HOW I DO IT

• How I Do It: Anticoagulation management for common urologic procedures

  Glick Lydia, Chandrasekar Thenappan, Hubosky G. Scott, Teplitsky Seth, Shah Mihir, Leong Joon Yau, Ouma Geoffrey, Mark R. James, MD Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA

  ---

  Appropriate perioperative management of antithrombotic medications is critical; for every patient, the risk of bleeding must be balanced against individual risk of thrombosis. There has been a rapid influx of new antithrombotic therapies in the past 5 years, yet there is a lack of clear and concise guidelines on the management of anticoagulant and antiplatelet therapy during urologic surgery. Here we describe our approach to perioperative antithrombotic counseling, including the timing of stopping and restarting these medications. These practice guidelines have been developed in consultation with the Vascular Medicine service at our institution as well as after a review of current literature, and apply to common urologic procedures. Many cases are complex and require medical consultation or a multidisciplinary approach to management. We believe that by presenting our systematic method of antithrombotic management, including when to involve other discplines, we can increase knowledge and comfort amongst urologists in managing these medications in the perioperative period.

  Dec 2020 (Vol. 27, Issue 6 , Page 10480)
  PDF (143.1KB)Free
• Next-generation DNA sequencing for infected genitourinary implants: How I do it

  Chung H. Paul, Leong Joon Yau, Teplitsky Seth, Shenot J. Patrick, Das K. Akhil, Gomella G. Leonard, MD Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia Pennsylvania, USA

  ---

  Infection of artificial urinary sphincters or inflatable penile prostheses is one of the most devastating complications after prosthetic surgery and can have a significant impact on a quality of life. Patients undergoing revision surgery with or without device replacement may have increased risk for infection when compared to initial primary surgery. As such, surgeons may utilize traditional culture results to direct antimicrobial therapy for these patients. Unfortunately, culture results can be inconclusive in up to one-third of the time even in the setting of active device infection. Next-generation sequencing (NGS) of DNA is an emerging technology capable of sequencing entire bacterial genomes and has the potential to identify microbial composition in explanted devices. Herein, we describe our institutional experience on NGS utilization in patients with genitourinary prostheses. We also highlight our methods and techniques to inform readers on the potential practices that can enhance the utility and diagnostic yield of this new and upcoming technology.

  Keywords: urethral stricture, inflatable penile prosthesis, IPP, artificial urinary sphincter, AUS, NGS, infection,

  Oct 2020 (Vol. 27, Issue 5 , Page 10418)
  PDF (75.3KB)Free
• How I Do It: The Optilume drug-coated balloon for urethral strictures

  Elterman S. Dean, Coutinho Karl, Hagedorn C. Judith, MD Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada

  ---

  Urethral stricture disease can be difficult to treat and stricture recurrence is common. The management of stricture disease has evolved and urethroplasty can achieve a high rate of lasting urethral patency. Nevertheless, endoscopic treatments still seem to have sub-optimal outcomes with high stricture recurrence rates. The Optilume drug-coated balloon represents a step forward in the endoscopic management of urethral strictures. The drug-coated balloon may offer an intermediate step prior to repeated dilations, urethrostomies, or urethroplasty. This treatment modality is a promising alternative to current endoscopic management and an option for patients that are poor surgical candidates or decline urethroplasty.

  Keywords: urethral stricture, urethral dilation, drug-coated balloon,

  Aug 2020 (Vol. 27, Issue 4 , Page 10322)
  PDF (473.4KB)Free
• Single port robotic radical prostatectomy with the da Vinci SP platform: a step by step approach

  Jones Rabun, Dobbs W. Ryan, Halgrimson R. Whitney, Vigneswaran T. Hari, Madueke Ikenna, Wilson Jessica, Abern R. Michael, Crivellaro Simone, MD Department of Urology, University of Illinois at Chicago, Chicago, Illinois, USA

  ---

  The da Vinci single port (SP) robotic system (Intuitive Surgical, Sunnyvale, CA, USA) is a recently approved robotic platform designed with several modifications to the previously available multi-port robotic systems. This article describes the technique performed utilizing the SP robotic system for radical robotic-assisted laparoscopic prostatectomy (RALP) with or without bilateral pelvic lymph node dissection from a single institution. In this report we describe our step-by-step approach, technical modifications from the multi-port technique and initial results for performing single port robotic-assisted laparoscopic prostatectomy (SP-RALP). We describe our initial experience and technique with the SP robotic system consisting of 23 consecutive patients who underwent SP-RALP between December 2018 and May 2019. The median patient age was 62 years with approximately half of the patients undergoing pelvic lymphadenectomy. The median operative time was 236 minutes, median estimated blood loss was 50 mL and median length of hospital stay was 1 day. No unplanned port placements occurred and no conversions to open surgery occurred. We demonstrate the safety and feasibility of performing a transperitoneal prostatectomy with either a posterior or anterior approach.

  Keywords: robotics, protate neoplasms, minimally invasive surgical procedures,

  Jun 2020 (Vol. 27, Issue 3 , Page 10263)
  PDF (703.9KB)Free
• How I Do It -MRI-ultrasound fusion prostate biopsy using the Fusion MR and Fusion Bx systems

  Perlis Nathan, Lawendy Bishoy, Barkin Jack, MD University of Toronto, Department of Surgery, Toronto, Ontario, Canada

  ---

  There is increasing evidence to support the use of multiparametric magnetic resonance imaging (MRI) in men at risk for clinically significant prostate cancer to help identify lesions and inform biopsy. Randomized, level 1 evidence demonstrates that men who are managed with MRI and MRI-ultrasound fusion targeted biopsy (MRF-TB) have more clinically significant prostate cancer and less clinically insignificant prostate cancer detected and avoid biopsy altogether more often than men who undergo systematic, whole-gland prostate biopsy (SPB). Furthermore, strategies that incorporate MRF-TB have lower rates of upgrading on radical prostatectomy compared to SPB. However, generalizing this data to wider practice is challenging because there is a learning curve for interpreting MRI and performing MRF-TB, and some of the fusion technologies are better than others. We describe our group's early experience with the Fusion MR and Fusion Bx systems (Focal Healthcare, Toronto, ON, Canada). These products are designed with elastic fusion technology that is user-friendly, intuitive and accurate. The Fusion MR contouring system is straightforward and allows for contouring with several MRI sequences simultaneously. The Fusion Bx biopsy system has a semi-robotic arm that accounts for prostate deformation and patient movement and allows for freehand-like access, which is a seamless transition from SPB for clinicians. There were 68 lesions targeted in the first 51 patients. The overall cancer detection rate was 22%/61%/83% for PI-RADS 3/4/5, respectively. The Gleason grade group 2 prostate cancer or higher rate was 6%/47%/75% for PI-RADS 3/4/5, respectively. There were no major complications in this cohort of patients. Limitations of this study include small number of patients and lack of formal follow up to rule out sepsis. Overall, the Fusion MR and Fusion Bx systems are accurate, straightforward and safe to use for MRF-TB. Early experience does not show any significant learning curve.

  Keywords: prostate cancer, multiparametric magnetic resonance imaging, systematic prostate biopsy, MRI-ultrasound fusion-targeted biopsy, Gleason grade group,

  Apr 2020 (Vol. 27, Issue 2 , Page 10185)
  PDF (461.9KB)Free