En-bloc Technique Research Articles

The long-term learning curve of holmium laser enucleation of the prostate (HoLEP) in the en-bloc technique: a single surgeon series of 500 consecutive cases

PurposeTo evaluate perioperative parameters, clinical outcomes, and the learning curve of holmium laser enucleation of the prostate (HoLEP) of a single surgeon in 500 consecutive cases.MethodsDemographic parameters, outcomes, and adverse events were evaluated. The learning curve for HoLEP in en-bloc technique of the first 500 consecutive patients was analyzed in clusters of 100 (clusters 1–5) using the Wilcoxen rank test, Chi² test and Kruskal Wallis test.ResultsEnucleation weight was similar in the clusters 1,2,3, and 5 (62 g, 63 g, 61 g, 61 g), in cluster 4 it was slightly higher at 73 g. There was a significant reduction in operating time from 67 min (cluster 1) to 57 min (cluster 2), 46 min (cluster 3), 53 min (cluster 4), and 43 min (cluster 5), p < 0.001. Enucleation efficiency (g/min) showed a steady increase (1.72, 2.24, 2.79, 2.92 vs. 2.99, p < 0.001). Laser energy efficiency also improved (2.17 vs. 2.12 vs. 1.71 vs. 1.65 vs. 1.55; p < 0.001). There was no measurable learning curve regarding the length of hospital stay (mean 2.5 days), catheterization time (1.9 days), hemoglobin drop (approx. 1 g/dl) or complications (p > 0.1).ConclusionsHoLEP using the en-bloc technique is a safe and highly effective method. Over time, a slight but steady learning curve and improvement in operation time, enucleation efficiency and laser energy efficiency were shown even for an experienced surgeon - after 500 cases, still no plateau was reached. There was no measurable learning curve regarding blood loss, complications, length of hospital stay, and catheterization time.

Real world propensity score matched analysis evaluating the influence of en-bloc vs. non en-bloc techniques, energy and instrumentation on enucleation outcomes for large and very large prostates

PurposeThe primary aim of the study was to evaluate if en-bloc vs. non en-bloc made a difference to intra-, peri- and post-operative surgical outcomes of anatomical endoscopic enucleation (AEEP) in large (> 80 cc) and very large prostates (> 200 cc). The secondary aim was to determine the influence of energy and instruments used.MethodsData of patients with > 80 cc prostate who underwent surgery between 2019 and 2022 were obtained from 16 surgeons across 13 centres in 9 countries. Propensity score matching (PSM) was used to reduce confounding. Logistic regression was performed to evaluate factors associated with postoperative urinary incontinence (UI).Results2512 patients were included with 991 patients undergoing en-bloc and 1521 patients undergoing non-en-bloc. PSM resulted in 481 patients in both groups. Total operation time was longer in the en-bloc group (p < 0.001), enucleation time was longer in the non en-bloc group (p < 0.001) but morcellation times were similar (p = 0.054). Overall, 30 day complication rate was higher in the non en-bloc group (16.4% vs. 11.4%; p = 0.032). Rate of late complications (> 30 days) was similar (2.3% vs. 2.5%; p > 0.99). There were no differences in rates of UI between the two groups. Multivariate analysis revealed that age, Qmax, pre-operative, post-void residual urine (PVRU) and total operative time were predictors of UI.ConclusionsIn experienced hands, AEEP in large prostates by the en-bloc technique yields a lower rate of complication and a slightly shorter operative time compared to the non en-bloc approach. However, it does not have an effect on rates of post-operative UI.

Applying the en-bloc technique in corpus callosum glioblastoma surgery contributes to maximal resection and better prognosis: a retrospective study.

Corpus callosum glioblastoma (ccGBM) is a specific type of GBM and has worse outcomes than other non-ccGBMs. We sought to identify whether en-bloc resection of ccGBMs based on T2-FLAIR imaging contributes to clinical outcomes and can achieve a satisfactory balance between maximal resection and preservation of neurological function. A total of 106 adult ccGBM patients (including astrocytoma, WHO grade 4, IDH mutation, and glioblastoma) were obtained from the Department of Neurosurgery in Nanfang Hospital between January 2008 and December 2018. The clinical data, including gender, age, symptoms, location of tumor, involvement of eloquent areas, extent of resection (EOR), pre- and postoperative Karnofsky Performance Status (KPS) scales, and National Institute of Health stroke scale (NIHSS) scores were collected. Propensity score matching (PSM) analysis was applied to control the confounders for analyzing the relationship between the en-bloc technique and EOR, and the change in the postoperative KPS scales and NIHSS scores. Applying the en-bloc technique did not negatively affect the postoperative KPS scales compared to no-en-bloc resection (P = 0.851 for PSM analysis) but had a positive effect on preserving or improving the postoperative NIHSS scores (P = 0.004 for PSM analysis). A positive correlation between EOR and the en-bloc technique was identified (r = 0.483, P < 0.001; r = 0.720, P < 0.001 for PSM analysis), indicating that applying the en-bloc technique could contribute to enlarged maximal resection. Further survival analysis confirmed that applying the en-bloc technique and achieving supramaximal resection could significantly prolong OS and PFS, and multivariate analysis suggested that tumor location, pathology, EOR and the en-bloc technique could be regarded as independent prognostic indicators for OS in patients with ccGBMs, and pathology, EOR and the en-bloc technique were independently correlated with patient's PFS. Interestingly, the en-bloc technique also provided a marked reduction in the risk of tumor recurrence compared with the no-en-bloc technique in tumors undergoing TR, indicating that the essential role of the en-bloc technique in ccGBM surgery (HR: 0.712; 95% CI: 0.535-0.947; P = 0.02). The en-bloc technique could contribute to achieving an enlarged maximal resection and could significantly prolong overall survival and progression-free survival in patients with ccGBMs.

High-power holmium laser versus thulium fiber laser for endoscopic enucleation of the prostate in patients with glands larger than 80 ml: Results from the Prostate Endoscopic EnucLeation study group

BackgroundEndoscopic enucleation of the prostate (EEP) has gained acceptance as an equitable alternative to transurethral resection of the prostate for benign prostate hyperplasia (BPH). Our primary aim is to compare peri-operative outcomes of EEP using thulium fiber laser (TFL) against high-power holmium laser (HPHL) in hands of experienced surgeons for large prostates (≥80 ml in volume). Secondary outcomes were assess complications within 1 year of follow up. Materials and MethodsWe retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with TFL or HPHL in 13 centers (January 2019-January 2023). Patients with prostate volume ≥80 ml were included, while those with concomitant prostate cancer, previous prostate/urethral surgery, and pelvic radiotherapy were excluded. ResultsOf 1,929 included patients, HPHL was utilized in 1,459 and TFL in 470. After propensity score matching (PSM) for baseline characteristics, 247 patients from each group were analyzed. Overall operative time (90 [70, 120] vs. 52.5 [39, 93] min, P < 0.001) and enucleation time (90 [70, 105] vs. 38 [25, 70] min, P < 0.001) were longer in the TFL group, with comparable morcellation time (13 [10, 19.5] vs. 13 [10, 16.5] min, P = 0.914). In terms of postoperative outcomes, there were no differences in 30-day complications such as acute urinary retention, urinary tract infection or sepsis. In the PSM cohort, univariable analyses showed that higher age, lower preoperative Qmax, higher preoperative PVRU, and longer operation time were associated with higher odds of postoperative incontinence, while 2-lobe enucleation had lower odds of incontinence compared to 3-lobe enucleation. ConclusionsThis real-world study reaffirms that HPHL and TFL in large prostates are equally efficacious in terms of 30-day complications. TFL with the en-bloc technique has a shorter operative time which significantly improves short- and medium-term functional outcomes.

Supramaximal resection based on en-bloc technique reduces tumor burden and prolongs survival in primary supratentorial lobar glioblastoma.

Resection beyond the contrast-enhanced zone contributed to reduce tumor burden and prolong survival in glioblastomas. The optimal extent of resection (EOR) and how to achieve it are worthy of continuous investigation for obtaining a satisfactory balance between maximal resection and the preservation of neurological function. A total of 340 adult supratentorial lobar glioblastomas (included astrocytoma, WHO 4, IDH mutation and glioblastoma) were retrospectively evaluated. The clinical data, EOR, technique of resection, postoperative complications, overall survival (OS) and progression-free survival (PFS) were assessed by univariate, multivariate and propensity score matched analysis. Histological staining was performed to comprehend the effect of the membranous structures and the cell distribution in tumoral and peritumoral regions. Supramaximal resection (SMR) was confirmed as resection with 100% EORCE and > 50% EORnCE in glioblastomas by Cox proportional hazards model. Histological results showed SMR reduced the cell density of surgical edge compared to total resection. En-bloc technique based on membranous structures, which had blocking effect on tumoral invasion, contributed to achieve SMR. Moreover, applying en-bloc technique and achieving SMR did not additionally deteriorate neurological function and had similarly effects on the improvement of neurological function. Multivariate analysis confirmed that IDH1 status, technique of resection and EOR were independently correlated with PFS, and > 64 years old, IDH1 status, technique of resection, EOR and preoperative NIHSS were independently correlated with OS. Applying en-bloc technique and achieving SMR, which could reduce tumor burden and did not increase additional complications, both had remarkedly positive effects on clinical outcomes in patients with primary supratentorial lobar glioblastomas.

MP04-12 EN-BLOC ENUCLEATION TECHNIQUE WITH EARLY APICAL RELEASE AND URINARY SPHINCTER PRESERVATION USING PULSE MODULATION (VIRTUAL BASKET) VS EN-BLOC HOLEP

You have accessJournal of UrologyCME1 May 2022MP04-12 EN-BLOC ENUCLEATION TECHNIQUE WITH EARLY APICAL RELEASE AND URINARY SPHINCTER PRESERVATION USING PULSE MODULATION (VIRTUAL BASKET) VS EN-BLOC HOLEP Moises Elias Socarras, Javier Reinoso Elbers, Fabio Esposito, Isabella Greco, Julio Fernandez del Alamo, Vanesa Cuadros Rivera, Diego Carrion Monsalve, Juan Gomez Rivas, Luis Llanes Gonzalez, Luis Llanes Gonzalez, and Fernando Gomez Sancha Moises Elias SocarrasMoises Elias Socarras More articles by this author , Javier Reinoso ElbersJavier Reinoso Elbers More articles by this author , Fabio EspositoFabio Esposito More articles by this author , Isabella GrecoIsabella Greco More articles by this author , Julio Fernandez del AlamoJulio Fernandez del Alamo More articles by this author , Vanesa Cuadros RiveraVanesa Cuadros Rivera More articles by this author , Diego Carrion MonsalveDiego Carrion Monsalve More articles by this author , Juan Gomez RivasJuan Gomez Rivas More articles by this author , Luis Llanes GonzalezLuis Llanes Gonzalez More articles by this author , Luis Llanes GonzalezLuis Llanes Gonzalez More articles by this author , and Fernando Gomez SanchaFernando Gomez Sancha More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002521.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pulse modulation represents one of the important advances in holmium lasers in recent years. We aimed to assess the feasibility, efficacy, safety and outcomes of En-Bloc technique with early apical release using pulse Modulation (Virtual Basket) and compare with En Bloc HoLEP. METHODS: n=261 patients underwent En Bloc enucleation of prostate (n= 126 En Bloc HoLEP using Pulse modulation (Virtual Basket) were compared with n=135 patients in En Bloc HoLEP group. Procedures were performed by a large experienced single surgeon in laser surgery for BPE (>5000 procedures), using the Cyber Ho 150W Holmium laser (Quanta SystemSpA). Setting 2 J/ 50 Hz, with Virtual Basket (VB) activated during enucleation time and 1.2J/40 Hz with Bubble Blast (BB) for hemostasis time. Intra- and post-operative parameters as well as functional results were assessed: prostate volume, Q max, PVR, PSA, IPSS, surgical time, enucleation time, ablation rate, length of hospitalization and complications according to Clavien Dindo. Both (VB & BB) are double pulse modulation effects, Virtual Basket provides excellent cutting, dissection and coagulation balance; while Bubble Blast is useful for coagulation time. RESULTS: Median patient age was 66.5±8.6 and 65.30±7.95, prostate volume 80.57±39.34 and 77.75±39.25, PSA 4.55±0.99 and 4.15±0.75 for En Bloc Holep using Virtual basket and En Bloc HoLEP respectively. Surgical time (37.32±11.9 vs 48.35±19.3), enucleation time (24.97±7.4 vs 32.75±13.08), ablation rate (3.87±1.35 vs 1.65±0.77 gr/min) and haemostasia time (2.36±2.35 vs 8.13±4.39) were significantly better for En Bloc HoLEP using Virtual basket (All p <0.001). Q max, PVR, PSA and IPSS showed significant improvement. No complications Clavien Dindo II – III were observed in En Bloc HoLEP using virtual basket group. CONCLUSIONS: En-Bloc HoLEP with early apical release using pulse modulation is feasible, safe and effective to treat patients affected by BPE. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e62 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Moises Elias Socarras More articles by this author Javier Reinoso Elbers More articles by this author Fabio Esposito More articles by this author Isabella Greco More articles by this author Julio Fernandez del Alamo More articles by this author Vanesa Cuadros Rivera More articles by this author Diego Carrion Monsalve More articles by this author Juan Gomez Rivas More articles by this author Luis Llanes Gonzalez More articles by this author Luis Llanes Gonzalez More articles by this author Fernando Gomez Sancha More articles by this author Expand All Advertisement PDF DownloadLoading ...

“En-Bloc” Enucleation With Early Apical Release Compared to Standard Holmium Laser Enucleation of the Prostate: A Retrospective Pilot Study During the Initial Learning Curve of a Single Surgeon

To compare operative efficiency of Holmium laser enucleation of the prostate (HoLEP) using both the standard multi-incisional approach and en-bloc enucleation with early apical release during the initial learning curve. We retrospectively reviewed the initial 95 consecutive men who underwent HoLEP between April 2019 and September 2020 by a single surgeon. We compared patient demographics, and pre-, intra-, and post-operative metrics between both groups. Differences between groups were evaluated with Mann-Whitney U and Kruskal-Wallis tests. Forty-nine patients underwent the standard HoLEP approach, and 46 patients underwent the en-bloc approach. Compared to a standard HoLEP, the en-bloc approach was associated with decreased operative time (131.11 minutes vs 153.59 minutes, P=.007) with similar weights of tissue removed. Operative efficiency, as measured by grams of prostate tissue removed per minute, was greater for the en-bloc approach (0.49 g/min vs 0.36 g/min, P=.005). There was no difference in length of stay (0.91 days vs 0.96 days, P=.383), laser efficiency (4.41 kJ/g vs 4.83 kJ/g, P=.200), or number of post-operative complications (10 vs 6, P=.236) between the groups. Utilization of the en-bloc technique during the initial learning curve allows for a faster, more efficient operation without any difference in functional outcomes or major complications compared to a standard HoLEP.

MP09-14 EN-BLOC ENUCLEATION TECHNIQUE USING MOSES LASER (EN-BLOC MOLEP) VS EN-BLOC HOLEP: COMPARING INTRA AND POST-OPERATIVE OUTCOMES FOR EN-BLOC ENUCLEATION TECHNIQUE WITH EARLY APICAL RELEASE, TO TREAT PATIENTS AFFECTED BY BENIGN PROSTATIC ENLARGEMENT (BPE)

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology II (MP09)1 Sep 2021MP09-14 EN-BLOC ENUCLEATION TECHNIQUE USING MOSES LASER (EN-BLOC MOLEP) VS EN-BLOC HOLEP: COMPARING INTRA AND POST-OPERATIVE OUTCOMES FOR EN-BLOC ENUCLEATION TECHNIQUE WITH EARLY APICAL RELEASE, TO TREAT PATIENTS AFFECTED BY BENIGN PROSTATIC ENLARGEMENT (BPE) Moises Rodriguez Socarras, Julio Fernandez Del Alamo, Fabio Esposito, Javier Reinoso Elbers, Juan Gomez Rivas, Diego Carrion, Vanesa Cuadros Rivera, Luis Llanes Gonzalez, Pablo Juarez del Dago, and Fernando Gomez Sancha Moises Rodriguez SocarrasMoises Rodriguez Socarras More articles by this author , Julio Fernandez Del AlamoJulio Fernandez Del Alamo More articles by this author , Fabio EspositoFabio Esposito More articles by this author , Javier Reinoso ElbersJavier Reinoso Elbers More articles by this author , Juan Gomez RivasJuan Gomez Rivas More articles by this author , Diego CarrionDiego Carrion More articles by this author , Vanesa Cuadros RiveraVanesa Cuadros Rivera More articles by this author , Luis Llanes GonzalezLuis Llanes Gonzalez More articles by this author , Pablo Juarez del DagoPablo Juarez del Dago More articles by this author , and Fernando Gomez SanchaFernando Gomez Sancha More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001982.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Moses technology, introduces a pulse-shape modulation for Holmium YAG; optimizing energy transmission to the target tissue, leading to more concise incisions and better coagulation profile. We aimed to assess the feasibility, efficacy and safety outcomes of En-Bloc technique with early apical release using Moses Laser Enucleation of Prostate (En-Bloc MoLEP) and compare with En Bloc HoLEP. METHODS: n=217 patients underwent En Bloc enucleation of prostate (n=80 En Bloc MoLEP, n=137 En Bloc HoLEP) April - November 2019. All procedures were performed by a large experienced single surgeon in laser surgery for BPE, using the Lumenis PulseTM 120W Holmium laser equipped with Moses technology, Settings: 2 J/60 Hz for enucleation,1 J/40Hz for hemostasis. Patients were followed-up at 1, 3, 6, 12 months and intra- and post-operative parameters as well as functional results were assessed: prostate volume, Q max, PVR, PSA, IPSS, surgical time, enucleation time, ablation rate, length of hospitalization and complications according to Clavien Dindo. RESULTS: Median patient age was 66.73±13.21 and 66.30±7.95, prostate volume 86.66±50.01 and 75.77±42.25 for En Bloc MoLEP and En Bloc HoLEP respectively. Surgical time (32.16±14.46 vs 47.58±21.32), enucleation time (22.10±9.27 vs 31.46±14.85), ablation rate (4.11±2.41 vs 2.54±1.31 gr/min) and haemostasia time (3.01±2.50 vs 8.35±5.38) were significantly better for En Bloc MoLEP (All p<0.05) Table 1, Fig.1. Q max, PVR, PSA and IPSS showed significant improvement. No patient needed blood transfusion and no major complications Clavien Dindo II - III were observed. CONCLUSIONS: En-Bloc MoLEP with early apical release is feasible, safe and effective to treat patients affected by BPE. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e165-e165 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Moises Rodriguez Socarras More articles by this author Julio Fernandez Del Alamo More articles by this author Fabio Esposito More articles by this author Javier Reinoso Elbers More articles by this author Juan Gomez Rivas More articles by this author Diego Carrion More articles by this author Vanesa Cuadros Rivera More articles by this author Luis Llanes Gonzalez More articles by this author Pablo Juarez del Dago More articles by this author Fernando Gomez Sancha More articles by this author Expand All Advertisement Loading ...

MP09-14 EN-BLOC ENUCLEATION TECHNIQUE USING MOSES LASER (EN-BLOC MOLEP) VS EN-BLOC HOLEP: COMPARING INTRA AND POST-OPERATIVE OUTCOMES FOR EN-BLOC ENUCLEATION TECHNIQUE WITH EARLY APICAL RELEASE, TO TREAT PATIENTS AFFECTED BY BENIGN PROSTATIC ENLARGEMENT (BPE)

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology II (MP09)1 Sep 2021MP09-14 EN-BLOC ENUCLEATION TECHNIQUE USING MOSES LASER (EN-BLOC MOLEP) VS EN-BLOC HOLEP: COMPARING INTRA AND POST-OPERATIVE OUTCOMES FOR EN-BLOC ENUCLEATION TECHNIQUE WITH EARLY APICAL RELEASE, TO TREAT PATIENTS AFFECTED BY BENIGN PROSTATIC ENLARGEMENT (BPE) Moises Rodriguez Socarras, Julio Fernandez Del Alamo, Fabio Esposito, Javier Reinoso Elbers, Juan Gomez Rivas, Diego Carrion, Vanesa Cuadros Rivera, Luis Llanes Gonzalez, Pablo Juarez del Dago, and Fernando Gomez Sancha Moises Rodriguez SocarrasMoises Rodriguez Socarras More articles by this author , Julio Fernandez Del AlamoJulio Fernandez Del Alamo More articles by this author , Fabio EspositoFabio Esposito More articles by this author , Javier Reinoso ElbersJavier Reinoso Elbers More articles by this author , Juan Gomez RivasJuan Gomez Rivas More articles by this author , Diego CarrionDiego Carrion More articles by this author , Vanesa Cuadros RiveraVanesa Cuadros Rivera More articles by this author , Luis Llanes GonzalezLuis Llanes Gonzalez More articles by this author , Pablo Juarez del DagoPablo Juarez del Dago More articles by this author , and Fernando Gomez SanchaFernando Gomez Sancha More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001954.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Moses technology, introduces a pulse-shape modulation for Holmium YAG; optimizing energy transmission to the target tissue, leading to more concise incisions and better coagulation profile. We aimed to assess the feasibility, efficacy and safety outcomes of En-Bloc technique with early apical release using Moses Laser Enucleation of Prostate (En-Bloc MoLEP) and compare with En Bloc HoLEP. METHODS: n=217 patients underwent En Bloc enucleation of prostate (n=80 En Bloc MoLEP, n=137 En Bloc HoLEP) April - November 2019. All procedures were performed by a large experienced single surgeon in laser surgery for BPE, using the Lumenis PulseTM 120W Holmium laser equipped with Moses technology, Settings: 2 J/60 Hz for enucleation,1 J/40Hz for hemostasis. Patients were followed-up at 1, 3, 6, 12 months and intra- and post-operative parameters as well as functional results were assessed: prostate volume, Q max, PVR, PSA, IPSS, surgical time, enucleation time, ablation rate, length of hospitalization and complications according to Clavien Dindo. RESULTS: Median patient age was 66.73±13.21 and 66.30±7.95, prostate volume 86.66±50.01 and 75.77±42.25 for En Bloc MoLEP and En Bloc HoLEP respectively. Surgical time (32.16±14.46 vs 47.58±21.32), enucleation time (22.10±9.27 vs 31.46±14.85), ablation rate (4.11±2.41 vs 2.54±1.31 gr/min) and haemostasia time (3.01±2.50 vs 8.35±5.38) were significantly better for En Bloc MoLEP (All p<0.05) Table 1, Fig.1. Q max, PVR, PSA and IPSS showed significant improvement. No patient needed blood transfusion and no major complications Clavien Dindo II - III were observed. CONCLUSIONS: En-Bloc MoLEP with early apical release is feasible, safe and effective to treat patients affected by BPE. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e165-e165 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Moises Rodriguez Socarras More articles by this author Julio Fernandez Del Alamo More articles by this author Fabio Esposito More articles by this author Javier Reinoso Elbers More articles by this author Juan Gomez Rivas More articles by this author Diego Carrion More articles by this author Vanesa Cuadros Rivera More articles by this author Luis Llanes Gonzalez More articles by this author Pablo Juarez del Dago More articles by this author Fernando Gomez Sancha More articles by this author Expand All Advertisement Loading ...

En bloc enucleation technique during holmium laser enucleation of the prostate: An analysis of its efficiency.

Despite the acknowledgment that holmium laser enucleation of the prostate (HoLEP) is a safe, efficacious procedure with benefits over traditional treatments, it is not widely adopted. Its steep learning curve is considered responsible, and the new en bloc technique (EBT) aims to improve this. A retrospective analysis of 268 consecutive patients (215 lobe technique [LT] and 53 EBT) who underwent HoLEP between May 2016 and April 2020 was performed. Data were collected on patient demographics, prostate volume, enucleation time, prostatic weight, and length of stay. There was no difference in mean prostate volume and enucleated prostatic weight between the LT and EBT (99.2 mL vs 98.5 mL, P= .95216, and 71.7 g vs 69.3 g, P= .92034, respectively). There was a reduction in mean enucleation time with the EBT to 37.7 minutes compared with 53.3 minutes (LT) (P< .00001). This translated to an improved operative efficiency of 1.84 g/min (EBT) compared to 1.33 g/min (LT) (P< .00001). The EBT demonstrated a continuous improvement in operative efficiency with increasing prostate size unlike the LT where efficiency plateaus. The EBT for HoLEP demonstrates a significant improvement in operative efficiency which has the potential to reduce the surgeons' learning curve and lead to more widespread adoption.

Robotic Total Pancreatectomy: A Narrative Review.

Studies on robotic total pancreatectomy (RTP) have been limited regardless of the increasing evidence on robotic pancreatoduodenectomy. The aim of this study was to review the current status of RTP in terms of surgical techniques and outcomes. A literature search using PubMed was conducted to investigate surgical techniques and outcomes of RTP. A total of eight case series with 56 patients were included. The indications for RTP consisted of benign or pre-malignant tumors in 43 patients and malignant tumors in 13 patients. Surgical techniques included the "dividing technique" and "en-bloc technique". Regarding surgical outcomes, the rate of conversion to open total pancreatectomy was 3.6% and the incidence of major complications was 10.7%. Although evidence for RTP is still lacking, RTP is feasible for selected patients when performed in specialized centers. Further studies are essential to investigate the effectiveness of RTP compared to open total pancreatectomy.

A “Pancreatectomy First" Approach Improves Both Hepatectomy and Pancreatectomy Times in Cadaveric Multi-organ Abdominal Retrieval

Introduction: The aim of organ retrieval is safe procurement of transplantable organs with acceptable warm ischaemia times. In the United Kingdom, organ retrieval is a centrally coordinated service delivered by 10 teams. Despite this, there is no standardised retrieval technique. Practiced techniques include hepatectomy first or en-bloc organ retrieval. Hepatectomy first approach exposes the pancreas to prolonged warm ischaemia while the liver is being retrieved and packed. While the en-bloc technique ensures swift and timely removal of both organs, extra time is spent at the back-table splitting the organs. We report on the Manchester “pancreatectomy first approach” which we believe is safe and time efficient for both organs. Methods: A retrospective analysis of a prospectively maintained database of a single centre's organ retrieval activity between 2016-2019 was performed. Primary outcomes were hepatectomy and pancreatectomy times. Secondary outcomes were organ damage and transplant outcomes. Results: 546 donor operations were conducted. Using the hepatectomy first approach, mean hepatectomy time when performing liver alone was comparable to liver/pancreas (30mins vs 33mins). The proportion taking more then 30 minutes increased when both organs were retrieved (41.3% vs 56.3%). Mean pancreatectomy time was 14mins after hepatectomy. 10 operations were performed using a “pancreatectomy first” approach. Median pancreatectomy time was 21 minutes with hepatectomy occurring 6 minutes later. There was no difference in organ damage or transplant outcomes. Conclusion: This small case series suggests that a pancreatectomy first approach at multi-organ retrieval is feasible, safe, efficient, and reduces warm ischaemia times for both liver and pancreas.

En-bloc resection of urinary bladder tumour - a prospective controlled multicentre observational study.

IntroductionTransurethral resection of bladder tumour (TURBT) is one of the most commonly performed urologic procedures. Because of the shortcomings of conventional TURBT, the en-bloc resection concept was created.AimTo analyse the influence of en-bloc technique on surgical and oncological outcomes of TURBT performed with electric current.Material and methodsThis non-randomized, prospective controlled multicentre study enrolled 427 consecutive patients undergoing TURBT performed by five experienced endourologists in five academic institutions. Choice of procedure was at the discretion of the surgeon. The vast majority of patients underwent monopolar resection. The en-bloc procedure was performed with Collin’s knife or the classic resection loop. Study end-points were surgery, catheterization and hospitalization time, presence of muscularis propria (MP) in the specimen and 3-month recurrence-free survival (RFS).ResultsThe study included 427 (274 conventional TURBT vs. 153 en-bloc) patients with mean age of 69 years (range: 18–99). There were more cases with MP present in the specimen in the en-bloc group (91.3% vs. 75.5%; p < 0.001). Surgery and hospitalization times were statistically shorter in the en-bloc group (both p < 0.05). A borderline significant difference was noted when the number of residual tumours in reTURBTs was analysed, with fewer cases of residual tumour in the en-bloc group (p = 0.051). RFS at 3 months was higher in the en-bloc group (88.4% vs. 80.1%; p = 0.027). After propensity score matching, differences in MP presence, hospitalization time and 3-month RFS status remained statistically significant.ConclusionsWhen compared to conventional TURBT, en-bloc resection of bladder tumour is associated with higher percentage of MP presence in histopathological specimen, higher 3-month RFS and shorter hospitalization time.

GUA-57 - Transurethral enucleation of prostate byone-step en-bloc technique

GUA-57 - Transurethral enucleation of prostate byone-step en-bloc technique

Predictive factors of the absence of residual disease at repeated transurethral resection of the bladder. Is there a possibility to avoid it in well-selected patients?

PurposeTo evaluate the predictive factors of pT0 at repeated transurethral resection of the bladder (re-TURB) in pT1 high-grade (HG) nonmuscle invasive bladder cancer in order to explore the possibility to avoid it in well-selected patients. MethodsThis multicenter retrospective study included patients with pT1HG nonmuscle invasive bladder cancer from 4 different centers who underwent a complete TURB. Re-TURB was defined as a second resection which involved the site of the first TURB performed within 2-6 weeks from the previous resection. A multivariable logistic-regression model was performed to evaluate the predictors of pT0 at re-TURB. A nomogram was built to calculate the probability of obtaining a negative histology at re-TURB. The performance of the nomogram and its net benefit were tested with the decision curve analysis. ResultsOverall, 321 patients were included in the study. On multivariable logistic regression, detrusor muscle in the specimen (HR 1.99, P = 0.02), concomitant carcinoma in situ (HR 0.29, P = 0.005) and resection performed with en-bloc technique (HR 7.71, P = 0.01) were independent predictors of pT0 at re-TURB. Decision curve analysis showed a net benefit for the nomogram for each probability over 0.35 compared to the strategy to perform a re-TURB in all pT1HG tumors. ConclusionsThe presence of detrusor muscle in TURB specimen, the absence of concomitant carcinoma in situ and the en-bloc resection were able to predict a negative histology at re-TURB, opening the door to the possibility to avoid it in an extremely well-selected cohort of patients. External validations and prospective studies are urgently needed.

En bloc kidney transplant from pediatric donor to an adult

The use of pediatric kidney donors is not a common practice. Transplant physicians and surgeons are concerned with technical issues as well as inadequate nephrons mass. We reported a case of en bloc kidney transplant from a pediatric donor to serve as a teaching case. The donor is a 3-year-old infant who died as a result of influenza. Due to the age and size discrepancy with an adult, it was decided to transplant the kidneys en bloc into an adult with successful outcome. En bloc technique renders the kidneys transplantable which would have been otherwise discarded and theoretically protect against hyperfiltration injury. Small pediatric donors are excellent resources and should be considered for donation whenever option is available.

Left- versus right-sided hepatectomy with hilar en-bloc resection in perihilar cholangiocarcinoma

BackgroundMajor liver resections with portal vein resection (PVR) have emerged as the preferred treatment for patients with perihilar cholangiocarcinoma (pCCA). Whether the resection of the liver should be preferably performed as left- (LH) or right-sided hepatectomy (RH) with or without hilar en-bloc technique is still subject of ongoing debate. MethodsBetween 2011 and 2016, 91 patients with pCCA underwent surgery in curative intent at our institution. Perioperative, pathological and survival data from all consecutive patients undergoing hilar en-bloc resection for pCCA were analyzed retrospectively. Patients undergoing hepatoduodenectomy (n = 8) or ALPPS (Associating liver partition and portal vein ligation for staged hepatectomy) (n = 2) were excluded from the analysis. ResultsTumor grading, microvascular invasion, lymphovascular invasion, N-category, T-category, R-status and UICC-tumor staging were similar in the RH (n = 45) and LH (n = 36) groups. Perioperative morbidity and mortality were higher after RH compared to LH (mortality: 15.6% (7/45) vs. 8.3% (3/36) p = 0.003). Three-year (62% vs. 51%) and the 5-year OS (30% vs. 46%) were comparable between LH and RH groups respectively (p = 0.519, log rank). ConclusionsThe present study supports the concept of surgically aggressive therapy in pCCA. LH and RH hilar en-bloc resection demonstrate a comparable long-term survival, suggesting that LH hilar en-bloc resections are feasible and safe in high-volume centers.

Development of a Complete En-Bloc Technique with Direct Bladder Neck Incision: A Newly Modified Approach for Holmium Laser Enucleation of the Prostate.

Introduction: The objectives of this study were to introduce a newly developed approach for holmium laser enucleation of the prostate (HoLEP) called the "complete en-bloc technique," and to compare the clinical outcomes of this approach with those of previously performed procedures. Methods: This study retrospectively assessed the perioperative findings from 548 patients with benign prostatic hyperplasia (BPH) undergoing HoLEP who were divided into the following groups according to the consecutive changes in surgical techniques: group A (n = 236), the three-lobe technique; group B (n = 137), the conventional en-bloc technique; and group C (n = 175), the complete en-bloc technique with direct bladder neck incision. Results: There were no significant differences in major clinical characteristics or urinary symptoms among groups A, B, and C. Although there was no significant difference in the resected prostate weight among the three groups, the enucleation time was significantly shorter and total laser energy was significantly lower in group C than in groups A and B. Therefore, the enucleation efficiency, calculated by dividing the resected prostate weight by the enucleation time, was significantly greater in group C than in groups A and B. Furthermore, no significant differences in the postoperative urinary symptoms, including the International Prostate Symptom Score (IPSS), quality of life, maximum flow rate, postvoid residual, and persistent stress urinary incontinence rate, were noted among the three groups, and there were no significant differences in the incidences of major perioperative complications, including the blood transfusion, bladder injury, urethral stricture, and bladder neck sclerosis among the three groups. Conclusions: These findings suggest that our complete en-bloc technique can improve the clinical outcomes of HoLEP in BPH patients, even in difficult cases, considering its markedly improved enucleation efficiency.

Green Laser Enucleation of the Prostate “En bloc Technique”: Surgical Technique and Initial Experience

Introduction and Objectives: Green laser “en bloc” enucleation of the prostate (GreenLEP) is an alternative enucleation technique for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. All endoscopic enucleation of the prostate procedures require significant endoscopic surgical skills and have a steep learning curve. The aim of this study is to demonstrate the GreenLEP surgical technique step-by-step and report our initial experience. Material and Methods: We report our single surgeon's (E.R.) initial experience with this novel technique. Thirty patients underwent GreenLEP between July 2015 and March 2016 in our institution with prostate volumes between 60 and 140 cc. All patients were evaluated preoperatively and after surgery (at 1, 3, and 6 months) by prostate-specific antigen, prostate volume, International Prostate Symptom Score, quality-of-life score, maximum flow rate, and postvoid residual urine volume, and all the complications were recorded. The surgery was performed with a 532-nm lithium triborate laser (GreenLight™ XPS 180W device; American Medical Systems, Minnetonka, MN), 2090 side-fire laser fiber at the following power settings: 80W for cutting, 25W for coagulation, and a Piranha™ morcellation system (Richard Wolf GmbH, Germany) using single-use blade. Results: The mean operative time was 64 minutes (range: 55–95 minutes) and the mean amount of retrieved prostate tissue was 70 g (range 40–120 g). There was no need for blood transfusion. Capsular perforation occurred in four cases. We did not have any case of bladder injuries related to the morcellation procedure. The postoperative catheterization time (same as hospital stay) was 48 hours, except in two cases: one of incomplete morcellation because of bleeding and required an endoscopic second look (morcellation for residual adenoma), and the other required open surgery conversion for removal of the enucleated adenoma (poor vision because of venous bleeding caused by surgical perforation of the capsule during enucleation). Transient urinary incontinence was present in three cases and was completely resolved in 2 months. Three months later, all the parameters evaluated preoperatively showed significant improvement. Conclusions: GreenLEP appears to be a safe alternative enucleation technique for the complete removal of en bloc adenomatous prostate tissue. Regardless of gland size, it is particularly advantageous for the treatment of large prostates (not recommended for small glands). Endoscopic laser enucleation of the prostate is feasible with a side-firing fiber. This technique is probably easier to learn in a progressive pathway, that is, vaporization, vapoenucleation, and finally enucleation. These promising results warrant further studies to assess long-term outcomes. No competing financial interests exist. Runtime of video: 10 mins

Combined heart-liver transplantation: Indications, outcomes and current experience.

Combined heart-liver transplantation is a rare, life-saving procedure that treats complex and often fatal diseases including familial amyloidosis polyneuropathy and late stage congenital heart disease status-post previous repair. There were 159 combined heart-liver transplantations performed between January 1, 1988 and October 3, 2014 in the United States. A multitude of potential techniques to be used for combined heart and liver transplant including: orthotopic heart transplant (OHT) and orthotopic liver transplant (OLT) on full cardiopulmonary bypass (CPB), OHT with CPB and OLT with venovenous bypass (VVB), OHT with CPB and OLT without VVB, en-bloc technique and sequential transplantation. Outcomes of combined heart-liver transplant have been demonstrated to be comparable to outcomes of isolated heart and isolated liver transplant. The liver graft may provide some tolerance of other allografts.