Can we predict HoLEP surgery operating times for a given prostate volume to enhance theatre utilization?

Introduction & Objectives: Holmium laser enucleation of the prostate (HoLEP) has the strongest evidence base for bladder outlet surgery, despite its steep learning curve. Rapid enucleation rates can be achieved in established hands with day-case surgery being the norm in service delivery. We have previously shown the validity of such a model. With the post Covid surgical backlog we have developed a tool to support theatre utilization based on established surgeon specific operating room (OR) times for a given prostate volume in our unit based on almost 1100 cases. Material(s) and Method(s): Four HoLEP naive surgeons completed 1096 HoLEPs over 7.5 years using a 50 Watt (W) Holmium laser (Auriga XL, Boston Scientific Inc., Piranha morcellator, Richard Wolf). Pre and post-operative data including TRUS/MRI volume, flow rate, residual volume, international prostate symptom score, quality of life, stop-clock enucleation, morcellation and total operating room (OR) times, hospital stay, histology, haemoglobin, creatinine, sodium and catheter times were prospectively recorded. Mentorship was provided by a senior 100W HoLEP surgeon from an adjoining hospital. Result(s): The data was independently analysed by a bio-statistician (IN). Statistical regression analysis of unit and surgeon specific OR times vs prostate volume were used to produce predictive linear graphs of OR times (mins) for a given prostate volume for individual surgeons and the unit. [Figure presented] Conclusion(s): Use of surgeon-specific and unit specific OR times allows the opportunity to maximize theatre operating schedules to help tackle the post Covid surgical backlog. We encourage this process for index specialist procedures across units.Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.

The Economic and Capacity Impact of Time Saved in the Operating Theatre Performing Holmium Laser Enucleation of the Prostate with MosesTM Technology vs Standard Technology

Objectives: Reducing operating theatre time can help hospitals to optimise operational efficiency and effectively allocate scarce resources. Holmium Laser Enucleation of the Prostate (HOLEP) is an established procedure for the treatment of symptoms secondary to Benign Prostatic Hyperplasia (BPH). It can be performed with Standard Technology (standard HOLEP) or MOSESTM Technology (MOLEP, Boston Scientific Corp). A recent meta-analysis demonstrated significantly reduced operative time with MOLEP vs. standard HOLEP. Our objective is to understand the potential economic impact of reducing theatre time with MOLEP vs. standard HOLEP and potential increases in operational capacity in hospitals in major European DRG-system countries, England, France, Germany and Italy. Method(s): We developed a health economic model to extrapolate theatre time savings reported in the meta-analysis to annual procedure volumes of a theoretical small (1 HOLEP/week), medium (3 HOLEP/week), and large (15 HOLEP/week) hospital. The model allows individual proportions of the time saved to feed into either theatre time cost savings or increased procedure throughput. We used national DRG tariffs and theatre cost per minute to estimate the economic impact. Result(s): Assigning all time savings to the performance of new procedures, small, medium, and large hospitals could perform up to 14, 44, and 229 additional procedures per year, respectively, increasing their procedure volume by 28-29%. In this example, potential revenue gains ranged from 32.573 (small French hospital) to 653.866 (large German hospital), for MOLEP vs. standard HOLEP. For every four procedures performed with MOLEP vs. standard HOLEP, sufficient time was saved to perform an additional procedure. Conclusion(s): Use of MOLEP saves time vs. standard HOLEP. Depending on the hospital aims, this efficiency gain can result in higher cost savings and generate additional revenue for the hospital. Aspects of operative efficiency and workflow improvements should be considered when evaluating the adoption of state-of-the-art medical technologies, especially in the post-COVID-19 pandemic era. Copyright © 2022

Ambulatory Tubeless Supine Mini-PCNL under Spinal Anaesthesia for Stones Size 1.5-3 cm: A Novel Approach in the COVID-19 Era for Minimising Risk of Contagion

Introduction &Objective: In the ongoing Covid-19 era where physical distancing is utmost important, we assessed the feasibility of ambulatory tubeless supine mini-PCNL under spinal anaesthesia for stone size between 1.5 - 3 cm to minimise hospitalisation. Method(s): Between June 2020 to August 2021, total 284 patients underwent PCNL out of which 122 underwent ambulatory tubeless mini-PCNL. The inclusion criteria were those consented for study, size of the stone 1.5 - 3 cm, pre-operative Covid-19 negative test (CT-chest and RT-PCR). Those excluded were with solitary kidney, morbidly obese, active UTI, congenital abnormalities. Patient's demographics, peri-operative parameters, stone free rate, blood loss, pleural complications and requirements of auxiliary procedures were prospectively evaluated Results: All the patients underwent supine mini-PCNL in FOSML (Flank-Oblique Supine Modified Lithotomy) position through a single tract of size 14/16 Fr. In, 18 (15%) patients' additional tracts were made for inaccessible secondary stones. Holmium laser and pneumatic source of energy were used for fragmentation of stones. Supra 12th rib tracts were made in 23 (19%) patients while in remaining 99 (81%) had infra-costal tracts. Complete SFR (stone-free rate) was achieved in 112 (92%) under fluoroscopy and the remaining 10 (8%) needed auxiliary procedure to render stone free. Average total operative time was 44 +/- 15 minutes and no nephrostomies were placed. All patients were discharged within 24 hours of operation with only 7 (6%) patients required readmission within 48 hours of discharge with hematuria and were managed conservatively. No other major complications occurred except for mild fever in few. Conclusion(s): Ambulatory supine tubeless mini-PCNL under spinal anaesthesia is safe and effective in this uncertain rapidly spreading COVID-19 era to minimise hospitalisation. It should be recommended whenever feasible, and it is easy to adapt to this newer approach especially for urologist already performing supine PCNL.

Outcomes of Same Day Discharge Following Holmium Laser Enucleation of the Prostate

Introduction &Objective: Performing holmium laser enucleation of the prostate (HoLEP) as a same day surgery is a safe and feasible option for the majority of patients. Shortening postoperative hospital stays can minimize patient burden and increase accessibility to surgical care. We present our experience of 155 patients who underwent HoLEP during the pandemic last year. Admissions were limited to patients that required continuous bladder irrigation given the limited surgical bed availability and other restrictions imposed by the Covid-19 pandemic. Method(s): From January 2021 till January 2022, 155 patients have undergone HoLEP surgery in which 135 were discharged on the same day and 20 patients were admitted. Perioperative data were retrospectively collected, and postoperative outcomes at least 2 months after the surgery were evaluated in terms of safety and efficacy and compared in both groups using chi-square and t-test. Multivariable logistic regression was also performed to identify factors associated with postoperative complications. Result(s): The mean age of the same day discharge group (n = 135) is 71.2 (SD = 7.1). The mean prostate specific antigen(ng/dL) and prostate volume(mL) in the same-day discharge group were 5.3 (range 0.16-48.4) and 112.6 (range 52-350), respectively, with 3.7% readmission rate and 9.6% emergency department visit rate. Our same-day discharge rate was 87% of the total patients. Prostate Specific Antigen (P =.001), prostate volume (P <.001), and enucleated tissue weight (P =.04) were significantly higher in the admitted group. There was no difference in the rate of postoperative emergency department visits (P =.80), readmissions (P = 1), postoperative complications, and catheterization time (P =.98) between both groups. Patients using blood thinners had 3.35 (95% CI: 1.24-9.08) greater odds of having postoperative complications. Conclusion(s): Same-day discharge following HoLEP is a safe and effective approach in most patients without an increase in postoperative complications.

ROCK AND ROLL AND LASER IN BETWEEN: BRONCHOSCOPIC LITHOTRIPSY

SESSION TITLE: Case Reports of Procedure Treatments Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Broncholiths are calcifications in the tracheobronchial tree that are most commonly associated with indolent infections. Disease manifestations range from asymptomatic stones in the airway to major complications such as massive hemoptysis or post-obstructive pneumonias. Depending on severity of the disease, patient management can range from conservative strategies to surgical interventions. We report successful reduction of a large obstructive broncholith in the right middle lobe via Holmium-yttrium aluminum garnet (Ho:YAG) laser lithotripsy. CASE PRESENTATION: Patient is a 55 year old male who presented with on going purulent cough, fever and pleuritic chest pain for 3 months. He had associated weight loss (>10 lbs in 3 months), malaise, increased fatigue, and scant hemoptysis. Initial chest x-ray was evident of right middle lobe consolidation. Respiratory infection panel, COVID PCR, AFB cultures and fungal cultures were negative. Subsequent CT of his chest showed right middle lobe opacities with areas of obstruction with a broncholith. Subsequently, patient underwent rigid bronchoscopy to allow for left sided airway protection via direct tamponade if patient develops massive hemoptysis. A bronchoscopic inspection was performed through the rigid scope that confirmed the broncholith. Obliteration of broncholith was then performed via Ho:YAG. After multiple laser treatments, we noted improvement in the size of the broncholith. Patient admitted to significant improvement in chest pain, hemoptysis and cough since the procedure. DISCUSSION: Broncholithiasis refers to calcified material eroding the tracheobronchial tree and causing inflammation and obstruction. Etiology of broncholiths include calcified peribronchiolar lymph nodes that erode into the airway lumen. Lymph node calcifications in the thorax are associated with lymphadenitis from fungal or mycobacterial infections. Management depends on the size of broncholiths. For larger stones, flexible bronchoscopy is often used to confirm diagnosis. When forceps extraction is not feasible, stone fragmentation with Ho:YAG is generally utilized, but they carry the risk of massive hemoptysis or bronchial injury. Surgical interventions, such as lobectomy or pneumonectomy, are reserved for patients with recurrent pneumonias, bronchiectasis, bronchial stenosis or broncho-esophageal or aorto-tracheal fistulas. In our case, we demonstrate successful reduction of a non-mobile broncholith by protecting the airway using rigid bronchoscopy by interventional pulmonology and subsequently avoiding surgical intervention in a patient with repeated post-obstructive pneumonia. CONCLUSIONS: Management of broncholiths should be individualized for symptomatic patients. A comprehensive assessment with appropriate imaging and involvement of interventional pulmonology can result in successful reduction of the stone and minimizing complications. Reference #1: Dakkak, M., Siddiqi, F., & Cury, J. D. (2015). Broncholithiasis presenting as bronchiectasis and recurrent pneumonias. Case Reports, 2015, bcr2014209035. Reference #2: Krishnan, S., Kniese, C. M., Mankins, M., Heitkamp, D. E., Sheski, F. D., & Kesler, K. A. (2018).Management of broncholithiasis. Journal of thoracic disease, 10(Suppl 28), S3419. Reference #3: Olson, E. J., Utz, J. P., & Prakash, U. B. (1999). Therapeutic bronchoscopy in broncholithiasis. American journal of respiratory and critical care medicine, 160(3), 766-770 DISCLOSURES: No relevant relationships by Jalal Damani No relevant relationships by Joseph Gatuz No relevant relationships by Fereshteh (Angel) Yazdi

Day case mini percutaneous nephrolithotomy (mini-PCNL): feasibility, safety, efficacy and patient acceptability study

Introduction: The objective was to investigate the feasibility, safety, efficacy, and patient acceptability of performing mini-PCNL as a day case procedure. To our knowledge, this is the first reported series in the UK. Method Mini-PCNL data was prospectively collected between April- December 2021. Renal access was achieved by the operating surgeon under fluoroscopic guidance in the prone position. The MIP-M system (Karl Storz, Germany) was used. Stones were fragmented using holmium LASER and retrieved by the Vortex effect and basket. Drainage was via a 6 Fr antegrade stent or 10 Fr nephrostomy tube. Patients suitable for same day discharge were identified using defined preoperative selection criteria. Stone related outcomes, duration of surgery, length of stay, readmission rate and complications were recorded. Results: Fifty patients underwent mini-PCNL (34 male,16 female) with a mean age of 60 years. Mean stone size was 24 mm with a mean operating time of 90 minutes. Twenty patients were suitable for same day discharge. Thirty patients stayed overnight (15 for social reasons, 13 for medical comorbidities and 2 for complications). We recorded 1 case of post-operative sepsis and bleeding requiring embolization. The readmission rate was 0% and 85% were stone free on post-operative CT KUB. Conclusion: Our study shows that day case mini-PCNL is safe, feasible and acceptable in selected group of patients. With the ever-rising pressures on stone services to drive efficiency particularly pertinent with the COVID pandemic, day case mini-PCNL represents an ideal therapeutic option in suitable cases.

Upskirt exposure: The effectiveness of lead skirts to protect the urologist during seated endoscopic stone surgery

Introduction & Objectives: The use of intra-operative image intensifier (II) has increased in urological practice as the mainstay of stone surgery is performed endoscopically. Here we examine the radiation exposure to the groin of the urologist performed endoscopic stone surgery. Our primary aim was to assess whether urologists are exposed to potentially avoidable radiation exposure in the seated position when using vest and skirt lead protection. We hypothesize that the level of exposure is negligible and should not influence surgeon decision on seated versus standing or on lead apron versus skirt and vest combination protective wear. Methods: We conducted a prospective, multicentre study across all public hospitals in the Hunter New England Area Health Network offering Holmium:YAG laser lithotripsy. Routinely, servicing a very large population base, the number of laser lithotripsy cases are quite high however during our research period the coronavirus pandemic diminished the number of elective cases performed. Because of this, we included a total of 50 cases in this study. Small multidimensional-reading dosimeters were worn on the medial aspect of both upper thighs of the urologist under the lead skirt as well as a third dosimeter worn on the outside of the lead protective skirt. All cases were performed with the II in an under-couch position and all cases included were either ureteroscopy or pyeloscopy with laser destruction of urinary stones. In one centre, all surgery was performed by a consultant urologist whilst in another it was all performed by a registrar. Screening time and total dose delivered were prospectively collected using the local network picture archiving and communication system (PACS). This data was analysed by an onsite physicist and collated. After calculating mean and median radiation dose exposures for each dosimeter and grouping those worn under the skirt, comparison was made between dosimeters worn under skirt versus over skirt and Results: Lead gowns reduced radiation dose exposure by 87% (p = <0.01);99% on the side opposite the II and by 76% on the same side of the II (p = 0.2). Mean total dose area product was 88.9 GyCm2 with a mean screening time of 80 seconds per case (range 12-311 seconds). Conclusions: These results support the hypothesis that there is no significant exposure risk in a seated position with vest and skirt combination lead protective wear. An unexpected result was the difference in exposure between the side closest versus furthest away from the image intensifier.

Randomized controlled trial comparing holmium laser en-bloc resection with monopolar transurethral resection in patients with large bladder tumors

Introduction & Objectives: The HoLERBT (Holmium Laser En-bloc Resection) has emerged as an alternative to classical TURBT (Transurethral Resection of Bladder Tumor) by using the en-bloc tumor resection technique. So far, the tumors in previous studies were mostly <3cm. We performed a previous pilot study with tumors >3cm (3-8cm) submitted to HoLERBT in 2019. All samples had detrusor muscle present and there were no peri-operative complications. These results support the present study to establish the best approach to endoscopic treatment of large bladder tumors. The objectives are to analyze differences between HoLERBT and TURBT in terms of presence of detrusor muscle in the histopathological analysis, intra-operative and peri-operative complications and oncological outcomes in large bladder tumors. Materials & Methods: This is a single-institution, randomized, single-blinded, prospective, controlled trial (RCT). The expected duration is of 24 months. The sample size calculated is 47 patients per group (n = 94). The study was approved by the Institutional Ethical Board and was submitted to the Brazilian Registry of Clinical Trials (ReBEC). Inclusion criteria is bladder tumor >3cm by CT or MRI. The exclusion criteria are diagnosis of invasive tumor on image examination (CT, MRI), urethral stenosis, systemic or intra-vesical chemotherapy or previous radiotherapy. The outcomes analyzed are quality of detrusor muscle, intra-operative and immediate post-operative complications, length of hospital stay (LOS);clinical progression, recurrence-free, overall and cancer-specific survival at 24 months. Results: This is an ongoing trial that began in January 2020, was suspended for 5 months due to Covid-19, restarted recruitment in September 2020 and currently has 9 patients in the group HoLERBT and 11 patients in the group TURBT. The first surgery was in 01/21/20. The current data represents 22% of the estimated sample and the analysis is partial. The median age (years) was 55.8 (29-83) and 65.5 (46-84), the median tumor size (cm) was 3.4 (2.1-5.4) and 3.1 (2.1-5.7), the median time of surgery (min) was 29 (16-49) and 37.6 (13-60), the LOS (days) was 1.25 (1-3) and 2.0 (1-4), complications rates Clavien I was 11% and 36% and Clavien >I was 0% and 9% for HoLERBT and TURBT. The presence of detrusor was 80% in both groups. The interim analysis will be made with 50% of the sample estimated to occur in June 2021 and the final analysis with 2 years of follow up is estimated to occur in January 2023. Conclusions: This is a RCT comparing HoLERBT and TURBT evolving large tumors, with a 2-year follow-up proposal. The initial analysis give support to continue the study in order to assess the real role of laser resection in high volume bladder tumor.