A randomized controlled trial comparing high and medium power settings for holmium laser enucleation of prostate.

PURPOSE: To report the results of a randomized controlled trial comparing outcomes between medium power (MP) and high power (HP) laser settings for HoLEPs. METHODS: The primary objective was to compare the enucleation efficiency (EE) of HP- HoLEP (80-100 W) with MP-HoLEP (50 - 60 W). The secondary objectives were to compare treatment efficacy and safety between both groups. To show a 25% difference in EE, a sample size of 45 individuals per treatment arm was required (alpha = 0.05; Beta = 0.80). Patients demographic and perioperative factors were analyzed, including EE, hemoglobin drop, duration of catheterization, and length of hospital stay. The surgical outcome was evaluated with AUA symptom score, maximum flow rate, postvoid residual urine, and complications to assess differences between MP and HP HoLEP at baseline, 3 months, 1, and 5 years. Quantitative outcomes were compared with independent sample t tests (2-tailed) and qualitative outcomes were compared with chi-square tests. RESULTS: Preoperative data with the exception of indication for surgery were comparable in both treatment arms. There was no statistically significant difference in enucleation efficiency between the HP-HoLEP and MP-HoLEP laser setting (0.97 ± 0.47 vs. 0.85 ± 0.47 gm/min, p = 0.209). MP laser settings did not increase perioperative or postoperative complications and resulted in durable outcome comparable with HP laser settings at 5-year follow-up. CONCLUSIONS: MP-HoLEP is safe and efficient and does not compromise the outcome for HoLEPs when compared with HP-HoLEP.

Holmium Laser Enucleation of Prostate Within 6 Weeks of Transrectal Ultrasound Guided Prostate Biopsy is Safe and Effective.

OBJECTIVE: To evaluate the safety and efficacy of performing Holmium laser enucleation of the prostate (HoLEP) for the treatment of bladder outlet obstruction secondary to an enlarged prostate within 6-weeks of a transrectal ultrasound (TRUS) guided prostate biopsy. MATERIALS AND METHODS: We performed a retrospective review of patients who underwent a HoLEP at our institution, excluding any patients with a confounding urologic history and compared patients who underwent a TRUS-guided 6- or 12-core prostate biopsy, and then underwent a HoLEP within 6 weeks (study group) with all other patients (control group). Our primary outcomes were enucleation efficiency (EE) and perioperative complication rate. Our secondary outcomes included postoperative drop in hemoglobin, duration of catheterization, length of hospital stay, voiding metrics at 1 and 6 months and rate of incidental prostate cancer diagnosed on histopathological examination of prostate specimens after HoLEP. To test for differences between the study and control groups, we performed independent sample t-test (2-tailed) and chi-square tests for quantitative and qualitative variables, respectively. P values of < 0.05 were considered statistically significant. RESULTS: 552 patients met inclusion criteria and 84 patients underwent prostate biopsy within a period of 45 days prior to HoLEP. Enucleation efficiency was higher in the study group (P = 0.00). There was no significant difference between the 2 groups regarding perioperative complications, postoperative voiding outcomes, or rate of incidental prostate cancer detection. CONCLUSIONS: TRUS prostate biopsy performed within 6 weeks of HoLEP does not negatively impact operative difficulty or treatment outcome.

Rapid versus gradual bladder decompression in acute urinary retention.

OBJECTIVE: To demonstrate a benefit in diminished adverse events such as hypotension and hematuria with gradual drainage of the bladder when compared to rapid decompression in patients with acute urinary retention (AUR) due to benign prostatic hyperplasia in a case-control study. METHODS: Sixty-two patients matched our selection criteria presenting with AUR. They were divided into two groups - the first was managed by rapid drainage of the bladder, the second was managed by gradual drainage through a urethral catheter (The first 100 mL immediately evacuated, then the rest evacuated gradually over 2 h). RESULTS: The mean age was 64.4 and 63.2 years in the first and second group, respectively. Diagnosed cause was benign hyperplasia of the prostate. Hematuria occurred in two patients in the first group and none in the second group. The two cases of hematuria were mild and treated conservatively. After the relief of the obstruction, the mean blood pressure was noticed to decrease by 15 mmHg and 10 mmHg in the first and second group, respectively, however, no one developed significant hypotension. Pain relief was achieved after complete drainage in the first group and after the evacuation of 100 mL in the second group. CONCLUSIONS: We conclude that there is no significant difference between rapid and gradual decompression of the bladder in patients with AUR. Hematuria and hypotension may occur after rapid decompression of the obstructed urinary bladder, but these complications are rarely clinically significant.

Early return of continence in patients undergoing robot-assisted laparoscopic prostatectomy using modified maximal urethral length preservation technique.

PURPOSE: To evaluate the impact of maximal urethral length preservation (MULP) technique in comparison with posterior urethral reconstruction and anterior bladder suspension (PRAS) technique on the continence rates (CR), time to achieve continence among patients with prostate cancer (PCa) undergoing robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: We prospectively analyzed the CR, time to achieve continence, pre- and postoperative prostate-specific antigen (PSA) levels, rates of positive margins among three groups of continent men with PCa undergoing RALP from whom consent was obtained. Each group consisted of 30 patients: PRAS was performed in group A, combined MULP and PRAS in group B, and MULP in group C. Continence was measured by patient self-reporting of the number of pads/24 h. RESULTS: No differences were detected in the age, preoperative PSA levels, biochemical recurrence, prostate volume, and positive margins for the three groups. Men in groups B and C had marked improvement in CR 1, 3, and 6 months after catheter removal vs group A (50% and 70% vs 10%, 90% and 96.66% vs 23.3% and 100%, 100% vs 53.3%, respectively, P<0.0001). The average and median times to continence were significantly shorter in group B (5.4 and 4 weeks) and C (3.8 and 3 weeks) vs group A (27.4 and 22.5 weeks), P<0.00001. Using Cox regression analysis, only MULP and MULP+PRAS techniques were significantly correlated with continence outcomes 1, 3, and 6 months after catheter removal. CONCLUSIONS: MULP rather than PRAS confers higher postoperative CR and shorter time to achieve continence among patients with PCa who underwent RALP without increasing risk of positive margin.

Ex vivo model for renal fracture in cryoablation.

OBJECTIVE: To demonstrate the formation of fractures due to cryoablative therapy in a controlled model and validate the new model for the study of the complication of fractures during renal cryoablation. METHODS: Endocare PERC-17 (1.7 mm) and Galil 17 ga IceRod (1.47 mm) probes were selected because of similar diameter and reported ice-ball size. The ex vivo model used here was a porcine kidney obtained at the supermarket. The kidneys were subsequently bivalved. The cryoprobes were inserted running just underneath the cut surface, entering the lateral surface of the kidney, and directed toward the medial surface of either the upper or lower pole. In this manner, we avoided the major calyces and involved the most parenchyma. Freeze-thaw-freeze cycles of various durations were performed. The probes were frozen parallel to each other at a distance of 20 mm apart. RESULTS: Evidence of cryoablation-induced fracture included popping sounds noted during thaw and cracks that became visible during the phase of second freeze. Cracks were noted to extend from the probe through the parenchyma. In multiple probe freezes, the intervening zone between the 2 ice-balls had smoother ice and the fractures that appeared there originated at either probe. Fracture formation was only observed with the Endocare probes, with single or parallel freezes. No fractures were noted in the IceRod freezes. CONCLUSION: The bivalved ex vivo kidney is an inexpensive, representative, and demonstrative model for study of fracture during cryoablation.