Transperineal laser ablation of the prostate as a treatment for benign prostatic hyperplasia and prostate cancer: The results of a Delphi consensus project

Objective: To evaluate transperineal laser ablation (TPLA) with Echolaser® (Echolaser® TPLA, Elesta S.p.A., Calenzano, Italy) as a treatment for benign prostatic hyperplasia (BPH) and prostate cancer (PCa) using the Delphi consensus method.Methods: Italian and international experts on BPH and PCa participated in a collaborative consensus project. During two rounds, they expressed their opinions on Echolaser® TPLA for the treatment of BPH and PCa answering online questionnaires on indications, methodology, and potential complications of this technology. Level of agreement or disagreement to reach consensus was set at 75%. If the consensus was not achieved, questions were modified after each round. A final round was performed during an online meeting, in which results were discussed and finalized.Results: Thirty-two out of forty invited experts participated and consensus was reached on all topics. Agreement was achieved on recommending Echolaser® TPLA as a treatment of BPH in patients with ample range of prostate volume, from <40 mL (80%) to >80 mL (80%), comorbidities (100%), antiplatelet or anticoagulant treatment (96%), indwelling catheter (77%), and strong will of preserving ejaculatory function (100%). Majority of respondents agreed that Echolaser® TPLA is a potential option for the treatment of localized PCa (78%) and recommended it for low-risk PCa (90%). During the final round, experts concluded that it can be used for intermediate-risk PCa and it should be proposed as an effective alternative to radical prostatectomy for patients with strong will of avoiding urinary incontinence and sexual dysfunction. Almost all participants agreed that the transperineal approach of this organ-sparing technique is safer than transrectal and transurethral approaches typical of other techniques (97% of agreement among experts). Pre-procedural assessment, technical aspects, post-procedural catheterization, pharmacological therapy, and expected outcomes were discussed, leading to statements and recommendations.Conclusion: Echolaser® TPLA is a safe and effective procedure that treats BPH and localized PCa with satisfactory functional and sexual outcomes.

Robotic Assisted Laparoscopic Apical Suspension. Description of a 4 Points Technique (RALAS-4): First Case Reported

The uterosacral ligaments (UTSL), together with the cardinal ligament (CL), hold the upper vagina and cervix over the levator plate. These 2 ligaments provided 4 points support at the apex. Here we describe our surgical technique of robotic assisted laparoscopic apical suspension (RALAS) using non-absorbable sutures and describe a new 4 points technique (RALAS-4). 73-year-old Caucasian woman, gravida 5, para 4 had symptomatic pelvic organ prolapse (POP) apical/anterior stage III. At pelvic ultrasound evaluation the uterus was small and normal appearing of adnexa bilaterally. She failed pessaries and was sexually active. The most relevant complaints were vaginal bulging, pressure and urinary incontinence, mainly stress urinary incontinence;she is using 5 - 7 pads/day. Robotic assisted laparoscopic hysterectomy, mid-urthral sling and apical suspension was successfully performed in 125 min. Once we finished with hysterectomy, we proceed with RALAS-4, we used V-Loc 3-0, CV-23 (Covidien) sutures (absorbable) on the right and left uterosacral ligaments (2 points) and theses were reinforced with Gore-Tex 2-0, CV-2 (non-absorbable, Gore Medical). On the right/left anterior apical support we used Gore-Tex 2-0 and these provided the 2 point suspension (UTLS = 2 and anterior vagina = 2). The 2 anterior apical support sutures are taken from the vagina to the transversalis fascia and the obliterated umbilical artery on the anterior abdominal wall. The tension of these anterior sutures was maintained with Hem-o-lock (TeleFlex) and LAPRA-TY (Ethicon). In our opinion RALAS-4 may represents an alternative to robotic or laparoscopic sacrocolpopexy. This new approach simulate the natural 4 points support given by uterosacral ligaments and cardinal ligament, with the additional benefit of no mesh and no dissection on the sacrum promontory. With this technique we are chasing the Trifecta: no mesh, no complications and good anatomic support.

Anatomic Evaluation of Uterosacral and Cardinal Ligament during Robotic and Laparoscopic Surgery for Pelvic Organ Prolapse

Introduction: It is widely accepted that the uterosacral ligaments (UTSL), together with the cardinal ligament (CL), hold the upper vagina and cervix over the levator plate. The aim of this study is to evaluate the anatomical relationship between the right vs. left CL and UTSL during robotic and laparoscopic utero-sacral ligament suspension (UTSLS) and its implication with the surgical technique during UTSL suspension. Material and Methods: We evaluated 25 women with apical pelvic organ prolapses of stages 2 - 4 and we analyzed 100 uterosacral and cardinal ligaments. They were assigned (non-randomly) to: a) robotic-assisted laparoscopic uterosacral ligament suspension (RAL-UTSLS), b) robotic-assisted single-site utero-sacral ligament suspension (RASS-UTSLS) or laparo-endoscopic single site utero-sacral ligament suspension (LESS-UTSLS). We evaluated the length (distance between origins and insertions) of the aforementioned ligaments using the Da Vinci Si and other laparoscopic instruments like calipers. Results: The mean length of the UTSL in their caudal-cranial extent was 3.5 ± 0.5 cm (right side) and 2.58 ± 0.3 cm (left side). Measurements were performed on the same way for the CL, resulting in 5.1 ± 0.3 cm (both side). The only significant difference was observed when comparing the right vs. left UTSL. This anatomic difference translates to 5 ± 1 suture stitches on the right UTSL vs. 2 ± 1 on the left UTSL. Conclusion: In our evaluation on cardinal and uterosacral ligament, the right UTSL was significantly longer as compared to the left and this allowed us to take 3 additional stitches on the right UTSL vs. left during RAL-UTSLS. Future studies are necessary to compare females with/without POP.

Management of prostatosymphyseal fistula following photoselective vaporization of the prostate:Case series and systematic review of the literature

Background:This study is aimed to describe our institutional experience and review the literature to date on prostatosymphyseal fistula(PSF),or puboprostatic fistula,following bladder outlet procedures such as transurethral resection of the prostate(TURP)or laser photoselective vaporization of the prostate(PVP).Materials and methods:We retrospectively queried our institutional experience for management of PSF following PVP performed for symptomatic benign prostatic hyperplasia.We also performed a systematic literature review for PSF following PVP or TURP.Finally,we describe our surgical approach to the management of this challenging condition.Results:We identified 7 cases of PSF following PVP from our institution,as well as an additional 7 cases following PVP and 9 cases following TURP from literature review.The diagnosis of PSF was made between 0.5 and 24 months following PVP,and the most specific symptoms were pubic pain and difficulty ambulating.Most patients requiring several evaluations before the diagnosis was made using appropriate imaging studies.Seventy percent of patients required surgical intervention including fistula repair or prostatectomy.Our surgical approach has evolved,and we now routinely perform robotic fistula repair with Y-V plasty and interposition flap with excellent results.Conclusions:Puboprostatic fistula is a rare and poorly described complication of PVP or TURP.To the best of our knowledge,this case series of PSF following PVP represents the largest series to date and doubles the number of reported cases in the literature.Robotic fistula repair with interposition of either peritoneal or perivesical fat flaps appears to be a viable management strategy.