Functional outcomes of GreenLight 180-W photoselective vaporization in patients with large (≥ 80 cc) prostates: an analysis of over 3000 men in the Global Greenlight Group (GGG) database.

INTRODUCTION: GreenLight photoselective vaporization of the prostate (PVP) has gained widespread adoption as an option to traditional transurethral resection of the prostate. Prior reports expressed concern with the use of PVP in large prostates. The aim of this study was to investigate the adjusted outcomes of GreenLight PVP in men with large (≥ 80 cc) vs. small prostates (< 80 cc). METHODS: Data were obtained from the Global Greenlight Group which pools data from 7 high volume centers. Men with established benign prostatic hyperplasia who underwent GreenLight PVP using the XPS-180 W system between 2011 and 2019 were eligible and assigned into two groups based on their prostate size (≥ 80 and < 80 cc). 11 functional and perioperative covariates were collected. Analyses were adjusted for patient age and presence of median lobe. RESULTS: 3426 men met the inclusion criteria. 34.6% (n = 1187) of patients had a large prostate size. Baseline age and prostate volume were significantly different between the groups. The magnitude of absolute improvement in unadjusted international prostate symptom score was significantly greater in the large (≥ 80 cc) prostate group at 12 months, with an absolute change of 19.17 points (95% CI 18.46-19.88; p < 0.01). There was also a significant drop in PVR at both 6- (p = 0.007) and 12 months (p = 0.005). There were no significant differences in transfusion (p = 0.42), hematuria (p = 0.80), or 30-day readmission rates (p = 0.28). CONCLUSIONS: Greenlight PVP is a safe and effective alternative for patients with prostate sizes ≥ 80 cc, with durable outcomes relatively independent from prostate size.

Safety and efficacy of GreenLight PVP in octogenarians: evaluation of the Global GreenLight Group database.

INTRODUCTION: The present study analyzes the largest international GreenLight database, the Global GreenLight Group (GGG), to evaluate the functional and safety profile of GreenLight photoselective vaporization of the prostate (PVP) in octogenarians. METHODS: The GGG is a database comprised of patients that underwent GreenLight PVP from 2011 to 2019 performed by 8 experienced urologists at 7 international hospitals. Patients 80 years or older at the time of surgery were categorized as octogenarians. They were compared to a similar group of PVP patients below the age of 80. RESULTS: Among 3,648 patients, 586 men were above the age of 80. Compared to patients under the age of 80, octogenarians had larger prostates (76.0 vs 71.9 ml, p = 0.02) and a lower BMI (25.6 vs 26.7, p = 0.045). Operative time was not significantly longer in octogenarians. The improvement in functional outcomes between 80-year-old patients and control patients was not significantly different at one-year follow-up, with the exception of maximum urinary flow (Qmax) that favoured younger patients (10.3 vs 12.6 ml/s, p = 0.02). The odds of transfusion were greater for older patients [OR 8.2 (95% CI 3.6-18.9, p < 0.01)], but they were not at increased risk of hematuria. Octogenarians had higher readmission rates (23.0 vs 11.9%, p < 0.01). CONCLUSIONS: GreenLight PVP is a safe option in well-selected octogenarians in a cohort of patients treated by surgeons experienced with the technology. The odds of transfusion were higher in patients over 80, but the absolute risk remains low. The 30-day hospital readmission rate was higher in octogenarians.

The impact of 5-ARI on perioperative and functional outcomes of GreenLight PVP: an analysis of the Global GreenLight Group database.

INTRODUCTION: In this study, we sought to investigate the impact of 5-alpha reductase inhibitors (5-ARI) on the perioperative and functional outcomes of 180-Watt XPS GreenLight photovaporization of the prostate (PVP) using a large international database. MATERIALS AND METHODS: Data were obtained from the Global GreenLight Group (GGG) database, which includes eight high-volume, experienced surgeons from seven international centers.  All men with established benign prostatic hyperplasia (BPH) with known 5-ARI status who underwent GreenLight PVP using the XPS-180W system between 2011 and 2019 were eligible for the study.  Patients were assigned to two groups based on the preoperative use of 5-ARI.  Analyses were adjusted for patient age, prostate volume, and American Society of Anesthesia (ASA) score. RESULTS: We included 3,500 men, of which 1,246 (36%) had preoperative 5-ARI use.  Patients in both groups were similar with regards to age and prostate size.  On multivariable analysis, total operative time was slightly shorter (-3.26 min 95% CI: 1.20 - 5.32, p < 0.01) and required 35.6kJ less laser energy (95% CI: -48.0kJ - -23.3kJ, p < 0.01) for patients on 5ARI compared to those without 5-ARI.  However, no clinically significant difference was appreciated regarding postoperative transfusion rates [OR 0.048 (95% CI -0.82-0.91; p = 0.91)], hematuria rates [OR 0.96 (95% CI 0.72-1.3; p = 0.81)], 30-day readmission rates [OR 0.98 (95% CI 0.71-1.4; p = 0.90)], or overall functional outcomes. CONCLUSION: Our findings suggest that preoperative 5-ARI is not associated with any clinically significant different perioperative or functional outcomes for GreenLight PVP using the XPS-180W system.  There is no role for the initiation or discontinuation of 5-ARI prior to GreenLight PVP.

GreenLight photovaporization of the prostate in high-medical-risk patients: an analysis of the Global GreenLight Group (GGG) database.

PURPOSE: We sought to characterize the adjusted outcomes of GreenLight photoselective vaporization of the prostate (PVP) in high-medical-risk (HMR) patients using data from the largest international database. METHODS: Data were obtained from the Global GreenLight Group (GGG) database which pools data of eight high-volume, experienced surgeons, from a total of seven international centers. Eligible study participants underwent GreenLight PVP using the XPS-180 W system between 2011 and 2019. HMR patients were defined as patients with ASA III or greater and were compared to non-HMR patients. Analyses were adjusted for patient age and prostate volume. RESULTS: In the HMR group, patients on average were older and had smaller prostates than the non-HMR control group. Compared to non-HMR patients, transfusions occurred more frequently (2.6% vs. 0.14%, p < 0.01) and the odds of readmission were elevated [OR 2.0, (95% CI 1.4-2.8, p < 0.01)] among HMR patients. Twelve months postoperatively, HMR patients experience greater improvement in QoL than the control group [+ 0.54 (95% CI 0.07-1.0, p = 0.02)]. PVR also decreased 93.1 ml more in HMR than in non-HMR patients after 12 months (95% CI 33.6-152.6, p < 0.01). CONCLUSION: We found that GreenLight PVP is safe and effective in improving functional outcomes in higher-risk patients with severe systemic disease compared to their lower-risk counterparts. Though absolute risks remain low, GreenLight PVP is associated with higher odds of transfusion and readmission in the high-risk cohort. The findings of our study reaffirm current guidelines that propose PVP as a viable treatment option for HMR patients.

Surgical treatment options for benign prostatic obstruction: beyond prostate volume.

PURPOSE OF REVIEW: Many surgical treatment options are available for patients who present with benign prostatic obstruction (BPO). This article reviews the current treatment options available and distinguishes them based on five clinical considerations: antithrombotic therapy, sexual function preservation, ambulatory procedures, anesthesia-related risks and duration of catheterization. RECENT FINDINGS: A comprehensive review of the literature was performed on 10 BPO procedures. Laser enucleation of the prostate (LEP), bipolar plasma transurethral vaporization of the prostate and photoselective vaporization (PVP) of the prostate reduces the risk of bleeding, which is recommended for anticoagulated men. Ejaculatory function is more likely to be preserved following transurethral incision of the prostate, Rezum, Aquablation, UroLift and iTind. Same-day discharge is possible for LEP, PVP and prostatic arterial embolization (PAE). For patients with high anesthesia-related risks, procedures compatible with local anesthesia (UroLift, Rezum, iTind and PAE) should be favored. Catheterization duration is shorter with UroLift, PVP and LEP. SUMMARY: BPO treatment options are growing rapidly. The optimal procedure for a given patient is based on factors such as associated risks, recovery and expected outcomes. Besides prostate volume, the clinical considerations in the present article can help elucidate the best surgical BPO treatment option for each patient based on their values, preferences, and risk tolerance.

Incidence and risk factors for recurrent Clostridioides difficile infection in pediatric at-risk groups in selected Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) hospitals.

OBJECTIVES: Incidence and risk factors for recurrent Clostridioides difficile infection (rCDI) are well established in adults, though data are lacking in pediatrics. We aimed to determine incidence of and risk factors for rCDI in pediatrics. METHODS: This retrospective cohort study of pediatric patients was conducted at 3 tertiary-care hospitals in Canada with laboratory-confirmed CDI between April 1, 2012, and March 31, 2017. rCDI was defined as an episode of CDI occurring 8 weeks or less from diagnostic test date of the primary episode. We used logistic regression to determine and quantify risk factors significantly associated with rCDI. RESULTS: In total, 286 patients were included in this study. The incidence proportion for rCDI was 12.9%. Among hospitalized patients, the incidence rate was estimated at 2.6 cases of rCDI per 1,000 hospital days at risk (95% confidence interval [CI], 1.7-3.9). Immunocompromised patients had higher incidence of rCDI (17.5%; P = .03) and higher odds of developing rCDI independently of antibiotic treatment given for the primary episode (odds ratio [OR], 2.31; 95% CI, 1.12-5.09). Treatment with vancomycin monotherapy did not show statistically significant protection from rCDI, independently of immunocompromised status (OR, 0.33; 95% CI, 0.05-1.15]). CONCLUSIONS: The identification of increased risk of rCDI in immunocompromised pediatric patients warrants further research into alternative therapies, prophylaxis, and prevention strategies to prevent recurrent disease burden within these groups. Treatment of the initial episode with vancomycin did not show statistically significant protection from rCDI.

Evaluating the perceptions of Canadian urology residents and program directors regarding the current training in genitourinary imaging.

INTRODUCTION: Competency in interpreting genitourinary (GU) imaging is an important skill for urologists; however, no nationally accredited GU imaging curriculum exists for Canadian urology residency training programs. The main objectives of our study were to 1) characterize GU imaging training in Canada; (2) evaluate residents' self-perceived competencies in interpreting GU imaging; (3) explore program directors' (PD) and residents' perceptions regarding the current imaging curriculum and suggestions for future directions. METHODS: From November to December 2022, a survey examining current imaging education in residency, perceived resident imaging knowledge, avenues for improvement in imaging education, and the role of point-of-care ultrasound within urology was distributed to all Canadian urology PDs and residents. RESULTS: All PDs (13/13) and 40% (72/178) of residents completed the survey. Only two programs had a formal GU imaging curriculum. PDs and residents reported trainees were least comfortable interpreting Doppler ultrasound of renal, gonadal, and penile vessels. PDs reported that residents were most comfortable with non-contrast computed tomography (CT) scans (9.5/10), CT urogram (9.3/10), and retrograde pyelography (9.3/10). All but one PD favored increasing imaging training in their program. PDs highlighted the lack of time in the curriculum (n=3) and lack of educators (n=3) as the primary barriers to increasing imaging training in their program. CONCLUSIONS: Most PDs and residents believe there needs to be more imaging training offered at their institution; however, addressing this is challenging due to the limited time in the curriculum and the need for available educators.

Clinical Applications of Machine Learning for Urolithiasis and Benign Prostatic Hyperplasia: A Systematic Review.

Introduction: Previous systematic reviews related to machine learning (ML) in urology often overlooked the literature related to endourology. Therefore, we aim to conduct a more focused systematic review examining the use of ML algorithms for the management of benign prostatic hyperplasia (BPH) or urolithiasis. In addition, we are the first group to evaluate these articles using the Standardized Reporting of Machine Learning Applications in Urology (STREAM-URO) framework. Methods: Searches of MEDLINE, Embase, and the Cochrane CENTRAL databases were conducted from inception through July 12, 2021. Keywords included those related to ML, endourology, urolithiasis, and BPH. Two reviewers screened the citations that were eligible for title, abstract, and full-text screening, with conflicts resolved by a third reviewer. Two reviewers extracted information from the studies, with discrepancies resolved by a third reviewer. The data collected were then qualitatively synthesized by consensus. Two reviewers evaluated each article according to the STREAM-URO checklist with discrepancies resolved by a third reviewer. Results: After identifying 459 unique citations, 63 articles were retained for data extraction. Most articles consisted of tabular (n = 32) and computer vision (n = 23) tasks. The two most common problem types were classification (n = 40) and regression (n = 12). In general, most studies utilized neural networks as their ML algorithm (n = 36). Among the 63 studies retrieved, 58 were related to urolithiasis and 5 focused on BPH. The urolithiasis studies were designed for outcome prediction (n = 20), stone classification (n = 18), diagnostics (n = 17), and therapeutics (n = 3). The BPH studies were designed for outcome prediction (n = 2), diagnostics (n = 2), and therapeutics (n = 1). On average, the urolithiasis and BPH articles met 13.8 (standard deviation 2.6), and 13.4 (4.1) of the 26 STREAM-URO framework criteria, respectively. Conclusions: The majority of the retrieved studies effectively helped with outcome prediction, diagnostics, and therapeutics for both urolithiasis and BPH. While ML shows great promise in improving patient care, it is important to adhere to the recently developed STREAM-URO framework to ensure the development of high-quality ML studies.

The Impact of Bilateral Stone Disease on Patients' Disease Progression and Health-Related Quality of Life.

Purpose: Patients with recurring kidney stone events can expect significant morbidity and functional impairment. Few studies have evaluated the effect of bilateral kidney stones on disease progression and quality of life. We wanted to determine the association of bilateral stone disease on age of onset, and the impact on number of stone events and individual kidney stone disease-specific health-related quality of life (HRQOL) by analyzing the validated and prospectively collected Wisconsin Stone Quality of Life (WISQOL) database. Materials and Methods: We studied 2906 stone patients from 16 centers in North America after having completed the WISQOL questionnaire from 2014 to 2019. Kidney stone formers were assessed if kidney stones were bilateral or unilateral on imaging. Analysis with a chi-square test compared categorical variables. Bilateral kidney stone disease and its impact on HRQOL were evaluated through a multivariable linear regression model. Results: Of 2906 kidney stone formers, 1340 had unilateral kidney stones and 1566 had bilateral kidney stones. We observed more frequently that patients with bilateral stones had an increased number of depression/anxiety symptoms, renal tubular acidosis, and rheumatoid arthritis (all p < 0.05). Patients with bilateral stones had a younger mean (standard deviation [SD]) age of kidney stone disease onset (37.2 ± 15.8 vs 46.4 ± 15.9 years of age, p < 0.001). Bilateral kidney stone formers had a higher mean (SD) number of stone events (11.3 ± 21.8) than unilateral kidney stone formers (3.0 ± 5.1) (p < 0.001). Within our multivariable analysis, we found that HRQOL was negatively affected by the presence of bilateral stones for kidney stone patients (ß = -11.2 [confidence interval: -19.5 to -3.0] points, p < 0.05). Conclusions: Bilateral kidney stone formers had a younger age of kidney stone disease onset and a higher number of stone events compared with unilateral kidney stone disease formers. The presence of bilateral kidney stone disease negatively impacted HRQOL.

Not Every Low-Dose Is Low-Dose: Impact of Revising Low-Dose CT Protocol on Mean Effective Radiation Exposure.

Introduction: According to the American Urological Association imaging guidelines, patients presenting with renal colic should undergo low-dose (LD) rather than standard-dose (SD) noncontrast CT. The aim of the present study was to assess how often physicians ordered LD CT scans and to calculate mean effective radiation exposure (ERE) from CT scans from dose length products, and determine mean cumulative ERE over 1-year follow-up period. Methods: After obtaining ethics approval, a retrospective chart review was conducted for patients with renal colic presenting to the emergency department between August 1, 2015 and July 31, 2016 (Phase I) and between April 1, 2019 and October 1, 2019 (Phase II). All imaging studies performed within 1-year of initial presentation were cataloged. Results: In Phase I, 146 patients, with mean age of 51 years and mean body mass index (BMI) of 28.6 kg/m2, underwent 220 CT scans. In Phase II, 225 patients, with mean age of 55 years and mean BMI of 26.7 kg/m2, underwent 273 CT scans. Urologists were the only physicians ordering LD CT scans and they ordered significantly more LD than SD CT scans (71.3% vs 28.7%, p < 0.001). In Phase II, after revision of LD CT scan protocol in March 2019, the mean ERE per LD CT significantly decreased (6.5 vs 1.6 mSv, p < 0.001). In addition, there were significant differences in mean ERE from LD CT scans between two hospitals in the same health system (1.6 vs 7.8 mSv, p < 0.001). The mean cumulative ERE in Phase II over the 1-year period was 19.3 mSv, with 6.9% of patients exceeding 50 mSv. Conclusions: Although LD CT scans are being ordered, a small percentage of patients continue to exceed the 50 mSv annual threshold. It is important to keep track of mean ERE of LD CT scans and collaborate with medical physicists and the diagnostic imaging department to further refine LD CT scan protocols since not every low-dose is low-dose.

Simulation-based prostate enucleation training: Initial experience using 3D-printed organ phantoms.

INTRODUCTION: Anatomical endoscopic enucleation of the prostate (AEEP) is an effective treatment for benign prostatic hyperplasia (BPH); however, there is controversy regarding the difficulty of learning such a technique. Simulation-based training can mimic real-life surgeries and help surgeons develop skills they can transfer to the operating room, thereby improving patient safety. This study aimed to evaluate the validity of a novel organ phantom for use in AEEP simulation training. METHODS: Participants performed AEEP on organ phantom simulators during a Masterclass using one of three energy modalities: holmium:YAG laser, thulium fiber laser, or bipolar energy. The organ phantom is composed of hydrogels and uses 3D molds to recreate prostatic tissue. Participants completed a questionnaire assessing content validity, face validity, feasibility, and acceptability of using the prostate organ phantom. RESULTS: The novice group consisted of 13 urologists. The median number of AEEP previously performed was 0 (interquartile range [IQR] 0-2). Two experts in AEEP (surgeons having performed over 100 AEEP interventions) also participated. All participants agreed or strongly agreed that there is a role for simulators in AEEP training. Participants positively rated the overall operative experience (7.3/10). Morcellation (4.7/10) and hemostasis (3.1/10) were deemed the least realistic steps. All participants considered it feasible to incorporate this organ phantom into training programs and 92.9% agreed that it teaches skills transferrable to the operating room. CONCLUSIONS: This study has established content and face validity for AEEP with three different energy sources for an organ phantom. Participants considered its use both feasible and appropriate for AEEP training purposes.

The Duration of Stone Disease and the Impact of a Stone Event on Patients' Quality of Life.

Introduction: With a 5-year stone recurrence rate of 30% to 50%, kidney stone formers are subject to significant morbidity that negatively impacts their health-related quality of life (HRQOL). We sought to determine the impact of age at kidney stone onset, duration of stone disease, and kidney stone event (surgery or stone passage) on HRQOL of individual patients by querying the validated and prospectively collected Wisconsin Stone Quality of Life (WISQOL) database. Patients and Methods: Cross-sectional data were obtained from a total of 2438 kidney stone formers from 14 institutions in North America who completed the WISQOL questionnaire during the period from 2014 to 2019. The 28-question survey has a 1- to 5-point scale for each item (total score range 0-140). Multivariable linear regression models assessed the impact of age at kidney stone onset, duration of stone disease, and time since most recent surgery or stone passage on HRQOL. Results: Of 2438 patients, older age at kidney stone onset and longer duration of disease were both independent predictors of better WISQOL scores (ß = 0.33 points/year; confidence interval [CI] 0.17-0.49; p < 0.001; and ß = 0.50 points/year; CI 0.32-0.68; p < 0.001, respectively). Of 1376 patients who underwent surgery between 2010 and 2019, longer time since most recent surgery was an independent predictor of better WISQOL scores (ß = 2.28 points/year; CI: 1.47-3.10; p = <0.001). Of 1027 patients with spontaneous stone passage occurring between 2010 and 2019, longer time since most recent stone passage was an independent predictor of better WISQOL scores (ß = 1.59 points/year; CI: 0.59-2.59; p = <0.05). Conclusions: Our study demonstrates that older age at onset, longer duration of disease, and longer time since most recent surgery or stone passage were independent predictors of better HRQOL in kidney stone formers. Results of future studies that focus on optimizing stone-related modifiable risk factors to decrease the number of recurrent stone episodes and thus the need for recurrent surgeries will be essential.