2168 HOLMIUM LASER ENUCLEATION OF THE PROSTATE IN PATIENTS REQUIRING ANTICOAGULATION

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2166 EVOLUTION OF THE LEARNING CURVE FOR HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HOLEP) - A SINGLE CENTRE EXPERIENCE OF THE FIRST 458 CASES IN THE UNITED KINGDOM Sashi Kommu, Zakarian Artaches*, Richard Popert, London, United Kingdom INTRODUCTION AND OBJECTIVES: Holmium laser enucleation of the prostate (HoLEP) is the only laser treatment for BPH with level 1 evidence and endorsement in both the American Urological Association (AUA) and European Association of Urology (EAU) guidelines. The learning curve for skill acquisition of HoLEP has been ill understood thus far. Herein, we aim to report the evolution of the learning curve in the skill acquisition for HoLEP in a single tertiary referral centre in the United Kingdom. METHODS: Four hundred and fifty eight (n⫽458) consecutive patients who underwent HoLEP from Jan 2003 to September 2012 by a single surgeon were studied. Perioperative clinical variables, including enucleation time, morcellation time, enucleation efficacy (enucleated weight/enucleation time) and early complication rate were analyzed. The patterns in skill acquisition as the technique evolved were studied. RESULTS: Mean prostate volume was 44cc(8?367cc). Parameters for two lobe versus three lobe resections were respectively (a)lasing time 39.1 vs. 41.3min(P⫽0.70); extraction time 12.0 vs. 13.5min(P⫽0.82); operative time 56.0 vs. 59 min(P⫽0.78); eneucleated tissue 20g vs. 26g(P⫽0.41); wt/laser time 0.47 g/min vs. 0.6 g/min(P⫽0.32) and catheter removal 2.0 days vs. 2.2 days(P⫽0.98). Pre and postop IPSS was 25 and 6 for the two lobe vs. 23 and 9 for the three lobe resection(P⫽0.97). Pre and postop Qmax was 8 and 21 for the two lobe vs. 8 and 20 for the three lobe resection(P⫽0.60). Median duration of postoperative indwelling catheter was 1(range 1-4) day and median hospital stay was 1(range 1-5)day. Mean morcellation time overall was 12 mins. There were 15/458(3.3%) early (⬍5days post op) surgery-related complications overall. There were 19/295(6.4%) complications at 48 months follow-up.With increasing experience larger prostates were undertaken. However, there was no correlation in complication rates by year of cumulative experience of the surgeon. There was an increasing trend of enucleation efficacy as the number of cases completed increased. The plateau of enucleation ratio efficacy was reached at the twentieth case. As the technique evolved in parallel with the number of cases done, three lobe resections were undertaken. CONCLUSIONS: Our results demonstrate that HoLEP is a safe and effective means for treating BPH. The operative learning curve plateau was reached after the first 20 cases. A step wise cumulative approach can aid in safe and optimal skill acquisition by progressing from two lobe to a three (“complete HoLEP”) lobe eneucleation. Source of Funding: N/A

2167 LASER PROSTATECTOMY IN THE SEVERELY ILL - OUTCOMES AND FEASIBILITY OF A RAPID AMBULATORY DISCHARGE PATHWAY Benjamin Herrick*, Johann Ingimarsson, Lebanon, NH; Ronald Yap, Concord, NH INTRODUCTION AND OBJECTIVES: Laser prostate surgery is increasingly being used to treat BPH while potentially decreasing morbidity compared to standard electrosurgical resection. However, little is known in the urologic literature regarding the outcomes or feasibility of an ambulatory discharge pathway in high anesthetic risk patients who have undergone such procedures. METHODS: A retrospective chart review was performed on patients undergoing holmium laser ablation of the prostate (HoLAP) between 2007 and 2011 by a single surgeon. Using the American Society of Anesthesiologists (ASA) physical status classification system, all patients with category 3 (“severe systemic disease”) or higher

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were included in this study. Patients were placed on a rapid ambulatory discharge pathway (RAD), discharged on the day of surgery with a urethral catheter in place with a voiding trial on post-operative day 3. Patients with less than 90 days of follow-up and patients that were planned post-operative admission were excluded. Preoperative, intraoperative, and postoperative outcomes and complications were analyzed using two-tailed Student t-tests (p ⬍0.05). All complications within 90 days of surgery were included in the analysis. RESULTS: 41 patients met inclusion criteria. Mean follow-up was 142 days. Average preoperative AUA symptom score (AUA-SS) and Quality of Life (QoL) scores were 20.4 and 3.5. Average prostate volume was 37 grams (range 20-100). The mean change in postoperative AUA-SS and QoL were -9.1 (p⬍0.05) and -1.1 (p⬍0.05). 33 patients (80%) remained on the RAD. Six patients (15%) were admitted: hematuria (3), urinary retention (1), CHF exacerbation (1), MI (1). Two patients (5%) visited the Emergency Department regarding catheter problems and were subsequently discharged. There was one death unrelated to surgery (passenger in a motor vehicle crash). CONCLUSIONS: This series suggests that it is feasible and safe to perform ambulatory laser ablation prostate surgery on high anesthetic risk patients with small to medium size prostates. Even in patients with severe systemic illness (ASA 3 or 4) 80% of them successfully remained on the pathway and were discharged on the day of surgery. Source of Funding: None

2168 HOLMIUM LASER ENUCLEATION OF THE PROSTATE IN PATIENTS REQUIRING ANTICOAGULATION Joseph M. Jacob*, Naeem Bhojani, James E. Lingeman, Indianapolis, IN INTRODUCTION AND OBJECTIVES: A significant number of patients with benign prostatic hyperplasia (BPH) requiring surgical intervention are receiving anticoagulation (AC) therapy. We evaluate the efficacy and morbidity of holmium laser enucleation of the prostate (HoLEP) in patients with BPH requiring intermittent and continuous AC. METHODS: From 1999 to 2011, 53 patients who underwent HoLEP and required intermittent or continuous AC were analyzed retrospectively and compared to 769 patients who underwent HoLEP and were not on AC therapy. Patients on intermittent AC were also compared to those on continuous AC. Pre, intra, and post-operative variables were analyzed to determine efficacy and morbidity. One-way ANOVA tests were used to identify statistically significant differences between groups. RESULTS: When comparing AC vs non-AC patients, there were no significant differences in pre, intra, and post-operative outcomes except for hemoglobin (Hb) (Table 1). Pre, as well as post-op Hb was lower in the AC group (13.7 versus 14.1 and 11.6 versus 12.4 respectively). Post-operatively, there were no significant differences in hospitalization stay (HS) (35.2 versus 25.8 hours), length of continuous bladder irrigation (CBI) (15.8 versus 13.9 hrs), and length of catheterization (20.0 versus 16.2 hrs). 1/53 (1.9%) patients in the AC group required a transfusion versus 13/769 (1.7%) patients in the non-AC group. 2 patients required re-operation in the AC group; one for clot retention after Plavix was restarted and one for incomplete morcellation. Patients on continuous AC versus intermittent AC did have significantly longer HS, length of CBI, as well as lower post-op Hb. However, they did not require any transfusions or re-operations nor did they suffer any complications. CONCLUSIONS: In patients with BPH requiring intermittent or continuous AC, HoLEP is an effective treatment modality with minimal morbidity and excellent patient outcomes.

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Table 1. Anticoagulated versus non-anticoagulated patients PRE-OPERATIVE NONANOVA CHARACTERISTICS ANTICOAGULATED ANTICOAGULATED (p) N 53 769

PRE-OPERATIVE INTERMITTENT CONTINUOUS ANOVA CHARACTERISTICS ANTICOAGULATION ANTICOAGULATION (p) Specimen weight; g (range) 83.7 (5-230) 56.7 (19-123) 0.3

PSA; ng/ml (range)

9.3 (1-121)

7.1 (0.1-143.7)

0.1

AUA SS (range)

20.3 (5-35)

20.2 (0-35)

0.1

Enucleation time; min (range)

57.4 (12-117)

43 (32-67)

0.2

Enucleation rate; g/ min (range)

1.6 (0.2-5.2)

1.5 (0.5-3.8)

0.9

Morcellation time; min (range)

18.5 (2-62)

9.6 (2-30)

0.3

5.4 (1.7-12.7)

7.6 (4.1-12.2)

0.1

PVR; cc (range)

242.1 (0-915)

177.5 (0-ⱖ 1000

0.1

Pre-operative Hb; g/dL (range)

13.7 (9.6-17.3)

14.1 (6.9-18.9)

0.009

TYPE OF ANTICOAGULATION Aggrenox

Morcellation rate; g/min (range) 2

none

ASA

4

none

Plavix

20

none

Coumadin

25

none

Plavix and Coumadin

2

INTRA-OPERATIVE CHARACTERISTICS ANTICOAGULATED Specimen weight; g (range)

78.8 (5-230)

POST-OPERATIVE OUTCOMES Hospitalization; hours (range)

none

0.5 0.05

1 (3) (2.2)

0 (0) (0)

0.7

Re-operation rate; # (%)

2 (4.4)

0 (0)

0.6

1

0

0.7

Morcellation time; min (range)

16.8 (2-62)

18.4 (1-133)

0.6

Complications; #

5.8 (1.7-12.7)

5.6 (0.5-31.5)

0.8

PVR (6 weeks); cc (range)

27.4 (0-90)

43.9 (0-87.8)

0.5

ANTICOAGULATED

NONANTICOAGULATED

ANOVA (p)

PSA; ng/mL (range)

0.8 (0.3-1.4)

0.5 (0.02-1.5)

0.3

0.7

AUA SS (1 month) (range)

10.6 (1-22)

9.2 (2-25)

0.7

0.6

AUA SS (6 months) (range)

5.1 (0-12)

5.7 (2-8)

0.8

Pathology (benign/ malignant)

41/4

8/0

0.4

35.2 (8-192) 15.8 (4-48)

25.8 (2-240) 13.9 (0-705)

20.0 (6-168)

16.2 (1-240)

0.3

11.6 (7.8-15.9)

12.4 (4.2-16.8)

0.001

Transfusions; number of patients (units) (%)

1 (3) (1.9)

13 (3.2) (1.7)

0.9

Re-operation rate; # (%)

2 (3.8)

14 (1.8)

0.3

1

8

0.6

PVR (6 weeks); cc (range)

28.8 (0-90)

42.0 (0-950)

0.5

PSA; ng/mL (range)

1.0 (0.02-3.8)

1.4 (0.01-49.1)

0.6

AUA SS (1 month) (range)

10.2 (1-25)

9.8 (0-33)

0.4

AUA SS (6 months) (range)

4.4 (0-12)

6.8 (0-31)

0.4

Pathology (benign/ malignant)

49/4

684/111

0.8

Table 2. Intermittent versus continuous anticoagulation PRE-OPERATIVE INTERMITTENT CONTINUOUS ANOVA CHARACTERISTICS ANTICOAGULATION ANTICOAGULATION (p) N 45 8 10.6 (1.2-121)

5.0 (1-15.7)

AUA SS (range)

22.4 (5-35)

19.7 (12-35)

0.5

PVR; cc (range)

235.1 (0-915)

329.1 (10.2-906)

0.5

14 (9.6-16)

13 (9.9-15.0)

0.2

Aggrenox

1

1

ASA

2

2

Plavix

18

2

Coumadin

22

3

Plavix and Coumadin

2

0

Hemoglobin; g/dL (range)

23.8 (12-48) 10.6 (7.8-12.6)

0.4

PSA; ng/mL (range)

15.7 (8-37) 11.8 (7.8-15.9)

1.5 (0.003-8.13)

Complications; #

0.002

Transfusions; number of patients (units) (%)

1.6 (0.2-5.2)

Lowest post-op Hb; g/dL (range)

23.4 (10-48)

Lowest post-op Hb; g/dL (range)

0.3

Catheterization; hours (range)

14.7 (6-36)

Catheterization; hours (range)

0.9

61.3 (10-245)

Length of CBI; hours (range)

0.07

81.7 (1-532)

57.0 (12-111)

Hospitalization; hours (range)

45.1 (23-96)

ANOVA (p)

Enucleation rate; g/ min (range)

POST-OPERATIVE OUTCOMES

30.4 (16-120)

Length of CBI; hours (range)

NONANTICOAGULATED

Enucleation time; min (range)

Morcellation rate; g/min (range)

INTERMITTENT CONTINUOUS ANOVA ANTICOAGULATION ANTICOAGULATION (p)

0.6

TYPE OF ANTICOAGULATION

INTRA-OPERATIVE INTERMITTENT CONTINUOUS ANOVA CHARACTERISTICS ANTICOAGULATION ANTICOAGULATION (p)

Source of Funding: None

2169 THE FACTORS ASSOCIATED WITH OCCURRENCE AND RECOVERY OF TRANSIENT URINARY INCONTINENCE AFTER HOLMIUM LASER ENUCLEATION OF THE PROSTATE Sung Woo Park, Seung Chan Jeong*, Jong Kil Nam, Sang Don Lee, Jeong Zoo Lee, Moon Kee Chung, Yangsan, Korea, Republic of INTRODUCTION AND OBJECTIVES: To investigate the factors associated with occurrence and recovery of transient urinary incontinence (TI) after Holmium Laser Enucleation of the Prostate (HoLEP) for the surgical treatment of benign prostatic hyperplasia (BPH). METHODS: We assessed 311 consecutive patients who were treated with HoLEP for BPH by single surgeon from March 2009 to February 2012 and were followed up for at least 6 months. After the HoLEP, patients were evaluated at 2weeks postoperatively and every month thereafter until recovery of continence using the International Prostate Symptom Score (IPSS), the Overactive Bladder Symptom Score (OABSS) and uroflowmetry. Urinary incontinence was defined according to the International Continence Society and by the question ‘Do you have involuntary loss of urine?’. Logistic regression test was used to investigate the factors associated with occurrence of TI and Kaplan-Meier was used to analyze TI recovery period. Factors affecting TI recovery period was investigated by using Cox regression test. RESULTS: The mean prostate volume was 56.2 ⫾ 21.6 g and the mean operation time was 69.3 ⫾ 24.1 min. TI after HoLEP was occurred in 18.6% (n⫽58) at postoperative 2 weeks and 76.9% of them were recovered within 3 months. Age (OR⫽3.494;95%CI⫽1.5657.803;p⫽0.002) and total operation time (OR⫽3.849;95%CI⫽1.6139.185;p⫽0.002) showed as the factors that were statistically significant in the occurrence. The patient’s age (OR⫽0.349;95%CI⫽0.169-0.718;