Persistent Lower Urinary Tract Symptoms After BPH Surgery.

PURPOSE OF REVIEW: Lower urinary tract symptoms (LUTS) after surgical management for BPH pose a significant clinical challenge for urologists. Despite high success rates in relieving LUTS, there is a subset of patients who experience persistent symptoms after intervention. In this review article, we describe the management of patients with new or persistent LUTS after endoscopic bladder outlet surgery. RECENT FINDINGS: Previously, the goal for BPH management was to remove as much adenomatous tissue as possible. While potentially effective, this may lead to unwanted side effects. There has been a recent paradigm shift for new minimally invasive surgical therapies (MIST) that strategically treat adenomatous tissue, adding potential complexity in managing patients with new or residual symptoms in the postoperative setting. There is a paucity of literature to guide optimal workup and care of patients with persistent LUTS after surgical management. We characterize patients into distinct groups, defined by types of symptoms, irritative versus obstructive, and timing of the symptomatology, short term versus long term. By embracing this patient-centered approach with shared decision management, clinicians can optimize outcomes efficiently improving their patients' quality of life.

Outcomes of octogenarians undergoing holmium laser enucleation of prostate.

PURPOSE: Holmium laser enucleation of prostate (HoLEP) is an effective surgical procedure in men with BPH. Due to the increase in the use of medical therapy for BPH related lower urinary symptoms more octogenarians are presenting in a delayed fashion with significant symptoms and urinary retention. We evaluate the feasibility and safety of octogenarians undergoing HoLEP. METHODS: We performed a retrospective review of HoLEPs at our institution from July 2018 to December 2019. Patients were stratified into two groups based on age: < 80 and ≥ 80. RESULTS: A total of 458 patients were identified, with 74 (16.2%) ≥ 80. In patients ≥ 80, prostate volume was higher (p < 0.0005), there was a higher rate of antiplatelet/anticoagulation (p = 0.029) use, and a lower rate of alpha-blocker use (p = 0.0016). As expected, ASA scores which correlate with increasing number of concomitant diseases were greater in the ≥ 80 cohort (p = 0.016). There was no significant difference in intraoperative complications (p = 0.14), 90 day complication (p = 0.34), readmission rates (p = 0.425) or emergency room visits between groups (p = 0.15). CONCLUSIONS: Despite higher medical comorbidities and increased rates of anticoagulation in octogenarians, there is no increase in operative or postoperative complication rates. Age alone should not be used as exclusion criteria for HoLEP.

The Effect of Pre-Stenting on Bleeding-Related Complications Following Ureteroscopy in Patients on Anticoagulation or Antiplatelet Therapy.

Introduction: The American Urological Association guidelines state that continuing anticoagulant (AC) and antiplatelet (AP) agents during ureteroscopy (URS) is safe. Through a multi-institutional retrospective study, we sought to determine whether pre-stenting in patients on AP or AC was associated with fewer URS bleeding-related complications. Methods: A series of 8614 URS procedures performed across three institutions (April 2010 to September 2017) was electronically reviewed for AC/AP use at time of URS. Records indicating AC or AP use at time of URS were then manually reviewed to characterize intraoperative and 30-day postoperative (intraoperative bleeding, postoperative hematuria, emergency department visits, hospital readmission, unplanned reoperation, phone calls, and other minor 30-day complications). Results: A total of 293 identified URS procedures were completed on patients on AC/AP therapy-112 cases were on AC only (38 were pre-stented), 158 on AP only (51 pre-stented), and 23 on both AP and AC (8 pre-stented). Patient characteristics and comorbidities were similar between the pre-stented and non-pre-stented groups. For AC and AP subjects, pre-stenting did not decrease the composite risk of bleeding complications (10.3% pre-stent vs 12.2% non-prestent, p = 0.6). Pre-stented patients did have a significantly lower likelihood of requiring an unplanned reoperation (1.0% vs 5.6%, p = 0.04). In the subgroup of patients on AP alone, pre-stented patients had significantly fewer episodes of intraoperative bleeding (0% vs 9%, p = 0.04), unplanned reoperations (0% vs 6.5%, p = 0.02), and 30-day complications (14% vs 27%, p = 0.05). In the subgroup of patients on AC alone, there were no significant differences in outcomes based on stent status. Conclusions: In this multi-institutional study, we found that pre-stenting before URS was not associated with fewer bleeding complications. However, pre-stenting appeared to be associated with improved outcomes for those patients on AP therapy. These results suggest a need for prospective studies to clarify the role of pre-stenting for URS.

Real-World Experience of Holmium Laser Enucleation of the Prostate with Patients on Anticoagulation Therapy.

Background: Holmium laser enucleation of the prostate (HoLEP) is a highly effective procedure for benign prostatic hyperplasia that is size independent and has been recommended for patients necessitating antiplatelet (AP) and anticoagulant (AC) medications. Although HoLEP is feasible in AP/AC patients, there is a lack of published results on real-world outcomes of patients on AP/AC therapy undergoing HoLEP. Patients and Methods: We performed a retrospective review of our institutional HoLEP database of demographics, perioperative and postoperative data, and outcomes of patients on AP and AC therapy compared with none. We also further stratified patients on warfarin compared with direct oral anticoagulants (DOACs). Results: Of 472 patients who underwent HoLEP at our institution from July 2018 to December 2019 with data on AP/AC drugs, 30 (6.3%) were on AP and 65 (17.2%) were on AC. One patient continued AP (3.3%), six patients (9.2%) were bridged on AC, and one patient (1.5%) continued AC through the time of HoLEP at the discretion of the prescribing provider. Preoperatively, only age was significantly different among the three groups (p < 0.001). There were no intraoperative differences. Postoperatively, there was a higher 90-day complication rate in AP and AC groups (p = 0.035), but not an increase in emergency department (ED) visits (p = 0.557) or Clavien ≥3 complications (p = 0.16). In comparison of patients on warfarin with DOAC, there was a lower rate of successful voiding trial (p = 0.009), higher 90-day complications (p = 0.003), and more ED visits (p = 0.003) in the warfarin group. Conclusions: HoLEP is safe and effective for patients who require AP or AC therapy. There is no increase in serious complications or worsened postoperative voiding parameters. Of patients on AC, those on DOAC have better outcomes compared with warfarin.

Early Surgical Intervention for Symptomatic Renal and Ureteral Stones is Associated With Reduced Narcotic Requirement Relative to Trial of Passage.

OBJECTIVES: To evaluate if trial of passage (TOP) or initial surgical intervention resulted in less narcotic analgesia utilization in patients with acute renal colic due to stone disease. METHODS: We retrospectively evaluated 135 patients with acute renal colic due to nephroureterolithiasis managed by a single surgeon. Patients were standardly offered TOP or surgical intervention with ureteroscopy (URS). A subset of patients were stented with delayed URS due to presence of infection, pain, or a nonaccommodating ureter. Our standard practice is narcotic-free URS, prescribing a stent cocktail including non-steroidal anti-inflammatories. We compared rates of narcotic prescription over the entire treatment course for patients electing TOP vs surgery (primary or delayed URS). We secondarily analyzed rates of surgical intervention among initial TOP. RESULTS: We included 135 patients, with 69 (51.1%) TOP as initial treatment, 39 (28.9%) stent with delayed URS, and 27 (20.0%) primary URS. Thirty-nine (56.5%) TOP patients underwent URS at a median time of 18 days (IQR 6-31 days) from diagnosis. More TOP patients required a narcotic prescription (60.9% vs 35.9% vs 33.3%, respectively; P = .010) compared to patients undergoing initial stent or URS. However, when an opioid prescription was provided, the total morphine milligram equivalents prescribed among each group was not statistically significant. CONCLUSION: Patients electing initial treatment with TOP for renal colic due to stone disease were more likely to require narcotic prescriptions than patients electing initial surgical intervention.

Comparison of laser fiber degradation and perioperative outcomes following holmium laser enucleation of the prostate using 550 and 1000 µm fiber diameters.

OBJECTIVE: To compare perioperative and post-operative outcomes for holmium laser enucleation of the prostate (HoLEP) between cases performed with a 550 µm or 1000 µm fiber. METHODS: We retrospectively reviewed the most recent 50 patients undergoing HoLEP with a 550 µm fiber and the most recent 50 patients with a 1000 µm fiber. The length of exposed laser fiber after stripping was measured pre- and post-enucleation, with the difference being our primary outcome of degradation length. We compared operative and clinical characteristics between patients undergoing HoLEP using 550 and 1000 µm laser fibers. RESULTS: All 100 patients met inclusion for analysis. Overall, the 550 µm fiber experienced more degradation than the 1000 µm fiber (2.9 vs 1.9 cm, respectively; p = 0.01). The 1000 µm fiber utilized significantly less energy compared to the 500 µm fiber (81 vs 109 kJ, respectively; p < 0.01). In addition, operations performed with the 1000 versus the 500 µm fiber were overall shorter (79 vs 88 min, respectively; p = 0.03), although both groups had statistically similar times for enucleation (45 vs 51 min, respectively; p = 0.42) and morcellation (10 vs 9 min, respectively; p = 0.50). These findings occurred in the context of statistically similar prostate weight enucleated and bladder stones treated between groups. Post-operatively patients experienced no difference in blood loss or dysuria. CONCLUSIONS: Use of the 1000 µm fiber resulted in significantly less fiber degradation, energy requirement, and total operative time during HoLEP, in spite of similar prostate size and time required for enucleation and morcellation. Different fiber diameters do not appear to affect post-operative blood loss or dysuria.

SMRT Regulates Metabolic Homeostasis and Adipose Tissue Macrophage Phenotypes in Tandem.

The Silencing Mediator of Retinoid and Thyroid Hormone Receptors (SMRT) is a nuclear corepressor, regulating the transcriptional activity of many transcription factors critical for metabolic processes. While the importance of the role of SMRT in the adipocyte has been well-established, our comprehensive understanding of its in vivo function in the context of homeostatic maintenance is limited due to contradictory phenotypes yielded by prior generalized knockout mouse models. Multiple such models agree that SMRT deficiency leads to increased adiposity, although the effects of SMRT loss on glucose tolerance and insulin sensitivity have been variable. We therefore generated an adipocyte-specific SMRT knockout (adSMRT-/-) mouse to more clearly define the metabolic contributions of SMRT. In doing so, we found that SMRT deletion in the adipocyte does not cause obesity-even when mice are challenged with a high-fat diet. This suggests that adiposity phenotypes of previously described models were due to effects of SMRT loss beyond the adipocyte. However, an adipocyte-specific SMRT deficiency still led to dramatic effects on systemic glucose tolerance and adipocyte insulin sensitivity, impairing both. This metabolically deleterious outcome was coupled with a surprising immune phenotype, wherein most genes differentially expressed in the adipose tissue of adSMRT-/- mice were upregulated in pro-inflammatory pathways. Flow cytometry and conditioned media experiments demonstrated that secreted factors from knockout adipose tissue strongly informed resident macrophages to develop a pro-inflammatory, MMe (metabolically activated) phenotype. Together, these studies suggest a novel role for SMRT as an integrator of metabolic and inflammatory signals to maintain physiological homeostasis.

Discrepancy Between Stone and Tissue Mineral Type in Patients with Idiopathic Uric Acid Stones.

Objectives: To describe the papillary pathology found in uric acid (UA) stone formers, and to investigate the mineral form of tissue deposits. Materials and Methods: We studied eight UA stone formers treated with percutaneous nephrolithotomy. Papillae were imaged intraoperatively using digital endoscopy, and cortical and papillary biopsies were taken. Biopsies were analyzed by light microscopy, micro-CT, and microinfrared spectroscopy. Results: As expected, urine pH was generally low. UA supersaturation exceeded one in all but one case, compatible with the stone material. By intraoperative imaging, the renal papillae displayed a heterogeneous mixture of plaque and plugging, ranging from normal to severe. All patients had mineral in ducts of Bellini and inner medullary collecting ducts, mainly apatite with lesser amounts of urate and/or calcium oxalate in some specimens. Papillary and cortical interstitial tissue injury was modest despite the tubule plugging. No instance was found of a stone growing attached to either plaque or plugs. Conclusions: UA stone formers resemble those with ileostomy in having rather low urine pH while forming tubule plugs that contain crystals that can only form at pH values above those of their bulk urine. This discrepancy between tissue mineral deposits and stone type suggests that local tubular pH exceeds that of the bulk urine, perhaps because of localized tubule injury. The manner in which UA stones form and the discordance between tubule crystals and stone type remain open research questions.

Trends and Perioperative Outcomes Across Major Benign Prostatic Hyperplasia Procedures from the ACS-NSQIP 2011-2015.

BACKGROUND AND PURPOSE: There are currently several different surgical options for patients with benign prostatic hyperplasia (BPH). The literature has demonstrated equivalent or superior results for holmium laser enucleation of prostate (HoLEP) but with exceptional long-term durability compared to other minimally invasive options. Despite this, HoLEP is not widely practiced. Herein, we investigate trends and outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to support a need for further adoption of HoLEP. METHODS: Using ACS-NSQIP data from 2011 to 2015, trends, baseline characteristics, and perioperative outcomes were collected for major BPH procedures: transurethral resection of prostate (TURP), TURP for regrowth, photovaporization of prostate (PVP), HoLEP, and simple prostatectomy. RESULTS: The most common procedure performed every year was TURP with PVP performed about half as often, while HoLEP (4%-5%) was performed about as infrequently as simple prostatectomy (3%). More African American men underwent simple prostatectomy except in 2011. International normalized ratio (INR) was highest every year for PVP. Hospital stay and transfusion rates were lowest with PVP and HoLEP. Transfusion rates for simple prostatectomy were high (16.0%-25.4%). Lower rates of readmission, reoperation, and urinary tract infection were seen in some years with HoLEP. CONCLUSIONS: Given the previously reported favorable outcomes and long-term durability of HoLEP, these ACS-NSQIP data further support that HoLEP should be more often practiced for patients undergoing surgery for BPH.

Percutaneous Nephrolithotomy in the 80 Years of Age and Older Population.

OBJECTIVE: To evaluate feasibility of percutaneous nephrolithotomy (PCNL) for complex nephrolithiasis in patients 80 years of age and older compared to younger individuals. METHODS: From an institutional IRB-approved database, 1,647 patients were identified who underwent PCNL from 1999 to 2019. Patients were stratified by age: group 1 (20-59), group 2 (60-79), and group 3 (>80). Statistics were performed using chi-square and ANOVA to compare outcomes. RESULTS: Of the 1,647 patients, median age was 46, 66, and 83, respectively (P <0.0001). Three patients within group 3 were 90 or older. Females made up 54%, 46%, 56% of patients (P = 0.02). Average stone size with SD was 2.6 ± 2.2, 2.5 ± 2.3, 2.2± 1.9 cm for each group (P = 0.06). Mean preoperative hemoglobin (Hgb) was significantly lower in the 80+ group (13.8, 13.4, 13.1 g/dL, P <.0001). Change in Hgb was not significantly different. There were more Clavien II-IV complications (10.4, 14.4, 28.8%; P = 0.02) and transfusions (2.3, 4.7, 10.2%; P <0.001) in the elderly. The most common complications in the 80+ group were bleeding related (10.1%). No difference in readmission rates or ICU admissions was noted. CONCLUSION: PCNL is feasible in the extremely elderly; however with a higher rate of complications and longer hospitalizations. No long-term sequelae or deaths in the 80 and older cohort were seen. This study allows us to appropriately counsel older patients on a realistic postoperative course and supports use of PCNL as the best means of long-term survival.

Best practice in the management of benign prostatic hyperplasia in the patients requiring anticoagulation.

In today's aging population, urologists are often treating older patients with multiple comorbidities. Lower urinary tract symptoms from benign prostate hyperplasia (LUTS/BPH) is a common condition that affects men, with increasing prevalence as men age. In a subset of patients, the symptoms are too severe or refractory to medical therapy and, therefore, surgical therapy is required to improve their LUTS. The use of medical therapy often delays the need to intervene surgically in men with LUTS/BPH and with advances in the management of cardiovascular disease, urologists are increasingly encountering more men requiring BPH surgery on chronic anticoagulation therapy. The decision of when to offer surgical intervention and how to manage anticoagulation medication in the perioperative setting is a dilemma with which surgeons are dealing with increasing frequency. The purpose of this review is to clarify the optimal approach to the surgical patient with LUTS/ BPH requiring anticoagulation therapy.

Initial Experience with Narcotic-Free Ureteroscopy: A Feasibility Analysis.

BACKGROUND AND PURPOSE: In the United States, there is an opioid abuse epidemic fueled by prescription medications. Concerns that uncontrolled pain after surgical procedures will result in poor patient satisfaction and increased workload for ancillary staff are potential factors that influence provider prescription habits. Currently, there is a paucity of literature on analgesic requirements after ureteroscopy (URS) for nephrolithiasis. Our study objective was to evaluate the safety of narcotic-free ureteroscopy (nf-URS) and assess its impact on provider workload. METHODS: We performed a retrospective chart review of 104 patients, between October 2017 and May 2018, who underwent URS and who required a stent postprocedure. Starting February 2018, patients without absolute contraindication or allergies to nonsteroidal anti-inflammatory drugs received a prescription for diclofenac instead of hydrocodone or oxycodone. Postoperative phone calls to nurses and residents, emergency room visits, and prescription monitoring reports were evaluated for all patients, and compared between the nf-URS and the standard ureteroscopy (s-URS). RESULTS: There were 52 nf-URS and 52 s-URS procedures. In the postoperative period, 9 (17%) nf-URS and 10 (19%) s-URS patients called with postoperative pain issues. Five (10%) nf-URS vs 9 (17%) s-URS patients obtained narcotics after seeking additional medical care after URS because of inadequate pain control. There were no postoperative complications in our cohort. Compared with s-URS, 6871.5 mg less of morphine equivalent dosage (1375 hydrocodone tablets) was administered to nf-URS patients immediately after surgery. CONCLUSIONS: Attempts to reduce the number of narcotic prescriptions are paramount in the fight against narcotic addiction in the United States. Although our initial cohort is small, this feasibility study provides compelling evidence that nf-URS is a safe and effective practice. Furthermore, nf-URS resulted in a dramatic decrease in the number of narcotics circulating in the community.

Testicular epidermoid cyst: A rare case.

Testicular epidermoid cysts are a rare cause of testicular pathology. No cases of recurrence or metastasis have been reported in the literature. As a result, inguinal partial orchiectomy with frozen section has recently become standard treatment. A 43-year-old male presented with right testicular discomfort and the presence of mass. Right inguinal partial orchiectomy with frozen section was performed, and the right testicle was preserved. The final pathology report confirmed the diagnosis of an epidermoid cyst. The importance of accurate diagnosis of this benign lesion is crucial for the prevention of unnecessary radical orchiectomy.