Strategies to Reduce Blood Loss in Robotic Inferior Vena Cava Thrombectomy
Alex Jones, MD, Logan McGuffey, MD, and Naveen Pokala, MD
Division of Urology, Department of Surgery, University of Missouri–Columbia School of Medicine, Columbia, Missouri.
Introduction: Renal neoplasms with inferior vena cava (IVC) tumor thrombus represent a complex surgical challenge. The reported incidence in the literature ranges from 4% to 10%.1 There have been various series describing the feasibility and safety of robot-assisted laparoscopic IVC thrombectomy with appropriate patient selection.2–5 Management of these tumors through a robotic approach may decrease blood loss; however, it still has a high risk of significant intraoperative blood loss.2,3 Transfusion rate has been reported to be 33%.2 In the Jehovah's Witness patient population who do not accept transfusion of blood products, the risk of intraoperative hemorrhage associated with IVC tumor thrombectomy remains high but may be decreased using the robotic approach.
Materials and Methods: Three patients underwent completely intracorporeal robot-assisted laparoscopic IVC tumor thrombectomy for level II IVC tumor thrombi. One patient, who was of the Jehovah's witness faith, refused transfusion of whole blood products, but did agree to the use of cryoprecipitate, albumin, volume expanders, and autologous blood in the form of acute normovolemic hemodilution if needed during surgery. During one case, we describe our technique and technical modifications in an attempt to decrease intraoperative blood loss. Specifically, we employed early utilization of the vascular stapler across the renal vein and artery after isolation but before opening of the IVC. The staple line and thrombus are then excised en bloc. A retrospective chart review was performed to extract procedure and patient data.
Results: Three cases were performed (N.P.) completely robotically without the need for conversion to open. Mean renal tumor size was 12 cm (range 9.6–14.5 cm) and mean tumor venous thrombus length was 3.23 cm (range 2–4.7 cm). Two patients presented with metastatic disease. Two patients underwent preoperative renal embolization. One patient underwent robot-assisted laparoscopic subtotal colectomy for a transverse colon mass in the same operating room setting. Mean console time was 388 minutes (range 268–556 minutes), estimated blood loss was 533 mL (range 300–900 mL), and hospital stay 9.3 days (range 7–13 days). In the third case, we employed our technique modification as already described. This led to a reduction in blood loss (300 mL compared with 900 and 400 mL in the two previous cases). No intraoperative complications occurred. Two Clavien IIIa postoperative complications occurred. One patient developed sepsis from an infected seroma and acute respiratory failure requiring intubation. Another patient experienced a ST-segment elevation myocardial infarction requiring stent placement. At a mean of 14.67 months of follow-up, two patients are still alive. One patient expired 5 months postoperatively because of progression of known metastatic disease. One patient developed progressive metastatic disease and was started on targeted therapy. One patient has no evidence of metastatic disease and is on surveillance.
Conclusion: Robotic IVC thrombectomy is feasible and safe in the Jehovah's Witness patient population with appropriate preoperative planning and patient selection.
BluteML, LeibovichBC, LohseCM, et al.The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumor thrombus. BJU Int, 2004; 94:33.a-0a-22GillIS, MetcalfC, AbreuA, et al.Robotic level III inferior vena cava tumor thrombectomy: The initial series. J Urol, 2015; 194:929–938.a-1a-5a-7a-23RamirezD, MauriceMJ, CohenB, et al.Robotic level III IVC tumor thrombectomy: Duplicating the open approach. Urology, 2016; 90:204–207.a-2a-6a-24SavageSJ, GillIS. Laparoscopic radical nephrectomy for renal cell carcinoma in a patient with a level I renal vein tumor thrombus. J Urol, 2000; 163:1243–1244.a-3a-25DesiaMM, GillIS, RamaniAP, et al.Laparoscopic radical nephrectomy for cancer with level I rena vein involvement. J Urol, 2003; 169:487–491.a-4a-26
3D Fusion MRI and (18)F-Choline-Positron Emission Tomography-Targeted Prostate Biopsies: A New Concept
Arnaud Marien, MD,1 Jean-Louis Bonnal, MD,1 Tanguy Blaire, MD,2 Alban Bailliez, MD,2 Arnaud Delebarre, MD,3 Pierre Gosset, PhD,4 Aurélien Rock, MD,1 Khaled El Maadarani, MD,1 Catherine Francois, MD,1 and Brigitte Mauroy, PhD1
1Department of Urology, Groupe Hospitalier de l'Institut Catholique Lillois, Faculté Libre de Médecine, Lille, France.
2Department of Nuclear Medicine, Groupe Hospitalier de l'Institut Catholique Lillois, Faculté Libre de Médecine, Lille, France.
3Department of Radiology, Groupe Hospitalier de l'Institut Catholique Lillois, Faculté Libre de Médecine, Lille, France.
4Department of Pathology, Groupe Hospitalier de l'Institut Catholique Lillois, Faculté Libre de Médecine, Lille, France.
Background: Contemporary transrectal ultrasound (TRUS) prostate biopsy can be guided by high-resolution ultrasound (US), magnetic resonance imaging (MRI), or MRI–US fusion.
Objectives: To assess the feasibility and the accuracy of targeted prostate biopsy with standard (systematic 12-core) biopsies after fusion imaging of choline-positron emission tomography (PET)/CT (choline-PET) and multiparametric MRI (mpMRI) with 3D-transrectal ultrasound (3DTRUS) to detect prostate cancer (PCa).
Methods: From December 2014 to October 2016, 31 patients with a rising prostate-specific antigen (PSA) ≥10 ng/mL or with a history of negative prostate biopsies were included, and underwent a choline-PET and an mpMRI. PET and T2-weighted MR volumes of the prostate were spatially registered. Biopsy targets were selected on both modalities. TRUS biopsy was done using the real-time 3DTRUS-tracking system (Urostation Touch®). Biopsy procedure was performed after registration of real-time TRUS with mpMRI and choline-PET by the same operator, using 3DTRUS-tracking system. At the time of biopsy, volume data of the mpMRI and PET 18Ch were elastically fused with TRUS. Each target was biopsied twice. Histologic results were determined from standard and targeted biopsy cores.
Results: Mean PSA was 13.01 ng/mL (5.32–73). Mean number of biopsies was 16 (13–21) and mean prostate volume was 63.41 cc (25–169). The cancer detection rate was 69%. The cancer detection rate with standard biopsies off target was 42% and that with prostate-targeted biopsy was 50% using PET, 65% using mpMRI with a sensibility of 72%, 94%, and 100%, respectively, for PET, mpMRI, or both. The average number of positive cores was, respectively, 1.77 (1–7) and 2.74 (3–11) for PET and mpMRI.
Conclusions: Double image fusion (MRI/PET 18Ch) is achievable with 3DTRUS to improve PCa detection. MRI is probably more reliable than PET 18Ch, but using both imageries could increase the sensibility of PCa detection. Study with the novel ligands targeting prostate-specific membrane antigen could improve our clinical results.
1Department of Urology, Sun Yat-sen Memorial Hospital, SYSU, Guangzhou, China.
2Department of Urology, Bir Hospital, NAMS, Kathmandu, Nepal.
Introduction and Objectives: Tract dilatation is a crucial step in percutaneous nephrolithotomy, which can be guided under fluoroscopy, ultrasound, or combination of both techniques. It can still be difficult to ascertain the optimal depth to prevent overdilation, causing collecting system perforation and vascular injury or underdilation, making the establishment of access tract in a single attempt strenuous.1–7 Here, we present our initial clinical experience in using the novel technique of visual dilator system to obtain real-time visual confirmation of accuracy during percutaneous tract dilatation.
Material and Methods: The visual dilator system used consisted of a transparent hollow dilator made of polyvenyl chloride and a 12F mini nephroscope inserted within its lumen. The nephroscope was connected to standard endoscopic camera system. The dilator system backloaded with access sheath was passed over guidewire to dilate percutaneous tract and position the access sheath under visual guidance. Saline was irrigated to maintain clarity during dilatation. Between December 2015 and December 2016, the visual dilator system was used during percutaneous tract dilatation in 13 percutaneous nephrolithotomy (PCNL) cases with mild or above hydronephrosis.
Results: All tracts were effectively dilated in a single attempt. The intervening tissue layers, approach into target calix, and the access sheath placement could be visually monitored through the dilator wall to confirm accuracy in dilatation. Mean dilatation time was 3.4 ± 0.9 minutes, hemoglobin drop was 1.4 ± 0.8 g/dL, primary stone-free rate and that after auxiliary treatment were 11/13 (84.6%) and 13/13 (100%), respectively. We experienced overdilatation in one of the initial cases. No complications such as collecting system perforation, loss of access, transfusion, and surrounding organ injury were experienced in rest of the cases. The X-ray exposure time during dilatation was significantly low. Larger number of cases and comparison with other dilatation technique are needed to further prove the efficacy of the technique, which is under study.
Conclusion: PCNL access tract dilation using the visual dilatation technique is clinically feasible. It provides a real-time visual monitoring and confirmation of accuracy in dilatation and lower X-ray exposure time during tract creation. It may improve the overall safety and efficacy of the PCNL procedure.
SkolarikosA, AlivizatosG, de la RosetteJJMCH. Percutaneous nephrolithotomy and its legacy. Eur Urol, 2005; 47:22–28.MichelMS, TrojanL, RassweilerJJ. Complications in percutaneous nephrolithotomy. Eur Urol, 2007; 51:899–906.a-8SkolarikosA, de la RosetteJ. Prevention and treatment of complications following percutaneous nephrolithotomy. Curr Opin Urol, 2008; 18:229–234.a-9Falahatkar, et al.Totally ultrasound versus fluoroscopically guided complete supine percutaneous nephrolithotripsy: A first report. J Endourol, 2010; 24:1421–1426.a-10KukrejaR, DesaiM, PatelS, BapatS, DesaiM. Factors affecting blood loss during percutaneous nephrolithotomy: Prospective study. J Endourol, 2004; 18:715–722.a-11DavidoffR, BellmanGC. Influence of technique of percutaneous tract creation on incidence of renal hemorrhage. J Urol, 1997; 157:1229–1231.a-12El-NahasAR, ShokeirAA, El-AssmyAM, et al.Post-percutaneous nephrolithotomy extensive hemorrhage: A study of risk factors. J Urol, 2007; 177:576–579.a-13
Needle-Assisted Laparoendoscopic Single-Site Radical Prostatectomy Using a New Series of Steerable Instruments: Feasible Option to Overcome Current Limits?
Frank Dewaele, MD,1 Tim De Pauw, MD,1 Alain F. Kalmar, MD, PhD,2 Nicolaas Lumen, MD, PhD,3 Ruben De Groote, MD,4 Peter Dekuyper, MD,5 Koen Traen, MD,6 Pieter Uvin, MD, PhD,4,7 Kevin Bauwens, Eng,8 Yves Van Nieuwenhove, MD, PhD,9 Alexandre Mottrie, MD, PhD,4,8 and Dirk Van Roost, MD, PhD9
1Department of Neurosurgery, Ghent University Hospital, Ghent, Belgium.
2Department of Anesthesia and Intensive Care Medicine, Maria Middelares Hospital, Ghent, Belgium.
3Department of Urology, Ghent University Hospital, Ghent, Belgium.
4Department of Urology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium.
5Department of Urology, Maria Middelares Hospital, Ghent, Belgium.
6Department of Gynaecology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium.
7Department of Development and Regeneration, Research Unit of Organ Systems, University Hospitals Leuven, Leuven, Belgium.
8ORSI Academy, Melle, Belgium.
9Department of Gastrointestinal Surgery, Ghent University, Ghent, Belgium.
Introduction: Laparoendoscopic single-site surgery (LESS) made its introduction in the urologic community in 2007 and has significantly evolved since then.1–3 However, such a procedure remains a technical challenge.4 In this study, we have evaluated the feasibility of a needle-assisted LESS-radical prostatectomy (RP) procedure using a recently developed series of steerable laparoscopic instruments (Steerable Instruments, Ghent, Belgium) each having seven degrees of freedom.5 In contrast with existing articulated instruments, the steerable instruments permit torque transmission, in which rotation of the surgeon's wrist results in a rotation of the tip, even in bent position.
Materials and Methods: The study was carried out in a nonsurvival porcine model, approved by the Ghent University ethical committee (EC2016/83). The procedure was designed and trained before on a series (more than six) of cadavers. A 12-mm Airseal® trocar enabling access for the steerable instruments and a 10-mm trocar for a 30° HD 3D endoscope were inserted through a 25 mm, transverse, umbilical incision. Both trocars perforated the peritoneum separately. Two needlescopic grasping forceps allowed retraction and fixation of structures. The vesicourethral anastomosis was performed using two V-Loc™ 90 2-0 barbed sutures. The primary outcome to be measured was the technical feasibility of the procedure.
Results: The surgery, using the steerable laparoscopic instruments series, was completed effectively without intraoperative complication. The steerable needle driver allowed the needle to be driven effortlessly through the tissue in a perpendicular manner, without losing time because of positioning of the needle on the instrument. The setup, resulting in a barely noticeable scar, combines a multitude of advantages. First, the 12-mm umbilical trocar provides a versatile access for the steerable instrument. The steerable instrument can be quickly exchanged for a large suction tube allowing adequate aspiration in case of serious hemorrhage. Furthermore, the introduction of suture and the use of clip appliers are not hindered in this configuration. Other setups by contrast require an additional paraumbilical 8- to 12-mm assistant port jeopardizing the concept of scarless surgery. Second, by bringing the instrument from a lateral position to the umbilicus and as such closer to the surgeon, ergonomy is enhanced. Third, the assisting bipolar needlescopic instrument leaves no scar and relieves the surgeon from the clashing instruments.6–8 The articulated tip allows enhanced dexterity and eliminates the phenomenon of eclipsing or overshadowing of the visual field by the instrument shaft. Finally, with its inversed delta-shaped handle, the instrument requires only a small extracorporeal working space, reducing clashing with the camera head.
Conclusion: The steerable laparoscopic instruments offer several considerable benefits during needle-assisted LESS-RP and address some major current limitations of minimally invasive approaches, with only a minimum of necessary hardware. The steerable laparoscopic instrument series is investigational. Further research is required to delineate the advantages and limitations of these instruments in a clinical setting and to optimize the surgical procedures to maximally benefit from its possibilities.
RamanJD, BensalahK, BagrodiaA, et al.Laboratory and clinical development of single keyhole umbilical nephrectomy. Urology, 2007; 70:1039–1042.a-14KaoukJH, AutorinoR, KimFJ, et al.Laparoendoscopic single-site surgery in urology: Worldwide multi-institutional analysis of 1076 cases. Eur Urol, 2011;60:998–1005.a-15MartínOD, AzharRA, ClavijoR, et al.Single port radical prostatectomy: Current status. J Robot Surg, 2016;10:87–95.a-16MartínOD, AzharRA, ClavijoR, et al.Single port radical prostatectomy: Current status. J Robot Surg, 2016;10:87–95.a-17DewaeleF, KalmarAF, De RyckF, et al.A novel design for steerable instruments based on laser-cut nitinol. Surg Innov, 2014; 21:303–311.a-18InakiN, TsujiT, DodenK, et al.Reduced port laparoscopic gastrectomy for gastric cancer. Transl Gastroenterol Hepatol, 2016; 9:1–38.a-19GrecoF, PiniG, AlbaS, AltieriVM, VerzeP, MironeV. Minilaparoendoscopic single-site pyeloplasty: The best compromise between surgeon's ergonomy and patient's cosmesis (IDEAL phase 2a). Eur Urol, 2016; 2:319–326.a-20InoueS, KajiwaraM, TeishimaJ, MatsubaraA. Needlescopic-assisted laparoendoscopic single-site adrenalectomy. Asian J Surg, 2016; 39:6–11.a-21
Laparoscopic In Situ Dismembered Pyeloplasty as a Modified Technique to Facilitate Suturing and Alignment During Laparosopic Pyeloplasty: A Video Demonstration
Alireza Aminsharifi, MD
Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran.
Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Purpose: This video demonstrates the technique of laparoscopic in situ dismembered pyeloplasty as a modified technique during which the alignment of ureter and renal pelvis remains intact during ureteropelvic junction (UPJ) anastomosis. We also showed the intraoperative and postoperative outcomes of this modification in comparison with standard laparoscopic dismembered pyeloplasty.
Methods: Patients with significant primary UPJ obstruction without any history of abdominal surgery, high ureter insertion, or renal anomalies were considered. After dissection and mobilization of the UPJ, a 1-cm longitudinal incision was made over the lateral aspect of the proximal ureter distal to the site of obstruction. Another 2-cm oblique incision was made on the lateral aspect of the renal pelvis at its most dependent portion to divide the posterior and anterior walls of the renal pelvis. The most dependent part of the incised renal pelvis was sutured to the distal end of the ureterotomy incision. Then both anterior and posterior anastomotic suture lines were completed over a Double-J stent. Once the dependent funnel-shaped anastomosis was completed, the ureter was divided above the site of anastomosis and the stenotic UPJ segment was removed. If required, pelvic trimming was done and the renal pelvis was then closed. Demographic data, intraoperative timings, and postoperative and follow-up outcomes were compared between the two cohorts of laparoscopic classic (Group I) vs laparoscopic in situ (Group II) dismembered pyeloplasty.
Results: Patients in Group I (n = 23) and Group II (n = 14) had similar demographic characteristics. Mean operative time was significantly longer in Group I (103.8 ± 19.95 minutes vs 89.5 ± 18.90 minutes, p = 0.038). Total duration of UPJ repair and anastomosis was also significantly longer in Group I (92.7 ± 15.82 minutes vs 78.4 ± 14.76 minutes, p = 0.021). The method of pyeloplasty significantly affected the time required to prepare ureter and renal pelvis (18.7 ± 7.92 minutes vs 12.5 ± 5.98 minutes, p = 0.017) and the duration of UPJ anastomosis (40 ± 9.77 minutes vs 31.9 ± 7.23 minutes, p = 0.014). Both were shorter in Group II. Mean follow-up period was 14.4 ± 7.42 months in Group I and 14.05 ± 7.93 months in Group II (p = 0.88). Success rate was 95.6% in Group I and 100% in Group II (p = 0.42).
Conclusion: Laparoscopic in situ pyeloplasty is a safe and effective approach that can help simplify laparoscopic pyeloplasty, especially at teaching centers where surgeons with variable levels of experience perform laparoscopic procedures.
Robot-Assisted Laparoscopic Dismembered Ureteral Reimplantation with Extracorporeal Tapering for Megaureter
Laura B. Cornwell, MD, Jared Manwaring, MD, and Jonathan V. Riddell, MD
Department of Urology, SUNY Upstate Medical University, Syracuse, New York.
Introduction: Children with symptomatic megaureter may have elements of obstruction, vesicoureteral reflux (VUR), or both, and are at risk for upper tract deterioration if left uncorrected. Although the gold standard is currently open reimplantation with ureteral tapering, some authors have advocated a laparoscopic/robotic approach.1–5 We present a series of seven pediatric patients with symptomatic megaureter and describe a novel technique for surgical correction involving a minimally invasive, three-port robot-assisted laparoscopic approach with a dismembered extravesical posterior ureteroneocystostomy after extracorporeal ureteral tapering through the ipsilateral port site.
Materials and Methods: Since 2012, symptomatic pediatric megaureter has been managed at our institution by robot-assisted laparoscopic reimplantation with extracorporeal tapering. Chart review identified seven pediatric cases, including nine megaureters (two bilateral presentations). Baseline demographics collected included age, gender, type of megaureter (refluxing vs obstructed), indication for surgery (pain or febrile urinary tract infection [UTI]), and preoperative ultrasound ureteral diameter. Perioperative data included operative time, estimated blood loss, length of hospital stay, 30-day Clavien complications, and duration of catheterization. Primary outcomes measured include postoperative ultrasound ureteral diameter (as compared with preoperative) and clinical success (defined as resolution of presenting indication for surgery).
Results: Of the seven patients, three were female and four were male and the median age was 53 months (range 13–128 months). Three patients had VUR with febrile UTI, two obstruction with febrile UTI, and two obstructions with pain. Patients have been followed for a median of 20 months (range 2–68 months). Mean operative time was 277 (±56) minutes (including two bilateral cases). Estimated blood loss was <5 mL in all cases. All patients were discharged home the next day, except one patient who was discharged on day 2 because of a culture-negative postoperative fever. Only one patient had a complication within 30 days, a febrile illness, not urinary in origin and was treated with antibiotic (Clavien 2). Four patients had their urinary catheter overnight and effectively voided the next day. Three patients empirically had their catheters left for 6 days with spontaneous voiding on removal. Postoperative ultrasound ureteral diameter above the tapered segment improved from 8.3 to 5.6 mm. Five of six patients had clinical success with resolution pain and/or febrile UTI; one with reflux and severe ongoing bowel–bladder dysfunction had febrile UTI with downgrading of reflux, but required supplemental dextranomer (Deflux®) injection ∼1 year postoperation. One patient was still pending their first follow up visit for these evaluations. Diuretic renography was performed in two of three patients with obstruction and showed improvement in both drainage and function. Routine postoperative voiding cystourethrograms were not obtained. We acknowledge that without routine voiding cystourethrogram, occult VUR might persist.
Conclusions: In conclusion, our technique of robot-assisted laparoscopic dismembered ureteroneocystostomy with extracorporeal ureteral tapering is a safe, effective, and feasible minimally invasive method for managing patients with symptomatic megaureter who have components of obstruction, reflux, or both. It has the distinct advantage of providing an orthotopic ureteral orifice with the precision and length of an open ureteral taper over other purely intracorporeal methods.
BoysenWR, EllisonJS, KimC, et al.Multi-institutional review of outcomes and complications of robot-assisted laparoscopic extravesical ureteral reimplantation for treatment of primary vesicoureteral reflux in children. J Urol, 2017; 197:1555–1561.AbrahamGP, DasK, RamaswamiK, et al.Laparoscopic dismemberment, excisional tailoring, reimplantation with antireflux: Megamanagement for megaureter. J Endourol Part B, Videourology. 2011, DOI: 10.1089/vid.2011.0049.AbrahamGP, DasK, RamaswamiK, et al.Laparoscopic reconstruction for obstructive megaureter: Single institution experience with short- and intermediate-term outcomes. J Endourol, 2012;26:1187–1191.VillanuevaCA. Extracorporeal ureteral tailoring during HIDES laparoscopic robotic-assisted ureteral reimplantation for megaureter. J Pediatr Urol, 2015; 11:362–363.LopezM, GanderR, RoyoG, VarletF, AsensioM. Laparoscopic-assisted extravesical ureteral reimplantation and extracorporeal ureteral tapering repair for primary obstructive megaureter in children. J Laparoendosc Adv Surg Tech A, 2017; 27:851–857.
Tips and Tricks for Safe Morcellation with the Lumenis VERSACUT
Danielle Whiting, DHMSA, BSc(Hons), MBBS, MRCS, and Mark Cynk, MBBS, MSc, FRCS(Urol)
Department of Urology, Maidstone and Tunbridge Wells NHS Trust, Maidstone Hospital, Maidstone, United Kingdom.
Introduction: Holmium laser enucleation of the prostate (HoLEP) is an effective treatment option for bladder outflow obstruction secondary to prostatic enlargement. However, concerns about bladder mucosal injuries secondary to morcellation of the prostatic adenoma after enucleation slow the learning curve and prevent some urologists from learning the procedure. We reviewed 13 years of experience in a single center and suggest some tips and tricks to perform a safe and quick morcellation.
Materials and Methods: A retrospective review of a prospective database of all HoLEP procedures performed by or under supervision of a single consultant urological surgeon was undertaken. Laser enucleation was performed using the Lumenis Pulse™ 120 Holmium laser and morcellation with the Lumenis VERSACUT™ tissue morcellator system. Data were recorded for morcellation time, retrieval time, and specimen weight and all case notes were reviewed for morcellation injury.
Results: Between December 2003 and March 2017, 1016 cases of HoLEP were performed at our center. Median patient age was 72 years (range 41–95). Median time required for morcellation was 10 minutes (range 1–120) (n = 525). The median specimen weight in these patients was 30 g (range 0.7–256) (n = 502). Retrieval of the remaining prostatic adenoma using a cold curette was necessary in 36 (6.9%) cases; median time for retrieval was 5 minutes (range 1–65). Of the 1016 cases performed, there was no incidence of bladder mucosal injury.
Conclusions: Our case series using the Lumenis Versacut™ tissue morcellator demonstrates that morcellation can be performed quickly and safely. These are some of the tips and tricks that are used at our center. (1) Make a smooth transition to morcellation without emptying the bladder to prevent bleeding that could interfere with vision during morcellation. (2) Use two ports of irrigation to keep the bladder full and, therefore, away from the morcellator. (3) Ensure the irrigation fluid does not run out to also keep the bladder full. (4) If the adenoma stops “dancing,” drop it and re-engage to prevent it from becoming polished and difficult to remove. (5) Flush the inner blade should the suction stop working. (6) Slow down morcellation when pieces become small to prevent them falling off the morcellator. (7) Use a cold curette to remove any small polished “beachballs.” (8) Always check the prostatic fossa for any hiding pieces of prostatic adenoma. By following these tips and tricks, morcellation after prostate enucleation can be performed quickly and safely.
