Current surgical techniques of enucleation in holmium laser enucleation of the prostate

Effect of detrusor underactivity on surgical outcomes of holmium laser enucleation of the prostate

OBJECTIVE

To evaluate the effect of detrusor underactivity (DUA) on the postoperative outcomes of holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Patients with BPH who underwent HoLEP between January 2018 and December 2022 were enrolled in this prospective database study. Patients were divided into DUA (bladder contractility index [BCI] <100) and non-DUA (BCI ≥100) groups. Objective (maximum urinary flow rate [Qmax], post-void residual urine volume [PVR]) and subjective outcomes (International Prostate Symptom Score [IPSS], Overactive Bladder Symptom Score [OABSS], satisfaction with treatment question [STQ], overall response assessment [ORA], and willingness to undergo surgery question [WUSQ]) were compared between the two groups before surgery, and at 3 and 6 months after HoLEP.

RESULTS

A total of 689 patients, with a mean (standard deviation [SD]) age of 69.8 (7.1) years, were enrolled. The mean (SD) BCI in the non-DUA (325 [47.2%]) and DUA (364 [52.8%]) groups was 123.4 (21.4) and 78.6 (14.2), respectively. Both objective (Qmax and PVR) and subjective (IPSS, IPSS-quality of life, and OABSS) outcomes after surgery significantly improved in both groups. The Qmax was lower in the DUA than in the non-DUA group postoperatively. At 6 months postoperatively, the total IPSS was higher in the DUA than in the non-DUA group. There were no significant differences in surgical complications between the two groups. Responses to the STQ, ORA, and WUSQ at 6 months postoperatively demonstrated that the patients were satisfied with the surgery (90.5% in the DUA group; 95.2% in the non-DUA group), their symptoms improved with surgery (95.9% in the DUA group; 100.0% in the non-DUA group), and they were willing to undergo surgery again (95.9% in the DUA group; 97.9% in the non-DUA group). There were no significant differences in the responses to the STQ and WUSQ between the two groups.

CONCLUSION

Our midterm results demonstrated that patients with BPH and DUA showed minimal differences in clinical outcomes after HoLEP compared to those without DUA. The overall satisfaction was high in the DUA group.

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.

Enhancing continence post holmium laser enucleation of the prostate: assessment of novel technique through randomized clinical trial

BACKGROUND

Transient urinary incontinence (UI) is distressing event following holmium laser enucleation of the prostate (HoLEP). Novel technique namely, veil sparing HoLEP (VS-HoLEP), was proposed to improve early continence outcome. In this trial (NCT03494049), VS-HoLEP was compared to standard HoLEP (St-HoLEP).

METHODS

VS-HoLEP entails early apical separation with sparing of ventral apical mucosal veil proximal to the verumontanum. Eligible symptomatic BPH patients were randomly allocated to St-HoLEP (91) and VS-HoLEP (89). The primary outcome was UI as depicted by one-hour pad test at one month postoperatively. Other outcome measures include all perioperative parameters, complications, and urinary outcome measures at different follow-up points.

RESULTS

Median preoperative prostate size was 138 (50:282) and 128 (50:228) mL in St-HoLEP and VS-HoLEP groups respectively. At one month the number of patients with positive one-hour pad test was 21 (23.1%) and 10 (11.4%) in St-HoLEP and VS-HoLEP groups respectively (P 0.047). The difference was significantly in favor of VS-HoLEP considering the number of patients reporting UI, the number of patients with positive one-hour pad test as well as the grade of UI reported at one and 4 months. The difference was not statistically significant at 12 months. The median time to patients' reported continence was 8 (1-52) and 1.5 (1-52) weeks in St-HoLEP and VS-HoLEP groups respectively (P≤0.005). The technique independently predicted positive one-hour pad test at one and four months respectively. At twelve months presence of DM (diabetes mellitus) and more percent PSA reduction independently predicted positive one-hour pad test.

CONCLUSIONS

Veil sparing HoLEP enhances significantly early postoperative urine continence both subjectively and objectively. Optimization of the surgical technique could cut short the number of leaking patients and reduce the degree as well as the duration of transient postoperative urine leak.

Endoscopic enucleation of the prostate with Thulium Fiber Laser (ThuFLEP). A retrospective single-center study

PURPOSE

The aim of the present, retrospective study was to describe our initial experience and early outcomes of Thulium Fiber Laser enucleation of the prostate (ThuFLEP) with the use of the FiberDust™ (Quanta System, Samarate, Italy) in patients with benign prostate hyperplasia.

METHODS

From June 2022 to April 2023, all patients who underwent endoscopic enucleation of the prostate at Urology Department of the University Hospital of Patras were included. A single surgeon utilizing the same standardized operative technique performed all the surgeries. The primary endpoints included the uneventful completion of the operation, the surgical time and any minor or major complication observed intra- or post-operatively.

RESULTS

Twenty patients with benign prostate hyperplasia were treated with ThuFLEP. All the surgeries were completed successfully and uneventfully. The enucleation phase of the operation was completed in a mean time of 45±9.1 min, while the average time needed for the morcellation was 17.65±3.42 min. No significant complications were observed intra- or post-operatively. The average hemoglobin drop was calculated to be 0.94±0.71 g/dL.

CONCLUSIONS

All the operations were successfully and efficiently completed with the use of the FiberDust™ (Quanta System, Samarate, Italy) in ThuFLEP. Significant blood loss or major complications were not observed.

The prostatic middle lobe: clinical significance, presentation and management

The role of the prostatic middle lobe in the presentation and management of benign prostatic hyperplasia (BPH) is under-appreciated. Middle lobe enlargement is associated with intravesical prostatic protrusion (IPP), which causes a unique type of bladder outlet obstruction (BOO) via a 'ball-valve' mechanism. IPP is a reliable predictor of BOO and the strongest independent factor for failure of medical therapy necessitating conversion to surgical intervention. Men with middle lobe enlargement tend to exhibit mixed symptoms of both the storage and the voiding types, but symptomatology will vary depending on the degree of IPP present. Initial assessments such as uroflowmetry and post-void residual volumes are inadequate to detect IPP and could confound the clinical picture. Radiological evaluation of prostate morphology is key to assessment as it provides important prognostic information and can help with operative planning. Treatment strategies employed for BPH should consider the shape and morphology of prostate adenomata, specifically the presence of middle lobe enlargement and the degree of associated IPP.

The Efficacy and Safety of 'Inverted Omega En-bloc' Holmium Laser Enucleation of the Prostate (HoLEP) for Benign Prostatic Hyperplasia: A Size-Independent Technique for the Surgical Treatment of LUTS

PURPOSE

To evaluate the safety, efficiency, and size-dependency of the 'Inverted omega En-bloc (Ʊ)' holmium laser enucleation of the prostate (HoLEP) in benign prostate hyperplasia (BPH) with lower urinary tract symptoms.

MATERIALS AND METHODS

A retrospective analysis of 716 consecutive patients who underwent HoLEP under the care of a single surgeon from 2014-2021. These patients were treated using the 'Inverted omega En-bloc' HoLEP technique for BPH. The patients were divided into 3 groups: Group 1 (<40 mL, n=328), Group 2 (40-60 mL, n=221), and Group 3 (≤60 mL, n=167). Perioperative parameters, safety, and functional outcomes were assessed and analyzed.

RESULTS

The perioperative parameters, like enucleation time (45.8±26.9 min), morcellation time (13.2±47.5 min), and catheterization duration (1.6±1.2 d) significantly differed to favor smaller prostate sizes (p<0.01). Significant improvements in the IPSS (total, voiding, storage, and quality of life), post-void residual urine, and maximum flow rate were observed 3 months post-HoLEP and continued during the 1-year follow-up period in all groups (p<0.01). The postoperative complications included urethral stricture in 11 patients (1.5%), bladder neck contracture in 12 (1.7%), urinary incontinence in 14 (2.0%), and bladder injuries in 4 (0.6%). Bladder neck contractures occurred only in Group 1. The postoperative surgical management for complications included urethral sounding (n=9, 1.3%), endoscopic internal urethrotomy (n=2, 0.3%), and re-HoLEP for bladder neck contractures in (n=12, 1.7%). The rate of re-HoLEP for regrowing adenomas was 15 (2.1%). Postoperative medications exceeding 6 months were α-blocker (n=22, 3.1%), cholinergics (n=16, 2.2%), anticholinergics (n=58, 8.1%), antidiuretics (n=18, 2.5%), and daily PDE5 inhibitor (n=38, 5.3%). Thirty-four patients (4.7%) had postoperative incidental prostate cancer.

CONCLUSIONS

The inverted omega En-bloc HoLEP technique is safe and effective for the treatment of BPH. Moreover, 'Inverted omega En-bloc' HoLEP is a size-independent and effective method for all prostate sizes.

En bloc enucleation of the prostate with early apical release using a high-power (200 W) thulium device: studying a learning curve

OBJECTIVE

The aim of this study was to reveal the learning curve of early apical release en bloc laser prostatectomy using a high-power thulium (200 W) laser device.

METHODS

We obtained data on the initial 60 patients who had thulium laser enucleation of the prostate by a single surgeon between October 2021 and August 2022 to treat the signs and symptoms of benign prostatic hyperplasia at our clinic. The cases were split into three groups, each consisting of 20 patients. Prostate volumes, prostate-specific antigen and hemoglobin levels, the International Prostate Symptom Score, Quality of Life scores, the International Index of Erectile Function-5 scores, and uroflowmetry parameters were documented preoperatively. The enucleation weight, the enucleation and morcellation times, as well as the efficiency, hospitalization, and catheterization durations were calculated. The patients were re-evaluated at 6 months postoperatively, examined for functional results, and compared to baseline conditions.

RESULTS

Enucleation times, morcellation times, enucleation weight, and enucleation efficiency were significantly different among the groups. However, there was no statistically significant difference in total operative time and morcellation efficiency. In terms of postoperative statistics, the reduction in hemoglobin was significantly greater in Group 1 compared to Group 2. Six months after surgery, all groups had comparable validated ratings (International Prostate Symptom Score, Quality of Life, and the International Index of Erectile Function-5) on postoperative examinations. There were no long-term complications in either group throughout the perioperative period.

CONCLUSION

Completing 40 first cases would be sufficient for managing the learning curve for early apical release en bloc thulium laser enucleation of the prostate.

A Delphi consensus to standardize the technique of anatomical endoscopic enucleation of prostate: a study by ESUT endoscopic enucleation of prostate study group

PURPOSE

Our objective was to establish a standardized technique for Anatomical Endoscopic Enucleation of Prostate (AEEP) utilizing a consensus statement to provide robust recommendations for urologists who are new to this procedure.

METHODS

The participants were electronically sent a questionnaire in three consecutive rounds. In the second and third rounds, the anonymous aggregate results of the previous round were presented. Experts' feedback and comments were then incorporated to refine existing questions or to explore more controversial topics in greater depth.

RESULTS

Forty-one urologists participated in the first round. In the second round, all Round 1 participants received a 22-question survey, resulting in a consensus on 21 items. In the third round, 76% (19/25) of the second-round respondents also participated, reaching a consensus on 22 additional items. The panelists consensually agreed on detaching the urethral sphincter at the beginning of the enucleation and not at the end of the enucleation. To prevent incontinence, it was recommended that the apical mucosa be preserved through various approaches between 11 and 1 o'clock while gently disrupting the lateral lobes in their apical part, avoiding an excess energy delivery approximation to the apical mucosa.

CONCLUSION

To optimize laser AEEP procedures, urologists must follow expert guidelines on equipment and surgical technique, including early apical release, using the 3-lobe technique for enucleation, preserving apical mucosa with appropriate approaches, gently disrupting lateral lobes at their apical regions, and avoiding excessive energy delivery near the apical mucosa. Following these recommendations can lead to improved outcomes and patient satisfaction.

Efficacy and safety of low power holmium laser enucleation of the prostate: A prospective short- and medium-term single-blind randomized trial

PURPOSE

We evaluated the efficacy and safety of mid-term follow-up in low-power (LP) Holmium laser enucleation of the prostate (HoLEP) compared with high-power (HP) surgery for benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

This prospective, single-blind, randomized controlled study was conducted between September 2020 and April 2021. Ninety male patients >50 years who underwent HoLEP for BPH were randomly assigned to HP (80 W/2 J/40 Hz) and LP (24 W/2 J/12 Hz) groups. The primary endpoint was the total International Prostate Symptom Score (IPSS) six months after surgery. The secondary endpoints were perioperative results and postoperative outcomes at two weeks, three and six months after the surgery, including Clavien-Dindo complication classification.

RESULTS

At six months after HoLEP, 41 and 42 patients were followed up in the HP and LP groups, respectively. There was no difference in the preoperative characteristics between the two groups. The prostate volumes were 67.1±23.7 mL for the HP group and 64.3±25.7 mL for the LP group (p=0.592), respectively. Although the total operative time was significantly longer by 13.1 minutes in the LP group (47.8±20.3 min vs. 60.9±23.3 min, p=0.006), the total delivered energy was significantly lower, which was only about 68% of the HP group (58.2±23.9 kJ vs. 39.9±13.2 kJ, p<0.001). Surgical outcomes significantly improved postoperatively in both groups compared to baseline, except for storage symptoms. Improvement in IPSS storage subscore was observed from the immediate postoperative 2 weeks in the LP group (8.1±3.1 to 6.9±3.8, p<0.001), whereas there was no significant recovery in the HP group (8.0±3.2 to 7.7±3.4, p=0.842). In the 6-month follow, there was no significant difference between the two groups in the IPSS total score (5.9±5.6 vs. 7.3±5.3, p=0.260) as well as IPSS storage subscore. In addition, there was no significant difference in postoperative complications, including bleeding or urinary incontinence, between the two groups.

CONCLUSIONS

The HoLEP procedure performed using an LP laser device resulted in lower total delivered energy, faster recovery, and significantly improved surgical outcomes up to mid-term follow-up. There was no difference in efficiency or safety between the HP device system.

Risk Factors of Salvage Procedure for Refractory Morcellation During Holmium Laser Enucleation of the Prostate

PURPOSE

We aimed to identify the risk factors for salvage procedure (SP) required for refractory adenomatous tissue resistant to morcellation during holmium laser enucleation of the prostate (HoLEP).

METHODS

Patients who underwent HoLEP between January 2010 and April 2020 at Seoul National University Hospital were analyzed. SPs were defined as cases of conversion to resection of the prostatic tissue using an electrosurgical loop after morcellation or secondary morcellation a few days after surgery or conversion to open cystotomy.

RESULTS

Among a total of 2,427 patients, 260 were identified as having SP (SP group) (transurethral resection-nodule [n = 250, 96.1%], secondary morcellation a few days after surgery [n = 9, 3.5%], and conversion to open cystotomy [n = 1, 0.4%]). Patients in the SP group were older and had higher 5-α reductase inhibitors use, higher prostate-specific antigen, larger total prostate volume, and larger transition zone volume (TZV) than those in the non-SP group. In the multivariable logistic regression analysis, only age and TZV were associated with SP. Compared to 40s and 50s, the odds ratios (ORs) were 3.84 in 60s (95% confidence interval [CI] 1.37-10.78, P = 0.011), 4.53 in 70s (95% CI, 1.62-12.62, P = 0.004), and 6.59 in 80s or older (95% CI, 2.23-19.46, P = 0.001). The ORs of the SP were analyzed per TZV quartile. Compared to TZV ≤ 20.3 mL, the OR was 3.75 in 32.0 mL < TZV ≤ 50.4 mL (95% CI, 2.00-7.04, P < 0.001) and 8.25 in 50.4 mL < TZV (95% CI, 4.06-16.77, P < 0.001).

CONCLUSION

The risk of refractory morcellation increased in patients aged > 60 years or those with TZV > 32 mL. In order to more efficiently remove these resistant adenomas, it is necessary to develop more efficient morcellators in the future.

Comparison of Postoperative Outcomes of Trans-urethral Resection of the Prostate, Laser Vaporization, and Laser Enucleation: A Double Propensity Score Matched Analysis

OBJECTIVE

To compare postoperative outcomes of 3 types of endourologic surgeries (trans-urethral resection of the prostate [TURP], laser vaporization [LVP], and laser enucleation [LEP]) for benign prostatic hypertrophy (BPH) treatment using the ACS-NSQIP database.

METHODS

The ACS-NSQIP database was queried for men who underwent TURP, PVP, and LEP for treatment of BPH from 2011 till 2019. Demographics, clinical, operative characteristics, and 30-day outcomes were compared. Univariate and multivariate regression models were constructed. Propensity score matching was then performed as a sensitivity analysis.

RESULTS

A total of 74,273 patients underwent endourologic surgeries for BPH, 65.4% had TURP, 28.6% PVP, and 5.9% LEP. Patients undergoing TURP were more likely to be older with higher ASA class, abnormal labs, and comorbidities (diabetic, congestive heart failure, and bleeding requiring transfusion) (P-value <.001). After adjusting for covariates and propensity score matching, LVP demonstrated shorter hospital stays, shorter operative times, less reoperation rates, decreased DVT/PE risk, with, however, higher odds of urinary tract infection and sepsis as compared to TURP (P-value<.028). Furthermore, LEP was found to have shorter hospital stays, longer operative times, and decreased odds of urinary tract infections and sepsis as compared to TURP (P-value<.006).

CONCLUSION

LVP and LEP showed better surgical outcomes and characteristics as compared to TURP. Further research is needed to account for longer duration of follow-up and patient-specific urologic outcomes, such as prostate size, urinary incontinence, erectile dysfunction, and retrograde ejaculation.

Predictive factors affecting morcellation efficiency in holmium laser enucleation of the prostate

PURPOSE

To determine the factors affecting morcellation efficiency in holmium laser enucleation of the prostate (HoLEP) surgery.

MATERIALS AND METHODS

Patients who underwent HoLEP surgery by a single surgeon between 2018 and 2022 were included in the study. Our primary outcome of interest in this study was morcellation efficiency. The effect of preoperative and perioperative variables on morcellation efficiency was evaluated with linear regression analysis.

RESULTS

A total of 410 patients were included in the study. The mean morcellation efficiency was 6.95±1.70 g/min. Univariable and multivariable linear regression analysis was performed to identify factors affecting morcellation efficiency. Presence of the "beach ball" effect (small, round prostatic tissue fragments that are fibrotic and difficult to morcellate), the learning curve, resectoscope sheath type, prostate-specific antigen (PSA) density, morcellated tissue weight, and the presence of prostate calcification were found to be independent predictive factors (β=-1.107, 95% CI: -1.59 to -0.55, p<0.001; β=-0.514, 95% CI: -0.85 to -0.17, p=0.003; β=-0.394, 95% CI: -0.65 to -0.13, p=0.003; β=-0.302, 95% CI: -0.59 to -0.09, p=0.043; β=0.062, 95% CI: 0.05 to 0.06, p<0.001; β=-0.329, 95% CI: -0.55 to -0.10, p=0.004; respectively).

CONCLUSIONS

This study reports that presence of the beach ball effect, the learning curve, small resectoscope sheath, PSA density, and presence of prostate calcification negatively affect morcellation efficiency. On the contrary, morcellated tissue weight has a linear relationship with morcellation efficiency.

Peri- and post-operative outcomes, complications, and functional results amongst different modifications of endoscopic enucleation of the prostate (EEP): a systematic review and meta-analysis

PURPOSE

To investigate and assess outcomes, complications, and functional results amongst different modifications of endoscopic enucleation of the prostate (EEP).

METHODS

We conducted a systematic review and meta-analysis according to the PRISMA checklist. We searched the Medline, Cochrane, and Embase databases. We included only randomised-controlled trials (RCT) comparing modifications of EEPs and assessed the risk of bias (RoB).

RESULTS

Seven RCTs were included in the study. Overall, 1266 patients were treated with Holmium laser enucleation of the prostate (HoLEP) and 80 patients with thulium laser vapo-enucleation of the prostate (ThuVEP). The operative time during pulse shape-modified HoLEP was shorter when compared to standard pulse HoLEP (MD 18.08 min, 95% CI 8.11-28.05 min, p = 0.0004). The decrease in haemoglobin was significantly lower for two-lobe HoLEP when compared to three-lobe HoLEP (MD 0.16 g/dl, 95% CI 0.22-0.1 g/dl, p < 0.00001). Virtual Basket (VB) HoLEP showed a smaller haemoglobin decrease when compared to standard pulse HoLEP (1.12 ± 1.78 vs. 2.54 ± 1.23 g/dl, p = 0.03). When directly comparing one- vs. two- vs. three-lobe HoLEP, surgical time (p < 0.001) and enucleation efficiency (p = 0.006) were significantly different and favouring one- and two-lobe HoLEP in the study with the largest patient population included. No significant differences for complications were observed; however, Clavien-Dindo IVa events were reported for two patients.

CONCLUSION

All variations of EEP improve symptoms and functional parameters with a low incidence of high-grade complications. One- and two-lobe approaches and pulse shape-modified HoLEP seem to be beneficial in terms of operative time and blood loss.

Holmium laser enucleation of a 696 cc prostate (HoLEP): The largest reported in the literature

Laser enucleation of the prostate represents the endoscopic response to open simple prostatectomy for the treatment of large benign prostatic hyperplasia (BPH) and an advanced technique for prostate surgery. To date, no more than 20 cases of giant prostatic hyperplasia (GPH) have been reported in the literature. We report a successful holmium laser enucleation of a 696 cc prostate in a 78 year-old patient on anticoagulation that was embolized prior to the intervention, urinary catheter was removed on the first day post-operatively and the patient was discharged home on the second day. This is considered the largest prostate treated endoscopically.

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HoLEP is feasible for GPH and is thus volume independent.

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HoLEP is a safe and a less morbid alternative for open simple prostatectomy.

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Multidisciplinary discussion and approaches are needed even for non-oncological cases.

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Six hundred and ninety-sixth grams is now the world Record for HoLEP.

Outcome of Patients With Elevated Prostate-Specific Antigen and Lower Urinary Tract Symptoms Receiving Holmium Laser Enucleation of the Prostate

Purpose

This study investigated functional outcomes in lower urinary tract symptoms (LUTS), the incidence of incidental prostate cancer (PCa), and changes in prostate-specific antigen (PSA) levels after holmium laser enucleation of the prostate (HoLEP) in patients with elevated PSA and benign prostatic hyperplasia (BPH).

Methods

A retrospective review of a prospectively designed protocol for patients who underwent HoLEP at our institution from January 2010 to May 2020 was conducted. Patients were classified into low-PSA (<3.0 ng/mL) and high-PSA (≥3.0 ng/mL) groups at baseline. Follow-up for PSA was performed at the sixth postoperative month. Baseline and postoperative clinical parameters, functional parameters, PCa incidence, and postoperative changes in PSA were compared between the low- and high-PSA groups.

Results

The baseline PSA of 1,296 patients (mean age, 69.7±6.8 years) was 4.0±4.1 ng/mL, with 712 patients (55.0%) in the low-PSA group (1.6±0.8 ng/mL), and 584 patients (45.0%) in the high-PSA group (6.9±4.7 ng/mL). Incidental PCa was detected in 82 patients (6.3%), with a similar incidence in the low-PSA (41 patients, 5.9%) and high-PSA (41 patients, 7.0%) groups (P>0.05). At 6 months postoperatively, both groups showed significant improvements in the maximum flow rate, postvoid residual volume, and all domains of the International Prostate Symptom Score (P<0.05). At postoperative 6 months, the PSA level significantly decreased by 66.6%±23.6% in all patients (54.3%±23.9% in the low-PSA group; 79.6%±14.7% in the high-PSA group) (P<0.05), and the PSA levels of 1,264 patients (97.6%) had normalized.

Conclusions

In patients with elevated PSA presenting with LUTS/BPH, our study demonstrated significant improvements in functional parameters and decreased PSA after HoLEP. The incidental PCa detection rate did not show a statistically significant difference between the low- and high-PSA groups. Timely surgery for LUTS/BPH without delay due to PSA monitoring should be considered.

Risk Factors for Transurethral Coagulation for Hemostasis During Holmium Laser Enucleation of the Prostate

PURPOSE

We aimed to identify risk factors for transurethral coagulation (TUC) using bipolar electrocautery for hemostasis during holmium laser enucleation of the prostate (HoLEP) surgery for benign prostatic hyperplasia (BPH).

METHODS

We analyzed the clinical outcomes of HoLEP surgery performed by a single surgeon between January 2010 and April 2020 at the Seoul National University Hospital. Patient characteristics and perioperative parameters were used to identify the risk factors for TUC. The TUC group was defined as a case of conversion to hemostasis using electrocautery during the hemostasis step after enucleation.

RESULTS

Of 1,563 patients, 357 underwent TUC (TUC group; 22.8%) as an adjuvant (n=299, 19.1%) or salvage (n=58, 3.7%) therapy. Patients in the TUC group were older (mean±standard deviation, 70.6±7.3 years vs. 69.3±7.0 years; P=0.002), had more 5-alpha reductase inhibitor (5-ARI) use (35.6% vs. 25.9%, P<0.001), higher serum prostate-specific antigen (PSA) (5.4 ±4.8 ng/mL vs. 3.8 ±4.5 ng/mL, P <0.001), larger total prostate volume (TPV) (89.5 ±44.7 mL vs. 66.0 ±32.6 mL, P<0.001), and larger transitional zone volume (TZV) (57.3±34.9 mL vs. 37.7±24.2 mL, P<0.001) than those who did not undergo TUC (non-TUC group). In univariate logistic regression analysis, age, 5-ARI use, PSA, TPV, and TZV correlated with TUC, whereas in multivariate logistic regression analysis, only TZV was associated with TUC. The odds ratios (ORs) of TUC were analyzed per TZV quartile. Compared to TZV<22.3 mL, the OR was 2.42 in 34.1 mL≤TZV<53.5 mL (95% confidence interval [CI], 1.58-3.72; P<0.001), 5.17 in ≥53.5 mL (95% CI, 3.44-7.77; P<0.001).

CONCLUSION

The risk of TUC during HoLEP surgery increases in patients with TZV >35 mL. Therefore, TUC may be potentially necessary in patients with a large transition zone volume in patients with BPH.

“Fenestration and Tunnel Method” a Modification for the Holmium Laser Transurethral Prostatectomy of Large-Volume Prostates >80 ml: A Retrospective Study Based on 1-Year Follow-Up

The purpose of this study was to promote the holmium laser enucleation of the prostate (HoLEP) technology for large-volume prostates (>80 ml) and compare it with the traditional method, we modified the technique and applied this technology to clinical practice. A retrospective study comprising 118 patients who underwent HoLEP surgery from February 2018 to December 2019 was conducted in our center. Group A consisted of 57 patients with large-volume prostate (>80 ml) who received modified “fenestration and tunnel method” from February 2019 till December 2019, while group B consisted of 61 patients who received the traditional trivalvular operation method from February 2018 to December 2018 for comparison. Control subjects are selected such that they match the cases concerning certain characteristics, and perioperative data, voiding outcomes, and complications were evaluated at 1- and 12-month follow-up. The international prostatic symptomatic score (IPSS), quality of life (QoL), and maximum flow rate (Qmax) at 1 month and 12 months were both significantly improved compared with the preoperative baseline, and no significant differences were found between Groups A and B. The mean enucleation time, operation time, catheter indwelling duration, and hemoglobin decrease during the operation of Group A showed superiority compared with Group B (p<.05). The modified “fenestration and tunnel method” of HoLEP was statistically superior to the traditional trivalvular method in terms of the operation time, enucleation time, catheter indwelling duration, and hemoglobin decrease. For large-volume prostates (>80 ml), modified HoLEP was suggested to be a better treatment option.

Safety of not withholding clopidogrel therapy during the immediate several days pre- and post-trans-urethral resection of prostate (TURP): a retrospective cohort study

BACKGROUND AND AIM

Benign prostatic hypertrophy or hyperplasia (BPH) is a frequent urological complain particularly in old-aged individuals. Those patients usually have other risk factors (such as ischemic cardiovascular diseases) for which they might be treated with anti-thrombotic agents chronically. These medicines may induce blood thinning and raise the incidence of hemorrhage. Thus, if those patients needed operative treatment for BPH, they may be at high risk of hemorrhage or its related adverse effects with the usage of anti-thrombotic drugs during the peri-operative time. On the other hand, dis-continuation of these agents can lead to ischemic events in susceptible individuals. Therefore, this research aims to assess the safety of the continuation of using anti-thrombotic agents throughout the peri-operative duration in patients with prostate surgery in form of Transurethral Resection of Prostate (TURP) only for Benign Prostatic Hypertrophy (BPH).

METHODS

Patients' notes were reviewed retrospectively. The entire participants were categorized into two categories. First category was on clopidogrel therapy (CTC) for prolong time and the usage of these agents was carried on throughout the peri-operative period. The second category was not on clopidogrel therapy at all (NCTC). Both of these categories had Transurethral Resection of Prostate (TURP) for Benign Prostatic Hypertrophy (BPH). A comparison had been conducted between the two categories with regards to: (i) the amount of blood lost intra-operatively (ii) the duration of operation (iii) hematocrit concentration per-operatively (iv) transfused packed red blood cells (PRBC) if needed (v) clearance of hematuria postoperatively (vi) secondary hemorrhage and clot retention after discharge. Pearson Chi-square test, Independent sample t test and test for numeric variables were used as appropriate.

RESULTS

The study identified 329 patients. One hundred and sixty five participants in the CTC (clopidogrel therapy category) and 164 in the NCTC (non-clopidogrel therapy category). It had been revealed that there was no statistically significant difference between the CTC and NCTC regarding: (i) the amount of blood lost intra-operatively (ii) the duration of operation (iii) hematocrit concentration per-operatively (iv) transfused packed red blood cells (packed RBC) if needed (v) clearance of hematuria postoperatively (vi) secondary hemorrhage and clot retention after discharge (P > 0.65).

CONCLUSION

The continuation of usage of anti-thrombotic therapy (clopidogrel) during peri-operative period in patients with TURP for BPH is a safe practice. It is not associated with high probability of hemorrhage or PRBC transfusion or other adverse effects.

Impact of diabetes mellitus on urinary continence after holmium laser enucleation of the prostate due to lower urinary tract symptoms: a retrospective study

Introduction

Diabetes mellitus (DM) is known as a risk factor of stress urinary incontinence after Holmium laser enucleation of the prostate (HoLEP). We aimed to compare the postoperative continence status of patients with and without DM, after HoLEP surgery.

Material and methods

A total of 214 patients who underwent HoLEP between January 2017 and January 2020 were retrospectively assessed. Functional outcomes, perioperative total operation time (TOT)(min), enucleation time (ET)(min), enucleation efficiency (EE)(g/min), enucleated tissue weight (ETW)(g), morcellation efficiency (ME)(g/min), morcellation time (MT)(min), continence status, intraoperative and postoperative complications according to Clavien–Dindo classification were recorded.

Results

A total of 96 patients had DM additional to benign prostate hyperplasia (BPH) (Group 1), while 118 patients had only benign prostate hyperplasia without DM (Group 2). When comparing preoperative and postoperative functional outcomes, a statistically significant improvement was observed in both groups from baseline to the 1^st and 6^th month follow-up (p ≤0.001). There were no statistically significant differences between groups in postoperative stress urinary incontinence at postoperative months 1 and 6 (1.7% vs 2.1%, p = 1 and 0.8% vs 1%, p = 1; respectively). There was no significant difference between groups in intraoperative and postoperative complications (p >0.05).

Conclusions

HoLEP is safe to perform in patients with DM at low complication and urinary incontinence rates.

Are all procedures for benign prostatic hyperplasia created equal? A systematic review on post-procedural PSA dynamics and its correlation with relief of bladder outlet obstruction

PURPOSE

To evaluate and provide a comprehensive literature review of Prostate specific antigen (PSA) dynamics after various surgical procedures for benign prostatic hyperplasia (BPH).

METHODS

A thorough PubMed database search was performed over last 30 years including terms "PSA" and various surgical procedures for BPH. PSA nadir after various procedure was evaluated. The post-operative improvement in International Prostate Symptom Score, maximum void rates and post-void residue after surgeries were recorded. An indirect correlation was made between PSA nadir and outcome of various BPH surgical procedures.

RESULTS

Enucleation procedures like simple prostatectomy and endoscopic enucleation of prostate (EEP) produced maximum drop in PSA level after surgery and were associated with the highest improvement in post-operative parameters. The PSA nadir following resection techniques like transurethral resection of prostate and Holmium laser resection of prostate and vaporization technique was variable and less robust when compared to EEP. Newer techniques like Aquablation, Rezum, Urolift, Prostate artery embolization and Temporary implantable nitinol devices (iTIND) produce relatively less reduction in PSA and lesser percentile improvement in post-operative parameters.

CONCLUSIONS

Various surgical procedures for BPH result in varying PSA nadirs level. Enucleation procedures and simple prostatectomy produce the most drastic and sustained decrease in PSA. There is a possible indirect evidence suggesting that the level of PSA nadir corresponds closely with the degree of post-operative improvement and durability of the procedure. Establishing the new PSA nadir at 3-6 months after the procedure is recommended as a part of routine surveillance for prostate cancer in eligible patients.

Morcellation After Endoscopic Enucleation of the Prostate: Efficiency and Safety of Currently Available Devices

CONTEXT

Although several studies have compared different morcellators and enucleation techniques for the management of benign prostatic hyperplasia (BPH), there is sparse literature on morcellation, so further experimental and clinical research is required for its optimization.

OBJECTIVE

To critically appraise the contemporary literature on prostate morcellation and to evaluate the safety and efficiency of currently available morcellators for endoscopic enucleation of the prostate (EEP) in the context of BPH.

EVIDENCE ACQUISITION

A comprehensive review of the English and French literature relevant to prostate morcellation was performed using the PubMed-MEDLINE, Cochrane Library, Web of Science, and Wiley Online Library database from 1998 to 2020 using PICOS (patient population, intervention, comparison, outcome, and study design) criteria.

EVIDENCE SYNTHESIS

We retrieved 26 studies involving 5652 patients treated with a morcellator that were eligible for data extraction and analysis. The mean patient age was 67.4 (range 61.4-72.8) yr. The weighted mean efficiency of Piranha, VersaCut, and DrillCut morcellators was 5.29, 3.95, and 5.3 g/min, respectively. Several approaches, such as en bloc, two-lobe, inverse, and improved techniques, may increase morcellation efficiency and safety. The lowest weighted mean rate of bladder wall injury was 1.24% for Piranha, followed by 1.98% for DrillCut, and 5.23% for VersaCut, while the VersaCut morcellator had the lowest weighted mean rate of device malfunction at 0.74%, compared to 2.07% for Piranha and 7.86% for DrillCut.

CONCLUSIONS

All three morcellators are efficient and safe for prostatic morcellation after EEP. Further development of devices and techniques may improve the efficiency and safety profile of morcellation. To increase safety, surgeon expertise, technical equipment, and patient characteristics should be considered. Therefore, interdisciplinary exchange of knowledge and further technological innovations are strongly encouraged.

PATIENT SUMMARY

We reviewed the safety and efficacy of devices called morcellators. These devices cut tissue into small pieces that are easier to remove from the body, and are used during laser surgery for benign enlargement of the prostate. Three morcellators are currently available on the market and are comparable in safety and efficacy.

Accuracy of Clarius, Handheld Wireless Point-of-Care Ultrasound, in Evaluating Prostate Morphology and Volume Compared to Radical Prostatectomy Specimen Weight: Is There a Difference between Transabdominal vs Transrectal Approach?

Background: Prostate size estimation is a valuable clinical measure widely utilized in urology. This study evaluated the accuracy of preoperative transabdominal ultrasound (TAUS) compared to radical prostatectomy specimens and transrectal ultrasound (TRUS) in estimating prostate volume and identifying presence of median lobe, across different size groups, using the standard ellipsoid formula. The effect of median lobe on accuracy was also assessed. Materials and Methods: Ninety-eight men undergoing robot-assisted radical prostatectomy were enrolled in this study. Preoperative evaluation of prostate volume was done using measurements obtained from TAUS using the Clarius C3 handheld wireless point-of-care ultrasound (POCUS) and from TRUS Clarius EC7. Participants were grouped based on prostate size (<30, 30-60, and >60 g). Mean absolute percentage of error was used to evaluate accuracy. Mean percentage of error determined if there was an overestimation or underestimation. Correlation between each TAUS size group, true prostate weight and TRUS was assessed. Results: Irrespective of body mass index, TAUS accurately identified median lobe in all men. No statistically significant difference was found between specimen weight and TAUS prostate size for the >60 g group. Among this same group, a strong correlation was noted between specimen weight and TAUS prostate size (r = 0.911, p < 0.001). There was also a strong correlation between TAUS and TRUS measurements for this group (r = 0.950, p < 0.001). Presence of median lobe did not have an impact on measurement accuracy. Conclusions: Bedside handheld wireless POCUS provides rapid, inexpensive, noninvasive, and clinically accurate TAUS prostate assessments for larger prostates. Such features as identifying median lobes and measuring prostate volumes are valuable tools, whereas patient counseling on lower urinary tract symptoms, elevated prostate-specific antigen, and benign prostate hyperplasia are surgical options.

Comparison of outcomes of Holmium enucleation of the prostate for small- and moderate-sized prostates

There is an ongoing discussion in the literature on the surgical treatment option for small prostate size benign prostate hyperplasia (BPH) patients. This study aimed to evaluate the efficacy of Holmium laser enucleation of the prostate (HoLEP) surgery in small (<30 ml) and moderate (30-80 ml) prostate size as accepted in European Association of Urology guideline. We retrospectively analysed our database between May 2016 and May 2019 and patients who underwent HoLEP surgery. Patients who have prostate size <80 ml were included the study. These patients were divided into two group: group 1 with prostate size <30 ml (n: 64) and group 2 with prostate size 30-80 ml (n: 101). Enucleation time (ET), morcellation time (MT), total operation time (OT), enucleation efficiency (EE), morcellation efficiency (ME), intra- and post-operative complications were analysed. While EE and Hb drop were better in favour of group 2; PSA drop, ET, MT, OT and ME were superior in favour of group 1. In group 1, intra-operative complications were higher (6 vs. 2; p < .05) and post-operative complications did not differ statistically between groups (p = .14). No statistically significant finding was found between groups regarding incontinence. In conclusion, HoLEP is a reliable method in terms of its results in patients with small prostates.

Holmium laser enucleation of prostate by using en-bloc and bladder neck preservation technique: technical consideration and influence on functional outcomes

Background

This study aimed to evaluate the efficacy and safety of holmium laser enucleation of prostate (HoLEP) by using en-bloc and bladder neck preservation technique on benign prostatic hyperplasia (BPH) and assess the influence of this procedure on urinary and sexual functional outcomes.

Methods

A total of 704 patients with BPH undergoing HoLEP were retrospectively analysed. Amongst them, 213 who met the sexual function assessment criteria were further assessed the influence of the technique on sexual functional outcomes.

Results

The mean operative time, resected prostate weight and mean estimated blood loss were 69.3±14.8 min, 53.4±17.6 g and 62.1±23.7 mL, respectively. The mean duration of catheterization after surgery and mean hospital stay were 2.1±1 and 5.4±3.6 days, respectively. The post-void residual volume, maximum urinary flow rate, international prostate symptom score and quality of life score were all significantly improved postoperation (P<0.05). Amongst the 213 patients with normal antegrade ejaculation before surgery, postoperative international index of erectile function scores slightly improved, although the difference was insignificant (P>0.05). The difference in the Erection Hardness Grading Scale before and after surgery was statistically insignificant (P>0.05). A total of 25 (11.7%) patients had retrograde ejaculation after surgery.

Conclusions

HoLEP by an en-bloc and bladder neck preservation technique can obtain good functional outcome with small injury and high efficiency, especially for patients who need to preserve normal sexual function and anterograde ejaculation.

The "Omega Sign": a novel HoLEP technique that improves continence outcomes after enucleation

PURPOSE

Holmium-laser enucleation of the prostate (HoLEP) has been a promising prostate surgery since its first introduction. Although there are 10 different HoLEP techniques in the literature, stress urinary incontinence (SUI) is common, because surgery is not performed based on the topographic anatomy of the external sphincter. We have developed a new HoLEP method named as the ''Omega Sign technique", which is based on the topographic anatomy of the external sphincter and could provide better continence outcomes by decreasing SUI rates.

MATERIALS AND METHODS

The data of 400 patients who underwent HoLEP by a single surgeon between May 2016 and February 2019 were retrospectively reviewed. The patients were divided into two groups, the first underwent the Gilling's technique (Group 1) and the second the novel ''Omega Sign'' technique (Group 2). Continence status and post-micturition symptoms (PMS) were evaluated according to the standards recommended by the international continence status.

RESULTS

The data of 400 HoLEP procedures between May 2016 and February 2019 were analyzed, comparing Group 1 (n = 200) and Group 2(n = 200). SUI rate was significantly lower in Group 2 at the day of catheter removal and first month (p < 0.005). In addition, urge urinary incontinence (UUI) rate and PMS were significantly lower in Group 2.

CONCLUSIONS

We could demonstrate improved continence results, comparable functional outcomes and equally minimal complications with the standard HoLEP technique. We believe that, the novel 'Omega sign' technique decreases SUI rates and will become standardised and easy to understand, thereby bringing and creating a shorter learning curve.

How to optimise urinary continence in anatomical endoscopic enucleation of the prostate?

The traditional transurethral resection of the prostate (TURP) is considered as gold-standard surgical treatment to relieve symptoms resulting from bladder outlet obstruction by prostate enlargement. However, with the advances of novel laser technologies and more experienced surgeon conquering the steep learning curve, anatomical endoscopic enucleation of prostate (AEEP) has become a more popular alternative surgical technique. Although AEEP has compatible functional outcome, less blood loss, shorter catheterisation duration and hospital stay, the risk of post-operative urinary incontinence (UI) is often an issue of concern. In this review, we focus on discussion about risk factors related to increased incidence of UI, some surgical tips to avoid damaging external urinary sphincter and treatment strategies to facilitate recovery of urinary continence after surgery.

What You Need to Know Before Reading Multiparametric MRI for Prostate Cancer

OBJECTIVE. Multiparametric MRI (mpMRI) has become the main imaging modality for the detection, localization, and local staging of prostate cancer over the past decade. For radiologists to achieve consistent and reproducible reporting of prostate mpMRI, a comprehensive evaluation of the gland including detailed knowledge of anatomy, pathology, and clinical data is required. This article familiarizes radiologists with common pitfalls and conditions that affect mpMRI performance during readouts. CONCLUSION. Consistent, accurate, and reproducible reporting of prostate mpMRI is vital. Additionally, radiologists should be aware of common diagnostic pitfalls that can hinder mpMRI performance.

Perioperative Safety and Efficacy of Holmium Laser Enucleation of the Prostate in Patients Receiving Antithrombotic Therapy: A Prospective Cohort Study

We investigated the efficacy of and risk from holmium laser enucleation of the prostate (HoLEP) due to discontinuation of antithrombotics in patients with benign prostatic hyperplasia (BPH). Patients in the prospective SNUH-BPH Database Registry who underwent HoLEP between December 2010 and December 2017 were enrolled. Preoperative evaluation included symptom score questionnaires, laboratory tests, urine tests, prostate-specific antigens, urodynamic study, and transrectal ultrasonography. Postoperative evaluation was performed at 2 weeks, 3 months, and 6 months. Information regarding the types of antithrombotics and their use, underlying disease, and antithrombotic management during surgery was collected. The study included 55 patients. The mean age and preoperative prostate volume were 68.7 ± 6.4 years and 70.3 ± 32.2 mL, respectively. The mean preoperative hemoglobin level was 13.5 ± 2.6 g/dL in the patients receiving antithrombotics. Of the patients, 71% were taking aspirin. Seventy-five (66.5%) and 70 patients (28.2%) discontinued the antithrombotic therapy 5–7 days and <1 week preoperatively, respectively. Three patients (1.21%) were switched to low-molecular-weight heparin therapy, and 10 (4.03%) continued antithrombotic therapy. No significant differences were found in the incidence rates of postoperative transfusion (p = 0.894) or complications from antithrombotic use, thrombosis (p = 0.946), haemorrhage requiring bladder irrigation (p = 0.959), transurethral coagulation (p = 0.894), cardiovascular events (p = 0.845), and cerebrovascular events (p = 0.848). Efficacy and complications related to the short-term antithrombotic withdrawal before and after HoLEP also showed no significant differences. HoLEP may be a beneficial surgical technique for patients with BPH who are receiving antithrombotics.