A randomized controlled trial comparing high and medium power settings for holmium laser enucleation of prostate.

PURPOSE: To report the results of a randomized controlled trial comparing outcomes between medium power (MP) and high power (HP) laser settings for HoLEPs. METHODS: The primary objective was to compare the enucleation efficiency (EE) of HP- HoLEP (80-100 W) with MP-HoLEP (50 - 60 W). The secondary objectives were to compare treatment efficacy and safety between both groups. To show a 25% difference in EE, a sample size of 45 individuals per treatment arm was required (alpha = 0.05; Beta = 0.80). Patients demographic and perioperative factors were analyzed, including EE, hemoglobin drop, duration of catheterization, and length of hospital stay. The surgical outcome was evaluated with AUA symptom score, maximum flow rate, postvoid residual urine, and complications to assess differences between MP and HP HoLEP at baseline, 3 months, 1, and 5 years. Quantitative outcomes were compared with independent sample t tests (2-tailed) and qualitative outcomes were compared with chi-square tests. RESULTS: Preoperative data with the exception of indication for surgery were comparable in both treatment arms. There was no statistically significant difference in enucleation efficiency between the HP-HoLEP and MP-HoLEP laser setting (0.97 ± 0.47 vs. 0.85 ± 0.47 gm/min, p = 0.209). MP laser settings did not increase perioperative or postoperative complications and resulted in durable outcome comparable with HP laser settings at 5-year follow-up. CONCLUSIONS: MP-HoLEP is safe and efficient and does not compromise the outcome for HoLEPs when compared with HP-HoLEP.

Holmium Laser Enucleation of Prostate Within 6 Weeks of Transrectal Ultrasound Guided Prostate Biopsy is Safe and Effective.

OBJECTIVE: To evaluate the safety and efficacy of performing Holmium laser enucleation of the prostate (HoLEP) for the treatment of bladder outlet obstruction secondary to an enlarged prostate within 6-weeks of a transrectal ultrasound (TRUS) guided prostate biopsy. MATERIALS AND METHODS: We performed a retrospective review of patients who underwent a HoLEP at our institution, excluding any patients with a confounding urologic history and compared patients who underwent a TRUS-guided 6- or 12-core prostate biopsy, and then underwent a HoLEP within 6 weeks (study group) with all other patients (control group). Our primary outcomes were enucleation efficiency (EE) and perioperative complication rate. Our secondary outcomes included postoperative drop in hemoglobin, duration of catheterization, length of hospital stay, voiding metrics at 1 and 6 months and rate of incidental prostate cancer diagnosed on histopathological examination of prostate specimens after HoLEP. To test for differences between the study and control groups, we performed independent sample t-test (2-tailed) and chi-square tests for quantitative and qualitative variables, respectively. P values of < 0.05 were considered statistically significant. RESULTS: 552 patients met inclusion criteria and 84 patients underwent prostate biopsy within a period of 45 days prior to HoLEP. Enucleation efficiency was higher in the study group (P = 0.00). There was no significant difference between the 2 groups regarding perioperative complications, postoperative voiding outcomes, or rate of incidental prostate cancer detection. CONCLUSIONS: TRUS prostate biopsy performed within 6 weeks of HoLEP does not negatively impact operative difficulty or treatment outcome.

Salvage Ultrasound-guided Targeted Cryoablation of The Perispermatic Cord For Persistent Chronic Scrotal Content Pain After Microsurgical Denervation Of The Spermatic Cord.

OBJECTIVE: To assesses the efficacy of ultrasound-guided targeted cryoablation (UTC) of the perispermatic cord as a salvage treatment for patients who failed microsurgical denervation of the spermatic cord. METHODS: Retrospective review of 279 cases (221 patients: 58 bilateral) undergoing UTC between November 2012 and July 2016, performed by 2 fellowship trained microsurgeons. UTC was performed using a 16-gauge cryo needle (Endocare, HealthTronics, Austin, TX). Branches of the genitofemoral, ilioinguinal, and inferior hypogastric nerves were cryoablated medial and lateral to the spermatic cord at the level of the external inguinal ring. Level of pain was measured preoperatively and postoperatively using the visual analog scale and Pain Index Questionnaire-6 (QualityMetric Inc., Lincoln, RI). RESULTS: Median age was 43 years, operative duration 20 minutes, and postoperative follow-up 36 months (24-60). Subjective visual analog scale outcomes: 75% significant reduction in ain (11% complete resolution and 64% ≥50% reduction in pain). Objective Pain Index Questionnaire-6 outcomes: 53% significant reduction at 1 month (279 cases), 55% at 3 month (279 cases), 60% at 6 month (279 cases), 63% at 1 year (279 cases), 65% at 2 years (275 cases), 64% at 3 years (232 cases), 59% at 4 years (128 cases) and 64% at 5 years (53 cases) post-op. COMPLICATIONS: 2 wound infections, 4 penile pain cases (resolved in a few months). CONCLUSION: UTC of the perispermatic cord is a safe potential treatment option for the salvage management of persistent chronic scrotal pain in patients who have failed microsurgical denervation of the spermatic cord.

Review of the role of robotic surgery in male infertility.

OBJECTIVES: To present the current state of the art in various robot-assisted microsurgical procedures in male infertility and review the latest literature, as the technology in infertility procedures has substantially developed since the incorporation of the Vinci® robotic platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA). MATERIALS AND METHODS: The search strategy in this review was conducted in accordance with Cochrane guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A search strategy was conducted in MEDLINE, PubMed and the Cochrane electronic databases (from 2000 to present) to identify studies that included both robotic and male infertility. RESULTS: In all, 23 studies were found, 12 of which met our inclusion criteria. Articles were excluded if the study did not include both male infertility and robotics. CONCLUSIONS: Robotic assistance for microsurgical procedures in male infertility appears to be safe and feasible. It has several advantages including elimination of tremor, multi-view magnification, additional instrument arms, and enhanced dexterity with articulating instrument arms. It also has a short learning curve with a small skin incision. However, larger, prospective studies are needed to establish the clinical benefits over standard microsurgery.

Targeted Robotic Assisted Microsurgical Denervation of the Spermatic Cord for the Treatment of Chronic Orchialgia or Groin Pain: A Single Center, Large Series Review.

PURPOSE: Microsurgical denervation of the spermatic cord is a treatment option for chronic orchialgia refractory to conservative treatment. A recent study showed specific nerve fibers as the possible cause of chronic orchialgia. Our goal was to present the outcomes of ligation of these nerves using a technique of targeted robotic assisted microsurgical denervation of the spermatic cord. MATERIALS AND METHODS: We retrospectively reviewed the records of 772 patients who underwent targeted robotic assisted microsurgical denervation of the spermatic cord from October 2007 to July 2016. Selection criteria were chronic testicular pain more than 3 months in duration, failed conservative treatments, negative neurological and urological workup, and temporary resolution of pain with a local anesthetic spermatic cord block. Targeted robotic assisted microsurgical denervation of the spermatic cord was performed. Pain was assessed preoperatively and postoperatively using a subjective visual analog scale and objectively with the standardized and validated PIQ-6 (Pain Impact Questionnaire-6) score. RESULTS: Followup data were available on 860 cases. During a median followup of 24 months (range 1 to 70) 718 cases (83%) showed a significant reduction in pain and 142 (17%) had no change in pain by subjective visual analog scale scoring. Of cases with a significant reduction in pain 426 (49%) had complete resolution and 292 (34%) had a 50% or greater reduction. Objective PIQ-6 analysis showed a significant reduction in pain in 67% of patients 6 months postoperatively, in 68% at 1 year, in 77% at 2 years, in 86% at 3 years and in 83% at 4 years. CONCLUSIONS: Targeted robotic assisted microsurgical denervation of the spermatic cord is an effective, minimally invasive approach with potential long-term durability in patients with refractory chronic orchialgia.

Rapid versus gradual bladder decompression in acute urinary retention.

OBJECTIVE: To demonstrate a benefit in diminished adverse events such as hypotension and hematuria with gradual drainage of the bladder when compared to rapid decompression in patients with acute urinary retention (AUR) due to benign prostatic hyperplasia in a case-control study. METHODS: Sixty-two patients matched our selection criteria presenting with AUR. They were divided into two groups - the first was managed by rapid drainage of the bladder, the second was managed by gradual drainage through a urethral catheter (The first 100 mL immediately evacuated, then the rest evacuated gradually over 2 h). RESULTS: The mean age was 64.4 and 63.2 years in the first and second group, respectively. Diagnosed cause was benign hyperplasia of the prostate. Hematuria occurred in two patients in the first group and none in the second group. The two cases of hematuria were mild and treated conservatively. After the relief of the obstruction, the mean blood pressure was noticed to decrease by 15 mmHg and 10 mmHg in the first and second group, respectively, however, no one developed significant hypotension. Pain relief was achieved after complete drainage in the first group and after the evacuation of 100 mL in the second group. CONCLUSIONS: We conclude that there is no significant difference between rapid and gradual decompression of the bladder in patients with AUR. Hematuria and hypotension may occur after rapid decompression of the obstructed urinary bladder, but these complications are rarely clinically significant.

Comparison of renal function following donor nephrectomy versus radical nephrectomy for renal tumor.

In this study, we compared renal function in patients after donor nephrectomy (DN) and radical nephrectomy (RN). We retrospectively reviewed 68 patients (mean follow-up 15 months), including 30 patients who had undergone DN and 38 patients who had undergone RN. The study was performed between April 2006 and July 2010 at a single institute. Patients were matched for age and co-morbidities (hypertension and diabetes mellitus). We calculated the estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease study group equation. Parameters studied included GFR (≥60 to <60 mL/min/1.73 m 2 ), serum creatinine (>2.0 mg/dL), metabolic acidosis (serum bicarbonate <22 mmol/L) and proteinuria (>30 mg). There were no significant demographic differences between the two study groups. After a mean follow-up of 15 months, low eGFR (<60 mL/min/1.73 m 2 ) was seen in 28% and 6.7% of patients in the RN and DN groups, respectively (P = 0.03). Similarly, proteinuria was seen in 21% vs 0%, P = 0.007, and de novo elevated creatinine was seen in 13% vs 0%, respectively P = 0.04; thus the changes were greater in the RN group. Our study shows that undergoing RN had a significantly greater risk of developing renal insufficiency and proteinuria compared with age-and co-morbidity-matched patients undergoing DN. We concluded that patients undergoing RN show a significantly greater risk of developing renal insufficiency and proteinuria compared with the patients undergoing DN.

Management of lower ureteric stones: a prospective study.

OBJECTIVE: To discuss the current concepts in lower ureteric stone management. MATERIAL AND METHODS: Between October 2008 and November 2010, 190 patients of both sexes and of different age groups with lower ureteric stones, underwent in situ extracorporeal shock wave lithotripsy (ESWL) (48 cases), ureterorenoscopy (URS) (120 cases) and open stone surgery (OSS) (22 cases). The patients' clinical and radiological findings, as well as stone characteristics, were reviewed and correlated with the stone-free status. RESULTS: In the ESWL group, the operative time was 43.13 +22.5 min; the average number of sessions/patients was 1.5 sessions; the average number of SW/patients was 4500 SW/patients; the average energy was 16.5 kV; the average stone burden was 7.8/mm; the overall stone-free rate was 75% (36/48); and the average radiation exposure time was 3.5 min. In the URS group, the operative time was 49.21 +16.09 min; the average stone burden was 10.81mm; the overall stone-free rate was 97.5% (117/120); the average hospital stay was 3.99 days; and the average radiation exposure time was 0.75 min. In the OSS group, the operative time was 112.38 +37.1 min; the overall stone-free rate was 100% (22/22); and the average hospital stay was 9.74 days. CONCLUSION: In the management of patients with lower ureteral stones, URS, SWL and OSS were considered acceptable treatment options. This recommendation was based on the stone-free results, morbidity and retreatment rates for each therapy.

Early return of continence in patients undergoing robot-assisted laparoscopic prostatectomy using modified maximal urethral length preservation technique.

PURPOSE: To evaluate the impact of maximal urethral length preservation (MULP) technique in comparison with posterior urethral reconstruction and anterior bladder suspension (PRAS) technique on the continence rates (CR), time to achieve continence among patients with prostate cancer (PCa) undergoing robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: We prospectively analyzed the CR, time to achieve continence, pre- and postoperative prostate-specific antigen (PSA) levels, rates of positive margins among three groups of continent men with PCa undergoing RALP from whom consent was obtained. Each group consisted of 30 patients: PRAS was performed in group A, combined MULP and PRAS in group B, and MULP in group C. Continence was measured by patient self-reporting of the number of pads/24 h. RESULTS: No differences were detected in the age, preoperative PSA levels, biochemical recurrence, prostate volume, and positive margins for the three groups. Men in groups B and C had marked improvement in CR 1, 3, and 6 months after catheter removal vs group A (50% and 70% vs 10%, 90% and 96.66% vs 23.3% and 100%, 100% vs 53.3%, respectively, P<0.0001). The average and median times to continence were significantly shorter in group B (5.4 and 4 weeks) and C (3.8 and 3 weeks) vs group A (27.4 and 22.5 weeks), P<0.00001. Using Cox regression analysis, only MULP and MULP+PRAS techniques were significantly correlated with continence outcomes 1, 3, and 6 months after catheter removal. CONCLUSIONS: MULP rather than PRAS confers higher postoperative CR and shorter time to achieve continence among patients with PCa who underwent RALP without increasing risk of positive margin.

Comparative study of laparoscopic pyelolithotomy versus percutaneous nephrolithotomy in the management of large renal pelvic stones.

BACKGROUND: The aim of the study is to investigate whether laparoscopic pyelolithotomy (LPL) could be used to manage large renal pelvic stones, generally considered excellent indications for percutaneous nephrolithotomy (PNL). METHODS: This study was performed from May 2009 to March 2012 at Al-Azhar University Hospitals (Assiut and Cairo), Egypt. It included two groups of patients with large renal pelvic stones; only patients with stones 2.5 cm(2) or greater were included. Group 1 included 40 patients treated by PNL and Group 2 included 10 patients treated by LPL. The differences between the two procedures were compared and analyzed. RESULTS: There was no difference between the two groups regarding patient demographics and stone size. There was a statistically significant difference between the groups regarding mean estimated blood loss (65 ± 12.25 [range: 52.75-77.25] vs. 180 ± 20.74 [range: 159.26-200.74] mL, p ≤ 0001), mean hospital stay (2.3 ± 0.64 [range: 1.66-2.94] vs. 3.7 ± 1.4 [range: 2.3-5.1] days, p ≤ 0.006), rate of postoperative blood transfusion (0% vs. 4.8%, p ≤ 0.0024), and stone-free rate (80% vs. 78.6%, p ≤ 0.23). The mean operative time was significantly longer in Group 2 (LPL) (131 ± 22.11 [range: 108.89-153.11) vs. 51.19 ± 24.39 [range: 26.8-75.58] min, p ≤ 0001), respectively. CONCLUSION: Although PNL is the standard treatment in most cases of renal pelvic stones, LPL is another feasible surgical technique for patients with large renal pelvic stones.

Ex vivo model for renal fracture in cryoablation.

OBJECTIVE: To demonstrate the formation of fractures due to cryoablative therapy in a controlled model and validate the new model for the study of the complication of fractures during renal cryoablation. METHODS: Endocare PERC-17 (1.7 mm) and Galil 17 ga IceRod (1.47 mm) probes were selected because of similar diameter and reported ice-ball size. The ex vivo model used here was a porcine kidney obtained at the supermarket. The kidneys were subsequently bivalved. The cryoprobes were inserted running just underneath the cut surface, entering the lateral surface of the kidney, and directed toward the medial surface of either the upper or lower pole. In this manner, we avoided the major calyces and involved the most parenchyma. Freeze-thaw-freeze cycles of various durations were performed. The probes were frozen parallel to each other at a distance of 20 mm apart. RESULTS: Evidence of cryoablation-induced fracture included popping sounds noted during thaw and cracks that became visible during the phase of second freeze. Cracks were noted to extend from the probe through the parenchyma. In multiple probe freezes, the intervening zone between the 2 ice-balls had smoother ice and the fractures that appeared there originated at either probe. Fracture formation was only observed with the Endocare probes, with single or parallel freezes. No fractures were noted in the IceRod freezes. CONCLUSION: The bivalved ex vivo kidney is an inexpensive, representative, and demonstrative model for study of fracture during cryoablation.

Validation study of a virtual reality robotic simulator--role as an assessment tool?

PURPOSE: Virtual reality simulators are often used for surgical skill training since they facilitate deliberate practice in a controlled, low stakes environment. However, to be considered for assessment purposes rigorous construct and criterion validity must be demonstrated. We performed face, content, construct and concurrent validity testing of the dV-Trainer™ robotic surgical simulator. MATERIALS AND METHODS: Urology residents, fellows and attending surgeons were enrolled in this institutional review board approved study. After a brief introduction to the dV-Trainer each subject completed 3 repetitions each of 4 virtual reality tasks on it, including pegboard ring transfer, matchboard object transfer, needle threading of rings, and the ring and rail task. One week later subjects completed 4 similar tasks using the da Vinci® robot. Subjects were assessed on total task time and total errors using the built-in scoring algorithm and manual scoring for the dV-Trainer and the da Vinci robot, respectively. RESULTS: Seven experienced and 13 novice robotic surgeons were included in the study. Experienced surgeons were defined by greater than 50 hours of clinical robotic console time. Of novice robotic surgeons 77% ranked the dV-Trainer as a realistic training platform and 71% of experienced robotic surgeons ranked it as useful for resident training. Experienced robotic surgeons outperformed novices in many dV-Trainer and da Vinci robot exercises, particularly in the number of errors. On pooled data analysis dV-Trainer total task time and total errors correlated with da Vinci robot total task time and total errors (p = 0.026 and 0.011, respectively). CONCLUSIONS: This study confirms the face, content, construct and concurrent validity of the dV-Trainer, which may have a potential role as an assessment tool.

Robotic pyeloplasty: the University of California-Irvine experience.

PURPOSE: For the treatment of ureteropelvic junction obstruction laparoscopic dismembered pyeloplasty and open pyeloplasty have similar outcomes. We present our experience with robot assisted laparoscopic dismembered pyeloplasty. MATERIALS AND METHODS: We retrospectively reviewed all adult robot assisted laparoscopic dismembered pyeloplasties performed at our institution between November 2002 and July 2009. Preoperative evaluation included abdominal computerized tomography angiogram to assess for crossing vessels and diuretic renal scan to quantify the degree of obstruction. Followup with diuretic renal scan and a patient pain analog scale was performed 3, 6 and 12 months after surgery. If the study was normal at 12 months, the patient was followed with ultrasound of the kidneys and bladder to look for ureteral jets. Absent ureteral jets, worsening hydronephrosis or patient complaint of pain necessitated repeat diuretic renogram. RESULTS: A total of 61 robot assisted laparoscopic dismembered pyeloplasties were performed in 21 men and 40 women. Followup was available for 57 patients with an average ± SD age of 35 ± 16 years and average followup of 18 ± 15 months. Mean operative time was 335 ± 88 minutes and estimated blood loss was 61 ± 48 ml. Average hospitalization time was 2 ± 0.9 days and the average postoperative analgesia requirement was 13 ± 9.6 mg morphine sulfate equivalents. The overall success rate was 81% based on a normal diuretic renogram and lack of pain using a validated pain scale. There were 3 grade III Clavien complications for a 4.9% major complication rate. CONCLUSIONS: Robot assisted laparoscopic dismembered pyeloplasty is a feasible technique for ureteropelvic junction reconstruction. When measured by the more stringent application of diuretic renography and analog pain scales, the success rate for ureteropelvic junction obstruction management appears similar to that of open or standard laparoscopic approaches.