement. At a median follow-up of 33 months (IQR: 32-44), patients with SA had a lower IPSS score (median 3 [IQR: 1-6] vs. 4 [IQR: 2-7], p = 0.039). However, no significant differences were observed with respect to any urinary incontinence, urge symptoms, and postoperative pain. CONCLUSION: In this large retrospective series, HoLEP under SA was a safe and efficacious procedure with comparable early and long-term functional outcomes.
Asunto(s)
Anestésicos , Terapia por Láser , Láseres de Estado Sólido , Hiperplasia Prostática , Masculino , Humanos , Próstata/cirugía , Estudios Retrospectivos , Hiperplasia Prostática/cirugía , Hiperplasia Prostática/complicaciones , Láseres de Estado Sólido/uso terapéutico , Calidad de Vida , Terapia por Láser/métodos , Holmio , Anestesia General , Resultado del TratamientoRESUMEN
Purpose: Apart from the existing level-one evidence, few centers have reported on long-term outcomes after Holmium Laser Enucleation of the Prostate (HoLEP). Against this backdrop we aimed to report on our treatment experience and identify predictors of persistent/recurrent lower urinary tract symptoms (LUTS) after the procedure. Materials and Methods: From 2006 to 2017, 2566 men underwent HoLEP at our institution. Only patients with available, cross-sectional follow-up (F/u) ≥6 months were included. Perioperative and F/u characteristics were compared by duration of F/u in months (quartiles). Multivariable logistic regression models (MVAs) were used to identify predictors of persistent/recurring symptoms, defined as International Prostate Symptom Score (IPSS) >7 at F/u. Results: A total of 774 patients with a median age of 70 years (interquartile range [IQR] = 66-75), prostate volume of 80 mL (IQR = 60-105), American Society of Anesthesiologists score 2 (IQR = 2-3), IPSS of 19 (IQR = 14-24), and quality of life (QoL) of 4 (3-5) at the time of operation were analyzed. Median F/u was 52 months (IQR = 32-77), overall current median prostate-specific antigen was 0.91 mg/dL (0.5-1.8), median IPSS and QoL were 3 (IQR = 1-7) and 1 (IQR 0-2), respectively. LUTS medication was present in 20 patients (2.6%), 15 (2%) patients required reoperation, and permanent urinary incontinence was present in 17 (2.2%) patients. On MVA age at operation (odds ratio [OR] = 1.04; 95% confidence interval [CI], 1.01-1.1; p = 0.013), prostate volume (OR = 0.99 [95% CI, 0.98-0.99;], p = 0.003), body mass index (OR = 1.06 [95% CI, 1.0-1.1], p = 0.043), presence of indwelling catheter (OR = 0.51 [95% CI, 0.32-0.81], p = 0.004), and anticholinergics before procedure (OR = 1.74 [95% CI, 1.01-3.0], p = 0.046) were predictors of persistent/recurring symptoms. Conclusions: Our HoLEP experience confirms durable and profound symptom relief in the vast majority men. A small fraction of patients complained about subjective persistent/recurring LUTS stressing the need for proper patient selection and timing of surgical intervention.
Asunto(s)
Terapia por Láser , Láseres de Estado Sólido , Síntomas del Sistema Urinario Inferior , Hiperplasia Prostática , Resección Transuretral de la Próstata , Masculino , Humanos , Anciano , Próstata/cirugía , Calidad de Vida , Láseres de Estado Sólido/uso terapéutico , Holmio , Estudios Transversales , Hiperplasia Prostática/cirugía , Resección Transuretral de la Próstata/métodos , Terapia por Láser/métodos , Síntomas del Sistema Urinario Inferior/etiología , Síntomas del Sistema Urinario Inferior/cirugía , Recurrencia , Resultado del TratamientoRESUMEN
A transurethral prostate biopsy device is proposed in this paper, which can shoot a biopsy needle at different angles to take samples from multiple locations within the prostate. Firstly, the traditional prostate biopsy methods, including transrectal prostate biopsy and transperineal prostate biopsy, are introduced and compared. Then, the working principles of the new prostate biopsy procedure are illustrated. The designs of the needle bending system and the flexible needle are presented, and a proofs-of-concept study of the robotic biopsy device is demonstrated. Design parameters, material selection, and control unit are introduced. Experiments are carried out to test and demonstrate the functions of the prototype. Theoretical and measured bending angles are compared and analyzed. The bending system can effectively bend the biopsy needle to any angle between 15 and 45°. The penetration force of the biopsy needle decreases with the increase of the bending angle. The range of rotation of the bending system on one hemisphere is ±25°. Together with the translational motion, the biopsy needle can reach any point within the workspace. Finally, a phantom test and a cadaver experiment were carried out to simulate biopsy.
Asunto(s)
Neoplasias de la Próstata , Robótica , Biopsia con Aguja , Humanos , Biopsia Guiada por Imagen , Masculino , Fantasmas de Imagen , PróstataRESUMEN
The development and widespread implementation of modern endourological procedures for the treatment of benign prostatic hyperplasia (BPH) has led to a significant reduction in postoperative complications, but these interventions are associated to an increase of bladder neck contracture (BNC) rate. Various data on the frequency, pathogenesis, and risk factors for the development of BNC after endourological interventions are presented in the literature review. The prevalence of BNC after transurethral procedures depending on the type of energy used reaches up to 10%. Risk factors of BNC included the presence of chronic prostatitis and urinary tract infections, as well as small volume BPH. The age, cardiovascular diseases, type 2 diabetes, obesity, and a long-term smoking are considered as additional risk factors. A detailed study of the risk factors for BNC will further minimize BNC rate after transurethral procedures, thus improving the quality of life of patients.
Asunto(s)
Contractura , Diabetes Mellitus Tipo 2 , Hiperplasia Prostática , Resección Transuretral de la Próstata , Obstrucción del Cuello de la Vejiga Urinaria , Contractura/epidemiología , Contractura/etiología , Humanos , Masculino , Próstata , Hiperplasia Prostática/cirugía , Calidad de Vida , Estudios Retrospectivos , Resección Transuretral de la Próstata/efectos adversos , Obstrucción del Cuello de la Vejiga Urinaria/epidemiología , Obstrucción del Cuello de la Vejiga Urinaria/etiología , Obstrucción del Cuello de la Vejiga Urinaria/cirugíaRESUMEN
Purpose: To assess perioperative outcomes of holmium laser enucleation of the prostate (HoLEP) in a real-world scenario and with a focus on demanding patient factors, such as large prostate size, advanced patient age, and anticoagulation therapy (AT). Materials and Methods: We retrospectively analyzed HoLEP procedures at our institution between 2010 and 2016. After stratification by prostate volume, age, and AT, perioperative and early voiding characteristics were compared. A multivariable regression model was employed to identify predictors of prolonged time of catheterization (defined as being above group's median). Results: The study cohort consisted of 1816 men with a median age of 71 years (interquartile range [IQR]: 66-76), a median prostate volume of 80 mL (IQR: 58-105), and American Society of Anesthesiologists score ≥3 in 618 men (34%). Median time of enucleation and morcellation was 43 minutes (IQR: 31-60) and 10 minutes (IQR: 6-18), respectively. Perioperative blood transfusions were administered in 44 (2.4%) cases, severe postoperative complications (Clavien-Dindo grade ≥3b) occurred in 61 (3.3%) cases. The median time of catheterization was 2 days (IQR: 2-2), with prolonged catheterization occurring in 277 (15%) cases. After adjustment, large prostates (fourth volume quartile [106-280 mL]) (odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.3-2.6, p = 0.001), therapeutic low-molecular-weight heparin bridging regimen (OR: 2.2, 95% CI: 1.4-3.6, p = 0.037), low-dose acetylsalicylic acid (OR: 1.5, 95% CI: 1.0-2.2, p = 0.015), and a history of direct oral anticoagulation (OR: 2.3, 95% CI: 1.2-4.0, p = 0.022), but not patient age, were independently associated with prolonged catheterization. Conclusions: We confirm HoLEP as safe and efficient; however, patients with large prostates and patients with a history of AT are at risk of prolonged catheterization.
Asunto(s)
Terapia por Láser , Láseres de Estado Sólido , Hiperplasia Prostática , Resección Transuretral de la Próstata , Anciano , Holmio , Humanos , Láseres de Estado Sólido/uso terapéutico , Masculino , Hiperplasia Prostática/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: In recent years, new endoscopic techniques have been developed to reduce the morbidity of transurethral resection of the prostate. Nonetheless, complications are still frequently encountered and bladder neck contracture (BNC) is a well-described complication after endoscopic surgery for benign prostatic obstruction (BPO). Our aim is to review and discuss the contemporary incidence, the relevant treatment strategies, and their outcomes. RECENT FINDINGS: Findings suggest that BNC is a common complication with an acceptably low incidence but can range in complexity. Most contractures were usually managed successfully with conservative measures; nevertheless, in patients with refractory BNC, various valuable management strategies were employed with different kinds of success and re-treatment rates. In consideration of these challenging possibilities, the treatment of BNC requires a tailored approach with patient-specific management that can range from simple procedures to complex surgical reconstruction.
Asunto(s)
Endoscopía/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/terapia , Hiperplasia Prostática/cirugía , Obstrucción del Cuello de la Vejiga Urinaria/epidemiología , Obstrucción del Cuello de la Vejiga Urinaria/terapia , Contractura/epidemiología , Contractura/etiología , Contractura/terapia , Humanos , Incidencia , Terapia por Láser , Masculino , Complicaciones Posoperatorias/etiología , Hiperplasia Prostática/complicaciones , Obstrucción del Cuello de la Vejiga Urinaria/etiologíaRESUMEN
CONTEXT: A number of transurethral ablative techniques based on the use of innovative medical devices have been introduced in the recent past for the surgical treatment of benign prostatic obstruction (BPO). OBJECTIVE: To conduct a systematic review of the literature and a meta-analysis of available randomized controlled trials (RCTs), and to evaluate the efficacy and safety of transurethral ablative procedures for BPO. EVIDENCE ACQUISITION: A systematic literature search was performed for all RCTs comparing any transurethral surgical technique for BPO to another between 1992 and 2013. Efficacy was evaluated after a minimum follow-up of 1 yr based on International Prostate Symptom Score, maximum flow rate, and postvoid residual volume. Efficacy at midterm follow-up, prostate volume, perioperative data, and short-term and long-term complications were also assessed. Data were analyzed using RevMan software. EVIDENCE SYNTHESIS: A total of 69 RCTs (8517 enrolled patients) were included. No significant difference was found in terms of short-term efficacy between bipolar transurethral resection of the prostate (B-TURP) and monopolar transurethral resection of the prostate (M-TURP). However, B-TURP was associated with a lower rate of perioperative complications. Better short-term efficacy outcomes, fewer immediate complications, and a shorter hospital stay were found after holmium laser enucleation of the prostate (HoLEP) compared with M-TURP. Compared with M-TURP, GreenLight photoselective vaporization of the prostate (PVP) was associated with a shorter hospital stay and fewer complications but no different short-term efficacy outcomes. CONCLUSIONS: This meta-analysis shows that HoLEP is associated with more favorable outcomes than M-TURP in published RCTs. B-TURP and PVP have resulted in better perioperative outcomes without significant differences regarding efficacy parameters after short-term follow-up compared with M-TURP. Further studies are needed to provide long-term comparative data and head-to head comparisons of emerging techniques. PATIENT SUMMARY: Bipolar transurethral resection of the prostate, photovaporization of the prostate, and holmium laser enucleation of the prostate have shown efficacy outcomes comparable with conventional techniques yet reduce the complication rate. The respective role of these new options in the surgical armamentarium needs to be refined to propose tailored surgical treatment for benign prostatic obstruction relief.
Asunto(s)
Terapia por Láser/métodos , Próstata/cirugía , Hiperplasia Prostática/cirugía , Resección Transuretral de la Próstata/métodos , Obstrucción del Cuello de la Vejiga Urinaria/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Humanos , Terapia por Láser/efectos adversos , Láseres de Estado Sólido/uso terapéutico , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Próstata/patología , Hiperplasia Prostática/complicaciones , Hiperplasia Prostática/patología , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Tiempo , Resección Transuretral de la Próstata/efectos adversos , Resultado del Tratamiento , Obstrucción del Cuello de la Vejiga Urinaria/etiología , VolatilizaciónRESUMEN
OBJECTIVE: To evaluate the association between urological procedures and the development of infective endocarditis (IE), as there are case-reports linking urological procedures to IE but evidence of a causal relationship is lacking and no major guidelines advise prophylaxis to prevent development of IE during transurethral urological procedures. No case-control study has been undertaken to examine the relationship between urological procedures and the development of IE. PATIENTS AND METHODS: Retrospective evaluation of the IE database at our institution. The population consisted of patients diagnosed with enterococcal, staphylococcal, Streptococcus bovis-group and oral streptococcal IE over a 10-year period. Possible risk factors for the development of IE, including urological procedures were collected. A case-control design was used and univariable and multivariable analyses were carried out. Missing data was accounted for using the multiple imputations method. RESULTS: We included 384 patients with IE. There was a statistical association between the development of enterococcal IE and preceding urological procedures (odds ratio 8.21, 95% confidence interval 3.54-19.05, P < 0.05). Increasing age and being an intravenous drug user were also associated with enterococcal IE. Haemodialysis and the presence of an intracardiac device were associated with the development of coagulase-negative staphyloccal IE. CONCLUSION: This is the first study to show a statistical association between urological procedures and the development of IE. The bacteraemia leading to IE may be a result of the urological procedures or a consequence of the underlying urological pathology causing recurrent subclinical bacteraemias.