Pelvic Hematoma Following UroLift procedure for BPH

Two cases of pelvic hematoma after prostatic urethral lift surgery

Introduction

There are few reports of pelvic hematoma after prostatic urethral lift. Here, we report two cases of pelvic hematoma in Japan.

Case presentation

The first case was a 71-year-old man with benign prostatic hyperplasia who underwent prostatic urethral lift. Although the procedure was uneventful, he experienced lower abdominal pain the day after the operation. CT revealed a hematoma in the right pelvis; however, it was manageable with conservative treatment. The second case was a 68-year-old man. The procedure was uneventful; however, 6 days after the operation, a subcutaneous hematoma appeared in the lower abdomen. CT revealed a hematoma in the left pelvis. We then performed pelvic hematoma removal surgery.

Conclusions

Pelvic hematomas after PUL may requires attention, particularly in men with the narrow pelvises. Appropriate compression of the prostate and a high lithotomy position procedure could effectively avoid the occurrence of pelvic hematomas.

New minimally invasive solutions for Benign Prostatic Obstruction (BPO) management: A position paper from the UrOP (Urologi Ospedalità Gestione Privata)

To the Editor, In recent years, alternative solutions have been proposed to obtain effective results comparable to TURP, which is currently considered the gold standard, and laser vapo-enucleation techniques (1, 2), but with the possibility of maintaining sexual functions. In recent years there has been a growing trend towards ejaculation preservation. Although the results of TURP (3), and most laser enucleation techniques are undoubted in the Benign Prostatic Hyperplasia (BPH) and Lower Urinary Tract Symptoms (LUTS) management, they often lack in the preservation of ejaculation. All the alternative recently proposed interventions (Rezum, AquaBeam, Urolift, TPLA, i-TIND, LEST) are procedures considered by some authors to be promising in both managing BPO and preserving sexual functions. However, all these methods are limited by a lack of long-term follow-up that would evaluate the efficacy over time, possible complications related to the method and the correct patient selection for a specific method. The aim of this letter is to summarize the available evidence and provide clinicians with practical recommendations on the use of the brand new minimally invasive techniques for the management of BPO. [...].

Complications and device failures associated with urolift: Findings from the MAUDE database

INTRODUCTION

Urolift is an established intervention for symptoms of bladder outflow obstruction caused by benign prostate enlargement. Reported advantages include its minimally invasive profile, short learning curve and feasibility as a day case procedure. Our aim was to use a national registry as a means to evaluate the nature of complications and device failures that have been documented to occur.

METHODS

Retrospective review was performed of the US Manufacturer and User Facility Device Experience (MAUDE) database, a prospective register, which contains voluntarily submitted adverse events associated with surgical devices. Information collected include event timing, underlying cause, procedural completion, complications and mortality status.

RESULTS

Between 2016 and 2023, 103 device failures, 5 intra-operative complications and 165 post-operative complications (early: 151, late: 14) were registered. The commonest device problem (56%, n = 58) was failure of the implant to deploy with subsequent requirement for complete replacement. There were 50 cases of documented urosepsis. 62 patients with post operative haematuria were registered including 12 that underwent emergency embolisation. Other complications included stroke (n = 5), pulmonary embolism (n = 3) and necrotising fasciitis (n = 1). Twelve ITU admissions were registered. In the reports, 22 cases were filed that recorded a hospital stay of 7 days or more. Eleven deaths were captured in the database over the study period.

CONCLUSION

While urolift is recognised as less invasive intervention compared to alternatives such as transurethral resection of the prostate, serious adverse events have been reported to occur including death. Our findings can provide learning points for surgeons and allow for improved patient counselling and treatment planning accordingly.

Bladder stone due to late clip migration after prostatic urethral lift procedure: A case report

BACKGROUND

Prostatic urethral lift (PUL) therapy is an alternative to minimally invasive and other surgeries in younger patients who want to preserve their sexual and ejaculatory functions, and in elderly male patients with benign prostatic hyperplasia who cannot be anesthetized because of the risk of anesthesia. The procedure can be performed as an outpatient and without anesthesia, and complications are few and temporary. In long-term follow-up, encrustations that require retreatment are rarely seen.

CASE SUMMARY

In our case, a 62-year-old prostate patient who had a PUL operation 8 years ago and had a stone on the PUL material near the bladder neck was treated. The patient's stone was removed by endoscopic cystolithotripsy using pneumatic fragmentation. Bipolar transurethral resection of the prostate was applied to the patient in the same session. After the patient's 7-year follow-up, the patient's complaints relapsed, and cystoscopy was performed again. In cystoscopy, stone formation adjacent to the wall was observed at the junction of the bladder neck to the left lateral wall. The stone was fragmented with a pneumatic lithotripter.

CONCLUSION

Placing clips too close to bladder neck in the PUL procedure may result in clip migration.

Angioembolization for massive pelvic hematoma after prostatic urethral lift

Introduction

Pelvic hematomas are a rare complication of prostatic urethral lift. We would like to report the first case of massive pelvic hematoma after prostatic urethral lift that was successfully managed by selective angioembolization.

Case presentation

An 83-year-old gentleman with benign prostatic hyperplasia underwent prostatic urethral lift. Although the procedure was uneventful, he developed shock while in the recovery room. Urgent contrast computed tomography scan showed a large heterogenous hematoma at the right pelvis extending to the right retroperitoneum with contrast extravasation noted. Urgent angiogram confirmed extravasation from the right prostatic artery. Angioembolization with coils and 33% N-butyl cyanoacrylate glue was successfully performed.

Conclusion

Prostatic urethral lift can be complicated by the rare massive pelvic hematoma, possibly more common in small prostates. With a prompt contrast computed tomography scan, pelvic hematomas can be managed with angioembolization first and hopefully prevent open exploratory surgery.

Pelvic Hematoma After UroLift: A Case Report and Literature Review

UroLift is a novel, minimally invasive surgical technique used to treat bladder outlet obstruction due to benign prostatic hyperplasia (BPH). UroLift was granted US FDA approval in 2013, and so far, it has gained acceptance and popularity worldwide. In this case report, we present a 69-year-old male patient that developed a pelvic hematoma with subacute clinical manifestations two months following UroLift. The patient was managed conservatively, resulting in the complete resolution of the hematoma. As more surgeons are trained, and the caseload increases, we expect to see more complications related to this novel technique. Surgeons should be aware of this procedure's potential short- and long-term complications.

Large Pelvic Hematoma after UroLift® Procedure for Treatment of BPH with Median Lobe

The UroLift® procedure is a minimally invasive technique used to treat benign prostatic hyperplasia (BPH) in the office or hospital setting. As of 2021, over 200,000 of these procedures have been performed, with an excellent safety profile. We present a case report of a patient who underwent the UroLift® procedure and was found to have a 16.5 cm pelvic hematoma within 16 hours. This study was done as a retrospective chart review. In addition, a comprehensive review of the literature was performed, and all relevant government and company websites were reviewed for thorough evaluation. The patient had an uncomplicated inpatient UroLift® procedure for BPH using 5 implants and was discharged from the hospital without incident. The patient presented to the emergency department with abdominal pain 16 hours after the procedure, and a 16.5 cm pelvic hematoma was found on computerized tomography (CT) scan. Since 2015, there have been 27 cases of pelvic hematoma after UroLift® reported to the United States Food and Drug Administration (FDA), and only 2 cases published in the literature. Our patient required hospital admission for 3 days and 3 units of packed red blood cells, but no surgical exploration or intervention. The procedure was technically successful as it improved the patient's voiding and lower urinary tract symptoms (LUTS) as of 2-month follow-up. Potential etiologies include implant firing depth beyond the extent of the prostate, as well as treatment of the median lobe.

Aquablation, Prostatic Urethral Lift, and Transurethral Water Vapor Therapy: A Comparison of Device-Related Adverse Events in a National Registry

Purpose: Aquablation, prostatic urethral lift (PUL), and transurethral water vapor therapy (TWVT) have demonstrated efficacy for the treatment of benign prostatic hyperplasia (BPH). Our objective was to describe device malfunctions and complications to help guide procedural selection and performance. Materials and Methods: The Manufacturer and User Facility Device Experience (MAUDE) database was examined for reports related to the use of these three procedures for the treatment of BPH between January 1, 2015, and July 1, 2020. Reports were evaluated for device malfunctions and surgical complications using a previously described externally validated classification system developed for the MAUDE database. Chi square analysis was used for statistical comparison between groups. Results: A total of 391 adverse events were reported: aquablation (n = 102), PUL (n = 132), and TWVT (n = 157). There were 79 (78%) severe or life-threatening adverse events for aquablation vs 69 (52%) for PUL vs 24 (15%) for TWVT (p < 0.001). There were 4 cases of rectal perforation with aquablation and 25 cases of the PUL implants needing to be removed or causing a problem with a later procedure. Blood transfusion frequencies were aquablation-32 (31%), PUL-21 (16%), and TWVT-1 (1%). The most common device malfunctions were: aquablation-motion error (n = 8), handpiece fracture/attachment malfunction (n = 8); PUL-device misfire (n = 27), needle fragmentation (n = 21); TWVT-unresolvable error message (n = 19). Conclusions: In a national database, aquablation and PUL had noteworthy complications or device-related malfunctions such as rectal perforation and the improper placement or failed deployment of the PUL implants. Both patients and providers should be aware of potential risks when selecting these novel BPH treatments.

Post-Surgical Complications After Bladder Outlet Reducing Surgery: An Analysis of The FDA Manufacturer and User Facility Device Experience (MAUDE) Database

OBJECTIVE

To examine voluntary reports in the Food & Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database, categorize complications and assign device-related causality with transurethral resection of the prostate (TURP), prostatic urethral lift (PUL), and transurethral water vapor therapy (TWVT).

METHODS

A review was performed using the terms "Urolift," "Rezum," and "transurethral resection of the prostate" between 01/01/2015 and 12/31/2019. Duplicate and incomplete reports were excluded. The Gupta system was used to report complications and device related causality.¹ Pearson's Chi-square analysis was performed to compare minor (Level 1) versus major (Levels 2-4) complications.

RESULTS

A total of 548 events were examined. After removal of duplicates (n = 60), irrelevant reports (n=65), and incomplete information (n = 14), we included 409 events (74.6%). Of the 409 events, 214 were for TURP, 112 for TWVT, and 83 for PUL. In aggregate, 39.4% of events were minor/Level 1 (n=161/409). The proportion of subjects with Level 2-4 complications versus Level 1 complications was significantly higher for PUL than TURP or TWVT [X² (2, N = 408) = 41.4023, P < .00001]. Device causality was attributable to device malfunction in 60.4% of cases (n=247/409).

CONCLUSION

Device malfunction was noted in all groups and 39.4% of these were minor (Level 1). However, the majority of PUL reports noted a Level 3 or 4 complication (50.6%, 42/83), primarily bleeding related. Previous studies have not revealed significant risk of bleeding and suggests a discrepancy between study data and real-world experience that may alter patient counseling practices.

Pharmacological and interventional treatment of benign prostatic obstruction: An evidence‐based comparative review

Introduction

The recommended treatment for bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) after the failure of behavioral therapy and fluid modification includes pharmacological, minimally invasive interventional, and surgical approaches. Each option has different risk and benefit profiles, and the urologist must be aware of the unique characteristics of each option in order to be able to accurately counsel the patients based on their individual values and preferences. We provide a comparative review of the commonest pharmacological and most widely performed interventional/surgical treatments for BPO, discussing the evidence for the treatment characteristics that are most useful for the practicing urologist.

Methods

A search of the PubMed database was performed for articles reporting on the following treatments for LUTS due to BPO: α‐blockers, 5α‐reductase inhibitors, phosphpdiesterase‐5 inhibitors, prostatic urethral lift (Urolift), convective radiofrequency water vapor thermal therapy (Rezum), Temporary implantable Nitinol Device (iTIND), prostate artery embolization (PAE), transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), Aquablation, and anatomical endoscopic enucleation of the prostate (AEEP). We performed a narrative review focussing on the following outcomes: efficacy, safety, durability, duration of catheterization, length of stay, re‐treatment rate, efficacy in special situations (enlarged median lobe, prostate size, urinary retention, and anticoagulant use), and sexual adverse events.

Results

AEEP offers the greatest long‐term improvement in maximum flow rate, IPSS, and prostate volume reduction, with lowest re‐treatment rate, followed by PVP, TURP, and Aquablation. Urolift, Rezum, and PAE have similar efficacy for prostate volume up to 80cc, and all are more effective than the pharmacological treatment. Urolift offers the lowest rate of sexual dysfunction, followed by Rezum, and both can be performed as a day case under local anesthesia.

Conclusion

Several treatment options exist to treat voiding LUTS due to BPO. Newer minimally invasive treatments reduce the hospital stay and postoperative complications, whereas AEEP provides the greatest long‐term symptom improvement at the expense of higher morbidity and sexual dysfunction. Men should be counseled regarding all suitable treatment options as some may favor reduced efficacy in association with reduced side effects.

Prostate Artery Embolization Used in the Management of Transfusion-Dependent Hematuria After Prostatic Urethral Lift Procedure in a Patient with Thrombocytopenia: A Case Report

Background: The prostatic urethral lift (PUL) procedure is a novel therapeutic method to treat lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). Gross hematuria after this procedure has been reported to be mild and transient. This report highlights a case of refractory transfusion-dependent hematuria after the PUL procedure in addition to its management with selective prostatic arterial embolization (PAE). Case Presentation: A 78-year-old Caucasian man with a history of myelodysplastic syndrome, thrombocytopenia, and intermittent urinary retention secondary to BPH underwent a PUL procedure. Before the procedure he received a platelet transfusion making his platelet count 58,000/μL. The day after the procedure he was admitted to a hospital for gross hematuria with clot retention. He was started on continuous bladder irrigation and taken to the operating room for clot evacuation and fulguration of prostate. His thrombocytopenia and anemia were managed with transfusions. He was treated with desmopressin, aminocaproic acid, and intravesical 1% alum without improvement. He returned to the operating room for clot evacuation in addition to photoselective vaporization of the prostate laser ablation of the prostatic fossa. He eventually required a total of four transurethral fulgurations without improvement in transfusion-dependent hematuria. Ultimately, resolution of the hematuria was achieved through bilateral PAE with Embosphere^® Microspheres performed by interventional radiology. He was discharged home 2 days after the embolization procedure without recurrence of hematuria or urinary retention at a 6-month follow-up visit. Conclusion: The PUL procedure has been shown to be an effective alternative to more invasive surgical options for LUTS caused by BPH. Despite careful consideration in an attempt to alleviate urinary retention, PUL still resulted in significant bleeding in this patient with thrombocytopenia. This is the first report to highlight the use of bilateral PAE as a method for achieving control of severe refractory hematuria after PUL.