Randomised trial of bipolar resection vs holmium laser enucleation vs Greenlight laser vapo-enucleation of the prostate for treatment of large benign prostate obstruction: 3-years outcomes.

OBJECTIVE: To compare transurethral resection in saline (TURIS), Greenlight laser vapo-enucleation of the prostate (GL.PVEP), and holmium laser enucleation of the prostate (HoLEP), for controlling lower urinary tract symptoms secondary to large benign prostatic hyperplasia (BPH) and to assess non-inferiority of 3-year re-treatment rates. PATIENTS AND METHODS: Eligible patients with BPH (prostate size 80-150 mL) were randomly assigned to one of the intervention groups. Non-inferiority of re-treatment rate was evaluated using a one-sided test at 5% level of significance. RESULTS: At the time of analysis, 60 GL.PVEP, 60 HoLEP and 62 TURIS procedures were included. Perioperative parameters were comparable between groups; however, the operative time was longer in GL.PVEP vs HoLEP and TURIS, at a mean (SD) of 92 (32) vs 73 (30) and 83 (28) min (P = 0.005); and was less effective with a mean (SD) removal of 1.2 (0.4) vs 1.7 (0.7) and 1.4 (0.6) g/min (P < 0.001), respectively. Perioperative complications and need for auxiliary procedures were similar in the three groups; however, there was a significantly higher rate of capsular perforation in TURIS group (five, 8%) compared to one (1.6%) in the GL.PVEP group and none in the HoLEP group (P = 0.01). There was a significantly longer hospital stay, catheter-time and higher rate of blood transfusion in the TURIS group. There was significant but comparable improvements in the International Prostate Symptom Score in three groups at different follow-up points. At 3 years, re-treatment for recurrent bladder outlet obstruction was required more after GL.PVEP and TURIS. More re-do surgeries for recurrent obstructing prostate adenoma was reported after GL.PVEP (four, 6.7%) and TURIS (six, 9.7%) than for HoLEP (none) (P = 0.04). CONCLUSION: The perioperative outcomes of GL.PVEP and HoLEP surpassed that of TURIS for the treatment of large prostates, but with a significantly prolonged operative time with GL.PVEP. The three techniques achieve good functional outcomes; however, 3-year re-treatment rates following TURIS and GL.PVEP were inferior to HoLEP.

A randomized trial comparing bipolar transurethral vaporization of the prostate with GreenLight laser (xps-180watt) photoselective vaporization of the prostate for treatment of small to moderate benign prostatic obstruction: outcomes after 2 years.

OBJECTIVE: To test the non-inferiority of bipolar transurethral vaporization of the prostate (TUVP) compared to GreenLight laser (GL) photoselective vaporization of the prostate (PVP) for reduction of benign prostatic hyperplasia-related lower urinary tract symptoms in a randomized trial. METHODS: Eligible patients with prostate volumes of 30-80 mL were randomly allocated to GL-PVP (n = 58) or bipolar TUVP (n = 61). Non-inferiority of symptom score (International Prostate Symptom Score [IPSS]) at 24 months was evaluated. All peri-operative variables were recorded and compared. Urinary (IPSS, maximum urinary flow rate and post-void residual urine volume) and sexual (International Index of Erectile Function-15) outcome measures were evaluated at 1, 4, 12 and 24 months. Need for retreatment and complications, change in PSA level and health resources-related costs of both procedures were recorded and compared. RESULTS: Baseline and peri-operative variables were similar in the two groups. At 1, 4, 12 and 24 months, 117, 116, 99 and 96 patients, respectively, were evaluable. Regarding urinary outcome measures, there was no significant difference between the groups. The mean ± sd IPSS at 1 and 2 years was 7.1 ± 3 and 7.9 ± 2.9 (P = 0.8), respectively, after GL-PVP and 6.3 ± 3.1 and 7.2 ± 2.8, respectively, after bipolar TUVP (P = 0.31). At 24 months, the mean difference in IPSS was 0.7 (95% confidence interval -0.6 to 2.3; P = 0.6). The median (range) postoperative PSA reduction was 64.7 (25-99)% and 65.9 (50-99)% (P = 0.006) after GL-PVP, and 32.1 (28.6-89.7)% and 39.3 (68.8-90.5)% (P = 0.005) after bipolar TUVP, at 1 and 2 years, respectively. After 2 years, retreatment for recurrent bladder outlet obstruction was reported in eight (13.8%) and 10 (16.4%) patients in the GL-PVP and bipolar TUVP groups, respectively (P = 0.8). The mean estimated cost per bipolar TUVP procedure was significantly lower than per GL-PVP procedure after 24 months (P = 0.01). CONCLUSIONS: In terms of symptom control, bipolar TUVP was not inferior to GL-PVP at 2 years. Durability of the outcome needs to be tracked. The greater cost of GL-PVP compared with bipolar TUVP is an important concern.

Erectile and ejaculatory functions changes following bipolar versus monopolar transurethral resection of the prostate: a prospective randomized study.

OBJECTIVES: To compare monopolar and bipolar transurethral resection of the prostate (M-TURP and B-TURP, respectively) focusing on erectile and ejaculatory functions in a randomized trial. METHODS: Between January 2013 and December 2014, all consecutive TURP candidates with benign prostatic hyperplasia (BPH) were prospectively randomized 1:1 into M-TURP/B-TURP arms and followed up at 2, and 4 weeks, 6 and 12 months after surgery. All patients were assessed using IIEF-15 (International index of erectile function-15) and Ej-MSHQ (ejaculatory domain-male sexual-health inventory). Changes in IIEF-15, its subdomains and Ej-MSHQ scores were compared between both intervention groups. RESULTS: Following M.TURP and B.TURP; 122 and 124 patients were included respectively and were considered for analysis at 1 year. Sexual function did not differ significantly between arms during follow-up (erectile function, P = 0.82; orgasmic function, P = 0.46; sexual desire, P = 0.29; intercourse satisfaction, P = 0.18; overall satisfaction, P = 0.92). There were no differences between arms in the distribution of EF evolution at any time compared with base line (at 12 months: M-TURP vs. B-TURP = improved, 24.5 vs. 26.6%; stable, 66.4 vs. 64.5%; deteriorated, 9.1 vs. 8.9%; P = 0.41). Newly developed erectile dysfunction (ED) was present in 8.2 and 7.3% of patients following M.TURP and B.TURP respectively and was related to presence of DM and obesity. Orgasm perception significantly reduced following M.TURP and B.TURP (P < 0.001). Newly reported ejaculatory dysfunction (Ej-MSHQ < 22) was significantly associated with low orgasm perception. CONCLUSIONS: There were no differences between M-TURP/B-TURP in any aspect of sexual function.

Low-Power Vs High-Power Holmium Laser Enucleation of the Prostate: Critical Assessment through Randomized Trial.

OBJECTIVE: To assess the non-inferiority of Low-power Holmium laser enucleation of the prostate (LP-HoLEP) to high-power (HP-HoLEP) for enucleation efficiency pertaining to the advantages of lower cost and minimal postoperative dysuria, storage symptoms, and negative sexual impact. PATIENTS AND METHODS: HoLEP was performed using 100W Versapulse, Luminis Inc., with 2J/25Hz for LP-HoLEP (61 patients) and 2J/50Hz for HP-HoLEP (60 patients). Two surgeons with different experience performed equal number of both procedures. Non-inferiority of enucleation efficiency (enucleated weight/min) was evaluated. All perioperative parameters were recorded and compared. Dysuria was assessed at 2 weeks by dysuria visual analog scale, urinary (Q.max and IPSS) and sexual (sexual health inventory for men score) outcome measures were evaluated at 1, 4, and 12 months. RESULTS: Baseline and perioperative parameters were comparable between the two groups. Mean enucleation efficiency was 1.42±0.6 vs 1.47±0.6 gm/min, P = .6 following LP-HoLEP and HP-HoLEP, respectively. Patients reported postoperative dysuria similarly in both groups as per dysuria visual analog scale. There was significant comparable improvement in IPSS (international prostate symptom score) and Q.max in both groups at different follow-up points. At one year, median IPSS and Q.max were comparable in both groups (P = .4 and .7 following LP-HoLEP and HP-HoLEP, respectively). Median postoperative reduction in prostate specific antigen was 89% (42:99) following LP-HoLEP vs 81% (62:94) after HP-HoLEP, P = .92. Both groups showed comparable perioperative and late postoperative complications. There were no statistically significant changes in the last follow-up sexual health inventory for men score in comparison to baseline score. CONCLUSION: LP-HoLEP is non-inferior to HP-HoLEP in terms of all efficiency parameters regardless level of surgeon experience.

Chemoprophylaxis during transrectal prostate needle biopsy: critical analysis through randomized clinical trial.

PURPOSE: To compare the efficacy of three chemoprophylaxis approaches in prevention of post-transrectal biopsy infectious complications (TBICs). METHODS: Patients were randomly assigned to receive ciprofloxacin 3 days 500 mg B.I.D 3 days starting the night prior to biopsy (standard prophylaxis), augmented prophylaxis using ciprofloxacin and single preprocedure shot of 160 mg gentamicin IM (augmented prophylaxis) and rectal swab culture-based prophylaxis (targeted prophylaxis). Patients were assessed 2 weeks prior to biopsy, at biopsy and 2 weeks after. Primary end point was occurrence of post-TBICs that included simple UTI, febrile UTI or sepsis. Secondary end points were post-biopsy change in the inflammatory markers (TLC, ESR and CRP), unplanned visits, hospitalization and occurrence of fluoroquinolones resistance (FQ-R; bacterial growth on MacConkey agar plate with 10 µg/ml ciprofloxacin) in the fecal carriage of screened men. RESULTS: Between April/2015 and January/2017, standard, augmented and targeted prophylaxes were given to 163, 166 and 167 patients, respectively. Post-TBICs were reported in 43 (26%), 13 (7.8%) and 34 (20.3%) patients following standard, augmented and targeted prophylaxes protocols, respectively (P = 0.000). Post-TBICs included UTI in 23 (4.6%), febrile UTI in 41 (8.2%) and sepsis in 26 (5.2%) patients. Significantly lower number of post-biopsy positive urine culture was depicted in the augmented group (P = 0.000). The number of biopsy cores was statistically different in the three groups (P = 0.004). On multivariate analysis, augmented prophylaxis had independently lower post-TBICs (OR 0.2, 95% CI 0.1-0.4, P = 0.000) when compared with the other two groups regardless of the number of biopsy cores taken (OR 1.07, 95% CI 0.95-1.17, P = 0.229). Post-biopsy hospitalization was needed in four (2%), one (0.6%) and ten (6%) patients following standard, augmented and targeted prophylaxes, respectively (P = 0.014). However, sepsis-related hospitalization was not statistically different. Post-biopsy changes in the inflammatory markers were significantly less in augmented prophylaxis (P < 0.05). FQ-R was depicted in 139 (83.2%) of the screened men. CONCLUSION: Augmented prophylaxis with single-dose gentamicin is an effective and practical approach. Targeted prophylaxis might be reserved for cases with contraindication to gentamicin.

A randomised controlled trial evaluating renal protective effects of selenium with vitamins A, C, E, verapamil, and losartan against extracorporeal shockwave lithotripsy-induced renal injury.

OBJECTIVE: To evaluate the protective effects of selenium with vitamins A, C and E (selenium ACE, i.e. antioxidants), verapamil (calcium channel blocker), and losartan (angiotensin receptor blocker) against extracorporeal shockwave lithotripsy (ESWL)-induced renal injury. PATIENTS AND METHODS: A randomised controlled trial was conducted between August 2012 and February 2015. Inclusion criteria were adult patients with a single renal stone (<2 cm) suitable for ESWL. Patients with diabetes, hypertension, congenital renal anomalies, moderate or marked hydronephrosis, or preoperative albuminuria (>300 mg/L) were excluded. ESWL was performed using the electromagnetic DoLiS lithotripter. Eligible patients were randomised into one of four groups using sealed closed envelopes: Group1, control; Group 2, selenium ACE; Group 3, losartan; and Group 4, verapamil. Albuminuria and urinary neutrophil gelatinase-associated lipocalin (uNGAL) were estimated after 2-4 h and 1 week after ESWL. The primary outcome was differences between albuminuria and uNGAL. Dynamic contrast-enhanced magnetic resonance imaging was performed before ESWL, and at 2-4 h and 1 week after ESWL to compare changes in renal perfusion. RESULTS: Of 329 patients assessed for eligibility, the final analysis comprised 160 patients (40 in each group). Losartan was the only medication that showed significantly lower levels of albuminuria after 1 week (P < 0.001). For perfusion changes, there was a statistically significant decrease in the renal perfusion in patients with obstructed kidneys in comparison to before ESWL (P = 0.003). These significant changes were present in the control or antioxidant group, whilst in the losartan and verapamil groups renal perfusion was not significantly decreased. CONCLUSIONS: Losartan was found to protect the kidney against ESWL-induced renal injury by significantly decreasing post-ESWL albuminuria. Verapamil and losartan maintained renal perfusion in patients with post-ESWL renal obstruction.

Holmium laser enucleation of the prostate for treatment for large-sized benign prostate hyperplasia; is it a realistic endourologic alternative in developing country?

OBJECTIVES: To assess the functional outcome and cumulative health-resource-related cost of holmium laser enucleation of the prostate (HoLEP) in comparison with transvesical open prostatectomy (TVOP) in a developing country. METHODS: Matching of 92 HoLEP and 91 TVOP procedures was performed using resected prostate tissue weight as a sole matching criterion. Safety, efficacy, and accordingly health-related cost-efficiency of both procedures were statistically compared. RESULTS: Preoperative criteria and mean prostate size (166.7 ± 49.7, 161.4 ± 35.7 ml) were similar in HoLEP and TVOP, respectively; however, HoLEP treated more comorbid patients. Blood transfusion was 2.1 and 26.1 % after HoLEP and TVOP, respectively (P = 0.001). Median time to catheter removal and hospital stay was 2 days after HoLEP and 5 and 9 days, respectively, after TVOP (P < 0.001). On modified Clavien scale, grade per grade, there was no statistically significant difference between the two groups apart from local wound complications in TVOP group. High-grade complications (≥ grade 3) were reported in 3.2 and 6.5 % in HoLEP and TVOP, respectively (P = 0.49). Resected prostate tissue weight was independently associated with high-grade periprocedure complications (OR[95 %CI] 1.22[1.02:1.49], P = 0.03). Last follow-up symptom score, peak urine flow rate, residual urine, % PSA reduction, and need for reoperation were comparable between the two groups. HoLEP costs the hospital in the first 3 months 4111.8EP (575US$) versus 4305.4EP (602US$) for TVOP (P = 0.09). CONCLUSION: In high-volume hospital, HoLEP procedure seems to be equally safe and effective as TVOP with the advantages of minimally invasive procedures. Two years after adopting the technique, HoLEP equally costs the hospital as TVOP. Significant hospital cost savings are anticipated in subsequent cases.

Incidental Prostate Cancer Diagnosis During Holmium Laser Enucleation: Assessment of Predictors, Survival, and Disease Progression.

OBJECTIVE: To determine the prevalence and predictors of incidental prostate cancer (IPCa) after Holmium laser enucleation of the prostate (HoLEP) and to assess its functional and oncological outcomes. METHODS: A prospectively maintained database was reviewed for cases with IPCa at the time of HoLEP. Patients with preoperative PCa were excluded. Patients were divided into two groups based on the presence (group I [GI]) or absence of cancer (group II [GII]) in histopathology. Univariate and multivariate logistic regression analyses were performed. RESULTS: Of 1242 patients, 70 (5.64%) were identified to have IPCa. Prostate size was comparable between both groups. GI patients had significantly higher preoperative prostate-specific antigen (PSA) and total PSA density (tPSAD) compared to cancer-free patients. T1a and T1b adenocarcinomas were detected in 54 (77.1%) and 16 (22.9%) patients, respectively. After a median follow-up of 48 (1-171) months, both groups were comparable in all functional outcomes but the quality of life was significantly better in GII. Patients' age and preoperative tPSAD independently predicted IPCa after HoLEP. A tPSAD cutoff value of 0.092 has a sensitivity and specificity of 0.83 and 0.67, respectively. Seven patients (11.7%) needed adjuvant therapy while other GI patients opted for active surveillance. The Kaplan-Meier analysis demonstrated an overall survival of 72.8% at 5 years and 63.5% at 10 years for patients with PCa. CONCLUSION: PCa is not uncommonly identified after HoLEP, even in those with negative preoperative biopsies. In older patients, total PSAD could be a predictor using a cutoff <0.1. After HoLEP, active surveillance for low-grade PCa carries good functional and oncological outcomes.

Postoperative Lower Urinary Tract Storage Symptoms: Does Prostate Enucleation Differ from Prostate Vaporization for Treatment of Symptomatic Benign Prostatic Hyperplasia?

PURPOSE: To assess the degree of postoperative storage symptoms after GreenLight™ laser photoselective vaporization of the prostate (PVP) and Holmium laser enucleation of the prostate (HoLEP) for management of benign prostatic hyperplasia (BPH) and its predictors. METHODS: A retrospective review was performed for patients who underwent HoLEP or PVP for non catheter-dependent patients with BPH. Patients were followed up at 1, 3, 6, and 12 months and then annually by International Prostate Symptoms Score (IPSS), quality of life index, peak flow rate, residual urine volume, and prostate-specific antigen (PSA) level. Moderate or severe storage symptoms were defined as IPSS storage subscore ≥ 9. RESULTS: Of 1673 laser procedures, a total of 1100 procedures met the inclusion criteria including 809 HoLEPs and 291 PVPs. The HoLEP group had significantly larger preoperative prostates and longer operative time. In the HoLEP group, postoperative IPSS was significantly better than in the PVP group at all follow-up points (P<0.05). Storage subscore was significantly higher after PVP and did not improve until 6 months postoperatively when it became comparable with that of the HoLEP group. The number of patients with IPSS-storage score ≥ 9 were significantly higher in the PVP group at 1 and 3 months follow-up (37.3% vs 15.1%, P<0.001) and (26.4% vs 17.5%, P=0.004), respectively. XPS-180W was associated with the lowest storage symptoms among the three GreenLight generations at all follow-up visits. In multivariate analysis, baseline IPSS-storage subscore ≥ 9, prolonged operative time >100 minutes, and lower percent of postoperative PSA level reduction significantly predicted less improvement of postoperative storage symptoms regardless of the laser procedure. CONCLUSION: Storage urinary symptoms significantly improved more after HoLEP compared with PVP, irrespective of the generation of GreenLight laser used. Recovery from bothersome storage urinary symptoms after prostate vaporization is time dependent, and baseline degree of storage symptoms, prolonged operative time, and lower percent of postoperative PSA level reduction negatively predicts postoperative improvement of storage symptoms regardless of the laser procedure.

Reoperation After Holmium Laser Enucleation of the Prostate for Management of Benign Prostatic Hyperplasia: Assessment of Risk Factors with Time to Event Analysis.

PURPOSE: To determine risk factors of reoperation after holmium laser enucleation of the prostate (HoLEP) for management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) with time to event analysis. METHODS: A prospectively maintained database was reviewed for patients undergoing HoLEP. Baseline and follow-up data were compared in terms of International Prostate Symptoms Score, quality of life, peak flow rate, residual urine, and prostate-specific antigen (PSA) at 1, 6, and 12-months and then annually. Perioperative and late adverse events were recorded. Reoperation was defined as the need for any surgical intervention to relieve bothersome LUTS after HoLEP. Multivariate logistic regression was used to determine covariates associated with reoperation and the Kaplan-Meier curve assessed the time to reoperation. RESULTS: A total of 1216 HoLEP procedures were performed between March 1998 and October 2013 with a mean prostate volume of 94.8 ± 52.7 cc. Catheter time and hospital stay were 1.4 ± 1.9 and 1.3 ± 1.6 days, respectively. After a median follow-up of 7.6 years (1-14 years), 52 (4.3%) patients needed reoperation for recurrent LUTS, including 13 (1.07%) for residual/recurrent adenoma, 14 (1.15%) for bladder neck contracture (BNC), and 25 (2.05%) for de novo urethral stricture. In multivariate regression, smaller prostate size (< 62 cc), PSA reduction < 50%, and history of previous prostate surgery were significantly associated with recurrence of adenoma. BNC was significantly associated with smaller glands (< 54 cc) while longer operative time and postoperative catheterization were significantly associated with urethral stricture. Kaplan-Meier curve demonstrates post-HoLEP freedom from reoperation of 96.9% at 5 years and 95.1% at 10 years. CONCLUSIONS: In a single center large series, HoLEP has 95% reoperation-free probability at 10 years. Relatively small-size prostate may have an impact on recurrence of adenoma and bladder neck contracture. PSA reduction < 50% was significantly associated with recurrence of adenoma while longer operative time and postoperative catheterization were significantly associated with postoperative urethral stricture.

Holmium:YAG transurethral incision versus laser photoselective vaporization for benign prostatic hyperplasia in a small prostate.

PURPOSE: We assess the perioperative, short-term and long-term functional outcomes of treating bladder outlet obstruction secondary to a small prostate by 1 of 2 laser techniques. MATERIALS AND METHODS: A retrospective review using a prospectively maintained database was performed of patients treated for bladder outlet obstruction secondary to a prostate smaller than 40 ml. Patients who were treated with GreenLight™ photoselective vaporization of the prostate or holmium laser transurethral incision of the prostate were included in the study. RESULTS: From January 2002 through December 2010, 191 cases of 1,682 laser prostate surgeries were described. GreenLight photoselective vaporization of the prostate was performed in 144 (75.4%) cases and holmium laser transurethral incision of the prostate was performed in 47 (24.6%) cases. A significantly shorter mean operating time, hospital stay and catheter duration were observed in the holmium laser transurethral incision of the prostate group (30.3 ± 16 minutes, 0.8 ± 0.8 days and 1.3 ± 1.9 days, respectively) than in the photoselective vaporization of the prostate group (45.8 ± 22 minutes, 0.3 ± 0.4 days and 0.4 ± 0.6 days, respectively, p <0.05). At 1 and 5 years after photoselective vaporization of the prostate there were reductions in mean International Prostate Symptom Score, quality of life score and residual urine with improvement in mean maximal flow rate of 57.7% and 62.8%, 58.3% and 57.2%, 65.4% and 73%, and 127.6% and 167.1%, respectively. At 1 and 5 years after holmium laser transurethral incision of the prostate there were reductions in mean International Prostate Symptom Score, quality of life score and residual urine with improvement of mean maximal flow rate of 55.3% and 52.8%, 49.2% and 49%, 45% and 78.1%, and 67.4% and 35.4%, respectively. Subjective and objective urine flow parameters were comparable at different followup points. There was no significant difference between the 2 groups in terms of early and late complications (p >0.05). Reoperation rates were 10.4% and 6.4% in the photoselective vaporization of the prostate and holmium laser transurethral incision of the prostate groups, respectively (p >0.05). The mean estimated cost per holmium laser transurethral incision of the prostate procedure was significantly lower than per photoselective vaporization of the prostate procedure (509.34CAD vs 1,765.92CAD, p = 0.002). CONCLUSIONS: Holmium laser transurethral incision of the prostate and GreenLight photoselective vaporization of the prostate seem to be equally effective, safe and durable surgical treatment options for small prostates even in high risk patients.

Transurethral laser surgery for benign prostate hyperplasia in octogenarians: safety and outcomes.

OBJECTIVE: To evaluate the morbidity and perioperative outcome of different laser prostate techniques among octogenarians. METHODS: We performed a retrospective review of our prospectively maintained laser prostate surgery database between 1998 and 2012. We identified 264 octogenarians (16.5%) who underwent laser prostate surgery. Perioperative morbidity and mortality in addition to the functional outcome of these procedures were assessed. Risk factors and predictors of the outcome were analyzed. RESULTS: The mean age at time of procedure was 84 ± 3.5 years. Holmium laser enucleation of the prostate was done in 171 (64.7%), holmium laser ablation of the prostate in 16 (6%), holmium laser transurethral incision of the prostate in 13 (5%) and photoselective vaporization of the prostate in 64 (24.3%). Procedures for octogenarians increased from 11% at the end of 2002 to 19% at 2012. A total of 68 perioperative complications occurred in 52 procedures (19.6%), without any perioperative deaths. There were 56 (82.3%) low-grade complications (Clavien grade I-II) and 12 (17.7%) high-grade complications (Clavien grade ≥ III). A longer operating time was an independent risk factor for perioperative morbidity on multivariate analysis. Significant improvement of symptoms score (International Prostate Symptom Score-Quality of Life) associated with objective improvement of urine flow parameters (maximum flow [Q-max] and postvoid residual) were reported at different follow-up assessments in the first year (P <.05). Persistent urge or stress incontinence, or both, were found in 4 (1.5%). Total urinary incontinence occurred in 1 patient, with neurologic deficit as the underlying cause. De novo urethral stricture was reported in 8 patients (3%). CONCLUSION: Octogenarians undergoing laser prostate surgery for treatment of benign prostate hyperplasia have limited perioperative morbidity. Laser prostate surgery can achieve good functional outcome and maintain quality of life of seniors. Furthermore, it is safe in seniors with a high morbidity index; however, longer operating time is an independent risk factor for perioperative morbidity.

Male sexual function outcome after three laser prostate surgical techniques: a single center perspective.

OBJECTIVE: To assess the change and predictors of sexual-related outcomes after laser prostate surgery. METHODS: This is a longitudinal study of 216 sexually active men who underwent laser prostatectomy between 2005 and 2010. The International Index of Erectile Function-15 questionnaire was used both preoperatively and during the first year of follow-up. Cases with unreliable answers or patients without interested partners were excluded. All relevant data of both groups were depicted and statistically analyzed. RESULTS: We identified 191 patients that met the inclusion criteria, 99 holmium laser enucleation of the prostate, 34 holmium laser ablation, and 58 photoselective vaporization of the prostate (GreenLight-532-mm laser photoselective vaporization of the prostate). There were significant differences among the 3 groups regarding the International Index of Erectile Function-15 direction of change at 1 year, being unchanged in (22.2%, 24.4%, and 29.3%), improved in (60.6%, 29.4%, and 41.4), and declined in (17.2%, 41.2%, and 29.3%) in the 3 groups, respectively (P < .05). After adjusting for clinical and perioperative variables, the independent risk factors for decline in the International Index of Erectile Function score were basal International Index of Erectile Function ≥ 55 and energy to prostate ratio. In holmium laser enucleation of the prostate group, there was significant improvement of the mean overall score, erectile function, desire, and intercourse satisfaction domains (P < .05). In holmium laser ablation and photoselective vaporization of the prostate groups, there were no significant changes between mean preopeative and postoperative scores (P > .05). The incidence of new onset retrograde ejaculation in the holmium laser enucleation of the prostate group was (77.3%) significantly different compared to (31.1%) in the holmium laser ablation group and (33.2%) in photoselective vaporization of the prostate group (P < .05). CONCLUSION: Laser prostate surgery using more size-related laser energy might have possible negative influence on sexual function. Patients with normal preoperative sexuality are more at risk.

Feasibility of holmium laser enucleation of the prostate (HoLEP) for recurrent/residual benign prostatic hyperplasia (BPH).

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? The major advantage of holmium laser enucleation of the prostate (HoLEP) depends on the ability to use the native anatomical plane between the prostate adenoma and surgical capsule, peeling each prostatic lobe from the capsule. HoLEP is associated with less catheterisation time, hospital stay and blood loss than transurethral resection of the prostate (TURP) or open prostatectomy. Urodynamic relief of obstruction has been reported to be better with HoLEP than TURP. However, surgical treatment of recurrent prostatic obstruction after previous transurethral surgery for symptomatic benign prostatic hyperplasia is more challenging because of loss of anatomical landmarks resulting in either incomplete removal or incontinence. HoLEP for recurrent symptoms due to residual or re-growing prostatic adenoma seems to be as safe, feasible and efficient as HoLEP for de novo cases. The surgical plane between the adenoma and the surgical capsule was still accessible resulting in a durable long-term outcome with minimal side-effects. Previous transurethral prostatic surgery is not a contraindication for HoLEP. OBJECTIVE: • To assess the technical feasibility, functional outcome and morbidity of holmium laser enucleation of the prostate (HoLEP) for symptomatic benign prostatic hyperplasia (BPH) in patients with previous transurethral prostate surgery. 'Redo' surgery for recurrent or residual BPH poses a technical challenge with uncertain outcome as a result of disturbed anatomical landmarks with no clear surgical limits. PATIENTS AND METHODS: • We retrospectively reviewed 1054 patients who underwent HoLEP for symptomatic BPH. • Patients were stratified into two groups, group-I with no previous prostate surgery or primary-HoLEP (978 patients) and group-II with history of previous prostate surgery or secondary-HoLEP (76). • All patients' variables as well as follow-up data were assessed and compared. RESULTS: • There were no significant differences in baseline criteria between the two groups (P > 0.05). • In group-II, HoLEP was done after a median (range) of 66 (13-121) months from previous prostate surgeries, including transurethral resection of the prostate (48 patients), HoLEP (eight), transurethral incision of the prostate (nine), photoselective vaporization of the prostate (four) and other procedures (seven). • In both groups, routine HoLEP technique was adopted, the plane of enucleation could be identified without extra difficulty. However, more energy per gram of prostate tissue was needed in group-II (P < 0.05). • Operative auxiliary procedures were indicated in 1.9% of group-I, and 1.3% of group-II (P > 0.05). There were no operative complications or blood transfusion in group-II. The mean hospital stay and catheter time was similar in both groups. Early and late postoperative complications were not statistically different (P > 0.05). • At 1 month the mean maximum urinary flow rate (Q(max) ) was 22.3 and 18.8 mL/s, postvoid residual urine volume (PVR) was 46 and 45 mL, International Prostate Symptom Score (IPSS) was 7.04 and 7.08, and the health-related quality of life (HRQL) score was 1.57 and 1.56, in group-I and II, respectively. At 1 year the mean Q(max) was 23.4 and 25.9 mL/s, PVR was 32.5 and 24.1 mL, IPSS was 4.5 and 4.4, and the HRQL score was 1.2 and 1.1,) in group-I and II, respectively (P > 0.05). • Reoperation for recurrent obstruction was indicated in 4% in group-I and 5.2% in group-II (P > 0.05). CONCLUSION: • Secondary-HoLEP procedures seem to be safe and technically feasible with comparable functional outcomes as those of primary-HoLEP.