Minimally invasive techniques in quest of Holy Grail of surgical management of enlarged prostates: a narrative review.

PURPOSE: Past decade has seen a renewed interest in minimally invasive surgical techniques (MISTs) for management of enlarged prostate. This narrative review aims to explore newer MIST for benign prostatic hyperplasia (BPH) which are not yet integrated into established societal guidelines. METHODS: We conducted a literature search across PubMed, Google Scholar, and FDA ClinicalTrials.gov databases on June 1st, 2023, to identify studies published within the past decade exploring various MISTs for BPH. Additionally, we gathered insights from abstracts presented in meetings of professional associations and corporate websites. We broadly classified these procedures into three distinct categories: energy-based, balloon dilation, and implant/stent treatments. We collected detail information about the device, procedure details, its inclusion and exclusion criteria, and outcome. RESULTS: Our review reveals that newer energy-based MISTs include Transperineal Laser Ablation, Transurethral Ultrasound Ablation, and High-Intensity Focused Ultrasound. In the sphere of balloon dilation, Transurethral Columnar Balloon Dilation and the Optilume BPH Catheter System were gaining momentum. The noteworthy implants/stents that are on horizon include Butterfly Prostatic Retraction Device, Urocross Expander System, Zenflow Spring System, and ProVee Urethral Expander System. CONCLUSION: The exploration of various MISTs reflects ongoing efforts to enhance patient care and address limitations of existing treatments. This review provides a bird-eye view and valuable insights for urologists and researchers seeking to navigate the dynamic landscape of MISTs in the quest for effective and minimally invasive solutions for enlarged prostates.

Evaluating Patient Tolerability for Urological Procedures Under Conscious Sedation: A Prospective Study.

OBJECTIVE: To prospectively evaluate patient-reported tolerability and surgical outcomes of urologic procedures with conscious sedation with or without local anesthesia. Administration of general or spinal anesthesia is associated with anesthetic-related complications, long wait times, and high costs. Using intravenous conscious sedation and/or local anesthesia is an emerging alternative for a myriad of urologic procedures. METHODS: Patients were enrolled from June-August 2021 at a tertiary care hospital. All procedures were completed using fentanyl, midazolam, or both with patient and procedural data recorded upon completion. Patients were telephoned 4-6 weeks post-procedure with a standardized patient tolerability questionnaire. A multivariable adjusted logistic regression analysis was performed to evaluate whether a patient would opt for conscious sedation again as opposed to general anesthesia. RESULTS: A total of 196 procedures were performed by 6 attending urologists with an overall success rate of 98.5% and 0% intraoperative complication rate. At 4-6 weeks follow-up, 85.6% of patients reported they would opt for conscious sedation as opposed to general anesthesia. Predictors of opting for conscious sedation in the future were older age (Odds Ratio (OR): 1.049; P = .017) and surgeon perceived level of patient tolerability (OR: 2.124; P <.001, scored 1-10). CONCLUSION: Physician directed, nursing administered IV conscious sedation is a viable alternative for various urologic procedures and has minimal risk of perioperative complications.

Is Holmium Laser Enucleation of the Prostate Truly Size-Independent? A Critical Evaluation at the Extreme Ends of the Spectrum.

OBJECTIVE: To assess the outcomes of holmium laser enucleation of the prostate (HoLEP) at the extremes of the size spectrum, comparing whether the results are consistent for very large and small prostates. METHODS: A retrospective review of 402 patient charts was conducted to compare the outcomes of HoLEP in patients with prostate size ≤40 g (group 1), 41-200 g (group 2), and >200 g (group 3). Various preoperative, perioperative, and postoperative variables were collected. RESULTS: HoLEP showed comparable voiding outcomes among all 3 groups, although patients with small prostates had a higher International Prostate Symptom Score during follow-up (P = .022). We noted a higher rate of perioperative blood transfusion in patients with very large prostates (P = .019) and a higher rate of transient acute urinary retention (AUR) in group 1 when compared to group 3 (P = .048). Patients with smaller prostates had a higher rate of bladder neck stenosis and urethral strictures, but the differences were not found to be statistically significant. The incidence of other complications, length of hospital stay, and catheterization duration did not differ significantly among the groups. CONCLUSION: HoLEP has consistent and safe outcomes across a wide range of prostate sizes. Although, the risk of blood transfusion is higher in patients with very large prostates and the risk of transient AUR is greater in patients with small glands, the overall efficacy and safety of HoLEP are not significantly influenced by prostate size.

Complications associated with minimally invasive surgical therapies (MIST) for surgical management of benign prostatic hyperplasia: a Manufacturer and User Facility Device Experience (MAUDE) database review.

PURPOSE: MAUDE database houses medical device reports of suspected device-related complications received by Food and Drug Administration. In the present study we aim to evaluate the MAUDE database for reported complications of MIST procedures. METHODS: The database was queried using keywords: rezum, urolift, prostate embolization (PAE), transurethral needle ablation (TUNA), transurethral microwave therapy (TUMT), prostate stent and Temporarily Implanted Nitinol Device (iTIND) on 10/1/22 to extract information regarding device problems and procedure-related complications. Gupta classification system was used to stratify complications. Statistical analysis was performed to compare frequency of complications among MIST procedures. RESULTS: We found a total of 692 reports (Rezum-358, urolift-226, PAE-53, TUNA-31, TUMT-19, prostatic stent-4, and iTIND-1). Most complications related to device or users were minor (level 1 and 2) and there was no significant difference among various MIST procedures. The screen/system error was responsible for 93% and 83% aborted cases in Rezum and TUNA, respectively, and PAE showed 40% of device component detachment/fracture. Overall Urolift and TUMT were associated with statistically significant higher incidence of major (level 3 and 4) complications (23% and 21%, respectively) as compared with Rezum (7%). Most major complications needing hospitalization after Urolift included hematoma and hematuria with clots and those after Rezum included urinary tract infection and sepsis. Thirteen deaths were reported, mostly due to cardiovascular events, which were classified as not associated with the proposed treatment. CONCLUSION: MIST for BPH can occasionally cause significant morbidity. Our data should assist urologists and patients in shared decision-making process.

Association between body mass index, metabolic syndrome and common urologic conditions: a cross-sectional study using a large multi-institutional database from the United States.

INTRODUCTION: The study aims to determine whether body mass index (BMI), metabolic syndrome (MS) or its individual components (primary hypertension, type 2 diabetes mellitus and dyslipidemias) are risk factors for common urological diseases. MATERIALS AND METHODS: Cross-sectional study with data collected on February 28, 2022 from the TriNetX Research Network. Patients were divided in cohorts according to their BMI, presence of MS (BMI > 30 kg/m2, type 2 diabetes mellitus, primary hypertension and disorders of lipoprotein metabolism) and its individual components and its association with common urological conditions was determined. For each analysis, odds ratio (OR) with 95% confidence intervals were calculated. Statistical significance was assessed at p < .05. RESULTS: BMI > 30 kg/m2 was associated with increased risk of lithiasis, kidney cancer, overactive bladder, male hypogonadism, benign prostatic hyperplasia, and erectile dysfunction (p < .05). On the contrary, BMI was inversely associated with ureteral, bladder and prostate cancer (p < .05). In all urological diseases, MS was the strongest risk factor, with prostate cancer (OR = 2.53) showing the weakest and male hypogonadism the strongest (OR = 13.00) associations. CONCLUSIONS: MS and its individual components were significant risk factors for common urological conditions. Hence holistic approaches with lifestyle modification might prevent common urological disease.Key messagesOverall, metabolic syndrome is the strongest risk factor for all the analysed urological diseases.Abnormally high body mass index can be a risk or protective factor depending on the threshold and urological disease that are being evaluated.Metabolic syndrome and increased BMI should be considered important factors associated to the prevalence of common urological diseases.

Impact of Low-Dose Melatonin Supplementation on Testosterone Levels in U.S. Adult Males.

OBJECTIVE: Amidst the rapid rise in melatonin supplementation, decreased testosterone levels amongst males in recent decades, and the unclear association between melatonin and the hypogonadal-pituitary-gland (HPG) axis, this study aimed to further examine the association between melatonin use and testosterone levels among men in a nationally representative sample. METHODS: U.S. men over the age of 18 surveyed from 2011-2016 via the National Health and Nutrition Examination Survey (NHANES) without missing demographic or pertinent health information were included in the analysis. A total testosterone (TT) level of less than 300 ng/dL was considered low. An average daily dose (ADD) was calculated to quantify participants' exposure to melatonin supplementation in the past 30 days. RESULTS: Analysis included 7,656 participants after selection criteria. The median age of participants was 47 [31-63] years old; the median TT level was 389.9 [289 - 513.9] ng/dL. Melatonin intake was reported in 51 (0.7%) individuals with an ADD of 1 [0.4 - 3] mg/day. We found no association between melatonin intake in the past 30 days and low TT levels (OR = 0.958, 95% CI: 0.496 -1.850; P=0.898). As expected, increasing BMI (OR = 1.133, 95% CI: 1.122 - 1.144; P < 0.001) and older age (OR = 1.019, 95% CI: 1.016 - 1.022; P < 0.001) were associated with low TT levels. CONCLUSION: Predominantly low-dose melatonin supplementation was not associated with low TT levels. Future studies are needed to better quantify the relationship between melatonin intake and low TT levels, especially in the setting of supratherapeutic doses and prolonged periods of exposure.

Are all procedures for benign prostatic hyperplasia created equal? A systematic review on post-procedural PSA dynamics and its correlation with relief of bladder outlet obstruction.

PURPOSE: To evaluate and provide a comprehensive literature review of Prostate specific antigen (PSA) dynamics after various surgical procedures for benign prostatic hyperplasia (BPH). METHODS: A thorough PubMed database search was performed over last 30 years including terms "PSA" and various surgical procedures for BPH. PSA nadir after various procedure was evaluated. The post-operative improvement in International Prostate Symptom Score, maximum void rates and post-void residue after surgeries were recorded. An indirect correlation was made between PSA nadir and outcome of various BPH surgical procedures. RESULTS: Enucleation procedures like simple prostatectomy and endoscopic enucleation of prostate (EEP) produced maximum drop in PSA level after surgery and were associated with the highest improvement in post-operative parameters. The PSA nadir following resection techniques like transurethral resection of prostate and Holmium laser resection of prostate and vaporization technique was variable and less robust when compared to EEP. Newer techniques like Aquablation, Rezum, Urolift, Prostate artery embolization and Temporary implantable nitinol devices (iTIND) produce relatively less reduction in PSA and lesser percentile improvement in post-operative parameters. CONCLUSIONS: Various surgical procedures for BPH result in varying PSA nadirs level. Enucleation procedures and simple prostatectomy produce the most drastic and sustained decrease in PSA. There is a possible indirect evidence suggesting that the level of PSA nadir corresponds closely with the degree of post-operative improvement and durability of the procedure. Establishing the new PSA nadir at 3-6 months after the procedure is recommended as a part of routine surveillance for prostate cancer in eligible patients.

Vitamin D and its effects on cardiovascular diseases: a comprehensive review.

Vitamin D is a molecule that is actively involved in multiple metabolic pathways. It is mostly known for its implications related to calcium metabolism. It has also been determined that it actively participates in the cardiovascular system, influencing blood pressure, coronary artery disease and other vascular diseases, such as heart failure and atrial fibrillation. Furthermore, it has been established that this vitamin is extensively involved in the regulation of both the renin angiotensin aldosterone system and the immune system. In this review, we present the different vitamin D metabolic pathways associated with the cardiovascular pathophysiology, and we include studies in animal and human models, as well as some of the controversies found in the literature. This review also incorporates an overview of the implications in the molecular biology and public health fields.

[Protein supplement consumption and its possible association with kidney damage in Mexican elite athletes]. / Consumo de suplemento proteico y su posible asociación con daño renal en atletas mexicanos de alto rendimiento.

BACKGROUND: Protein supplements are one of the most used ergogenic supplements by elite athletes. Nonetheless, it has been postulated that the use of these type of supplements may cause chronic renal failure. The objective of this study is to analyze the effects of the consumption of protein supplements in the renal function of elite athletes of the Mexican Olympic Training Center. METHODS: 74 athletes provided urine samples in order to quantify urinary proteins. Some of them were excluded since they had conditions that could cause proteinuria or alter the quality of the samples. Those that were not excluded were divided into two groups: the experimental group, which included those individuals that had the antecedent of consuming protein supplements, and the control group, that encompassed those individuals that did not had the antecedent of consuming protein supplements. RESULTS: Of the 74 analyzed athletes, 44 were excluded, 11 individuals were included in the experimental group, and 19 in the control group. Microproteinuria was encountered in only one urine sample (control group), and it was determined that there was no significant differences between both groups. CONCLUSION: From the gathered results it can be concluded that protein supplements do not affect renal function. Nonetheless, in the future protein supplements should be evaluated in groups with pathologies or conditions that may compromise renal function.

Introducción: los suplementos proteicos son unos de los suplementos ergogénicos más utilizados por los atletas de alto rendimiento. Sin embargo, se ha postulado que el consumo de estos pudiese ser causa de insuficiencia renal crónica. El objetivo fue analizar los efectos del consumo de suplementos proteínicos en la función renal de los atletas de alto rendimiento del Centro Deportivo Olímpico Mexicano. Métodos: se evaluaron 74 atletas, en cuya muestra de orina se cuantificaron las proteínas. Se excluyeron los atletas con antecedentes o condiciones que pudiesen causar proteinuria o que pudieran alterar la calidad de la muestra. Los elegidos se dividieron en dos grupos con base en el antecedente de consumo de suplemento proteico: el grupo experimental lo conformaron los consumidores y el control los no consumidores. Resultados: de 74 atletas analizados, 44 fueron excluidos, 11 se incluyeron al grupo experimental y 19 al grupo control. Se obtuvo un resultado positivo para microproteinuria en este último grupo. Se determinó estadísticamente que ambos grupos eran similares y se estableció, en relación con el resultado positivo de microproteinura, que no existe una diferencia significativa entre ambos grupos. Conclusión: el consumo de suplemento proteico no ha afectado la función renal de los atletas analizados. Pese a esto, consideramos que la seguridad del suplemento proteico debe ser evaluada en un futuro en ciertos grupos con patologías o antecedentes que pudieran comprometer la función renal.