Khaled Fareed

Single-port transvesical simple prostatectomy: initial clinical report.

INTRODUCTION To present the initial report of single-port transvesical enucleation of the prostate in 3 patients with large-volume benign prostatic hyperplasia. METHODS Single-port transvesical enucleation of the prostate was performed in 3 patients with large-volume (187, 93, and 92 g) benign prostatic hyperplasia. A novel single-port device (r-Port) was introduced percutaneously into the bladder through a 2.5-cm incision under cystoscopic guidance. After establishing pneumovesicum, the adenoma was enucleated in its entirety transvesically under laparoscopic visualization using standard and articulating laparoscopic instrumentation. The adenoma was extracted through the solitary skin and bladder incision after bivalving the prostate lobes within the bladder. RESULTS Single-port transvesical enucleation of the prostate was technically feasible in all 3 cases. The operative time was 6, 1.5, and 2.5 hours, and the blood loss was 900, 250, and 350 mL. In patient 1, who had previously undergone open suprapubic surgery, a bowel injury occurred during r-Port insertion; the injury was recognized and repaired intraoperatively without sequelae. The urethral Foley catheter was removed on day 4, and all patients were voiding spontaneously with a minimal postvoid residual volume and full continence. CONCLUSIONS Transvesical single-port laparoscopic simple prostatectomy is technically feasible. Additional experience at our and other institutions is necessary to determine its role in the surgical management of large-volume symptomatic benign prostatic hyperplasia.

Importance of Additional “Extreme” Anterior Apical Needle Biopsies in the Initial Detection of Prostate Cancer

OBJECTIVES To describe our experience of adding extreme apical cores in men undergoing initial biopsy. Prostate cancer detection efforts have focused on increasing the number of cores. A more significant factor, however, may be their location. Laterally directed and apical cores have been associated with the highest cancer detection rate, especially the apical cores for men undergoing repeated biopsies. METHODS A prospective trial was conducted between September 2007 and April 2009. A total of 181 men with increased prostate-specific antigen (PSA) or abnormal digital rectal examination (DRE), or both, underwent an initial transrectal ultrasound-guided biopsy (TRUS-BX). All patients underwent a standard 12-core biopsy scheme plus 2 additional cores taken from the extreme anterior apex, defined as the site immediately lateral to the junction of apex and urethra. Each core was marked by a special colored ink for identification. Site-specific detection and tumor characteristics were reported. RESULTS Prostate cancer was detected in 86 patients (47.5%). The apical cores (3 on each side) achieved the highest cancer detection rate (73.6% of all cancers), and the additional extreme anterior apical cores (1 on each side) achieved the highest rate of unique cancer detection (P = .011). CONCLUSIONS From our experience, the apical cores, especially the extreme apical cores, increase prostate cancer detection on initial TRUS-BX and minimize the potential for misdiagnosis and need for repeat biopsy.

Office based transrectal saturation biopsy improves prostate cancer detection compared to extended biopsy in the repeat biopsy population.

PURPOSE Multiple studies have shown significant prostate cancer detection for repeat biopsy. However, the best approach regarding core number and location remains controversial. Transrectal saturation biopsy is believed to increase cancer detection but to our knowledge no studies comparing it to 12 to 14-core extended biopsy have been published. We compared saturation and extended repeat biopsy protocols after initially negative biopsy. MATERIALS AND METHODS A total of 1,056 men underwent prostate biopsy after initially negative biopsy. The extended biopsy group included 393 men with 12 to 14-core repeat biopsy. The saturation biopsy group included 663 men with 20 to 24-core repeat biopsy. We analyzed demographics and prostate cancer between the 2 groups. We compared prostate cancer detection in patients with previous atypical small acinar proliferation and/or high grade prostatic intraepithelial neoplasia as well as the risk of detecting clinically insignificant tumors. RESULTS Prostate cancer was detected in 315 of the 1,056 patients (29.8%). Saturation biopsy detected almost a third more cancers (32.7% vs 24.9%, p=0.0075). In patients with a benign initial biopsy saturation biopsy achieved significantly greater prostate cancer detection (33.3% vs 25.6%, p=0.027). For previous atypical small acinar proliferation and/or high grade prostatic intraepithelial neoplasia there was a trend toward higher prostate cancer detection rate in the saturation group but it did not attain statistical significance (31.2% vs 23.3%, p=0.13). Of 315 positive biopsies 119 (37.8%) revealed clinically insignificant cancer (40.1% vs 32.6%, p=0.2). CONCLUSIONS Compared to extended biopsy, office based saturation biopsy significantly increases cancer detection on repeat biopsy. The potential for increased detection of clinically insignificant cancer should be weighed against missing significant cases.

Morbidity Of Prostate Biopsy After Simplified Versus Complex Preparation Protocols: Assessment of Risk Factors

OBJECTIVE To determine whether prostate biopsy complications were affected by 2 varying prebiospy protocols implemented at our institution. Although transrectal ultrasound (TRUS) guided prostate biopsy is considered generally safe, it is associated with significant complications. METHODS We retrospectively evaluated a total of 1438 TRUS-guided prostate biopsies between January 2001 and June 2008. In group A, 931 men had only one dose of a quinolone antibiotic immediately before the procedure, and no enema was performed. In group B, 507 men who underwent a prebiopsy enema and were given oral antibiotics starting the day before the procedure for 3 days. We analyzed demographics and biopsy complications between the 2 groups. RESULTS The overall complication rates were categorized as infection (2.2%), urine retention (0.8%), hematuria (4.4%), rectal bleeding (1.5%), sepsis (0.2%). There was no significant statistical difference in the incidence of infection or sepsis between the 2 groups (2.7% vs 1.4%, P = .157 and 0.1% vs 0.4%, P = .285 respectively, for group A vs B). Both hematuria and hematospermia were more common in group B (2.5% vs 7.9%, P < .001 and 0.2% vs 2%, P < .001 respectively, for group A vs B). Prostate size was a significant risk for both hematuria (odds ratio = 1.7, 95% confidence interval = 1.2-2.44, P = .003) and acute urinary retention (odds ratio = 4.45, 95% confidence interval = 2.01-9.84, P < .001). CONCLUSIONS This study demonstrates that a single antibiotic dose before prostate biopsy may be sufficient. In addition, use of prebiopsy enemas is unnecessary to decrease overall complication rates.

Single‐port transvesical enucleation of the prostate: a clinical report of 34 cases

Study Type – Therapy (case series)
Level of Evidence 4

A nomogram for predicting upgrading in patients with low‐ and intermediate‐grade prostate cancer in the era of extended prostate sampling

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b

SPIDER Surgical System for Urologic Procedures With Laparoendoscopic Single-Site Surgery: From Initial Laboratory Experience to First Clinical Application

This case study describes our initial laboratory experience using the SPIDER surgical system (TransEnterix, Morrisville, NC, USA) for laparoendoscopic single-site surgery (LESS) urologic procedures and reports its first clinical application. The SPIDER system was tested in a laboratory setting and used for a clinical case of renal cyst decortication. Three tasks were performed during the dry lab session, and different urologic procedures were conducted in a porcine model. The time to complete the tasks and penalties were registered during the dry lab session. Perioperative outcomes and subjective assessment by the surgeons were registered. The surgeons had a positive experience with the SPIDER system, with a mean overall score of 3.6 (on a scale of 1-5). The surgeons were able to gain proficiency in performing tasks regardless of their level of expertise. The highest scores recorded were for ease of device insertion, instrument insertion and exchange, and triangulation. The lowest scores were for retraction. During the clinical case, the platform provided good triangulation without instrument clashing. However, retraction was challenging because of the lack of strength and precise maneuverability with the tip of the instruments fully deployed. The SPIDER system offers intuitive instrument maneuverability and restored triangulation without external instrument clashing. Further refinements are awaited to define its role in the urologic LESS armamentarium.

Robotic single port suprapubic transvesical enucleation of the prostate (R‐STEP): initial experience

Study Type – Therapy (case series)

Development and validation of a nomogram for predicting a positive repeat prostate biopsy in patients with a previous negative biopsy session in the era of extended prostate sampling

Study Type – Prognosis (case series)
Level of Evidence 4

When serial prostate biopsy is recommended: most cancers detected are clinically insignificant

Study Type – Disagnostic (exploratory cohort)