Revisiting the issue of "beach balls" in holmium laser enucleation of prostate: clinical and histological characterization.

PURPOSE: To clinically and histologically characterize prostatic nodules resistant to morcellation ("beach balls," BBs). PATIENTS AND METHODS: We reviewed a consecutive cohort of 559 holmium laser enucleation of the prostate (HoLEP) procedures performed between January 2020 and November 2023. The BBs group comprised 55 men (10%) and the control group comprised 504 men (90%). The clinical, intraoperative, outcome, and histologic data were statistically processed for the prediction of the presence of BBs and their influence on the perioperative course and outcome. RESULTS: The BBs group in comparison to the controls was older (75 vs 73 years, respectively, p = 0.009) and had higher rates of chronic retention (51 vs 29%, p = 0.001), larger prostates on preoperative abdominal ultrasound (AUS) (140 vs 80 cc, p = 0.006E-16), longer operating time (120 vs 80 min, p = 0.001), higher weights of removed tissue (101 vs 60 gr, p = 0.008E-10), higher complication rates (5 vs 1%, p = 0.03), and longer hospitalization (p = 0.014). A multivariate analysis revealed that larger prostates on preoperative AUS and older age independently predicted the presence of BBs which would prolong operating time. ROC analyses revealed that a threshold of 103 cc on AUS predicted BBs with 94% sensitivity and 84% specificity. BBs were mostly characterized histologically by stromal component (p = 0.005). CONCLUSIONS: BBs are expected in older patients and cases of chronic retention. Prostatic volume is the most reliable predictor of their presence. They contribute to prolonged operating time and increased risk of complications. The predominantly stromal composition of the BBs apparently confers their resistance to morcellation.

Incidence of complications and urinary incontinence following endoscopic enucleation of the prostate in men with a prostate volume of 80 ml and above: results from a multicenter, real-world experience of 2512 patients.

PURPOSE: To evaluate complications and urinary incontinence (UI) after endoscopic enucleation of the prostate (EEP) stratified by prostate volume (PV). METHODS: We retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with different energy sources in 14 centers (January 2019-January 2023). INCLUSION CRITERIA: prostate volume ≥ 80 ml. EXCLUSION CRITERIA: prostate cancer, previous prostate/urethral surgery, pelvic radiotherapy. PRIMARY OUTCOME: complication rate. SECONDARY OUTCOMES: incidence of and factors affecting postoperative UI. Patients were divided into 3 groups. Group 1: PV = 80-100 ml; Group 2 PV = 101-200 ml; Group 3 PV > 200 ml. Multivariable logistic regression analysis was performed to evaluate independent predictors of overall incontinence. RESULTS: There were 486 patients in Group 1, 1830 in Group 2, and 196 in Group 3. The most commonly used energy was high-power Holmium laser followed by Thulium fiber laser in all groups. Enucleation, morcellation, and total surgical time were significantly longer in Group 2. There was no significant difference in overall 30-day complications and readmission rates. Incontinence incidence was similar (12.1% in Group 1 vs. 13.2% in Group 2 vs. 11.7% in Group 3, p = 0.72). The rate of stress and mixed incontinence was higher in Group 1. Multivariable regression analysis showed that age (OR 1.019 95% CI 1.003-1.035) was the only factor significantly associated with higher odds of incontinence. CONCLUSIONS: PV has no influence on complication and UI rates following EEP. Age is risk factor of postoperative UI.

Results from a global multicenter registry of 6193 patients to refine endoscopic anatomical enucleation of the prostate (REAP) by evaluating trends and outcomes and nuances of prostate enucleation in a real-world setting.

PURPOSE: To collect a multicentric, global database to assess current preferences and outcomes for endoscopic enucleation of the prostate (EEP). METHODS: Endourologists experienced in EEP from across the globe were invited to participate in the creation of this retrospective registry. Surgical procedures were performed between January 2020 and August 2022. INCLUSION CRITERIA: lower urinary tract symptoms not responding to or worsening despite medical therapy and absolute indication for surgery. EXCLUSION CRITERIA: prostate cancer, concomitant lower urinary tract surgery, previous prostate/urethral surgery, pelvic radiotherapy. RESULTS: Ten centers from 7 countries, involving 13 surgeons enrolled 6193 patients. Median age was 68 [62-74] years. 2326 (37.8%) patients had large prostates (> 80 cc). The most popular energy modality was the Holmium laser. The most common technique used for enucleation was the 2-lobe (48.8%). 86.2% of the procedures were performed under spinal anesthesia. Median operation time was 67 [50-95] minutes. Median postoperative catheter time was 2 [1, 3] days. Urinary tract infections were the most reported complications (4.7%) followed by acute urinary retention (4.1%). Post-operative bleeding needing additional intervention was reported in 0.9% of cases. 3 and 12-month follow-up visits showed improvement in symptoms and micturition parameters. Only 8 patients (1.4%) required redo surgery for residual adenoma. Stress urinary incontinence was reported in 53.9% of patients and after 3 months was found to persist in 16.2% of the cohort. CONCLUSION: Our database contributes real-world data to support EEP as a truly well-established global, safe minimally invasive intervention and provides insights for further research.

Mini-HoLEP (MILEP) vs HoLEP: a propensity score-matched analysis.

BACKGROUND AND PURPOSE: Minimal invasiveness improves outcome in many surgical fields including urology. We aimed to assess intraoperative performance and clinical outcome of miniaturized holmium laser enucleation of prostate (MiLEP) (22FR). METHODS: We ran a propensity score-matched analysis among all consecutive laser enucleations of prostate performed between 9/2022 and 2/2023. It resulted in two matched comparison groups: MiLEP 22 FR (n = 40) and holmium laser enucleation of prostate (HoLEP 26 Fr) (n = 40). Statistical analysis was performed. RESULTS: MiLEP was associated with significantly less intraoperative irrigation (20.5 L vs 15 L, p = 0.002E-3), less decrease in body core temperature (0.6°C vs 0.1°C, p = 0.003E-5), and less need for meatal dilation (25% vs 78%, p = 0.01E-3). These parameters were identified as being independent in the multivariate analysis. There was a trend toward less and a shorter period of postoperative stress incontinence (SI) for the MiLEP group compared to the HoLEP group: 15% and 42% (p = 0.01) at 1 month, 8% and 14% (p = 0.07) at 2 months, and 0 and 0.3% (p = 1) at 3 months, respectively. There were no differences in prostatic enucleation effectiveness, operative time, hospital stay, complications, and improvement in the international prostate symptom score and quality of life score. CONCLUSIONS: MiLEP is feasible and provides better maintenance of body core temperature, reduction in amount of fluid irrigation, and decrease in need for meatal dilation without affecting effectiveness in comparison with HoLEP. MiLEP may reduce early postoperative stress incontinence, thereby shortening the recovery period.

Endourologic procedures combined with other surgical and urologic interventions--early experience.

OBJECTIVES: To assess the feasibility of performing endourologic interventions combined with other operations during the same operative session. METHODS: Eighteen patients underwent simultaneous operations endourologically for upper urinary tract pathologic findings and other surgical and urologic indications. The operating time, technical feasibility, operative success, complications, hospital stay, and patient satisfaction were analyzed. RESULTS: The average patient age was 63 years (range 40 to 83). Five patients underwent percutaneous nephrolithotomy combined with either contralateral laparoscopic nephrectomy, contralateral open nephrectomy, radical retropubic prostatectomy, inguinal/umbilical hernia repair, transurethral resection of prostate, or cystolithotripsy. Thirteen patients underwent 15 retrograde endoscopic procedures (13 for stone disease and 2 for diagnostic purposes) that were combined with open contralateral nephrectomy, inguinal hernia repair, circumcision, closure of ileostomy, transurethral resection of bladder tumor, excision of lymphoma of thigh, drainage and sclerozation of hydrocele, or percutaneous gastrostomy. All procedures were successfully completed without complications. The average hospital stay was 5 days (range 3 to 6) in the percutaneous nephrolithotomy group and 2 days (range 1 to 5) in the retrograde endoscopic procedure group. The duration of hospitalization was related to the more complex operation; combining the procedures did not prolong it. The average follow-up was 11 months (range 3 to 24). All patients were highly satisfied because they were spared the need for more than one surgical session. CONCLUSIONS: Our results support the concept of performing simultaneous endourologic procedures and other operations during one surgical session. This approach obviates the need for repeated anesthesia, patient inconvenience, the psychological stress related to multiple operations, and reduces the total hospital stay.

Refinements in treatment of large bladder calculi: simultaneous percutaneous suprapubic and transurethral cystolithotripsy.

OBJECTIVES: To present a combined endourologic approach to treat bladder calculi consisting of simultaneous percutaneous suprapubic and transurethral cystolithotripsy. METHODS: We report on a series of 12 consecutive patients with bladder stone burdens of 40 mm or greater. Percutaneous 30F access was obtained under cystoscopic control. Fragmentation and stone removal were performed simultaneously by two urologists using a Swiss lithoclast, holmium laser, and/or ultrasound lithotriptor through both percutaneous and transurethral routes. Suprapubic and transurethral catheters were placed postoperatively. RESULTS: Twelve patients with a median age of 66 years (range 33 to 80) were treated by simultaneous percutaneous suprapubic and transurethral cystolithotripsy. Six underwent transurethral resection of the prostate at the completion of stone clearance. The median stone size was 60 mm (range 40 to 80), and the median lithotripsy time was 56 minutes (range 45 to 70). The median postoperative hospitalization was 2.7 days (range 2 to 5), and complete stone clearance was achieved in all cases. One patient, who underwent concomitant transurethral resection of the prostate, developed urinary retention 1 week postoperatively and was successfully treated by temporary transurethral catheterization. One patient with a positive urine culture preoperatively developed fever on the first postoperative day and was treated with intravenous antibiotics according to the antibiogram results for 5 days. No other complications had occurred after a median follow-up of 10 months (range 3 to 15). CONCLUSIONS: Simultaneous percutaneous suprapubic and transurethral cystolithotripsy appears to be a safe approach for the management of large bladder calculi and may shorten the total fragmentation time. It can be combined with transurethral resection of the prostate without prolonging hospitalization. The simultaneous use of two modalities of stone fragmentation represents an effective and minimally invasive way of treating large bladder calculi.

The procedure of transrectal ultrasound guided biopsy of the prostate: a survey of patient preparation and biopsy technique.

PURPOSE: We surveyed urologists in community and academic practice regarding their standard approach to patient preparation and their technique of transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS: We mailed 110 surveys to community urologists in Florida and urological oncologists at academic centers across the United States. Responses were calculated per group. RESULTS: Of the 88 respondents 34% were at academic centers and 66% were community urologists. Overall 79% of respondents prescribe an enema in preparation for biopsy, 81% administer an oral fluoroquinolone before biopsy, 50% give some type of analgesia, usually an oral agent, 63% obtain 8 or more cores per biopsy session, 36% biopsy the lateral and midline locations, and 83% do not use prostate specific antigen density to plan the biopsy strategy. CONCLUSIONS: The majority of urologists who responded to our survey ask their patients to use an enema in preparation for a transrectal biopsy procedure, prescribe an oral antibiotic and administer some type of analgesia. Few urologists administer a periprostatic nerve block. The majority obtain at least 8 biopsies and only 17% perform sextant biopsy. Some of these practices are not consistent with the literature. This survey provides insight into the practice patterns of urologists in regard to one of the most commonly performed office procedures.