Propensity score-matched evaluation of palliative transurethral resection and holmium laser enucleation of the prostate for bladder outlet obstruction in patients with prostate cancer.

BACKGROUND: While transurethral resection of the prostate (TURP) is the standard-of-care, Holmium laser enucleation of the prostate (HoLEP) is widely accepted as a size-independent method for surgical treatment of patients with lower urinary tract symptoms (LUTS) secondary to bladder outlet obstruction (BOO). However, in an ageing society an increasing number of patients presents with BOO due to locally advanced prostate cancer. There is currently no guidelines recommendation as to the enucleation or resection technique. Therefore, we compared intraoperative performance, postoperative outcomes, and safety for palliative (p)TURP and (p)HoLEP. METHODS: We conducted a retrospective, propensity score-matched analysis of 1373 and 2705 men who underwent TURP or HoLEP for LUTS/BOO between 2014 and 2021, respectively. Patients were matched for age, prostate size and preoperative international prostate symptom score (IPSS). Patients were stratified by technique and groups were compared for perioperative parameters, safety, and functional outcomes. RESULTS: While postoperative symptoms and urodynamic parameters improved irrespective of technique, we report significantly increased resection and enucleation times for palliative indication. For corresponding efficiency parameters, we observed a two-fold higher surgical performance (g/min) for both techniques in patients without prostate cancer. While adverse events were comparable between groups, we found a two-fold higher hemoglobin drop in palliative patients. CONCLUSIONS: Currently, there is no standard-of-care for patients with BOO and locally advanced prostate cancer. Our data show that both TURP and HoLEP offer adequate symptom improvement and comparable safety profiles. While HoLEP is feasible even in larger prostates, both procedures become more difficult in patients with prostate cancer. Taken together, this study covers an important gap in current literature, helping urological surgeons to make evidence-based decisions for the benefit of their patients.

[Minimally invasive treatment of benign prostatic hyperplasia : The German S2e guideline 2023-part 4]. / Minimalinvasive Therapien des benignen Prostatasyndroms : Die deutsche S2e-Leitlinie 2023 ­ Teil 4/4.

BACKGROUND: Lower urinary tract symptoms suggestive for benign prostatic obstruction (LUTS/BPO) are one of the most frequent diseases in men and can have a significant impact on quality of life. Instrumental therapies are common, and many patients seek minimally invasive treatment options. OBJECTIVE: Presentation and evidence-based evaluation of the minimally invasive therapy for benign prostatic syndrome. MATERIALS AND METHODS: Summary and overview of chapters 11-13 on minimally invasive therapies for LUTS/BPO of the current long version of the German S2e guideline. RESULTS: In case of absolute indication for surgery or after unsatisfactory or undesired medical therapy, minimally invasive treatments such as UroLift® (Neotract Inc., Pleasanton, CA, USA), Rezá¿¡m™ (Boston Scientific, Malborough, MA, USA), iTIND™ (Olympus America Inc., Westborough, MA, USA), and prostatic artery embolization (PAE) can be considered. These indirect/delayed ablative therapies offer lower morbidity and the possibility of performing them under local anesthesia, but they are inferior to direct ablative/resective techniques in terms of effectiveness and sustainability. CONCLUSIONS: The updated German S2e guideline summarizes evidence-based recommendations for new minimally invasive therapies for LUTS/BPO, which present alternative treatment options for selected patients.

[Surgical treatment options of lower urinary tract symptoms due to benign prostatic obstruction : The German S2e guideline 2023-part 3]. / Operative Therapie des benignen Prostatasyndroms ­ klassische Desobstruktion : Die deutsche S2e-Leitlinie 2023 ­ Teil 3.

BACKGROUND: Lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) are one of the most common diagnoses in clinical practice. Bothersome LUTS impact considerably quality of life of men and may cause severe complications without treatment. According to the diagnostic assessment every patient should be treated with an adequate therapy. Management comprises a conservative approach, medication, novel minimally invasive options, and surgical procedures with the aim to remove the obstructing adenoma. The German guideline panel has updated the German guidelines on diagnostic evaluation and management of LUTS due to BPO. OBJECTIVES: Evidence-based recommendations of surgical treatment options of LUTS due to BPO are evaluated. MATERIALS AND METHODS: Chapters 11.1.1 and 11.2 of the updated German S2e guideline on the management of LUTS due to BPO are summarized as a review article. RESULTS: A treatment algorithm based on current evidence has been proposed. It is considered to provide guidance for the selection of the best procedure according to the needs of the patient. Anatomic features of the prostate, the patients' morbidity, and the preservation of ejaculatory function are taken into account for the choice of the best procedures. These surgical options can be divided into techniques with direct, delayed or no removal of the adenoma, procedures with suprapubic access, and embolizing approaches. CONCLUSIONS: The updated German S2e guideline on the management of LUTS due to BPO provides evidence-based recommendations for the selection of the best procedure according to the needs of the individual patient.

[Diagnostic work-up of benign prostatic hyperplasia : The German S2e-guideline 2023 part 1]. / Diagnostik des benignen Prostatasyndroms : Die deutsche S2e-Leitlinie 2023 Teil 1.

BACKGROUND: Lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH; in German guidelines: benign prostatic syndrome [BPS]) is the most frequent urological disease in men and can result in a considerable deterioration of quality-of-life. BPS can be associated with LUTS, benign prostatic enlargement (BPE), and bladder outlet obstruction (BOO) or benign prostatic obstruction (BPO), respectively. The expert group on BPS of the German Society of Urology has re-evaluated the tests for the assessment of BPH and provides evidence-based recommendations. OBJECTIVES: Presentation and evidence-based rating of tests for the assessment of patients with BPS. MATERIALS AND METHODS: Summary and overview of chapters 5, 6, and 8 of the latest long version of the German S2e guideline on BPS. RESULTS: The diagnostic work-up should clarify (1) whether the complaints of the patient are caused by BPS, (2) how relevant the complaints are and whether treatment is necessary, (3) whether complications of the lower or upper urinary tract already exist, and (4) which treatment will be most suitable. Baseline assessment should be done in all BPS patients and include history, measurement of LUTS and quality-of-life, urinalysis, serum prostate-specific antigen, post-void residual, ultrasound of the lower urinary tract, including measurements of prostate volume, intravesical prostatic protrusion and detrusor wall thickness, and ultrasound of the upper urinary tract. Additional tests can follow when questions remain unanswered after baseline assessment. These optional tests include bladder diaries, uroflowmetry, serum creatinine, urethrocystoscopy, other noninvasive tests for the determination of BOO/BPO such as penile cuff test, condom catheter method and near-infrared spectroscopy, and other imagining tests such as X­ray and MRI investigations. CONCLUSIONS: The updated German S2e guideline summarizes evidence-based recommendations on the diagnostic work-up, including the assessment of the BPS components BPE, LUTS, and BOO/BPO.

[Laser Techniques in the Treatment of Benign Prostatic Syndrome]. / Lasertechniken in der Behandlung des benignen Prostatasyndroms.

Laser Techniques in the Treatment of Benign Prostatic Syndrome Abstract: Lasers have a wide range of applications in endourological therapy. Not only in the treatment of stones, but also in the treatment of benign prostatic syndrome (BPS), their importance continues to grow. The endourological treatment of BPH with different laser techniques will be discussed in more detail in the following. The physical differences between the individual lasers will be explained first, followed by the treatment options that can be performed with a laser. The main focus will be on the concrete comparison of the treatment methods, especially in clinical contexts. In particular, the duration of surgery, length of hospitalisation, risk of post-operative bleeding, catheterisation duration, risk of urinary retention and risk of post-operative complications such as retrograde ejaculation, bladder neck sclerosis, urethra stricture and adenoma recurrence will be listed and compared for the most important methods. Nevertheless, the distribution of TURP to laser is still 30:1 in favour for TURP [1].

[Benign Prostate Hyperplasia - Current Medical Therapy, New Developments, and Side Effects]. / Benigne Prostatahyperplasie.

Benign Prostate Hyperplasia - Current Medical Therapy, New Developments, and Side Effects Abstract: Lower urinary tract symptoms (LUTS) consist of both voiding and storage symptoms. Urethral obstruction leading to voiding symptoms is most commonly attributed to benign prostatic hyperplasia (BPH), where hyperplastic growth and increased smooth muscle tone in the hyperplastic prostate may lead to benign prostate obstruction (BPO). Spontaneous contractions of the detrusor muscle may cause storage symptoms, which are referred to as overactive bladder (OAB). With a considerable proportion of patients suffering from "mixed LUTS", a combination of voiding and storage symptoms, LUTS affect a large portion of the population worldwide, with major impact on quality of life (QoL). A demographic shift in society, will lead to higher incidence and prevalence of LUTS, with a growing economic burden. Standard-of-care medical treatment for LUTS/BPO includes α1-adrenoceptor antagonists and phosphodiesterase-5 (PDE-5) inhibitors, for reduction of prostate smooth muscle tone, and 5α-reductase inhibitors (5-ARI) to slow down disease progression. Medical therapy for LUTS/OAB includes muscarinic receptor antagonists, and ß3-agonists for relief of spontaneous bladder contractions. When left untreated, LUTS may cause considerable adverse events, ranging from acute urinary retention with kidney failure, and recurring infections, to social withdrawal, and depression.

Efficacy, Efficiency, and Safety of En-bloc vs Three-lobe Enucleation of the Prostate: A Propensity Score-matched Analysis.

OBJECTIVE: To assess efficacy, efficiency, and safety in holmium laser enucleation of the prostate (HoLEP), we directly compared intraoperative performance, postoperative outcomes, and safety in the original 3-lobe enucleation technique with the more recent en-bloc method. As HoLEP is widely accepted as a size-independent method for surgical treatment of patients with lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO), detailed understanding of its benefits is mandatory. METHODS: We conducted a retrospective, propensity score-matched analysis of 1,396 men who underwent HoLEP for LUTS/BPO between 2017 and 2020. We included 606 patients in the final analysis (en-bloc n = 303; 3-lobe n = 303), who were matched for prostate size (50 cc), age, body mass index, and preoperative international prostate symptom score. Patients were then stratified by technique, and groups were compared for perioperative parameters, safety, and short-term functional outcomes. RESULTS: While postoperative symptoms and urodynamic parameters improved irrespective of technique, we report significantly less adverse events (Clavien-Dindo classification ≥II vs

Performance variability of radiomics machine learning models for the detection of clinically significant prostate cancer in heterogeneous MRI datasets.

Background: Radiomics promises to enhance the discriminative performance for clinically significant prostate cancer (csPCa), but still lacks validation in real-life scenarios. This study investigates the classification performance and robustness of machine learning radiomics models in heterogeneous MRI datasets to characterize suspicious prostate lesions for non-invasive prediction of prostate cancer (PCa) aggressiveness compared to conventional imaging biomarkers. Methods: A total of 142 patients with clinical suspicion of PCa underwent 1.5T or 3T biparametric MRI (7 scanner types, 14 institutions) and exhibited suspicious lesions [prostate Imaging Reporting and Data System (PI-RADS) score ≥3] in peripheral or transitional zones. Whole-gland and index-lesion segmentations were performed semi-automatically. A total of 1,482 quantitative morphologic, shape, texture, and intensity-based radiomics features were extracted from T2-weighted and apparent diffusion coefficient (ADC)-images and assessed using random forest and logistic regression models. Five-fold cross-validation performance in terms of area under the ROC curve was compared to mean ADC (mADC), PI-RADS and prostate-specific antigen density (PSAD). Bias mitigation techniques targeting the high-dimensional feature space and inherent class imbalance were applied and robustness of results was systematically evaluated. Results: Trained models showed mean area under the curves (AUCs) ranging from 0.78 to 0.83 in csPCa classification. Despite using mitigation techniques, high performance variability of results could be demonstrated. Trained models achieved on average numerically higher classification performance compared to clinical parameters PI-RADS (AUC =0.78), mADC (AUC =0.71) and PSAD (AUC =0.63). Conclusions: Radiomics models' classification performance of csPCa was numerically but not significantly higher than PI-RADS scoring. Overall, clinical applicability in heterogeneous MRI datasets is limited because of high variability of results. Performance variability, robustness and reproducibility of radiomics-based measures should be addressed more transparently in future research to enable broad clinical application.

Permixon®, hexane-extracted Serenoa repens, inhibits human prostate and bladder smooth muscle contraction and exerts growth-related functions in human prostate stromal cells.

AIMS: Recently, the European Association of Urology recommended hexane-extracted fruit of Serenoa repens (HESr) in their guidelines on management of non-neurogenic male lower urinary tracts symptoms (LUTS). Despite previously lacking recommendations, Permixon® is the most investigated HESr in clinical trials, where it proved effective for male LUTS. In contrast, underlying mechanisms were rarely addressed and are only marginally understood. We therefore investigated effects of Permixon® on human prostate and detrusor smooth muscle contraction and on growth-related functions in prostate stromal cells. MAIN METHODS: Permixon® capsules were dissolved using n-hexane. Contractions of human prostate and detrusor tissues were induced in organ bath. Proliferation (EdU assay), growth (colony formation), apoptosis and cell death (flow cytometry), viability (CCK-8) and actin organization (phalloidin staining) were studied in cultured human prostate stromal cells (WPMY-1). KEY FINDINGS: Permixon® inhibited α1-adrenergic and thromboxane-induced contractions in prostate tissues, and methacholine-and thromboxane-induced contractions in detrusor tissues. Endothelin-1-induced contractions were not inhibited. Neurogenic contractions were inhibited in both tissues in a concentration-dependent manner. In WPMY-1 cells, Permixon® caused concentration-dependent breakdown of actin polymerization, inhibited colony formation, reduced cell viability, and proliferation, without showing cytotoxic or pro-apoptotic effects. SIGNIFICANCE: Our results provide a novel basis that allows, for the first time, to fully explain the ubiquitous beneficial effects of HESr in clinical trials. HESr may inhibit at least neurogenic, α1-adrenergic and thromboxane-induced smooth muscle contraction in the prostate and detrusor, and in parallel, prostate stromal cell growth. Together, this may explain symptom improvements by Permixon® in previous clinical trials.

The COVID-19 pandemic - what have urologists learned?

On 11 March 2020, the WHO declared the coronavirus disease 2019 (COVID-19) outbreak a pandemic and COVID-19 emerged as one of the biggest challenges in public health and economy in the twenty-first century. The respiratory tract has been the centre of attention, but COVID-19-associated complications affecting the genitourinary tract are reported frequently, raising concerns about possible long-term damage in these organs. The angiotensin-converting enzyme 2 (ACE2) receptor, which has a central role in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) invasion, is highly expressed in the genitourinary tract, indicating that these organs could be at a high risk of cell damage. The detection of SARS-CoV-2 in urine and semen is very rare; however, COVID-19 can manifest through urological symptoms and complications, including acute kidney injury (AKI), which is associated with poor survival, severe structural changes in testes and impairment of spermatogenesis, and hormonal imbalances (mostly secondary hypogonadism). The effect of altered total testosterone levels or androgen deprivation therapy on survival of patients with COVID-19 was intensively debated at the beginning of the pandemic; however, androgen inhibition did not show any effect in preventing or treating COVID-19 in a clinical study. Thus, urologists have a crucial role in detecting and managing damage of the genitourinary tract caused by COVID-19.

How does symptom severity impact clinical outcomes of men with lower urinary tract symptoms after holmium laser enucleation or transurethral resection of the prostate?

Introduction: International Prostate Symptom Score (IPSS) is a validated outcome measure for the evaluation of patients with lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). When treating patients with transurethral resection of the prostate (TURP) or holmium laser enucleation of the prostate (HoLEP), patient selection is key to achieve the best clinical outcome. Therefore, we analyzed how the severity of LUTS as determined by IPSS influenced postoperative functional outcomes. Material and methods: We conducted a retrospective, matched-pair analysis of 2,011 men who underwent HoLEP or TURP for LUTS/BPO between 2013-2017. We included 195 patients in the final analysis (HoLEP n = 97; TURP n = 98), who were matched for prostate size (50 cc), age, and body mass index. Patients were then stratified by IPSS. Groups were compared for perioperative parameters, safety and short-term functional outcomes. Results: While preoperative symptom severity was a significant predictor of postoperative clinical improvement, patients who received HoLEP showed superior postoperative functional results with higher peak flow rates and 2-fold greater improvement in IPSS. In patients presenting with severe symptoms, we observed 3- to 4-fold less Clavien-Dindo grade ≥II and overall complications after receiving HoLEP compared to TURP. Conclusions: Patients with severe LUTS were more likely to experience clinically significant improvement after surgery than patients with moderate LUTS, and HoLEP showed superior functional outcomes than TURP. However, patients with moderate LUTS should not be denied surgery, but may warrant a more comprehensive clinical work-up.

Holmium laser enucleation of the prostate: A truly size-independent method?

OBJECTIVES: To evaluate the impact of prostate size on functional outcomes and perioperative morbidity, we analyzed patients undergoing holmium laser enucleation of the prostate (HoLEP) for lower urinary tract symptoms (LUTS). As LUTS secondary to benign prostatic obstruction (BPO) are a chronic progressive disease, prevalence and prostate size increase with age. HoLEP is a size-independent method for surgical treatment of LUTS/BPO and can be offered in medication-refractory patients with durable long-term results and reduced perioperative morbidity. METHODS: We retrospectively collected data of 852 patients who underwent HoLEP for LUTS secondary to BPO between 2014-2018. Patients were divided into group 1 (≤60 cc), group 2 (>60 < 120 cc), group 3 (≥120 cc). Perioperative parameters, safety and short-term functional outcomes were assessed and analyzed. RESULTS: Patients in group 3 were significantly older and showed a significantly higher median prostate-specific antigen level. Perioperative parameters, such as enucleation time and morcellation time significantly differed in favor of smaller prostate sizes, while enucleation and morcellation speed showed favorable results for larger prostate sizes. Larger prostates ≥120 cc showed a significantly higher postoperative drop in hemoglobin. However, patients did not differ in postoperative functional outcomes or Clavien-Dindo grade ≥II complications (4.8% of all patients [41/852]). There was no difference in perioperative complications between all groups (P = 0.760). CONCLUSION: While larger prostates take significantly longer to operate on, postoperative functional outcomes show no difference between all sizes. In conclusion, HoLEP is a size-independent and effective method for surgical treatment of LUTS/BPO in prostates ≥30 cc.

Spinal Versus General Anesthesia for Holmium Laser Enucleation of the Prostate of High-risk Patients - A Propensity-score-matched-analysis.

OBJECTIVE: To compare perioperative management and functional outcome of spinal anesthesia (SpA) to general anesthesia (GA) in high-risk patients treated for lower urinary tract symptoms with Holmium laser enucleation of the prostate (HoLEP). METHODS: In the current retrospective analysis, a propensity-score-matching of patients treated for lower urinary tract symptom with HoLEP (n = 300) in SpA with ASA>2 (n = 100), GA with ASA>2 (GA-high-risk) (n = 100) or GA with ASA≤2 (GA-low-risk) (n = 100) was performed. The impact of anesthesiologic mode on perioperative anesthesiologic outcome, early functional outcome and treatment related adverse events (according to Clavien Dindo), was evaluated. RESULTS: Hypotensive episodes were significantly less frequent in the SpA-cohort (9%) compared to the GA-high-risk cohort (32%) and the GA low-risk cohort (22%) (each P <.05 respectively). SpA-patients showed a significantly shorter median time in post anesthesia care unit (PACU-time: 135 minutes; 120-166.5) compared to GA-high-risk patients (186 minutes; 154-189.5), with significant less referrals to Intermediate care unit (1% vs 9 %); (each P <.05). PACU-time (99 minutes) and Intermediate care unit referrals (0%) for GA-low-risk were lower than for both other cohorts. Postoperative requirement for analgesics was significantly lower in the SpA-cohort (2%), compared to both GA-cohorts (74% and 61% respectively; P <.05). No significant difference was found regarding early functional outcome or treatment related adverse events (p-range: 0.201-1.000). CONCLUSION: For patients undergoing HoLEP, SpA provides greater hemodynamic stability and allows faster overall postoperative recovery with preferable pain management. Yielding a comparable functional outcome, it is a safe and efficient alternative to GA in high-risk patients.

Dynamics of urinary and respiratory shedding of Severe acute respiratory syndrome virus 2 (SARS-CoV-2) RNA excludes urine as a relevant source of viral transmission.

PURPOSE: To investigate the expression of the receptor protein ACE-2 alongside the urinary tract, urinary shedding and urinary stability of SARS-CoV-2 RNA. METHODS: Immunohistochemical staining was performed on tissue from urological surgery of 10 patients. Further, patients treated for coronavirus disease (COVID-19) at specialized care-units of a university hospital were assessed for detection of SARS-CoV-2 RNA in urinary samples via PCR, disease severity (WHO score), inflammatory response of patients. Finally, the stability of SARS-CoV-2 RNA in urine was analyzed. RESULTS: High ACE-2 expression (3/3) was observed in the tubules of the kidney and prostate glands, moderate expression in urothelial cells of the bladder (0-2/3) and no expression in kidney glomeruli, muscularis of the bladder and stroma of the prostate (0/3). SARS-CoV-2 RNA was detected in 5/199 urine samples from 64 patients. Viral RNA was detected in the first urinary sample of sequential samples. Viral RNA load from other specimen as nasopharyngeal swabs (NPS) or endotracheal aspirates revealed higher levels than from urine. Detection of SARS-CoV-2 RNA in urine was not associated with impaired WHO score (median 5, range 3-8 vs median 4, range 1-8, p = 0.314), peak white blood cell count (median 24.1 × 1000/ml, range 5.19-48.1 versus median 11.9 × 1000/ml, range 2.9-60.3, p = 0.307), peak CRP (median 20.7 mg/dl, 4.2-40.2 versus median 11.9 mg/dl, range 0.1-51.9, p = 0.316) or peak IL-6 levels (median: 1442 ng/ml, range 26.7-3918 versus median 140 ng/ml, range 3.0-11,041, p = 0.099). SARS-CoV-2 RNA was stable under different storage conditions and after freeze-thaw cycles. CONCLUSIONS: SARS-CoV-2 RNA in the urine of COVID-19 patients occurs infrequently. The viral RNA load and dynamics of SARS-CoV-2 RNA shedding suggest no relevant route of transmission through the urinary tract.

Occurrence of symptomatic lymphocele after open and robot-assisted radical prostatectomy.

INTRODUCTION: The aim of this article was to evaluate the prevalence and predictors of symptomatic lymphocele after open retropubic radical prostatectomy (RRP) and robot-assisted radical prostatectomy (RARP). MATERIAL AND METHODS: A total of 472 patients undergoing RRP (n = 241) or RARP (n = 231) were retrospectively analyzed with a 2-year follow-up for age, body mass index (BMI), total serum prostate-specific antigen (PSA), lymphocele formation and histopathological features. Univariate and multivariate logistic regression models were used to identify independent predictors of symptomatic lymphocele. RESULTS: Patients undergoing RRP developed significantly less overall lymphoceles than after RARP (8.2% vs 16.7%; p = 0.049), but no difference was determined for symptomatic events requiring intervention (7.4% vs 11.7%, p = 0.315). Although more pelvic lymph node dissections (PLND) were performed during RARP (70.1% vs 50.6%; p <0.001), significantly more cases with lymphatic invasion were observed after RRP (18% vs 6.2%, p = 0.002). The median lymph node yield during RRP and RARP were 11 and 10, respectively (p = 0.381). In multivariate logistic regression, we identified the number of dissected lymph nodes (n = 11) (OR 1.1; 95% Cl 1.055 - 1.147; p = 0.001), the Gleason score ≥ 8 (OR 4.7; 95% Cl 2.365 - 9.363; p = 0.001) and the total PSA ≥10 ng/ml (OR 1.05; 95% Cl 1.02 - 1.074; p = 0.001) as independent predictors for the development of symptomatic lymphocele. CONCLUSIONS: Next to an extended lymph node yield, high-grade disease was associated with a higher risk to develop symptomatic lymphocele irrespective of the technical approach. The identification of risk factors might prove valuable in clinical practice when assessing and counselling patients considering surgical treatment of prostate cancer.

The impact of preoperative lower urinary tract symptoms medication on the functional performance of holmium laser enucleation of the prostate.

INTRODUCTION: Medical treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) targets prostate size, to prevent disease progression, and prostate smooth muscle tone for rapid relieve of LUTS. Holmium laser enucleation of the prostate (HoLEP) is a size-independent method for surgical treatment of LUTS/BPO in medication-refractory patients and offers durable long-term results with reduced perioperative morbidity. As up to 50% of patients receive medical treatment for LUTS/BPO prior to surgery, we analyzed the impact of alpha-blockers and 5-alpha reductase inhibitors (5-ARI) on outcomes and perioperative morbidity in patients undergoing HoLEP for LUTS. MATERIAL AND METHODS: We retrospectively gathered data of 1,057 patients, who underwent HoLEP for LUTS/BPO from 2013-2018, and divided patients into group 1 (no medication), group 2 (α-blockers), and group 3 (5-ARI and α-blockers). Perioperative parameters, short-term functional outcomes and safety were assessed and statistical analysis was performed using SPSS V26.0 software. RESULTS: Even though preoperative LUTS profile was significantly different between groups, all patients improved significantly after HoLEP, irrespective of preoperative LUTS medication. Median improvement of IPSS was 9, 8 and 7 points, of Qmax was 10, 12 and 9.5 ml/s, with significant improvement of quality of life (QoL) and reduction of post-void residual volume (PVR) for groups 1-3, respectively, 30 days after surgery. With only 4.0% (42/1,057) of patients experiencing a Clavien-Dindo grade ≥II complication, there was no difference in prevalence of perioperative complications between groups (p = 0.943). CONCLUSIONS: Although preoperative LUTS medication does not impair efficacy of HoLEP with acceptable perioperative morbidity, the time gap between medical therapy and surgical treatment may favor an earlier response.

[The role of the microbiome in urological diseases]. / Die Rolle des Mikrobioms bei urologischen Erkrankungen.

The use of modern molecular technologies in the last decade has given us new insights into the complex interactions of the human microbiome in health and in the pathogenesis of diseases. Among other things, the sterility concept of the urinary tract has been discarded and the goal is now to identify the different microbial signatures associated with various diseases. Dysbalances of the microbiome are increasingly suspected of causing negative effects on various malignant and benign diseases. Recently, such associations have also been shown for prostate carcinoma, renal cell carcinoma and urinary bladder carcinoma. This may lead to the discovery of new potential biomarkers for the diagnosis and as a therapeutic target of the diseases mentioned. For the diagnosis of some benign diseases such as interstitial cystitis, urge incontinence and chronic prostatitis or chronic pelvic pain syndrome, microbial involvement was previously considered an exclusion criterion. However, current studies show that the individual patient's microbiome can have an influence on the development and severity of the respective disease.

Enucleation vs. Resection: A Matched-pair Analysis of TURP, HoLEP and Bipolar TUEP in Medium-sized Prostates.

OBJECTIVE: To evaluate efficacy and safety of holmium laser enucleation of the prostate (HoLEP), bipolar enucleation of the prostate (bTUEP) and transurethral resection of the prostate (TURP) in medium-sized prostates (50cc). METHODS: We present a retrospective analysis of 2230 patients treated for lower urinary tract symptoms. We analysed perioperative parameters, short-term clinical outcomes and adverse events in matched-pair cohorts. RESULTS: Both HoLEP and bTUEP were superior in terms of efficacy compared to TURP (surgery time: 51min and 50min vs. 60min; P < 0.001; tissue retrieval percentage: 71.4% and 70% vs. 50%; P < 0.001) and showed stronger improvement of LUTS (change IPSS: -15 and -14 vs. -10; P = 0.008). Furthermore, urodynamic parameters (Qmax: +15 ml/s and +19 ml/s vs. +12 ml/s; P < 0.001; PVR: -100 ml and -95 ml vs. - 80ml; P < 0.008) were significantly more improved after enucleation than after TURP. All techniques showed an equally low complication rate (6.9% and 6.9% vs. 10.3%; P = 0.743). No relevant difference of clinical outcomes was identified between HoLEP and bTUEP. CONCLUSION: Both resection and enucleation are efficient and safe procedures in patients with medium-sized prostates (50cc), but irrespective of the technical approach, transurethral enucleation is superior to TURP in terms of perioperative and functional outcomes.