Holmium Laser Enucleation of the Prostate vs Robot-Assisted Simple Prostatectomy for Lower Urinary Tract Symptoms in Patients with Extremely Large Prostates ≥200 cc: A Comparative Analysis.

Introduction and Objectives: Robot-assisted simple prostatectomy (RASP) and holmium laser enucleation of the prostate (HoLEP) are both well-established, minimally invasive surgical treatment options for lower urinary tract symptoms caused by benign prostatic enlargement. We have reported the first comparative analysis of both techniques in patients with prostates of ≥200 cc. Materials and Methods: Between 2009 and 2020 a total of 53 patients with a prostate volume of ≥200 cc were surgically treated at OLV Hospital Aalst (Belgium): 31 underwent RASP and 22 underwent HoLEP. Preoperative and postoperative assessments included uroflowmetry with maximum urinary flow rate (Qmax) and postvoid residual volume (PVR), as well as the International Prostate Symptom Score (IPSS) and quality of life (IPSS-QoL). The complication rates were evaluated according to the Clavien-Dindo Classification. Results: Patients treated with RASP had significantly larger prostate volumes compared with HoLEP (median 226 cc vs 204.5 cc, p = 0.004). After a median follow-up of 14 months, both groups showed a significant improvement in the maximum flow rate (+10.60 mL/s vs +10.70 mL/s, p = 0.724) and a reduction of the IPSS score (-12.50 vs -9, p = 0.246) as well as improvement of the QoL (-3 vs -3, p = 0.880). Median operative time was similar in both groups (150 minutes vs 132.5 minutes, p = 0.665). The amount of resected tissue was lower in the RASP group (134.5 g vs 180 g, p = 0.029) and there was no significant difference in postoperative prostate-specific antigen (1.2 ng/mL vs 0.8 ng/mL, p = 0.112). Despite a similar median catheterization time (3 days vs 2 days, p = 0.748), the median hospitalization time was shorter in the HoLEP group (4 days vs 3 days, p = 0.052). Complication rates were similar in both groups (32% vs 36%, p = 0.987). Conclusion: Our results suggest similar outcomes for RASP and HoLEP in patients with very large prostates ≥200 cc. These findings will require external validation at other high-volume centers.

Transvesical Approach in Robot-Assisted Bladder Diverticulectomy: Surgical Technique and Outcome.

Objective: Treatment for bladder diverticula may become necessary in case of incomplete bladder emptying or recurrent urinary tract infections (UTIs). When bladder outlet obstruction is present, a simultaneous desobstructive procedure can be performed. In this video, we present our technique for a transvesical approach in robot-assisted bladder diverticulectomy (RABD) and discuss its outcomes. Patients and Surgical Procedure: We retrospectively analyzed the outcomes of 23 patients who underwent a transvesical RABD between March 2015 and May 2020 at the OLV hospital of Aalst. After retrograde filling, a cystotomy is performed. The orifices are identified and the bladder diverticulum is observed. The mucosa covering the diverticular neck is incised and the plane between the mucosa and the muscularis is identified. The mucosa is separated from the surrounding structures. The base of the diverticulum is transected using cautery. The defect is closed with a barbed suture. Results: Median age was 66 years (interquartile range [IQR] 60-69). The number of diverticula removed ranged from 1 to 3. Ten patients were treated with diverticulectomy alone, 12 underwent a simultaneous adenomectomy, 1 a radical prostatectomy. Median operative was 140 minutes (IQR 120-180), median estimated blood loss was 250 mL (IQR 28-438). Median catheterization time was 2 days (IQR 1-5), median hospitalization time 3 days (IQR 2-4). One patient developed urinary leakage after catheter removal, one patient developed a UTI. Median follow-up was 9 months (IQR 3.5-14). No late postoperative complications nor relapse were recorded. Average postvoid residual was 42 mL (IQR 0-111), with a median decline of 120 mL (IQR -402 to -33). Conclusions: Transvesical approach for RABD is a safe and reliable technique that gives the advantage of a quick localization of the diverticulum and orifices, and direct access to the prostate when simultaneous desobstruction is necessary. Catheterization time is short. No relapse has been observed.

Reusable, Single-Use, or Both: A Cost Efficiency Analysis of Flexible Ureterorenoscopes After 983 Cases.

Objectives: To determine which flexible ureterorenoscopy program would be most cost-efficient in our center, a cost efficiency analysis and a formula to assess cost efficiency feasibility of a hybrid model were performed. Methods: Total cost per case of reusable flexible ureterorenoscopes (rfURS) was retrospectively calculated and compared with two single-use flexible ureterorenoscopes (sufURS) marketed. A mathematical formula was developed from our data to identify the necessary increase of use of rfURS (NIU-rfURS) to be cost-efficient in a hybrid system utilizing sufURS for only high-risk-of-breakage cases. Results: In 57 months, 983 procedures were performed using 4 digital rfURS (Flex-XC; Storz), necessitating 45 repairs, with a total repair cost of €256.809. Including the capital investment of €24.000 per scope and €60 per sterilization cycle, the cost per case averaged €419 after 983 cases. Consistently using sufURS would have cost 55% to 127% more (respectively, Uscope PU3022® and Lithovue® at €650 and €950 manufacturer suggested retail price). On a per case analysis, the cost was initially extremely high, but declined to reach a plateau around €480 after ∼400 cases. After 155 or 274 procedures, a rfURS program appeared more cost-efficient than consistently using Lithovue or Uscope PU3022, respectively. Based on our data and formula, if we would hypothetically use Uscope PU3022 or Lithovue for 15% of the cases, the NIU-rfURS is, respectively, 28% or 74% (∼6 or 16 cases). The NIU-rfURS increases exponentially with an increased use of sufURS. Conclusion: Consistently using rfURS is more cost-efficient than the constant use of sufURS after 155 to 274 cases. We describe the first mathematical formula that allows a calculation and feasibility assessment of using both reusable and disposable fURS. To identify whether a hybrid system may be a feasible cost-efficient alternative to a rfURS-only program, any center can calculate the NIU-rfURS by entering center-specific data in the formula.

The Impact of Previous Prostate Surgery on Surgical Outcomes for Patients Treated with Robot-assisted Radical Cystectomy for Bladder Cancer.

BACKGROUND: The feasibility and safety of robot-assisted radical cystectomy (RARC) may be undermined by unfavorable preoperative surgical characteristics such as previous prostate surgery (PPS). OBJECTIVE: To compare perioperative outcomes for patients undergoing RARC with versus without a history of PPS. DESIGN, SETTING, AND PARTICIPANTS: The study included 220 consecutive patients treated with RARC and pelvic lymph node dissection for bladder cancer at a single European tertiary centre. Of these, 43 had previously undergone PPS, defined as transurethral resection of the prostate/holmium laser enucleation of the prostate (n=21) or robot-assisted radical prostatectomy (n=22). SURGICAL PROCEDURE: RARC in patients with a history of PPS. MEASUREMENTS: Data on postoperative complications were collected according to the quality criteria for accurate and comprehensive reporting of surgical outcomes recommended by the European Association of Urology guidelines. Multivariable logistic, linear, and Poisson regression analyses were performed to test the effect of PPS on surgical outcomes. RESULTS AND LIMITATIONS: Overall, 43 patients (20%) were treated with RARC after PPS. Operative time (OT) was longer in the PPS group (360 vs 330min; p<0.001). Patients with PPS experienced higher rates of intraoperative complications (19% vs 6.8%) and higher rates of 30-d (67% vs 39%), and Clavien-Dindo >3 (33% vs 16%) postoperative complications (all p<0.05). Moreover, the positive surgical margin (PSM) rate after RARC was higher in the PPS group (14% vs 4%; p=0.03). On multivariable analyses, PPS at RARC independently predicted higher risk of intraoperative (odds ratio [OR] 2.10, 95% confidence interval [CI] 1.04-6.21; p=0.01) and 30-d complications (OR 2.26, 95% CI 1.05-5.22; p=0.02), as well as longer OT (relative risk [RR] 1.03, 95% CI 1.00-1.05; p=0.02) and length of stay (RR 1.13, 95% CI 1.02-1.26; p=0.02). Lack of randomization represents the main limitation. CONCLUSIONS: RARC in patients with a history of PPS is feasible, but it is associated with a higher risk of complications and longer OT and length of stay. Moreover, higher PSM rates have been reported for these patients. Thus, measures aimed at improving surgical outcomes appear to be warranted. PATIENT SUMMARY: We investigated the effect of previous prostate surgery (PPS) on surgical outcomes after robot-assisted removal of the bladder. We found that patients with PPS have a higher risk of complications and longer hospitalization after bladder removal. These patients deserve closer evaluation before this type of bladder operation.

Thiel-embalmed cadavers as a novel training model for ultrasound-guided supine endoscopic combined intrarenal surgery.

OBJECTIVE: To evaluate Thiel-embalmed cadavers (TEC) as a training model for percutaneous nephrolithotomy (PCNL), more specifically for ultrasound (US)-guided supine endoscopic combined intrarenal surgery (ECIRS). SUBJECTS AND METHODS: Thirteen urologists (nine experienced endourologists, four fellows/residents) performed an US-guided supine ECIRS procedure on a TEC. The model was evaluated by way of a questionnaire (5-point Likert scale). Descriptive statistical analysis was performed and results were graphically presented using divergent bar graphs. RESULTS: US images were appreciated as lifelike in all aspects. Although distention of the collecting system was not ideal in one out of three TEC, US visualisation of the distended calyces during puncture was good. Skin penetration was more difficult and less realistic in TEC, while kidney puncture and dilatation were deemed very realistic. Ureteric and collecting system anatomy and consistency were similar to real life, although the mucosa appeared paler. US needle guidance was perceived as excellent. Overall, needle puncture assessment was realistic and useful as a training tool. Overall quality and satisfaction of TEC in US-guided supine ECIRS was good to excellent and comparable to a real-life procedure. Overall appropriateness of the TEC model was considered excellent for both initial and advanced supine PCNL training. CONCLUSION: Despite the minor drawbacks of tough skin and non-ideal collecting system dilatation during ureteroscopy, the TEC model was considered good to excellent as a training model for US-guided PCNL, in particular, US-guided needle puncture of the kidney during supine ECIRS.

Oncological and functional efficacy of nephron-sparing surgery versus radical nephrectomy in renal cell carcinoma stages ≥cT1b: a single institution, matched analysis.

INTRODUCTION: The purpose of this paper is to compare oncological outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) in renal cell carcinoma (RCC) clinical stages ≥T1b, in a retrospective propensity-score matched cohort of a high-volume, tertiary referral center. This paper also aims to compare renal function and complication rates between groups. MATERIAL AND METHODS: Our single-institution RCC database was queried to select patients with clinical stages defined by tumor size (T), lymph nodes(N), and metastasis (M) scores of T1b-4 N0 M0, that underwent PN or RN between 2000 and 2014. All images of patients that underwent RN were reviewed, and only patients deemed eligible for PN were included. Medical records were reviewed to obtain data on tumor characteristics, comorbidities, renal function, and complications. After propensity score matching, 152 patients (76 per group) were included in the final analysis. Primary outcomes were cancer specific survival (CSS), overall survival (OS), and clinical progression-free survival (CPFS). Secondary outcomes were renal function preservation and post-operative complication rates. RESULTS: Groups were propensity-score matched. The only parameters that were significantly different between groups were the median follow-up time (RN: 79 months, range 24.1-100.5 vs. PN: 38.5 months, range 20.5-72.1) and a better performance status in the RN group (p = 0.002). The five-year CPFS, CSS, and OS rates were 77.2%, 90.5%, and 86.4%, respectively, in the RN group, and 83.6%, 91.1%, and 82.0%, respectively, in the PN group (p = 0.33, p = 0.55, and p = 0.33, respectively). In the multivariate Cox model, the surgical method was not an independent predictor of CPFS, CSS, or OS. The RN group showed a significantly greater reduction in estimated glomerular filtration rate (RN: 14.1 vs. PN: 5.4 ml/min per 1.73 m²; p <0.03). There was no significant difference in complication rates between the two groups (p = 0.3). The main limitations of this study were its retrospective design and the medium-term follow-up. CONCLUSIONS: Our results demonstrated the efficacy and safety of PN in patients with RCC in clinical stages ≥T1b. We observed no significant difference in oncological outcomes between the PN and RN groups at medium-term follow ups. The surgical method did not influence these outcomes. Renal function was preserved significantly more frequently in the PN than in the RN group, but the groups had similar complication rates.These findings suggested that PN could be considered an oncologically safe procedure for treating large RCC tumors; thus, PN should always be considered, when technically feasible, regardless of tumor stage.