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.

Our experience on Fournier's gangrene in a tertiary-stage care center and analysis of its relationship with blood count parameters.

BACKGROUND: Fournier's gangrene (FG) is rapidly progressing and life-threatening necrotizing fasciitis of genital and perineal regions. The aim of the study was to share our experience with FG and to analyze the relationship of clinical data with whole blood count parameters, inflammation cells, and systemic inflammation markers. METHODS: The digital medical records of the adult patients followed-up and treated with diagnosis of FG between January 2016 to December 2020 were retrospectively analyzed. Data were as age, gender, total length of hospital stay, predisposing factors, etiological factors, total number of debridement's, surgical procedures, and antibiotherapy were collected. Serum glucose levels, complete blood count parameter levels, serum inflammation indicators and C-reactive protein (CRP) levels measured at the initial day of hospital admission, post-debridement 1st and 7th days were measured. RESULTS: Thirty-six male patients were included, with a mean age of 56.42 (22-86) years. The most common predisposing factor was diabetes mellitus (n=13; 36.1%). The most frequently seen etiological cause was scrotal abscess (n=19; 52.8%). A statistically significant decrease was found in White blood cell count, neutrophil level, neutrophil-to-lymphocyte ratio (NLR) value and CRP level measured before debridement, post-debridement 1st and 7th days (p<0.05). There was a positive correlation between the number of debridement's and age, NLR, platelet-to-lymphocyte ratio, and CRP values at the initial admission time (p<0.05). CONCLUSION: The infections of urogenital region are the essential etiological origin of FG. As a rare urological emergency, significant changes were observed in clinical data and blood count parameters during the course of FG.

Sodium butyrate ameliorates erectile dysfunction through fibrosis in a rat model of partial bladder outlet obstruction.

BACKGROUND: In different animal models, a histone deacetylase (HDAC) inhibitor, sodium butyrate (NaBu) reduced inflammation, oxidative stress and fibrosis which were involved in the pathogenesis of erectile dysfunction (ED), but whether NaBu could improve ED in an experimental animal model of benign prostate hyperplasia (BPH) was not known. OBJECTIVE: To investigate the preventive effect of NaBu on ED in a partial bladder outlet obstruction (PBOO) rat model. MATERIALS AND METHODS: PBOO was induced by partial urethral obstruction. NaBu (20 mg/kg/day) was administered orally to rats for 6 weeks after creation of PBOO. In vivo erectile responses, in vitro relaxation and contraction responses in cavernosal tissue were measured. Real-time polymerase chain reaction (RT-PCR) and Western blot were performed to determine the gene and protein expression. Inflammation, fibrosis, and localization of proteins were evaluated using histological techniques. HDAC activity and tumor necrosis factor (TNF)-α levels were measured in penile tissues. RESULTS: NaBu improved decreased intracavernosal pressure/mean arterial pressure, nitrergic and endothelium-dependent relaxation responses, and contractile responses to phenylephrine and electrical field stimulation in the PBOO group without affecting increased bladder weight. Increased endothelial nitric oxide synthase (eNOS), transforming growth factor (TGF)-ß1, and nuclear factor kappa B (NF-κB) gene levels in PBOO group were ameliorated by NaBu treatment. The administration of NaBu to PBOO rats significantly increased neuronal NOS (nNOS) and decreased TGF-ß1 protein expression. The nuclear/cytosolic ratio of NF-κB demonstrated a decrease in PBOO and all treatment groups compared to control. A significant increase in the nuclear-to-cytoplasmic ratio of nuclear factor erythroid 2-related factor 2 (Nrf2) after PBOO was reduced by the treatment. Both eNOS and inducible NOS (iNOS) protein expression, together with TNF-α levels did not differ in the penile tissue of all groups. In histological analysis, increased TGF-ß1 protein expression and fibrosis, as well as decreased nNOS protein in PBOO, were reversed by the treatment. NaBu did not normalize moderate inflammation in obstructed rats. An increase in the HDAC activity in PBOO was significantly suppressed by NaBu. DISCUSSION: Inhibition of the HDAC activity by NaBu in penile tissue could ameliorate fibrosis-associated changes induced by PBOO. CONCLUSION: NaBu promotes recovery of erectile function, and also significantly prevents penile fibrosis and normalizes TGF-ß1 and nNOS protein expression in a rat model of PBOO. The HDAC pathway may present a promising target to prevent ED in patients with BPH.

Post-chemotherapy modified template retroperitoneal lymph node dissection in patients with nonseminomatous germ cell tumours.

INTRODUCTION/BACKGROUND: Although a full bilateral template RPLND is thought to be the standard of care for the management of postchemotherapy retroperitoneal residual masses for nonseminomatous germ cell tumors (NSGCT), in the past decade modified templates have become increasingly popular. In this study, we aimed to present our oncological and perioperative outcomes of consecutive seventeen NSGCT patients who underwent a modified template unilateral PC-RPLND for retroperitoneal residual disease. MATERIALS AND METHODS: We retrospectively evaluated the medical records of 17 consecutive NSGCT patients who underwent modified template unilateral PC-RPLND in our university hospital between 2017 and 2020. All patients had normal serum tumour markers with residual disease in the retroperitoneum. Surgical characteristics including the size of the retroperitoneal residual mass, residual tumor pathology, removed lymph nodes, positive percentage of removed lymph nodes, accompanying operations, complications, mean operation time and hospital stay, and long-term results including survival and antegrade ejaculation were evaluated. RESULTS: Eleven patients underwent left and six right-sided surgery. Median residual lymph node diameter was 41mm. Median hospitalisation time was 3.5 days. Median follow-up time was 10.5 months. Necrosis/fibrosis was seen in 6 patients, and teratoma in 11 patients. No viable tumour was seen. No patients died in the follow-up period. None of the patients relapsed during follow-up. Ten/seventeen patients had antegrade ejaculation. CONCLUSIONS: Modified template unilateral PC-RPLND leads to very good oncological outcomes with decreased perioperative morbidity as well as better antegrade ejaculation rates. Low volume retroperitoneal disease seems to fit this procedure best.

Bladder neck sparing during robot-assisted laparoscopic radical prostatectomy: Six-year experience.

OBJECTIVE: Prostate cancer is the most frequently diagnosed cancer among men in developed countries. Radical prostatectomy (RP) is the standard surgical treatment for patients with organ-confined disease and robot-assisted laparoscopic radical prostatectomy (RALP) procedures get more popular in the past 20 years. The most important factor of continence after RP is the preservation of the functional sphincter mechanisms. Tunc et al. described the novel bladder neck preserving technique in RALRP in 2015. The purpose of this study is to present our long-term results of our novel technique during RALP performed by single surgeon (LT). METHODS: In this study, 331 patients who went under procedure RALP between January 2012 and December 2017 analyzed retrospectively. Bladder neck sparing technique was performed for all patients used by a four-armed da Vinci robotic surgical system (Intuitive Surgical, Inc., Sunnyvale, CA). Quality of life (QoL) scores were assessed before RALP, after urethral catheter removal, and at the 1st month after RALP used by SF-12 QoL questionnaire. Patients without urine leakage during coughing or sneezing, as well as those who stayed totally dry, were considered as continent. Those who used more than 1 protective pad per day and/or had urine leakage during coughing, sneezing, or during the night were considered incontinent. RESULTS: The mean operation time, docking time, and anastomosis time were 76.9±28.9, 7.2±2.2, and 18±3.1 min, respectively. Estimated blood loss was 51.6±22.9 ml. The mean hospital stay was 2.2±0.8 days. The mean duration of the catheter was 7.1±1.3 days. After catheter removal, 310 (93.6%) of patients were continent immediately. During follow-up, 318 (96%) were continent after 1 month and 329 (99.3%) were totally continent after 1 year. No patient received surgical treatment for stress incontinence. CONCLUSION: Since we have defined bladder neck sparing technique, we have realized that our technique is very effective with our long-term results. Our novel technique provided very early continence at the time of catheter removal after RALP within short-term follow-up in addition to favorable oncologic results.

Is 'Omega Sign' anatomical endoscopic enucleation of the prostate technique reproducible?

We aimed to evaluate the learning curve of the surgically standardised 'Omega Sign' anatomical endoscopic enucleation (AEEP) of the prostate surgery technique for junior surgeons. This study is a retrospective comparison of cases that underwent AEEP by a mentor surgeon and three junior surgeons who have completed their learning curve. A video-based laser enucleation of the prostate assessment tool (LEAT) composed of 8 steps of the technique was used to assess a senior surgeon and junior surgeons' surgical compatibility and consistency. The surgeon who defined Omega Sign technique was determined as group 1, and cases by three junior surgeons were identified as group 2. The end points were to assess the reproducibility and repeatability and operative post-operative outcomes of the technique. 55 patients' videos were rated by five experienced endourologists. There was no significant difference in LEAT scores between the groups among all steps. The most symmetry was found in the 1st and 3rd steps. Inter-rater consistency was also high for each step, with no statistically significant difference between the evaluators. The standardised anatomical 'Omega Sign' technique is reproducible for the junior surgeons. The operative steps can be performed with high consistency, and the functional and perioperative outcomes are comparable with the senior surgeon.

Laser enucleation for prostates larger than 100 mL: Comparison of HoLEP and ThuLEP.

Recently, with the advancements in laser technology, Holmium laser enucleation of the prostate (HoLEP) and Thulium laser enucleation of the prostate (ThuLEP) have come to the fore in the surgical treatment of benign prostatic hyperplasia (BPH). We aimed to evaluate and compare the outcomes of HoLEP and ThuLEP in patients with >100 ml prostate volume. Patients who underwent HoLEP and ThuLEP between July 2017 and March 2020 were reviewed retrospectively. The patients were divided into two groups as HoLEP (Group 1, n = 121) and ThuLEP (Group 2, n = 104). Perioperative parameters, functional outcomes, continence status, intra and post-operative complications were compared between groups in the post-operative 1st and 6th month. No significant difference was found in terms of total laser energy (TLE), morcellation efficiency (ME), enucleated tissue weight (ETW), complication rates (CR) and continence status of patients between both groups (p > .05). In favour of ThuLEP group, there were statistically significant differences regarding total operation time (TOT), laser efficiency (LE), enucleation time (ET) and enucleation efficiency (EE) between groups (p ≤ .05). HoLEP and ThuLEP can be used safely and effectively in prostates larger than 100 ml.

The effects of bladder neck sparing with an additional anterior urethral fixation on postoperative continence after robot-assisted radical prostatectomy.

OBJECTIVE: Urinary incontinence remains one of the main problems affecting the quality of life after radical prostatectomy. Along with the improved understanding of the precise anatomy of the prostate, urethra and their surrounding structures, minimally invasive surgical techniques have been refined and described, aiming to improve functional outcomes without oncological compromise. This study aimed to investigate the impacts of anterior urethral fixation (AUF) and bladder neck sparing (BNS) on the early continence success after Robot-assisted Radical Prostatectomy (RALP). METHODS: This retrospective study included 120 patients who underwent RALP between January 2018 and June 2019. Patients were allocated to one of two groups; group 1 (n=60) underwent RALP with BNS, group 2 (n=60) underwent RALP with both AUF and BNS. The patient continence status was measured at baseline on day 7 and in the 1st, 3rd, and 6th months postoperatively. RESULTS: Concerning Incontinence Impact Questionnaire-7 form, statistically significant better results in group 2 were recorded in all visits, but the last (month 6) (p=0.023). Following catheter removal, postmicturition symptoms, including incomplete emptying and post-micturition dribble rate, were significantly higher in group 1 after catheter removal and in the 1st month (13.3% vs. 0 p=0.006). This difference was not recorded at the next visits (months 3 and 6). CONCLUSION: Our findings showed that the combination of AUF and BNS significantly increases early continence rates and decreases post-mictional symptoms after RALP without hampering oncologic outcomes.

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.

Ventral onlay buccal mucosa graft urethroplasty for female urethral stricture.

OBJECTIVES: Female urethral stricture is a rare disease. Urethroplasty with different techniques using grafts or flaps are successful treatment options. The objective of this study was to present our experience with ventral onlay buccal mucosa graft urethroplasty for the treatment of female urethral stricture disease. METHODS: Eight female patients treated with ventral onlay buccal mucosa graft urethroplasty were identified retrospectively. Patient evaluation included physical examination, uroflowmetry with postvoid residual urine measurement, videourodynamics and urethrocystoscopy. Stricture was identified by videourethrography and/or urethrocystoscopy. Urodynamic evidence of stricture was considered as a persistent low maximum flow rate of <12 mL/s combined with detrusor pressure at maximum measured flow rate of >20 cmH2 O in the pressure flow study. RESULTS: The mean age was 50.5 ± 4.14 years. Stricture etiology was idiopathic (62.5%) or iatrogenic (37.5%). Two patients (25%) had undergone prior urethral dilations before buccal mucosa graft urethroplasty. Mean stricture length was 1.62 ± 0.44 cm. Stricture location was as follows: four distal urethra (50%), two mid-distal (25%) and two mid-urethra (25%). The mean postoperative follow-up period was 16.37 ± 5.75 months, and the during follow-up success rate was 100%. No complication, such as incontinence or vaginal fistula, was noted, except dyspareunia developed in one patient (12.5%). CONCLUSIONS: Ventral onlay buccal mucosa graft urethroplasty is a safe and effective treatment option for female urethral stricture. Unnecessary dilation should not be carried out and buccal mucosa graft urethroplasty in expert centers should be recommended to these patients.

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 1st and 6th 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.

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.

HoLEP after prostate biopsy: does it have any impact?

PURPOSE: Holmium laser enucleation of the prostate (HoLEP) has recently become the recommended treatment for prostate in all sizes in benign prostate hyperplasia surgery. A recent prostate biopsy performed prior to the HoLEP procedure can make surgeons concerned about the surgery. We aimed to investigate the per- and postoperative outcomes of the HoLEP procedure in patients who underwent prostate biopsy and to evaluate the most appropriate surgery time after biopsy. METHODS: The data of 160 patients who underwent HoLEP by a single surgeon between March 2017 and December 2019 were retrospectively reviewed. The patients were divided into two groups, Group 1 consisted of 80 patients without prostate biopsy and Group 2 consisted of 80 patients with prior prostate biopsy. All HOLEP procedures in group 2 were performed at least 2 weeks following biopsy. Per- and postoperative outcomes, complications were evaluated. RESULTS: No significant differences were found between groups in terms of by enucleation time, efficiency of laser, efficiency of enucleation, hospitalization time, and catheterization removal time. Only morcellation time was shorter in biopsy naïve patients. There were no statistical differences in postoperative outcomes. Previous prostate biopsy did not affect the continence status in our study group. There were not any Clavien grade 4 or higher complications. Urinary tract infection was higher in early post-biopsy period, there was no difference among the groups. CONCLUSiON: Our study confirms that HoLEP is a safe and efficient surgical procedure for the patients with prior prostate biopsy. We believe that it can be safely performed 2nd week following prostate biopsy.

The clinical features and treatment options of intratesticular epidermoid cysts. / Las características clínicas y opciones de tratamiento de los quistes epidermoides intratesticulares.

OBJECTIVES: In this study, we aimed to define the clinico-radiological data and treatment options for intratesticular epidermoid cysts (IEC). MATERIALS AND METHODS: We retrospectively reviewed the medical records of the patients that under went surgery for testicular mass between 1995 and 2017. Data of the patients whose histopathological evaluation revealed IEC were recorded.  RESULTS: A total of 20 patients with IEC were identified.While three of 20 patients were excluded due to incomplete data, the remaining 17 patients with pathologically proven IEC were reviewed and analyzed in the study. The mean patient age was 22.2 years (range, 17-29 years). All patients were presented with painless testicular swelling and/or mass. Serum tumor markers of all patients were within the ranges. Four patients treated with radical orchiectomy (23.5%), while 13 patients under went partial orchiectomy (76.5%). The mean size ofthe IEC was 17.7x15.1 mm (range, 26x10 mm). IEC swere mostly located in the middle pole of the testes (10of 17 patients, 58.8%). CONCLUSIONS: This study is designed in retrospective nature, but the patient population is one the largest reported in the literature. According to our study, we can easily state that partial orchiectomy can be performed safely after FSA in patients that have IECs.

OBJETIVOS: En este estudio, nuestro objetivofue definir los datos clínico-radiológicos y las opciones de tratamiento de los quistes epidermoides intratesticulares (CEI). MATERIALES Y MÉTODOS: Revisamos retrospectivamente los registros médicos de los pacientes que se sometieron a cirugía para la masa testicular entre 1995 y 2017. Entre ellos se registraron los datos de los pacientes cuya evaluación histopatológica reveló IEC. RESULTADOS: Se identificaron un total de 20 pacientes con IEC. Mientras que tres de los 20 pacientes fueron excluidos debido a los datos incompletos, los 17pacientes restantes con IEC patológicamente probada se revisaron y analizaron en el estudio. La edad media de los pacientes fue de 22,2 años (rango, 17-29años). A todos los pacientes se les presentó hinchazón y/o masa testicular indolora. Los marcadores tumorales séricos de todos los pacientes estaban dentro de los rangos. Cuatro pacientes tratados con orquiectomía radical (23,5%), mientras que 13 pacientes se sometieron a orquiectomía parcial (76,5%). El tamaño medio de la IEC fue de 17,7x15,1 mm (rango, 26x10 mm). Los IEC se encontraban principalmente en el polo medio de los testículos (10 de 17 pacientes, 58,8%). CONCLUSIONES: Este estudio está diseñado de forma retrospectiva, pero la población de pacientes es una de las más numerosas que se han publicado en la literatura. Según nuestro estudio, podemos afirmar fácilmente que la orquiectomía parcial se puede realizar de manera segura después de la FSA en pacientes que tienen CEI.

Holmium laser enucleation of the prostate for the treatment of size-independent BPH: A single-center experience of 600 cases.

OBJECTIVE: Holmium laser enucleation of the prostate (HoLEP) is an endourologic minimal invasive intervention of benign prostate hyperplasia (BPH). The interest on HoLEP is increasing in the literature. The aim of the present study was to evaluate the learning curve and our preliminary results. MATERIAL AND METHODS: A retrospective analysis on 600 patients with BPH who underwent HoLEP between July 2015 and April 2019 was performed. Perioperative measures including enucleation efficiency (EE), morcellation efficiency (ME), and percentage of resected tissue weight (PRW) were recorded. Hospitalization time (HT) and catheterization time (CT) were measured. Functional outcomes, Clavien-Dindo classification complications, and continence status were assessed at 1-, 3-, and 6-month follow-up. RESULTS: The mean age, prostate size, and prostate-specific antigen levels of the patients were 64.54 years, 91 g, and 4.54 ng/mL, respectively. There were 38.3% of patients with ≥100 g prostate size. The measured EE, ME, and PRW were 1.12 g/min, 4 g/min, and 72%, respectively. The mean HT and CT were 24.53 h and 21.50 h, respectively. Functional outcomes showed significant improvement at 1-, 3-, and 6-month follow-up. Intraoperative and postoperative complications were comparable with the literature. The most common perioperative complication was superficial bladder mucosal injury (n=8, 1.33%). Only one patient had persistent stress urinary incontinence at 6-month follow-up. CONCLUSION: As mentioned in the literature, HoLEP indications are independent from prostate size. Our results showed similarity with the literature on functional outcomes, complication rates, and continence status. With its superior results, our HoLEP series from Turkey supports that HoLEP will replace transurethral resection of the prostate as the known current gold standard.

The role of laparoscopic experience on the learning curve of HoLEP surgery: A questionnaire-based study.

OBJECTIVE: Holmium laser enucleation of the prostate (HoLEP) is an established method for treating benign prostatic obstruction. Nonetheless, its steep learning curve limits its wide distribution. The purpose of the present study was to demonstrate the impact of laparoscopic experience on HoLEP learning curve by evaluating the association between learning curves of surgeons performing both laparoscopy and HoLEP surgery. MATERIAL AND METHODS: A questionnaire was prepared to identify surgeon's experience on laparoscopy and HoLEP, as well as their learning curves. This questionnaire was then distributed via e-mail to 110 urologists who are actively involved in endourology/laparoscopy. RESULTS: Of the 110 urologists, 80 (72.7%) responded and completed the questionnaire. Of the 80 surgeons, 47 (58.8%) reported that they had completed the HoLEP learning curve with <20 cases. Moreover, 33 (41.2%) reported that they were able to complete the learning curve by performing >20 cases. Completion of the HoLEP learning curve in <20 cases was reached at 1.3%, 13.8%, and 43.8% by beginner, moderate skilled, and experienced laparoscopists, respectively (p<0.001). CONCLUSION: Laparoscopic experience appears to be beneficial for surgeons while learning HoLEP. Highly experienced laparoscopic surgeons have a shorter HoLEP learning curve.

The cognitive fusion prostate biopsy using a smart phone in the diagnosis of prostate cancer. / Biopsia de próstata cognitiva utilizando un dispositivo móvil.

OBJECTIVES: In this research, we designed a cognitive fusion(CF) prostate biopsy(PB) (CFPB) technique by examining the multiparametric MRI of prostate (MP_MRI-P) images in a smart-phone near the trans-rectal ultrasound (TRUS) device, and examined the results. METHODS: Between January 2011 and January 2017, a total of 344 men who had PB enrolled in this study. Group 1 had a minimum of a 12-core standard TRUS PB (TRUSPB). Group 2 had CFPB while examining the MP_ MRI-P images in a smartphone near the TRUS device. A minimum 12 cores + cognitive targeted 1-3 biopsy were taken. The detection of Pca and significant Pca in group 1 and 2 were evaluated and compared. Then, the effect of MP_MRI-P findings on the detection of prostate cancer (Pca) and significant Pca were evaluated. RESULTS: Group 1 and 2 included 138 and 206 patients. After the PB, 45(32.8%) and 33(23%) patients ingroup 1, and 74(35.9%) and 60(29%) patients in-group 2 were detected to have Pca and significant Pca, respectively (p=0.001 for both). Higher PIRADS caused significant detection of Pca and significant Pca (p=0.004 and 0.002). Nodule in MP_MRI-P caused significant detection of Pca and significant Pca (p=0.001 and 0.001). Especially, when PSA was <10ng/ml, higher PIRADS and nodule in MP_MRI-P caused significant detection of Pca and significant Pca (p=0.02 and 0.019 for PIRADS, and p=0.01 and 0.042 for nodules). CONCLUSIONS: In the advanced hands with our new technique, the CFPB using prebiopsy MP_MRI-P seems to be an effective method to detect Pca and significant Pca.

OBJETIVOS: En este estudio de investigación diseñamos una técnica de biopsia de próstata (BxP) con fusión cognitiva (FC) (BxPFC) mediante el examen de la RMN multiparamétrica (RMNmp) de la próstata en un dispositivo móvil cerca del aparato de ecografía transrectal (ETR) y examinamos los resultados.MÉTODOS: Entre enero de 2011 y enero del 2017 se incluyeron en el estudio un total de 344 varones sometidos a BxP. El Grupo 1 hizo una BxP guiada por ecografía transrectal estándar que tenía un mínimo de 12 muestras. El Grupo 2 fue sometido a BxPFC utilizando un dispositivo móvil para evaluar las imágenes de la RMNmp de próstata cerca del aparato de ecografía transrectal. Se tomaron un mínimo de 12 muestras + 1-3 dirigidas de forma cognitiva. Se evaluaron y compararon la detección de CaP y de CaP significativo entre los grupos. También se evaluó el efecto de los hallazgos de la RMNmp de próstata sobre la detección de cáncer de próstata y CaP significativo. RESULTADOS: Los grupos 1 y 2 incluyeron 138 y 206 pacientes respectivamente. Después de la BxP, se detectaron 45(32,8%) pacientes con CaP y 33(23%) con CaP significativo en el grupo 1, y 74(35,9%) y 60(29%) pacientes en el Grupo 2, respectivamente (p=0,001 para ambos). Los valores más altos de PIRADS se asociaron con una detección significativa de CaP y CaP significativo (p=0,004 y 0,002). La presencia de un nódulo en la RMNmp se asocia con una detección significativa de CaP y CaP significativo (p=0,001 y 0,001). Especialmente, cuando el valor del PSA era <10 ng/ml, el PIRADS más alto y existía un nódulo en la RMN mp el diagnóstico de CaP y CaP significativo era significativamente mayor (p=0,02 y 0,019 para PIRADS, y p=0,01 y 0,042 para nódulos). CONCLUSIONES: Con nuestra nueva técnica en manos expertas, la BxP con fusión cognitiva utilizando las imágenes de RMNmp previa parece ser un método efectivo para detectar CaP y CaP significativo.

Descending laparoscopic radical nephrectomy and proven advantages in long term. / Nefrectomía radical laparoscópica descendente. Ventajas a largo plazo demostradas.

OBJECTIVES: We aim to present and analyze the long term results of descending transperitoneal laparoscopic nephrectomy (TLN) technique (Tunc technique). METHODS: A total of 308 patients that underwent descending TLN were included to the study between January 2011 and March 2018. Mean operation time, mean estimated blood loss, duration of hospital stay, complications, mean tumor size, and pathologic margin status were analyzed. RESULTS: A total of 308 patients underwent the descending TLN technique. Mean tumor size was 6.5±1.83 (range 3.5-12 cm). Mean intraoperative estimated blood loss was 38±6.91mL. Mean operation time was 24.97±6.8 minutes. Duration of hospital stay was1.85±0.69 days. Only one patient received postoperative blood transfusion for chronic anemia. Two of the patients had endoGIA stapler malfunction. None of the patients required conversion to open surgery intraoperative. There was no positive margin status. CONCLUSIONS: We could prove the safety and effectiveness of descending TLN technique. The main advantages of descending TLN over traditional ascending nephrectomy technique are shorter operation time and hospital stay.

OBJETIVOS: El objetivo fue presentar y analizar los resultados a largo plazo de la técnica de nefrectomía laparoscópica transperitoneal (TLN) descendente (técnica Tunc).MÉTODOS: Un total de 308 pacientes sometidos a TLN descendente se incluyeron en el estudio entre enero de 2011 y marzo de 2018. Se analizaron el tiempo medio de operación, la pérdida sanguínea estimada media, la duración de la estancia hospitalaria, las complicaciones, el tamaño tumoral medio y el estado del margen patológico. RESULTADOS: Un total de 308 pacientes se sometieron a la técnica de TLN descendente. El tamaño promedio del tumor fue de 6,5 ± 1,83 (rango de 3,5-12 cm). La pérdida de sangre estimada intraoperatoria media fue de 38 ± 6,91 ml. El tiempo medio de operación se calculó en 24,97 ± 6,8 minutos. La duración de la estadía hospitalaria fue de 1,85 ± 0,69 días. Solo un paciente recibió transfusión de sangre postoperatoria por anemia crónica. Dos de los pacientes tenían mal funcionamiento de la engrapadora endoGIA. Ninguno de los pacientes requirió conversión a cirugía abierta intraoperatoria. No hubo un estado de margen positivo. CONCLUSIONES: Podríamos demostrar la seguridad y efectividad de la técnica de TLN descendente. Las principales ventajas de la TLN descendente sobre la técnica tradicional de nefrectomía ascendente son el tiempo de operación más corto y la estancia hospitalaria.

Prostate shape significantly affects the HoLEP procedure time and energy usage: A retrospective pilot study.

Introduction: In this study we evaluate the influence of longitudinal and transverse length of prostate size measured on the magnetic resonance imaging (MRI) scan on the overall outcomes of HoLEP. Material and methods: The patients were divided into two groups based on the shape of the prostate. Group 1 had a longitudinal shape with a longitudinal diameter greater than the transverse diameter, whereas group 2 had an oval shape with a transverse diameter greater than the longitudinal diameter. The pre-operative, peri-operative and the one-month post-operative data along with the urinary parameters were then evaluated. Results: The two groups were comparable with regard to their pre-operative values. While the median lobe enucleation time and morcellation time showed no difference, group 1 showed a significantly shorter (p < 0.01) operative time for lateral lobe enucleation, lower laser energy usage and better enucleation efficiency. However, there was no difference in the median lobe enucleation time, morcellation time, haemoglobin drop, duration of urethral catheterization and hospital stay. The groups were also comparable with regard to the improvement in urinary parameters and complications. Conclusion: Prostate shape plays a significant role in the surgical treatment of BPH.

Comparison of 3 Different Teaching Methods for a Behavioral Therapy Program for Female Overactive Bladder: A Randomized Controlled Trial.

PURPOSE: The purpose of this study was to compare the effect of 3 instructional methods for behavioral therapy on lower urinary tract symptom (LUTS) severity and health-related quality of life (HRQOL) in women with overactive bladder. DESIGN: Single-center, parallel-group, randomized, clinical trial. SUBJECTS AND SETTING: The sample comprised 60 women diagnosed with overactive bladder. The study setting was a university-based female urology clinic in Ankara, Turkey; data were collected from November 2012 to May 2013. Eligible participants were ambulatory women 18 years or older with predominant overactive bladder and urge urinary incontinence (UI) symptoms, with or without stress UI symptoms. METHODS: Subjects were randomized into 4 groups based on educational intervention; group 1 received structured verbal instruction plus a leaflet, group 2 received structured verbal instruction, group 3 received a leaflet alone, and group 4 received usual care that included unstructured verbal counseling about continence care. The primary outcome measures were Incontinence Impact Questionnaire-7 (IIQ-7) and Urinary Distress Inventory-6 (UDI-6) scores. We also measured changes in UI-specific HRQOL scores via the Urinary Incontinence Quality of Life Instrument (I-QOL). All outcomes were measured before and 6 to 8 weeks after the interventions. The Wilcoxon test was used to identify differences in LUTS severity and HRQOL before and after the educational intervention. The Kruskall-Wallis test was used to compare differences among the groups. RESULTS: The severity of LUTS and UI-specific quality of life assessed by the IIQ-7, UDI-6, and I-QOL scores significantly improved after training in all 4 groups (P < .05). The group that received structured verbal instruction plus an educational leaflet achieved significantly lower LUTS scores and significantly higher UI-specific HRQOL when compared to the other groups (P < .05). CONCLUSIONS: Findings suggest that structured verbal instruction plus educational leaflet is the most effective method of bladder training in women with overactive bladder and urge UI.