HoLEP Learning Curve-Resident Perspective: Survey of Senior Residents from High-Volume Tertiary Center.

Objective: We aim to report the learning curve and experience performing holmium laser enucleation of the prostate (HoLEP) from a resident standpoint trained at a tertiary high-volume center. Methods: An electronic survey was distributed to 10 surveyees that included recently graduated chief residents trained at Indiana University in the past 3 years i.e., between 2020 and 2022 with a 100% response rate. The questionnaire focused on HoLEP training experience based on a recently established mentorship curriculum in training the residents through each individual step of the surgery. Results: The average learning curve for performing HoLEP was reported to be greater than 25 cases with 50% of the residents reporting >50 cases to master the technique. The surgical difficulty of steps of the HoLEP were rated on a subjective scale of 1-5: 1 = very easy, 2 = easy, 3 = neutral, 4 = hard, and 5 = very hard. The common challenging steps in decreasing the order of difficulty as reported are performing apical enucleation, joining anterior and posterior planes, and dividing anterior commissure with a mean rating of 3.5, 3.1, and 3.1, respectively. The most difficult aspect of the surgery to master was performing apical dissection (60%). Comparing operative parameters for HoLEP with transurethral resection of the prostate in aspects of resection volume and times, 70% of candidates reported it better for HoLEP whereas 20% had similar times for both procedures. A total of 90% of the residents felt confident to offer HoLEP as part of their practice without the need for any further training. Regarding the initial challenge of including HoLEP surgery in practice, the majority (60%) reported difficulty with equipment set up in their practice while 20% reported difficulty maintaining efficient operating room (OR) times and turnover. Conclusion: We believe HoLEP can be performed immediately after residency training and incorporated into practice with high volume, repeated exposure to HoLEP surgery throughout residency based on study results. The average learning curve reported for performing HoLEP was greater than 25 cases.

Holmium Laser Enucleation of Prostate in Patients with Pre-Existing Localized Prostate Cancer, Dual Center Study.

Background: Holmium laser enucleation of the prostate (HoLEP) has been used as an effective minimally invasive technique for management of enlarged prostates. We aimed to report the role of HoLEP in prostate cancer (PCa) patients either on active surveillance with bothersome lower urinary tract symptoms (LUTS) or for prostate debulking before radiation therapy and the impact on PCa management plans. Methods: Prospectively maintained database in two institutions was reviewed for patients with localized PCa managed by HoLEP with at least a follow-up of 1 year. We assessed prostate-specific antigen (PSA) trends, effect on international prostate symptom score (IPSS) and further management of PCa. Results: Out of >2000 HoLEP patients, 117 patients with a median follow-up of 30 months were included. Mean (standard deviation) age was 72.3 (±8.3) years with median (interquartile range, IQR) IPPS of 22 (16-28) and median (IQR) PSA at 7.6 (5.3-14.9) ng/mL. Gleason grade group was 1, 2, 3, and 4 in 47 (73.2%), 32 (27.35%), 7 (5.9%), and 4 (3.4%) patients, respectively. Median (IQR) PSA has significantly dropped to 1.3 (0.6-3.1), 1.4 (0.75-2.9), and 1.7 (0.86-2.75) ng/mL at 6-week, 3-month, and 1-year follow-up, respectively (p < 0.001). IPSS scores post-HoLEP obviously improved with mean (IQR) IPSS of 10 (5-13), 7 (3-12), and 3 (2-5) at 6-week, 3-month, and 1-year, respectively (p < 0.001). Eighty-eight (72%) patients stayed on active surveillance, whereas 27 (23%) patients had radiotherapy ± androgen deprivation therapy for persistently high or relapsing PSA. Within 36 intermediate-risk patients, 15 (41.6%) and patients had radiotherapy, whereas 21 (58.3%) patients continued active surveillance. Conclusions: HoLEP is beneficial in debulking large prostate in PCa patients with bothersome LUTS on active surveillance or before radiotherapy. HoLEP reduces the contribution of large adenoma to PSA level, thus reflecting PSA level better and helping reduce overtreatment.

Removal of Small, Asymptomatic Kidney Stones and Incidence of Relapse.

BACKGROUND: The benefits of removing small (≤6 mm), asymptomatic kidney stones endoscopically is unknown. Current guidelines leave such decisions to the urologist and the patient. A prospective study involving older, nonendoscopic technology and some retrospective studies favor observation. However, published data indicate that about half of small renal stones left in place at the time that larger stones were removed caused other symptomatic events within 5 years after surgery. METHODS: We conducted a multicenter, randomized, controlled trial in which, during the endoscopic removal of ureteral or contralateral kidney stones, remaining small, asymptomatic stones were removed in 38 patients (treatment group) and were not removed in 35 patients (control group). The primary outcome was relapse as measured by future emergency department visits, surgeries, or growth of secondary stones. RESULTS: After a mean follow-up of 4.2 years, the treatment group had a longer time to relapse than the control group (P<0.001 by log-rank test). The restricted mean (±SE) time to relapse was 75% longer in the treatment group than in the control group (1631.6±72.8 days vs. 934.2±121.8 days). The risk of relapse was 82% lower in the treatment group than the control group (hazard ratio, 0.18; 95% confidence interval, 0.07 to 0.44), with 16% of patients in the treatment group having a relapse as compared with 63% of those in the control group. Treatment added a median of 25.6 minutes (interquartile range, 18.5 to 35.2) to the surgery time. Five patients in the treatment group and four in the control group had emergency department visits within 2 weeks after surgery. Eight patients in the treatment group and 10 in the control group reported passing kidney stones. CONCLUSIONS: The removal of small, asymptomatic kidney stones during surgery to remove ureteral or contralateral kidney stones resulted in a lower incidence of relapse than nonremoval and in a similar number of emergency department visits related to the surgery. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Veterans Affairs Puget Sound Health Care System; ClinicalTrials.gov number, NCT02210650.).

Aquablation therapy in large prostates (80-150 cc) for lower urinary tract symptoms due to benign prostatic hyperplasia: WATER II 3-year trial results.

Objective: The objective of this study is to determine if Aquablation therapy can maintain its effectiveness in treating men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with large-volume (80-150 cc) prostates at 3 years. Subjects and Methods: One hundred one men with moderate-to-severe BPH symptoms and prostate volumes between 80 and 150 cc were enrolled in a prospective, nonrandomized, multicenter, international clinical trial in late 2017. Baseline, procedural, and follow-up parameters were recorded at baseline and scheduled postoperative visits. IPSS, Qmax, and treatment failure are reported at 3 years. Results: The mean prostate volume was 107 cc (range 80-150). Mean IPSS improved from 23.2 at baseline to 6.5 at 3 years (16.3-point improvement, p < 0.0001). Mean IPSS quality of life improved from 4.6 at baseline to 1.1 at 3 years (improvement of 3.4 points, p < 0.0001). Maximum urinary flow increased from 8.7 to 18.5 cc/s. At 3 year follow-up, 6% of treated patients needed BPH medication and an additional 3% required surgical retreatment for LUTS. Conclusions: Three-year follow-up demonstrates a sustained symptom reduction response along with low irreversible complications to Aquablation in men with LUTS due to BPH and prostates of 80-150 cc. Current treatment options available for men with prostates of this size have similar efficacy outcomes but are burdened with high rates of irreversible complications. There are now numerous clinical studies with Aquablation used in various prostates sizes, and it should be offered as an option to men with LUTS due to BPH.

Fragmentation of Stones by Burst Wave Lithotripsy in the First 19 Humans.

PURPOSE: We report stone comminution in the first 19 human subjects by burst wave lithotripsy (BWL), which is the transcutaneous application of focused, cyclic ultrasound pulses. MATERIALS AND METHODS: This was a prospective multi-institutional feasibility study recruiting subjects undergoing clinical ureteroscopy (URS) for at least 1 stone ≤12 mm as measured on computerized tomography. During the planned URS, either before or after ureteroscope insertion, BWL was administered with a handheld transducer, and any stone fragmentation and tissue injury were observed. Up to 3 stones per subject were targeted, each for a maximum of 10 minutes. The primary effectiveness outcome was the volume percent comminution of the stone into fragments ≤2 mm. The primary safety outcome was the independent, blinded visual scoring of tissue injury from the URS video. RESULTS: Overall, median stone comminution was 90% (IQR 20, 100) of stone volume with 21 of 23 (91%) stones fragmented. Complete fragmentation (all fragments ≤2 mm) within 10 minutes of BWL occurred in 9 of 23 stones (39%). Of the 6 least comminuted stones, likely causative factors for decreased effectiveness included stones that were larger than the BWL beamwidth, smaller than the BWL wavelength or the introduction of air bubbles from the ureteroscope. Mild reddening of the papilla and hematuria emanating from the papilla were observed ureteroscopically. CONCLUSIONS: The first study of BWL in human subjects resulted in a median of 90% comminution of the total stone volume into fragments ≤2 mm within 10 minutes of BWL exposure with only mild tissue injury.

Label-free imaging of non-deparaffinized sections of the human kidney to determine tissue quality and signatures of disease.

Label-free fluorescence imaging of kidney sections can provide important morphological information, but its utility has not been tested in a histology processing workflow. We tested the feasibility of label-free imaging of paraffin-embedded sections without deparaffinization and its potential usefulness in generating actionable data. Kidney tissue specimens were obtained during percutaneous nephrolithotomy or via diagnostic needle biopsy. Unstained non-deparaffinized sections were imaged using widefield fluorescence microscopy to capture endogenous fluorescence. Some samples were also imaged with confocal microscopy and multiphoton excitation to collect second harmonic generation (SHG) signal to obtain high-quality autofluorescence images with optical sectioning. To adjudicate the label-free signal, the samples or corresponding contiguous sections were subsequently deparaffinized and stained with Lillie's allochrome. Label-free imaging allowed the recognition of various kidney structures and enabled morphological qualification for adequacy. SHG and confocal imaging yielded quantifiable high-quality images for tissue collagens and revealed specific patterns in glomeruli and various tubules. Disease specimens from patients with diabetic kidney disease and focal segmental glomerulosclerosis showed distinctive signatures compared to specimens from healthy controls with normal kidney function. Quantitative cytometry could also be performed when DAPI is added in situ before imaging. These results show that label-free imaging of non-deparaffinized sections provides useful information about tissue quality that could be beneficial to nephropathologists by maximizing the use of scarce kidney tissue. This approach also provides quantifiable features that could inform on the biology of health and disease.

Stone Morphology Distinguishes Two Pathways of Idiopathic Calcium Oxalate Stone Pathogenesis.

Introduction: About 1 in 11 Americans will experience a kidney stone, but underlying causes remain obscure. The objective of the present study was to separate idiopathic calcium oxalate stone formers by whether or not they showed positive evidence of forming a stone on Randall's plaque (RP). Materials and Methods: In patients undergoing either percutaneous or ureteroscopic procedures for kidney stone removal, all stone material was extracted and analyzed using micro-CT imaging to identify those attached to RP. Twenty-four-hour urine samples were collected weeks after the stone removal procedure and patients were off of medications that would affect urine composition. The endoscopic video was analyzed for papillary pathology (RP, pitting, plugging, dilated ducts, and loss of papillary shape) by an observer blinded to the data on stone type. The percent papillary area occupied by RP and ductal plugging was quantified using image analysis software. Results: Patients having even one stone on RP (N = 36) did not differ from non-RP patients (N = 37) in age, sex, BMI, or other clinical characteristics. Compared with the non-RP group, RP stone formers had more numerous, but smaller, stones, more abundant papillary RP formation, and fewer ductal plugs, both by quantitative measurement of surface area (on average, three times more plaque area, but only 41% as much plug area as in non-RP patients) and by semiquantitative visual grading. Serum and blood values did not differ between RP and non-RP stone formers by any measure. Conclusions: Growth of many small stones on plaque seems the pathogenetic scheme for the RP stone-forming phenotype, whereas the non-RP phenotype stone pathogenesis pathway is less obvious. Higher papillary plugging in non-RP patients suggests that plugs play a role in stone formation and that these patients have a greater degree of papillary damage. Underlying mechanisms that create these distinctive phenotypes are presently unknown.

Randomized Placebo-Controlled Trial of Reloxaliase in Enteric Hyperoxaluria.

BACKGROUND: Enteric hyperoxaluria is caused by increased intestinal oxalate absorption and can lead to kidney stones, chronic kidney disease, and kidney failure. Reloxaliase is an orally administered recombinant enzyme that degrades oxalate along the gastrointestinal tract, thereby preventing its absorption. METHODS: We randomly assigned participants with enteric hyperoxaluria to reloxaliase or placebo, three to five times per day with food for 4 weeks. The primary end point was percent change from baseline in 24-hour urinary oxalate (UOx) excretion during weeks 1 to 4. Secondary end points included the proportion of participants with more than a 20% reduction in 24-hour UOx and an efficacy assessment in the bariatric surgery subgroup. RESULTS: A total of 115 patients underwent randomization. The 24-hour UOx decreased from a baseline geometric mean of 83.2 to 67.4 mg/24 hr during weeks 1 to 4 in reloxaliase-treated participants. Corresponding data for placebo-treated participants were 84.2 to 78.1 mg/24 hr. Estimates from the mixed-effect model repeated-measures (MMRM) analysis showed a 22.6% reduction in geometric mean UOx during weeks 1 to 4 for reloxaliase and 9.7% for placebo, a difference of 14.3 percentage points (95% confidence interval [CI], 4.9 to 22.8; P=0.004). A 20% or greater reduction in 24-hour UOx was observed in 48.3% of reloxaliase-treated participants and 31.6% of placebo-treated participants (P=0.06). In the bariatric surgery subgroup, MMRM analysis showed a 21.2% reduction in geometric mean UOx for reloxaliase and a 6.0% reduction for placebo, for a difference of 16.2 percentage points (95% CI, 4.2% to 26.7%). Adverse events occurred in 69% of reloxaliase-treated participants versus 53% of individuals taking placebo and were most commonly gastrointestinal. All but one of the adverse events were grade 1 or 2 in severity; no reloxaliase-treated participants discontinued the study. CONCLUSIONS: Reloxaliase treatment for 4 weeks reduced UOx excretion in patients with enteric hyperoxaluria; adverse events were relatively common, but not dose-limiting. These data establish the foundation for a clinical trial to determine the impact of reloxaliase on nephrolithiasis in patients with enteric hyperoxaluria. (Funded by Allena Pharmaceuticals; ClinicalTrials.gov number, NCT03456830.)

Multimodal imaging reveals a unique autofluorescence signature of Randall's plaque.

Kidney stones frequently develop as an overgrowth on Randall's plaque (RP) which is formed in the papillary interstitium. The organic composition of RP is distinct from stone matrix in that RP contains fibrillar collagen; RP in tissue has also been shown to have two proteins that are also found in stones, but otherwise the molecular constituents of RP are unstudied. We hypothesized that RP contains unique organic molecules that can be differentiated from the stone overgrowth by fluorescence. To test this, we used micro-CT-guided polishing to expose the interior of kidney stones for multimodal imaging with multiphoton, confocal and infrared microscopy. We detected a blue autofluorescence signature unique to RP, the specificity of which was also confirmed in papillary tissue from patients with stone disease. High-resolution mineral mapping of the stone also showed a transition from the apatite within RP to the calcium oxalate in the overgrowth, demonstrating the molecular and spatial transition from the tissue to the urine. This work provides a systematic and practical approach to uncover specific fluorescence signatures which correlate with mineral type, verifies previous observations regarding mineral overgrowth onto RP and identifies a novel autofluorescence signature of RP demonstrating RP's unique molecular composition.

A Comparison of Perioperative Stone-Free Rates and Complications Following Unilateral, Single-Access Percutaneous Nephrolithotomy by Access Location in 767 Patients.

OBJECTIVE: To compare perioperative outcomes between lower, mid, and upper pole access locations for patients undergoing single-access, unilateral percutaneous nephrolithotomy (PCNL). METHODS: We queried our institutional PCNL database to include patients who had unilateral, single access procedures. We excluded patients who had a contralateral procedure during the same admission or multiaccess procedures. Patients were grouped by the site of PCNL access (lower, mid, or upper pole). Among groups, we compared postoperative day 1 (POD1) stone-free rates as measured by abdominal CT scan or plain-film X-ray and consequent need for a secondary procedure. We further compared postoperative complication rates. RESULTS: We included 767 patients for analysis, with the majority of access locations being in the lower pole (80.2%). Patients across groups had similar age, body mass index, and stone laterality. Patients with horseshoe kidneys more commonly had mid or upper pole access compared to lower pole. The percentage of patients with no residual stone fragments seen on POD 1 imaging was similar for lower, mid, and upper pole groups (57.7% vs 65.0% vs 61.6%, respectively; P = .526). Additionally, we observed no difference in the percentage of patients requiring a secondary procedure among the above groups (33.5% vs 22.5% vs 31.3%, respectively; P = .337). Patients experienced no difference in complications among groups. CONCLUSION: When performing unilateral PCNL using a single site of access, we observed no difference in stone-free rates or complications between lower, mid, and upper pole locations. Appropriate selection of access location in PCNL should be individualized to patient factors and surgeon experience.

Aquablation for benign prostatic hyperplasia in large prostates (80-150 cc): 2-year results.

INTRODUCTION: To report 2-year safety and effectiveness of the Aquablation procedure for the treatment of men with symptomatic benign prostatic hyperplasia (BPH) and large-volume 80-150 cc prostates. MATERIALS AND METHODS: Between September-December 2017, 101 men with moderate-to-severe BPH symptoms and prostate volumes of 80-150 cc underwent an ultrasound-guided robotically executed Aquablation procedure in a prospective multicenter international clinical trial (WATER II). Baseline, procedural and follow up parameters were recorded at baseline and scheduled postoperative visits. Herein we report 2-year safety and efficacy for this cohort. RESULTS: Mean prostate volume was 107 cc (range 80-150 cc). Mean IPSS improved from 23.2 at baseline to 5.8 at 2 years (17-point improvement, p < .0001). Mean IPSS quality of life improved from 4.6 at baseline to 1.1 at 2 years (p < .0001). Maximum urinary flow increased from 8.7 to 18.2 cc/sec. Two subjects underwent a repeat procedure for BPH symptoms over the 2-year follow up period. By 2 years or study exit, all but 2 of 74 subjects stopped taking alpha blockers. Similarly, all but 4 of 32 subjects stopped taking 5α-reductase inhibitors. CONCLUSIONS: Two-year prospective multicenter follow up demonstrated that the Aquablation procedure is safe and effective in the treatment of men with LUTS due to BPH and prostates 80-150 cc with durable treatment efficacy, acceptable safety profile and a low retreatment rate. ClinicalTrials.gov number, NCT03123250.

Operative time comparison of aquablation, greenlight PVP, ThuLEP, GreenLEP, and HoLEP.

INTRODUCTION: The BPH surgical armamentarium is composed of a rapidly expanding number of technologies and techniques. These include greenlight photovaporization of the prostate (PVP), greenlight enucleation of the prostate (GreenLEP), holmium laser enucleation of the prostate (HoLEP), thulium laser enucleation of the prostate (ThuLEP) and, more recently, the aquablation procedure. To the best of our knowledge, no direct comparison in operative time has been performed. METHODS: Data for this study were pooled from five sources. For aquablation, patient-level data from four studies of the aquablation procedure were provided by the device manufacturer as well as from a high-volume commercial user. PVP, GreenLEP, HoLEP, and ThuLEP were performed by high-volume, experienced experts. Endpoints included total operative time, resection time, and proportion of total operative time for resection. General linear models were used to evaluate the relationship between prostate volume (or other continuous predictors) and procedure time. RESULTS: Total procedure time was related to prostate size. Except for the small prostate size range (size < 40 cc), at any given prostate volume, procedure time was highest for PVP, intermediate for LEPs, and lowest for Aquablation. The relationship between procedure time and prostate size (i.e., slope of the fitted lines) was 0.16 min/g for aquablation, 0.32 min/g, 0.28 min/g and 0.32 min/g for GreenLEP, HoLEP and ThuLEP, respectively, and 0.63 min/g for PVP. CONCLUSION: In our analysis of pooled data of multi-surgical techniques and technologies, aquablation provided the lowest operative time across all prostate volumes. PVP had the longest procedure time for prostates > 40 cc.

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

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

Robot-Assisted Radical Prostatectomy in Patients with a History of Holmium Laser Enucleation of the Prostate: The Indiana University Experience.

Introduction: We sought to update our experience of oncologic and functional outcomes of robot-assisted radical prostatectomy (RARP) for prostate cancer in patients with history of holmium laser enucleation of the prostate (HoLEP). Patients and Methods: Twenty-seven patients with previous HoLEP who underwent RARP were matched 1:1 with RARP patients with no history of transurethral surgery. Demographic, operative, oncologic, continence, and erectile function outcomes were analyzed. Results: Median time between HoLEP and RARP was 31 months with a mean prostate-specific antigen doubling time of 4.28 ng/mL/year. Operative times were significantly longer with higher bladder neck reconstruction rates and similarly low complication rates. Biochemical recurrence was relatively low (7%) in the HoLEP group, identical to the comparative group. Continence at last follow-up was not statistically significant between groups, although time to continence favored the non-HoLEP cohort. Erectile function recovery was generally poor in the post-HoLEP cohort (11%), although bilateral nerve sparing was rarely performed (11%). Compared with our initial experience, there were significant improvements in time to continence (16 vs 36 weeks). No T2 post-HoLEP RARP since 2010 has had a positive surgical margin. Conclusions: Post-HoLEP prostatectomy remains feasible with similar perioperative and oncologic outcomes compared with matched cohorts. Functional recovery remains slowed yet may continue to improve with technical familiarity.

In Vivo Renal Tubule pH in Stone-Forming Human Kidneys.

Introduction: There is evidence that patients with a history of ileostomies, who produce acidic urine and form uric acid or calcium oxalate stones, may plug some collecting ducts with calcium phosphate (CaP) and urate crystals. This is a paradoxical finding as such minerals should not form at an acid pH. One possible explanation is the presence of acidification defects due to focal damage to inner medullary collecting duct and Bellini duct (BD) cells. We sought to further investigate this hypothesis through direct measurement of ductal pH in dilated BDs in patients with ileostomies undergoing percutaneous nephrolithotomy (PCNL) for stone removal. Methods: After obtaining institutional review board approval, we used a fiber-optic pH microsensor with a 140-µm-diameter tip to measure intraluminal pH from the bladder, saline irrigant, and dilated BDs of patients undergoing PCNL. Results: Measurements were taken from three patients meeting inclusion criteria. Measured pH of bladder urine ranged from 4.97 to 5.58 and pH of saline irrigant used during surgery ranged from 5.17 to 5.75. BD measurements were achieved in 11 different BDs. Mean intraductal BD pH was more than 1 unit higher than bulk urine (6.43 ± 0.22 vs 5.31 ± 0.22, p < 0.01). Conclusions: This is the first evidence for focal acidification defects within injured/dilated BDs of human kidneys producing highly acidic bulk phase urine. These results may help explain the paradoxical finding of CaP and urate plugs in dilated ducts of patients with stone-forming diseases characterized by highly acidic urine.

Variability in stone composition and metabolic correlation between kidneys in patients with bilateral nephrolithiasis.

PURPOSE: To evaluate the clinical significance of discordant stone analyses in patients undergoing bilateral ureteroscopy. MATERIALS AND METHODS: A retrospective chart review was performed for all patients undergoing stone extraction with bilateral ureteroscopy at our institution in an aim to identify patients who had bilateral stone analysis and 24-h urine chemistry data available. Stones were then classified based upon the dominant present (> 50%). Twenty-four hour urinalysis results were reviewed and statistical analysis performed comparing discordant and concordant patient populations, assessing significant differences that would potentially influence clinical management. RESULTS: We identified 79 patients (158 renal units) who had bilateral stones removed at the time of ureteroscopy. The majority of stones were classified as calcium oxalate (CaOx) (60.1%) followed by calcium phosphate (CaP) (27.8%), brushite (5.1%), uric acid (UA) (4.4%), and cystine (2.5%). Discrepancies in stone classifications were present 24% of the time. Evaluation of 24-h urinalysis results demonstrated that patients with CaOx:CaP stone discordance compared to CaOx:CaOx concordant stone formers were more likely to have an elevated pH (p = 0.02) and lower uric acid supersaturation (p = 0.01). CONCLUSIONS: Discrepancies in stone mineral content are common in patients with bilateral stone disease. A single stone analysis from one side in the setting of bilateral stone disease is insufficient for management of patients with bilateral renal stones, and may lead to mismanagement when this misrepresented information is utilized in addition to 24-h urinalysis results. At least one stone analysis should be performed from both sides during a bilateral stone extraction procedure.

The Role of Prostate Specific Antigen Monitoring after Holmium Laser Enucleation of the Prostate.

PURPOSE: Prostate specific antigen screening for prostate cancer has recently been challenged due to poor sensitivity. In addition to prostate cancer, a number of conditions elevate prostate specific antigen, of which benign prostatic hyperplasia is most common. The objective of this study was to assess the positive predictive value of prostate specific antigen and prostate specific antigen density for prostate cancer risk following holmium laser enucleation of the prostate. MATERIALS AND METHODS: We queried an institutional review board approved database of holmium laser enucleation of the prostate performed at Indiana University from 1999 to 2018 to identify 1,147 patients with prostate specific antigen data available after holmium laser enucleation. A total of 55 biopsies after enucleation were recorded. Demographics, prostate specific antigen, prostate volume and oncologic details were analyzed. The primary outcome was biopsy proven prostate cancer. RESULTS: A total of 55 patients underwent transrectal ultrasound prostate biopsy for cause after holmium laser enucleation of the prostate. Cancer was identified in more than 90% of biopsied cases. Men with prostate specific antigen above 1 ng/ml at biopsy had a 94% probability of cancer detection and an 80% risk of clinically significant disease. Prostate specific antigen density above 0.1 ng/ml2 was associated with a 95% risk of cancer and an 88% risk of clinically significant cancer. Prostate specific antigen greater than 5.8 ng/ml or prostate specific antigen density greater than 0.17 ng/ml2 was universally associated with biopsy proven cancer. CONCLUSIONS: Prostate specific antigen and prostate specific antigen density have high positive predictive value for prostate cancer risk after holmium laser enucleation of the prostate. Thresholds for biopsy should be lower than in patients who do not undergo holmium laser enucleation. Those who undergo that procedure and have prostate specific antigen above 1 ng/ml or prostate specific antigen density above 0.1 ng/ml2 are at higher risk for harboring clinically significant disease and should undergo biopsy. Referring physicians should be aware of these significant risk shifts.

Holmium laser enucleation of the prostate in Jehovah's Witness patients.

PURPOSE: To evaluate if HoLEP is a viable option for male patients with medication-refractory urinary symptoms due to an enlarged prostate who are surgical candidates, but do not accept blood product transfusion. MATERIALS AND METHODS: Between August 2008 and March 2019, nine Jehovah's Witness patients were undergoing HoLEP for relief of lower urinary tract symptoms and urinary retention. We described change in hemoglobin, change in PSA, enucleated prostate weight, enucleation and morcellation times, length of stay, and postoperative retention rate. RESULTS: The average age was 71.4 years (range 53-87). Urinary retention requiring catheterization was present in seven patients (78%). Two patients had a known diagnosis of prostate cancer preoperatively. The mean preoperative PSA on average was 21.6 ng/dL. Patients had a wide range of gland sizes, with a mean enucleated weight of 141 g (range 18-344 g). Mean reduction in hemoglobin was 16.9% following HoLEP. All patients managed to void postoperatively. All but one patient went home on postoperative day 1, and this patient went home on postoperative day 2. No patients required blood product transfusion or return to the operating room for clot irrigation postoperatively. CONCLUSION: HoLEP is a reasonable option for Jehovah's Witness and other patients with contraindications to blood product transfusion requiring surgical management of urinary symptoms due to enlarged prostate.

Aquablation for Benign Prostatic Hyperplasia in Large Prostates (80-150 cc): 1-Year Results.

OBJECTIVE: To report 12-month safety and effectiveness outcomes of the Aquablation procedure for the treatment of men with symptomatic benign prostatic hyperplasia (BPH) and large-volume prostates. METHODS: One hundred and one men with moderate-to-severe BPH symptoms and prostate volumes of 80-150 cc underwent a robotic-assisted Aquablation procedure in a prospective multicenter international clinical trial. Functional and safety outcomes were assessed at 12 months postoperatively. RESULTS: Mean prostate volume was 107 cc (range 80-150). Mean operative time was 37 minutes and mean Aquablation resection time was 8 minutes. The average length of hospital stay following the procedure was 1.6 days. Mean International Prostate Symptom Score improved from 23.2 at baseline to 6.2 at 12 months (P <.0001). Mean International Prostate Symptom Score quality of life improved from 4.6 at baseline to 1.3 at 12-month follow-up (P <.0001). Significant improvements were seen in Qmax (12-month improvement of 12.5 cc/sec) and postvoid residual (drop of 171 cc in those with postvoid residual >100 at baseline). Antegrade ejaculation was maintained in 81% of sexually active men. No patient underwent a repeat procedure for BPH symptoms. There was a 2% de novo incontinence rate at 12 months, and 10 patients did require a transfusion postoperatively while 5 required take back fulgurations. At 12 months, prostate-specific antigen reduced from 7.1 ± 5.9 ng/mL at baseline to 4.4 ± 4.3 ng/mL. CONCLUSION: The Aquablation procedure is demonstrated to be safe and effective in treating men with large prostates (80-150 cc) after 1 year of follow-up, with an acceptable complication rate and without a significant increase in procedure or resection time compared to smaller sized glands. ClinicalTrials.gov number, NCT03123250.