Which Men Do or Do Not Achieve Long-Term Symptom Relief After Holmium Laser Enucleation of the Prostate (HoLEP): 11 Years of HoLEP Experience.

Purpose: Apart from the existing level-one evidence, few centers have reported on long-term outcomes after Holmium Laser Enucleation of the Prostate (HoLEP). Against this backdrop we aimed to report on our treatment experience and identify predictors of persistent/recurrent lower urinary tract symptoms (LUTS) after the procedure. Materials and Methods: From 2006 to 2017, 2566 men underwent HoLEP at our institution. Only patients with available, cross-sectional follow-up (F/u) ≥6 months were included. Perioperative and F/u characteristics were compared by duration of F/u in months (quartiles). Multivariable logistic regression models (MVAs) were used to identify predictors of persistent/recurring symptoms, defined as International Prostate Symptom Score (IPSS) >7 at F/u. Results: A total of 774 patients with a median age of 70 years (interquartile range [IQR] = 66-75), prostate volume of 80 mL (IQR = 60-105), American Society of Anesthesiologists score 2 (IQR = 2-3), IPSS of 19 (IQR = 14-24), and quality of life (QoL) of 4 (3-5) at the time of operation were analyzed. Median F/u was 52 months (IQR = 32-77), overall current median prostate-specific antigen was 0.91 mg/dL (0.5-1.8), median IPSS and QoL were 3 (IQR = 1-7) and 1 (IQR 0-2), respectively. LUTS medication was present in 20 patients (2.6%), 15 (2%) patients required reoperation, and permanent urinary incontinence was present in 17 (2.2%) patients. On MVA age at operation (odds ratio [OR] = 1.04; 95% confidence interval [CI], 1.01-1.1; p = 0.013), prostate volume (OR = 0.99 [95% CI, 0.98-0.99;], p = 0.003), body mass index (OR = 1.06 [95% CI, 1.0-1.1], p = 0.043), presence of indwelling catheter (OR = 0.51 [95% CI, 0.32-0.81], p = 0.004), and anticholinergics before procedure (OR = 1.74 [95% CI, 1.01-3.0], p = 0.046) were predictors of persistent/recurring symptoms. Conclusions: Our HoLEP experience confirms durable and profound symptom relief in the vast majority men. A small fraction of patients complained about subjective persistent/recurring LUTS stressing the need for proper patient selection and timing of surgical intervention.

Assessing the Outcome of Holmium Laser Enucleation of the Prostate by Age, Prostate Volume, and a History of Blood Thinning Agents: Report from a Single-Center Series of >1800 Consecutive Cases.

Purpose: To assess perioperative outcomes of holmium laser enucleation of the prostate (HoLEP) in a real-world scenario and with a focus on demanding patient factors, such as large prostate size, advanced patient age, and anticoagulation therapy (AT). Materials and Methods: We retrospectively analyzed HoLEP procedures at our institution between 2010 and 2016. After stratification by prostate volume, age, and AT, perioperative and early voiding characteristics were compared. A multivariable regression model was employed to identify predictors of prolonged time of catheterization (defined as being above group's median). Results: The study cohort consisted of 1816 men with a median age of 71 years (interquartile range [IQR]: 66-76), a median prostate volume of 80 mL (IQR: 58-105), and American Society of Anesthesiologists score ≥3 in 618 men (34%). Median time of enucleation and morcellation was 43 minutes (IQR: 31-60) and 10 minutes (IQR: 6-18), respectively. Perioperative blood transfusions were administered in 44 (2.4%) cases, severe postoperative complications (Clavien-Dindo grade ≥3b) occurred in 61 (3.3%) cases. The median time of catheterization was 2 days (IQR: 2-2), with prolonged catheterization occurring in 277 (15%) cases. After adjustment, large prostates (fourth volume quartile [106-280 mL]) (odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.3-2.6, p = 0.001), therapeutic low-molecular-weight heparin bridging regimen (OR: 2.2, 95% CI: 1.4-3.6, p = 0.037), low-dose acetylsalicylic acid (OR: 1.5, 95% CI: 1.0-2.2, p = 0.015), and a history of direct oral anticoagulation (OR: 2.3, 95% CI: 1.2-4.0, p = 0.022), but not patient age, were independently associated with prolonged catheterization. Conclusions: We confirm HoLEP as safe and efficient; however, patients with large prostates and patients with a history of AT are at risk of prolonged catheterization.

The impact of cytoreductive nephrectomy on survival outcomes in patients treated with tyrosine kinase inhibitors for metastatic renal cell carcinoma in a real-world cohort.

BACKGROUND: Tyrosine kinase inhibitor therapy (TKI) has changed the treatment paradigm of metastatic renal cell carcinoma (mRCC). The recent CARMENA and SURTIME trials challenged the role of the cytoreductive nephrectomy (CN). OBJECTIVE: To assess the impact of CN prior to TKI therapy in patients with mRCC in a real-world setting. METHODS: Overall, 262 consecutive patients with mRCC were treated with CN plus TKI or TKI only at our institution between 2000 and 2016. Patients with prior immunotherapy or metastasectomy were excluded. Multiple imputation and inverse probability of treatment weighting (IPTW) were performed to account for missing values and imbalances between the treatment groups, respectively. Unadjusted and adjusted Kaplan-Meier estimates were used to determine differences in progression-free (PFS), overall (OS), and cancer-specific survival (CSS). RESULTS: Overall, 104 (40%) patients received CN before TKI treatment. Most frequent first line therapy was Sunitinib (66%), followed by Sorafenib (20%) and Pazopanib (10%). After adjustment with IPTW, there was no difference in PFS, CSS, and OS (all P > 0.05) between the treatment groups. In subgroup analyses, CSS was improved when CN was performed in patients with sarcomatoid features and clear cell histology (P = 0.04 and P = 0.03) and PFS was improved in patients with clear cell histology when CN was performed [0.04]). CN did not improve OS in any subgroup analysis. CONCLUSION: The role of CN remains controversial. We found no difference in survival outcomes between patients treated with and without CN before TKI therapy. However, CN was associated with improved survival in specific patient subgroups. Tailored, individualized treatment is key to further improve oncological outcomes for mRCC.

Prospective analysis of artificial urinary sphincter AMS 800 implantation after buccal mucosa graft urethroplasty.

OBJECTIVES: To analyze functional outcomes and complication rates of artificial urinary sphincter (AUS) implantation in patients who had undergone buccal mucosa graft urethroplasty (BMGU) beforehand. PATIENTS AND METHODS: This prospectively maintained single-center database comprises data from 236 patients from 2009 to 2015 who underwent AUS implantation. A total of 17 patients after BMGU were available for analysis. Primary endpoints consisted of continence and complication rates. Continence was defined as no use of safety pads, social continence as < 2 pads per day. Stricture recurrence was defined as a decrease in uroflowmetry, a maximum flow rate < 10 ml/s or residual urine volume (> 100 ml). Kaplan-Meier analysis determined explantation-free survival. RESULTS: Median follow-up was 24 months (interquartile range [IQR] 6-31 months). Indication for AUS implantation was severe urinary incontinence with a history of radical prostatectomy (RRP) in 8 (47.1%), trauma in 1 (5.9%) and TUR-P in 8 (47.1%) patients. Pelvic irradiation was reported in 13 (76.5%) cases. The median length of buccal mucosa graft for urethroplasty was 4 cm (3-5 cm). A double cuff was implanted in 14 patients (82.4%), 3 patients received a single cuff. Complete and social continence was achieved in 76.5% and 100% of the patients, respectively. There was no significant difference in complications and explantation-free survival (log-rank, p = 0.191) between patients who had undergone BMGU before AUS compared to patients with no history of BMGU. CONCLUSIONS: According to the prospective follow-up data in a homogenous cohort, AUS implantation seems to be a viable, safe and effective therapeutic strategy for incontinence treatment despite previous BMGU.

Assessment of energy density usage during 180W lithium triborate laser photoselective vaporization of the prostate for benign prostatic hyperplasia. Is there an optimum amount of kilo-Joules per gram of prostate?

OBJECTIVES: To assess the effect of energy density (kJ/mL) applied on adenoma during photoselective vaporization of the prostate (PVP) treatment for benign prostate hyperplasia (BPH) on functional outcomes, prostate-specific antigen (PSA) reduction and complications. PATIENTS AND METHODS: After exclusions, a total of 440 patients who underwent GreenLight (tm) laser XPS-180W lithium triborate PVP for the treatment of BPH were retrospectively reviewed. Data were collected from seven different international centres (Canada, USA, UK and France). Patients were stratified into four energy density groups (kJ/mL) according to intra-operative energy delivered and prostate volume as determined by preoperative transrectal ultrasonography (TRUS): group 1: <3 kJ/mL; group 2: 3-5 kJ/mL; group 3: 5-7 kJ/mL; and group 4: ≥7 kJ/mL. Energy density groups were chosen arbitrarily. PSA reduction and functional outcomes (International Prostate Symptom Score, quality of life, post-void residual urine volume, maximum urinary flow rate) were compared at 6, 12 and 24 months. Peri-operative complications and retreatment rates were also compared among the groups. RESULTS: The PSA reduction rates at 24 months after the procedure were 51, 61, 79 and 83% for the energy density groups <3, 3-5, 5-7 and ≥7 kJ/mL, respectively (P ≤ 0.01). This held true after accounting for baseline confounders. Energy density was not associated with higher complication rates, including haematuria, stricture formation, incontinence, refractory urinary retention, urinary tract infection and conversion to transurethral resection of the prostate. Functional outcomes at 2 years of follow-up were equivalent among the groups (P > 0.05 for all) and similar retreatment rates were observed (P = 0.36). CONCLUSION: Higher energy usage per cc of prostate was associated with a more significant reduction in PSA level (>50%) at 6, 12 and 24 months, suggesting increased vaporization of adenoma tissue; however, this did not translate into differences in functional outcomes at 2-year follow-up.