Efficiency of HoLEP in patients with detrusor underactivity and renal dysfunction secondary to BPO.

PURPOSE: The purpose of this study was to assess the bladder and renal functional outcomes of holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic obstruction (BPO) complicated by detrusor underactivity (DU) and secondary renal dysfunction. METHODS: Thirty-one patients were included in this prospective study. Eligible patients had urinary retention, a bladder outlet obstruction index (BOOI) greater than 40, a bladder contractility index (BCI) less than 100, abnormal renal function at the initial diagnosis (serum creatinine > 132 µmol/L) and a renal pelvis anteroposterior diameter (PRAPD) > 1.5 cm bilaterally. All patients underwent HoLEP in a routine manner and were evaluated preoperatively and at 1, 3 and 6 months after surgery. The baseline characteristics of the patients, perioperative data, postoperative outcomes and complications were assessed. RESULTS: Significant improvement was observed in the international prostate symptom score (IPSS), quality of life (QoL) score, maximal urinary flow rate (Qmax), post-void residual volume (PVR), Scr and RPAPD at the 6-month follow-up. Bladder wall thickness (BWT) exhibited a decreasing trend but did not significantly differ from the preoperative values. No grade 3 or higher adverse events occurred, and grade 3 and lower complications were treated conservatively. Three patients required reinsertion of indwelling catheters, and they were able to void spontaneously after two weeks of catheterisation training and medication treatment. CONCLUSION: HoLEP is an effective treatment for men with BPO accompanied by DU and consequent renal function impairment. Patients are able to regain spontaneous voiding. Both bladder and renal functions were preserved and improved.

Local Injection of Stem Cells Can Be a Potential Strategy to Improve Bladder Dysfunction after Outlet Obstruction in Rats.

This study investigates whether hAFSCs can improve bladder function in partial bladder outlet obstruction (pBOO) rats by targeting specific cellular pathways. Thirty-six female rats were divided into sham and pBOO groups with and without hAFSCs single injection into the bladder wall. Cystometry, inflammation/hypoxia, collagen/fibrosis/gap junction proteins, and smooth muscle myosin/muscarinic receptors were examined at 2 and 6 weeks after pBOO or sham operation. In pBOO bladders, significant increases in peak voiding pressure and residual volume stimulated a significant upregulation of inflammatory and hypoxic factors, TGF-ß1 and Smad2/3. Collagen deposition proteins, collagen 1 and 3, were significantly increased, but bladder fibrosis markers, caveolin 1 and 3, were significantly decreased. Gap junction intercellular communication protein, connexin 43, was significantly increased, but the number of caveolae was significantly decreased. Markers for the smooth muscle phenotype, myosin heavy chain 11 and guanylate-dependent protein kinase, as well as M2 muscarinic receptors, were significantly increased in cultured detrusor cells. However, hAFSCs treatment could significantly ameliorate bladder dysfunction by inactivating the TGFß-Smad signaling pathway, reducing collagen deposition, disrupting gap junctional intercellular communication, and modifying the expressions of smooth muscle myosin and caveolae/caveolin proteins. The results support the potential value of hAFSCs-based treatment of bladder dysfunction in BOO patients.

GPER expression prevents estrogen-induced urinary retention in obese mice.

Long-term administration of exogenous estrogen is known to cause urinary retention and marked, often fatal, bladder distention in both male and female mice. Estrogen-treated mice have increased bladder pressure and decreased urine flow, suggesting that urinary retention in estrogen-treated mice is due to infravesicular obstruction to urine outflow. Thus, the condition is commonly referred to as bladder outlet obstruction (BOO). Obesity can also lead to urinary retention. As the effects of estrogen are mediated by multiple receptors, including estrogen receptors ERα and ERß and the G protein-coupled estrogen receptor (GPER), we sought to determine whether GPER plays a role in estrogen-induced BOO, particularly in the context of obesity. Wild type and GPER knockout (KO) mice fed a high-fat diet were ovariectomized or left ovary-intact (sham surgery) and supplemented with slow-release estrogen or vehicle-only pellets. Supplementing both GPER KO and wild type obese mice with estrogen for 8 weeks resulted in weight loss, splenic enlargement, and thymic atrophy, as expected. However, estrogen-treated obese GPER KO mice developed abdominal distension, debilitation, and ulceration of the skin surrounding the urogenital opening. At necropsy, these mice had prominently distended bladders and hydronephrosis. In contrast, estrogen-treated obese wild type mice only rarely displayed these signs. Our results suggest that, under conditions of obesity, estrogen induces BOO as a result of ERα-driven pathways and that GPER expression is protective against BOO.

[Establishment of a predictive scoring model and preventive measures for bladder neck contracture after laparoscopic enucleation of the prostate with urethra preservation].

OBJECTIVE: To establish a predictive scoring model for bladder neck contracture (BNC) after laparoscopic enucleation of the prostate with preservation of the urethra (Madigan surgery) and explore the preventive measures against this postoperative complication. METHODS: We included 362 cases of BPH treated by laparoscopic Madigan surgery from January 2019 to March 2022 (45 with and 317 without postoperative BNC) in the training group and another 120 cases treated the same way in the verification group, collected the clinical data on the patients and evaluated the results of surgery. Using the least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression, we analyzed the risk factors for postoperative BNC and constructed a predictive scoring model for evaluation of the factors. RESULTS: Compared with the baseline, the IPSS, quality of life (QOL) score and postvoid residual urine volume (PVR) were significantly decreased (P < 0.05) while the maximum urinary flow rate (Qmax) remarkably increased (P < 0.05) in the BPH patients at 3 months after surgery. Eight non-zero characteristic predictors were identified by LASSO regression analysis. Multivariate logistic regression analysis showed that short clinical experience of the surgeon, concurrent prostatitis, bladder rinse solution temperature <34℃, catheter blockage, urethral balloon injection volume >40 ml and postoperative constipation were independent risk factors for postoperative BNC (P < 0.05). The best cut-off value was 2.36 points in both the training and the verification groups. The results of evaluation exhibited a high discriminability of the predictive scoring model. CONCLUSION: Laparoscopic Madigan surgery is a safe and effective method for the treatment of BPH. Short clinical experience of the surgeon, concurrent prostatitis, bladder rinse solution temperature <34℃, catheter blockage, water injected into the urethral balloon >40 ml and postoperative constipation were independent risk factors for postoperative BNC. The predictive scoring model constructed in this study has a good discriminability and is simple and feasible, contributive to the prediction of postoperative BNC in BPH patients undergoing laparoscopic Madigan surgery.

Simultaneous primary posterior urethral valves ablation and bladder neck incision may decrease kidney and bladder failure in long-term follow-up in patients with bladder neck hypertrophy and poor bladder function at presentation: report of 301 cases.

OBJECTIVES: To investigate the effects of bladder neck incision (BNI) and primary valves ablation on long-term kidney and bladder function in children with posterior urethral valves (PUV) and bladder neck hypertrophy (BNH). PATIENTS AND METHODS: From 1997 to 2016, a total of 1381 children with PUV were referred to our tertiary hospital. Of these patients, 301 PUV patients with bladder neck hypertrophy need concurrent BNI and valve ablation. All patients were followed up every 3-6 months on regular basis in first 2 post-surgical years and annually then after. The paired t-test and chi-square test were used to perform statistical analysis with p value < 0.05 defined as the level of significance. RESULTS: Mean age at diagnosis was 7.22 ± 2.45 months (ranging from 7 days to 15 months) with a mean follow-up of 5.12 ± 2.80 years. The incidence of hydronephrosis was decreased from 266 (88.3%) at the baseline to 73 (24.3%) patients in long-term follow-up. At baseline, 188 (62.5%) patients were diagnosed with VUR, which decreased to 20 (6.6%) individuals at the end of follow-up. Bladder and renal function were improved in follow-ups following concomitant PUV ablation and BNI. No Myogenic failure was depicted in all patients with BNH. No ureteric reimplantation was needed during the two decades follow-up. CONCLUSION: Simultaneous valve ablation with BNI may present further profits in children with PUV and BNH particularly cases of BNH with poor bladder function at the time of presentation. This method can improve the results of urodynamic and imaging studies after the surgery. We hypothesize every child with PUV presentation who has concurrent vesicoureteral reflux, CKD or persistent hydrourethronephrosis may suffer from secondary bladder neck obstruction. This secondary bladder outlet obstruction must be managed through BNI as the surgical relief.

Application of Urethral Contrast Computed Tomography Three-Dimensional Imaging in the Postoperative Assessment of Prostate Hyperplasia.

This study assesses the morphological effectiveness of benign prostatic hyperplasia (BPH) surgery using multislice spiral computed tomography three-dimensional imaging (CT3D) with urethral contrast. Twenty-five male patients with BPH and bladder outlet obstruction (BOO) who underwent bipolar transurethral resection of the prostate were selected. Preoperative and postoperative CT3D indicators of retrograde and voiding cystourethrography, including bladder neck diameter, length of the posterior urethra, and degree of prostate protrusion into the bladder and upper and lower diameter of the prostate were used to assess bladder neck and posterior urethra morphology and BOO severity. In addition, preoperative and postoperative International Prostate Symptom Scores and maximum urine flow rates were compared. Postoperative CT3D was used to evaluate changes following obstruction relief postsurgery. Preoperative CT3D indicated significant BOO, whereas postoperative imaging showed improved patency but with irregular posterior urethral lumens and varying degrees of residual glandular tissue. Comparative analysis of preoperative and postoperative bladder outlet metrics revealed significant changes (p < .05). Urethral contrast CT3D effectively visualizes the prostate, bladder neck, and prostatic urethra. It quantifies changes in the urethral lumen postsurgery, correlating the extent of posterior urethral lumen spaciousness with urinary flow rates.

Return of voiding function after greenlight photovaporisation of the prostate for a patient with giant bladder.

Giant bladder is a rare condition with varied definitions and causes. It can lead to complications such as urinary tract infections, retrograde urine reflux, pyelonephritis, renal damage and occasionally vascular obstruction. In this case report, we present a man in his 70s with massive urinary retention >7 L and severe bilateral hydronephrosis. The patient underwent a successful Greenlight photovaporisation of the prostate to address underlying bladder outlet obstruction. The surgical procedure resulted in significant improvement in urinary function, enabling the patient to live catheter and infection free, and without renal damage. This case demonstrates that bladder outlet surgery can be useful in selected cases of giant bladder to avoid complications of chronic catheterisation or ongoing retention.

Development of the UroARC Surgical Calculator: A Novel Risk Calculator for Older Adults Undergoing Surgery for Bladder Outlet Obstruction.

PURPOSE: Bladder outlet obstruction (BOO) is common in older adults. Many older adults who pursue surgery have additional vulnerabilities affecting surgical risk, including frailty. A clinical tool that builds on frailty to predict surgical outcomes for the spectrum of BOO procedures would be helpful to aid in surgical decision-making but does not currently exist. MATERIALS AND METHODS: Medicare beneficiaries undergoing BOO surgery from 2014 to 2016 were identified and analyzed using the Medicare MedPAR, Outpatient, and Carrier files. Eight different BOO surgery categories were created. Baseline frailty was calculated for each beneficiary using the Claims-Based Frailty Index (CFI). All 93 variables in the CFI and the 17 variables in the Charlson Comorbidity Index were individually entered into stepwise logistic regression models to determine variables most highly predictive of complications. Similar and duplicative variables were combined into categories. Calibration curves and tests of model fit, including C statistics, Brier scores, and Spiegelhalter P values, were calculated to ensure the prognostic accuracy for postoperative complications. RESULTS: In total, 212,543 beneficiaries were identified. Approximately 42.5% were prefrail (0.15 ≤ CFI < 0.25), 8.7% were mildly frail (0.25 ≤ CFI < 0.35), and 1.2% were moderately-to-severely frail (CFI ≥0.35). Using stepwise logistic regression, 13 distinct prognostic variable categories were identified as the most reliable predictors of postoperative outcomes. Most models demonstrated excellent model discrimination and calibration with high C statistic and Spiegelhalter P values, respectively, and high accuracy with low Brier scores. Calibration curves for each outcome demonstrated excellent model fit. CONCLUSIONS: This novel risk assessment tool may help guide surgical prognostication among this vulnerable population.

Randomized Controlled Trial Comparing Open Simple Prostatectomy or Prostate Artery Embolization in Large Prostates: Clinical and Urodynamic Assessment - PoPAE Study.

OBJECTIVE: To evaluate the effects of Prostate artery embolization (PAE) and open simple prostatectomy (OP) on lower urinary tract symptoms and urodynamic parameters in subjects with prostate size >80cc³. METHODS: PoPAE study (OP or PAE) was a randomized, open-label controlled trial performed between January 2020 and May 2022. Subjects with large prostates (>80cc³), urodynamic parameters meeting obstruction criteria (Bladder Outlet Obstruction Index-BOOI>40), and good detrusor function (Bladder contractility index>100) were included. The primary and co-primary endpoints were the variation in peak flow rate on uroflowmetry (Qmax) and BOOI. The secondary endpoints were the IPSS and ultrasonographic changes. RESULTS: Twenty three and 25 subjects underwent PAE and OP were evaluated, respectively. At baseline, the 2 groups have shown similar clinical, radiological, laboratory, and urodynamic parameters. After 6 months, Qmax improved 8,3 ± 4.17 mL/sec in PAE and 15.1 ± 8.04 mL/sec in OP (mean difference 6.78 in favor of PE; P = .012 [CI -9.00 to -3.00]). After treatment, 88% of those men underwent OP were classified as unobstructed or equivocal (BOOi<40). On the other hand, 70% of subjects underwent PAE remained obstructed (BOOI>40) and none of them shifted to unobstructed status (BOOI<20). It was observed a similar reduction in IPSS and PVR in both groups. CONCLUSION: PAE was inferior to conventional surgery for releasing BOO and improving peak urinary flow in large prostates. Nevertheless, PAE was able to improve symptoms and PVR, and might be an alternative method in selected patients.

Outcomes of bladder outlet obstruction following extensive vaginal pelvic reconstruction surgery on patient with advanced pelvic organ prolapse.

OBJECTIVE: To evaluate the impact of extensive vaginal pelvic reconstruction surgery (PRS) on advanced pelvic organ prolapse (POP) patients with bladder outlet obstruction (BOO). METHODS: We conducted a single-center, retrospective analysis of women who received extensive vaginal pelvic reconstruction surgery for advanced POP (POP-Q ≥3) with BOO from January 2006 to January 2016. Data regarding preoperative evaluation, surgical procedure, and postoperative management were abstracted from medical records. Patients were considered to have BOO when detrusor pressure at maximum flow (Dmax) was ≥20 cm H2O and peak flow rate (Qmax) was ≤15 mL/s. Patients with postoperative value of Dmax lower than 20 cm H2O or Qmax higher than 15 mL/s were regarded as objectively cured. RESULTS: A total of 1894 patients with POP stages III or IV were assessed. The incidence of BOO was 22.8% (431/1894) within this patient population of advanced POP. One year after the vaginal PRS, the objective cure rate of BOO was 98.1%. Urodynamic parameters showed a significant increase in Qmax (P < 0.001), while Dmax (P < 0.001) and postvoid residual urine (PVR) (P < 0.001) were significantly decreased. Previous POP surgery, native tissue repair (NTR), PVR ≥200 mL, and maximal cystometric capacity (MCC) ≥500 mL increase the likelihood of persistent BOO in patients. CONCLUSION: Vaginal PRS demonstrated effectiveness in treating BOO in patients with advanced POP. Irrespective of the types of transvaginal mesh (TVM), using TVM achieved better outcome than did NTR. Previous POP surgery, preoperative PVR ≥200 mL, and MCC ≥500 mL were the risk factors predicting the failure of PRS in improving BOO.

Bladder Outlet Obstruction Relief and Symptom Improvement Following Medical and Surgical Therapies for Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia: A Systematic Review.

BACKGROUND AND OBJECTIVE: Symptomatic benefit and urodynamic obstruction relief represent relevant outcomes of therapies for lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH). We summarized evidence from studies concurrently assessing variations in terms of symptoms severity and invasive urodynamic measures of obstruction following medical and surgical therapies for LUTS/BPH. METHODS: We performed a systematic review of PubMed, Scopus, and Web of Science in June 2023. KEY FINDINGS AND LIMITATIONS: We identified 29 publications: 14 (872 patients) and 15 (851 patients) studies addressing medical and surgical therapies, respectively. The mean percentage total International Prostate Symptom Score (IPSS) improvements ranged from -2.5% to 56.3% and from 35.1% to 82.1% following medical and surgical therapies, respectively. The corresponding mean percentage Bladder Outlet Obstruction Index (BOOI) improvements ranged from 7.8% to 53.5% and from 22.4% to 138.6%, respectively. Holmium laser enucleation of the prostate (HoLEP) provided IPSS improvements in the higher range and the greatest BOOI reduction. CONCLUSIONS AND CLINICAL IMPLICATIONS: Globally, based on available evidence, more pronounced symptomatic benefits are observed following treatments providing greater deobstructive effect. In detail, patients undergoing surgery exhibit greater IPSS and BOOI improvements than those receiving medical therapy.

Protective effect of equol intake on bladder dysfunction in a rat model of bladder outlet obstruction.

OBJECTIVES: This study evaluates the impact of equol, a metabolite of soy isoflavone, on bladder dysfunction in rats with bladder outlet obstruction (BOO). In addition, we investigate its potential as a neuroprotective agent for the obstructed bladder and discuss its applicability in managing overactive bladder (OAB). METHODS: Eighteen male Sprague-Dawley rats were divided into three groups (six rats per group) during the rearing period. The Sham and C-BOO groups received an equol-free diet, while the E-BOO group received equol supplementation (0.25 g/kg). At 8 weeks old, rats underwent BOO surgery, followed by continuous cystometry after 4 weeks of rearing. The urinary oxidative stress markers (8-hydroxy-2'-deoxyguanosine and malondialdehyde) were measured, and the bladder histology was analyzed using hematoxylin-eosin, Masson's trichrome, and immunohistochemical staining (neurofilament heavy chain for myelinated nerves, peripherin for unmyelinated nerves, and malondialdehyde). RESULTS: Equol reduced BOO-induced smooth muscle layer fibrosis, significantly prolonged the micturition interval (C-BOO: 193 s, E-BOO: 438 s) and increased the micturition volume (C-BOO: 0.54 mL, E-BOO: 1.02 mL) compared to the C-BOO group. Equol inhibited the increase in urinary and bladder tissue malondialdehyde levels. While the C-BOO group exhibited reduced peripherin alone positive nerve fibers within the smooth muscle layer, equol effectively attenuated this decline. CONCLUSIONS: Equol reduces lipid peroxidation and smooth muscle layer fibrosis in the bladder and exhibited neuroprotective effects on bladder nerves (peripheral nerves) and prevented the development of bladder dysfunction associated with BOO in rats. Consumption of equol is promising for the prevention of OAB associated with BOO.

Role of urine glycosaminoglycan levels in the diagnosis and follow-up in men with lower urinary tract symptoms.

OBJECTIVE: The aim of this study was to investigate whether urinary glycosaminoglycans (GAG) levels reflect clinical status in men with lower urinary tract symptoms and if they could be used as a marker in management of overactive bladder (OAB). METHODS: A total of 34 patients were recruited who were admitted with LUTS and diagnosed as having clinically bladder outlet obstruction (BOO) due to prostate enlargement. These newly diagnosed, never treated patients underwent routine investigation, consisting of history, physical examination, PSA, ultrasound, uroflowmetry, assessment of symptoms scored by both International Prostate Symptom Score (IPSS) and Marmara- Overactive Bladder Questionnaire (M-OBQ). The patients were divided into two groups as those with an initial M-OBQ score < 12 (group 1) and ≥ 13 (group 2). Alfa blocker was initiated in eligible patients. Further evaluations included prostate volume measurement, pre- and post-treatment urinary GAG levels, IPSS and M-QAOB values and maximum urine flow rate (Qmax). RESULTS: Before treatment, urinary GAG level was 21.5 mg/gCr (6.1-45.5) in Group 1, and 23.35 mg/gCr (15.6-32.6) in Group 2 (p =0.845). After the treatment, the GAG level in Group 1 and Group 2 were found to be 19.8 mg/gCr (7.4-70.5) and 18 (7.6- 41.7), respectively (p = 0.511). No difference in GAG levels was found in subgroup analysis for patients with or without OAB. CONCLUSIONS: In recent years, there have been many studies investigating the relationship between LUTS and urinary markers. However, in our prospective study, no relationship was found between pre- and post- treatment urinary GAG levels in patients with LUTS with or without OAB.

Management of the Devastated Bladder Outlet after Prostate CANCER Treatment.

PURPOSE OF REVIEW: Devastating complications of the bladder outlet resulting from prostate cancer treatments are relatively uncommon. However, the combination of the high incidence of prostate cancer and patient longevity after treatment have raised awareness of adverse outcomes deteriorating patients' quality of life. This narrative review discusses the diagnostic work-up and management options for bladder outlet obstruction resulting from prostate cancer treatments, including those that require urinary diversion. RECENT FINDINGS: The devastated bladder outlet can be a consequence of the treatment of benign conditions, but more frequently from complications of pelvic cancer treatments. Regardless of etiology, the initial treatment ladder involves endoluminal options such as dilation and direct vision internal urethrotomy, with or without intralesional injection of anti-fibrotic agents. If these conservative strategies fail, surgical reconstruction should be considered. Although surgical reconstruction provides the best prospect of durable success, reconstructive procedures are also associated with serious complications. In the worst circumstances, such as prior radiotherapy, failed reconstruction, devastated bladder outlet with end-stage bladders, or patient's severe comorbidities, reconstruction may neither be realistic nor justified. Urinary diversion with or without cystectomy may be the best option for these patients. Thorough patient counseling before treatment selection is of utmost importance. Outcomes and repercussions on quality of life vary extensively with management options. Meticulous preoperative diagnostic evaluation is paramount in selecting the right treatment strategy for each individual patient. The risk of bladder outlet obstruction, and its severest form, devastated bladder outlet, after treatment of prostate cancer is not negligible, especially following radiation. Management includes endoluminal treatment, open or robot-assisted laparoscopic reconstruction, and urinary diversion in the worst circumstances, with varying success rates.

Clinical value of neutrophil to lymphocyte ratio and ultrasonic parameters in the diagnosis of bladder outlet obstruction in benign prostatic hyperplasia.

AIM: This study aimed to investigate the clinical significance of neutrophil-to-lymphocyte ratio and ultrasonic parameters in diagnosing bladder outlet obstruction in patients with benign prostatic hyperplasia. MATERIAL: Between September 2022 and January 2024, a total of 106 patients with benign prostatic hyperplasia were collected from Hongqi Hospital affiliated to Mudanjiang Medical University followed by urodynamic testing. The patients were categorized into three groups based on the International Prostate Symptom Score: mild (45 cases), moderate (36 cases), and severe (25 cases). Thirty-five healthy men were recruited at the hospital as a control group. All patients had blood tests and ultrasound scans. RESULTS: Neutrophil-to-lymphocyte ratio, detrusor wall thickness, detrusor muscle elastic modulus, internal gland elastic modulus, intravesical prostatic protrusion, and post-voiding residual volume were significantly correlated with the bladder outlet obstruction stage and showed good diagnostic efficiency (all P<0.05. There was no statistically significant difference observed in the external gland elastic modulus between the experimental group and the control group (P>0.05). CONCLUSIONS: The neutrophil-to-lymphocyte ratio, detrusor wall thickness, elastic modulus of the detrusor and glandular gland may hold clinical significance for diagnosing bladder outlet obstruction resulting from benign prostatic hyperplasia.

Minimally invasive interventions for lower urinary tract symptoms: What sits between medical therapy and transurethral resection of the prostate.

BACKGROUND: There are a variety of medical and surgical treatment options available today for the management of lower urinary tract symptoms (LUTS) secondary to bladder outlet obstruction due to benign prostatic hyperplasia (BPH). OBJECTIVE: The aim of this paper is to highlight the various treatment options available for the management of bladder outlet obstruction secondary to BPH and discuss the benefits and potential drawbacks of each. DISCUSSION: Lifestyle and dietary modification and medical therapies, such as an alpha-1 blocker as monotherapy, should be considered as first-line when initially counselling a patient for LUTS secondary to bladder outlet obstruction due to BPH. If bothersome LUTS persist despite medical management, or if medical management is not suitable or preferable, then surgical interventions can be considered. The mainstay of surgical intervention has traditionally been transurethral resection of the prostate (TURP); however, the treatment landscape is rapidly evolving with the development of minimally invasive procedures.

Antegrade ejaculation preservation in surgical treatment for benign prostatic hyperplasia: quest for balance between voiding and sexual function.

PURPOSE OF REVIEW: Surgical treatment of benign prostatic hyperplasia (BPH) carries a significant risk of ejaculation dysfunction. Preservation of antegrade ejaculation while providing effective, well tolerated, and durable treatment of BPH is a paramount component of physical and sexual well being for significant number of men. We reviewed available literature with an aim of providing status on antegrade ejaculation preserving BPH surgical therapies. RECENT FINDINGS: Minimally invasive surgical therapies for BPH have been developed over the last decade, with significant marketing emphasis on their potential for preservation of antegrade ejaculation. However, the question about durability of relief of bladder outlet obstruction remains. Parallel to this technological development, the understanding of anatomical structures involved in ejaculation have resulted in technical modifications of well established surgical treatments modalities like transurethral resection of prostate, endoscopic enucleation of prostate and simple prostatectomy, thereby providing safe and durable relief of bladder outlet obstruction secondary to BPH with a satisfactory preservation of antegrade ejaculation. SUMMARY: Preservation of antegrade ejaculation is an important goal for significant number of men needing BPH surgery. Novel minimally invasive surgical technologies have been developed for this purpose; but understanding of the anatomical structures essential for antegrade ejaculation have allowed technical modification of existing surgical techniques with excellent preservation of antegrade ejaculation.

Iatrogenic or recurrent bladder neck contracture treated by the Palminteri-Ferrari technique: a new way to approach a frustrating condition.

PURPOSE: Bladder neck stricture (BNS) is a bothersome disease which may affect patients after trauma or prostatic surgery. It is frustrating due to the low durable success rate of currently available surgical techniques. The aim of the study is to explore the efficacy of a novel technique. MATERIALS & METHODS: The surgical protocol was developed by two high case-volume surgeons. The technique consists of Holmium laser incisions at 3-6-9-12 o'clock. Subsequently, triamcinolone acetonide 40 mg is injected. Two months later, the BNS is endoscopically checked in operatory room and re-procedure take place, if necessary (max 3 times). Failure was defined as the need of definitive urinary diversion. Subjective satisfaction was measured through PGI-I Questionnaire. RESULTS: A total of 45 patients were enrolled. Median age was 63 (IQR 59-69) years and BNS developed by different causes. Naïve BNS procedure patients were 12 (26.7%), others 33 (73.3%) underwent median 2 (IQR 1-4) previous urethrotomies, including 16 other surgeries. Suprapubic bladder catheter was present in 34 patients (75.6%). No complications were registered. Re-procedure at control was necessary in 24 patients (53.3%) for a median of 1 (IQR 1-3) procedures. At median follow-up of 18 months, failures were 4 (8.9%) and urinary incontinence was reported in 2 patients (4.5%) who required incontinence surgery. Median PGI-I was 2. CONCLUSIONS: Our technique of BNS treatment allows good outcomes and high rate of subjective improvement amongst patients. Moreover, naïve patients seem to have better results. However, longer follow-up and higher sample size are mandatory to further assess these data.

Can we predict and manage persistent storage and voiding LUTS following bladder outflow resistance reduction surgery in men? ICI-RS 2023.

AIMS: Lower urinary tract symptoms (LUTS) persist in up to 50% of patients after bladder outflow resistance reduction surgery (BORRS) in men. Our think tank aims to address the predictive factors for persistent LUTS after BORRS and to propose the recommendations for future research to enable improved better patient counseling and selection by more accurate prediction of treatment outcome. METHODS: A think tank of ICI-RS gathered in 2023, Bristol, UK, to discuss the pre and postsurgical clinical and urodynamic evaluation of men undergoing BORRS and whether it is possible to predict which men will have persistent LUTS after BORRS. RESULTS: Our think tank agrees that due to the multifactorial, and still not fully understood, etiology of male LUTS it is not possible to precisely predict in many men who will have persistent LUTS after BORRS. However, severe storage symptoms (overactive bladder, OAB) in association with low volume and high amplitude detrusor overactivity and low bladder capacity in preoperative urodynamics, increase the likelihood of persistent OAB/storage symptoms after BORRS. Furthermore, patients who are clearly obstructed and have good bladder contractility on preoperative pressure flow studies do better postoperatively compared to their counterparts. However, the benefit of pressure flow studies is decreased in patients who do not acceptably void during the study. Poor voiding after BORRS may occur due to persistent obstruction or detrusor underactivity. CONCLUSION: Future research is needed to increase our understanding of why male LUTS persist after surgery, and to enable better patient selection and more precise patient counseling before BORRS.