Mahmoud Laymon

Risk factors of hospital readmission after radical cystectomy and urinary diversion: analysis of a large contemporary series

To determine the incidence, risk factors and causes of hospital readmission in a large series of patients who underwent radical cystectomy (RC) and urinary diversion.

Towards optimizing prostate tissue retrieval following holmium laser enucleation of the prostate (HoLEP): Assessment of two morcellators and review of literature

INTRODUCTION We assess different approaches to retrieve the enucleated adenoma after transurethral enucleation of the prostate, particularly using the holmium laser. METHODS A retrospective review through our prospectively maintained database was performed looking for safety and efficacy of two morcellators. The enucleation phase of the holmium laser enucleation of the prostate (HoLEP) was classically performed followed by retrieval of the intravesical adenoma using either the Piranha (Wolf Inc., Knittlingen, Germany) or VersaCut (Lumenis) morcellator. A PubMed-MEDLINE search was conducted for all transurethral enucleation procedures and relevant data regarding methods of prostate tissue retrieval were extracted. RESULTS Strictly limiting the study to 3 reusable blades with each morcellator, we performed 67 and 55 consecutive procedures with Piranha and VersaCut, respectively. There was no significant difference between the two morcellators regarding perioperative complications, apart from 5 bladder mucosal injuries with the VersaCut (9%). Furthermore, there were similar retrieved tissue weight, mechanical problems-rate, catheter-time and hospital-stay in both morcellators. However, the Piranha morcellator needed significantly less morcellation-time, needed to use cold loop to remove non-morcellated pieces and to score the adenoma by laser for better bite of the adenoma, and had a higher median morcellation-rate 6.2 (rate: 2.8-12) g/min. Despite little reporting on morcellation, we had data on the tissue retrieval rate (2.6 to 6.5 g/min with Piranha and 1.9 to 11 g/min with VersaCut. Furthermore, bladder mucosal injury was reported in 1.4% and 0.7 to 5.7% with Piranha and VersaCut, respectively; bladder perforation with VersaCut was experienced in about 0.1 to 1.5% of patients. Our study is limited by its non-randomization. CONCLUSION The Piranha morcellator was the most efficient and safe way to retrieve tissue after a transurethral enucleation of a prostate adenoma.

Prospective Assessment of Learning Curve of Holmium Laser Enucleation of the Prostate for Treatment of Benign Prostatic Hyperplasia Using a Multidimensional Approach

Purpose: Despite being endorsed in most guidelines, wide adoption of holmium laser enucleation of the prostate is hindered by learning difficulties. We prospectively assessed the learning curve using a multidimensional approach. Materials and Methods: We prospectively report all perioperative safety and efficacy outcome measures as well as the need for reoperation and continence status. Case difficulty and learning curve characterization variables were considered, looking for predictors of different outcome measures. Our analysis included the first 313 procedures done by a total of 3 surgeons. Results: Prostate volume and the number of previously performed cases independently predicted operative and enucleation efficiency (mean ± SD 0.76 ± 0.36 and 1.2 ± 0.6 gm per minute, respectively). Both measures plateaued only after the first 40 procedures. The mean percent reduction in postoperative prostate specific antigen was 80% ± 19%. A significantly lower decrease was independently predicted by the transrectal ultrasound depiction of a grossly multinodular prostate (p = 0.000, R2 = 0.59). Perioperative safety measures showed significant improvement after the first and second 20 procedures apart from hospital stay and catheter time. Urinary incontinence was reported in 89 (28.5%), 26 (8.3%) and 7 cases (2.2%) at 1, 4 and 12 months, respectively. Only the number of previously performed cases predicted urinary incontinence at 1 month, which was significantly reduced following the first 20 procedures (plateau) (OR 0.99, 95% CI 0.98–0.999, p = 0.03). The I‐PSS (International Prostate Symptom Score) preoperative storage subdomain (OR 0.7, 95% CI 0.4–0.9, p = 0.04), case density (OR 0.3, 95% CI 0.2–0.6, p = 0.01) and number of previously performed cases (OR 0.97, 95% CI 0.98–0.999, p = 0.02) predicted urinary incontinence at 4 months, which was significantly reduced after the first and second 20 procedures. Persistent urinary incontinence at 12 months was significantly associated with fewer previously performed cases (median 60, range 0 to 211 vs 20, range 0 to 99, p = 0.04) with no plateauing through the curve. Conclusions: Plateauing through the learning curve of holmium laser enucleation of the prostate is a moving target. Looking at different outcome measures, different levels of experience are needed to reach the plateau. Preoperative prostate volume, the number of previously performed cases and case density are the main influential factors in the curve. Urinary incontinence is the most relevant clinical outcome that was significantly affected by learning, although its transient nature is assuring.

Is there a way to predict failure after direct vision internal urethrotomy for single and short bulbar urethral strictures

Abstract Objective: To identify patient and stricture characteristics predicting failure after direct vision internal urethrotomy (DVIU) for single and short (<2 cm) bulbar urethral strictures. Patients and methods: We retrospectively analysed the records of adult patients who underwent DVIU between January 2002 and 2013. The patients’ demographics and stricture characteristics were analysed. The primary outcome was procedure failure, defined as the need for regular self-dilatation (RSD), redo DVIU or substitution urethroplasty. Predictors of failure were analysed. Results: In all, 430 adult patients with a mean (SD) age of 50 (15) years were included. The main causes of stricture were idiopathic followed by iatrogenic in 51.6% and 26.3% of patients, respectively. Most patients presented with obstructive lower urinary tract symptoms (68.9%) and strictures were proximal bulbar, i.e. just close to the external urethral sphincter, in 35.3%. The median (range) follow-up duration was 29 (3–132) months. In all, 250 (58.1%) patients did not require any further instrumentation, while RSD was maintained in 116 (27%) patients, including 28 (6.5%) who required a redo DVIU or urethroplasty. In 64 (6.5%) patients, a redo DVIU or urethroplasty was performed. On multivariate analysis, older age at presentation [odds ratio (OR) 1.017; P = 0.03], obesity (OR 1.664; P = 0.015), and idiopathic strictures (OR 3.107; P = 0.035) were independent predictors of failure after DVIU. Conclusion: The failure rate after DVIU accounted for 41.8% of our present cohort with older age at presentation, obesity, and idiopathic strictures independent predictors of failure after DVIU. This information is important in counselling patients before surgery.

Prostate tissue retrieval after holmium laser enucleation of the prostate; assessment of non-morcellation approaches

Abstract Objectives: To review non-morcellation approaches for tissue retrieval after holmium laser enucleation of the prostate (HoLEP) and whether these approaches demolish the advantages of the HoLEP procedure. Patients and methods: We reviewed our prospectively maintained laser prostate database for HoLEP procedures where non-morcellation approaches were used for retrieval of the enucleated adenoma. Non-morcellation approaches were adopted in cases of morcellator malfunction or whenever concomitant pathology indicated laparotomy. Patients were stratified into the laparotomy group (Group I) or the transurethral resection (TUR) group (Group II). Safety and efficacy of each approach were assessed and compared. Results: Between August 2012 and July 2015, of 392 HoLEP procedures non-morcellation approaches were used for tissue retrieval in 37 (9.4%). In 19 procedures a laparotomy approach was adopted (17 mini-laparotomies and two conventional laparotomies for concomitant diverticulectomy). TUR of the enucleated adenoma was adopted in 18 patients. Baseline demographic data and indications for surgery were comparable between the groups. However, significantly larger prostates were treated in Group I. There were no significant differences between the groups for tissue retrieval time, histopathological findings of retrieved tissue, and peri-procedure biochemical changes. However, significantly more tissue was retrieved (median tissue weight 115 vs 38 g) and at a faster rate (4.6 vs 1.09 g/min) in Group I. The median hospital stay was similar in both groups, but the median time to catheter removal was longer in Group I (5 vs 2 days). Minimal and similar peri-procedure complications were reported in both groups and in both groups there was a significant and comparable improvement in all urinary outcome measures. Conclusion: In the absence or malfunction of a tissue morcellator, or whenever concomitant pathology indicates laparotomy, non-morcellation tissue retrieval approaches are feasible options for endourologists practicing transurethral enucleation of prostate adenoma. These approaches are valid alternatives retaining most of the advantages of the transurethral prostate enucleation procedure.

MP58-15 IMPACT OF TUMOR HISTOPATHOLOGIC TYPES ON PATTERN OF TUMOR RECURRENCE AFTER RADICAL CYSTECTOMY FOR MUSCLE INVASIVE BLADDER CANCER (MIBC).

RESULTS: Out of 540 patients, 43 (7,9%) showed rare histotypes of bladder cancer. In 5 (11,6%) cases the uncommon histotypes was revealed by palliative TURBT . The remaining 38 patients were submitted to cystectomy for bladder tumors of considerable size (mean diameter 7,8 cm; range of 5-11 cm); 14 (36,8%) harbored a pT4 tumor. The rare histotypes were: squamous carcinoma 6 (13,9%), sarcomatoid 2 (4,8%), undifferentiated 5 (11,6%), neuroendocrine 3 (6,9%), mixed 27 (62,8%). TUR revealed an uncommon histotypes in 26 (68,4%) cases only. Moreover, in 5 (23.8%) patients an additional uncommon histology not detected by previous TUR, was demonstrated in cystectomy specimens. CONCLUSIONS: The prognostic role of uncommon histotypes in bladder cancer is well documented. Unrecognized rare histotypes might have important therapeutic implications since possibly less responsive to neoadjuvant chemotherapy. These patients could benefit from an immediate cystectomy avoiding neo-adjuvant chemotherapy. The inaccuracy of TUR in everyday clinical practice in detecting uncommon variants could be explained by an inadequate sampling of large tumors. The 00pre-cystectomy00 TUR is often performed only to confirm the infiltration. As a matter of fact, the pathologists might not receive an adequate amount of tissue. To standardize the TURBT strategy including sampling of different areas of bulky tumors could be of clinical value in patients undergoing neoadjuvant chemotherapy.

Low-Power Vs High-Power Holmium Laser Enucleation of the Prostate: Critical Assessment through Randomized Trial

OBJECTIVE To assess the non-inferiority of Low-power Holmium laser enucleation of the prostate (LP-HoLEP) to high-power (HP-HoLEP) for enucleation efficiency pertaining to the advantages of lower cost and minimal postoperative dysuria, storage symptoms, and negative sexual impact. PATIENTS AND METHODS HoLEP was performed using 100W Versapulse, Luminis Inc., with 2J/25Hz for LP-HoLEP (61 patients) and 2J/50Hz for HP-HoLEP (60 patients). Two surgeons with different experience performed equal number of both procedures. Non-inferiority of enucleation efficiency (enucleated weight/min) was evaluated. All perioperative parameters were recorded and compared. Dysuria was assessed at 2 weeks by dysuria visual analog scale, urinary (Q.max and IPSS) and sexual (sexual health inventory for men score) outcome measures were evaluated at 1, 4, and 12 months. RESULTS Baseline and perioperative parameters were comparable between the two groups. Mean enucleation efficiency was 1.42±0.6 vs 1.47±0.6 gm/min, P = .6 following LP-HoLEP and HP-HoLEP, respectively. Patients reported postoperative dysuria similarly in both groups as per dysuria visual analog scale. There was significant comparable improvement in IPSS (international prostate symptom score) and Q.max in both groups at different follow-up points. At one year, median IPSS and Q.max were comparable in both groups (P = .4 and .7 following LP-HoLEP and HP-HoLEP, respectively). Median postoperative reduction in prostate specific antigen was 89% (42:99) following LP-HoLEP vs 81% (62:94) after HP-HoLEP, P = .92. Both groups showed comparable perioperative and late postoperative complications. There were no statistically significant changes in the last follow-up sexual health inventory for men score in comparison to baseline score. CONCLUSION LP-HoLEP is non-inferior to HP-HoLEP in terms of all efficiency parameters regardless level of surgeon experience.

MP54-07 PENTAFECTA AND TRIFECTA CRITERIA FOR REPORTING OUTCOMES OF RADICAL CYSTECTOMY FOR MUSCLE INVASAIVE UROTHELIAL BLADDER CANCER (MIBC)

used to identify patient and disease variables, including RARC volume, associated with overall and additional treatment-free survival. RESULTS: Of the 2,773 patients that underwent RARC, 975 (35%) died during follow-up. 948 RARC were performed at 00low volume centers00 (table 1). On multivariable analysis (table 2), age >80 years (HR 1.91, 95% CI 1.06-3.43, p1⁄40.03), stage (vs. <pT2, pT2 (HR 1.58 95% CI 1.19-2.11), pT3 (HR 3.33 95% CI 2.54-4.38), pT4 (HR 4.43 95% CI 3.21-6.10), all p<0.01), and length of stay (HR 1.01, 95% CI 1.001.01, p1⁄40.04) were associated with overall survival. RARC volume (>10) was independently associated with both overall (HR 0.74, 95% CI 0.59-0.93, p<0.01) and additional treatment free survival (HR 0.66 95% CI 0.49-0.88, p<0.01). CONCLUSIONS: Accounting for disease and hospital related variables, patients undergoing RARC at low volume centers had worse overall and additional treatment free survival. This suggests that adequate center volume may be important for conferring surgical quality and ultimately survival outcomes.

MP58-16 ONCOLOGIC OUTCOMES OF SQUAMOUS CELL CARCINOMA VERSUS UROTHELIAL CARCINOMA WITH SQUAMOUS DIFFERENTIATION AFTER RADICAL CYSTECTOMY FOR MUSCLE INVASIVE BLADDER CANCER (MIBC)

RESULTS: Out of 540 patients, 43 (7,9%) showed rare histotypes of bladder cancer. In 5 (11,6%) cases the uncommon histotypes was revealed by palliative TURBT . The remaining 38 patients were submitted to cystectomy for bladder tumors of considerable size (mean diameter 7,8 cm; range of 5-11 cm); 14 (36,8%) harbored a pT4 tumor. The rare histotypes were: squamous carcinoma 6 (13,9%), sarcomatoid 2 (4,8%), undifferentiated 5 (11,6%), neuroendocrine 3 (6,9%), mixed 27 (62,8%). TUR revealed an uncommon histotypes in 26 (68,4%) cases only. Moreover, in 5 (23.8%) patients an additional uncommon histology not detected by previous TUR, was demonstrated in cystectomy specimens. CONCLUSIONS: The prognostic role of uncommon histotypes in bladder cancer is well documented. Unrecognized rare histotypes might have important therapeutic implications since possibly less responsive to neoadjuvant chemotherapy. These patients could benefit from an immediate cystectomy avoiding neo-adjuvant chemotherapy. The inaccuracy of TUR in everyday clinical practice in detecting uncommon variants could be explained by an inadequate sampling of large tumors. The 00pre-cystectomy00 TUR is often performed only to confirm the infiltration. As a matter of fact, the pathologists might not receive an adequate amount of tissue. To standardize the TURBT strategy including sampling of different areas of bulky tumors could be of clinical value in patients undergoing neoadjuvant chemotherapy.

MP27-15 READMISSION FOLLOWING TRANSURETHRAL PROSTATECTOMY FOR TREATMENT OF BENIGN PROSTATE HYPERPLASIA IN THE POST TURP ERA; DOES THE TECHNIQUE DIFFER?

INTRODUCTION AND OBJECTIVES: Bipolar TURP by resection loop and vaporization button are commonly used nowadays for treatment of BPH because it causes less intraoperative bleeding, and avoids free water absorption. However, bipolar vaporization may be associated with increased operative time and postoperative morbidity. By adding resection we can minimize operative time and clean prostatic fossa from prostatic tissue shreds making prostatic fossa more smooth and regular. We compare results of combined Bipolar TURP using the resection loop and vaporization versus vaporization alone for BPH to determine the relative safety and efficacy of both technique. METHODS: 77 patients with BPH were included in this study and randomized to operation either by Olympus (Gyrus) Bipolar loop TURP and Olympus (Gyrus) Bipolar button vaporization (Group 1) 40 patients or Olympus (Gyrus) Bipolar button vaporization alone( Group 2) 37 patients . Inclusion criteria were; BPH with qmax <10ml/sec, IPSS score>18 and prostate volume >40 gm. All patients were evaluated preoperatively and at 1, 3 and 9 months postoperatively by IPSS, uroflowmetry and prostate ultrasound. Clavien complications and operative time were recorded. RESULTS: This study included 40 patients in Group1 (combined Bipolar Vaporization And Resection) and 37 patients in Group 2. (Bipolar Vaporization alone).There was no significant difference as regard age ( 51 + 9.9 and 52.5 + 8.2) , hospital stay (1-2 days) or catheterization period (1-2 days) in both groups. Preoperative prostate volume (58 g v 55 g p1⁄40.51) and IPSS (20 v 22 p1⁄40.38) was equivalent. Significant increase in operative time was noticed in Group 2 (79 15 minutes range 45-105 p <0.001) , versus (mean 59 10 minutes range 35-75 minutes ,smale non-significant difference in blood loss occurred in both Groups (0.8% compared to 0.9% drop in hemoglobin, p<0.55) but increased postoperative urinary frequency (75% in G2 vs 45% in G1 ( p <0.001), hematuria with clots as long as 3 weeks after surgery (18% vs 2%, p <0.001s p1⁄40.22), :) and postoperative urethral stricture (4% vs 0%). There was No significant difference in Q max improvement Qmax (20 cc/s vs 18 cc/ s ) or postoperative prostate volume (32 vs 31 g p1⁄40.31) and IPSS (6 v 5 p1⁄40.22) equivalently CONCLUSIONS: Combined Bipolar vaporization and resection of the prostate, is superior to Bipolar Vaporization alone as regard operative time and postoperative morbidity without compromising its efficacy and safety.