Holmium Laser Enucleation of the Prostate Is Associated with Complications and Sequelae Even in the Hands of an Experienced Surgeon Following Completion of the Learning Curve

Diosgenin alleviates lipid accumulation in NAFLD through the pathways of ferroptosis defensive and executive system

The most prevalent liver condition globally is non-alcoholic fatty liver disease (NAFLD), for which no approved therapies currently exist. Diosgenin, an important component in plants from the Leguminosae, Dioscoreaceae, and Solanaceae families, has demonstrated considerable anti-inflammatory and antioxidant effects. Nonetheless, the specific mechanism by which it may act in managing NAFLD remains unclear. Our research aims to explore the effects and molecular mechanisms of DG on NAFLD by utilizing both in vivo and in vitro experimental approaches. To investigate the effect of DG on hepatic steatosis, we used Sprague-Dawley rats induced by a high-fat diet (HFD) and HepG2 cells exposed to free fatty acids. Oil red O staining and hematoxylin-eosin (H&E) staining were used to explore lipid accumulation and hepatic degeneration. ROS staining, SOD, MDA, and Fe2+kits were used to detect the indexes related to oxidative stress in ferroptosis in hepatic tissues and cells. IFSP1 and pcDNA3.1-ACSL4 plasmid were used to knock down Ferroptosis suppressor protein1 (FSP1) and promote the expression of acyl-CoA synthetase long-chain family member 4 (ACSL4) in HepG2 cells. DG improved lipid metabolism disorders and liver damage induced by a high-fat diet in rats with NAFLD. Furthermore, the administration of DG notably decreased oxidative stress levels and liver Fe2+ concentrations in rats. Additionally, in vitro experiments demonstrated that DG treatment markedly attenuated ferroptosis and ROS accumulation in HepG2 cells induced by FFAs. Moreover, overexpression of hepatic ACSL4 expression by pcDNA3.1-ACSL4 plasmid promoted the regulatory effects of DG on LPCAT3 and ALOX15. Our research shows that DG can alleviate NAFLD by regulating the FSP1/COQ10 pathway of the ferroptosis defense system and the ACSL4/LPCAT3/ALOX15 pathway of the ferroptosis execution system. Therefore, DG may serve as a novel inhibitor of ferroptosis for the treatment of NAFLD.

Single-port transvesical simple prostatectomy for the surgical treatment of benign prostatic hyperplasia: functional and continence outcomes

BACKGROUND

Robot-Assisted Simple Prostatectomy (RASP) is recommended for the treatment of large prostate glands. The introduction of the Single-Port (SP) platform in 2018 has enabled transvesical approach to SP-RASP with promising outcomes. Our aim was to describe the functional and urinary continence outcomes of SP-RASP.

METHODS

Clinical and surgical data from all consecutive patients who underwent transvesical SP-RASP between February 2020 and March 2024 were collected in a prospectively maintained institutional dataset and retrospectively analyzed. All procedures were performed using the da Vinci SP platform without any conversions to open surgery. Postoperative outcomes were gathered and analyzed, with a particular focus on the incidence of urinary incontinence (UI) and the time to continence recovery.

RESULTS

Overall, 89 patients underwent SP-RASP, with a median prostate size of 110 grams (90-171.5) and a median PSA level of 5.5 mg/dl (2.77-10.93). All patients were on at least one prostate medication prior to surgery. Preoperative evaluations showed a median International Prostate Symptoms Score (IPSS) of 23 (20-27), Quality of Life (QoL) of 4 (3-5), and Post-voiding Residual (PVR) of 153 ml (60-400). The median operative time was 180 min (164-200), with a median estimated blood loss of 100 ml (30-180). Postoperatively, no patients required continuous bladder irrigation. The median postoperative opioid intake was 6.5 morphine equivalents (0-10), with over 78% not requiring narcotics after discharge. Overall, 77.5% were same day discharged. No Clavien-Dindo > 2 complications were recorded. The median follow-up time was 18 (7-35) months. At the last postoperative urological evaluation, the median IPSS was 5 (3-7), QoL was 1 (0-2), and PVR was 10 ml (0-25). Only 4 patients (4.5%) experienced UI postoperatively, and all were continent within 3 months.

CONCLUSIONS

The UI incidence rate and functional outcomes of SP-RASP are very encouraging, likely due to precise adenoma and urethra dissection and bladder neck reconstruction. This approach also allows for same-day discharge.

Endoscopic enucleation of the prostate in men aged 80 years and older. Outcomes from a global, large, and multicenter series using different energy sources and techniques

PURPOSE

To provide the outcomes from a multicentric series of men aged 80 years and above, understand the feasibility of endoscopic enucleation of the prostate (EEP), and compare different energy sources and techniques.

METHODS

We extracted data on patients who underwent EEP in 15 Centers (January 2019-January 2023). Continuous variables are expressed as medians and interquartile ranges while categorical variables as absolute numbers and percentages. A multivariable logistic regression analysis was performed to identify predictors of overall postoperative incontinence and reported as odds ratio (OR) and 95% confidence interval (CI).

RESULTS

731 patients were included. Median age was 82 years and median prostate volume (PV) was 90 cc. 33.1% of participants had PV ≤ 80 ml, 28.4%. between 81 and 100 ml, 36.7% between 101 and 200 ml, and 1.8% of more than 200 ml. Median International Prostate Symptom Score was 23 [20-26]. EEP was mainly performed with the en-bloc technique (367 cases, 50.3% of the total). Total median operation time was 80 min [60-110]. Postoperative urinary incontinence was reported in 113 patients (15.5%). Complication rate was low with only 16 patients (2.2%) suffering from major complications (sepsis: 1 case; bleeding requiring surgical control: 13 cases; secondary morcellation: 2 cases). At multi-variable analysis, PV > 200 ml was significantly associated with higher odds of incontinence (OR 5.84 95% CI 1.76-18.96), whilst en-bloc enucleation with lower odds (OR 0.51 95% CI 0.32-0.80).

CONCLUSION

EEP in men aged 80 years and above is a safe, efficacious, and size-independent procedure. In glands larger than 200 ml there may be a prolonged period of incontinence, mainly stress-related. En-bloc enucleation may be a better approach to minimize early urinary incontinence.

Laser-Driven Dissection Achieves Earlier Continence Recovery Than Blunt Dissection During Holmium Laser Enucleation of the Prostate

OBJECTIVES

During holmium laser enucleation of the prostate (HOLEP), blunt dissection (BD) by pushing the tip of the scope may exert mechanical force on the sphincter that could be avoided by adopting laser dissection (LD). This study evaluates the continence recovery in consecutive patients who underwent BD and LD.

METHODS

A prospective cohort of patients who underwent LD was compared with a retrospective control that underwent BD. In both groups, early apical release was performed, and the adenoma was split at 12 O'clock after complete enucleation. In LD, a trans-capsular plane was sharply created by LD and is guided by the circular capsular fibers. A mechanical push with the resectoscope tip was used to create and maintain the ideal surgical plane in the BD group while the laser energy was used to achieve timely hemostasis. The primary outcome was stress urinary incontinence (SUI), defined as the need to use any number of pads, immediately after catheter removal, at 1 week and 1 month postoperatively.

RESULTS

Consecutive 51 (48.6%) and 54 (51.4%) patients underwent BD and LD, respectively. The LD group tends to be older while other demographics were comparable. Both groups were comparable regarding the estimated prostate volume, enucleation time, and postoperative resolution of symptoms. Continence recovery was in favor of the LD group immediately after removing the catheter (77.8% vs. 43.1%; p < 0.001), at 1 week (92.6% vs. 66.7%; p = 0.002), with no significant difference at 1 month (98.1% vs. 88.2%; p = 0.06).

CONCLUSIONS

LD tends to have favorable early continence recovery compared with BD mostly because of less mechanical stress. Minimizing the periods of blunt pushes during the enucleation might benefit continence recovery.

Residual Prostatic Tissue Mimics Anterior Wall Carcinoma of the Bladder: A Rare Complication of the Holmium Laser Enucleation of the Prostate (HoLEP)

The holmium laser enucleation of the prostate (HoLEP) is a widely accepted and reliable treatment for benign prostatic hyperplasias. In developing countries where HoLEP surgery has only recently been introduced, its popularity is steadily increasing. In our case, the patient's history of HoLEP and the image of the irregular mass extending from the anterior bladder wall into the lumen were initially misdiagnosed as bladder cancer. In our review of the English literature, we were not able to find any cases similar to ours, in which the residual prostatic tissue following a HoLEP mimicked a bladder cancer.

Prospective study of urinary incontinence recovery following endoscopic enucleation of the prostate

OBJECTIVE

To investigate the clinical trajectories and identify risk factors linked to post-enucleation urinary incontinence (UI).

PATIENTS AND METHODS

In this prospective study (April 2020 to March 2022) at a single institution, 316 consecutive patients receiving endoscopic enucleation due to benign prostatic enlargement were included. Patient information and perioperative details were collected. Follow-ups, from 1 to 6 months, assessed postoperative UI using International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and a four-item pad questionnaire, classified per International Continence Society definitions. Logistic regression analysed predictors at 1 week, while generalised estimating equation assessed risk factors from 1 to 3 months postoperatively.

RESULTS

Patients with a median prostate volume of 57 mL underwent enucleation, with 22.5% experiencing postoperative UI at 1 week, 5.6% at 3 months, decreasing to 1.9% at 6 months. Multivariable analysis identified age (>80 years), specimen weight (>70 g), en bloc with anteroposterior dissection, and anal tone (Digital Rectal Examination Scoring System score <3) as potential factors influencing UI. Subgroup analysis revealed that specimen weight was associated with both continuous and stress UI. Anal tone was related to both other types and stress UI, while overactive bladder symptoms were associated with urge UI.

CONCLUSION

In summary, our study elucidates transient risk factors contributing to temporary post-enucleation UI after prostatectomy. Informed decisions and personalised interventions can effectively alleviate concerns regarding postoperative UI.

The Learning Curve for Holmium Laser Enucleation of the Prostate: A Single-Center Analysis of Surgical And Functional Outcomes

Background: To report the surgical and functional outcomes of the holmium laser enucleation of the prostate (HoLEP) surgical program implemented at a high-volume tertiary referral center and to estimate the learning curve (LC) duration for this surgical procedure. Methods: Data of all consecutive patients undergoing HoLEP at the University of Verona between June 2022 and April 2024 were retrieved from a prospectively maintained institutional database of patients undergoing benign prostatic hyperplasia (BPH) surgical treatment. The primary endpoint was functional outcomes evaluation during the surgeons' LC. The secondary endpoint was to define the surgical LC for HoLEP. A multivariable test of means was performed to compare functional outcomes at different time points. After adjusting for potential confounders (age, preoperative pharmacotherapy, and prostate volume), multivariable linear regression models were fitted to evaluate the effect of experience on operative time (OT) and enucleation efficiency. To assess LCs for HoLEP surgery, the non-risk-adjusted cumulative sum (CUSUM) method was used. Results: A statistically significant improvement in International Prostate Symptoms Score (IPSS) score, delta% IPSS score, IPSS quality of life (IPSS-QoL) score, and delta% IPSS-QoL score was observed over the study period. Furthermore, the incidence of irritative symptoms (p < 0.001) and stress incontinence (p = 0.01) significantly decreased over time, with a 12-month incidence of 8.4% and 9.5%, respectively. A statistically significant association between experience and both OT and enucleation efficiency was observed in multivariable linear regression analysis. The CUSUM chart for OT and enucleation efficiency showed a steep initial upward/downward trend of ∼50 cases each, and a plateau until ∼100 procedures are reached, where the breakpoint is recognized for both variables and where the CUSUM curve goes below the locally weighted scatterplot smoothing curve in the corresponding observed-expected CUSUM plot. Conclusions: HoLEP represents an effective treatment for BPH, demonstrating significant improvement in BPH-related symptoms over the study period, despite the considerable LC of ∼50 cases associated with the procedure.

Postoperative urinary incontinence following BPH surgery: insights from a comprehensive national database analysis

BACKGROUND

Postoperative urinary incontinence (UI) is a feared complication of BPH surgery. Our study aims to investigate the incidence of UI among patients undergoing different procedures for BPH.

METHODS

A retrospective analysis was conducted using a large national database, containing patient records between 2011 and 2022. The most employed surgical procedures for BPH were considered, including TURP, Transurethral Incision of the Prostate (TUIP), Holmium/Thulium Laser Enucleation of the Prostate (HoLEP/ThuLEP), Open Simple Prostatectomy (OSP), minimally invasive simple prostatectomy (Lap/Rob SP), Photoselective Vaporization of the Prostate (PVP), Prostatic Urethral Lift (PUL), Robotic Waterjet Treatment (RWT - Aquablation®), Water Vapor Thermal Therapy (WVTT - Rezum®) and Prostatic Artery Embolization (PAE). Rates of any type of UI, including stress UI (SUI), urge UI (UUI) and mixed UI (MUI) were assessed. Multivariate regression analysis was used to identify predictors of "persistent" postoperative UI, defined as the presence of an active UI diagnosis at 12 months post-surgery.

RESULTS

Among 274,808 patients who underwent BPH surgery, 11,017 (4.01%) experienced persistent UI. UUI rates varied between 0.62% (PAE) and 2.71% (PVP), SUI ranged from 0.04% (PAE) and 2.75% (Lap/Rob SP), while MUI between 0.11% (PAE) and 1.17% (HoLEP/ThuLEP). On multivariable analysis, HoLEP/ThuLEP (OR 1.612; 95% CI: 1.508-1.721; P<0.001), PVP (OR 1.164; 95% CI:1.122-1.208; P<0.001), Open SP (OR 1.424; 95% CI:1.241- 1.624; P<0.001), and Lap/Rob SP (OR 1.667; 95% CI:1.119-2.384; P<0.01) showed significant higher likelihood of UI compared to TURP. PUL (OR 0.604; 95% CI:0.566-0.644; P<0.001), WVTT (OR 0.661; 95% CI:0.579-0.752; P<0.001), RWT (OR 0.434; 95% CI:0.216-0.767; P<0.01), and PAE (OR 0.178; 95% CI:0.111-0.269; P<0.001) were associated with lower likelihood of UI.

CONCLUSIONS

UI remains a concerning complication following BPH surgery, but it is an uncommon event affecting <5% of patients. Some differences in UI rates and risk might exist among various BPH procedures. These findings underscore the need for thorough patient selection and counseling.

The early learning curve of the bipolar enucleation of the prostate: a multicenter cohort study

OBJECTIVES

To evaluate the early learning curve of BipolEP (Bipolar Enucleation of the Prostate).

SUBJECTS/PATIENTS AND METHODS

We conducted a retrospective, multicenter analysis of surgical and functional outcomes of patients treated with BipolEp for BPO (benign prostatic obstruction). We evaluated the first 20 cases of BipolEp performed by four different surgeons in three different countries. The following baseline parameters were obtained: age, IPSS, indwelling catheter, transrectal measured prostate volume, post void residual volume (PVR) and uroflowmetry. The learning curve was analysed based on perioperative parameters and the influence of perioperative parameters was correlated with the sequence of BipolEp cases.

RESULTS

84 BipolEp operations performed by 4 different surgeons in their early learning curve were studied. Mean prostate volume was 75 ml, 39% of cases had an indwelling catheter and the average operating time was 101 min. Three out of four surgeons performed at least 50% of successful operations according to Trifecta (complete enucleation and morcellation < 90 min., no conversion to TUR-P). Conversion rate to TURP was 11.9% in total which however was driven by a single surgeon with an almost 50% conversion rate. Mean enucleated prostate was 33.3 gr (18-54.5). Intraoperative complications and reported stress incontinence ranged from 0 to 38.1%. At six-weeks review, the IPPS improved by 12.5 (8-16) points and Qmax by 208% (109.8-266.7). Uroflowmetry outcomes correlated with the sequence of cases with a linear improvement during 20 consecutive cases (p = 0.018) in all centres. Major complications (Clavien Dindo ≥ 3) were rare (4.8%) and comparable between the groups.

CONCLUSION

Surgeons starting to learn BipolEp can expect to be able to achieve a linear improvement in Uroflow at the six-week postoperative evaluation after 20 consecutive cases. BipolEp can be successfully performed during the early learning curve with an acceptable rate of conversion to standard TUR-P.

Incidence of urinary incontinence following endoscopic laser enucleation of the prostate by en-bloc and non- en-bloc techniques: a multicenter, real-world experience of 5068 patients

We aim to evaluate the incidence of incontinence following laser endoscopic enucleation of the prostate (EEP) comparing en-bloc (Group 1) versus 2-lobe/3-lobe techniques (Group 2). We performed a retrospective review of patients undergoing EEP for benign prostatic enlargement in 12 centers between January 2020 and January 2022. Data were presented as median and interquartile range (IQR). Univariable and multivariable logistic regression analysis was performed to evaluate factors associated with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI). There were 1711 patients in Group 1 and 3357 patients in Group 2. Patients in Group 2 were significantly younger (68 [62-73] years vs 69 [63-74] years, P = 0.002). Median (interquartile range) prostate volume (PV) was similar between the groups (70 [52-92] ml in Group 1 vs 70 [54-90] ml in Group 2, P = 0.774). There was no difference in preoperative International Prostate Symptom Score, quality of life, or maximum flow rate. Enucleation, morcellation, and total surgical time were significantly shorter in Group 1. Within 1 month, overall incontinence rate was 6.3% in Group 1 versus 5.3% in Group 2 ( P = 0.12), and urge incontinence was significantly higher in Group 1 (55.1% vs 37.3% in Group 2, P < 0.001). After 3 months, the overall rate of incontinence was 1.7% in Group 1 versus 2.3% in Group 2 ( P = 0.06), and SUI was significantly higher in Group 2 (55.6% vs 24.1% in Group 1, P = 0.002). At multivariable analysis, PV and IPSS were factors significantly associated with higher odds of transient SUI/MUI. PV, surgical time, and no early apical release technique were factors associated with higher odds of persistent SUI/MUI.

Impact of age and anterior fibromuscular stroma preservation on post-enucleation voided volume

PURPOSE

This study is centered on the critical role of anterior fibromuscular stroma (AFS) preservation in prostate enucleation, an emerging strategy aimed at minimizing postoperative urinary incontinence-a common concern in benign prostatic hyperplasia (BPH) surgeries. By focusing on postoperative voiding volumes (VV), our research investigates the efficacy of AFS preservation. This approach, distinct in its methodology, is hypothesized to improve urinary function post-surgery, thereby offering a potentially significant advancement in BPH surgical treatments.

MATERIALS AND METHODS

A retrospective analysis was conducted, comparing patients who underwent prostate enucleation in 2017 without intentional AFS preservation to those in 2019 with this technique. We examined variables including age, BMI, diabetes, hypertension, and preoperative VV to assess their effect on post-catheter removal VV. The study's methodology includes a thorough review of the primary statistical analysis methods employed.

RESULTS

Our analysis indicates that while the 2017 and 2019 cohorts were similar in most preoperative parameters, the 2019 group that underwent AFS-preserved surgery showed a significant improvement in postoperative VVs. This was less pronounced in the patient group aged over 70, underscoring the importance of this demographic in our study.

CONCLUSIONS

The study concludes that intentional preservation of AFS during prostate enucleation positively impacts early postoperative VVs, with limited improvement in older patients. These findings highlight the potential of AFS preservation not only in enhancing urinary outcomes post-surgery but also in shaping future BPH surgical procedures and research directions.

Influence of Early Apical Release on Outcomes in Endoscopic Enucleation of the Prostate: Results From a Multicenter Series of 4392 Patients

OBJECTIVE

To evaluate outcomes after laser endoscopic enucleation of the prostate (EEP) stratified by whether early apical release (EAR) was performed or not.

METHODS

We retrospectively reviewed patients with clinical benign prostatic hyperplasia who underwent EEP with holmium or thulium fiber laser in 8 centers (January 2020-January 2022).

EXCLUSION CRITERIA

previous prostate/urethral surgery, prostate cancer, pelvic radiotherapy, concomitant lower urinary tract surgery. One-to-one propensity score-matching was performed between patients with EAR vs no EAR, with covariates including age, prostate volume, diabetes mellitus, hypertension, preoperative indwelling catheter, IPSS, Qmax, enucleation, and laser types. Multivariable logistic regression analyses were performed to evaluate independent predictors of 30-day postoperative complications and urinary incontinence.

RESULTS

EAR was performed in 2094 of 4392 included patients. The matched cohort consisted of 787 patients per arm. Total operation time was significantly longer in the EAR group (median 75 vs 67 minutes, P = .004). Early complications were higher in the EAR group (18.6% vs 12.5%, P = .001), while postoperative incontinence rates were similar (14.1% vs 13.1%, P = .61). Multivariable regression analysis showed that 3-lobe enucleation and operation time were significant predictors of postoperative complications; preoperative indwelling catheterization, higher prostate volume, and en-bloc enucleation were associated with higher odds of postoperative incontinence.

LIMITATION

retrospective nature.

CONCLUSION

Performing EAR during EEP is associated with a greater incidence of early complications, which was mainly driven by higher rates of postoperative hematuria and perioperative transfusion. The risk of postoperative incontinence and its duration are not affected by EAR.

Patient reported outcome and quality of life measured by a simple questionnaire in patients with symptomatic benign prostate hyperplasia treated by holmium laser enucleation of the prostate (HoLEP)

Introduction

Holmium Laser Enucleation of the Prostate (HoLEP) is established as an effective transurethral treatment option for LUTS due to BPH with improved postoperative outcome. The aim of this study was to evaluate the medium-term results by patient reported outcome measurement and to detect potential risk factors for postoperative complications or impaired outcome.

Methods

We performed a retrospective single-center cohort study including all patients undergoing HoLEP in the study center between April 2019 and December 2021. Therefore, perioperative parameters and postoperative outcome was documented and all patients were asked for their outcome (PROM), complications, IPSS, QoL and changes in sexual and continence function by a questionnaire at a single time point.

Results

In the study period, a total of 541 patients with a mean age of 72.5 ± 8.4 years were treated by HoLEP in the study center. 71.7% of the questionnaires were returned after a mean observation period of 14.9 ± 6.3 month. 91% of the patients reported to the single-timepoint questionnaire reporting a good satisfaction with the procedure and a low postoperative complication rate. The international prostate symptom score could be reduced significantly to 6.2 ± 5.7 (preoperative 19.0 ± 7.2; p < 0.001). Patients with an ASA score ≥ 3, prostate volume > 80 ml, medication with platelet inhibitors or DOAK or preoperative need of an indwelling catheter didn't show an increased complication rate.

Conclusion

The overall satisfaction with the procedure and its results are high. We could not identify any independent risk factors for postoperative complications after HoLEP. The used questionnaire is a simple tool for postoperative patient reported outcome measurement with a good correlation to clinical parameters.

Advances in lasers for the minimally invasive treatment of upper and lower urinary tract conditions: a systematic review

PURPOSE

Technological advancements in laser lithotripsy are expanding into numerous fields of urology, like ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and benign and malignant soft-tissue treatments. Since the amount of research regarding lasers in urology has grown exponentially, we present a systematic review of the most recent and relevant advances encompassing all lasers used in urological endoscopic treatment.

METHODS

We performed a literature search using PubMed (May 2023) to obtain information about lasers for urological purposes. We included only recent data from published articles between 2021 and 2023 or articles ahead of print.

RESULTS

Lasers are widely used in lithotripsy for ureteric, renal, and bladder stones, benign prostate surgery, and bladder and upper tract tumor ablation. While the holmium (Ho:YAG) laser is still predominant, there seems to be more emphasis on pulse modulation and newer lasers such as thulium fiber laser (TFL) and pulsed Tm:YAG laser.

CONCLUSION

The use of lasers and related technological innovations have shown increasing versatility, and over time have proven to be invaluable in the management of stone lithotripsy, treatment of benign and malignant prostate diseases, and urothelial tumors. Laser endoscopic treatment is heavily based on technological nuances, and it is essential to know at least the basics of these technologies. Ultimately the choice of laser used depends on its availability, cost, surgeon experience and expertise.