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

OBJECTIVE: To evaluate the effect of detrusor underactivity (DUA) on the postoperative outcomes of holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Patients with BPH who underwent HoLEP between January 2018 and December 2022 were enrolled in this prospective database study. Patients were divided into DUA (bladder contractility index [BCI] <100) and non-DUA (BCI ≥100) groups. Objective (maximum urinary flow rate [Qmax], post-void residual urine volume [PVR]) and subjective outcomes (International Prostate Symptom Score [IPSS], Overactive Bladder Symptom Score [OABSS], satisfaction with treatment question [STQ], overall response assessment [ORA], and willingness to undergo surgery question [WUSQ]) were compared between the two groups before surgery, and at 3 and 6 months after HoLEP. RESULTS: A total of 689 patients, with a mean (standard deviation [SD]) age of 69.8 (7.1) years, were enrolled. The mean (SD) BCI in the non-DUA (325 [47.2%]) and DUA (364 [52.8%]) groups was 123.4 (21.4) and 78.6 (14.2), respectively. Both objective (Qmax and PVR) and subjective (IPSS, IPSS-quality of life, and OABSS) outcomes after surgery significantly improved in both groups. The Qmax was lower in the DUA than in the non-DUA group postoperatively. At 6 months postoperatively, the total IPSS was higher in the DUA than in the non-DUA group. There were no significant differences in surgical complications between the two groups. Responses to the STQ, ORA, and WUSQ at 6 months postoperatively demonstrated that the patients were satisfied with the surgery (90.5% in the DUA group; 95.2% in the non-DUA group), their symptoms improved with surgery (95.9% in the DUA group; 100.0% in the non-DUA group), and they were willing to undergo surgery again (95.9% in the DUA group; 97.9% in the non-DUA group). There were no significant differences in the responses to the STQ and WUSQ between the two groups. CONCLUSION: Our midterm results demonstrated that patients with BPH and DUA showed minimal differences in clinical outcomes after HoLEP compared to those without DUA. The overall satisfaction was high in the DUA group.

Factors Considered by Experienced Urologists when Selecting Alpha-Blockers for Patients with Lower Urinary Tract Symptoms or Benign Prostatic Hyperplasia according to Age.

INTRODUCTION: The objectives of the study were to examine the opinions of urology specialists on whether there are actual differences in efficacy among α1-blockers and to identify the factors that should be considered when prescribing these medications according to age. METHODS: We surveyed 50 South Korean urology specialists with over 3 years of clinical experience in secondary or tertiary hospitals in July-August 2021. The survey covered urologists' demographics, awareness of α1-blocker prescription differences, and key factors in α1-blocker selection based on LUTS severity and patient age. RESULTS: Overall, 82% of the respondents believed that there were differences in the efficacy of α1-blockers in actual practice according to age. Over 90% of the respondents agreed on the need for head-to-head comparison studies to compare the effects of different α1-blockers. Regardless of the severity of LUTS, urologists prioritize cardiovascular side effects when prescribing α1-blockers to patients aged ≥70 years. Further, 19% of the urologists prioritized ejaculatory side effects for mild-to-moderate LUTS and 9% for severe LUTS (p < 0.001). CONCLUSIONS: This study shows that head-to-head studies comparing the efficacy of different α1-blockers are highly valuable for the real-world clinical application of α1-blockers. Notably, urologists prioritize cardiovascular and ejaculatory side effects in older and younger patients while prescribing α1-blockers, respectively.

Urolithiasis in Kidney Transplant Patients: A Multicenter KSER Research Series.

Background and Objectives: Urolithiasis occurrence is uncommon in kidney transplantation patients, though it has serious implications, including acute kidney injury in the transplanted kidney. This study investigates the leading causes of urolithiasis in kidney transplantation patients, the diagnostic process, and the outcomes of multimodal management. Materials and Methods: Data collection spanned from January 1997 to December 2021, involving kidney transplantation patients with urolithiasis from the database of the Korean Society of Endourology and Robotics (KSER) research committee. Analysis encompassed factors triggering urolithiasis, the diagnostic process, stone attributes, treatment methods, and outcomes. Results: Our analysis included 58 kidney transplantation patients with urolithiasis from eight medical centers. Of these patients, 37 were male and 4 had previous urolithiasis diagnoses. The mean age was 59.09 ± 10.70 years, with a mean duration from kidney transplantation to diagnosis of 76.26 ± 183.14 months. The most frequent method of stone detection was through asymptomatic routine check-ups (54.7%). Among the 58 patients, 51 underwent stone treatment. Notably, 95.3% of patients with ureter stones received treatment, a significantly higher rate than the 66.7% of patients with renal stones (p = 0.010). Success rates showed no significant differences between renal (70%) and ureter stone (78.0%) groups (p = 0.881). Conclusions: Urolithiasis in transplanted kidneys constitutes an acute condition requiring emergency intervention. Endo-urological interventions are effective for kidney transplantation patients with urolithiasis. To ensure prevention and early detection, diligent follow-up and routine imaging tests are necessary.

Lowering the percent body fat in the obese population might reduce male lower urinary tract symptoms.

PURPOSE: This study aimed to investigate the practicality of percent body fat (PBF), calculated using bioelectrical impedance analysis (BIA), in predicting benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS). METHODS: This study included 844 men who underwent medical checkups at our institution between 2014 and 2022. Demographic characteristics, serum PSA levels, and prostate volume were collected using TRUS. BPH was defined as a prostate volume ≥ 30 cc. Subjects were divided into two groups according to their quartiles of PBF: the normal PBF group (first to third quartile; PBF < 27.9%) and the high PBF group (fourth quartile; PBF ≥ 27.9%). Characteristics between the groups were compared using the chi-square test and Student's t-test. Multivariate logistic regression analysis was performed to evaluate risk factors for BPH and severe LUTS. RESULTS: The prostate volume (25.21 ± 8.4 vs 27.30 ± 9.0, p = 0.005) and percentage of BPH (22.9% vs. 32.1%, p = 0.007) were greater in the high PBF group. After multivariate analysis, old age (OR = 1.066, p < 0.001), higher appendicular skeletal muscle mass index (ASMI) (OR = 1.544, p = 0.001), and PBF ≥ 27.9% (OR = 1.455, p = 0.037) were risk factors for BPH. Larger prostate volume (OR = 1.035, p = 0.002) and PBF ≥ 27.9% (OR = 1.715, p = 0.025) were risk factors for severe LUTS. However, a greater ASMI had a protective effect against severe LUTS (OR = 0.654, p = 0.011). CONCLUSIONS: This study shows that PBF and ASMI are useful for predicting BPH/LUTS. We suggest that lowering PBF to the normal range in a population with high PBF might prevent BPH, while lowering PBF and maintaining adequate ASMI could lower LUTS.

Lymphocyte-to-monocyte ratio is a predictor of clinically significant prostate cancer at prostate biopsy.

BACKGROUND: Inflammation plays critical roles at different stages of carcinogenesis and cancer progression. Several previous studies showed conflicting results for the predictive role of systemic inflammation markers in the detection of clinically significant prostate cancers (CSPCs). We aimed to determine the predictive roles of lymphocyte-to-monocyte (LMR) and eosinophil-to-lymphocyte ratios (ELR) in the detection of CSPC at standard 12-core transrectal ultrasound-guided prostate biopsy (12-core-TRUS-Bx) using our large-cohort database. METHODS: Clinical and pathological data of a total of 1740 men, who underwent initial standard 12-core TRUS-Bx, were analyzed. LMR and ELR were calculated from the prebiopsy complete blood count. Definitions of CSPC, LMR, and ELR were "Gleason grade group ≥2," "the lymphocyte counts/the monocyte counts," and "the eosinophil counts/the lymphocyte counts," respectively. RESULTS: Median (interquartile range) of serum prostate-specific antigen (PSA) level and prostatic volume before TRUS-Bx were 7.59 (5.02-13.12) ng/ml and 38.2 (29.0-52.9) ml, respectively. Benign prostatic lesions, clinically insignificant prostate cancers (CIPCs), and CSPCs were detected in 1179 (67.8%), 180 (10.3%), and 381 (21.9%) patients, respectively. The patients with CSPCs had older age, a higher prevalence of diabetes mellitus or hypertension, a higher rate of digital rectal examination abnormality, higher serum PSA level, lower serum testosterone level, and lower LMR than those with benign lesions or CIPCs. However, there was no difference in ELR among the three (benign lesions, CIPCs and CSPCs). In all the patients, multivariate regression analysis showed that lower LMR was an independent predictor of CSPCs compared with ELR. In the subset of men with prostate volume ≥39.3 ml, lower LMR was an independent predictor of CSPCs compared with ELR. In the subset of men with prostate volume <39.3 ml, men with lower LMR showed the tendency of having a higher probability of CSPCs without any statistical significance on the contrary to ELR. CONCLUSIONS: Our data indicate that LMR can play an independent predictive role in the detection of CSPCs at initial 12-core-TRUS-Bx compared with ELR. The predictive role of the LMR appears to be significant for men with larger prostate volume rather than those with smaller prostate volume.

Mirabegron for treatment of overactive bladder symptoms in patients with Parkinson's disease: A double-blind, randomized placebo-controlled trial (Parkinson's Disease Overactive bladder Mirabegron, PaDoMi Study).

AIMS: This study aimed to investigate the efficacy and safety of mirabegron for Parkinsonism patients with overactive bladder (OAB) symptoms in a randomized, placebo-controlled, multicenter study. MATERIALS AND METHODS: Inclusion criteria are Parkinsonism with OAB symptoms for 4 weeks or more, OAB symptom score (OABSS) questionnaire scores greater than 2, and OABSS urgency question scores greater than 1. After a 2-week wash-out period, the patients were randomized into placebo and mirabegron groups at visit 2. Visit 3 was performed after 4 weeks of medication. Mirabegron was prescribed to the two groups for the rest of the study period at visit 4. RESULT: The mean age was 68.1 ± 8.1 years and 72 males and 64 females were included. A total of 136 patients were screened, 117 patients were randomized, and 25 patients dropped out. The OABSS scores were significantly different between the two groups at Weeks 4 and 8. The OABSS scores became the same in the two groups at Week 12 (visit 5). The postvoid residual urine volume showed a mild increase to 64 ml in the mirabegron group compared to the placebo group at visit 4. Adverse events occurred in 27 patients (23.1%). The degree was mild in 26 cases (78.8%), moderate in five (15.2%), and severe in two (6.1%). Only 13 cases (39.4%) showed medication-related adverse events. Acute urinary retention occurred in a single case. The treatment satisfaction questionnaires showed no significant differences between the two groups. CONCLUSION: Mirabegron was effective in treating OAB symptoms in patients with Parkinsonism with acceptable adverse events.

Adult height after gonadotropin-releasing hormone agonist treatment in girls with early puberty: A meta-analysis.

OBJECTIVE: This analysis of previously published reports was performed to examine the effects of gonadotropin-releasing hormone (GnRH) agonist treatment on adult height and the factors associated with adult height outcomes. CONTEXT: GnRH agonists are first-line agents in the treatment of precocious puberty. However, studies regarding the treatment effect on subjects with early puberty have reported inconsistent results. DESIGN: A total of 14 studies identified from a search of electronic databases (AMED, EMBASE, MEDLINE and RISS) were included. Controlled studies with girls who developed puberty before 10 years of age and measurements of the adult heights of the subjects were selected. Studies using only long-acting GnRH agonists to suppress puberty were included. Adult height, duration of the treatment, age at the start of treatment and bone age advancement were analysed. RESULTS: The mean age of the subjects ranged from 6.3 to 9.0 years. The meta-analysis showed a pooled mean difference in adult height of 3.2 cm and a 95% confidence interval of 1.3-5.1 cm. The height difference between the treated subjects and controls was significantly associated with the duration of treatment (P = .005) rather than the age at the start of treatment (P = .084) or the difference between bone age and chronological age (P = .427). CONCLUSIONS: Administration of GnRH agonists in girls who develop early puberty and demonstrate advanced bone age may be effective for increasing adult height, especially if a sufficiently long treatment duration can be achieved.

Effect of udenafil administration on postmicturition dribbling in men: a prospective, multicenter, double-blind, placebo-controlled, randomized clinical study.

PURPOSE: Postmicturition dribbling (PMD) is a stressful symptom in middle-aged men characterized by urinary leakage after the completion of normal voiding. Appropriate treatments have not yet been introduced. This study assessed the efficacy of treatment of PMD with 75 mg udenafil daily. MATERIALS AND METHODS: The study included 138 men with regular sexual lifestyles. The Hallym PMD questionnaire (HPMDQ) was used to assess PMD symptoms. After all basic examinations, patients were randomly assigned to either udenafil or placebo. Patients completed the surveys, uroflowmetry (UFM), a bladder scan, and the paper test during the follow-up visit. RESULTS: The mean age of the patients was 57.6 years. PMD with one of every three urinations was experienced by 59 patients (42.8%), whereas 45 patients (32.6%) experienced PMD with two of every three urinations. PMD with every urination was experienced by 34 patients (24.6%). More than half of the patients (89 patients, 65.4%) indicated that persistent PMD symptoms would likely result in moderate to severe discomfort in their daily activities. As time passed, the udenafil group showed significant improvement in PMD symptoms (p = 0.001). CONCLUSION: Udenafil 75 mg once daily can be an effective treatment for patients with PMD symptoms.

Does deep sedation with analgesia have positive effects on anxiety, pain and compliance in patients before and after prostate biopsy?

AIMS: To investigate whether deep sedation for transrectal prostate biopsy could reduce anxiety and pain and enhance rebiopsy compliance. METHODS: A two-centre prospective observation study was conducted under two different anaesthetic conditions: deep sedation with analgesia and local anaesthesia with lidocaine. A 12-core prostate biopsy was taken in all patients. Scores on a 0-10 visual analogue scale, the State-Trait Anxiety Inventory-X-1, the Beck Anxiety Inventory and a five-level Likert satisfaction scale were evaluated. Finally, all patients were asked about their willingness to undergo the same procedure again if necessary and whether they wanted to change the anaesthetic method (deep sedation to local anaesthesia or local to sedation) if a repeat procedure was required. RESULTS: A total of 135 patients were included in this study, including 69 patients in the sedation group and 66 patients in the local group. Lower pain scores (P < .001) and higher satisfaction scores (P = .019) were observed in the sedation group than in the local group after the procedure. Anxiety scores in the sedation group were significantly decreased after the procedure, whereas those were not changed in the local group. The question regarding rebiopsy compliance tended to be more positive in the sedation than in the local group (73.9% vs 62.1%, respectively, P = .099). The proportion of patients who wanted to change their anaesthetic method was much higher in the local than in the sedation group (68.2% vs 11.6%, respectively, P < .001). CONCLUSION: Deep sedation with analgesia during transrectal prostate biopsy could reduce pain and postprocedural anxiety and enhance rebiopsy compliance. Considering the psychological and oncological benefits, we strongly recommend inducing deep sedation during transrectal prostate biopsy.

A Prediction Model Using Machine Learning Algorithm for Assessing Stone-Free Status after Single Session Shock Wave Lithotripsy to Treat Ureteral Stones.

PURPOSE: The aim of this study was to develop and validate a decision support model using a machine learning algorithm to predict treatment success after single session shock wave lithotripsy in ureteral stone cases. MATERIALS AND METHODS: Of the 1,803 patients treated with shock wave lithotripsy we selected those with ureteral stones who had preoperative computerized tomography available. Treatment success after single session shock wave lithotripsy was defined as freedom from stones or residual stone fragments less than 2 mm long on computerized tomography or plain x-ray of the kidneys, ureters and bladder 2 weeks later. Decision tree analysis was done using a machine learning algorithm to identify relevant parameters. A decision support model was developed to calculate the probability of treatment success. RESULTS: A total of 791 patients were enrolled in study. Mean ± SD stone length was 5.9 ± 2.3 mm and mean stone volume was 89.3 ± 140.0 mm3. The overall treatment success rate after SWL was 64.4% (509 cases). The rate for upper, middle and lower ureter stones was 59.8%, 65.5% and 69.6%, respectively. On decision tree analysis the top 3 performance criteria factors were volume, length and HU. Decision models were constructed with all possible combinations of factors. The model with 15 factors had greater than 92% accuracy and an average ROC AUC of 0.951. CONCLUSIONS: We applied a machine learning algorithm, a subfield of artificial intelligence, to predict the outcome after single session shock wave lithotripsy for ureteral stones. A 92.29% accurate decision model was developed with 15 factors and an average ROC AUC of 0.951.

The transgluteal approach to shockwave lithotripsy to treat distal ureter stones: a prospective, randomized, and multicenter study.

PURPOSE: We compared the outcomes of SWL to treat distal ureter stones with regard to the conventional prone and supine positions using the transgluteal approach through the greater sciatic foramen. METHODS: A prospective, randomized, single-blind, and multicenter study was conducted between October 2014 and July 2015. The inclusion criteria were radio-opaque distal ureter stones with a maximum diameter of 0.5-2 cm as measured on a CT scan. The included 160 patients were randomly assigned to two groups: the prone group (n = 80; treated in the conventional prone position) and the transgluteal group (n = 80; treated in the supine position using a transgluteal approach). In the latter group, the focused shock wave was transmitted through the greater sciatic foramen with the head positioned at a 40° angle to the vertical. "Stone-free" was defined as the complete clearance of stone fragments, assessed using a CT scan at 2 weeks after treatment. Overall satisfaction was self-reported using a 0-5 Likert scale. RESULTS: The overall efficacy was 66.9%. The stone-free rate was significantly higher in the transgluteal group (72.6%) than in the prone group (54.7%; odds ratio 2.413, 95% CI 1.010-5.761, P = 0.023). No serious adverse events due to treatment were observed in either group. The satisfaction score of the transgluteal group was 4.21 ± 0.81, and 83.6% were willing to repeat the same procedure if necessary. CONCLUSIONS: SWL using the transgluteal approach via a supine position through the greater sciatic foramen was more effective than via the conventional prone position. Furthermore, this approach provided a comparably safe and satisfactory procedure.

Author Correction to: The transgluteal approach to shockwave lithotripsy to treat distal ureter stones: a prospective, randomized, and multicenter study.

The funding number was incorrect in the original published article. The correct funding number should read as follows.

Extended versus Standard Pelvic Lymph Node Dissection in Radical Prostatectomy on Oncological and Functional Outcomes: A Systematic Review and Meta-Analysis.

BACKGROUND: We evaluated the effect of the extent of pelvic lymph node dissection (PLND) on oncological and functional outcomes in patients with intermediate- to high-risk prostate cancer (PCa) by conducting a systematic review and meta-analysis. METHODS: Two independent researchers performed a systematic review of radical prostatectomy (RP) with extended PLND (ePLND), and RP with standard (sPLND) or limited PLND (lPLND) in patients with PCa using the PubMed, EMBASE, and Cochrane Library databases and using the terms 'prostatectomy', 'lymph node excision', and 'prostatic neoplasm'. The primary outcome was biochemical-free survival, which was analyzed by extracting survival data from the published Kaplan-Meier (KM) curves. In addition, we obtained summarized survival curves by reconstructing the KM data. Secondary outcomes of the recovery of erection and continence were also analyzed. RESULTS: Nine studies involving over 1554 patients were included, one of which was a randomized controlled trial. The pooled analysis showed a significant difference in biochemical recurrence between ePLND and sPLND (hazard ratio 0.71, 95% confidence interval 0.56-0.90, p = 0.005), with no significant between-study heterogeneity (I 2 = 37%). From the summary survival curves, it can be observed that the curves for the two groups diverged more and more as a function of time. From the analyses of functional outcomes including only three studies, no statistically significant differences in the recovery of erectile function and continence were observed. No evidence of significant publication bias was found. CONCLUSIONS: In patients with PCa, ePLND could be an oncological benefit; however, a functional compromise cannot be determined.

Impact of positive surgical margins and their locations after radical prostatectomy: comparison of biochemical recurrence according to risk stratification and surgical modality.

PURPOSE: We investigated the influence of positive surgical margins (PSMs) and their locations on biochemical recurrence (BCR) according to risk stratification and surgical modality. METHODS: A total of 1,874 post-radical-prostatectomy (RP) patients of pT2-T3a between 2000 and 2010 at three tertiary centers, and who did not receive neoadjuvant/adjuvant therapy, were included in this study. Patients were stratified according to BCR risk: low risk (PSA <10, pT2a-b, and pGS ≤6), intermediate risk (PSA 10-20 and/or pT2c and/or pGS 7), and high risk (PSA >20 or pT3a or pGS 8-10). The median follow-up was 43 months. RESULTS: PSMs were a significant predictor of BCR in both the intermediate- and high-risk-disease groups (P = .001, HR 2.1, 95 % CI 1.3-3.4; P < .001, HR 2.8, 95 % CI 2.0-4.1). Positive apical margin was a significant risk factor for BCR in high-risk disease (P = .003, HR 2.0, 95 % CI 1.2-3.3), but not in intermediate-risk disease (P = .06, HR 1.7, 95 % CI 0.9-3.1). Positive bladder neck margin was a significant risk factor for BCR in both intermediate- and high-risk disease (P < .001, HR 5.4, 95 % CI 2.1-13.8; P = .001, HR 4.5, 95 % CI 1.8-11.4). In subgroup analyses, robotic RP provided comparable BCR-free survival regardless of risk stratification. Patients with PSMs showed similar BCR-free survival between open and robotic RP (log-rank, P = .897). CONCLUSIONS: Post-RP PSMs were a significantly independent predictor of disease progression in high-risk disease as well as intermediate-risk disease. Both positive apical and bladder neck margins are also significant risk factors of BCR in high-risk disease. Patients with PSMs showed similar BCR-free survival between open and robotic surgery.

Predictors of positive surgical margins and their location in Korean men undergoing radical prostatectomy.

OBJECTIVE: To evaluate preoperative predictors of positive surgical margins and their location in Korean men undergoing radical prostatectomy. METHODS: A total of 3227 patients who had undergone radical prostatectomy (open, robotic or laparoscopic) for clinically localized prostate cancer at three centers between 2000 and 2010 were analyzed. Patients were stratified by using the D'Amico risk criteria. Positive surgical margins were categorized according to their location. Patients were divided depending on their prostate volume: <29, 29-36, 36-46 and ≥46 mL. All of the patients had a minimum of six. A total of 2041 patients (84.9%) underwent 12-14 core biopsies. In each patient, the number and location of positive cores with cancer were assessed. In the analysis of predictive factors for positive surgical margin locations, regression analysis was carried out using only open and robotic prostatectomy. RESULTS: The preoperative prostate-specific antigen, prostate volume, biopsy Gleason scores and clinical stage were significantly associated with an increased risk of positive surgical margins. The predictive variables for positive apical margin were small prostate volume (less than 29 mL) and positive apical biopsy. There were no statistically significant predictors for positive posterolateral or basal margin. Positive apical biopsy was the predictor of positive apical margin in open (odds ratio 1.7, P = 0.009) and robotic prostatectomy (odds ratio 2.2, P = 0.041). Small prostate volume was the predictor of positive apical margin in open prostatectomy (odds ratio 1.6, P = 0.012), but for positive basal margin in robotic radical prostatectomy (odds ratio 4.5, P < 0.001). In survival analysis, positive basal margin showed worse prognoses on biochemical recurrence than positive apical margin. CONCLUSIONS: High prostate-specific antigen and small prostate volume are predictive factors of positive surgical margin in Korean patients undergoing radical prostatectomy. Apical positivity on extended transrectal biopsy represents a predictive factor of positive surgical margin. Small prostate volume is associated with higher risk of positive surgical margins at the apex in open radical prostatectomy and at the base in robotic-assisted laparoscopic radical prostatectomy.

Effect of Self-Training Using Virtual Reality Head-Mounted Display Simulator on the Acquisition of Holmium Laser Enucleation of the Prostate Surgical Skills.

PURPOSE: We aimed to evaluate the effect of self-training using a virtual reality head-mounted display simulator on the acquisition of surgical skills for holmium laser enucleation surgery. METHODS: Thirteen medical students without surgical skills for holmium laser enucleation of the prostate were trained using multimedia to learn the technique via simulator manipulation. Thereafter, participants performed the technique on a virtual benign prostatic hyperplasia model A (test A). After a 1-week wash-out period, they underwent self-training using a simulator and performed the technique on model B (test B). Subsequently, participants were asked to respond to Training Satisfaction Questions. Video footage of hand movements and endoscope view were recorded during tests A and B for later review by 2 expert surgeons. A 20-step Assessment Checklist, 6-domain Global Rating Scale, and a Pass Rating were used to compare performance on tests A and B. RESULTS: Thirteen participants completed both tests A and B. The 20-step Assessment Checklist and 6-domain Global Rating Scale evaluation results showed significantly improved scores in test B than in test A (P<0.05). No evaluator rated participants as passed after test A, but 11 participants (84.6%) passed after test B. Ten participants (76.9%) indicated that the simulator was helpful in acquiring surgical skills for holmium laser enucleation of the prostate. CONCLUSION: The virtual reality head-mounted display holmium laser enucleation of the prostate simulator was effective for surgical skill training. This simulator may help to shorten the learning curve of this technique in real clinical practice in the future.

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

PURPOSE: We evaluated the efficacy and safety of mid-term follow-up in low-power (LP) Holmium laser enucleation of the prostate (HoLEP) compared with high-power (HP) surgery for benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: This prospective, single-blind, randomized controlled study was conducted between September 2020 and April 2021. Ninety male patients >50 years who underwent HoLEP for BPH were randomly assigned to HP (80 W/2 J/40 Hz) and LP (24 W/2 J/12 Hz) groups. The primary endpoint was the total International Prostate Symptom Score (IPSS) six months after surgery. The secondary endpoints were perioperative results and postoperative outcomes at two weeks, three and six months after the surgery, including Clavien-Dindo complication classification. RESULTS: At six months after HoLEP, 41 and 42 patients were followed up in the HP and LP groups, respectively. There was no difference in the preoperative characteristics between the two groups. The prostate volumes were 67.1±23.7 mL for the HP group and 64.3±25.7 mL for the LP group (p=0.592), respectively. Although the total operative time was significantly longer by 13.1 minutes in the LP group (47.8±20.3 min vs. 60.9±23.3 min, p=0.006), the total delivered energy was significantly lower, which was only about 68% of the HP group (58.2±23.9 kJ vs. 39.9±13.2 kJ, p<0.001). Surgical outcomes significantly improved postoperatively in both groups compared to baseline, except for storage symptoms. Improvement in IPSS storage subscore was observed from the immediate postoperative 2 weeks in the LP group (8.1±3.1 to 6.9±3.8, p<0.001), whereas there was no significant recovery in the HP group (8.0±3.2 to 7.7±3.4, p=0.842). In the 6-month follow, there was no significant difference between the two groups in the IPSS total score (5.9±5.6 vs. 7.3±5.3, p=0.260) as well as IPSS storage subscore. In addition, there was no significant difference in postoperative complications, including bleeding or urinary incontinence, between the two groups. CONCLUSIONS: The HoLEP procedure performed using an LP laser device resulted in lower total delivered energy, faster recovery, and significantly improved surgical outcomes up to mid-term follow-up. There was no difference in efficiency or safety between the HP device system.

Prognostic Role of Preoperative Neutrophil-To-Lymphocyte Ratio (NLR) and Recurrence at First Evaluation after Bacillus Calmette-Guérin (BCG) Induction in Non-Muscle-Invasive Bladder Cancer.

We investigated the prognosis of BCG induction-only treatment and non-complete response (CR) at the first 3-month evaluation and examined factors associated with CR. In total, 209 patients with moderate- and high-risk NMIBC who received BCG induction-only treatment between 2008 and 2020 were retrospectively analyzed. Recurrence-free survival (RFS) and progression-free survival (PFS) were assessed based on the initial NMIBC stage. PFS and associated factors of non-CR compared to CR were also assessed. Initial T1 high-grade (HG) (n = 93) had poorer RFS and PFS after BCG induction-only treatment than Ta low-grade (LG) (p = 0.029, p = 0.002). Non-CR (n = 37) had a different neutrophil-to-lymphocyte ratio (NLR) (2.81 ± 1.02 vs. 1.97 ± 0.92) and T staging from CR (p < 0.001, p = 0.008). T1HG recurrence was associated with a worse PFS compared to non-T1HG (13.7 months vs. 101.7 months, p < 0.001). There was no difference in PFS between T1HG and T1LG. T1 and NLR were predictors of response at 3 months in multivariable analysis (p = 0.004, p = 0.029). NLR was also found to be an associated factor with RFS and PFS of bladder cancer (p < 0.001, p < 0.001). BCG induction-only treatment was effective for high-risk TaLG but not for T1HG. T1HG recurrence at 3 months after BCG induction has a poor prognosis for bladder cancer. Preoperative NLR and T1 were predictors of non-CR, and NLR was also associated with the long-term prognosis of bladder cancer.

Korean Society of Endourology and Robotics (KSER) recommendation on the diagnosis, treatment, and prevention of urolithiasis.

This article provides evidence-based recommendations and expert opinions to aid urologists in making optimal decisions regarding managing urolithiasis in various clinical scenarios. The most frequently asked questions by urologists in their clinical practice have been collected and answered in the form of FAQs; based on the latest evidence and expert opinions. The natural history of urolithiasis is divided into active treatment and silent phases, with the active treatment stage divided into typical and special situations and peri-treatment management. The authors address 28 key questions, offering practical guidance for the proper diagnosis, treatment, and prevention of urolithiasis in clinical practice. This article is expected to be served as a valuable resource for urologists.

Value of prostate-specific antigen (PSA) mass ratio in the detection of prostate cancer in men with PSA levels of ≤10 ng/mL.

UNLABELLED: A group of researchers introduced a parameter named PSA mass ratio, which is defined as total circulating PSA protein (PSA [ng/mL] x plasma volume [L]) per prostate volume, as a prostate cancer screening tool. They suggested that PSA mass ratio may be representative of a PSA value adjusted for potentially influencing factors, such as haemodilution and prostate volume. By adjusting for the combined effects of plasma volume and prostate volume, it can be hypothesized that PSA mass ratio would enhance the predictive value of the PSA test. Although PSA mass ratio appears to be an attractive alternative to serum PSA level, PSA mass ratio may not significantly enhance the currently available method to predict prostate cancer detection among men with PSA level of ≤10 ng/mL who are undergoing prostate biopsy. OBJECTIVE: To investigate the value of prostate-specific antigen (PSA) mass ratio, defined as total PSA in circulation per prostate volume (PV), in the prediction of prostate cancer detection among men with PSA levels of ≤10 ng/mL who are undergoing prostate biopsy. PATIENTS AND METHODS: We reviewed records of 2431 men aged 56-80 years who presented with PSA levels of ≤10 ng/mL and underwent multi (≥12)-core transrectal ultrasound-guided prostate biopsy at our institution. Predictive accuracies of relevant variables and multivariate models in the prostate cancer detection via biopsy were assessed with receiver operating characteristics-derived area under the curve and compared. RESULTS: When compared one-on-one, PSA mass ratio had a significantly higher accuracy than PSA in the prediction of prostate cancer among our subjects (0.638 vs 0.565, P < 0.001). Meanwhile, when multivariable model for the prediction of prostate cancer detection via prostate biopsy was devised incorporating patient age, body mass index, digital rectal examination findings, PV, number of biopsy cores, and PSA level, the replacement of PSA level with PSA mass ratio (P = 0.102) or the addition of PSA mass ratio (P = 0.164) in the model was not associated with significantly increased accuracy of model for predicting prostate cancer detection via biopsy. CONCLUSION: Although PSA mass ratio appears to be an attractive alternative to PSA level, PSA mass ratio may not significantly enhance the currently available method to predict prostate cancer detection among men with PSA levels of ≤10 ng/mL who are undergoing prostate biopsy.