Outcomes of Holmium Laser Enucleation of the Prostate in the Re-Treatment Setting.

PURPOSE: Holmium laser enucleation of the prostate can also be applied in the re-treatment setting when other benign prostatic hyperplasia therapies fail. We compared outcomes in men who underwent holmium laser enucleation of the prostate in the primary vs the re-treatment setting. MATERIALS AND METHODS: We retrospectively reviewed the records of 2,242 patients who underwent holmium laser enucleation of the prostate at a total of 4 academic hospitals between 2003 and 2015. Patient demographics, and operative and perioperative outcomes were compared between re-treatment and primary holmium laser enucleation of the prostate. RESULTS: Of the 360 of 2,242 men (16%) who underwent re-treatment holmium laser enucleation of the prostate the procedure was done for residual urinary symptoms in 71%. The most common primary procedure was transurethral resection of the prostate in 42% of cases. Mean time between prior benign prostatic hyperplasia surgery and re-treatment was 68 months (range 1 to 444). There were no significant differences in age, prostate size, AUA (American Urological Association) symptom score or average flow rate between the cohorts. Perioperatively, re-treatment holmium laser enucleation of the prostate was associated with significantly shorter operative time, reduced blood loss, lower specimen weight and shorter length of stay. The AUA symptom score improved in both groups, although it remained higher in men who underwent re-treatment (6.5 vs 5.0, p <0.001). The likelihood of clot retention (4.7% vs 1.8%, p = 0.01) and urethral stricture (3.3% vs 1.5%, p = 0.043) was slightly higher in the re-treatment group. CONCLUSIONS: Immediate perioperative outcomes of holmium laser enucleation of the prostate performed in the re-treatment setting were no different from those in the primary setting. While re-treatment was associated with an increased likelihood of clot retention, urethral stricture and higher AUA symptom score, these minimal differences must be considered against the overall favorable symptom improvement across both cohorts.

Antimicrobial resistance patterns in cases of obstructive pyelonephritis secondary to stones.

OBJECTIVE: To characterize the local antimicrobial resistance pattern in patients with obstructing ureteral stones and fever, compare this with our local antibiograms, and guide recommendations for empiric antibiotic regimens. METHODS: A retrospective chart review was performed of patients who underwent ureteroscopic intervention for the management of ureteral stones at a neighboring private hospital and a public hospital to identify those patients who had undergone prior decompression for obstructing ureteral stones and fever between 2004 and 2011. Urine culture results were captured to identify uropathogens and sensitivity patterns to antibiotics. These were compared with respective hospital antibiograms. RESULTS: Sixty-five patients were identified, of which 35 had positive urine culture results. More than 25% of the voided urine and upper urinary tract urine cultures differed. Antimicrobial resistance patterns were higher for patients at the public hospital than the hospital antibiogram. The opposite was true at the private hospital. The public hospital demonstrated an overall higher resistance pattern than the private hospital. CONCLUSION: Antimicrobial resistance makes the selection of empiric antibiotic treatment challenging in patients with obstructive pyelonephritis secondary to ureteral stones. Because of discordance between voided urine cultures and those captured at the time of decompression, it is imperative to obtain both voided urine and urine from the kidney to ensure adequate antibiotic coverage. Local population-specific antimicrobial guidelines that are frequently updated are essential to ensure adequate coverage and treatment of obstructive pyelonephritis, and condition-specific antibiograms would be recommended in the future.