Benjamin V. Stone

GreenLight laser for prostates over 100 ml: what is the evidence?

Purpose of review GreenLight photoselective vaporization of the prostate (PVP) has emerged as a minimally invasive, well tolerated, efficacious alternative to transurethral resection of the prostate (TURP) or simple prostatectomy for the treatment of benign prostatic hyperplasia. However, some authors have expressed concern with the use of PVP in large prostates. In this review, we present the most relevant recent literature regarding PVP for treatment of benign prostatic hyperplasia in prostates over 100 ml. Recent findings Recent studies have found that the subjective and objective outcomes of GreenLight PVP, including International Prostate Symptom Score, quality of lifescore, maximum urinary flow rate, and postvoid residual are comparable in large and small prostates. Though larger glands require increased operative time, energy delivery, and fiber use, the short duration of hospitalization and catheterization does not vary with prostate size. The overall complication rates do not increase with prostate size, though some studies have reported increased conversion to electrocautery TURP hemostasis. The trend toward increased retreatment rates in some studies of PVP in large prostates may be because of inadequate energy density delivered. Summary GreenLight photoselective PVP is a well tolerated and efficacious procedure regardless of prostate size, and should therefore be considered as a viable alternative to TURP, holmium laser enucleation of the prostate, or simple prostatectomy in large prostates.

Prognostic Significance of a Negative Prostate Biopsy: An Analysis of Subjects Enrolled in a Prostate Cancer Screening Trial

Purpose: To our knowledge the optimal treatment of patients following a negative prostate biopsy is unknown. Consequently, resources are increasingly being directed toward risk stratification in this cohort. However, the risk of prostate cancer mortality in this group before the introduction of supplemental biomarkers and imaging techniques is unclear. Materials and Methods: The PLCO (Prostate, Lung, Colorectal and Ovarian Cancer) Screening Trial provides survival data prior to the implementation of new diagnostic interventions. We divided men with an initial positive screen and a subsequent prostate biopsy into cohorts based on positive or negative results. Prostate cancer specific mortality was then compared to that in the trial control arm to estimate the prognostic significance of biopsy results relative to the general population. Results: A total of 36,525 and 36,560 patients comprised the screening and control arms, respectively. Of 4,064 subjects with a positive first screen 1,233 underwent a linked biopsy, of which 473 were positive and 760 were negative. At a median followup of 12.9 years, 1.1% of men in the negative biopsy cohort had died of prostate cancer. The difference in mortality rates between the negative biopsy and control arms was 0.734 deaths per 1,000 person‐years. The proportional subhazard ratios of prostate cancer specific mortality for negative biopsy and positive biopsy relative to the control arm were 2.93 (95% CI 1.44–5.99) and 18.77 (95% CI 12.62–27.93), respectively. Conclusions: After a negative prostate biopsy, men face a relatively low risk of death from prostate cancer when followed with traditional markers and biopsy techniques. This suggests limited potential for new diagnostic interventions to improve survival in this group.

Robot‐assisted partial cystectomy: perioperative outcomes and early oncological efficacy

To report on patients undergoing robot‐assisted partial cystectomy (RAPC), focusing on perioperative outcomes over a range of clinical, anatomical and pathological variables, as well as the overall oncological efficacy of this approach.

Health Services ResearchEvaluation of Unplanned Hospital Readmissions After Major Urologic Inpatient Surgery in the Era of Accountable Care

OBJECTIVE To provide a multi-institutional analysis of clinical factors predicting unplanned hospital readmission after major inpatient urologic surgery. MATERIALS AND METHODS The American College of Surgeons National Surgical Quality Improvement Program is a risk-adjusted data collection mechanism for analyzing clinical outcomes data including 30-day perioperative readmissions and complications. We identified 23,108 patients who underwent major inpatient urologic surgery from 2011 to 2012. Readmission rates were determined and stratified by procedure type. Multiple logistic regression was used to determine independent risk factors for 30-day unplanned hospital readmissions. RESULTS Of a total of 23,108 patients undergoing urologic surgery, 1329 patients (5.8%) had unplanned readmissions. Upper tract reconstruction and urinary diversion without cystectomy (21/102) and with cystectomy (291/1662) had the highest rates of readmission of all procedures analyzed. Readmitted patients had a 64.2% (853/1329) and 64.4% (855/1329) rate of major and minor complications, respectively, compared with 6.7% (1459/21,779) and 15.9% (3462/21,779) for patients not readmitted (P <.02). Organ space infection (odds ratio [OR] 15.23), pulmonary embolism (OR 12.14), deep venous thrombosis (OR 10.96), and return to the operating room (OR 8.46) were the most substantial predictors of readmission. Laparoscopic-robotic procedures had significantly lower readmission rates compared with open procedures for prostatectomy, partial nephrectomy, and nephrectomy (P <.01). CONCLUSION Readmission after inpatient urologic surgery occurs at a rate of 5.8%, with cystectomy and urinary diversion demonstrating the highest rates. Major and minor postoperative complications were the most substantial predictors of readmission. These results may guide risk reduction initiatives to prevent readmissions after major urologic surgery.

Prostate size, nocturia and the digital rectal examination: a cohort study of 30 500 men

To evaluate the utility of the digital rectal examination (DRE) in estimating prostate size and the association of DRE with nocturia in a population‐based cohort.

Trends in Ambulatory Management of Urinary Incontinence in Women in the United States

Objectives Urinary incontinence (UI) is a common condition, but despite the availability of guidelines, variations exist in the care of patients. We sought to assess the changes in assessment and management of women with UI over time in the United States. Methods The National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey are annual surveys from a nationally representative sample of visits to physicians. From 1999 through 2010, we identified visits by women to physicians where the chief complaint was UI using reason-for-visit and International Classification of Diseases, Ninth Revision codes. Results Using 2-year intervals between 1999–2000 and 2009–2010, the number of visits by women with UI to physicians increased (5.3 million to 6.8 million). There was no difference in patient age, race/ethnicity, or physician specialty (primary care, urology, gynecology). The majority did not have their incontinence characterized (42.4%–47.4%). The use of urinalysis significantly decreased (53%–37.2%, P = 0.02), whereas antimuscarinic use significantly increased (16.7%–35%, P = 0.006). There was an overall increased trend in number of referrals to another physician (5.8%–14.7%, P = 0.06). Urologists had a significant increase in antimuscarinic use (23.5%–44.2%, P = 0.003). All physician specialties demonstrated a decreased trend in use of urinalysis between 1999 and 2010. Although imaging rates were low, they were at highest rates among urologists. Conclusions The majority of women do not have the type of UI characterized, whereas there is underutilization of urinalysis. Given the widespread prevalence of UI and its implications on quality of life, greater adherence to guidelines is warranted.

V9-03 RANDOMIZED CLINICAL TRIAL OF THE NO-FLIP SHANGRING CIRCUMCISION FOR ADOLESCENTS AND ADULTS IN AFRICA

INTRODUCTION AND OBJECTIVES: Non-curvature penile deformities are prevalent and bothersome manifestations of Peyronie’s disease (PD) that can result in functional impairment and psychological distress. The quantitative metrics that are currently used to describe these deformities are inadequate and non-standardized, which has historically been a barrier to clinical research and patient care. Our aim is to introduce three-dimensional photography as a technique to improve the evaluation of patients with PD, partially by the measurement of erect penile volume (EPV) and percent erect penile volume loss (EPVL), and to assess the reliability of measurements acquired by 3D photography. METHODS: Six penis models were constructed using computer-assisted design software, and physical models were produced using a 3D printer. 3D photographs of each model were captured in triplicate by 4 observers using an inexpensive 3D camera (Structure Sensor, Occipital, San Francisco, CA). Computer software (Blender, Amsterdam, Netherlands) was used to generate automated measurements of EPV, penile length, minimum circumference, and maximum circumference. 3D images were then digitally reconstructed to restore each image to a non-deformed shape. Percent EPVL was calculated for each model as the percent difference between the EPV of the original model and the EPV after digital reconstruction. The automated measurements were then statistically compared to measurements obtained using water displacement experiments and a tape measure. RESULTS: On average, 3D photography was accurate to within 0.1% for measurement of penile length. It overestimated maximum and minimum circumference by averages of 5.0% and 1.8%, respectively; overestimated EPV by an average of 8.6%; and underestimated percent EPVL by an average of 1.9%. All inter-test, inter-observer, and intraobserver ICC values were greater than 0.75, reflective of excellent methodological reliability. CONCLUSIONS: Erect penile volume and percent EPVL are novel, highly descriptive metrics that may be useful in describing all variants of non-curvature, volume-loss deformities resulting from PD. These metrics can be quickly, accurately, and reliably determined using computational analysis of 3D photographs. Clinical research using 3D photography for assessment of EPV and percent EPVL will empower clinicians and researchers to better understand the clinical impact of penile volume-loss deformities and to study how these deformities respond to therapy.

V9-08 MALE INFERTILITY MICROSURGERY TRAINING – TRICKS OF THE TRADE

INTRODUCTION AND OBJECTIVES: Gender confirmation surgery is an essential component in the management of gender identity disorder. However, short vaginal length, vaginal stenosis, or complications in the perineal dissection are significant limitations of current techniques in male to female surgery. Here we describe our technique for the robot assisted penile inversion vaginoplasty that addresses these needs. METHODS: The patient is prepped and draped in low lithotomy position. The penis is degloved through a circumcision incision. The neurovascular bundle, urethra and corpora cavernosa are dissected out. A six cm bulbar perineal incision is then made, and the dissection is carried to the bulbar urethra. The dissected urethra, neurovascular bundle, glans and corpora are delivered through this incision. The bilateral corpora are transected at their most proximal limit and overswen. The penile skin is inverted and gently retracted to allow a two cm incision above the neovagina for the neoclitoris. Immediately below this, an incision for the neomeatus is made. The urethra is brought through this incision and sutured to the skin. The remaining urethral tissue is used as an inlay onto the incised dorsal epithelial surface of the penile skin. The robotic portion of the surgery uses 4 port incisions: periumbiical Gelport with two pre-placed robotic trocars, right and left lateral ports, and an assistant port in the upper right abdomen. The dissection is from the posterior prostate, staying above Denonviller’s fascia to reach the endopelvic fascia. Under direct vision, the endopelvics are opened sharply from below and opened to a width of two fingerbreadths. The neovagina is passed into robotic field and pexed to the anterior reflection of the posterior peritoneum. The peritoneal reflection is then closed. The neoclitoris is fashioned from the glans penis and approximated. Labia majora and minora are fashioned with local skin flaps. A foley catheter is left indwelling as well as a vaginal stent. RESULTS: The index case required 7 hours of surgical time with an estimated blood loss of 100 mL. The vaginal length was greater than 15 cm. The patient was discharged home on post-operative day three, with no complications. The patient endorses sensation at the neoclitoris and anterior neovagina, and finds the vaginal depth satisfactory CONCLUSIONS: Our novel method for robot assisted penile inversion vaginoplasty is an important step in optimizing outcomes for our patients. This technique achieves maximal vaginal length in a safe and reproducible manner.

Accurate Estimation of Prostate Size in the Evaluation of Nocturia

Purpose of ReviewThe clinical utility of the digital rectal exam (DRE) in the workup of lower urinary tract symptoms has been questioned in the literature. This review aims to critically examine the recent literature regarding the accuracy and reliability of the DRE in the assessment of lower urinary tract symptoms (LUTS) and benign prostatic hypertrophy (BPH). Here, we specifically focus on the clinical importance of the DRE in the evaluation of nocturia.Recent FindingsEstimates of prostate size on DRE have high interexaminer variability and poor correlations with transrectal ultrasound (TRUS) volume. Prostate size estimates correlate poorly with LUTS and nocturia, while cardiovascular comorbidities are strongly associated with nocturia.SummaryThe DRE is a highly variable and inaccurate method of predicting prostate size, with limited ability to assess LUTS. Nocturia is a multifactorial condition that is often associated with medical comorbidities, and estimates of prostate size are highly unlikely to have clinical utility in the workup of this condition.

MP42-15 TREATMENT OF SYMPTOMATIC BENIGN PROSTATIC HYPERPLASIA IN PATIENTS OVER 80 YEARS OLD USING 180W HIGH POWER 532NM LASER VAPORIZATION-ENUCLEATION TECHNIQUE

INTRODUCTION AND OBJECTIVES: GreenLight Laser is a safe and efficacious treatment for benign prostatic hyperplasia (BPH). There is limited evidence on its use in very large prostates, for which simple prostatectomy is the traditional procedure. The objective of this study is to demonstrate the safety and efficacy of 180W high power 532 nm laser vaporization-enucleation prostatectomy in prostates measuring over 150cc. METHODS: We performed a retrospective chart analysis of all patients treated with the GreenLight XPS-180W system (AMS, MN, USA) in our institution from Sep 2011 to Oct 2015 with a prostate measuring over 150 cc on transrectal ultrasound preoperatively. Data collected include prostate volume, IPSS and quality of life (QoL) scores, maximum urinary flow rate (Qmax), postvoid residual (PVR), prostate specific antigen (PSA), complications, and reintervention rates. Statistical analysis was performed using SPSS (version 21). All procedures were performed by the same surgeon using a vaporization-enucleation technique that provides tissue for histologic analysis. RESULTS: We included 70 male patients with a total of 72 procedures. The median prostate size was 203 cc (152-376cc). There were 42 patients (58%) with an indwelling catheter preoperatively. Using the ASA physical status classification system, 37 patients were ASA class 2 and 33 were ASA class 3. Median operative time was 180 minutes, laser time 97 minutes, energy utilization 674kJ, and energy density 3.3kJ/cc, with a median 3 fibers used per case. Median length of stay and length of catheterization were both one day. IPSS and QoL scores demonstrated significant improvements at 6, 12, and 24 months postoperatively. Qmax and PVR, measured at 6 and 12 months postoperatively, were also significantly improved (Table 1). All patients had prostate tissue resected with BPH present in all specimens. One patient required a long-term indwelling catheter for refractory urinary retention. Two patients (2.9%) required retreatment with a second PVP procedure. CONCLUSIONS: In our experience, high-power 532 nm laser vaporization-enucleation prostatectomy provides excellent and durable subjective and objective improvements in symptoms and voiding parameters, regardless of prostate size.