Transperineal vs. transrectal prostate biopsies under local anesthesia: A prospective cohort study on patient tolerability and complication rates.

OBJECTIVES: An increasing number of urologists is switching from transrectal (TR) to transperineal (TP) biopsy procedures for the diagnosis of prostate cancer. Local anesthesia (LA) might be advantageous in terms of patient management, risks and costs. We aimed to evaluate the tolerability and complication rates of TP prostate biopsy performed under LA. METHODS: This is a monocentric, prospective, comparative, observational cohort study. Between July 2020 and July 2021 we included 128 consecutive patients (TR, n = 61; TP, n = 67), with a suspicion of prostate cancer. Transrectal vs. transperineal prostate biopsies were both performed under LA. To evaluate the tolerability we administered a validated visual analog pain score (VAS) during the different steps of the biopsy procedure as well as at 12-, 24- and 48-hours post procedure. The International Prostate Symptom Score (IPSS) questionnaire was administered before the procedure and at the same time intervals. The presence of hematuria, hematospermia, rectal blood loss, acute retention and febrile urinary tract infection (UTI) were also monitored. RESULTS: There were no significant differences in pain or IPSS between groups, except for a significantly higher pain score during the LA of the prostate in the TP group. In general, complication rates were similar, only the prevalence of hematuria at 24 hours was significantly higher in the TP group, as was rectal blood loss at 12 hours postprocedure in the TR group. CONCLUSIONS: In conclusion, our study showed that transperineal prostate biopsy under local anesthesia could be performed with similar pain scores and complication rates, compared to the transrectal procedure.

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.

Early Catheter Removal on Postoperative Day 2 After Robot-assisted Radical Prostatectomy: Updated Real-life Experience with the Aalst Technique.

We evaluated the feasibility and impact on short- and long-term functional outcomes of very early catheter removal on postoperative day (POD) 2 after robot-assisted radical prostatectomy (RARP). To the best of our knowledge, this is the first multisurgeon study with the largest cohort on very early (POD 2) catheter removal after RARP with follow-up of >1 yr. In 255/369 patients (69%) treated with RARP ±â€¯pelvic lymph node dissection, the catheter was removed on POD 2. Among the 255 patients, 33 (13%) required recatheterisation because of acute urinary retention after catheter removal. Of these 33 patients, five (2%) also experienced anastomotic leakage after catheter removal. The early (≤3 mo) urinary continence rate was 67% and the median time to urinary continence recovery was 1 mo. After median follow-up of 18 mo (interquartile range 13-24), 236 patients (88%) were continent. No anastomotic strictures occurred. Our observations confirm the feasibility and safety of POD 2 catheter removal after RARP and support its adoption for selected patients. PATIENT SUMMARY: After removal of the prostate for cancer, patients have a urinary catheter inserted. We investigated whether earlier removal of the catheter affects long-term urinary continence. The results show that it may be safe to remove the catheter on postoperative day 2 for selected patients.

Robot-Assisted Radical Cystectomy for Bladder Cancer in Octogenarians.

OBJECTIVE: To evaluate perioperative morbidity and mortality rate, a 3-year recurrence-free survival, and cancer-specific mortality rate in patients older than 80 years undergoing robot-assisted radical cystectomy (RARC). MATERIALS AND METHODS: We retrospectively collected data of 155 consecutive patients who received RARC for muscle-invasive or high-risk nonmuscle-invasive urothelial carcinoma of the bladder between 2003 and 2014 at a high-volume robotic center. Diversion was performed intra- or extracorporeally according to the surgeon's preferences. Complications were graded according to the Clavien-Dindo system. Logistic regression analyses were used to assess the impact of age on postoperative outcomes. RESULTS: Of 155 consecutive patients, 22 (14.2%) patients were 80 years or older. Octogenarians did not significantly differ from younger patients in ASA score (p = 0.4) and Charlson comorbidity index (p = 0.4). Prevalence of any grade and high-grade complications was similar in both groups (all p ≥ 0.6). Older patients had a significantly higher pathologic tumor grade (p = 0.04) and a lower use of pelvic lymphadenectomy (p < 0.001). No perioperative mortality rate was recorded within 90 days from surgery. Elderly patients had a similar risk of 3-year oncologic recurrence after surgery compared with their younger counterparts (odds ratio [OR] 1.63; p = 0.2). Conversely, the risk of cancer-specific mortality rate was significantly higher (OR 2.78; p = 0.02). CONCLUSIONS: Patients 80 years or older undergoing RARC for bladder cancer did not have a higher risk of peri- and postoperative morbidity and mortality rate and had a similar 3-year recurrence-free survival, suggesting that RARC can be safely performed in selected elderly patients by experienced surgeons.

Evaluation of different techniques to create chronic urinary incontinence in the rat.

OBJECTIVE: To evaluate models for chronic urinary incontinence (UI) in the rat. MATERIALS AND METHODS: Two models were fully evaluated: one of repeated dilatation of the vagina, simulating birth trauma, the vaginal dilatation (VD) group; the other, with surgical transposition of the urethra to a vertical position, the urethral transposition (UT) group. The VD rats were evaluated by the sneeze test. When negative, vaginal dilatation was repeated in a similar way. The UT group was evaluated by observation of continuous urine leakage. The leak-point pressure (LPP) was measured at study end in all the rats. RESULTS: All the VD rats had occasional negative sneeze tests and all had to be dilated again. This resulted in persistent UI on sneeze testing for the entire period. In the UT group, 12 rats leaked continuously during the whole study period; in the other four UI became less at 4, 5, 6, and 7 weeks, respectively. The LPP in the rats with UI was significantly lower than in the respective control groups. CONCLUSIONS: These models permit study of chronic stress UI and continuous UI in the rat. Spontaneous recovery of continence was seen mostly in the VD group.

Healthy, middle-aged, history-free, continent women--do they strain to void?

PURPOSE: We evaluated to what extent abdominal straining is used for voiding in an asymptomatic, continent, healthy, middle-aged female population. MATERIALS AND METHODS: A total of 32 women (mean age 49 +/- 6 years old) could be prospectively included. Technical investigations consisted of flowmetry, pressure flowmetry with EMG and electrosensation evaluation. Some data were compared with those of stress incontinent women investigated prospectively in the same way. RESULTS: There were 4 women who were excluded from analysis because of abnormal sensory evaluation. The symptom-free participants voided with low detrusor pressure, a high flow rate and no residual. A large segment (42%) used additional abdominal straining to void on cystometry and reported that such straining was their usual habit for voiding at home. Straining was seen as frequent in women with stress incontinence. However, significantly more women with stress incontinence used straining without detrusor contraction. CONCLUSIONS: These healthy middle-aged women without a history of pelvic surgery, or symptoms or signs of urological, anorectal or gynecological problems, voided with a mean Pdetmax of 25 cm H(2)O, mean Qmax of 29 ml per second, and the majority without residual. Many of them strained during detrusor contraction and this had not led to the development of signs or symptoms. The way straining is done may make the difference in that during reflex bladder contraction and urethral relaxation, additional straining may have little negative effect. If straining is used to void without the initiation of the micturition reflex, voiding dysfunction and incontinence might develop more easily.

A normal flow pattern in women does not exclude voiding pathology.

It is a widespread assumption that normal micturition behaviour is reflected in a normal flow pattern. This would also mean that a normal flow curve would correspond with normal voiding and would even permit to exclude voiding difficulties. In our study we investigated the value of a normal flow pattern in four different groups: stress incontinent women, women with bladder overactivity, healthy middle-aged volunteers and healthy students. These women voided with a bell-shaped flow curve on pressure flow in 50, 65, 57 and 50%, respectively. Women who strained to void, a major component of dysfunctional voiding, managed to void a bell-shaped flow curve in 46, 60, 70 and 100%, respectively. Our study demonstrates that a "normal" bell-shaped flow curve does not exclude voiding dysfunction in women.