Relevance of Adopting a Hybrid Strategy Mixing Single-Use and Reusable Ureteroscopes for Stones Management: An Economic Study to Support the Best Strategy.

Endoscopic procedures such as ureteroscopy (URS) have seen a recent increase in single-use devices. Despite all the advantages provided by disposable ureteroscopes (sURSs), their cost effectiveness remains questionable, leading most teams to use a hybrid strategy combining reusable (rURS) and disposable devices. Our study aimed to create an economic model that estimated the cut-off value of rURS procedures needed to support the profitability of a hybrid strategy (HS) for ureteroscopy. We used a budget impact analysis (BIA) model that estimated the financial impact of an HS compared to 100% sURS use. The model included hospital volume, sterilization costs and the private or public status of the institution. Although the hybrid strategy generally remains the best economic and clinical option, a predictive BIA model is recommended for the decision-making. We found that the minimal optimal proportion of rURS procedures in an HS was mainly impacted by the activity volume and overall number of sterilization procedures. Private and public institutions must consider these variables and models in order to adapt their HS and remain profitable.

Influence of the median lobe on the results at 4 years of the prostate vaporization by GreenLight laser.

OBJECTIVE: The aim of this study was to examine the influence of a median lobe (ML) on complications and functional results after 4 years of GreenLight photoselective vaporization of the prostate (PVP). METHODS: All men undergoing GreenLight PVP for benign prostatic hyperplasia were included in the baseline analysis and followed prospectively. Two groups were formed according to the presence or absence of the prostatic ML. Complications classified according Clavien and Dindo and functional results (International Prostate Symptom Score [IPSS], quality of life, maximum urinary flow rate [Qmax], and postvoid residual [PVR]) were evaluated with 4 years of follow-up. The pre- and postoperative data were compared by a chi-square test (χ2 ) for the qualitative variables and by a Student t test for the quantitative variables. RESULTS: A total of 432 patients (172 with ML and 260 without ML) were included prospectively from September 2005 to October 2013. The initial populations were comparable. At 4 years of follow-up, the improvement in mean IPSS was significantly greater for patients with ML at 6, 12, 24, and 48 months. The improvement in Qmax was significantly greater for patients with ML at 1, 6, 24, and 48 months. There was no significant difference between the two groups concerning the PVR reduction, the occurrence of complications, the level of average prostate-specific antigen, and the average ultrasound volume at 4 years. CONCLUSION: There is a clearer and longer-lasting improvement in urinary symptoms in patients with prostatic ML. The indication of PVP in those patients seems to be excellent, with good results persisting at 4 years.

Switching to Single-use Flexible Ureteroscopes for Stones Management: Financial Impact and Solutions to Reduce the Cost Over a 5-Year Period.

OBJECTIVES: To assess the financial impact of switching to single-use ureteroscopes (sURS) in urolithiasis management for a hospital, over a 5-year period, and to identify possible solutions to contain or reduce it. METHODS: A Budget Impact (BI) model was designed for a public hospital performing around 200 ureteroscopies or extracorporeal shockwave lithotripsies per year. The BI was estimated as the difference between financial balances (between costs and revenues) of 2 environments (with and without sURS). The population was defined as adults treated for urolithiasis. The BI model was based on assumptions about the expected progression in the incidence of urolithiasis, and the expected change in clinical practices due to the availability of sURS. We considered the costs and revenues of hospital stays, the purchase price of sURS and the costs of digital or fiberoptic reusable ureteroscopes (rURS). Univariate and multivariate sensitivity analyses were performed. RESULTS: The cumulative 5-year financial impact of switching completely to sURS was €807,824 and €649,677 in comparison with fiberoptic and digital rURS respectively. This impact could be reduced by half or more if the health-care facility were to adopt different solutions, including negotiating the purchase price of sURS, developing outpatient activity and reducing production costs for ureteroscopy procedures. CONCLUSION: The BI model gives decision-makers a more accurate picture of the financial impact of switching to sURS and highlights ways to reduce the expected additional cost.

Anterior suspension combined with posterior reconstruction during robot-assisted laparoscopic prostatectomy improves early return of urinary continence: a prospective randomized multicentre trial.

UNLABELLED: What's known on the subject? and What does the study add? Urinary incontinence is one of the major drawbacks of radical prostatectomy, regardless of the procedure used (i.e. open, laparoscopic or robotic-assisted). Several technical modifications have been described to improve postoperative continence, highlighting the role of puboprostatic ligaments and posterior reconstruction of the rhabdomyosphincter. The results obtained are inconsistent when applied to robotic surgery. The present multicentre randomized study shows that anterior suspension combined with posterior reconstruction is a safe and easy-to-perform technique for improving early continence after robotic-assisted laparoscopic prostatectomy. OBJECTIVE: To assess the impact on urinary continence of anterior retropubic suspension with posterior reconstruction during robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: In total, 72 patients who were due to undergo prostatectomy between July 2009 and July 2010 were prospectively randomized into two groups: group A underwent a standard RALP procedure and group B had anterior suspension and posterior reconstruction during RALP. The primary outcome measure was urinary continence, assessed using the University of California Los Angeles Prostate Cancer Index questionnaire at 15 days, and at 1, 3 and 6 months, after surgery. Other data recorded were operation duration, blood loss, length of hospital stay, duration of bladder catheterization, complications and positive margin rate. RESULTS: The continence rates at 15 days, and at 1, 3 and 6 months, after surgery were 3.6%, 7.1%, 15.4% and 57.9%, respectively, in group A, and 5.9%, 26.5%, 45.2% and 65.4%, respectively, in group B. The continence rates differed statistically between groups at 1 and 3 months (P = 0.047 and P = 0.016, respectively). There was no significant difference between groups regarding complications (P = 0.8) or positive margin rate (P = 0.46). CONCLUSION: Anterior suspension associated with posterior reconstruction during RALP improved the early return of continence, without increasing complications.

Influence of photoselective vaporization of the prostate on sexual function: results of a prospective analysis of 149 patients with long-term follow-up.

BACKGROUND: Even though transurethral resection of the prostate remains the gold standard treatment for lower urinary tract symptoms (LUTS) refractory to medical therapy, photoselective vaporization of the prostate (PVP) has become a popular alternative. Early PVP studies seem encouraging, but few data exist regarding the effect of PVP on sexual function at long-term follow-up. OBJECTIVE: Our aim was to evaluate the impact of PVP on erectile function (EF) at long-term follow-up in men with LUTS due to benign prostatic hyperplasia (BPH). DESIGN, SETTING, AND PARTICIPANTS: One hundred forty-nine consecutive patients who underwent a prostate vaporization with the GreenLight laser performed by a single surgeon (FB) were prospectively enrolled in this study. INTERVENTION: All patients underwent PVP with the GreenLight laser performed by one experienced surgeon. MEASUREMENTS: All patients were evaluated by International Index of Erectile Function (IIEF-5) preoperatively and at 1, 3, 6, and 12 mo and then once a year. At each visit, the questionnaires were collected, and each patient's maximum flow rate and postvoid residual volume were measured with ultrasound. Biologic data were also collected at each visit, including prostate-specific antigen, creatinine, and bacterial urine culture. RESULTS AND LIMITATIONS: One hundred forty-nine patients were enrolled in the study. Median patient age was 74 yr. Urinary function was significantly improved over baseline in both men with normal or abnormal preoperative erectile function. Energy used was 255+/-129kJ. Hospitalization stay was 2.2+/-3.1 d. Other than a temporary difference at 1 yr, IIEF-5 scores were comparable preoperatively and postoperatively if we consider all the population. However, considering patients with preoperative IIEF-5 >19, the postoperative IIEF-5 scores were significantly decreased at 6, 12, and 24 mo. CONCLUSIONS: Sexual function appears to be maintained after PVP; however, in patients with normal preoperative EF, we showed a significant decrease in EF after PVP.

Effect of patient position on pain experienced during prostate biopsy.

OBJECTIVES: To compare pain during prostate biopsy performed in two different positions. METHODS: We carried out a prospective, randomized study to compare the pain experienced during biopsy in two different positions: lithotomy (group 1) and lateral (group 2). Pain was evaluated using a visual analog scale (VAS). RESULTS: 70 patients were randomized to the two positions for biopsy. The median number of samples taken was the same for both groups (n = 10). The median VAS rating after biopsy was 30 in group 1 and 45 in group 2. 96.6% of the men in group 1 were prepared to undergo a repeat examination according to the same modalities, against only 86.7% in group 2. Only 14.3% of the men in group 1 would have preferred more analgesic against 37.1% in group 2. Pain after biopsy was less in group 1. The men with prostate adenocarcinoma tolerated biopsies better than the others. CONCLUSION: Our results suggest that the lithotomy position induced less pain and less post-biopsy hematuria than did the lateral position during prostate biopsy. Men with prostate adenocarcinoma tolerated the procedures better.