Impact of an Expanded Definition of Family History on Outcomes of Active Surveillance for Prostate Cancer.

PURPOSE: Despite family history being an established risk factor for prostate cancer, the role of a broader definition of family history inclusive of not just prostate cancer but other genetically related malignancies has not been investigated in the active surveillance population. Here, we evaluate the impact of an expanded definition of family history on active surveillance outcomes. MATERIALS AND METHODS: Patients undergoing active surveillance for prostate cancer at Massachusetts General Hospital from 1997-2019 with detailed data available on family cancer history were identified. Primary outcome was biopsy progression-free survival, and secondary outcomes were treatment-free survival, adverse pathological features at prostatectomy, and biochemical recurrence after treatment. Statistical analyses were conducted using the Kaplan-Meier method and Cox regression. RESULTS: Among 855 evaluable patients, 300 (35.1%) patients had any family history of prostate cancer, and 95 (11.1%) had a family history of related malignancies suggestive of a hereditary cancer syndrome. Family history of prostate cancer alone was not associated with biopsy progression, whereas family history suggestive of a hereditary cancer syndrome was associated with a significantly increased risk of biopsy progression (HR 1.43, 95%CI 1.01-2.02), independent of other known clinicopathological risk factors in multivariable analysis. Similarly, family history suggestive of a hereditary cancer syndrome was associated with significantly lower treatment-free survival (HR 1.58, 95%CI 1.14-2.18) in multivariable analysis. No significant association was found between family history and adverse features on surgical pathology or biochemical recurrence. CONCLUSIONS: An expanded family history suggestive of a hereditary cancer syndrome is an independent predictor of biopsy progression during active surveillance. Men with such a family history may still be offered active surveillance but should be counseled regarding the higher risk of disease progression.

Contrast-Enhanced Ultrasound and Shear Wave Elastography: Novel Methods for the Evaluation of Urethral Stricture Disease.

PURPOSE: Urologists will benefit from an imaging modality which can assess intra and extraluminal characteristics of urethral strictures. We conducted a prospective pilot study evaluating the utility of contrast-enhanced ultrasound and shear wave elastography for the evaluation of bulbar urethral stricture disease. MATERIALS AND METHODS: Patients with a single, bulbar urethral stricture were prospectively recruited. Contrast-enhanced ultrasound and shear wave elastography were performed at the time of surgical repair and at 4 months' followup using an Aplio i800 scanner (Canon Medical Systems, Tustin, California) with an i8CX1 transducer. Sulfur hexafluoride lipid-type A microsphere ultrasound contrast (Lumason®, Bracco Imaging, Princeton, New Jersey) was injected retrograde through the urethra. Stiffness of the corpus spongiosum was measured at and adjacent to the stricture site. Stricture lengths based on retrograde urethrogram, grayscale ultrasound and contrast-enhanced ultrasound were correlated with measured intraoperative stricture length. RESULTS: Thirty men were enrolled. Contrast-enhanced ultrasound (R2=0.709) showed the best correlation with intraoperative measured stricture length compared to retrograde urethrogram (R2=0.016) or grayscale ultrasound (R2=0.471). Stiffness of the spongiosum was greater at the site of the stricture (32.6±5.4 vs 27.3±5.8 kPa, p=0.044) and in narrower caliber strictures (p=0.044) but did not differ by stricture length (p=0.182). At followup (4.3±1.1 months) contrast-enhanced ultrasound detected stricture recurrence with 80% sensitivity, 100% specificity, and 93% accuracy compared to cystoscopy. CONCLUSIONS: This pilot study demonstrates the ability of contrast-enhanced ultrasound and shear wave elastography to become safe, accurate, and potentially efficacious modalities for assessing bulbar urethral strictures and spongiofibrosis.

Microorganism Profiles of Penile Prosthesis Removed for Infection, Erosion, and Mechanical Malfunction Based on Next-Generation Sequencing.

BACKGROUND: Next-generation sequencing (NGS) is an emerging technology that may allow for more sensitive and sophisticated microbial testing of the microbiota of penile prostheses (PP). AIM: To describe the microorganism profiles of PP explanted for infection, erosion, and mechanical malfunction using NGS. METHODS: All patients who underwent PP removal by two physicians at two institutions were identified. Differences in alpha diversity (ie, number of species detected, species diversity across samples) and microbiome compositional profiles (Bray-Curtis community dissimilarities) across samples were assessed using ANOVA and PERMANOVA, respectively. OUTCOMES: Number of species detected, species diversity across samples, and microbiome compositional profiles. RESULTS: A total of 83 patients who underwent device removal for infection (n = 8, 10%), erosion (n = 5, 6%), and mechanical malfunction (n = 70, 84%) were included. When considering all devices, 56% (n = 48) of NGS and 29% (n = 24) of standard cultures resulted positive for presence of microorganisms. Culture only detected the most abundant NGS species in 62.5% (n = 5) of infected devices. Species richness and microbiome compositional profiles varied by surgical indication, but not by age, race, diabetes status, or implant duration. Most frequent organisms by surgical indication were Pseudomonas aeruginosa (infection), Staphylococcus epidermidis (erosion), and Escherichia coli (mechanical malfunction). The highest relative abundance organisms were P aeruginosa (infection), Corynebacterium jeikeium (erosion), and E coli (mechanical malfunction). CLINICAL IMPLICATIONS: Identifying microbiome profiles of PP removed for infection, erosion, and mechanical malfunction may guide the selection of peri-operative antibiotics and PP antibiotic coatings or hydrophilic dip solutions for each individual scenario. STRENGTHS AND LIMITATIONS: While this is the first study to utilize next-generation sequencing to evaluate penile prosthesis biofilm, the clinical significance of these findings has yet to be determined. A prospective, randomized trial aimed at evaluating the clinical significance of NGS in patients with PP infection is currently underway. CONCLUSION: NGS testing identified distinct microbiome profiles of PP removed for infection, erosion, and mechanical malfunction. Chung PH, Leong JY, Phillips CD, Henry GD. Microorganism Profiles of Penile Prosthesis Removed for Infection, Erosion, and Mechanical Malfunction Based on Next-Generation Sequencing. J Sex Med 2022;19:356-363.

General surgeons' comfort and urologists' perceptions of bladder trauma management.

INTRODUCTION: Utilizing a physician-reported survey, we assessed general surgeons (GS) comfort level in the management of bladder trauma, from a GS and urologist's perspective. MATERIALS AND METHODS: Online questionnaires were distributed electronically to physicians of the American College of Surgeons and American Urological Association. This survey queried demographic data, clinical factors that may influence urology consultations, and bladder injury scenarios of varying severities. Two questions were presented for each scenario, the first querying GS comfort level in bladder trauma management, the second assessing the likelihood of obtaining urology consultations in such scenarios. Responses were graded on a Likert scale. RESULTS: Overall, 108 (51%) GS and 104 (49%) urologists responded. When compared to managing Grade I injuries, the comfort level of GS decreased as the severity of bladder trauma increased, while the likelihood of obtaining a urology consultation increased. While the perceived comfort of GS by urologists decreased from 84% to 5% for Grade I to Grade V injuries, GS reported a significantly higher comfort level (Grade I: 92%, p = 0.09; Grade V: 31%, p < 0.001). Majority of GS indicated that preoperative diagnosis on imaging (56%), intraoperative diagnosis (62%), and timing of patient presentation (76%), did not affect their decision to consult urology for assistance in bladder trauma (p < 0.001). CONCLUSIONS: GS-reported comfort levels for bladder trauma management remains higher than urology-perceived comfort levels. Contrary to urologists' perception, most peri-injury factors did not affect GS decision to consult urology for bladder trauma. We hope this study can foster discussion and improve interdisciplinary collaboration in bladder trauma management.

Impact of penile prostheses and intracavernosal injections on psychosocial functioning.

INTRODUCTION: Prior studies evaluating the efficacy of penile prostheses (PP) and intracavernosal injections (ICI) have focused predominantly on sexual function, not psychosocial health. We utilized the freelisting technique and the Self-Esteem and Relationship (SEAR) questionnaire to evaluate the impact of PP and ICI treatments on psychosocial functioning. MATERIALS AND METHODS: IRB-approval was obtained to perform an evaluation of patients who underwent PP or ICI treatment for erectile dysfunction (ED). Using a modified freelisting approach, participants were asked to give three one-word responses to questions about sexual function and relationships. Participants also completed the SEAR questionnaire and results were calculated based on the previously described formulas. RESULTS: Fifty patients agreed to participate in the study (25 ICI, 25 PP). In the freelisting portion of the study, PP patients had more positive responses than ICI patients in 2 out of 3 questions. The freelisting study also identified important areas of concern for ED patients such as self-esteem, confidence, and treatment reliability. PP patients reported numerically higher SEAR total scores than ICI patients (63.9 vs. 53.9, p = 0.12), especially in confidence with duration of (p = 0.003), satisfaction with sexual performance (p = 0.06), and confidence with sexual performance (p = 0.02). SEAR confidence domain (p = 0.83), self-esteem subscale (p = 0.68), and overall relationship sub-scales (p = 0.90) were similar between PP and ICI patients. CONCLUSIONS: PP appears to have a stronger psychosocial impact compared to ICI; however, both PP and ICI patients continue to struggle with self-esteem, confidence, and treatment reliability. Further patient counseling before and after treatment may help to address these concerns and improve patient satisfaction.

Molecular testing with next-generation sequencing appears to identify biofilm on penile prostheses better than traditional cultures: The new gold standard?

INTRODUCTION: Traditional culture is the current standard-of-care to determine therapeutic antibiotics for patients suffering from penile prostheses (PP) infections. However, approximately 50% of PPs removed for infection are culture negative. Next-generation sequencing (NGS) compares DNA sequences to reference sequences with known microbial taxonomies to identify isolates and report relative abundances. We aim to compare the ability for standard culture and NGS techniques to identify microorganisms and biofilm composition on PPs. MATERIALS AND METHODS: Ninety-one PPs explanted for mechanical malfunction were included in this study. Devices removed for infection or erosion were excluded. During revision surgery, two specimens were collected and sent for culture testing at institutional laboratory and for NGS testing (MicroGenDx, Lubbock, TX, USA). Species' relative abundances, sample diversity and richness, and compositional differences among samples were analyzed. RESULTS: NGS had a higher rate of microbial detection (n = 72, 79.1%) compared to culture results (n = 3, 3.3%). Some of the bacteria identified using both methods were known prosthetic infectious pathogens, with NGS producing more isolates (mean: 11) than culture (mean: 1). Escherichia coli was the most abundant and most frequently occurring bacteria detected on NGS. Coagulase-negative Staphylococci were the most common bacteria detected on traditional culture. CONCLUSIONS: NGS appears to be beneficial in its thorough analysis of PP biofilm composition when compared to culture methods. We hope that further research will be able to demonstrate a clinical benefit of NGS in characterizing distinct microbiomes and biofilms of infected PP, which can aid in tailoring antimicrobial therapy and improving patient outcomes.

UroLift and Rezum: minimally invasive surgical therapies for the management of benign prostatic hyperplasia.

INTRODUCTION Minimally invasive surgical therapies for benign prostatic hyperplasia (BPH) are popular alternatives to the gold standard transurethral resection of the prostate (TURP). These procedures have fewer discernable side effects on urinary and sexual function, when compared to TURP, making it a desirable option for many patients. MATERIALS AND METHODS: We provide an updated literature review on the current landscape of minimally invasive modalities, specifically the prostatic urethral lift (UroLift) and water vapor thermal therapy (Rezum), for the surgical treatment of BPH. RESULTS: Both UroLift and Rezum have demonstrated excellent efficacy and durability in relieving lower urinary tract symptoms (LUTS) in the BPH patient. When compared to TURP, these minimally invasive therapies can be performed in an outpatient setting, with decreased hospitalization, operative and catheterization times, which minimizes overall healthcare costs. Moreover, these therapies have no discernable adverse effects on sexual function (both ejaculatory and erectile) or sexual satisfaction, making it a desirable option for many patients. CONCLUSIONS: Both the UroLift and Rezum are office-based, minimally invasive techniques capable of providing durable, and significant relief of LUTS secondary to BPH. In select patients, they demonstrate comparable efficacy to TURP with the added advantage of preserving sexual function and minimizing patient morbidity and healthcare cost. An individualized, shared decision-making approach is essential in selecting the optimal treatment option for each patient.

Aquablation of the prostate: a review and update.

INTRODUCTION Historically, transurethral resection of the prostate (TURP) was considered the endoscopic "gold standard" surgical treatment of benign prostatic hyperplasia (BPH). Over the years, several other endoscopic procedures emerged, including the size-independent holmium laser enucleation of the prostate (HoLEP). In an effort to reduce the cost and morbidity associated with traditional endoscopic techniques, novel minimally invasive techniques have been developed, one of which is Aquablation. This review is an update of a previously published review article looking at the most recently published available data on Aquablation. MATERIALS AND METHODS: This review article covers the technical aspects of Aquablation and provides an update on the recently published literature regarding Aquablation compared to TURP and HoLEP. RESULTS: At up to 3 years of follow up, Aquablation performs favorably when compared to TURP in terms of alleviation of lower urinary tract symptoms (LUTS) and preservation of sexual function compared to TURP. Safety profile was similar between Aquablation and TURP. CONCLUSIONS: Aquablation is a safe and effective method of treating LUTS associated with BPH. At up to 3 years of follow up, it has shown a durable with efficacy similar to TURP.

Twitter and academic Urology in the United States and Canada: a comprehensive assessment of the Twitterverse in 2019.

OBJECTIVE: To provide the first comprehensive analysis of the Twitterverse amongst academic urologists and programmes in North America. METHODS: Using national accreditation and individual programme websites, all active urology residency programmes (USA and Canada) and academic Urology faculty at these programmes were identified. Demographic data for each programme American Urological Association [AUA] section, resident class size) and physician (title, fellowship training, Scopus Hirsch index [H-index] and citations) were documented. Twitter metrics (Twitter handle, date joined, # tweets, # followers, # following, likes) for programmes and physicians were catalogued (data capture: March-April 2019). Descriptive analyses and temporal trends in Twitter utilisation amongst programmes and physicians were assessed. Multivariable logistic regression was used to identify predictors of Twitter use. RESULTS: In all, 156 academic programmes (143 USA, 13 Canada) and 2214 academic faculty (2015 USA, 199 Canada) were identified. Twitter utilisation is currently 49.3% and 34.1% amongst programmes and physicians, respectively, and continues to increase. On multivariable analysis, programmes with 3-5 residents/year and programmes with a higher percentage of faculty Twitter engagement were more likely to have Twitter accounts. From a physician perspective, those with fellowship training, lower academic rank (Clinical Instructor, Assistant Professor, Associate Professor vs Professor) and higher H-indices were more likely to have individual Twitter accounts. CONCLUSION: There is a steady increase in Twitter engagement amongst Urology programmes and academic physicians. Faculty Twitter utilisation is an important driver of programme Twitter engagement. Twitter social media activity is strongly associated with academic productivity, and may in fact drive academic metrics. Within Urology, social media presence appears to be proportional to academic activity.

Industry payments to female pelvic medicine and reconstructive surgeons: an analysis of Sunshine Act open payments from 2014-2017.

INTRODUCTION AND HYPOTHESIS: We aim to examine the financial relationship between industry and female pelvic medicine and reconstructive surgeons (FPMRS) during the first four full calendar years since the implementation of the Sunshine Act. METHODS: All board-certified FPMRS specialists were identified using the American Board of Medical Specialties directory. Program directors (PDs) were identified using an Accreditation Council for Graduate Medical Education (ACGME) database. All identified physicians were categorized by gender, specialty, and American Urological Association (AUA) region. Payment data for each individual from 2014 to 2017 were accessed using the Centers for Medicare and Medicaid Services (CMS) Open Payments website. Statistical analyses were performed to elucidate payment trends. RESULTS: Of the 1,307 FPMRS physicians identified, 25.1% (n = 328) are urology-trained and 74.9% (n = 979) are obstetrics/gynecology (OB/GYN)-trained. Of all physicians analyzed, 6.8% had no reported payments over the 4-year period. 90.1%, 86.5%, 85.3%, and 84.4% received some sort of payment in 2014 to 2017 respectively. Median total payments for all physicians decreased yearly, whereas mean payments decreased from 2014 to 2015 before increasing in all subsequent years. Median general payments were higher for men versus women, urology-trained versus OB/GYN-trained, and PDs versus non-PDs in all years analyzed. The largest contributor to overall payments was the "others" compensation category, which includes gifts, royalties, honoraria, and non-continuing medical education speaking engagements. CONCLUSIONS: Since institution of the Sunshine Act, the percentage of physicians receiving payments has decreased each year. Additionally, there has been a decrease in median total payments and an increase in yearly research payments in all years analyzed.

How I Do It: Anticoagulation management for common urologic procedures.

Appropriate perioperative management of antithrombotic medications is critical; for every patient, the risk of bleeding must be balanced against individual risk of thrombosis. There has been a rapid influx of new antithrombotic therapies in the past 5 years, yet there is a lack of clear and concise guidelines on the management of anticoagulant and antiplatelet therapy during urologic surgery. Here we describe our approach to perioperative antithrombotic counseling, including the timing of stopping and restarting these medications. These practice guidelines have been developed in consultation with the Vascular Medicine service at our institution as well as after a review of current literature, and apply to common urologic procedures. Many cases are complex and require medical consultation or a multidisciplinary approach to management. We believe that by presenting our systematic method of antithrombotic management, including when to involve other discplines, we can increase knowledge and comfort amongst urologists in managing these medications in the perioperative period.

Next-generation DNA sequencing for infected genitourinary implants: How I do it.

Infection of artificial urinary sphincters or inflatable penile prostheses is one of the most devastating complications after prosthetic surgery and can have a significant impact on a quality of life. Patients undergoing revision surgery with or without device replacement may have increased risk for infection when compared to initial primary surgery. As such, surgeons may utilize traditional culture results to direct antimicrobial therapy for these patients. Unfortunately, culture results can be inconclusive in up to one-third of the time even in the setting of active device infection. Next-generation sequencing (NGS) of DNA is an emerging technology capable of sequencing entire bacterial genomes and has the potential to identify microbial composition in explanted devices. Herein, we describe our institutional experience on NGS utilization in patients with genitourinary prostheses. We also highlight our methods and techniques to inform readers on the potential practices that can enhance the utility and diagnostic yield of this new and upcoming technology.

Simple frameshifts in minimally invasive surgery postoperative pain management significantly reduce opiate prescriptions.

INTRODUCTION: To evaluate the impact of an 'opt-in' non-narcotic postoperative pain regimen on narcotic utilization and patient-reported pain scores. MATERIALS AND METHODS: A prospective, non-blinded pre- and post-interventional trial was conducted, including a lead-in period for baseline evaluation. The intervention group received a new pain protocol prioritizing non-narcotic medications, an 'opt-in' requirement for opiates, and standardized patient education. Study outcomes included opiate prescription and utilization (measured in Morphine Equivalent Doses) and reported pain scores on postoperative day (POD) 1, discharge and follow up. RESULTS: At discharge, 70% fewer patients were prescribed any opioids (ARR: -0.7; p < 0.001); the amount prescribed was reduced by 95% (pre-intervention 69.3 mg versus post-intervention 3.5 mg, p < 0.001). Mean opioids used following discharge decreased by 76% (14.7 mg versus 3.5 mg, p = 0.011). In a subgroup analysis of robotic prostatectomies, there was a 95% reduction in mean opioids prescribed at discharge (64.6 mg versus 3.2 mg, p < 0.001) and 82% reduction in utilization over entire postoperative course (87.6 mg versus 15.7 mg, p = 0.001). There was no significant difference in pain scores between intervention groups at POD 1, discharge and follow up for patients (entire cohort and post-prostatectomy). CONCLUSION: A standardized pain protocol with 'opt-in' requirements for opiate prescription, emphasis on non-narcotic medications, and patient education, resulted in significant reductions in opioid use. Simple frameshifts in pain management can yield significant gains in the opioid epidemic.

Superb Microvascular Imaging Improves Detection of Vascularity in Indeterminate Renal Masses.

OBJECTIVES: Vascular assessment of indeterminate renal masses (iRMs) remains a crucial element of diagnostic imaging, as the presence of blood flow within renal lesions suggests malignancy. We compared the utility of Superb Microvascular Imaging (SMI; Canon Medical Systems, Tustin, CA), a novel Doppler technique, to standard color Doppler imaging (CDI) and power Doppler imaging (PDI) for the detection of vascularity within iRMs. METHODS: Patients undergoing contrast-enhanced ultrasound (CEUS) evaluations for iRMs first underwent a renal ultrasound examination with the following modes: CDI, PDI, color Superb Microvascular Imaging (cSMI), and monochrome Superb Microvascular Imaging (mSMI), using an Aplio i800 scanner with an i8CX1 transducer (Canon Medical Systems). After image randomization, each mode was assessed for iRM vascularity by 4 blinded readers on a diagnostic confidence scale of 1 to 5 (5 = most confident). The results were compared to CEUS as the reference standard. RESULTS: Forty-one patients with 50 lesions met inclusion criteria. Relative to the other 3 modalities, mSMI had the highest sensitivity (63.3%), whereas cSMI had the highest specificity (62.1%). Both cSMI and mSMI also had the highest diagnostic accuracy (0.678 and 0.680, respectively; both P < 0.001) compared to CDI (0.568) and PDI (0.555). Although the reader-reported confidence interval of mSMI (mean ± SD, 3.6 ± 1.1) was significantly lower than CDI (4.1 ± 1.0) and PDI (4.0 ± 1.0; P < 0.001), the confidence level of cSMI (4.1 ± 0.9) was not (P > 0.173). CONCLUSIONS: Preliminary data suggest that SMI is a potentially useful modality in detecting microvasculature in iRMs compared to standard Doppler techniques. Future studies should aim to compare the efficacy of both SMI and CEUS and to assess the ability of SMI to characterize malignancy in iRMs.

Predictors of prostate-specific antigen testing in men aged ≥55 years: A cross-sectional study based on patient-reported outcomes.

OBJECTIVES: To examine the predictors of prostate-specific antigen discussion with a physician and prostate-specific antigen testing in men aged ≥55 years. METHODS: Utilizing the USA Health Information National Trends Survey, 4th Ed., a cross-sectional study from 2011 to 2014 was carried out to analyze the factors predicting prostate-specific antigen testing and discussion in men ≥55 years. Associations between each covariate and prostate-specific antigen discussion/testing were determined. Multivariable logistic regression models were used to determine clinically relevant predictors of prostate-specific antigen discussion/testing. Due to multiple comparisons, the Bonferroni correction was used. RESULTS: A total of 2731 men included in the Health Information National Trends Survey were analyzed. Several socioeconomic parameters were found to increase the likelihood of men aged ≥55 years to undergo prostate-specific antigen testing: living with a spouse, a higher level of education (college graduate or above), a higher income (>$50 000 annually) and previous history of any cancer. In contrast, current smokers were less likely to undergo prostate-specific antigen testing. Having a prostate-specific antigen discussion with a physician was more likely for men surveyed in 2014, for men who were living with a spouse, who had a higher annual income (>$50 000 annually) and those with a history of any cancer. CONCLUSIONS: Significant inequalities in prostate-specific antigen testing and discussion exist among men in the USA, mainly driven by socioeconomic factors. Ideally, prostate-specific antigen testing and discussion should be based on relevant clinical factors with a shared decision-making approach for every man. Therefore, a better understanding of the socioeconomic factors influencing prostate-specific antigen testing/discussions can inform strategies to reduce existing gaps in care.

Stress Urinary Incontinence post-Holmium Laser Enucleation of the Prostate: a Single-Surgeon Experience.

PURPOSE: To identify incidence and predictors of stress urinary incontinence (SUI) following Holmium laser enucleation of the prostate (HoLEP). MATERIALS AND METHODS: We performed a retrospective review of 589 HoLEP patients from 2012-2018. Patients were assessed at pre-operative and post-operative visits. Univariate and multivariate regression analyses were performed to identify predictors of SUI. RESULTS: 52/589 patients (8.8%) developed transient SUI, while 9/589 (1.5%) developed long-term SUI. tSUI resolved for 46 patients (88.5%) within the first six weeks and in 6 patients (11.5%) between 6 weeks to 3 months. Long-term SUI patients required intervention, achieving continence at 16.4 months on average, 44 men (70.9%) with incontinence were catheter dependent preoperatively. Mean prostatic volume was 148.7mL in tSUI patients, 111.6mL in long-term SUI, and 87.9mL in others (p < 0.0001). On univariate analysis, laser energy used (p < 0.0001), laser "on" time (p=0.0204), resected prostate weight (p < 0.0001), overall International Prostate Symptom Score (IPSS) (p=0.0005), and IPSS QOL (p=0.02) were associated with SUI. On multivariate analysis, resected prostate weight was predictive of any SUI and tSUI, with no risk factors identified for long-term SUI. CONCLUSION: Post-HoLEP SUI occurs in ~10% of patients, with 1.5% continuing beyond six months. Most patients with tSUI recover within the first six weeks. Prostate size >100g and catheter dependency are associated with increased risk tSUI. Larger prostate volume is an independent predictor of any SUI, and tSUI.

Office-based therapies for benign prostatic hyperplasia: a review and update.

INTRODUCTION: Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is one of the most common conditions affecting the aging man. Over the years, various treatment modalities with distinct efficacy and safety profiles have emerged in experimental and clinical use. However, only a handful have gained in popularity and stood the test of time. MATERIALS AND METHODS: We provide an update on minimally invasive treatment modalities for BPH, specifically focused on office-based procedures namely the prostatic urethral lift (UroLift) and the convective water vapor ablation therapy (Rezum). RESULTS: Both the UroLift and Rezum have demonstrated excellent efficacy and durability in relieving LUTS in the BPH patient. When compared to the gold standard TURP, these novel therapies can also be performed as an outpatient procedure under local anesthesia, which allows for decreased hospitalization, operative and catheterization times, subsequently allowing for increased cost savings. Moreover, these procedures have no discernable adverse effects on postoperative sexual function, making it a desirable treatment option for many patients. CONCLUSIONS: Both the UroLift and Rezum are minimally invasive treatment options capable of providing rapid, significant and durable relief of LUTS secondary to BPH. They demonstrate comparable efficacy to TURP with the added advantage of preserving sexual function and decreasing patient morbidity and healthcare costs.

Photoselective vaporization of the prostate: application, outcomes and safety.

INTRODUCTION: Open prostatectomy and transurethral resection of the prostate (TURP) has been the gold standard therapy for moderate to severe lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). In recent years, laser vaporization technologies have now been recognized by international guidelines as an effective treatment alternative to TURP for treating BPH. MATERIALS AND METHODS: In this contemporary review, we aim to discuss the application, outcomes and safety of photoselective vaporization of the prostate (PVP), specifically with the GreenLight laser. We also discuss the properties and evolution of the GreenLight laser as understanding the basic principles of this laser system. RESULTS: GreenLight PVP is a durable and effective alternative to TURP, especially in high-risk patients on systemic anticoagulation. Aside from providing similar efficacy and safety, the GreenLight PVP also allows for decreased hospitalization times, catheterization times and subsequently decreased healthcare costs. The latest generation laser, 180W XPS system, is found to be more cost-effective and efficacious in tissue vaporization when compared to previous laser generations. CONCLUSIONS: Laser vaporization is a safe and effective option to treating LUTS secondary to BPH. A patient-centered approach considering patient preference and preoperative parameters should be employed to determine the ideal treatment option for each individual patient.

A retrospective comparison of diode to holmium for laser enucleation of the prostate.

INTRODUCTION: Holmium endoscopic laser enucleation of the prostate (HoLEP) is a well-established alternative to traditional transurethral resection and open prostatectomy for the treatment of benign prostatic hyperplasia (BPH). We investigate the 1470 nm diode laser for enucleation as an alternative to HoLEP. The safety, efficacy, and initial outcomes of diode enucleation of the prostate (DiLEP), when compared to HoLEP, were examined. MATERIALS AND METHODS: We reviewed records of 50 patients who underwent DiLEP between 2012 and 2015 and matched them with 50 HoLEP patients during the same time period. Objective evaluation of efficacy was determined by comparing preoperative post-void residual volume (PVR) and peak flow (Qmax) to postoperative values at 4-16 weeks and 1 year following surgery. Subjective evaluation was measured using the International Prostate Symptom Score (IPSS) before and after the operation. Safety was evaluated by the development of persistent Clavien-Dindo grade 1, or 2 or higher postoperative complications. Statistical analyses were conducted using chi-squared and paired Student's t-tests. RESULTS: Subjective and objective postoperative results showed no difference between DiLEP and HoLEP. Average PVR volume following DiLEP was 47.1 mL at 1 year. The mean increase in Qmax was 16.4 mL/s at 1 year. The IPSS improved by a mean of 12.7 points, and by 2.6 points on quality of life questioning at 1 year post operation. Compared to HoLEP patients there was no statistically significant difference. Safety assessments were the same across both procedures. CONCLUSIONS: Diode laser is safe and effective for use in patients with BPH, with no significant difference in outcomes compared to HoLEP.

Overlapping surgeries: defining the 'critical portions' of the procedure.

INTRODUCTION: An important aspect of overlapping surgery is to determine the 'critical portion' of an operation. Currently, there are no guidelines that standardize the critical portions of common urologic procedures. We sought to determine the relationship between the critical portions of common urologic operations as defined by the primary surgeon compared to the trainee at a single academic medical center. MATERIALS AND METHODS: In an open-ended survey of the Urology Department at Thomas Jefferson University, attending surgeons and urology residents, were asked to list five of their most commonly performed surgeries and subsequently identify what they defined as the critical portion for each. Responses were examined for surgeon-trainee congruence. Response agreement was defined as identifying key words that provided reasonable evidence that the responders were referring to identical portions of the case. RESULTS: Nine residents and eight attending physicians provided 67 and 63 responses, respectively, encompassing 28 different procedures. Six procedures were chosen for further analysis based on high volume of responses. Overall, of the 67 resident-reported critical portions, 32 (47.8%) were in agreement with attending-reported critical portions. Year of training in residency was not a predictor of surgeon-trainee agreement. CONCLUSION: External pressures from the public and lawmakers alike may demand that providers be present during all 'critical portions' of a procedure. Our study shows that the understanding of critical portions of an operation is often incongruent between surgeons and trainees. Critical portions of all procedures should be established by the surgical team in order to accurately schedule overlapping surgeries.