Enucleation Technique Research Articles

Partial nephrectomy for patients with limited life expectancy?

A new study reports that selected patients with short life expectancy can safely undergo partial nephrectomy with perioperative outcomes that approximate those of patients with long life expectancy. The authors suggest that extensive centre and/or surgeon experience, a robot-assisted approach, and off-clamp and simple enucleation techniques might facilitate favourable outcomes in these challenging patients.

Photoselective sharp enucleation of the prostate with a front-firing 532-nm laser: an innovative surgical technique for benign prostatic hyperplasia-a single-center study of 475 cases.

To describe the novel technique of photoselective sharp enucleation of the prostate (PSEP) with a front-firing 532-nm laser and evaluate its efficacy and safety. A seven-step standardized surgical procedure was established, and PSEP was performed in an en bloc or lobulate manner according to the size of the middle lobe of the prostate. The following clinical data of 583 patients who underwent PSEP in our center from November 2016 to May 2018 were retrospectively reviewed: maximum flow rate (Qmax), International Prostate Symptom Score (IPSS), quality of life score (Qols), post-void residual volume (PVR), prostate volume, operation time, serum prostate-specific antigen (PSA) concentration, and complications at 1, 6, and 12months postoperatively. Of the 583 patients, 475 had complete clinical information and were included in the study. The median operation time was 39min. There were significant improvements in the Qmax, IPSS, Qols, PVR and PSA concentration at each follow-up time point postoperatively. Postoperative hemorrhage occurred in 22 patients (4.6%), urinary retention in 29 (6.1%), urinary tract infection in 55 (11.6%), bladder neck contracture in 8 (1.7%), urethral strictures in 11 (2.3%), and stress urinary incontinence in 9 (1.9%). PSEP is effective and safe for the treatment of benign prostatic hyperplasia. The innovative technique integrates the excellent hemostatic property of the 532-nm laser and the high efficiency of enucleation. It decreases the occurrence of postoperative incontinence associated with "blunt" enucleation of 532-nm laser and eliminates the lack of tissue samples problem associated with photoselective vaporization of the prostate.

Cervical Schwannoma of the Vagus Nerve: Systematic Review and Two Illustrative Cases

Background: Cervical schwannoma is a rare and benign tumor exclusively developed from the cell of Schwann that rarely involve the vagus nerve. Methods: We have conducted a retrospective review with strategy of the consulted references and database included articles published in Portuguese, English and French in PUBMED, MEDLINE, EMBASE, LILACS and SciELO, since 1936 until the present day, associated with a description of two illustrative cases. Both patients presented with a history of painless palpable mass in the cervical region. Results: About 160 cases has been described in literature. Most cases of manifest between the third and sixth decades of the patient's life as a slow growing firm, painless mass in the lateral neck. Imaging is essential to management. Histopathological examination can reveals encapsulated, biphasic spindle cell neoplasia. The best choice of treatment for this type of tumor is complete surgical removal with preservation of the vagus nerve by means of intracapsular resection. In both ilustrative cases the lesions were diagnosed by means of imaging studies and were totally ressected. Surgical findings and histopathology confirmed the diagnosis of vagus nerve schwannoma. There was no recurrence at five years of follow-up. In one case there was disphonya that solved within six months after the surgery. Conclusion: Vagus nerve schwannomas are rare benign tumors. The enucleation technique is used to obtain the most functional preservation and complete excision without permanent deficit is possible even with the occurrence of large lesions.

Robotic enucleation of pancreatic head insulinoma in two cases with challenging tumor locations

Presenter: John D Karalis MD | University of Texas Southwestern Medical Center Background: Insulinomas are rare neuroendocrine tumors for which surgical resection is the cornerstone of treatment. Enucleation of insulinomas located in the head of the pancreas can be challenging but is preferable to avoid the morbidity associated with pancreaticoduodenectomy. Our video-presentation aims to describe our technique for robotic enucleation of pancreatic head insulinomas. Methods: Our video describes the clinical presentation, diagnostic imaging and technical aspects of the surgical approach in two patients with pancreatic head insulinomas that underwent robotic enucleation. Results: The first patient is a 76-year-old female who presented with a 2-month history of syncope. Biochemical work-up revealed a blood glucose level of 35 mg/dl, C-peptide of 3.3 ng/mL, and proinsulin of 90 pmol/L. CT imaging revealed a 1.5x1.3 cm medial pancreatic head mass, located posterior to the superior mesenteric artery and superior mesenteric vein, anterior to the left renal vein, and in close proximity to the pancreatic duct. Pre-operatively, to aid with intra-operative visualization of the pancreatic duct, a pancreatic duct stent was placed endoscopically. Robotic enucleation of the mass was performed. Intraoperative ultrasound was used to identify the mass and preserve the integrity of the pancreatic duct. Pathology revealed a 1.2 cm well-differentiated neuroendocrine tumor. The patient’s post-operative course was uneventful; her glucose levels normalized, she received a diet on post-operative day 1, her drain was removed on post-operative day 3, and she was discharged home on post-operative day 5. The second patient is a 61-year-old male with a previous history of renal cell carcinoma treated with a robotic-assisted right nephrectomy who presented with mild symptoms attributed to hypoglycemia, with a blood glucose level ranging from 50-70 mg/dl. Biochemical work-up revealed an elevated C-peptide and proinsulin of 8.9 ng/ml and 98 pmol/L, respectively. CT imaging revealed a 1.2 cm pancreatic head mass in close proximity to the pancreatic duct. Pre-operatively, to aid with intra-operative visualization of the pancreatic duct, a pancreatic duct stent was placed endoscopically. Robotic enucleation of the mass was performed. Intraoperative ultrasound revealed that the mass was abutting the main pancreatic duct requiring careful dissection. Pathology revealed a 1.5 cm well-differentiated neuroendocrine tumor. The patient’s post-operative course was uneventful; he received a diet on post-operative day 1, his drain was removed on post-operative day 4, and she was discharged home on post-operative day 5. Conclusion: Robotic enucleation is a safe and feasible option for treatment of pancreatic head tumors in challenging locations. Preoperative pancreatic duct stenting is useful for identification and preservation of the pancreatic duct during the operation, and the use of intraoperative ultrasound is essential for tumor localization. Surgical proficiency and profound understanding of the anatomy of the pancreas are essential for successful robotic enucleation of pancreatic head tumors.

Use of posterior radial nephrotomy in laparoscopic enucleation of renal hilar tumors.

Centrally located completely endophytic renal hilar tumors pose a technical challenge, especially during a minimally invasive surgery. Relation of the tumor to the renal vasculature decides the approach. Tumors placed anterior to the vasculature can be approached in the anterior trans-hilar manner. However, tumors placed posterior to the vasculature need a posterior approach, which is quite a difficult maneuver during transperitoneal laparoscopy. Adequate exposure to access the resection plane is the key principle. We describe a laparoscopic technique for enucleation of such tumors, applying the surgical principle of radial nephrotomy in the intersegmental plane which is usually performed to remove renal stones.

Hysteroscopic myomectomy for submucosal type 2 fibroids with cold enucleation technique and complete fibroid extraction using a double-lumen intracervical cannula

To introduce a new double-lumen intracervical cannula designed to allow a single-step hysteroscopic myomectomy with nonfragmented complete fibroid extraction after cold enucleation of submucosal type 2 fibroids, avoiding complications related to the use of energy and hypo-osmolar solutions. Video article depicting the use of a new double-lumen intracervical cannula for single-step hysteroscopic cold myomectomy, according to our institutional care guidelines and after obtaining the patient's informed consent. (The publication of this video has been authorized by the Institutional Ethics Committee of CES University in Medellín, Colombia.) SETTING(S): Private infertility clinic. A 45-year-old woman with abnormal uterine bleeding consisting of polymenorrhea and hypermenorrhea, nonresponsive to medical treatment, caused by three type 2 (FIGO leiomyoma subclassification system) submucosal fibroids of 17, 15, and 13 mm with more than 80% of intramyometrial component. Hysteroscopic enucleation of three submucosal fibroids performed by blunt dissection using the 30° Bettocchi hysteroscope's bevel under continuous observation of the avascular subcapsular plane of the fibroids. Once full enucleation was attained, cervical dilatation to 12 mm with Hegar plugs was performed followed by intracervical placement of a newly designed double-lumen intracervical cannula that allows the concomitant introduction of the Bettocchi diagnostic hysteroscope and a 5-mm laparoscopic tenaculum into the uterine cavity for complete nonfragmented fibroid extraction under direct visualization. Complete and unfragmented fibroid extraction in a single intervention, absence of surgical complications, and postoperative course. Ambulatory hysteroscopic myomectomy of three submucosal type 2 fibroids was successfully performed by blunt enucleation and complete nonfragmented fibroid extraction using the double-lumen intracervical cannula. The total operative time was 32 minutes, and the total amount of distension media (normal saline) used was 800 mL with a liquid balance of 50 mL. No surgical or anesthesia-related complications occurred. In the postsurgical evaluation, the patient classified her pain as minimal, giving it a score of 1 on a pain scale of 1 to 5 (in which 1 is the lowest and 5 the highest pain perception). When asked about the level of satisfaction with the surgical procedure, the patient reported the highest degree of satisfaction with a score of 5 on a satisfaction scale of 1 to 5 (in which 1 is the lowest and 5 the highest satisfaction). The patient reported having postsurgical regular menstrual cycles every 28 days and 3 bleeding days without hypermenorrhea. An efficient hysteroscopic myomectomy of submucosal type 2 fibroids with deep intramyometrial component can be performed with complete and nonfragmented fibroid extraction in a single intervention by using a newly designed double-lumen intracervical cannula. This technique allows the completion of the surgery without the need of a resectoscope, electrosurgery, or hypo-osmolar uterine distension media, thus avoiding potential complications such as thermal-induced myometrial injury and hyponatremia; a second surgical intervention will not be required because the fibroid enucleation is complete. The procedure can be performed with the use of a diagnostic hysteroscope that is widely available in gynecologic practices. (Acknowledgment: The authors thank Dr. David Olive for the invaluable help and guidance with this surgical technique and video article.).

Holmium Laser Enucleation, Laparoscopic Simple Prostatectomy, or Open Prostatectomy: The Role of the Prostate Volume in terms of Operation Time

Introduction: To compare the prostate removal speeds of 3 enucleation techniques and to evaluate how the operating times change depending on the prostate volume. Methods: Medical records of patients with 80-g or larger prostates who underwent holmium laser enucleation of the prostate (HoLEP), laparoscopic simple prostatectomy (LSP), or open prostatectomy (OP) due to medical treatment-resistant benign prostatic hyperplasia (BPH) were reviewed retrospectively. Patients were classified into 3 groups according to the surgical procedure. Age, BMI, prostate weights, total operation times, prostate removal speeds, hospitalization and catheterization days, complications, and improvements on functional outcomes in the 3rd month of follow-up were compared between groups. In addition, the association between prostate weight and total operation time was analyzed for each group. Results: HoLEP, LSP, and OP groups consisted of 60, 61, and 37 patients, respectively. While HoLEP was similar to OP in terms of prostate removal speed and total operation time, LSP was statistically slower and required more operation time than HoLEP and OP. There was a relationship between prostate weight and total operation time only in HoLEP. Conclusion: LSP, one of the enucleation techniques in the treatment of large prostates, was slower and required more operation time than HoLEP and OP in terms of total operation time and prostate removal speed. HoLEP seems going to be the fastest candidate for the rapid removal of large prostates in the future.

Mandibular dentigerous cyst: Enucleation and bone reconstruction – Case report

Purpose: The dentigerous cyst is the second most common odontogenic cyst in the jaws. These lesions are observed in routine examinations. The third molars and maxillary canines are the most affected teeth. Definition of marsupialization and enucleation techniques as well as consideration of important objective criteria for the treatment plan like cyst size, age, and proximity to anatomical structures, clinical importance of the tooth or teeth associated with the lesion and risk of bone fracture. This paper will present a case report treated by maneuver of decompression followed by enucleation and bone reconstruction. Case report: A 43-year-old female patient, Caucasian, attended the Oral-Maxillofacial Surgery consultation at Clitrofa - Centro Médico, Dentário e Cirúrgico, in Trofa - Portugal, to assess extraction of 3.8 and 4.8. On intraoral physical examination, a slight bulging of the cortical bone was noted in the region of the left external oblique line. Aspiration puncture was performed and a small amount of light-yellow liquid confirmed the cystic nature of the lesion. In a second stage, osteotomy through piezoelectric surgery was performed. The cystic capsule was excised together with the extraction of tooth 3.8 included and tooth 3.7. Bone regeneration was performed. The material obtained from the cystic cavity was sent for pathological examination, confirming the diagnosis of dentigerous cyst. During observation of the patient for twelve months, no hypoesthesia or any sign of recurrence of the lesion was observed. Conclusion: The technique preserved the neurosensory function and was effective for the enucleation and reconstruction of the lesion. Despite the clinical peculiarities of each case and the chosen treatment method, the prognosis of these lesions is favourable when appropriate therapy is used.

Revisiting the Surgical Management of Giant Hepatic Hemangiomas: Enucleation Versus Anatomical Resection?

Resection is rarely indicated in giant hepatic hemangiomas (HHs) that are symptomatic. Enucleation (EN), compared with anatomical resection (AR), is considered the better technique to resect them as EN has been reported to have lower morbidity while conserving the normal liver tissue. But no study has yet clearly established the superiority of EN over AR. In addition, the independent predictors of postoperative morbidity have not been established. All consecutive patients operated for HH at two specialized hepatobiliary centers were reviewed. Patient demographics, operative variables, and postoperative outcomes were analyzed and compared between two techniques. Postoperative complications were graded as per Clavien-Dindo classification of surgical complications. The aims of this study were to compare two techniques of HH resection with respect to postoperative outcomes and to identify the risk factors for 90-day major postoperative morbidity and mortality. A total of 64 patients, including 41 who underwent AR, 22who underwent EN, and 1 who underwent liver transplantation, were operated for hemangiomas during the study period. Ten patients (9 who were operated for hemangiomas of size ≤4cm and 1 who underwent transplantation) were excluded. Fifty-four patients, the majority being women (85%), with a median age of 48 years, were operated for giant HH. These patients were classified into two groups based on the technique of resection, namely, EN (22 patients) and AR (32 patients). Both groups were comparable in all aspects except that the number of liver segments resected was significantly more with AR. Postoperative outcomes were similar in both groups. Independent predictors of 90-day major complications including mortality were the use of total vascular exclusion (relative risk [RR]: 2.3, p=0.028) and duration of surgery >4.5h (RR: 2.3, p=0.025). Both techniques yield similar results with respect to 90-day postoperative morbidity and mortality. The choice of technique should be based on the location of tumor and simplicity of liver resection.

Is it enucleation or organ-sparing techniques for choroid melanoma treatment?

Choroid melanoma belongs to malignant tumors. The choice of treatment modality depends on a tumor size and site, ocular tunics conditions, clinic logistics, and the patient’s will. The aim of the study was to evaluate the effectiveness of treatment of patients with choroid melanoma. The data of the Belarusian Cancer Registry and the case histories of patients with choroid melanoma (C69.3, ICD-10) over the period of 1999–2018 were studied. The incidence rates were evaluated on the basis of the analysis of the absolute number of persons taken ill with the disease, crude intensive rates calculated per 1,000,000 of population. To calculate the survival, the disease-specific cumulative 5-year survival rate was used. Significance evaluation was made applying the chisquare test. The incidence rates varied over the 20-year period and were 0.9 ‰ on the average. Enucleation was performed in 724 patients, 13.9 % (101 patients) being registered with synchronous and metachronous cancer. Patients with a sole tumor of choroid melanoma were analyzed. The amount of enucleations performed decreased by a factor of 1.8. To evaluate the survival, the groups of patients with large tumors were formed after enucleation and combination treatment was carried out. Of 623 patients subjected to enucleation, disease progression was established in 159 (25.5 %). Of 159 patients, the onset of disease progression occurred in 25 (15.7 %) in the 1st year, in 50 (31.5 %) in the 2nd year, and in 84 (52.8 %) in the 4th year and later. In the combination treatment group, consisting of 58 patients, decease progression was ascertained in 10 (17.2 %): in the 1st year – in 1 (10.0 %), in the 2nd year – in 6 (60.0 %), and in the 4th and later – in 3 (30.0 %). The survival rate after the organ-sparing treatment is insignificantly higher and increases to the 5th year of the follow-up, although the data are statistically insignificant (p > 0.5). At present, enucleation does not play the leading role in the choice of treatment modality for patients with clinical diagnosis of choroid melanoma. The disease-specific cumulative 5-year survival rate in patients receiving organ-sparing treatment was 85.7 ± 5.1 %, and in those subjected to enucleation – 67.2 ± 2.2 %, the data being statistically insignificant (p > 0.5). The promising trend in treating choroid melanoma patients is the development of organ-sparing treatment techniques.

Sexual outcomes of endoscopic enucleation of prostate.

The emergence of various endoscopic enucleation techniques in the past decade has provided surgeons with more options and opportunities in performing enucleation. With the same surgical principle as holmium laser enucleation of prostate, the early results of different techniques were comparable. However, sexual outcomes of endoscopic enucleation of the prostate (EEP) were less commonly reported than the voiding and urodynamic outcomes. In this review, the sexual outcomes including erectile function, ejaculatory and orgasmic function of various endoscopic enucleation technique would be studied. The overall sexual outcomes were heterogeneous and inconclusive. Outcomes measurement, sample size calculation, hypothesis generation and selection criteria were not specifically designed for sexual outcomes or even available. There were also limitations in the individual sexual assessment tools. Nonetheless, most studies showed no significant deterioration of erectile function after EEP, and ejaculation dysfunction was common. Looking forward in the field of benign prostatic enlargement surgery, the 'one size fits all' notion should be abandoned. Treatment should be tailor-made according to the prostate size, co-morbidities and sexual needs. The sexual outcomes of enucleation have to be better studied and defined. More prospective controlled studies focusing primarily on sexual functions are needed. For enucleation surgeons, exploring different ejaculatory-sparing technique could be the golden opportunities in further consolidating the role and expanding the indication of enucleation surgery.

Robotic-Assisted Simple Prostatectomy: A Systematic Review.

Contemporary minimally invasive surgical (MIS) treatment options of patients with male Lower Urinary Tract Symptoms (LUTS) in men with prostate glands >80 mL include Holmium Laser Enucleation Prostate (HoLEP), Thulium laser VapoEnucleation Prostate (ThuVEP), and Laparoscopic (LSP) or Robotic-Assisted Simple Prostatectomy (RASP). Implementing new laser technologies is costly, and the steep learning curve of these laser techniques limit their wide range use. This promoted the use of LSP and RASP in centers with readily established laparoscopy or robotic surgery programs. The aim of this study is to review case and comparative series of RASP. We systematically reviewed published data from 2008 to 2020 on RASP and have identified 26 non-comparative and 9 comparative case series. RASP has longer operation time but less time spent in hospital and less blood loss. The outcomes of improvements in symptom score, post-voiding residual urine (PVR), postoperative PSA decline, complications, and cost are similar when compared to open and laser enucleation techniques. These outcomes position RASP as a viable MIS treatment option for patients with male LUTS needing surgical treatment for enlarged prostates. Nevertheless, prospective, randomized controlled trials (RCTs) with multicenter and large sample size are needed to confirm the findings of this systematic review.

Bipolar enucleation of the prostate-step by step.

Bipolar enucleation of prostate (BipolEP) is a useful method for treatment of benign prostatic hyperplasia (BPH). Compared with conventional transurethral resection, the enucleation technique has several advantages. However, since the cost of laser equipment used for enucleation is relatively high, enucleation using bipolar devices has been attempted by many previous surgeons. We consider bipolar enucleation is an effective and safe procedure, and we would like to share our experience of equipment settings and procedures through this article. We will introduce the equipment and settings of BipolEP and then present the actual step-by-step procedures and surgical tips. First, circular incisions are made on bladder neck and mucosa at the level of verumontanum. Then, enucleation is performed in the order of median and lateral lobes as in laser enucleation. Haemostasis should be done throughout the procedure. After enucleation and haemostasis, prostatic tissue is evacuated by morcellator. Currently, there are several types of electrode and morcellator systems. In our experience, BipolEP has a steep learning curve but it is safe and effective procedure for managing BPH. In particular, effective haemostasis is the greatest advantage of BipolEP when compared to traditional TUR or laser enucleation.

Shira's Technique, an Alternative for the Enucleation of Cervicofacial Cysts

Treatment of cystic lesions includes multiple options, ranging from resection, decompression or marsupialization to enucleation. Different techniques for enucleation have been reported for head and neck cysts. This paper describes Shira's technique, using alginate as a filling material inside the cystic cavity, allowing demarcating the limits of the cystic lesions, maintaining their integrity.

Endoscopic Treatment of Prostatic Hyperplasia in Elderly Patients: A Comparative Analysis of Resection and Enucleation Technique

Introduction. The pharmacological market, which is rapidly developing, as well as the appearance of combined forms of drugs, determine the trend in the conservative treatment of patients with symptoms of the lower urinary tract due to benign prostatic hyperplasia (BPH). However, simultaneous administration of drugs from several drug groups, by the patients, who are burdened with concomitant diseases (cardiovascular disease, diabetes) in certain cases, makes surgical treatment of BPH preferable and sometimes the only possible option. In this instance, the doctor’s task is to choose the optimal method of surgery that minimizes the risks of complications and provides a long-term clinical effect. The actively developing technique of endoscopic enucleation of prostate corresponds to the current needs. Various types of energies, which have appeared lately in urological practice for enucleation of the prostate, have become an attractive alternative to transurethral resection of the prostate (TURP). The introduction of a bipolar technology into clinical practice has allowed to significantly expand the use of operations among elderly patients with comorbidities. Laser endourology has gone further in reducing the risks of possible complications. Currently we are witnessing a lack of research, which compares the use of modern methods with bipolar TURP (B-TURP) in elderly patients, i.e. groups with a high risk of intraoperative & postoperative complications.Purpose of the study. To compare the results of various types of BPH endoscopic surgical treatment in elderly patients (> 60 years old).Materials and methods. The study included patients who underwent three different operations treating BPH (B-TURP, B-TUEP, HoLEP) from October 2017 to September 2018. The criteria for inclusion in the study were as follows: the presence of moderate or severe obstructive symptoms of the lower urinary tract, prostate volume > 40 cm3, maximum urine flow <15 ml/s. Exclusion criteria were as follows: the presence of cystostomy drainage, the presence of the oncological process in urinary tract, active inflammatory process of urogenital system, earlier received surgical interventions on the organs of the urinary system. Each group of patients has been assessed on following criteria: International Prostate Symptom Score (IPSS and QoL), international index of erectile function (IIEF-5), the dynamics of postoperative changes in prostate specific antigen (PSA), maximum flow of urine, postvoid residual urine volume, intraoperative and postoperative parameters.Results. 190 patients operated during the year were examined in the current study. Duration of operation, extent of resection, time of postoperative catheterization and duration of hospital stay rates were significantly lower in the HoLEP group. There have been no cases of complications above the 3 level by the Clavien‒Dindo scale.Conclusions. HoLEP is the preferred method of surgical treatment of prostatic hyperplasia over 40 cm3 in terms of surgical safety, efficacy, and the duration of the patient’s recovery period. This method can serve as an alternative to electrosurgical techniques in elderly patients.

Modified “En Bloc” Bipolar Plasma Enucleation of Prostate: Our Technique for Treatment of Obstructive Benign Prostatic Hyperplasia

Introduction and Objectives: Although transurethral resection of prostate has been the gold-standard intervention, in recent times, endoscopic enucleation of prostate (EEP) has been introduced as safe and effective procedure for the treatment of benign prostatic enlargement. Enucleation of the adenoma can be done by any energy source such as Holmium-YAG laser, Thulium laser, or plasmakinetic energy. The acronym EEP is a coding for common ground of endoscopic enucleation techniques.1 We are presenting our modification of single-lobe technique of bipolar plasma enucleation of prostate (BPEP), which is simplified in four different steps. Materials and Patients: Thirty-nine patients were included in our study of BEEP between December 2016 and June 2018. Average volume of prostate in our study was 58.6 cc. All patients were evaluated preoperatively by International Prostate Symptom Score (IPSS), uroflowmetry, sonography of prostate and urinary tract for prostate volume and post void residue estimation, prostate-specific antigen, and quality of life score. Endoscopic enucleation was done by 26F continuous flow resectoscope and Button electrode with high-frequency bipolar generator (Olympus Medical Systems). Modified technique of single-lobe enucleation was followed as published by our group.2 Tissue morcellator (Richard Wolf) was used for removal of enucleated adenoma from the bladder. Postprocedure follow-up was done at 3, 6, and 12 months. Results: Mean enucleation time for the prostate was 33.33 minutes (10–80 minutes) and estimated blood loss during procedure was 71.81 mL (16–350 mL). No patient in our study required blood transfusions. Mean catheterization time was 49.78 hours and mean hospital stay was 73.72 hours. Clavien Grade 1 complication was seen in four patients, one patient required cystoscopy and clot evacuation. Two patients had stress urinary incontinence for 3 months. Significant improvement in IPSS and Qmax was seen on follow-up at 3, 6, and 12 months. Conclusions: Our technique of BPEP is a simplified hybrid version of “en bloc” enucleation of adenoma in the treatment of obstructive BPH. However, long-term randomized trials are required for establishing any procedure. This technique of single-lobe enucleation with button electrode and bipolar energy can be useful for overcoming the learning curve of EEP. No competing financial interests exist. Runtime of video: 8 mins 35 secs

V08-08 ROBOTIC EXTRAPERITONEAL EXTRAVESICAL PROSTATE ADENOMECTOMY WITH RUNNING SUTURE OF THE BLADDER NECK ONTO THE INTRAPROSTATIC URETHRA

You have accessJournal of UrologyBPH & Bladder Outlet Obstruction (V08)1 Apr 2020V08-08 ROBOTIC EXTRAPERITONEAL EXTRAVESICAL PROSTATE ADENOMECTOMY WITH RUNNING SUTURE OF THE BLADDER NECK ONTO THE INTRAPROSTATIC URETHRA Mustafa Tutal*, Christian Padevit, Beat Foerster, Anja Sauck, Christoph Schregel, Kevin Horton, and Hubert John Mustafa Tutal*Mustafa Tutal* More articles by this author , Christian PadevitChristian Padevit More articles by this author , Beat FoersterBeat Foerster More articles by this author , Anja SauckAnja Sauck More articles by this author , Christoph SchregelChristoph Schregel More articles by this author , Kevin HortonKevin Horton More articles by this author , and Hubert JohnHubert John More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000909.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic prostate adenomectomy was first reported by Sotelo et al. in transperitoneal and by John et al. in extraperitoneal approach. Meanwhile simple robotic prostatectomies have been modified with transperitoneal or extraperitoneal access using transvesical or extravesical enucleation techniques. We demonstrate our routinely preferred technique with extraperitoneal approach, extravesical prostate adenomectomy and bladder neck reconstruction by running suture of the bladder neck with the intraprostatic urethra. METHODS: Standardized extraperitoneal access is performed with balloon dilatation and placement of a 4-arm daVinci Xi® System under visual control of the instrument tips. The Santorini Plexus is ligated with 3-0 Monocryl to prevent back flow bleeding. The bladder neck is prepared and dissected around the indwelling catheter. Depending on the position of the ureteral orifices, ureteral stents are placed to exclude postoperative ureteral obstruction. The enucleation of the prostate gland is performed with blunt dissection and visually controlled bipolar coagulation of penetrating vessels from the prostate capsule. Preliminary dorsal fixation of the bladder neck to the posterior prostate capsule is performed with 4-0 Stratafix® barbed suture to prevent further tension and additionally minimize capsular bleeding. Thereafter, the urethral tract is reconstructed by direct continuous double armed suture 4-0 Stratafix® according to van Velthoven of the bladder neck with the intraprostatic urethral stump - thereby excluding the prostatic fossa totally. If necessary longitudinal running suture of the ventral bladder neck closes the urinary bladder and patency is tested. The prostate capsule is adapted onto the ventral bladder wall. A suprapubic catheter is placed, the specimen removed and a drain placed between the anterior bladder wall and prostate capsule according to surgeon preference. RESULTS: No irrigation is needed, the indwelling catheter is removed after 24h-48h and the patient discharged after 2-3 days. Cystography excludes urinary leak after 5 days. CONCLUSIONS: This extraperitoneal extravesical robotic adenomectomy provides a minimal invasive procedure in large BPH, thus avoiding significant blood loss, postoperative bleeding, infections and urgencies associated with the enucleated fossa, bladder neck stenosis and urethral injury. The demonstrated operative technique has become our standard after development of our Millin program over 10 years and more than 60 cases. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e737-e737 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mustafa Tutal* More articles by this author Christian Padevit More articles by this author Beat Foerster More articles by this author Anja Sauck More articles by this author Christoph Schregel More articles by this author Kevin Horton More articles by this author Hubert John More articles by this author Expand All Advertisement PDF downloadLoading ...

A novel surgical technique for enucleation in rabbits to reduce the risk of intra- and post-operative orbital hemorrhage.

A 10-year-old male castrated Holland Lop rabbit (Oryctolagus cuniculus) was presented for severe ulcerative stromal keratitis of the right eye and a luxated hypermature cataract and glaucoma of the left eye. Staged bilateral enucleation was elected. A LigaSure™ electrosurgical bipolar vessel-sealing device was used as a means to minimize intraoperative and post-operative hemorrhage, especially that associated with the orbital venous plexus. The LigaSure™ was used to ligate and transect all extraocular muscles, the optic nerve bundle, and the base of the third eyelid with no complications encountered. Overall, the LigaSure™ was easy to use, resulted in minimal hemorrhage, and reduced surgery time. This is the first report of the use of a LigaSure™ to aid in the enucleation of a rabbit. Although only positive results were achieved as an alternative to conventional methodologies, its use in clinical practice should be that of caution until a larger study evaluating the long-term results is performed.

UP02 - En bloc and two-lobe techniques for laser endoscopic enucleation of the prostate: Retrospective comparative analysis of peri- and postoperative outcomes

UP02 - En bloc and two-lobe techniques for laser endoscopic enucleation of the prostate: Retrospective comparative analysis of peri- and postoperative outcomes

Bone-lid technique for cystic enucleation using piezosurgical unit.

Bone-lid technique for cystic enucleation using piezosurgical unit.