Transurethral Prostatic Surgery Research Articles

Anesthetic implications for transurethral resection of prostate in a COVID-19 survivor with Stanford-A aortic dissection with acute urinary retention due to metastatic carcinoma prostate: a case report

BackgroundAortic dissection is a new addition to the long COVID-19 complication catalog. We report this rare and novel complication, which can be missed without a high index of suspicion in the ever-burgeoning population of COVID-survivors presenting for un-related surgery. We emphasize the importance of recording blood pressure in both the upper limbs in COVID-survivors during pre-anesthetic checkup, especially in patients with a dilated aorta on the chest radiograph to identify any interarm blood pressure discrepancy characteristic of aortic dissection. Discontinuation of antihypertensive based on low/normal blood pressure in left upper limb can precipitate concealed and catastrophic rise in blood pressure in the right upper-limb propagating the dissection of aorta to a fatal conclusion. The cardinal anesthetic consideration is to mitigate the effect of hemodynamic perturbations on the dissected aorta.Case presentationWe report the successful management of the case of a 76-year-old male prostatic cancer patient with COVID-induced aortic-dissection and acute urinary retention, posted for transurethral resection of prostate. CT angiography revealed an intimal flap in the ascending aortic lumen and aortic arch till the origin of left subclavian artery resulting in a double-barreled aorta. An arterial line was secured in right radial artery and non-invasive blood pressure recorded in left arm simultaneously (202/60 mmHg in right upper-limb and 92/70 mmHg in the left upper-limb on wheeling into the operation theatre). He underwent transurethral prostatic resection and bilateral orchidectomy under low-dose subarachnoid block with prophylactic use of labetalol infusion.ConclusionsThe importance of recording blood pressure in both the upper limbs in COVID survivors maintaining a high index of suspicion for aortic dissection cannot be overemphasized. Transurethral prostatic resection surgery under low-dose subarachnoid block is possible under the umbrella of judicious selection and optimal use of cardiac medication with an interventional cardiologist as standby in patients with aortic dissection.

Treating overactive bladder symptoms after transurethral prostatic surgery for benign prostatic hyperplasia - Which medication to choose?

Overactive bladder (OAB) symptoms are often encountered in patients after transurethral resection of the prostate (TUR-P) or transurethral incision of the prostate (TUI-P) for benign prostatic obstruction (BPO). Either antimuscarinics or β-3 agonist has been found effective in relieving OAB symptoms. However, urologists usually do not prescribe such medication immediately after TUR-P or TUI-P to avoid an increase in postvoid residual and risk of urinary tract infection. If OAB medication can be used and adverse events (AEs) can be reduced to minimum, patients' quality of life after bladder outlet obstruction surgery could be improved. This study compared the safety and efficacy between solifenacin and mirabegron in men undergoing TUR-P or TUI-P. This prospective, randomized trial compared the safety and efficacy of OAB medication on the reduction in Urgency Severity Score (USS), OAB Symptoms Score (OABSS), International Prostate Symptom Score, and urgency urinary incontinence episodes in men with BPO undergoing surgical intervention. All patients could void smoothly after catheter removal and were randomly received daily solifenacin 5 mg, mirabegron 50 mg, or no interventions for 4 weeks. At 2 and 4 weeks postoperatively, participants' OAB symptoms and AEs were evaluated. A total of 57 men were enrolled in this study with a mean age of 70.8 ± 6.1 years. At 2 weeks postoperatively, USS (1.56 ± 1.72 vs. 2.39 ± 1.72 vs. 2.26 ± 1.73, P < 0.011) and OABSS (5.33 ± 3.65 vs. 7.67 ± 4.19 vs. 8.58 ± 4.31, P < 0.000) were significantly reduced in patients taking solifenacin, mirabegron, or control, respectively. Two patients in the solifenacin group developed urinary retention. However, the changes of variables at 4 weeks postoperatively were insignificant among the three groups. Solifenacin and mirabegron are two different drug classes both equally effective in treating immediate OAB symptoms after TUR-P or TUI-P. However, OAB symptoms could be relieved at 4 weeks without any medication. Considering AEs, β-3 agonist has a more favorable safety profile than antimuscarinics.

Isotonic saline causes greater volume overload than electrolyte-free irrigating fluids.

Systemic absorption of the irrigating fluid used to flush the operating site is a potentially serious complication in several types of endoscopic operations. To increase safety, many surgeons have changed from a monopolar to a bipolar resection technique because 0.9% saline can then be used instead of electrolyte-free fluid for irrigation. The present study examines whether the tendency for excessive plasma volume expansion is greater with saline than with electrolyte-free fluid. Pooled data were analyzed from four studies in which a mean of 1.25L of either 0.9% saline or an electrolyte-free irrigating fluid containing glycine, mannitol, and sorbitol was given by intravenous infusion on 80 occasions to male volunteers and patients scheduled for transurethral prostatic surgery. The distribution of the infused fluid was analyzed with a population volume kinetic model based onfrequently measured hemodilution and the urinary excretion. Electrolyte-free fluid distributed almost twice as fast and was excreted four times faster than 0.9% saline. The distribution half-life was 6.5 and 10.6min for the electrolyte-free fluid and saline, respectively, and the elimination half-lives (by urinary excretion) from the plasma volume were 21 and 87min. Simulation showed that the plasma volume expansion was twice as great from 0.9% saline than from electrolyte-free fluid. Isotonic (0.9%) saline expands the plasma volume by twice as much as occurs with electrolyte-free irrigating fluids. This difference might explain why signs of cardiovascular overload are the most commonly observed adverse effects when saline is absorbed during endoscopic surgery.

MP01-20 A STANDARDIZED METHOD FOR ESTIMATING THE CARBON FOOTPRINT OF DISPOSABLE MINI-INVASIVE SURGICAL DEVICES: APPLICATION IN TRANSURETHRAL PROSTATE SURGERY

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology I (MP01)1 Sep 2021MP01-20 A STANDARDIZED METHOD FOR ESTIMATING THE CARBON FOOTPRINT OF DISPOSABLE MINI-INVASIVE SURGICAL DEVICES: APPLICATION IN TRANSURETHRAL PROSTATE SURGERY Vincent Misrai, Enrique Rijo, Kevin Zorn, Dmitry Enikeev, Dean Elterman, Naeem Bhojani, Alexandre De La Taille, Thomas Herrmann, Grégoire Robert, and Benjamin Pradere Vincent MisraiVincent Misrai More articles by this author , Enrique RijoEnrique Rijo More articles by this author , Kevin ZornKevin Zorn More articles by this author , Dmitry EnikeevDmitry Enikeev More articles by this author , Dean EltermanDean Elterman More articles by this author , Naeem BhojaniNaeem Bhojani More articles by this author , Alexandre De La TailleAlexandre De La Taille More articles by this author , Thomas HerrmannThomas Herrmann More articles by this author , Grégoire RobertGrégoire Robert More articles by this author , and Benjamin PradereBenjamin Pradere More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001962.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The healthcare sector accounts for 4.4% of the annual human-induced CO2 net emissions (CO2e). Operating rooms are facing the arrival of a plethora of disposable mini-invasive surgical devices (MISDs) often made from nonbiodegradable materials that may be liable for the negative impacts on the environment. The estimation of their CO2e is central to empowering the healthcare supply chain. To propose a standardized methodology for estimating the embodied carbon footprint (CF) of disposable MISDs and their application in transurethral benign prostatic hyperplasia (BPH) surgery. METHODS: The proposed methodology relied on a partial product lifecycle assessment and was restricted to a specific part of Scope 3, which comprised the manufacturing of MISDs- and non-device-associated products (packaging/user manual) (NDAPs). The process-sum inventory method was used. The seven latest disposable MISDs used worldwide for transurethral prostatic surgery were dismantled, and each piece was categorized, sorted into the appropriate raw material group, and weighed. The CF was estimated according to the formula: activity data (weight of raw material) x emission factors of the corresponding raw material (kg CO2e/kg). RESULTS: The total weights of disposable packaging and user manuals ranged from 0.062 to 1,492 kg. Plastic was the most common and least emissive raw material (2.38 kg CO2e/kg) identified. The estimated embodied CF of MISDs ranged from 0.07 to 3.3 kg CO2e, of which 9 to 86% was attributed to NDAPs (Figure 1). Rezūm MISD had the most CO2e due to the multiplicity of its components. Despite its technical simplicity, the disposable plasma loop was found to have the third highest CF due to the manufacturing of cables designed to support a high electric amperage. The lowest use of raw materials was found for the iTind and HoLEP devices, which were also found to have the lowest estimated CO2e compared to the other devices. CONCLUSIONS: This study described a simple and independent calculation method for estimating the embodied CF of MISDs, regardless of country speciAcations. Using this method, our results showed a wide discrepancy in the estimated CO2 emissions of the most recent disposable MISDs for transurethral BPH surgery. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e9-e10 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vincent Misrai More articles by this author Enrique Rijo More articles by this author Kevin Zorn More articles by this author Dmitry Enikeev More articles by this author Dean Elterman More articles by this author Naeem Bhojani More articles by this author Alexandre De La Taille More articles by this author Thomas Herrmann More articles by this author Grégoire Robert More articles by this author Benjamin Pradere More articles by this author Expand All Advertisement Loading ...

A Standardized Method for Estimating the Carbon Footprint of Disposable Minimally Invasive Surgical Devices: Application in Transurethral Prostate Surgery.

To propose a standardized methodology for estimating the embodied carbon footprint (CF) of disposable minimally-invasive surgical devices (MISDs) and their application in new benign prostatic hyperplasia (BPH) MISDs. The estimation of the CO2e emissions of disposable surgical devices is central to empowering the healthcare supply chain. The proposed methodology relied on a partial product lifecycle assessment and was restricted to a specific part of scope 3, which comprised the manufacturing of surgical device- and non-device-associated products (NDAPs), including packaging and user manual. The process-sum inventory method was used, which involves collecting data on all the component processes underpinning disposable MISDs. The seven latest disposable MISDs used worldwide for transurethral prostatic surgery were dismantled, and each piece was categorized, sorted into the appropriate raw material group, and weighed. The CF was estimated according to the following formula: activity data (weight of raw material) × emission factors of the corresponding raw material (kg CO2e/kg). The total weights of disposable packaging and user manuals ranged from 0.062 to 1.013 kg. Plastic was the most common and least emissive raw material (2.38 kg CO2e/kg) identified. The estimated embodied CF of MISDs ranged from 0.07 to 3.3 kg CO2e, of which 9% to 86% was attributed to NDAPs. This study described a simple and independent calculation method for estimating the embodied CF of MISDs. Using this method, our results showed a wide discrepancy in the estimated CO2 emissions of the most recent disposable MISDs for transurethral BPH surgery. Thus, the lack of CF information should be of major concern in the development of future MISDs.

Shedding light on polypragmasy of pain after transurethral prostate surgery procedures: a systematic review and meta-analysis.

To evaluate and compare the incidences of post-operative pelvic pain (PPP) in patients undergoing ablation, enucleation and conventional transurethral resection of the prostate (TURP). A systematic review and meta-analysis was conducted according to the PRISMA guidelines. Using MEDLINE via PubMed and Cochrane CENTRAL, randomised control trials (RCTs) and observational studies reporting PPP rates post-ablation, enucleation or TURP were identified. The risk of biases (RoB) in RCTs and observation studies were assessed using the Cochrane RoB1.0 tool and the Newcastle-Ottawa Scale, respectively. 62 studies were included for qualitative analysis, while 51 of them reported number of patients with PPP post-intervention. Three observational studies and 13 RCTs compared the rates of PPP in patients undergoing ablation, enucleation or TURP. The most reported types of PPP are dysuria, abdominal pain and irritative symptoms. The pooled incidence of PPP at 1-month follow-up in patients undergoing ablation, enucleation and TURP were 0.15 (95% CI 0.10-0.22), 0.09 (95% CI 0.04-0.19 and 0.10 (95% CI 0.06-0.15), respectively. PPP is no longer prevalent at 3-months and onwards post-operatively. Ablation is associated with a higher risk of PPP than enucleation (RR 2.19, 95% CI 1.04-4.62) and TURP (RR 2.40, 95% CI 1.03-5.62) in observational studies but not RCTs; and there were no significant differences in the rates of PPP upon comparison of other modalities. PPP is common after transurethral benign prostatic hyperplasia surgery. Patients undergoing ablation had a higher rate of post-intervention PPP than those undergoing enucleation and TURP in observational studies.

Duration of smoking cessation is negatively associated with the magnitude of chronic prostatic inflammation and storage dysfunction in patients with benign prostatic hyperplasia

To evaluate the impact of smoking and the benefit of smoking cessation on lower urinary tract function and prostatic inflammation in patients with benign prostatic hyperplasia. The medical records of 118 benign prostatic hyperplasia patients who underwent transurethral prostatic surgery between 2006 and 2016 were analyzed. Their smoking history was confirmed. The relationship between smoking and main clinical parameters, International Prostate Symptom Scores, uroflowmetry, pressure flow study, magnitude of prostatic inflammation and the level of serum C-reactive protein was investigated. Furthermore, the relationships between smoking cessation and these clinical parameters were assessed. The International Prostate Symptom Scores for straining among the non-smokers were significantly lower than those of the smokers (1.71 vs 2.60, P= 0.029). In the pressure flow study, there were negative correlations between the duration of smoking and strong desire to void (correlation coefficient -0.314, P=0.013), urgency (correlation coefficient -0.349, P=0.008) and bladder volume at initial detrusor overactivity (correlation coefficient -0.417, P=0.021). The duration of smoking cessation was negatively correlated with the magnitude of chronic prostatic inflammation (correlation coefficient -0.253, P=0.027). In the pressure flow study, the duration of smoking cessation was positively correlated with urgency (correlation coefficient 0.286, P=0.030) and maximum cystometric capacity (correlation coefficient 0.241, P=0.050). Smoking could be a risk factor for the exacerbation of storage dysfunction in benign prostatic hyperplasia patients. Smoking cessation is effective in improving chronic prostatic inflammation and storage dysfunction.

From the Journal archives: Complications of transurethral prostatic surgery: back to the future?

John Desmond MBBS FRCP(C) Complications of transurethral prostatic surgery. Can Anaesth Soc J 1970; 17: 25-36. To review complications of transurethral resection of the prostate (TURP) as they pertain to anesthesiologists. In this article published in January 1970 in the Canadian Anaesthetists’ Society Journal, now the Canadian Journal of Anesthesia (the Journal), the author reviews complications relating to TURP, including age group, cardiovascular status, plasminogen activation, bacteremia, hemorrhage, too-light general anesthesia, perforation of the bladder, inadvertently high spinal anesthetic, the danger of using vasopressors, and burns. Complications involving the endocrine system, erection, adductor spasm, explosions, and hypothermia are also mentioned. Furthermore, there is a detailed discussion regarding the composition of the irrigation solution and the effects of its intravenous absorption on the cardiovascular system and on serum osmolality and natremia. The results of slow absorption of irrigation fluid at the prostatic level combined with good left-ventricular function are associated with slight dilutional hyponatremia (≤ 10 mEq·L−1) and a good outcome. Rapid absorption of irrigation fluid and/or poor left-ventricular function in the context of possible acute blood loss, hypotension following spinal anesthesia, or myocardial depression with general anesthesia can lead to a marked drop in osmolality and more severe dilutional hyponatremia. This may lead to cerebral edema, pulmonary edema, heart failure, and cardiovascular collapse. In a series of 72 randomly chosen patients at the author’s institution, 18 patients experienced a reduction in serum sodium of > 10 mEq·L−1; eight patients experienced a reduction of > 20 mEq·L−1, and two patients experienced a decrease in both osmolality and natremia, with both developing cerebral and pulmonary edema. With an understanding of the possible complications and physiological implications of TURP, anesthesiologist caring for such patients may help reduce adverse outcomes or decrease their impact with proper management. In the late 1960s, mortality at the author’s institution was reduced from 1.5-0.4% in three years.

Feasibility of holmium laser enucleation of the prostate (HoLEP) for recurrent/residual benign prostatic hyperplasia (BPH)

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? The major advantage of holmium laser enucleation of the prostate (HoLEP) depends on the ability to use the native anatomical plane between the prostate adenoma and surgical capsule, peeling each prostatic lobe from the capsule. HoLEP is associated with less catheterisation time, hospital stay and blood loss than transurethral resection of the prostate (TURP) or open prostatectomy. Urodynamic relief of obstruction has been reported to be better with HoLEP than TURP. However, surgical treatment of recurrent prostatic obstruction after previous transurethral surgery for symptomatic benign prostatic hyperplasia is more challenging because of loss of anatomical landmarks resulting in either incomplete removal or incontinence. HoLEP for recurrent symptoms due to residual or re-growing prostatic adenoma seems to be as safe, feasible and efficient as HoLEP for de novo cases. The surgical plane between the adenoma and the surgical capsule was still accessible resulting in a durable long-term outcome with minimal side-effects. Previous transurethral prostatic surgery is not a contraindication for HoLEP. • To assess the technical feasibility, functional outcome and morbidity of holmium laser enucleation of the prostate (HoLEP) for symptomatic benign prostatic hyperplasia (BPH) in patients with previous transurethral prostate surgery. 'Redo' surgery for recurrent or residual BPH poses a technical challenge with uncertain outcome as a result of disturbed anatomical landmarks with no clear surgical limits. • We retrospectively reviewed 1054 patients who underwent HoLEP for symptomatic BPH. • Patients were stratified into two groups, group-I with no previous prostate surgery or primary-HoLEP (978 patients) and group-II with history of previous prostate surgery or secondary-HoLEP (76). • All patients' variables as well as follow-up data were assessed and compared. • There were no significant differences in baseline criteria between the two groups (P > 0.05). • In group-II, HoLEP was done after a median (range) of 66 (13-121) months from previous prostate surgeries, including transurethral resection of the prostate (48 patients), HoLEP (eight), transurethral incision of the prostate (nine), photoselective vaporization of the prostate (four) and other procedures (seven). • In both groups, routine HoLEP technique was adopted, the plane of enucleation could be identified without extra difficulty. However, more energy per gram of prostate tissue was needed in group-II (P < 0.05). • Operative auxiliary procedures were indicated in 1.9% of group-I, and 1.3% of group-II (P > 0.05). There were no operative complications or blood transfusion in group-II. The mean hospital stay and catheter time was similar in both groups. Early and late postoperative complications were not statistically different (P > 0.05). • At 1 month the mean maximum urinary flow rate (Q(max) ) was 22.3 and 18.8 mL/s, postvoid residual urine volume (PVR) was 46 and 45 mL, International Prostate Symptom Score (IPSS) was 7.04 and 7.08, and the health-related quality of life (HRQL) score was 1.57 and 1.56, in group-I and II, respectively. At 1 year the mean Q(max) was 23.4 and 25.9 mL/s, PVR was 32.5 and 24.1 mL, IPSS was 4.5 and 4.4, and the HRQL score was 1.2 and 1.1,) in group-I and II, respectively (P > 0.05). • Reoperation for recurrent obstruction was indicated in 4% in group-I and 5.2% in group-II (P > 0.05). • Secondary-HoLEP procedures seem to be safe and technically feasible with comparable functional outcomes as those of primary-HoLEP.

Impact of Hospital Volume and Laser Use on Postoperative Complications and In-Hospital Mortality in Cases of Benign Prostate Hyperplasia

We analyzed the impact of hospital volume and laser use on postoperative complications and in-hospital mortality in transurethral prostatic surgery. We evaluated data from 18,578 patients in 686 hospitals who underwent transurethral prostatic surgery between July and December, 2006 to 2008, using the Diagnosis Procedure Combination database in Japan. Cases were divided into low (14 or less per year), medium (14 to 29 per year) or high (30 or more per year) hospital volume groups. Logistic regression analyses were conducted to determine the concurrent effects of hospital volume, laser use and other factors on postoperative complications, transfusion and in-hospital mortality. Laser devices included neodymium:yttrium aluminum garnet and holmium:yttrium aluminum garnet lasers. The overall in-hospital mortality was 0.05% (10 of 18,578 patients) and was not significantly different among groups. The transfusion rates of the low, medium and high volume groups were 8.3%, 7.0% and 5.5%, respectively (low vs high volume adjusted odds ratio 1.55, p <0.01), and postoperative complication rates were 3.7%, 3.2% and 2.6% (low vs high volume OR 1.425, p = 0.016), respectively. An absence of laser use was also a significant risk factor on both measures (OR 1.46 and 2.02, both p <0.01). Teaching hospitals were associated with a higher transfusion rate (OR 1.75), and comorbidities of chronic lung disease, chronic renal failure and malignancy were related to complication rates (OR 1.89, 2.32 and 1.50, respectively). The mortality rate of transurethral prostatic surgery is extremely low and is not affected by hospital volume. However, higher surgical volumes and laser use were significantly associated with lower rates of complications and transfusions.

Practice Pearl: A Novel Anesthetic Solution for Decreasing the Blood Loss at the Recipient Site of Hair Transplantation (Namazi Solution)

The tumescent anesthetic technique offers both anesthesia and vasoconstriction. A solution of 0.1% lidocaine, 1:1000,000 epinephrine, and 10 mEq/l of sodium bicarbonate is injected into the subcutaneous tissue until it becomes quite firm. A dual level of tumescent anesthetic infiltration expedites hair grafting or strip harvesting for hair transplantation, facilitates the placement of the correct incisional angle of instruments inserted into the donor site, reduces bleeding, and increases the exit angle of the hairs, thereby promoting increased survivorship of hair shafts and bulbs [2, 3]. However, despite the use of this technique, bleeding from the recipient sites frequently occurs, which makes transplantation of the harvested follicles difficult. Tranexamic acid is a synthetic derivative of the amino acid lysine that exerts its antifibrinolytic effect through the reversible blockade of lysine-binding sites on plasminogen molecules. Tranexamic acid is useful in a wide range of hemorrhagic conditions. The drug reduces postoperative blood loss in a number of surgery types such as cardiac surgery with cardiopulmonary bypass, orthotopic liver transplantation, and transurethral prostatic surgery. Tranexamic acid decreases the blood loss from upper gastrointestinal bleeding, menorrhagia, placental bleeding, traumatic hyphema, postpartum hemorrhage, and conisation of the cervix. Tranexamic acid significantly reduced mean blood loss after oral surgery for patients with hemophilia and was effective as a mouthwash for dental patients receiving oral anticoagulants. Systemically administered tranexamic acid is well tolerated. Nausea and diarrhea are the most common adverse events. Increased risk of thrombosis with the drug has not been demonstrated in clinical trials [1]. The antifibrinolytic property of tranexamic acid could be elegantly used for the reduction of bleeding at hair transplantation recipient sites. The addition of one 500-mg (5 ml) ampule of tranexamic acid to the tumescent anesthetic solution can significantly speed and ease the transplantation of the harvested follicles into the recipient sites while decreasing the stress of the operation.

Dynamic dose-feedback prostate brachytherapy in patients with large prostates and/or planned transurethral surgery before implantation

To compare the quality of permanent prostate brachytherapy (PPB) implants, dosimetric outcomes and urinary morbidity between patients with large (>50 mL) and those with smaller prostates, treated with a dynamic dose-feedback technique as monotherapy for localized prostate cancer. The series included patients with pre-existing bladder outlet obstruction managed with planned transurethral resection or incision of the prostate; 155 consecutive men had PPB implants as monotherapy for localized prostate cancer using a dynamic dose-feedback approach. Dosimetric variables assessed included the implant volume, the minimum dose to 90% of the prostate (D90), and the volumes of prostate receiving 100% and 150% of the prescribed dose as a percentage of the total volume (V100 and V150), during and after implantation. Urinary morbidity was recorded in terms of acute urinary retention (AUR), the need for surgical intervention after implantation and the American Urologic Association (AUA) symptom score at baseline, 1.5, 3, 6, 9, 12 and 18 months. In all, 38 patients had prostate volumes of >or=50 mL; prostate volume had no influence on any dosimetric variable assessed. Two patients with large prostates (>or=50 mL) had AUR and required delayed surgery. Three patients with small prostates (<50 mL) had transient retention; the differences were not statistically significant (Fisher's exact test). AUA symptom scores peaked at 6 weeks and returned to baseline within a year; there were no statistically significant differences between the groups. Eight patients had planned transurethral surgery at >or=4 months before implantation; they all had D90s of >130 Gy and had no incontinence. Using the dynamic feedback technique, there was no adverse dosimetric and urinary morbidity in men having PPB and with prostates of >50 mL. Likewise, there were no impediments, e.g. pubic arch interference, which precluded a favourable dosimetric implant in men with a large prostate. Large prostates should not be a contraindication to PPB and require no hormonal cytoreduction. Patients with obstructive lower urinary tract symptoms can be managed with planned transurethral prostatic surgery before implantation, without compromising implant quality or morbidity.

IDENTIFICATION OF THE RETROTRIGONAL LAYER AS A KEY ANATOMICAL LANDMARK DURING ROBOTICALLY ASSISTED RADICAL PROSTATECTOMY

OBJECTIVE: To define the gross and microscopic anatomy, and the surgical significance, of the newly described retrotrigonal layer of the bladder neck, as an aid during robotic radical prostatectomy (RRP). MATERIALS AND METHODS: The data for this study were obtained from five fresh cadaveric dissections and 100 consecutive RRPs. Five male cadavers with no previous pelvic or urethral surgery were dissected to expose the posterior bladder neck and identify the retrotrigonal layer. This same layer was reproducibly identified in all 100 RRPs. The gross appearance of this layer, and its relationship to neighbouring structures, was documented using still photographs and intraoperative video. The microscopic composition of this layer was assessed using routine haematoxylin and eosin stains, and special staining for smooth muscle (desmin), neural tissue (S-100), and elastin. RESULTS: Grossly, the retrotrigonal layer is a well-defined midline strip located posterior to the bladder neck, that extends from the trigone (superiorly) to the base of the prostate (inferiorly). Microscopically, this layer was predominantly composed of smooth muscle with intervening connective tissue. The retrotrigonal layer serves as a key anatomical landmark to facilitate posterior prostatic dissection, particularly in men with large prostates, prominent median lobes, or previous transurethral prostatic surgery. Further, in our practice, this layer marks the posterior limit of dissection in which electrocautery is still used. Finally, the retrotrigonal layer serves to buttress the posterior layer of the urethrovesical anastomosis. CONCLUSION: The retrotrigonal layer is a key landmark during the posterior bladder neck dissection in the antegrade technique of RRP.

Identification of the retrotrigonal layer as a key anatomical landmark during robotically assisted radical prostatectomy

To define the gross and microscopic anatomy, and the surgical significance, of the newly described retrotrigonal layer of the bladder neck, as an aid during robotic radical prostatectomy (RRP). The data for this study were obtained from five fresh cadaveric dissections and 100 consecutive RRPs. Five male cadavers with no previous pelvic or urethral surgery were dissected to expose the posterior bladder neck and identify the retrotrigonal layer. This same layer was reproducibly identified in all 100 RRPs. The gross appearance of this layer, and its relationship to neighbouring structures, was documented using still photographs and intraoperative video. The microscopic composition of this layer was assessed using routine haematoxylin and eosin stains, and special staining for smooth muscle (desmin), neural tissue (S-100), and elastin. Grossly, the retrotrigonal layer is a well-defined midline strip located posterior to the bladder neck, that extends from the trigone (superiorly) to the base of the prostate (inferiorly). Microscopically, this layer was predominantly composed of smooth muscle with intervening connective tissue. The retrotrigonal layer serves as a key anatomical landmark to facilitate posterior prostatic dissection, particularly in men with large prostates, prominent median lobes, or previous transurethral prostatic surgery. Further, in our practice, this layer marks the posterior limit of dissection in which electrocautery is still used. Finally, the retrotrigonal layer serves to buttress the posterior layer of the urethrovesical anastomosis. The retrotrigonal layer is a key landmark during the posterior bladder neck dissection in the antegrade technique of RRP.

Transurethral Prostatic Surgery. By Kyril B. Conger, M.D., F.R.A.C.S. 9 × 6 in. Pp. 150, with 52 illustrations. 1963. London: Baillière, Tindall &amp; Cox Ltd. 72s

Transurethral Prostatic Surgery. By Kyril B. Conger, M.D., F.R.A.C.S. 9 × 6 in. Pp. 150, with 52 illustrations. 1963. London: Baillière, Tindall &amp; Cox Ltd. 72s

WILLARD E. GOODWIN: EDUCATOR, INNOVATOR AND PIONEER

No AccessJournal of UrologyHistorical Article1 Jul 2004WILLARD E. GOODWIN: EDUCATOR, INNOVATOR AND PIONEER GANESH S. PALAPATTU, DAVID A. BLOOM, ROBERT B. SMITH, and RICHARD J. BOXER GANESH S. PALAPATTUGANESH S. PALAPATTU More articles by this author , DAVID A. BLOOMDAVID A. BLOOM More articles by this author , ROBERT B. SMITHROBERT B. SMITH More articles by this author , and RICHARD J. BOXERRICHARD J. BOXER More articles by this author View All Author Informationhttps://doi.org/10.1097/01.ju.0000132123.01060.c2AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail References 1 : Studies in ketosis. J Bio Chem1937; 117: 131. Google Scholar 2 : Hematuria and sickle cell disease: unexplained, gross unilateral, renal hematuria in negroes, coincident with the blood sickling trait. J Urol1950; 63: 79. Link, Google Scholar 3 : Hemoglobinemia and lower nephron nephrosis following transurethral prostatic surgery. J Urol1951; 65: 1075. Link, Google Scholar 4 Boxer R.J. Personal interview of Peter L. Scardino, M. D. Google Scholar 5 : Percutaneous trocar (needle) nephrostomy in hydronephrosis. J Am Med Assoc1955; 157: 891. Google Scholar 6 : Human renal transplantation. I, clinical experiences with six cases of renal homotransplantation. J Urol1963; 89: 13. Link, Google Scholar 7 Boxer R.J. Personal interview of Robert S. McNamara. Google Scholar 8 Palapattu G.S. Personal interview of Joseph E. Murray, M. D. Google Scholar 9 : The ureter in renal transplantation. J Urol1969; 101: 680. Link, Google Scholar 10 : Percutaneous antegrade pyelography and hydronephrosis. Direct, intrapelvic injection of urographic contrast material to secure a pyeloureterogram after percutaneous needle puncture and aspiration of hydronephrosis. J Urol1955; 74: 164. Link, Google Scholar 11 : “Cup-patch” technique of ileocystoplasty for bladder enlargement or partial substitution. J Urol2002; 168: 667. Abstract, Google Scholar 12 : Replacement of the ureter by small intestine: clinical application and results of the “ileal ureter.”. J Urol1959; 81: 406. Link, Google Scholar 13 : Discussion on carcinoma of the prostate; diagnosis and treatment by J. C. Presti. Calif Med1953; 78: 440. Google Scholar 14 : Needle biopsy in diagnosis of prostatic cancer. Calif Med1954; 81: 308. Google Scholar 15 : The cure of hypertension by nephrectomy. Surgery1950; 28: 67. Google Scholar 16 : Three angiotensin tests in the investigation of renal hypertension; bioassay, infusion, renogram. J Urol1966; 96: 858. Abstract, Google Scholar 17 : Open, transcolonic ureterointestinal anastomosis; a new approach. Surg Gynecol Obstet1953; 97: 295. Google Scholar 18 : Experiments with intussuscepted ileal valve in ureteral substitution. J Urol1959; 81: 526. Link, Google Scholar 19 : Renal hypertension secondary to renal tuberculosis. Report of cure in four patients treated by nephrectomy. Am J Med1965; 38: 337. Google Scholar 20 : A malignant testis tumor with hepatic metastasis in a grizzly bear. J Urol1953; 69: 845. Abstract, Google Scholar From the Department of Urology, (GSP, RBS), University of California-Los Angeles School of Medicine, Los Angeles, California, Section of Urology, University of Michigan (DAB), Ann Arbor, Michigan, and Departments of Surgery/Urology, Health Policy and Community Medicine, Medical College of Wisconsin (RJB), Milwaukee, Wisconsin© 2004 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 172Issue 1July 2004Page: 40-44 Advertisement Copyright & Permissions© 2004 by American Urological Association, Inc.MetricsAuthor Information GANESH S. PALAPATTU More articles by this author DAVID A. BLOOM More articles by this author ROBERT B. SMITH More articles by this author RICHARD J. BOXER More articles by this author Expand All Advertisement PDF DownloadLoading ...

HUGH HAMPTON YOUNG: A PIONEER IN PEDIATRIC UROLOGY

Hugh Hampton Young (1870-1945) is regarded as a major force in urology during the first half of the 20th century. While he is acknowledged for many advances in open and transurethral prostatic surgery, his contributions to pediatric urology have been less well recognized. The manuscripts and autobiography of Hugh Hampton Young were reviewed and major contributions to pediatric urology were identified. Patient records corresponding to these areas were then obtained from the Alan Mason Chesney Medical Archives and reviewed. Hugh Hampton Young was the first clinically to recognize and surgically treat posterior urethral valves, the first to develop a procedure to correct incontinence in patients with the epispadias-exstrophy complex and the first to describe bilateral subtotal adrenalectomy for virilization secondary to congenital adrenal hyperplasia. He was successful in his endeavors and his techniques are still in use today or have become the building blocks of future modifications. The contributions of Hugh Hampton Young to pediatric urology were numerous. In addition to his accomplishments in academic and adult urology, Young should be recognized as a true pioneer in pediatric urology.

A Randomized Controlled Trial Evaluating the Use of Sterile Water as an Irrigation Fluid During Transurethral Electrovaporization of the Prostate

Objective To compare the safety of sterile water and glycine when used as bladder irrigation during transurethral electrovaporization of the prostate (TUVP) in a randomized controlled trial. Patients and methods The study comprised 50 consecutive patients admitted for transurethral prostatic surgery who were randomly allocated to receive bladder irrigation with either sterile water or 1.5% glycine during TUVP. After surgery, serum electrolytes and the presence of free plasma haemoglobin (suggesting haemolysis) were determined and the patients observed for clinical evidence of the transurethral resection (TUR) syndrome. Results There was no significant difference in the level of free plasma haemoglobin between the groups and no difference in serum sodium levels. None of the patients developed any signs of the TUR syndrome. Conclusions Water is a safe irrigant for use during TUVP and has several advantages over 1.5% glycine.

Ethanol monitoring of irrigating fluid absorption in transcervical resection of the endometrium

We evaluated the precision in using ethanol to indicate and quantify absorption of irrigating fluid during transcervical resection of the endometrium. The ethanol concentration in the expired breath, the serum sodium level, the blood loss and the volumetric fluid balance were measured over 10-min periods during 62 operations. A solution containing glycine 1.5% and ethanol 1% was used to irrigate the uterus. Most principles previously outlined for ethanol monitoring in transurethral prostatic surgery could also be applied in endometrial resection. In the 21 patients who showed the intravascular pattern of ethanol changes, the breath alcohol measurement corrected for absorption time predicted the volume of irrigant absorbed (up to 2,531 ml) with a standard error of 230 ml at the end of any 10-min period of absorption. Repeated measurement of serum sodium indicated intravascular fluid absorption with practically the same precision as the breath test. Extravascular absorption was found in 14 patients. In these operations, the volume of irrigant absorbed (up to 1,767 ml) could be predicted with a standard error of 92 ml from the ethanol concentration at the plateau level attained after absorption had occurred. Ethanol monitoring is precise enough to allow monitoring of irrigating fluid absorption in endometrial resection.

Prostatic tissue levels of ofloxacin

The prostatic tissue levels of ofloxacin were determined in 20 patients undergoing transurethral resection of the prostate. Ofloxacin was administered in two separate dosages of 300 mg PO from twenty-two to two hours preoperatively. The ofloxacin plasma concentrations ranged from 3.73 to 1.85 micrograms/mL at the time of surgery, and the tissue concentrations ranged from 4.55 to 1.94 micrograms/mL. The ofloxacin tissue/plasma ratios ranged from 0.9 to 1.2. These findings indicate that ofloxacin may be useful in prophylaxis prior to transurethral prostatic surgery and also in the treatment of bacterial prostatitis.