Overcoming Challenges During Holmium Laser Enucleation of the Prostate
Hazem Elmansy, MD, MSc, FRCSC,
Amr Hodhod, MD, MSc, PhD,
Fabiola Oquendo, MD,
Ruba Abdul-Hadi, RD,
Ahmed Kotb, MD, FRCS, FEBU,
Owen Prowse, MD, MPH, FRCSC, and Walid Shahrour, FRCSC, MDCM
Department of Urology, Northern Ontario School of Medicine, Thunder Bay, Canada.
Introduction: Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment for benign prostatic hyperplasia (BPH) with durable and excellent long-term outcomes. However, HoLEP is characterized by its steep learning curve. In this video, we introduce the challenges we faced during HoLEP, and describe the steps we took to overcome them.
Methods: We obtained the Institutional Review Board approval before conducting our study. From October 2017 to October 2018, we prospectively video-recorded all HoLEP procedures, after obtaining patient's consent, performed at our institution. The cases were managed by a single surgeon (H.E). We used a 100 W Holmium:YAG laser (Lumenis, Yokneam, Israel) with a 550 çm laser fiber. A 28F continuous sheath resectoscope (Karl Storz, Germany) was also utilized. Video clips of the challenges we faced during HoLEP were extracted from the original recordings. The steps we took to address and overcome these difficulties were included in the video.
Results: These challenges identified from the recordings include difficulty with positioning the patient, multinodular adenomas, HoLEP after previous BPH surgery, difficult tissue planes, and patients receiving anticoagulant therapy and blood thinners. We also present the obstacles of morcellation in the prostatic fossa, subtrigonal nodules, and the need for perineal urethrostomy. Addressed in this video are patients with urethral strictures before HoLEP, as well as precautions to avoid ureteral injuries.
Conclusion: A concern surgeons have about performing HoLEP is the purported steep learning curve. This video attempts to bridge the gap for those performing HoLEP from novice to expert. In this video, we discussed structured techniques to overcome these difficulties, and ways to prevent serious mistakes.
Sven Schiermeier, MD, PhD, and Michael Anapolski, MD
University of Witten Herdecke, Germany.
Introduction: The overstretching of the posterior vaginal wall can cause a rectocele or enterocele. Although these defects can be asymptomatic, they often cause discomfort such as bulging or stool bulking. The defect can be managed by classic vaginal repair (posterior colporrhaphy) through suturing the pelvic fascia and often additionally the levator muscles. In the 19th century, Breisky (1879), Savage (1868), and Fritsch (1881) developed and adopted these strategies.1 These techniques were performed until the late 1990s; some of them are still in use.2,3 The application of the traditional approach decreased constantly after introduction of vaginal mesh surgery, until the Food and Drug Administration issued its warnings in 2008 and 2009 (www.fda.gov/cdrh/safety/102008-surgicalmesh.html). The combination of vaginal native tissue repair and appropriate apical fixation provides significantly better outcome4 compared with vaginal native tissue alone. We performed laparoscopic apical repair (sacropexy/pectopexy) with vaginal colporrhaphy and/or laparoscopic lateral repair with excellent results. To reduce time and effort, we switched from the combined vaginal/laparoscopic to the entirely laparoscopic route in 2015.5
Methods: The video demonstrates the compression of the stretched posterior vaginal wall by performing the suturing laparoscopically. The fascia and vaginal mucosa are not divided and persist as one tissue layer. No tissue is resected and no vaginal scar results. The peritoneum is opened in the pouch of Douglas at the “fatty tissue” line. We use a bipolar grasper and a scissor for the dissection. The posterior vaginal wall is dissected down to the levator muscles, and the rectum is dissected to its entrance into the perineal body. We place a small clamp at the hymen area vaginally to mark the deepest preparation point. The fascia is sutured horizontally in an interrupted laparoscopic technique. We use a size 1 polyglycolic acid suture to provide firmness of the suture as well as a good stimulus for fibrozation. For the semicircular sutures, we take five to six bites to compress the tissue. While placing the deepest suture, the clamp at the hymen is pushed forward to ensure the deepest possible placement of the suture. The peritoneum is closed at the end of the procedure. In most cases, the approach is combined with an apical support procedure. We generally use the pectopexy to provide apical stability.
Results: In a first examination series of 18 patients treated by posterior laparoscopic fascia repair, we detected one apical and two posterior relapse after 15 months. One patient had complaints related to the rectocele and received a reintervention. No pain, defecation disorders, or dyspareunia occurred. If the perineal body has to be narrowed, an additional vaginal access is needed. The video demonstrates the technique step by step.
Conclusions: The combination of laparoscopic apical support surgery with native tissue repair by one route is feasible. As only one workspace is necessary, fewer instruments are needed and no time is lost due to change of setting, gloves, and so on. As no scars in the vaginal tissue result, the acceptance especially in younger women is very high. However, long-term follow-up date should be obtained before recommending this technique for daily use?
Kaltenbach HU. The Operative Gynecology 1886: Ferdinand Enke, Germany.
Ober KG, M.H.F.E.S.E. General and Special Surgical Education in Gynecological Techniques, Vol. 2. Germany: Springer, 1964, p. 638.
Zander J, Ackermann R, Graeff H. Gynecological Surgeries. Springer, 1991.
Rooney K, Kenton K, Mueller ER, et al. Advanced anterior vaginal wall prolapse is highly correlated with apical prolapse. Am J Obstet Gynecol 2006;195:1837–1840.
Banerjee C, Leufgen H, Hatzmann W, et al. Complication, re-prolapse, and functional outcome after laparoscopic sacropexy: A cohort-study. Geburtshilfe Frauenheilkd 2010;70:379–384.
Thulium Laser Coagulation of Residual Ureteral Endometriosis
Claudia Signorini, MD,
Gloria Motta, MD,
Damiano Vizziello, MD,
Maria Chiara Clementi, MD,
Sebastiano Nazzani, MD,
Oskar Blezien, MD,
Robert Stubinski, MD,
Pietro Acquati, MD,
Stefano Picozzi, MD,
Elisabetta Finkelberg, MD,
Dario Ratti, MD,
Martina Manfredi, MD, and Luca Carmignani, MD
IRCCS Policlinico San Donato, Urology Department, University of Milan, Milan.
Introduction: Urinary tract endometriosis (UTE) was considered a rare clinical disease. However, recent reports showed an increasing incidence.1–3 The incidence of UTE ranges from 1% to 6% of all women affected by endometriosis.4,5 The ureter is the second most common site affected by UTE and its obstruction may lead to progressive hydroureteronephrosis and silent renal failure (25%–50%).6 In 84%–91% of the patients, ureteral endometriosis is silent. Most frequent symptoms are dysmenorrhea, dyspareunia, pelvic pain, and menorrhagia. However, renal colic, flank pain, and catamenial hematuria are rare.7–9 This condition is incidentally diagnosed during a gynecologic checkup in most cases. Some authors suggested that localization of endometriosis involving uterosacral ligaments, broad ligament, and rectovaginal septum is strictly associated with ureteral involvement, particularly in the presence of nodules >3 cm.10,11 Which is the best treatment option for ureteral endometriosis is a controversial issue.12–19 In this article, we present a case report of a 36-year-old woman suffering from deep infiltrating endometriosis since 2009 who underwent left ureteral reimplantation with Leadbetter–Politano technique in 2011. In May 2018, the patient underwent hormonal stimulation for assisted reproductive treatment (ART) with the following appearance of macrohematuria, refractory to conservative treatment. We performed a thulium laser coagulation of bleeding spots of endometriosis in the left residual ureter.
Materials and Methods: Medical history of the patient showed she underwent exploratory laparotomy for hemoperitoneum caused by tubaric vasal hemorrage, thoracoscopy, and biopsy for pleural effusion and pneumothorax in 2009. Moreover, she underwent appendectomy, ureterolysis, and left salpingectomy and a following left ureteral reimplantation with Leadbetter–Politano technique and psoas hitch in 2011. Renal function was preserved, with no signs of hydroureteronephrosis at renal ultrasonography. In May 2018, the patient underwent hormonal stimulation for ART with the following appearance of macrohematuria. A flexible cystoscopy and a semirigid ureteroscopy were performed with the evidence of an endometriotic bleeding spot in the left residual ureter.
Results: To control the bleeding, a thulium laser coagulation (272 μm fiber, 15 W; Quanta System Cyber™) of the lesion was performed with immediate resolution of the symptoms. Preoperative hemoglobin was 13.5 g/dL. Postoperative hemoglobin was 12.7 g/dL. No bladder irrigation was required. Urinary catheter was removed after 1 day and the same day the patient was discharged. No further episodes of macrohematuria occurred during the 6 months of follow-up. As far as we know, this is the first case of thulium laser coagulation for endometriotic lesions. Castaneda et al.20 performed a holmium laser ablation of ureteral endometriosis with an overall success rate of 80% in terms of eradication of the disease. However, three of five patients developed ureteral strictures and underwent stenting and balloon dilatation. In our opinion, thulium laser could be considered a proper alternative to holmium laser in the treatment of ureteral endometriosis. Specifically, thulium laser characteristics allow to obtain an optimal coagulative effect with a shallow penetration in the tissues.21–24
Conclusion: Thulium laser can effectively coagulate endometriotic bleeding spots in residual ureteral tissue and could be used to control ureteral endometriosis with an endoscopic approach. However, a longer follow-up is needed.
Vercellini P, Meschia M, De Giorgi O, Panazza S, Cortesi I, Crosignani PG. Bladder detrusor endometriosis: Clinical and pathogenetic implications. J Urol 1996;155:84–86.
Vercellini P, Frontino G, Pietropaolo G, Gattei U, Daguati R, Crosignani PG. Deep endometriosis: Definition, pathogenesis, and clinical management. J Am Assoc Gynecol Laparosc 2004;11:153–161.
Yohannes P. Ureteral endometriosis. J Urol 2003;170:20–25.
Antonelli A, Simeone C, Zani D, et al. Clinical aspects and surgical treatment of urinary tract endometriosis: Our experience with 31 cases. Eur Urol 2006;49:1093–1097.
Nezhat CH, Malik S, Nezhat F, et al. Laparoscopic ureteroneocystostomy and vescicopsoas hitch for infiltrative endometriosis. JSLS 2004;8:3–7.
Vercellini P, Viganò P, Somigliana E, et al. Endometriosis: Pathogenesis and treatment. Nat Rev Endocrinol 2014;10:261–275.
Vercellini P. Introduction: Management of endometriosis: Moving toward a problem-oriented and patient-centered approach. Fertil Steril 2015;104:761–763.
Comiter CV. Endometriosis of the urinary tract. Urol Clin North Am 2003;30:133–150.
Chapron C, Dubuisson JB, Fritel X, et al. Operative management of deep endometriosis infiltrating the uterosacral ligaments. J Am Assoc Gynecol Laparosc 1999;6:31–37.
Donnez J, Nisolle M, Squifflet J. Ureteral endometriosis: A complication of rectovaginal endometriotic (adenomyotic) nodules. Fertil Steril 2002;77:32–37.
Berlanda N, Vercellini P, Carmignani L, et al. Ureteral and vescical endometriosis. Two different clinical entities sharing the same pathogenesis. Obstet Gynecol Surv 2009; 64:830–842.
Frenna V, Santos L, Ohana E, et al. Laparoscopic management of ureteral endometriosis:our experience. J Minim Invasive Gynecol 2007;14:169–171.
Maccagnano C, Pellucchi F, Rocchini L, et al. Ureteral endometriosis: Proposal for a diagnostic and therapeutic algorithm with a review of the literature. Urol Int 2013;91:1–9.
Perez-utrilla Perez M, Aguilera Bazan A, Alonso Dorrego JM, et al. Urinary tract endometriosis: Clinical, diagnostic, and therapeutic aspects. Urology 2009;73:47–51.
Collinet P, Marcelli F, Regis C, et al. Management of endometriosis of the urinary tract. Gynecol Obstet Fertil 2006;34:347–352.
Uccella S, Cromi A, Casarin J, et al. Laparoscopy for ureteral endometriosis: Surgical details, long-term follow-up, and fertility outcomes. Fertil Steril 2014;102:160–166.
Vercellini P, Carmignani L, Rubino T, et al. Surgery for deep endometriosis: A pathogenesis-oriented approach. Gynecol Obstet Invest 2009;68:88–103.
Stepniewska A, Grosso G, Molon G, et al. Clinical and radiological follow-up after laparoscopic ureteroneocystostomy. Hum Reprod 2011;26:112–116.
Castaneda CV, Shapiro EY, Ahn JJ, Van Batavia JP, Silva MV, Tan Y, Gupta M. Endoscopic Management of Intraluminal Ureteral Endometriosis. Urology 2013;82:307–312.
Sheng L, Zhang ZY, Qian WQ, Zhang HJ, Sun ZQ. Treatment of ureteral fibroepithelial polyp by ureteroscopy combined with holmium laser or thulium laser: A retrospective study. Photomed Laser Surg 2016;34:456–459.
Generao SE, Keene KD, Das S. Endoscopic diagnosis and management of ureteral endometriosis. J Endourol 2005;19:1177–1179.
Fried NM, Murray KE. High-power thulium fiber laser ablation of urinary tissues at 1.94 microm. J Endourol 2005;19:25–31.
Kallidonis P, Kamal W, Panagopoulos V, et al. Thulium laser in the upper urinary tract: Does the heat generation in the irrigation fluid pose a risk? Evidence from an in vivo experimental study. J Endourol 2016;30:555–559.
Transurethral Enucleation and Resection of Prostate Made Easy
Jingzeng Du, MD,
Tze K. Ng, MD,
Kenneth Chen, MD,
Allen S.P. Sim, MD,
Keong T. Foo, MD, and John S.P. Yuen, MD
Department of Urology, Singapore General Hospital, Singapore, Singapore.
Introduction: Transurethral enucleation and resection of prostate (TUERP) allows enucleation of prostatic hyperplastic adenoma and complete resection of the isolated adenomata, achieving superior surgical control of benign prostate hyperplasia (BPH). However, TUERP is a technically challenging procedure. The main difficulties are (1) defining the plane between adenoma, pseudo-capsule, and surrounding stroma, and (2) freeing the enucleated adenoma from surrounding stroma without perforating prostatic capsule. We present a step-by-step video presentation illustrating crucial surgical technique of TUERP, modified from the conventional TURP to ease overcoming steep learning curve in TUERP.
Material and Methods: The video presents a TUERP surgery for BPH on a 69-year-old man with worsening lower urinary tract symptoms despite medical treatment. The outcome of a single-surgeon (J.S.P.Y.) TUERP series of 25 consecutive cases from 2017 to 2018 was presented after the technical video presentation. Statistical analysis performed (SPSS Version-23) with p < 0.05 was considered as statistically significant.
Results: The video presented a technical step-by-step presentation of TUERP from modified conventional TURP techniques, with emphasis on the following key sequential steps: (1) resection of the median and bilateral lateral troughs at 2 and 10 O'clock positions down to the capsule, (2) entry into surgical plane between the hyperplastic adenoma and capsule by incising the mucosal bridges between the median and lateral troughs guided by the depth of the resected troughs, (3) retrograde enucleation of the adenomata facilitated by a “double-loop” resection and “pusher” loops proximally to bladder neck, and (4) resection of the enucleated adenomata and anterior tissues and hemostasis. A single-surgeon series of 25 consecutive modified TUERP was presented, with the patient characteristics as follows: median age 69 (63–74) years old, median prostate volume 70 (53.0–82.5) mL, median weight resected 39 (26–55) g, and median operation time 95 (85–130) minutes. Early functional outcome data showed that 11 patients (40.1%) with acute urinary retention were all able to void postoperatively, with median post-TUERP peak-flow rate of 17.5 (10.4–32.2) mL/second. For 12 patients (44.4%) who failed medical therapy, there was statistically significant improvement in peak-flow rate pre- and post-TUERP: 8.2(7.4–9.5) vs 16.4 (8.6–27.2) mL/second (p < 0.05). Four (14.8%) patients had failed trial-off catheter immediately post-TUERP but were all able to void within 30 days postsurgery. Two (7.4%) patients had transient stress urinary incontinence who recovered fully within 2 months postsurgery. One (3.7%) patient each had urinary tract infection and developed clot-retention that required IV antibiotic and cystodiathermy postoperatively, respectively. No patients required blood transfusion perioperatively. Seventeen patients had significant pre- and post-TUERP prostate specific antigen reduction recorded: 6.1 (4.2–7.2) vs 0.54 (0.30–1.55) ng/mL (p < 0.05).
Conclusion: This video presents an intuitive technique that modifies conventional TURP into TUERP with easy to understand steps for beginners who are proficient in TURP surgery. The critical step of this technique involves incision of the mucosal bridges between median and lateral resected troughs that allows easy entry into the enucleation plane. A series of 25 consecutive patients who underwent this operation had excellent postoperative functional outcomes.
Robotic Sacral Colpopexy with Fascia Lata for Pelvic Organ Prolapse
Isamu Tachibana, MD,
Mark Pickhardt, MD, and C.R. Powell, MD
Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana.
Introduction: Robotic sacral colpopexy with mesh is a minimally invasive method to treat women suffering from pelvic organ prolapse with significant apical descent.1 There are concerns about mesh, and fascia lata may avoid those concerns while offering equivalent outcomes.
Materials and Methods: A prospective registry was examined for patients who chose to undergo robotic sacral colpopexy with fascia lata instead of mesh or porcine dermis. Patients were followed postoperatively to assess and quantify improvement in prolapse as well as monitor for complications associated with the procedure, including assessment of the patient's harvest site. Objective outcomes included pelvic organ prolapse quantification (POP-Q) examination and patient-reported outcomes included Urogenital Distress Inventory-6 (UDI-6), quality of life (QoL), and Incontinence Impact Questionnaire-7 (IIQ-7).
Results: Eight patients from November 2017 to December 2018 chose to undergo fascia lata robotic sacral colpopexy.2 All patients had at least 2 cm apical descent, median POP-Q stage 3. Two patients had a stage 2 cystocele (25%), five patients had a stage 3 cystocele (63%), and one patient had a stage 4 cystocele (13%). No patients in the postoperative examination had recurrence of their prolapse. POP-Q point C went from −5.1 ± 2.0 preoperatively to −8.0 ± 1.2 (p < 0.01) at a mean postoperative follow-up of 110 ± 103 days. On average 1.0 ± 1.2 pads were used during the preoperative period, improved to 0.3 ± 0.5 postoperatively. On average, patients had a UDI-6 score of 12.6 ± 4.2, IIQ-7 of 14.9 ± 8.5, and QoL score of 6.4 ± 2.4 (1 being best, 9 being worst). Postoperatively, UDI-6 was 4.9 ± 2.9 (p < 0.01), IIQ-7 was 4.8 ± 7.9 (p < 0.05), and QoL score was 3.4 ± 2.4 (p < 0.05). One patient had swelling in her lower extremity that warranted Doppler examination but did not show deep venous thrombosis. One patient had a postoperative seroma that has not resolved at last follow-up. Two patients had a muscle bulge at the harvest site not caused by seroma. One patient did have some noticeable bruising and discoloration at her harvest site as well, but did not have any swelling or pain. Average operating room time including hysterectomy and anesthesia was 290 ± 34 minutes (SEM). Harvest time ranged from 15 to 40 min (mean 25.9 ± 8.9 min). Five patients underwent a supracervical hysterectomy at the time of the procedure and one underwent total hysterectomy. Patients had a hospital stay of 1.5 ± 0.5 days.
Conclusion: We present short-term experience with fascia lata robotic sacral colpopexy. No patients had recurrence of prolapse and the fascia lata harvest is associated with minimal complications. Fascia lata may be a viable alternative to mesh for robotic sacral colpopexy, but longer term randomized controlled trial data are needed.
1Department of Radiology, Hôpital Gabriel Montpied, CHU Clermont-Ferrand, Clermont-Ferrand, France.
2Endoscopy and Computer Vision Group, Université Clermont Auvergne, CNRS, SIGMA Clermont, Institut Pascal, Clermont-Ferrand, France.
3Department of Urologic Surgery, Clinique de la Châtaigneraie, Beaumont, France.
4Department of Urologic Surgery, Hôpital Gabriel Montpied, CHU Clermont-Ferrand, Clermont-Ferrand, France.
5Department of Gynecology Surgery, Hôpital Estaing, CHU Clermont-Ferrand, Clermont-Ferrand, France.
Introduction: Augmented reality (AR) aims at improving the vision of the anatomy in laparoscopy. AR works with regular, robot-assisted, and 3D laparoscopies. It modifies the intraoperative vision to provide the surgeon with effects such as a virtual transparency of the organ, to reveal the organ's inner structures, namely tumors and the major vessels.1–5 AR is a technical challenge and only recently has the first AR software capable of handling soft tissue deformation on a mobile organ been proposed.1 This AR software has been developed by an interdisciplinary research team involving surgeons and computer scientists. The software works by fusing a preoperative MR or CT volume with the laparoscopy video. It is image based; it does not require a special hardware nor the use of artificial markers. It can thus be used easily in any standard laparoscopy-equipped operating room. Its benefits were evaluated in an ex vivo preclinical study for guiding tumor resections with porcine kidneys.2 Performance was measured with the negative margin rate across 59 resected pseudotumors. This was 85.2% with AR guidance and 41.9% without, showing a significant improvement. We present the first two cases of using the AR software1 in laparoscopic partial nephrectomy (PN).
Materials and Methods: Both PN cases concerned the resection of a partly exophytic tumor near the arterial pedicle. The procedures used robot-assisted and regular laparoscopies, respectively. First, we created the preoperative 3D model of the kidney from the CT using the Medical Imaging Interaction Toolkit,6 including the tumor and arterial pedicle. Second, we intraoperatively filmed a checkerboard to calibrate the laparoscope and recorded the surgery video. Third, we postoperatively aligned the preoperative 3D model to a laparoscopy image roughly using a tactile screen. The AR software then automatically refined the alignment and augmented the video by overlaying the kidney with the tumor and the arterial pedicle.
Results: The AR software performed effectively in both cases. The kidney was highly mobilized, but the AR software coped and rendered the expected virtual transparency effect. The kidney was not detected at times because of strong occlusions, but AR always resumed quickly and automatically as soon as the part of the kidney nearby the tumor was sufficiently visible. The display of the inner anatomical structures is customizable, and we found that they were made greatly visible using virtual transparency. Although the tumors were already partly visible outside the organ, AR revealed their internal extent and rich information on the organ's inner anatomy.
Conclusion: These two case studies belong to a first series aiming to show AR feasibility in laparoscopic PN. They show that AR in laparoscopic PN may fruitfully complement endoultrasonography. The latter is the current gold standard but has a substantially higher deployment cost than the AR software.1 Much work remains to be done, including running AR intraoperatively and evaluating on a cohort of patients with representative endophytic and exophytic tumors in PN.
Collins T, Chauvet P, Debize C, Pizarro D, Bartoli A, Bourdel N, et al. A system for augmented reality guided laparoscopic tumour resection with quantitative ex-vivo user evaluation. In: Computer-Assisted and Robotic Endoscopy. Springer International Publishing, 2017, pp. 114–126.
Chauvet P, Collins T, Debize C, Bartoli A, Canis M, Bourdel N. Augmented reality in a tumor resection model. Surg Endosc 2017. [Epub ahead of print]; DOI: 10.1007/s00464-017-5791-7.
Phutane P, Buc E, Poirot K, Özgür E, Pezet D, Bartoli A, et al. Preliminary trial of augmented reality performed on a laparoscopic left hepatectomy. Surg Endosc 2018;32:514–515.
Nicolau S, Soler L, Mutter D, Marescaux J. Augmented reality in laparoscopic surgical oncology. Surg Oncol 2011;20:189–201.
Hughes-Hallett A, Pratt P, Mayer E, Martin S, Darzi A, Vale J, et al. Augmented reality partial nephrectomy: Examining the current status and future perspectives. Urology 2014;83:266–273.
Wolf I, Vetter M, Wegner I, Nolden M, Bottger T, Hastenteufel M, et al. The Medical Imaging Interaction Toolkit (MITK). www.mitk.org Accessed April 1, 2019.
