Ehab A. Elzayat

Holmium Laser Enucleation of the Prostate in Patients on Anticoagulant Therapy or With Bleeding Disorders

PURPOSE We evaluated the safety and efficacy of HoLEP in patients on anticoagulation with significant obstructive symptoms secondary to BPH refractory to medical therapy. MATERIALS AND METHODS From May 1999 to October 2004, 83 patients with a mean age of 76.6 years who had symptomatic BPH and were on chronic oral anticoagulant therapy or had bleeding disorders underwent HoLEP. Mean preoperative prostate size estimated by transrectal ultrasound was 82.4 cc (range 25 to 222). A total of 14 patients underwent HoLEP without oral anticoagulant withdrawal, 34 underwent surgery with low molecular weight heparin substitution and 33 stopped anticoagulants before surgery, including 8 on antiplatelet therapy. All patients were assessed preoperatively, and 1, 3, 6 and 12 months after surgery. RESULTS HoLEP was performed successfully in all patients with a mean enucleation time of 86.5 minutes (range 35 to 210). Mean morcellation time was 20.1 minutes (range 3 to 100). Peak urinary flow, post-void residual urine, International Prostate Symptom Score and quality of life score were significantly improved by 1 month after surgery and they continued to improve during subsequent followup. One patient required intraoperative platelet transfusion and 7 required blood transfusion early in the postoperative period due to hematuria coinciding with restarting oral anticoagulant therapy. Mean preoperative and postoperative hemoglobin was 13.5 (range 8.3 to 16.4) and 12.2 gm/dl (range 5.3 to15.4), respectively (p <0.0001). There were no major operative or postoperative complications, or thromboembolic events. CONCLUSIONS HoLEP is a safe and effective therapeutic modality in patients on anticoagulation with symptomatic BPH refractory to medical therapy.

Holmium laser ablation versus photoselective vaporization of prostate less than 60 cc: long-term results of a randomized trial.

PURPOSE We evaluated the long-term results and durability of photoselective vaporization and holmium laser ablation as surgical treatment of small to medium prostates in a prospective, randomized study in men with obstructive benign prostatic hyperplasia. MATERIALS AND METHODS From March 2005 to April 2007 we randomly allocated 109 patients with a prostate gland of less than 60 cc to prostate photoselective vaporization (52) or holmium laser ablation (57) and evaluated them 1, 2 and 3 years postoperatively. Functional followup included measurement of maximum urinary flow rate, post-void residual urine, International Prostate Symptom Score, quality of life, International Index of Erectile Function and prostate specific antigen. RESULTS Mean ± SD preoperative prostate volume was 33.1 ± 14.5 and 37.3 ± 13.6 in the laser ablation and vaporization groups, respectively. All functional parameters improved significantly compared to baseline values in each group. There was no difference in International Prostate Symptom Score, quality of life, maximum urinary flow rate, post-void residual urine or percent of prostate specific antigen decrease between the 2 groups 1, 2 and 3 years postoperatively. At 3-year followup International Prostate Symptom Score had improved by 70.5%, quality of life had improved by 69.4%, maximum urinary flow rate had increased by 164% and post-void residual urine had decreased by 81% in the holmium laser ablation group. In the photoselective vaporization group International Prostate Symptom Score improved by 64.1%, quality of life improved by 65.5%, maximum urinary flow rate increased by 189% and post-void residual urine decreased by 79.5%. The overall re-treatment rate was 15.8% for holmium laser ablation vs 19.3% for photoselective vaporization. CONCLUSIONS Prostate photoselective vaporization and holmium laser ablation are effective surgical treatments for benign prostatic hyperplasia. Postoperative functional improvements were significant and durable, and equivalent in the 2 groups. The 2 techniques have a similar complication rate.

Botulinum toxin type A inhibits the growth of LNCaP human prostate cancer cells in vitro and in vivo.

Botulinum toxin type A (BTA) intraprostatic injection induces an improvement of urinary symptoms related to benign prostatic hypertrophy (BPH). Infra‐clinical prostate cancer (PCa) foci and pre‐neoplasic lesions occur concomitantly with BPH in a significant number of patients. The objective of this study was to address whether BTA influences the growth of prostate tumors.

Holmium Laser Ablation of the Prostate Versus Photoselective Vaporization of Prostate 60 cc or Less: Short-Term Results of a Prospective Randomized Trial

PURPOSE We report on the first randomized trial to our knowledge comparing holmium laser ablation and photoselective vaporization of the prostate in patients with a small to moderate size prostate. MATERIALS AND METHODS Between March 2005 and April 2007, 109 patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia and prostate size 60 cc or smaller were randomized to photoselective vaporization of the prostate (52) or holmium laser ablation of the prostate (57). All patients were evaluated by preoperative and postoperative International Prostate Symptom Score, peak flow rate and post-void residual urine volume, measurement of prostate specific antigen and transrectal ultrasound prostate volume. Followup evaluations were performed during visits at 1, 3, 6 and 12 months. RESULTS Mean +/- SD preoperative prostate volume was 33.1 +/- 14.5 and 37.3 +/- 13.6 cc in the holmium laser ablation group and the photoselective vaporization group, respectively. Holmium laser ablation of the prostate required more operating time than photoselective vaporization (69.8 vs 55.5 minutes, p = 0.008). In the holmium laser ablation group the International Prostate Symptom Score improved from 20 +/- 6.8 to 6.2 +/- 3.9 and peak urinary flow rate increased from 6.7 +/- 3.9 to 17.2 +/- 8 ml per second. In the photoselective vaporization group the International Prostate Symptom Score improved from 18.4 +/- 6.6 to 8.2 +/- 6.2 and peak urinary flow rate increased from 6.4 +/- 3.9 to 18.4 +/- 8.4 ml per second. Urethral stricture rates were 1.7% vs 5.7%, bladder neck contractures were 3.5% vs 7.7% and revaporization rates were 3.5% vs 1.9% in the holmium laser ablation and photoselective vaporization groups, respectively. CONCLUSIONS Holmium laser ablation and photoselective vaporization of the prostate are safe and effective in patients with benign prostatic hyperplasia with a small to moderate size prostate. Both procedures are easy to learn but holmium laser ablation of the prostate requires a longer operating time.

Prostatic-specific Antigen Velocity After Holmium Laser Enucleation of the Prostate: Possible Predictor for the Assessment of Treatment Effect Durability for Benign Prostatic Hyperplasia and Detection of Malignancy

OBJECTIVES To evaluate the prostate-specific antigen velocity (PSAV) as an indicator for effectiveness and durability of size reduction after holmium laser enucleation of the prostate (HoLEP). Additionally, PSAV monitoring in the detection of prostate cancer was also evaluated. METHODS Between 1998 and 2006, we reviewed the prostate-specific antigen (PSA) data of 335 men who underwent HoLEP and had a complete PSA data including preoperative PSA, postoperative PSA (reset), and a minimum of 2 annual PSA readings after PSA reset. PSAV was calculated by 3 methods--simple arithmetic method, linear regression method, and rate method. RESULTS In the benign group, the mean PSA dropped from 5.44 to 0.91 ng/mL (P <0.001). The prostate cancer patients who were newly discovered in the follow-up period had significantly higher baseline PSA (P = .032) and significantly lower PSA reduction than that of the benign group (75.39% vs 47.49%, P <.001). PSAV was calculated by 3 different methods and produced identical results; however, linear regression method produced significantly lower estimates at 7 years. In the malignant group, the mean PSAV at 1 and 3 years was higher than that of the benign group (1.28 vs 0.13 and 2.4 vs 0.09, P <0.022, 0.001, respectively). CONCLUSIONS HoLEP results in a significant reduction in PSA that remained at lower levels during follow-up, suggesting that the glandular size reduction after HoLEP is durable. Monitoring of PSAV is important in long-term follow-up of patients for prostatic carcinoma detection after prostatic surgery.

Laser treatment of symptomatic benign prostatic hyperplasia

The treatment of lower urinary symptoms secondary to benign prostatic hyperplasia (BPH) after failure of medical therapies remains controversial for most urologic surgeons. The complications of traditional surgery are the driving force behind the development of several minimally invasive treatments of symptomatic BPH. Laser prostatectomy is one of the most investigated such modalities. In this article we reviewed the results of the most common types of lasers used in prostatic surgery.

Severe soft tissue infection of the thigh after vaginal erosion of transobturator tape for stress urinary incontinence

Since the beginning of use of synthetic midurethral slings, several complications, usually benign, have been reported. Recently, three consecutive cases of severe thigh infection secondary to transobturator insertion of a synthetic tape alarmed us. This is a case report about these three cases and a review of literature about complications of transobturator tapes.

Electrode–tissues interface: modeling and experimental validation

The electrode-tissues interface (ETI) is one of the key issues in implantable devices such as stimulators and sensors. Once the stimulator is implanted, safety and reliability become more and more critical. In this case, modeling and monitoring of the ETI are required. We propose an empirical model for the ETI and a dedicated integrated circuit to measure its corresponding complex impedance. These measurements in the frequency range of 1 Hz to 100 kHz were achieved in acute dog experiments. The model demonstrates a closer fitting with experimental measurements. In addition, a custom monitoring device based on a stimuli current generator has been completed to evaluate the phase shift and voltage across the electrodes and to transmit wirelessly the values to an external controller. This integrated circuit has been fabricated in a CMOS 0.18 microm process, which consumes 4 mW only during measurements and occupies an area of 1 mm(2).

Holmium Laser Enucleation of Prostate in Patients With Prostate Size ≤60 cm3

OBJECTIVES To evaluate the safety and efficacy of holmium laser enucleation of the prostate in patients with small to moderate size prostate. METHODS We retrospectively reviewed the data of 224 patients with a preoperative prostate size </=60 cm(3), who had undergone holmium laser enucleation of the prostate at our institution from March 1998 to February 2005. The patient characteristics, indications for surgery, preoperative and postoperative International Prostate Symptom Score, including quality-of-life score, peak urinary flow rate, postvoid residual urine volume, enucleation time, morcellation time, total energy used, enucleated tissue weight, catheterization time, hospital stay, pathologic examination findings, and complications were recorded. RESULTS The mean prostate size was 43 +/- 11.1 cm(3), the mean operative time was 80 minutes, and the enucleated tissue weight was 24 g. The mean catheterization time and hospital stay was 1.2 and 1.4 days, respectively. No major intraoperative complications were encountered. Only 2 patients (0.9%), who were receiving anticoagulation therapy, required a postoperative blood transfusion. At 1 year postoperatively, the International Prostate Symptom Score had improved from 17.6 +/- 6.7 to 4.9 +/- 4.4 (72%), the quality-of-life score had improved from 3.5 +/- 1.3 to 1.2 +/- 1.3 (66%), the peak urinary flow rate had increased from 7.5 +/- 3.1 to 21.2 +/- 9.5 mL/s (183%), and the postvoid residual urine volume had decreased from 155 +/- 170 to 27 +/- 48 mL (83%). CONCLUSIONS Holmium laser enucleation of the prostate is safe and effective treatment in patients with small to moderate size prostate as well as those with larger prostates, with low morbidity and a short catheterization time and hospital stay.

Detection of the bladder volume from the neural afferent activities in dogs: experimental results

Abstract Objective: We evaluate the bladder volume and pressure through recording the bladder afferent activity in the sacral nerve roots in acute experiments of paraplegic dogs. These measurements are intended to report the status of the bladder and to adjust the stimulation parameters of an implantable electric stimulator. Methods: The extraction of neural information for feedback in functional electrical stimulation is limited by the poor signal to noise ratio (SNR) in the sacral nerve recordings. We propose to inject a very low amplitude sinusoidal current with high SNR to the bladder through the nerve using a tripolar cuff electrode wrapped around the S2 nerve root. The application of this current (0.4 μA peak to peak, 30 Hz) allows detecting bladder afferent activity in its amplitude and the tissues impedance of the nerve. Acute experiments in dogs were performed to evaluate the proposed method. In each dog, the bladder infusion with saline was carried out at both slow and high filling rates. At the same time, the changes in the amplitude of the sinusoidal output voltage V OUT were recorded through the cuff nerve electrode. Results: The data obtained from 26 acute experiments using eight dogs demonstrate that the amplitude of the recorded sinusoidal voltage V OUT varies proportionally with the bladder pressure during the bladder filling with saline solution. It also demonstrates that the bladder volume can be estimated from the increasing amplitude of the recorded V OUT. Conclusion: This study shows that the increase in the V OUT is proportionally related to the increase in bladder pressure. The difference between the recorded V OUT during the bladder filling and the baseline V OUT can be a useful indicator of the changes in the bladder volume.