Minimally invasive techniques in quest of Holy Grail of surgical management of enlarged prostates: a narrative review.

PURPOSE: Past decade has seen a renewed interest in minimally invasive surgical techniques (MISTs) for management of enlarged prostate. This narrative review aims to explore newer MIST for benign prostatic hyperplasia (BPH) which are not yet integrated into established societal guidelines. METHODS: We conducted a literature search across PubMed, Google Scholar, and FDA ClinicalTrials.gov databases on June 1st, 2023, to identify studies published within the past decade exploring various MISTs for BPH. Additionally, we gathered insights from abstracts presented in meetings of professional associations and corporate websites. We broadly classified these procedures into three distinct categories: energy-based, balloon dilation, and implant/stent treatments. We collected detail information about the device, procedure details, its inclusion and exclusion criteria, and outcome. RESULTS: Our review reveals that newer energy-based MISTs include Transperineal Laser Ablation, Transurethral Ultrasound Ablation, and High-Intensity Focused Ultrasound. In the sphere of balloon dilation, Transurethral Columnar Balloon Dilation and the Optilume BPH Catheter System were gaining momentum. The noteworthy implants/stents that are on horizon include Butterfly Prostatic Retraction Device, Urocross Expander System, Zenflow Spring System, and ProVee Urethral Expander System. CONCLUSION: The exploration of various MISTs reflects ongoing efforts to enhance patient care and address limitations of existing treatments. This review provides a bird-eye view and valuable insights for urologists and researchers seeking to navigate the dynamic landscape of MISTs in the quest for effective and minimally invasive solutions for enlarged prostates.

Real world propensity score matched analysis evaluating the influence of en-bloc vs. non en-bloc techniques, energy and instrumentation on enucleation outcomes for large and very large prostates.

PURPOSE: The primary aim of the study was to evaluate if en-bloc vs. non en-bloc made a difference to intra-, peri- and post-operative surgical outcomes of anatomical endoscopic enucleation (AEEP) in large (> 80 cc) and very large prostates (> 200 cc). The secondary aim was to determine the influence of energy and instruments used. METHODS: Data of patients with > 80 cc prostate who underwent surgery between 2019 and 2022 were obtained from 16 surgeons across 13 centres in 9 countries. Propensity score matching (PSM) was used to reduce confounding. Logistic regression was performed to evaluate factors associated with postoperative urinary incontinence (UI). RESULTS: 2512 patients were included with 991 patients undergoing en-bloc and 1521 patients undergoing non-en-bloc. PSM resulted in 481 patients in both groups. Total operation time was longer in the en-bloc group (p < 0.001), enucleation time was longer in the non en-bloc group (p < 0.001) but morcellation times were similar (p = 0.054). Overall, 30 day complication rate was higher in the non en-bloc group (16.4% vs. 11.4%; p = 0.032). Rate of late complications (> 30 days) was similar (2.3% vs. 2.5%; p > 0.99). There were no differences in rates of UI between the two groups. Multivariate analysis revealed that age, Qmax, pre-operative, post-void residual urine (PVRU) and total operative time were predictors of UI. CONCLUSIONS: In experienced hands, AEEP in large prostates by the en-bloc technique yields a lower rate of complication and a slightly shorter operative time compared to the non en-bloc approach. However, it does not have an effect on rates of post-operative UI.

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.

Experts' recommendations in laser use for the treatment of bladder cancer: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training and Research in Urological Surgery and Technology (TRUST)-Group.

PURPOSE: To identify laser settings and limits applied by experts during laser vaporization (vapBT) and laser en-bloc resection of bladder tumors (ERBT) and to identify preventive measures to reduce complications. METHODS: After a focused literature search to identify relevant questions, we conducted a survey (57 questions) which was sent to laser experts. The expert selection was based on clinical experience and scientific contribution. Participants were asked for used laser types, typical laser settings during specific scenarios, and preventive measures applied during surgery. Settings for a maximum of 2 different lasers for each scenario were possible. Responses and settings were compared among the reported laser types. RESULTS: Twenty-three of 29 (79.3%) invited experts completed the survey. Thulium fiber laser (TFL) is the most common laser (57%), followed by Holmium:Yttrium-Aluminium-Garnet (Ho:YAG) (48%), continuous wave (cw) Thulium:Yttrium-Aluminium-Garnet (Tm:YAG) (26%), and pulsed Tm:YAG (13%). Experts prefer ERBT (91.3%) to vapBT (8.7%); however, relevant limitations such as tumor size, number, and anatomical tumor location exist. Laser settings were generally comparable; however, we could find significant differences between the laser sources for lateral wall ERBT (p = 0.028) and standard ERBT (p = 0.033), with cwTm:YAG and pulsed Tm:YAG being operated in higher power modes when compared to TFL and Ho:YAG. Experts prefer long pulse modes for Ho:YAG and short pulse modes for TFL lasers. CONCLUSION: TFL seems to have replaced Ho:YAG and Tm:YAG. Most laser settings do not differ significantly among laser sources. For experts, continuous flow irrigation is the most commonly applied measure to reduce complications.

Experts' recommendations in laser use for the treatment of urolithiasis: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group.

PURPOSE: To identify laser lithotripsy settings used by experts for specific clinical scenarios and to identify preventive measures to reduce complications. METHODS: After literature research to identify relevant questions, a survey was conducted and sent to laser experts. Participants were asked for preferred laser settings during specific clinical lithotripsy scenarios. Different settings were compared for the reported laser types, and common settings and preventive measures were identified. RESULTS: Twenty-six laser experts fully returned the survey. Holmium-yttrium-aluminum-garnet (Ho:YAG) was the primary laser used (88%), followed by thulium fiber laser (TFL) (42%) and pulsed thulium-yttrium-aluminum-garnet (Tm:YAG) (23%). For most scenarios, we could not identify relevant differences among laser settings. However, the laser power was significantly different for middle-ureteral (p = 0.027), pelvic (p = 0.047), and lower pole stone (p = 0.018) lithotripsy. Fragmentation or a combined fragmentation with dusting was more common for Ho:YAG and pulsed Tm:YAG lasers, whereas dusting or a combination of dusting and fragmentation was more common for TFL lasers. Experts prefer long pulse modes for Ho:YAG lasers to short pulse modes for TFL lasers. Thermal injury due to temperature development during lithotripsy is seriously considered by experts, with preventive measures applied routinely. CONCLUSIONS: Laser settings do not vary significantly between commonly used lasers for lithotripsy. Lithotripsy techniques and settings mainly depend on the generated laser pulse's and generator settings' physical characteristics. Preventive measures such as maximum power limits, intermittent laser activation, and ureteral access sheaths are commonly used by experts to decrease thermal injury-caused complications.

Antegrade ejaculation preservation in surgical treatment for benign prostatic hyperplasia: quest for balance between voiding and sexual function.

PURPOSE OF REVIEW: Surgical treatment of benign prostatic hyperplasia (BPH) carries a significant risk of ejaculation dysfunction. Preservation of antegrade ejaculation while providing effective, well tolerated, and durable treatment of BPH is a paramount component of physical and sexual well being for significant number of men. We reviewed available literature with an aim of providing status on antegrade ejaculation preserving BPH surgical therapies. RECENT FINDINGS: Minimally invasive surgical therapies for BPH have been developed over the last decade, with significant marketing emphasis on their potential for preservation of antegrade ejaculation. However, the question about durability of relief of bladder outlet obstruction remains. Parallel to this technological development, the understanding of anatomical structures involved in ejaculation have resulted in technical modifications of well established surgical treatments modalities like transurethral resection of prostate, endoscopic enucleation of prostate and simple prostatectomy, thereby providing safe and durable relief of bladder outlet obstruction secondary to BPH with a satisfactory preservation of antegrade ejaculation. SUMMARY: Preservation of antegrade ejaculation is an important goal for significant number of men needing BPH surgery. Novel minimally invasive surgical technologies have been developed for this purpose; but understanding of the anatomical structures essential for antegrade ejaculation have allowed technical modification of existing surgical techniques with excellent preservation of antegrade ejaculation.

En bloc resection of bladder tumors (ERBT) revisited 12 years after reintroduction: too good to be further ignored.

En bloc resection of bladder tumors (ERBT) orginally described in 1980 and adopted by few centers in the late 1990s has regained attention in the 2010s as a renaissance of a technique with high potential. The advent of new lasers indirectly lead to a better understanding of anatomical dissection from the experience in anatomical dissection in endoscopic enucleation of the prostate. 12 years after the reintroduction of ERBT evidence mounts that it is not only equivalent but better in some regards. However, ERBT still falls short with regard to wide adoption despite the striking technique inherent and reproducible features of accurate staging and specimen quality as requested by pathologist, as well and despite the high intraoperative safety and fast adoption of this technique even in early phase of training. The editorial walks the reader through the timeline of the renaissance speculating why there is a blockage between cognitive understanding and dissonance in surgical practice. The special issues presents the meta-analysis of surgical and oncological data on one hand and the level of understanding and power of this surgical technique in fields offsite oncological results in training achieving results almost right from the start after adoptation. Unlike in earlier years reviewing the literature of ERBT in 2023, ERBT seems not only to be a viable alternative, but something one should turn towards no to underperform with regards to the endpoints achievable by ERBT in a critical disease like bladder cancer.

Peri- and post-operative outcomes, complications, and functional results amongst different modifications of endoscopic enucleation of the prostate (EEP): a systematic review and meta-analysis.

PURPOSE: To investigate and assess outcomes, complications, and functional results amongst different modifications of endoscopic enucleation of the prostate (EEP). METHODS: We conducted a systematic review and meta-analysis according to the PRISMA checklist. We searched the Medline, Cochrane, and Embase databases. We included only randomised-controlled trials (RCT) comparing modifications of EEPs and assessed the risk of bias (RoB). RESULTS: Seven RCTs were included in the study. Overall, 1266 patients were treated with Holmium laser enucleation of the prostate (HoLEP) and 80 patients with thulium laser vapo-enucleation of the prostate (ThuVEP). The operative time during pulse shape-modified HoLEP was shorter when compared to standard pulse HoLEP (MD 18.08 min, 95% CI 8.11-28.05 min, p = 0.0004). The decrease in haemoglobin was significantly lower for two-lobe HoLEP when compared to three-lobe HoLEP (MD 0.16 g/dl, 95% CI 0.22-0.1 g/dl, p < 0.00001). Virtual Basket (VB) HoLEP showed a smaller haemoglobin decrease when compared to standard pulse HoLEP (1.12 ± 1.78 vs. 2.54 ± 1.23 g/dl, p = 0.03). When directly comparing one- vs. two- vs. three-lobe HoLEP, surgical time (p < 0.001) and enucleation efficiency (p = 0.006) were significantly different and favouring one- and two-lobe HoLEP in the study with the largest patient population included. No significant differences for complications were observed; however, Clavien-Dindo IVa events were reported for two patients. CONCLUSION: All variations of EEP improve symptoms and functional parameters with a low incidence of high-grade complications. One- and two-lobe approaches and pulse shape-modified HoLEP seem to be beneficial in terms of operative time and blood loss.

Tissue thermal effect during lithotripsy and tissue ablation in endourology: a systematic review of experimental studies comparing Holmium and Thulium lasers.

PURPOSE: We looked into the Thulium: yttrium-aluminum-garnet (TM:YAG), Thulium Fibre laser (TFL) and Holmium: yttrium-aluminum-garnet (Ho:YAG) thermal laser tissue effect during lithotripsy and tissue ablation. METHODS: We performed a PubMed, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) search. RESULTS: During lithotripsy, the Ho:YAG generated temperatures from 24 to 68.7 °C at powers < 20 W, the Tm:YAG from 43.7 °C at 30 W to 68 °C at powers < 20 W, and the TFL from 33 to 40.46 °C. During ablation, the Ho:YAG and continuous wave (cw) Tm:YAG tissue incision depths ranged from 0.08 to 2.26 mm, and from 0.28 to 3.22 mm. The Ho:YAG and Tm:YAG vaporization areas ranged from 0.044 to 0.078 mm2 and from 0.050 to 0.078 mm3 and their coagulation zones were 0.075 mm2 and 0.125 mm3 respectively. Ho:YAG and Tm:YAG laser damage zones ranged from 0.093 to 2.6 mm3 and from 0.207 to 0.98 mm3 respectively. The TFL incision depth ranged from 0.04 to 5.7 mm. The cw and SuperPulsed (SP) vaporization volumes ranged from 8 to 28.2 mm3/s and from 4 to 11 mm3/s. TFL coagulation depth and coagulation zone ranged from zero to 1.1 mm, 2.2 to 5.1 mm3 in SP mode and from 7.7 to 18.1 mm3 in cw mode. CONCLUSION: During lithotripsy all lasers caused similar temperature changes and had a safe temperature profile at < 40 W. During tissue ablation, Ho:YAG has a deeper incision depth, while cwTm:YAG and cwTFL have broader coagulation and total laser areas.

A 10-year renaissance of en bloc resection of bladder tumors (ERBT): Are we approaching the peak or is it back to the trough?

BACKGROUND: The number of studies suggesting that en bloc resection of bladder tumor (ERBT) is superior to transurethral resection of bladder tumor (TURBT) for non-muscle-invasive bladder cancer (NMIBC) management is growing. The aim of this review is to discuss the features of these procedures and to determine the prospects of en bloc in NMIBC management. MATERIALS AND METHODS: We conducted a literature search using two databases (Medline and Scopus) and included any research which reported ERBT outcomes. RESULTS: The lasers with minimal tissue penetration depth are becoming the main tool for ERBT. Unfortunately, most of the systematic reviews continue to be characterized by high heterogeneity. However, recent studies indicate that ERBT may have the edge when it comes to the detrusor muscle rate and the quality of the histological specimen. ERBT may favor in terms of in-field relapse, but its rate in the studies varies greatly. As for out-field relapse-free survival, the data are still lacking. The strongest evidence supports that ERBT is superior to TURBT in complications rate (bladder perforation). ERBT is feasible irrespective to tumor size and location. CONCLUSIONS: ERBT has gained in momentum with the increasingly widespread use of this kind of laser surgery. The introduction of novel sources (TFL and Thulium:YAG pulsed laser) will definitely affect how the field develops and will result in further improvements in safety and precision. The latest trials make us more certain in our belief that ERBT will be beneficial in terms of histological specimen quality, relapse rate and complications rate.

Holmium laser with MOSES technology (MoLEP) vs Thulium fiber laser enucleation of the prostate (ThuFLEP) in a real-world setting. Mid-term outcomes from a multicenter propensity score analysis.

PURPOSE: To compare Holmium laser with MOSES technology (MoLEP) and Thulium fiber laser enucleation of the prostate (ThuFLEP) in terms of surgical and functional outcomes. METHODS: We performed a retrospective analysis of all patients who underwent either procedure in five centers (January 2020-January 2022). EXCLUSION CRITERIA: previous urethral/prostatic surgery, radiotherapy, concomitant surgery. Propensity score matching (PSM) analysis was performed to adjust for the bias inherent to the different characteristics at baseline. Differences between procedures were estimated using Firth Penalized Likelihood regression for International prostate symptom score (IPSS), quality of life (QL), maximum flow rate (Qmax). RESULTS: PSM retrieved 118 patients in each group. Baseline characteristics were similar except for PSA and number of men on indwelling catheter (higher in MoLEP group). Median surgical time was significantly longer in the MoLEP group despite the enucleation and morcellation times being similar. Median catheter dwelling time and postoperative length of stay were similar. Most of the early complications were Clavien ≤ 2 grade. There were only two Clavien grade 3 complications (one for each group), one grade 4 in MoLEP group. Rate and type of early and persistent incontinence (> 3 months) were similar. At 12-month, proportion of patients reaching a decrease (Δ) of IPSS ≥ 18 from baseline was significantly larger in MoLEP group, with no significant difference in ΔQmax > 12 ml/sec and ΔQL ≥ -3. CONCLUSION: MoLEP and ThuFLEP were safe and efficacious procedures with similar short-term operative and functional outcomes. At 1-year, MoLEP patients had a sustained reduction of IPPS score.

The emerging role of the urinary microbiome in benign noninfectious urological conditions: an up-to-date systematic review.

PURPOSE: The goal of this systematic review was to examine the current literature on the urinary microbiome and its associations with noninfectious, nonmalignant, urologic diseases. Secondarily, we aimed to describe the most common bioinformatics used to analyze the urinary microbiome. METHODS: A comprehensive literature search of Ovid MEDLINE using the keywords "microbiota" AND "prostatic hyperplasia," "microbiota" AND "urinary bladder, overactive," "microbiota" AND "pelvic pain," and "microbiota" AND "urolithiasis" OR "nephrolithiasis" OR "urinary calculi" AND "calcium oxalate" was performed to identify relevant clinical microbiome studies associated with noninfectious benign urological conditions published from 2010 to 2022. We included human studies that evaluated the urinary, stone, or semen microbiota, or any combination of the above-mentioned locations. RESULTS: A total of 25 human studies met the inclusion criteria: 4 on benign prostatic hyperplasia (BPH), 9 on overactive bladder (OAB), 8 on calcium oxalate stones, and 4 on chronic pelvic pain syndrome (CPPS). Specific taxonomic profiles in the urine microbiome were associated with each pathology, and evaluation of alpha- and beta-diversity and relative abundance was accounted for most of the studies. Symptom prevalence and severity were also analyzed and showed associations with specific microbes. CONCLUSION: The study of the urogenital microbiome is rapidly expanding in urology. Noninfectious benign urogenital diseases, such as BPH, calcium oxalate stones, CPPS, and OAB were found to be associated with specific microbial taxonomies. Further research with larger study populations is necessary to solidify the knowledge of the urine microbiome in these conditions and to facilitate the creation of microbiome-based diagnostic and therapeutic approaches.

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.

Experts' recommendations in laser use for the endoscopic treatment of prostate hypertrophy: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group.

PURPOSE: To identify expert laser settings for BPH treatment and evaluate the application of preventive measures to reduce complications. METHODS: A survey was conducted after narrative literature research to identify relevant questions regarding laser use for BPH treatment (59 questions). Experts were asked for laser settings during specific clinical scenarios. Settings were compared for the reported laser types, and common settings and preventive measures were identified. RESULTS: Twenty-two experts completed the survey with a mean filling time of 12.9 min. Ho:YAG, Thulium fiber laser (TFL), continuous wave (cw) Tm:YAG, pulsed Tm:YAG and Greenlight™ lasers are used by 73% (16/22), 50% (11/22), 23% (5/22), 13.6% (3/22) and 9.1% (2/22) of experts, respectively. All experts use anatomical enucleation of the prostate (EEP), preferentially in one- or two-lobe technique. Laser settings differ significantly between laser types, with median laser power for apical/main gland EEP of 75/94 W, 60/60 W, 100/100 W, 100/100 W, and 80/80 W for Ho:YAG, TFL, cwTm:YAG, pulsed Tm:YAG and Greenlight™ lasers, respectively (p = 0.02 and p = 0.005). However, power settings within the same laser source are similar. Pulse shapes for main gland EEP significantly differ between lasers with long and pulse shape modified (e.g., Moses, Virtual Basket) modes preferred for Ho:YAG and short pulse modes for TFL (p = 0.031). CONCLUSION: Ho:YAG lasers no longer seem to be the mainstay of EEP. TFL lasers are generally used in pulsed mode though clinical applicability for quasi-continuous settings has recently been demonstrated. One and two-lobe techniques are beneficial regarding operative time and are used by most experts.

Experts' recommendations in laser use for the treatment of upper tract urothelial carcinoma: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training Research in Urological Surgery and Technology (T.R.U.S.T.) group.

PURPOSE: To highlight and compare experts' laser settings during endoscopic laser treatment of upper tract urothelial carcinoma (UTUC), to identify measures to reduce complications, and to propose guidance for endourologists. METHODS: Following a focused literature search to identify relevant questions, a survey was sent to laser experts. We asked participants for typical settings during specific scenarios (ureteroscopy (URS), retrograde intrarenal surgery (RIRS), and percutaneous treatment). These settings were compared among the reported laser types to find common settings and limits. Additionally, we identified preventive measures commonly applied during surgery. RESULTS: Twenty experts completed the survey, needing a mean time of 12.7 min. Overall, most common laser type was Holmium-Yttrium-Aluminum-Garnet (Ho:YAG) (70%, 14/20) followed by Thulium fiber laser (TFL) (45%, 9/20), pulsed Thulium-Yttrium-Aluminum-Garnet (Tm:YAG) (3/20, 15%), and continuous wave (cw)Tm:YAG (1/20, 5%). Pulse energy for the treatment of distal ureteral tumors was significantly different with median settings of 0.9 J, 1 J and 0.45 J for Ho:YAG, TFL and pulsed Tm:YAG, respectively (p = 0.048). During URS and RIRS, pulse shapes were significantly different, with Ho:YAG being used in long pulse and TFL in short pulse mode (all p < 0.05). We did not find further disparities. CONCLUSION: Ho:YAG is used by most experts, while TFL is the most promising alternative. Laser settings largely do not vary significantly. However, further research with novel lasers is necessary to define the optimal approach. With the recent introduction of small caliber and more flexible scopes, minimal-invasive UTUC treatment is further undergoing an extension of applicability in appropriately selected patients.

Thulium fiber laser in endourology: current clinical evidence.

PURPOSE OF REVIEW: To review and summarize preclinical and clinical data on thulium fiber laser's (TFL) effectiveness (ablation rate, stone-free rate etc.) and safety in terms of laser injuries and thermal damage. This enables us to assess how the in-vitro evidence translates into the clinical real-life scenario. RECENT FINDINGS: In this analysis, a total of 21 preclinical trials have been included. Most of the trials use conventional Holmium:YAG laser as a comparator, with only a few assessing lasers with pulse modulation. Most of the trials focus on the superior ablation rate and superior dusting features of TFL, as well as comparison of retropulsion (both in conventional Ho:YAG and in a pulse modulation), with a few studies assessing safety aspects. A total of 13 trials assessed TFL, clinically, in percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS). The clinical data obtained suggest that lithotripsy by TFL is safe, facilitates effective stone fragmentation, and results in a reduction of retropulsion. Unfortunately, most of the clinical trials lack a direct comparator, and so no clear-cut comparisons are possible. SUMMARY: During in-vitro studies, TFL demonstrated to be a new energy source with a great potential for improved ablation, lower retropulsion and improved dusting. These claims are supported in contemporary clinical studies, reporting superior ablation and negligible retropulsion in both PCNL and RIRS. However, it should be noted that the data regarding clinical results compared with conventional Ho:YAG is still limited.

Generated temperatures and thermal laser damage during upper tract endourological procedures using the holmium: yttrium-aluminum-garnet (Ho:YAG) laser: a systematic review of experimental studies.

PURPOSE: To perform a review on the latest evidence related to generated temperatures during Ho:YAG laser use, and present different tools to maintain decreased values, and minimize complication rates during endourological procedures. METHODS: We performed a literature search using PubMed, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials-CENTRAL, restricted to original English-written articles, including animal, artificial model, and human studies. Different keywords were URS, RIRS, ureteroscopy, percutaneous, PCNL, and laser. RESULTS: Thermal dose (t43) is an acceptable tool to assess possible thermal damage using the generated temperature and the time of laser exposure. A t43 value of more than 120 min leads to a high risk of thermal tissue injury and at temperatures higher than 43 °C Ho:YAG laser use becomes hazardous due to an exponentially increased cytotoxic effect. Using open continuous flow, or chilled irrigation, temperatures remain lower than 45 °C. By utilizing high-power (> 40 W) or shorter laser pulse, temperatures rise above the accepted threshold, but adding a ureteral access sheath (UAS) helps to maintain acceptable values. CONCLUSIONS: Open irrigation systems, chilled irrigation, UASs, laser power < 40 W, and shorter on/off laser activation intervals help to keep intrarenal temperatures at accepted values during URS and PCNL.

Irrigation fluid absorption during transurethral bipolar and laser prostate surgery: a systematic review.

PURPOSE: Transurethral endoscopic procedures using bipolar current, or laser energy are nowadays widely accepted and have replaced the traditional monopolar resection. A major advantage of these techniques is the utilization of isotonic saline as irrigation solution, which minimizes side effects such as symptoms associated to classical transurethral resection syndrome (TUR-syndrome). Nonetheless, clinically significant IFA also occurs with saline and is determined by pressure gradients, systemic resistance and by the amount of irrigation fluid. We aimed to investigate the extend of IFA and symptoms due to volume overload during bipolar transurethral resection (bTUR) and laser procedures of the prostate. METHODS: We performed a systematic literature search using PubMed, restricted to original English-written articles, including animal, artificial model, and human studies. Search terms were TUR, transurethral, laser, HoLEP, ThuLEP, greenlight, enucleation, fluid absorption, fluid uptake, and TUR-syndrome. RESULTS: Mean and maximum IFA during bTURP ranges between 133 and 915 ml and 1019 ml and 2166 ml, respectively. Absorption during laser procedures can be significant with maximum values up to 4579 ml and mainly occurs during prostate vaporization techniques. Incidence of moderate to severe symptoms from iso-osmolar volume overload reaches 9%. CONCLUSIONS: Irrigation fluid absorption during bTUR and laser surgery of the prostate is not negligible. Iso-osmolar overhydration with development of non-classical TUR-syndrome should be identified peri- and postoperatively and surgical teams should be aware of complications. Breath ethanol, venous pH, serum chloride, and bicarbonate could be markers for detecting dangerous events of IFA with saline.

Are all procedures for benign prostatic hyperplasia created equal? A systematic review on post-procedural PSA dynamics and its correlation with relief of bladder outlet obstruction.

PURPOSE: To evaluate and provide a comprehensive literature review of Prostate specific antigen (PSA) dynamics after various surgical procedures for benign prostatic hyperplasia (BPH). METHODS: A thorough PubMed database search was performed over last 30 years including terms "PSA" and various surgical procedures for BPH. PSA nadir after various procedure was evaluated. The post-operative improvement in International Prostate Symptom Score, maximum void rates and post-void residue after surgeries were recorded. An indirect correlation was made between PSA nadir and outcome of various BPH surgical procedures. RESULTS: Enucleation procedures like simple prostatectomy and endoscopic enucleation of prostate (EEP) produced maximum drop in PSA level after surgery and were associated with the highest improvement in post-operative parameters. The PSA nadir following resection techniques like transurethral resection of prostate and Holmium laser resection of prostate and vaporization technique was variable and less robust when compared to EEP. Newer techniques like Aquablation, Rezum, Urolift, Prostate artery embolization and Temporary implantable nitinol devices (iTIND) produce relatively less reduction in PSA and lesser percentile improvement in post-operative parameters. CONCLUSIONS: Various surgical procedures for BPH result in varying PSA nadirs level. Enucleation procedures and simple prostatectomy produce the most drastic and sustained decrease in PSA. There is a possible indirect evidence suggesting that the level of PSA nadir corresponds closely with the degree of post-operative improvement and durability of the procedure. Establishing the new PSA nadir at 3-6 months after the procedure is recommended as a part of routine surveillance for prostate cancer in eligible patients.

Long-term evaluation of outcomes and costs of urolithiasis re-interventions after ureteroscopy, extracorporeal shockwave lithotripsy and percutaneous nephrolithotomy based on German health insurance claims data.

PURPOSE: Comparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term follow-up are rare. We aimed to analyze re-intervention rates, costs and sick leave days of URS, SWL and PCNL patients within 7 years. METHODS: This retrospective cohort study was based on German health insurance claims data. We included 54,609 urolithiasis patients incidentally treated in 2008-2010. We investigated time to re-intervention, number of sick leave days and healthcare costs. We applied negative binomial, extended Cox regression and gamma models. RESULTS: 54% were incidentally treated with URS, 40% with SWL and 6% with PCNL. 15% of URS, 26% of SWL and 23% of PCNL patients were re-treated within 7 years. Time to re-intervention was significantly lower for PCNL (955 days) and SWL (937 days) than URS (1078 days) patients. Costs for incident treatment were significantly higher for PCNL (2760€) and lower for SWL (1342€) than URS (1334€) patients. Yet, total costs including re-interventions were significantly higher for PCNL (5783€) and SWL (3240€) than URS (2979€) patients. Total number of sick leave days was increased for PCNL (13.0 days) and SWL (10.1 days) compared to URS (6.8 days) patients. CONCLUSION: This study describes outcomes after use of different intervention options for urolithiasis. URS patients showed longest time free of re-interventions and lowest number of sick leave days. Although SWL patients initially had lower costs, URS patients had lower costs in the long run. PCNL patients showed high costs and sick leave days.