Revisiting the issue of "beach balls" in holmium laser enucleation of prostate: clinical and histological characterization.

PURPOSE: To clinically and histologically characterize prostatic nodules resistant to morcellation ("beach balls," BBs). PATIENTS AND METHODS: We reviewed a consecutive cohort of 559 holmium laser enucleation of the prostate (HoLEP) procedures performed between January 2020 and November 2023. The BBs group comprised 55 men (10%) and the control group comprised 504 men (90%). The clinical, intraoperative, outcome, and histologic data were statistically processed for the prediction of the presence of BBs and their influence on the perioperative course and outcome. RESULTS: The BBs group in comparison to the controls was older (75 vs 73 years, respectively, p = 0.009) and had higher rates of chronic retention (51 vs 29%, p = 0.001), larger prostates on preoperative abdominal ultrasound (AUS) (140 vs 80 cc, p = 0.006E-16), longer operating time (120 vs 80 min, p = 0.001), higher weights of removed tissue (101 vs 60 gr, p = 0.008E-10), higher complication rates (5 vs 1%, p = 0.03), and longer hospitalization (p = 0.014). A multivariate analysis revealed that larger prostates on preoperative AUS and older age independently predicted the presence of BBs which would prolong operating time. ROC analyses revealed that a threshold of 103 cc on AUS predicted BBs with 94% sensitivity and 84% specificity. BBs were mostly characterized histologically by stromal component (p = 0.005). CONCLUSIONS: BBs are expected in older patients and cases of chronic retention. Prostatic volume is the most reliable predictor of their presence. They contribute to prolonged operating time and increased risk of complications. The predominantly stromal composition of the BBs apparently confers their resistance to morcellation.

Use of Validated Questionnaires to Predict Cosmetic Outcomes of Hypospadias Repair.

INTRODUCTION: Hypospadias is a syndrome of penile maldevelopment. The primary goal of hypospadias surgery is to create a penis with normal appearance and function. Historically, the outcome of hypospadias repair has been assessed based on the need for reoperation due to urethroplasty complications (UC), including fistula formation, dehiscence, meatal stenosis, or development of a urethral stricture. The Glans-Urethral Meatus-Shaft (GMS) score is a standardized tool to predict UC. Analysis of the cosmetic outcomes of hypospadias repair based on the appearance of the reconstructed penis has been validated, and standardized scores have been published. The Hypospadias Objective Penile Evaluation (HOPE) score is a validated questionnaire used to assess postoperative cosmetic outcomes. Although predictors of surgical outcomes and UC have been well documented, predictors of optimal cosmetic outcomes are lacking in the literature. Furthermore, reoperation due to cosmetic considerations has been poorly reported. OBJECTIVE: To identify predictors of cosmetic outcomes after hypospadias repair and to assess the reoperation rate according to cosmetic considerations. MATERIALS AND METHODS: This prospective cohort study included 126 boys who underwent primary hypospadias repair. The severity of hypospadias, degree of penile curvature, glans width, preoperative HOPE, and GMS scores were documented. The standard technique for single-stage repairs, the tubularized incised plate urethroplasty, was performed. The primary endpoint was cosmetic outcomes evaluated by the HOPE score questionnaire six months postoperatively. Optimal cosmetic results were defined by HOPE scores ≥ 57. RESULTS: The study population consisted of the following cases: 87 (69%) subcoronal, 32 (25%) shaft, and 7 (6%) proximal hypospadias. Among the study participants, 102 boys (81%) had optimal cosmetic results (HOPE ≥ 57), and 24 boys (19%) had surgeries with suboptimal cosmetic outcomes (HOPE < 57). Ancillary procedures were performed in 21 boys (16%), of which 14 (11%) were solely for cosmetic considerations, and 7 were secondary to UC. Using the Receiver Operating Characteristic analysis of potential predictors of optimal cosmetic outcomes, the preoperative HOPE score had the highest area under the curve (AUC = 0.79; 95% CI 0.69-0.89, p < 0.001). After multivariable analysis, the degree of penile chordee (p = 0.013), glans width (p = 0.003), GMS score (p = 0.007), and preoperative HOPE score (p = 0.002) were significant predictors of cosmetic outcomes. Although meatal location predicted suboptimal cosmetic results in univariate analysis, it was not a factor in multivariable analysis. CONCLUSIONS: Over 80% of boys undergoing hypospadias repair achieved optimal cosmetic outcomes. More than 10% of cases underwent ancillary procedures, secondary solely to cosmetic considerations. Predictors of optimal cosmetic outcomes after hypospadias surgery included degree of chordee, glans width, and preoperative HOPE and GMS scores, which were the best predictors of satisfactory cosmetic results. Although meatal location is the main predictor of UC, it was not a predictor for cosmetic outcomes. Factors affecting cosmetic outcomes should be clearly explained to parents during the preoperative consultation.

Feasibility of Sacral Neuromodulation in Patients With Underlying Neurologic Lower Urinary Tract Dysfunction and Fecal Incontinence.

OBJECTIVE: To evaluate the efficacy and safety of sacral neuromodulation (SNM) in patients with underlying neurologic conditions and compare outcomes to non-neurogenic patients. METHODS: Between 2017-2022 patients undergoing 2-staged implantation of InterStim II were included in a single-center retrospective study. Patients were allocated into two groups: underlying neurologic conditions (group 1) or non-neurogenic (group 2). Efficacy and safety were evaluated by comparing patients' bladder/bowel logs pre- and post-operative. Patients' demographics, indications, preimplantation urodynamic study variables, surgery duration, number of postop visits, and time to revision/removal procedures were compared and included in the data analysis. RESULTS: Sixty-seven patients (64.2% female) with a mean age of 63.23 ± 14.15years were included in the study - 16/67(23.9%) patients assigned to group 1. There is no statistically significant difference between the groups regarding the indication for the treatment. The most common indication was nonobstructing urinary retention (NOUR) in both study groups. The common neurologic pathologies were multiple sclerosis, disc disease, and spinal stenosis. Overall and subgroup (based on an indication for SNM implantation) analyses showed no significant difference in patients' demographics, the surgery duration, or the chances for clinical success with a similar follow-up period. During the follow-up, the device was removed in 4 (25.0%) and 10 (19.6%) of the patients in group 1 and group 2, respectively (P = .912). There was no significant difference between the groups in the time till InterStim II removal (P = .905). All NOUR patients with clinical success in group 1 had an improvement of at least 75% from the baseline compared to 69% of patients in group 2 (P = .42). Univariate analysis in NOUR patients demonstrated that maximal cystometric capacity below 430 mL and the presence of detrusor contraction at voiding were statistically significant predictors of successful SNM. Overall, at the end of the follow-up period, 8 (50.0%) and 29 (56.9%) patients in groups 1 and 2, respectively, were defined as clinical success (P = .775).