ABSTRACT
Background and Objective In recent years, GreenLight laser photoselective vaporisation of the prostate (GL-PVP) has emerged as the primary ablative surgical treatment option for symptomatic bladder outlet obstruction (BOO) secondary to benign prostatic enlargement (BPE). Unlike the reference procedure, monopolar-transurethral resection of the prostate (M-TURP), GL-PVP can be performed as a day case. As waiting list pressures continue to burden health boards across the UK, exacerbated by the COVID-19 pandemic, enhanced access to day case surgery to optimise patient flow is now of paramount importance. We evaluated the safety and feasibility of day case GL-PVP at our high-volume UK centre and identified predictors of a postoperative overnight stay. Material and Methods We performed a retrospective observational cohort study of all patients who underwent primary GL-PVP at a single institution between October 2016 and June 2021. All procedures were performed utilising the 180W GreenLight XPS™ laser therapy system. Various clinical, operative and functional data were col-lated, and outcomes were compared between patients who underwent day case surgery and those admitted overnight postoperatively. Results In all, 538 patients underwent GL-PVP during the study period. Median patient age was 72 (interquartile range (IQR) 66–77), and median prostate volume was 62.5cc (IQR 45–90). Five hundred nineteen patients (96.5%) were discharged within 23 hours of admission, and 366 patients (68.0%) were managed as a true day case. Operative and functional outcomes were comparable between patients managed as a day case and those admitted overnight. There was higher patient-reported satisfaction and a lower rate of early hospital readmission in the day-case group. On univariate logistic regression analysis, patients aged ≥80 years (Odds Ratio 2.64 [95% Confidence Interval 1.65– 4.24], p = < 0.001), those with American Society of Anaesthesiologists (ASA) physical status classification score ≥3 (OR 1.92 [95% CI 1.33–2.78], p = < 0.001), those with prostate volume ≥80cc (OR 1.62 [95% CI 1.00–2.61], p = 0.05) and those in whom the operation time ≥60 minutes (OR 1.66 [95% CI 1.10–2.52], p = 0.02) were more likely to be admitted overnight following GL-PVP. On multivariate logistic regression analysis, age ≥80 (OR 2.64 [95% CI 1.47–4.73], p = 0.001) and ASA score ≥3 (OR 2.03 [95% CI 1.28–3.22], p = 0.003) remained predictive variables of an overnight stay. Conclusion From our observations of a large cohort of patients over a study period of almost five years, day case GL-PVP is a feasible concept and does not appear to compromise perioperative outcomes. With appropriate service redesign and optimisation of postoperative patient pathways, day case GL-PVP can be established in other centres and may have a role in alleviating waiting list pressures.
ABSTRACT
Background: Isolated myoclonus and opsoclonus myoclonus ataxia syndrome (OMAS) as an initial manifestation of the coronavirus disease 2019 (COVID-19) has not yet been described. Case History: A 55-year-old right-handed Hispanic woman, with no history of neurological dysfunction, was asymptomatic without fever, headaches, respiratory symptoms, myalgia or chemosensory dysfunction until four days prior to presentation when she gradually lost muscle control with uncontrollable arrhythmic nonrepetitive jerking and shaking throughout, involving her abdomen, arms, face and hands both with intention and at rest. Later that same day, she observed oscillopsia, whereby her visual field flickered vertically. On the fourth day after onset of symptoms, the patient's COVID-19 RT-PCR on nasopharyngeal swab test was positive. Physical examination on day five: Afebrile. Cranial Nerve (CN) examination: CN III, IV, VI: Opsoclonus, spontaneous conjugate multidirectional eye movements without nystagmus and intersaccadic interval not restricted to a horizontal or vertical gaze. CN VII: Intermittent rapid closing and fluttering of eyelids. Gait: Unable to stand. Cerebellar examination: Finger-to-nose testing: Severe intention myoclonus. Myoclonic jerks were present on drift testing with inability to raise the arms due to upwards and negative myoclonic movements. Negative myoclonus on wrist extension. Lumbar puncture on day five: WBC count: 2 cells/mL, RBC count: 0 cells/mL, protein 26 mg/dl, gram stain negative, viral serology negative. Discussion: Those who present with myoclonus, oscillopsia, ataxia or opsoclonus without preexisting respiratory or chemosensory symptoms warrant evaluation for presence of COVID-19 infection.