Stone-free Outcomes of Flexible Ureteroscopy for Renal Calculi Utilizing Computed Tomography Imaging.

OBJECTIVE: To assess stone-free rates following ureteroscopy (URS) for renal calculi at our institution using low-dose renal only computed tomography (CT). METHODS: A retrospective review of patients undergoing flexible URS for renal stones only with subsequent CT scan within 3 months. Meticulous basketing of all stone fragments was performed whenever possible. A "true" zero-fragment stone-free rate was determined by reviewing the CT scan and radiologist's report. Patients with nephrocalcinosis (as determined by visual inspection of papilla at the time of URS) were assigned the "stone-free" category. RESULTS: Flexible URS was performed in 288 renal units of 214 patients with renal calculi from 2013 to 2016. Median preoperative stone size was 6.2 mm with the average kidney containing 6.4 stones. An access sheath was used in 92% of cases. A total of 73% (209/288) renal units were completely stone free by CT assessment. Patients with residual fragments were as follows: 1 mm in 2% (7/288), 2-4 mm in 16% (46/288), and >4 mm in 9% of kidneys (26/288). CONCLUSION: The true stone-free rate in patients undergoing flexible URS for renal calculi utilizing active basketing of fragments as determined by strict CT assessment was 73%. In patients with residual fragments, the majority are 2-4 mm in size making URS a treatment option for renal calculi with excellent stone-free results.

Holmium:YAG transurethral incision versus laser photoselective vaporization for benign prostatic hyperplasia in a small prostate.

PURPOSE: We assess the perioperative, short-term and long-term functional outcomes of treating bladder outlet obstruction secondary to a small prostate by 1 of 2 laser techniques. MATERIALS AND METHODS: A retrospective review using a prospectively maintained database was performed of patients treated for bladder outlet obstruction secondary to a prostate smaller than 40 ml. Patients who were treated with GreenLight™ photoselective vaporization of the prostate or holmium laser transurethral incision of the prostate were included in the study. RESULTS: From January 2002 through December 2010, 191 cases of 1,682 laser prostate surgeries were described. GreenLight photoselective vaporization of the prostate was performed in 144 (75.4%) cases and holmium laser transurethral incision of the prostate was performed in 47 (24.6%) cases. A significantly shorter mean operating time, hospital stay and catheter duration were observed in the holmium laser transurethral incision of the prostate group (30.3 ± 16 minutes, 0.8 ± 0.8 days and 1.3 ± 1.9 days, respectively) than in the photoselective vaporization of the prostate group (45.8 ± 22 minutes, 0.3 ± 0.4 days and 0.4 ± 0.6 days, respectively, p <0.05). At 1 and 5 years after photoselective vaporization of the prostate there were reductions in mean International Prostate Symptom Score, quality of life score and residual urine with improvement in mean maximal flow rate of 57.7% and 62.8%, 58.3% and 57.2%, 65.4% and 73%, and 127.6% and 167.1%, respectively. At 1 and 5 years after holmium laser transurethral incision of the prostate there were reductions in mean International Prostate Symptom Score, quality of life score and residual urine with improvement of mean maximal flow rate of 55.3% and 52.8%, 49.2% and 49%, 45% and 78.1%, and 67.4% and 35.4%, respectively. Subjective and objective urine flow parameters were comparable at different followup points. There was no significant difference between the 2 groups in terms of early and late complications (p >0.05). Reoperation rates were 10.4% and 6.4% in the photoselective vaporization of the prostate and holmium laser transurethral incision of the prostate groups, respectively (p >0.05). The mean estimated cost per holmium laser transurethral incision of the prostate procedure was significantly lower than per photoselective vaporization of the prostate procedure (509.34CAD vs 1,765.92CAD, p = 0.002). CONCLUSIONS: Holmium laser transurethral incision of the prostate and GreenLight photoselective vaporization of the prostate seem to be equally effective, safe and durable surgical treatment options for small prostates even in high risk patients.

Two laser ablation techniques for a prostate less than 60 mL: lessons learned 70 months after a randomized controlled trial.

OBJECTIVE: To report lessons learned and predictors of long-term outcome after a randomized trial comparing 2 widely available lasers (2123 nm and 532 nm) in prostate ablation as treatment of symptomatic benign prostatic hyperplasia. METHODS: Between March 2005 and April 2007, 109 patients with a prostate volume of less than 60 mL were recruited and randomized to treatment: 57 underwent holmium laser ablation of the prostate (HOLAP) and 52 underwent photoselective vaporization of the prostate (PVP) using an 80-W potassium titanyl phosphate laser. The changes in subjective (International Prostate Symptom Score quality of life and International Index of Erectile Function-15) and objective (postvoid residual urine maximal flow rate) outcome parameters were compared. The long-term outcome, timing, and predictors of negative outcome were assessed. Cost analysis was included. RESULTS: After a median of 71.3 months, significant comparable improvement was documented in all subjective and objective urinary parameters from baseline measures at different points of follow-up. Retreatment for infravesical obstruction was 19.2% in HOLAP and 25% in PVP (P >.05). Smaller prostate volume was significantly associated with bladder neck contracture (BNC) after laser ablation, regardless the type of laser used. BNC and de novo urethral stricture seem to be the main causes for an early (first-year) reintervention. Redo treatment for recurring prostate adenoma was associated with less postoperative prostate-specific antigen reduction (<20%). Procedure costs were CaD $200.45 higher in the PVP group (P >.05). CONCLUSION: PVP and HOLAP seem to be equally effective and safe, with similar long-term outcome data, including cost. Regardless the laser wavelength, at least 1 of 5 patients will need retreatment. BNC is a more prevalent cause of early retreatment in smaller glands with both lasers. Postoperative prostate-specific antigen reduction of less than 20% warrants careful follow-up for recurrent symptoms secondary to residual prostate tissue.

Transurethral laser surgery for benign prostate hyperplasia in octogenarians: safety and outcomes.

OBJECTIVE: To evaluate the morbidity and perioperative outcome of different laser prostate techniques among octogenarians. METHODS: We performed a retrospective review of our prospectively maintained laser prostate surgery database between 1998 and 2012. We identified 264 octogenarians (16.5%) who underwent laser prostate surgery. Perioperative morbidity and mortality in addition to the functional outcome of these procedures were assessed. Risk factors and predictors of the outcome were analyzed. RESULTS: The mean age at time of procedure was 84 ± 3.5 years. Holmium laser enucleation of the prostate was done in 171 (64.7%), holmium laser ablation of the prostate in 16 (6%), holmium laser transurethral incision of the prostate in 13 (5%) and photoselective vaporization of the prostate in 64 (24.3%). Procedures for octogenarians increased from 11% at the end of 2002 to 19% at 2012. A total of 68 perioperative complications occurred in 52 procedures (19.6%), without any perioperative deaths. There were 56 (82.3%) low-grade complications (Clavien grade I-II) and 12 (17.7%) high-grade complications (Clavien grade ≥ III). A longer operating time was an independent risk factor for perioperative morbidity on multivariate analysis. Significant improvement of symptoms score (International Prostate Symptom Score-Quality of Life) associated with objective improvement of urine flow parameters (maximum flow [Q-max] and postvoid residual) were reported at different follow-up assessments in the first year (P <.05). Persistent urge or stress incontinence, or both, were found in 4 (1.5%). Total urinary incontinence occurred in 1 patient, with neurologic deficit as the underlying cause. De novo urethral stricture was reported in 8 patients (3%). CONCLUSION: Octogenarians undergoing laser prostate surgery for treatment of benign prostate hyperplasia have limited perioperative morbidity. Laser prostate surgery can achieve good functional outcome and maintain quality of life of seniors. Furthermore, it is safe in seniors with a high morbidity index; however, longer operating time is an independent risk factor for perioperative morbidity.

Male sexual function outcome after three laser prostate surgical techniques: a single center perspective.

OBJECTIVE: To assess the change and predictors of sexual-related outcomes after laser prostate surgery. METHODS: This is a longitudinal study of 216 sexually active men who underwent laser prostatectomy between 2005 and 2010. The International Index of Erectile Function-15 questionnaire was used both preoperatively and during the first year of follow-up. Cases with unreliable answers or patients without interested partners were excluded. All relevant data of both groups were depicted and statistically analyzed. RESULTS: We identified 191 patients that met the inclusion criteria, 99 holmium laser enucleation of the prostate, 34 holmium laser ablation, and 58 photoselective vaporization of the prostate (GreenLight-532-mm laser photoselective vaporization of the prostate). There were significant differences among the 3 groups regarding the International Index of Erectile Function-15 direction of change at 1 year, being unchanged in (22.2%, 24.4%, and 29.3%), improved in (60.6%, 29.4%, and 41.4), and declined in (17.2%, 41.2%, and 29.3%) in the 3 groups, respectively (P < .05). After adjusting for clinical and perioperative variables, the independent risk factors for decline in the International Index of Erectile Function score were basal International Index of Erectile Function ≥ 55 and energy to prostate ratio. In holmium laser enucleation of the prostate group, there was significant improvement of the mean overall score, erectile function, desire, and intercourse satisfaction domains (P < .05). In holmium laser ablation and photoselective vaporization of the prostate groups, there were no significant changes between mean preopeative and postoperative scores (P > .05). The incidence of new onset retrograde ejaculation in the holmium laser enucleation of the prostate group was (77.3%) significantly different compared to (31.1%) in the holmium laser ablation group and (33.2%) in photoselective vaporization of the prostate group (P < .05). CONCLUSION: Laser prostate surgery using more size-related laser energy might have possible negative influence on sexual function. Patients with normal preoperative sexuality are more at risk.

Can we predict the outcome of 532 nm laser photoselective vaporization of the prostate? Time to event analysis.

PURPOSE: We evaluated the safety, efficacy and predictability of the long-term outcome of GreenLight™ (532 nm laser) photoselective vaporization of the prostate to treat patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia. MATERIALS AND METHODS: We performed a longitudinal study of patients who underwent GreenLight (532 nm laser) photoselective vaporization of the prostate at our center between June 2002 and November 2011. All patient data were prospectively maintained in the prostate unit database. Two types of laser equipment were used, including the KTP in 91 cases (31.6%) and the GreenLight HPS™ in 197 (68.4%). RESULTS: Larger glands were treated with HPS and KTP photoselective vaporization (mean ± SD volume 45.6 ± 22.5 and 39.6 ± 15.2 ml, respectively, p <0.05). After photoselective vaporization with the KTP laser, we noted a 59.1% and 61.8% decrease in the International Prostate Symptom Score, and a 140.7% and 118.4% improvement in the maximal urine flow rate at 1 and 5 years, respectively. Similarly, after prostate vaporization with the HPS we observed a 65.1% and 62.1% decrease in the International Prostate Symptom Score, and a 123.1% and 107.3% improvement in the maximal urine flow rate at 1 and 4 years, respectively. At a mean of 40.5 months (range 3 to 114) of followup reoperation was indicated in 7.6% of cases. The overall rates of bladder neck contracture, de novo urethral stricture and residual/recurrent adenoma were 3.4% (10 cases), 2.1% (6) and 2.1% (6) with no statistically significant difference between vaporization with the KTP and HPS lasers. Most adverse events occurred during year 1 postoperatively. More bladder neck contractures developed after vaporization was done in smaller glands (p <0.05). More cases with residual prostatic adenoma had a prostate volume of 50 ml or greater vs less than 50 ml (4 of 71 or 5.6% vs 2 of 207 or 0.96%). CONCLUSIONS: GreenLight (532 nm laser) photoselective vaporization of the prostate seems to be safe and effective for lower urinary tract symptoms secondary to benign prostatic hyperplasia. A long lasting, successful outcome is predictable. With careful surveillance during year 1 postoperatively and early intervention for adverse events, a sustainable functional outcome could be achieved without re-treatment.

Feasibility of holmium laser enucleation of the prostate (HoLEP) for recurrent/residual benign prostatic hyperplasia (BPH).

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? The major advantage of holmium laser enucleation of the prostate (HoLEP) depends on the ability to use the native anatomical plane between the prostate adenoma and surgical capsule, peeling each prostatic lobe from the capsule. HoLEP is associated with less catheterisation time, hospital stay and blood loss than transurethral resection of the prostate (TURP) or open prostatectomy. Urodynamic relief of obstruction has been reported to be better with HoLEP than TURP. However, surgical treatment of recurrent prostatic obstruction after previous transurethral surgery for symptomatic benign prostatic hyperplasia is more challenging because of loss of anatomical landmarks resulting in either incomplete removal or incontinence. HoLEP for recurrent symptoms due to residual or re-growing prostatic adenoma seems to be as safe, feasible and efficient as HoLEP for de novo cases. The surgical plane between the adenoma and the surgical capsule was still accessible resulting in a durable long-term outcome with minimal side-effects. Previous transurethral prostatic surgery is not a contraindication for HoLEP. OBJECTIVE: • To assess the technical feasibility, functional outcome and morbidity of holmium laser enucleation of the prostate (HoLEP) for symptomatic benign prostatic hyperplasia (BPH) in patients with previous transurethral prostate surgery. 'Redo' surgery for recurrent or residual BPH poses a technical challenge with uncertain outcome as a result of disturbed anatomical landmarks with no clear surgical limits. PATIENTS AND METHODS: • We retrospectively reviewed 1054 patients who underwent HoLEP for symptomatic BPH. • Patients were stratified into two groups, group-I with no previous prostate surgery or primary-HoLEP (978 patients) and group-II with history of previous prostate surgery or secondary-HoLEP (76). • All patients' variables as well as follow-up data were assessed and compared. RESULTS: • There were no significant differences in baseline criteria between the two groups (P > 0.05). • In group-II, HoLEP was done after a median (range) of 66 (13-121) months from previous prostate surgeries, including transurethral resection of the prostate (48 patients), HoLEP (eight), transurethral incision of the prostate (nine), photoselective vaporization of the prostate (four) and other procedures (seven). • In both groups, routine HoLEP technique was adopted, the plane of enucleation could be identified without extra difficulty. However, more energy per gram of prostate tissue was needed in group-II (P < 0.05). • Operative auxiliary procedures were indicated in 1.9% of group-I, and 1.3% of group-II (P > 0.05). There were no operative complications or blood transfusion in group-II. The mean hospital stay and catheter time was similar in both groups. Early and late postoperative complications were not statistically different (P > 0.05). • At 1 month the mean maximum urinary flow rate (Q(max) ) was 22.3 and 18.8 mL/s, postvoid residual urine volume (PVR) was 46 and 45 mL, International Prostate Symptom Score (IPSS) was 7.04 and 7.08, and the health-related quality of life (HRQL) score was 1.57 and 1.56, in group-I and II, respectively. At 1 year the mean Q(max) was 23.4 and 25.9 mL/s, PVR was 32.5 and 24.1 mL, IPSS was 4.5 and 4.4, and the HRQL score was 1.2 and 1.1,) in group-I and II, respectively (P > 0.05). • Reoperation for recurrent obstruction was indicated in 4% in group-I and 5.2% in group-II (P > 0.05). CONCLUSION: • Secondary-HoLEP procedures seem to be safe and technically feasible with comparable functional outcomes as those of primary-HoLEP.

Holmium laser enucleation of the prostate: long-term durability of clinical outcomes and complication rates during 10 years of followup.

PURPOSE: We assessed the long-term durability of subjective and objective outcomes and complication rates after holmium laser enucleation of the prostate. MATERIALS AND METHODS: We conducted a retrospective analysis of 949 evaluable patients treated with holmium laser enucleation of the prostate between March 1998 and September 2010 at a single center. Study variables included International Prostate Symptom Score, quality of life, maximum urinary flow rate, post-void residual urine volume and prostate specific antigen. RESULTS: Mean followup was 62 months. Mean preoperative post-void residual volume, maximal flow rate, International Prostate Symptom Score and quality of life were 311 ml, 7.9 ml per second, 19 and 3.8, respectively. Postoperatively all variables showed significant improvement starting at month 1 of followup and remained improved for the entire followup period. Patients with acute urinary retention represented 36% (343) of the cohort. Postoperative mean post-void residual volume was 45, 25.7 and 52 ml, mean maximal flow rate was 21.5, 24.3 and 23.4 ml per second, mean International Prostate Symptom Score was 7.3, 4.4 and 3.8, and mean quality of life was 1.7, 1 and 0.7 at 1 month, 1 year and 10 years, respectively. Persistent urge and stress incontinence were found in 1% and 0.5% of patients, respectively. Bladder neck contracture, urethral stricture and reoperation due to residual adenoma developed in 0.8%, 1.6% and 0.7% of patients. CONCLUSIONS: Holmium laser enucleation of the prostate represents an effective treatment modality for men with symptomatic benign prostatic hyperplasia with a low rate of complications during a long followup. Patients who experience improvement from baseline to early followup maintain improvement at later followup.

Is there a way to predict stress urinary incontinence after holmium laser enucleation of the prostate?

PURPOSE: In this study we defined high risk patients at high risk of stress urinary incontinence after holmium laser enucleation of the prostate. MATERIALS AND METHODS: We performed a retrospective analysis during a 10-year period of 949 consecutive patients treated with holmium laser enucleation of the prostate by a single surgeon. Patients were divided into group 1--those without postoperative stress urinary incontinence (902) and group 2--those with stress urinary incontinence (47). All preoperative, intraoperative and postoperative clinical variables were compared between the 2 groups. RESULTS: Patient age, preoperative and postoperative prostate specific antigen, preoperative medications, preoperative acute retention and duration of postoperative catheter time were not associated with postoperative stress urinary incontinence. The presence of diabetes mellitus was significantly associated with a higher incidence of stress urinary incontinence (p <0.001). Using medians of the whole cohort, prostate volume greater than 81 gm, operative time greater than 96 minutes and reduction in prostate specific antigen greater than 84% were significantly associated with stress urinary incontinence. On multivariate analysis prostate volume greater than 81 gm, the presence of diabetes mellitus and greater than 84% reduction in prostate specific antigen remained statistically significant. CONCLUSIONS: Holmium laser enucleation of the prostate results in stress urinary incontinence at a rate comparable to that of other surgical techniques for the treatment of benign prostatic hyperplasia. The presence of diabetes mellitus, large prostate volume and a greater reduction in postoperative prostate specific antigen remained statistically significant for the development of stress urinary incontinence. Patients with diabetes, especially those with a large prostate, should be encouraged to start Kegel exercises in the immediate postoperative period.

Holmium laser ablation versus photoselective vaporization of prostate less than 60 cc: long-term results of a randomized trial.

PURPOSE: We evaluated the long-term results and durability of photoselective vaporization and holmium laser ablation as surgical treatment of small to medium prostates in a prospective, randomized study in men with obstructive benign prostatic hyperplasia. MATERIALS AND METHODS: From March 2005 to April 2007 we randomly allocated 109 patients with a prostate gland of less than 60 cc to prostate photoselective vaporization (52) or holmium laser ablation (57) and evaluated them 1, 2 and 3 years postoperatively. Functional followup included measurement of maximum urinary flow rate, post-void residual urine, International Prostate Symptom Score, quality of life, International Index of Erectile Function and prostate specific antigen. RESULTS: Mean ± SD preoperative prostate volume was 33.1 ± 14.5 and 37.3 ± 13.6 in the laser ablation and vaporization groups, respectively. All functional parameters improved significantly compared to baseline values in each group. There was no difference in International Prostate Symptom Score, quality of life, maximum urinary flow rate, post-void residual urine or percent of prostate specific antigen decrease between the 2 groups 1, 2 and 3 years postoperatively. At 3-year followup International Prostate Symptom Score had improved by 70.5%, quality of life had improved by 69.4%, maximum urinary flow rate had increased by 164% and post-void residual urine had decreased by 81% in the holmium laser ablation group. In the photoselective vaporization group International Prostate Symptom Score improved by 64.1%, quality of life improved by 65.5%, maximum urinary flow rate increased by 189% and post-void residual urine decreased by 79.5%. The overall re-treatment rate was 15.8% for holmium laser ablation vs 19.3% for photoselective vaporization. CONCLUSIONS: Prostate photoselective vaporization and holmium laser ablation are effective surgical treatments for benign prostatic hyperplasia. Postoperative functional improvements were significant and durable, and equivalent in the 2 groups. The 2 techniques have a similar complication rate.

Prostatic-specific antigen velocity after holmium laser enucleation of the prostate: possible predictor for the assessment of treatment effect durability for benign prostatic hyperplasia and detection of malignancy.

OBJECTIVES: To evaluate the prostate-specific antigen velocity (PSAV) as an indicator for effectiveness and durability of size reduction after holmium laser enucleation of the prostate (HoLEP). Additionally, PSAV monitoring in the detection of prostate cancer was also evaluated. METHODS: Between 1998 and 2006, we reviewed the prostate-specific antigen (PSA) data of 335 men who underwent HoLEP and had a complete PSA data including preoperative PSA, postoperative PSA (reset), and a minimum of 2 annual PSA readings after PSA reset. PSAV was calculated by 3 methods--simple arithmetic method, linear regression method, and rate method. RESULTS: In the benign group, the mean PSA dropped from 5.44 to 0.91 ng/mL (P <0.001). The prostate cancer patients who were newly discovered in the follow-up period had significantly higher baseline PSA (P = .032) and significantly lower PSA reduction than that of the benign group (75.39% vs 47.49%, P <.001). PSAV was calculated by 3 different methods and produced identical results; however, linear regression method produced significantly lower estimates at 7 years. In the malignant group, the mean PSAV at 1 and 3 years was higher than that of the benign group (1.28 vs 0.13 and 2.4 vs 0.09, P <0.022, 0.001, respectively). CONCLUSIONS: HoLEP results in a significant reduction in PSA that remained at lower levels during follow-up, suggesting that the glandular size reduction after HoLEP is durable. Monitoring of PSAV is important in long-term follow-up of patients for prostatic carcinoma detection after prostatic surgery.