Analysing the learning curve of prostate enucleation with the Holmium laser: A retrospective, single-center experience.

BACKGROUND: Holmium laser enucleation of the prostate (HoLEP) is a proven surgical technique for the treatment of benign prostatic hyperplasia (BPH). However, its challenging learning curve prevents its widespread adoption by urologists. The aim of this study was to analyse the learning curve of HoLEP and to determine the factors accelerating it. METHODS: This was a retrospective, monocentric cohort study of the first 60 cases of HoLEP performed by three operators. The primary outcome measure was operative efficiency, defined as the ratio of preoperative prostate volume estimated by trans-abdominal ultrasound (TAUS)to total surgical time in minutes. The studied learning curve parameters included the number of previously performed cases (NPPCs) and monthly case density (CD) (number of monthly performed cases before the studied one). RESULTS: Overall, 180 patients with a mean age of 71 (±9) years and a mean prostate volume (g) of 80.4 (±41) were included. The mean operative efficiency in the population was 0.74 (±0.37) g/min. Operative efficiency was increased in patients who had been operated on by surgeons with a CD ≥3 (CD ≤2: 0.66 (±0.27) g/min vs. CD ≥3: 0.79 (±0.43) g/min; P=0.012). At 3months, 46 patients (29%) developed stress urinary incontinence (SUI). Early SUI was significantly decreased in patients who had been operated on by surgeons with a CD ≥3 (CD ≤2: 37%, (n=26) vs CD ≥3: 22%, (n=20); P=0.045). CONCLUSIONS: A high frequency HoLEP procedures, set as one case per week, appeared to accelerate learning curves by improving operative efficiency. A high CD was also associated with reduced rates of early SUI. LEVEL OF PROOF: 5.

Real-life outcomes after artificial urinary sphincter explantation in women suffering from severe stress incontinence.

PURPOSE: Artificial urinary sphincter (AUS) implantation in female patients results in high satisfaction rates and high functional outcomes, but implantation can be challenging and explantation of the device is fairly common. The objective of this study was to review outcomes after AUS explantation in women. METHODS: This is a retrospective, monocentric study of all women who underwent open or laparoscopic AUS implantation between November 1994 and July 2019, and patients with AUS explantation were included. Management after AUS explantation using descriptive analysis was assessed. RESULTS: Over a span of 26 years, 111 women had an AUS implanted by a single surgeon. Of these surgeries, 35 explantations in 29 patients were later required: 20 initial AUSs, nine revised AUSs and six reimplanted AUS (rAUSs). The median time to explantation was 15.5 month (± 0.55). After explantation, 13 rAUSs in 10 patients were successful and two attempts failed. The median time between explantation and rAUS was 8 months (± 0.95). At the last follow-up, five patients still had their rAUS and six rAUSs had required explantation after a median time of 6.5 months (± 0.65). Surgery was still possible for 12 patients who did not have a rAUS: three cystectomies, one bladder neck closure with continent urinary diversion, and six mid-urethral slings or adjustable continence therapy balloon implantations. Among the 23 patients who did not need a cystectomy or a bladder neck closure with continent urinary diversion, four were completely dry (17.4%), 11 were improved (47.8%), and eight (34.8%) experienced unchanged incontinence with the post-explantation management. Limitations include retrospective design, heterogeneous management over time and a relatively small population of patients in our cohort. CONCLUSION: Reimplantation of an AUS after an explantation seems feasible after at least 6 months. However, the surgery will be more difficult and satisfaction is not guaranteed. Multicenter databases should be created to help surgeons and patients decide on appropriate management strategies after explantation of an AUS.

Outcomes of artificial urinary sphincter in female with neurological stress urinary incontinence: a long-term follow-up.

PURPOSE: To report the outcomes of AUS in women with neurological SUI resulting from intrinsic sphincter deficiency after a follow-up from 3 to 20 years. METHODS: The charts of female with moderate to severe neurological SUI who underwent open or laparoscopic AUS implantation between November 1994 and July 2014 were reviewed retrospectively. All patients were operated by a single experienced surgeon. Primary endpoint was a postoperative continence categorized as complete continence (no pads used), improved incontinence or unchanged incontinence. RESULTS: Twenty-three women (mean age 54 years, range 19-77) underwent open or laparoscopic AUS implantation. At the last follow-up, 7 (30.4%) initial artificial urinary sphincters remained in situ and 9 (39.1%) patients had at least one revision or reimplantation. Sixteen patients were fully continent (69.6%), four (17.4%) had improved incontinence and three (13.0%) had unchanged incontinence. After a median follow-up of 11.6 years (3-22), 8 (34.8%) explanations in 7 patients and 16 (69.6%) revisions in 11 patients occurred. The average time without explanation or revision was 10.9 and 8.5 years, respectively. Survival rates without AUS explanation were 94.4%, 76.5%, 72.8%, 50% and without revision were 83.3%, 64.7%, 45.5% and 16.7% at 5, 10, 15 and 20 years, respectively. CONCLUSION: Although all methods are imperfect at best, AUS remain toward our experience a good way to achieve long-term continence in female patients suffering from neurological SUI with preserved manual dexterity.

[Percutaneous MR-guided prostate cancer cryoablation: Predictive factors and oncologic outcomes]. / Cryothérapie totale de la prostate sous IRM par voie périnéale : résultats carcinologiques et facteurs prédictifs.

OBJECTIVE: To determine the pejorative predictive factors on oncologic outcomes of percutaneous MR-guided whole gland prostate cancer cryoablation (CA). METHODS: Medical records of patients treated from 2009 to 2012, to assess medium-term oncologic outcomes, were reviewed. Prostate biopsies were performed in local recurrence suspicion (biochemical failure, MR follow-up failure). RESULTS: Among 18 patients, mean age of 72.6 (61-78), 2 (11 %) and 7 (38.9 %) biological and reported biopsy-proven local recurrence respectively with our initial technic of CA. Mean follow-up and recurrence were 56.3 (±21.7) and 20.7 (±13.9) months respectively. A previous treatment of prostate cancer (P=0.5), pre-treatment PSA (P=0.2), pre-treatment Gleason/ISUP score (P=0.4), nadir PSA post-CA (P=0.22) were not associated with recurrence. Bilateral positive cores appears as a pejorative predictive factor (P=0.04). However mean pre-treatment positive cores percentage, 25 (±16.5) in responding patients versus 40.7 (±25.2) in case of recurrence, and maximum percentage of cancer extent in each positive core, 10.6 (±9.3) in responding patients versus 18.7 (±16.5) in case of recurrence, seemed associated with local recurrence after prostate CA but our analysis wasn't able to find a difference (P=0.09 and P=0.3 respectively) due to a lack of power. CONCLUSION: Bilateral positive cores appears as a pejorative predictive factor. In our experience, important tumor volume seem to be a pejorative predictive factor for oncologic outcomes after PCA whereas treatment, PSA, Gleason/ISUP score, nadir PSA are not. LEVEL OF EVIDENCE: 4.