Use of the Schelin Catheter for transurethral intraprostatic anesthesia prior to Rezum treatment.

Minimally invasive surgery techniques (MIST) have become newly adopted in urological care.  Given this, new analgesic techniques are important in optimizing patient outcomes and resource management. Rezum treatment (RT) for BPH has emerged as a new MIST with excellent patient outcomes, including improving quality of life (QoL) and International Prostate Symptom Scores (IPSSs), while also preserving sexual function.  Currently, the standard analgesic approach for RT involves a peri-prostatic nerve block (PNB) using a transrectal ultrasound (TRUS) or systemic sedation anesthesia.  The TRUS approach is invasive, uncomfortable, and holds a risk of infection.  Additionally, alternative methods such as, inhaled methoxyflurane (Penthrox), nitric oxide, general anesthesia, as well as intravenous (IV) sedation pose safety risks or mandate the presence of an anesthesiology team.  Transurethral intraprostatic anesthesia (TUIA) using the Schelin Catheter (ProstaLund, Lund, Sweden) (SC) provides a new, non-invasive, and efficient technique for out-patient, office based Rezum procedures.  Through local administration of an analgesic around the prostate base, the SC has been shown to reduce pain, procedure times, and bleeding during MISTs.  Herein, we evaluated the analgesic efficacy of TUIA via the SC in a cohort of 10 patients undergoing in-patient RT for BPH.

Comparing prostatic artery embolization to surgical and minimally invasive procedures for the treatment of benign prostatic hyperplasia: a systematic review and meta-analysis.

BACKGROUND: To summarize current evidence to report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) with transurethral resection of the prostate (TURP) and open simple prostatectomy (OSP) for the treatment of benign prostatic hyperplasia (BPH). METHODS: A systematic literature search was performed to identify studies published from inception until August 2021. The search terms used were (prostate embolization OR prostatic embolization) AND (prostatic hyperplasia OR prostatic obstruction) as well as the abbreviations of PAE and BPH. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool for observational studies. Random-effects meta-analysis was performed using Revman 5.4. RESULTS: Seven studies were included with 810 patients: five RCTs and one observational study compared PAE with TURP, and one observational study compared PAE with OSP. The included studies had considerable risk of bias concerns. TURP and OSP were associated with more statistically significant improvements in urodynamic measures and BPH symptoms compared to PAE. However, PAE seems to significantly improve erectile dysfunction compared to OSP and improve other outcome measures compared to TURP, although not significantly. PAE appeared to reduce adverse events and report more minor complications compared with TURP and OSP, but it is unclear whether PAE is more effective in the long-term. CONCLUSION: PAE is an emerging treatment option for patients with symptomatic BPH who cannot undergo surgery or have undergone failed medical therapy. Overall, PAE groups reported fewer adverse events. Future ongoing and longer-term studies are needed to provide better insight into the benefit of PAE compared to other treatment options.

How I Do It: Transcutaneous tibial nerve stimulation TENSI+ system.

Overactive bladder (OAB) is a common condition that significantly impacts the quality of life (QoL), well-being and daily functioning for both men and women. Among various treatments, peripheral tibial nerve stimulation (PTNS) emerges as an effective third-line treatment for OAB symptoms, with options for either a percutaneous approach (P-PTNS) or by transcutaneous delivery (T-PTNS). Recent studies have shown negligible differences between P-PTNS and T-PTNS efficacy in alleviating urinary urgency and frequency and QoL improvement and, overall no difference in efficacy over antimuscarinic regimens. The TENSI+ system offers a cutting-edge transcutaneous approach, allowing patients to self-administer treatment conveniently at home with electrical stimulation delivery through surface electrodes. It stands out for its ease of preparation, tolerability, and high levels of patient satisfaction. Prospective multicentric data highlights TENSI+ to be an effective and safe treatment for lower urinary tract symptoms with high treatment adherence at 3 months. This paper aims to familiarize readers with the TENSI+ system, current studies, device assembly, operation, and treatment recommendations.

Aquablation versus TURP: 5-year outcomes of the WATER randomized clinical trial for prostate volumes 50-80 mL.

INTRODUCTION: To report the 5-year efficacy and safety of Aquablation compared with transurethral resection of the prostate for the management of lower urinary tract symptoms secondary to benign prostatic hyperplasia in men with prostate volumes 50-80 mL. MATERIALS AND METHODS: In a large double-blinded, multicenter, and prospective randomized controlled trial, 96 randomized men with 50-80 mL prostates who underwent Aquablation or transurethral prostate resection were prospectively identified for subgroup analysis. Follow up was performed for up to 5 years. The primary efficacy endpoint was the reduction in International Prostate Symptom Score (IPSS) at 6 months. The primary safety endpoint was the occurrence of Clavien-Dindo (CD) postoperative complications grade 1 persistent and grade 2 or higher at 3 months. RESULTS: Both groups had comparable baseline characteristics. Reduction in IPSS score was significantly higher in the Aquablation group across 5 years of follow up (-14.1 vs. -10.8, p = 0.02). The Aquablation group achieved a significantly lower rate of CD1P and CD2 or higher events at 3 months follow up (risk difference of -23.1%). Among recorded adverse events, de novo postoperative ejaculatory dysfunction was notably lower in Aquablation (risk difference of -21.9%), while the risk of bleeding remained similar after 6 months. The surgical and medical retreatment rate at 6 months was also lower in Aquablation (risk difference of -14.4%). CONCLUSIONS: In the 50-80 mL prostate volume subgroup, Aquablation yields superior long-term symptom relief and lower complication rates than standard transurethral resection, with notably lower rates of ejaculatory dysfunction. This further supports the adoption of Aquablation for men with medium-sized prostates.

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.

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.

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.

Effect of Surgeon and Facility Volume on Outcomes of Benign Prostatic Hyperplasia Surgery: Implications of Disparities in Access to Care at High-Volume Centers.

OBJECTIVE: To report the effect of surgeon and facility volume on outcomes of transurethral resection of the prostate (TURP) and laser treatment of benign prostatic hyperplasia (BPH). We also investigate disparities in access to care by identifying demographic predictors of receipt of treatment at high-volume facilities. METHODS: We used New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) data. We included 18,041 (41.4%) and 25,577 (58.6%) adult patients that underwent TURP and laser procedures in the outpatient setting between January 2005 and December 2018, respectively. Average annual surgeon and facility volumes were broken down by tertile. The effect of volume on short-term outcomes (30-day and 90-day readmission) was examined using mixed-effect logistic regression models. Cox-proportional-hazard models were used to assess the association between volume and long-term stricture development and reoperation. Demographic predictors of treatment at high-volume facilities were assessed using multinomial logistic regression. RESULTS: High-volume facilities were more likely to offer laser procedures compared to low-volume facilities. Higher facility and surgeon volume were associated with lower odds of 30 and 90-day readmissions compared to low-volume facilities. There was no difference in reoperation and stricture development between surgeon volume groups. Medicaid insurance, Hispanic ethnicity, and Black race were inversely associated with treatment at high-volume facilities. CONCLUSION: Higher surgeon and facility volumes were associated with lower odds of readmission. Higher facility volume was associated with lower hazards of reoperation and developing strictures. Medicaid insurance and non-white race were associated with lower odds of treatment at high-volume facilities, highlighting racial and socioeconomic disparities in access to high-volume BPH surgery facilities.

Pharmacotherapy vs. minimally invasive therapies as initial therapy for moderate-to-severe benign prostatic hyperplasia: a cost-effectiveness study.

BACKGROUND: Recently, minimally invasive therapies (MITs), such as water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL) have become an alternative to surgery or pharmacotherapy to manage benign prostatic hyperplasia (BPH), offering symptom relief with a favorable safety profile. The objective of this study was to evaluate the cost-utility of MITs (WVTT and PUL) compared to pharmacotherapy as initial treatment for patients with moderate-to-severe BPH. METHODS: In this model-based economic evaluation we simulated BPH progression in men (mean age 65 years, average International Prostate Symptom Score 16.6) over their lifetime and estimated healthcare costs (from the US public payer perspective) per quality-adjusted life year (QALY), discounted at 3% annually. Various clinical scenarios were evaluated given that most men undergo several lifelong therapies up to surgical intervention and potentially thereafter. As such, in the study model men could receive up to three lines of therapy: (1) initial pharmacotherapy with MIT as second-line, and transurethral resection of the prostate (TURP) or pharmacotherapy as third-line; (2) initial MIT (WVTT or PUL) with MIT again, TURP or pharmacotherapy as second-line, and TURP as third-line. Model was populated using data from the published literature. Probabilistic analyses were performed. RESULTS: Initial treatment with WVTT led to the highest QALYs (13.05) and the lowest cost ($15,461). The cumulative QALYs and lifetime costs were 12.92 QALYs and $20,280 for pharmacotherapy followed by WVTT, 12.87 QALYs and $22,424 for pharmacotherapy followed by PUL, 12.86 QALYs and $20,930 for initial treatment with PUL. In the cost-utility analysis, WVTT as initial treatment dominated all three strategies, i.e., generated more QALYs at a lower cost. CONCLUSION: WVTT is an effective and cost-saving procedure, and may be an appropriate first-line alternative to pharmacotherapy for moderate-to-severe BPH patients who seek faster improvement and no lifelong commitment to daily medications.

How I do it: Aquablation in very large prostates (> 150 mL).

Aquablation has been well-studied in prostates sizes up to 150 mL. Recently, American Urological Association guidelines distinguish surgical interventions for men with large prostates (80 mL-150 mL) and now very large prostates (> 150 mL). Readers will gain an understanding of how to use Aquablation in the very large prostate size category.

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.

Assessing the Accuracy, Quality, and Readability of Information Related to the Surgical Management of Benign Prostatic Hyperplasia.

Objectives: To assess the accuracy, quality, and readability of online educational health information in English related to the most common benign prostatic hyperplasia (BPH) guideline-approved surgical treatments. Methods: The terms "benign prostatic hyperplasia," "BPH," and all eight guideline-approved treatment modalities studied, were searched to retrieve the first five relevant websites and first two paid advertised websites related to the surgical treatment options for BPH. These modalities included transurethral resection of the prostate (TURP), GreenLight photovaporization, endoscopic enucleation of the prostate, Rezum, Urolift, Aquablation, open simple prostatectomy, and robotic simple prostatectomy (RSP). All relevant websites were assessed for their accuracy, quality, and readability using standardized scoring systems. Results: The mean accuracy score for each of the treatment modalities were all indicative of good accuracy, with 76%-99% of the information presented as being accurate. The median quality score was statistically different across the eight treatment modalities (p = 0.015). The median readability grade level was statistically different across the eight treatment modalities (p = 0.009). Websites that described TURP (median readability grade level, 9.00 [interquartile range (IQR) 8.00-10.80]) were significantly easier to read than those related to RSP (median readability grade level, 14.35 [IQR, 11.08-16.50]) (p = 0.011). No other statistically significant differences were found within the other treatment modality websites. Conclusions: The majority of websites retrieved were found to be of high accuracy, good quality, and poor readability. Additionally, it was found that none of the retrieved websites included descriptions for all the other included treatment modalities. Given these findings, the authors recommend the development of centralized resources with all guideline-approved treatment modalities and accurate, readable, and high-quality information related to the surgical treatment of BPH.

Safety and efficacy of TURP vs. laser prostatectomy for the treatment of benign prostatic hyperplasia in multi-morbid and elderly individuals aged ≥ 75.

PURPOSE: To compare the safety and durability of transurethral resection of the prostate (TURP) and Laser prostatectomy (LP) among multi-morbid and elderly patients. METHODS: Using data retrieved from the New York State Department of Health Statewide Planning and Research Cooperative System and the California Office of Statewide Health Planning and Development, we selected cohorts of 1) multi-morbid (Charlson comorbidity index ≥ 3) and 2) elderly (aged ≥ 75) patients with benign prostatic hyperplasia who underwent laser coagulation, vaporization, enucleation, or TURP between January 2005 and December 2016. We assessed the post-operative incidence of hospital readmission and ER visit at 30 days and 90 days, complications at 90 days, and reoperation and the development of urethral stricture at 6 months or longer. RESULTS: We found 12,815 and 29,806 patients in the multi-morbid and elderly cohort, respectively. Compared to LP, TURP was associated with lower odds of 90-day hospital readmission and ER visit in the multi-morbid cohort (OR 0.92, 95% CI 0.85-1.00) and higher odds in the elderly cohort (OR 1.07, 95% CI 1.01-1.14). The multi-morbid cohort showed lower odds of urinary tract infections (Ref: LP, OR 0.83, 95% CI 0.73-0.93). The elderly cohort showed higher odds of experiencing hematuria (OR 1.28, 95% CI 1.03-1.59) post TURP. TURP was associated with a 19% (95% CI 0.66-1.00) and 20% (95% CI 0.71-0.91) reduced hazard of reoperation at 6 months or longer for multi-morbid and elderly cohorts, respectively. CONCLUSION: Compared to LP, TURP was associated with higher complication rates for the multi-morbid and elderly cohorts overall but a lower hazard of reoperation, supporting its durability.

Operative time comparison of aquablation, greenlight PVP, ThuLEP, GreenLEP, and HoLEP.

INTRODUCTION: The BPH surgical armamentarium is composed of a rapidly expanding number of technologies and techniques. These include greenlight photovaporization of the prostate (PVP), greenlight enucleation of the prostate (GreenLEP), holmium laser enucleation of the prostate (HoLEP), thulium laser enucleation of the prostate (ThuLEP) and, more recently, the aquablation procedure. To the best of our knowledge, no direct comparison in operative time has been performed. METHODS: Data for this study were pooled from five sources. For aquablation, patient-level data from four studies of the aquablation procedure were provided by the device manufacturer as well as from a high-volume commercial user. PVP, GreenLEP, HoLEP, and ThuLEP were performed by high-volume, experienced experts. Endpoints included total operative time, resection time, and proportion of total operative time for resection. General linear models were used to evaluate the relationship between prostate volume (or other continuous predictors) and procedure time. RESULTS: Total procedure time was related to prostate size. Except for the small prostate size range (size < 40 cc), at any given prostate volume, procedure time was highest for PVP, intermediate for LEPs, and lowest for Aquablation. The relationship between procedure time and prostate size (i.e., slope of the fitted lines) was 0.16 min/g for aquablation, 0.32 min/g, 0.28 min/g and 0.32 min/g for GreenLEP, HoLEP and ThuLEP, respectively, and 0.63 min/g for PVP. CONCLUSION: In our analysis of pooled data of multi-surgical techniques and technologies, aquablation provided the lowest operative time across all prostate volumes. PVP had the longest procedure time for prostates > 40 cc.

New Technologies and Applications in Sacral Neuromodulation: An Update.

Recently rechargeable devices have been introduced for sacral neuromodulation (SNM) with conditional safety for full-body magnetic resonance imaging (MRI). Currently a recharge-free SNM device represents the standard implant; however, it is only approved for MRI head scans. As further new technologies with broader MRI capabilities are emerging, the advantages as well as disadvantages of both rechargeable versus recharge-free devices will be briefly discussed in this commentary from the perspective of patients, healthcare professionals, and providers.

The Role of Aquablation for the Surgical Treatment of LUTS/BPH.

PURPOSE OF REVIEW: To explore the potential applicability of a novel, heat-free, and robotically controlled ablative therapy for surgical management of benign prostatic enlargement. RECENT FINDINGS: With the emergence of new technology to provide personalized care and overcome the complications associated with options such as TURP, holmium laser enucleation of the prostate, GreenLight laser, or simple prostatectomy, Aquablation has been studied across a variety of prostate volumes. The functional outcome of Aquablation seems to be uncompromised by prostate volume. The sexual profile seems superior to TURP and the risk of retrograde ejaculation is lower. The robotic system provides a reproducible ablation, independent of prostate volume, without requiring extensive training for performing the procedure. The mean ablation time in the prostate as large as 150 ml does not exceed 9.1 min, and the blood transfusion rates do not seem to be higher than open prostatectomy.

Pharmacotherapy vs surgery as initial therapy for patients with moderate-to-severe benign prostate hyperplasia: a cost-effectiveness analysis.

OBJECTIVE: To evaluate the cost-effectiveness of using a surgery, such as transurethral resection of the prostate (TURP) or photoselective vaporisation of the prostate using greenlight laser (GL-PVP), as initial treatment for men with moderate-to-severe benign prostate hyperplasia (BPH) compared to the standard practice of using pharmacotherapy as initial treatment followed by surgery if symptoms do not resolve. PATIENTS AND METHODS: We compared a combination of eight strategies involving upfront pharmacotherapy (i.e., α-blocker, 5α-reductase inhibitor, or combination) followed by surgery (e.g. TURP or GL-PVP) upon failure vs TURP or GL-PVP as initial treatment, for a target population of men with moderate-to-severe BPH symptoms, with a mean age of 65 years and no contraindications for treatment. A microsimulation decision-analytic model was developed to project the costs and quality-adjusted life years (QALYs) of the target population over the lifetime. The model was populated and validated using published literature. Incremental cost-effectiveness ratios (ICERs) were determined. Cost-effectiveness was evaluated using a public payer perspective, a lifetime horizon, a discount rate of 1.5%, and a cost-effectiveness threshold of $50 000 (Canadian dollars)/QALY. Sensitivity and probabilistic analyses were performed. RESULTS: All options involving an upfront pharmacotherapy followed by TURP for those who fail were economically unattractive compared to strategies involving a GL-PVP for those who fail, and compared to using either BPH surgery as initial treatment. Overall, upfront TURP was the most costly and effective option, followed closely by upfront GL-PVP. On average, upfront TURP costs $1015 more and resulted in a small gain of 0.03 QALYs compared to upfront GL-PVP, translating to an incremental cost per QALY gained of $29 066. Results were robust to probabilistic analysis. CONCLUSIONS: Surgery is cost-effective as initial therapy for BPH. However, the health and economic evidence should be considered concurrently with patient preferences and risk attitudes towards different therapy options.

The novel Axonics® rechargeable sacral neuromodulation system: Procedural and technical impressions from an initial North American experience.

AIMS: The rechargeable Axonics® r-SNM™ System is currently approved and available in Europe and Canada, with US FDA approval pending. This article provides a review of the system along with technique and technical considerations for its implantation based on my clinical experience with the new Axonics r-SNM System. METHODS: The description of the surgical technique and technological considerations for the Axonics r-SNM System is based my clinical experience of 11 cases performed at UHN Toronto Western Hospital. RESULTS: While the Axonics system is intended to provide similar therapy to the existing SNM system, the Axonics system has several new technological advances. Understanding these differences and optimizing surgical technique is anticipated to improve outcomes and patient experience. CONCLUSIONS: Overall the Axonics r-SNM System and implant procedure requires minimal learning curve for experienced SNM implanters and provides several enhanced features for physicians and patients. Further experience by others may elucidate other nuances important to the implantation of this novel SNM system.

Trends and Clinical Practice Patterns of Sacral Neuromodulation for Overactive Bladder.

OBJECTIVES: The aim of this study was to investigate surgical practice patterns of American urologists treating refractory overactive bladder (OAB) over the past decade. Refractory OAB remains a management challenge to urologists. When multiple medical therapies have failed, treatment options may include sacral neuromodulation (SNM) or surgery such as augmentation cystoplasty (AC). METHODS: Data on SNM and AC performed between 2003 and 2012 by certifying and recertifying urologists were obtained in the form of annualized case logs from the American Board of Urology (ABU). Associations between surgeon characteristics (type of certification, annual volume, practice type, and location) and these procedures were evaluated. RESULTS: Over the past decade, 756 of 6355 urologists certified with the ABU performed SNM or AC for the treatment of refractory OAB. Forty-five (6%) of these surgeons completed fellowships in female urology and 71 surgeons (9%) completed another type of fellowship program. Surgeons recertifying with ABU performed 76% of all SNM procedures. Although SNM and AC have increased from 64 to 2086 between 2003 and 2012, however, this is mainly driven by the increase of SNM from 48 to 2068 cases. Rates of AC have remained stable with 14 to 38 cases reported annually. However, they have declined relative to the total, from 25% in 2003 to less than 1% in 2012. CONCLUSIONS: Sacral neuromodulation has increased dramatically over the past decade in surgeons certified with the ABU. This is in contrast to AC, which while remaining stable in number of procedures.

BPH update: medical versus interventional management.

Benign prostatic hyperplasia (BPH) is a common condition that afflicts a large proportion of aging men. The primary care physician has an important role with the identification and early treatment of bothersome urinary symptoms caused by BPH. This includes a detailed history and physical exam, as well as initiation of a number of medications such as alpha-blockers, 5-alpha reductase inhibitors and phosphodiesterase-5 inhibitors. It is also very important for the primary care giver to determine when additional evaluation and referral to a urologist needs to occur, specifically when surgical intervention is needed. This review will summarize the management of this common disorder and is designed to aid the generalist with the pertinent information needed to provide excellent care.