Prospective Multicenter Evaluation of Pain Before and After Removal of Nonobstructing Renal Calculi: A CoRE Initiative.

PURPOSE: Flank pain associated with stone disease is typically caused by a stone that obstructs urine flow. However, it is plausible that nonobstructing kidney stones may still cause pain. We performed a multicenter, observational trial to evaluate whether treatment of small nonobstructing calyceal stones improves pain and kidney stone-specific health-related quality of life. MATERIALS AND METHODS: Patients aged 18 years or older with nonobstructing renal stone(s) up to 10 mm in longest diameter and moderate to severe pain were recruited. All participants completed 3 questionnaires: the Brief Pain Inventory (BPI), the Patient-Reported Outcomes Measurement Information System pain interference form 6a, and the Wisconsin Stone Quality of Life questionnaire. Thereafter, all participants underwent ureteroscopy for renal stone treatment. All 3 questionnaires were repeated at 2, 6 to 8, and at 12 weeks postprocedure. The primary outcomes were change in preoperative to 12-week postoperative mean BPI score and worst BPI pain score. RESULTS: A total of 43 patients with nonobstructing kidney stones and associated flank pain were recruited. All stones were removed. Preoperatively, BPI scores for mean pain and worst pain were 5.5 and 7.2, respectively which decreased to 1.8 and 2.8 respectively at 12 weeks postoperatively. Wisconsin Stone Quality of Life questionnaire mean score increased from 70.4 to 115.3 at 12 weeks postoperatively. A total of 86% and 69% of patients had at least a 20% and 50% reduction in their mean pain scores, respectively. CONCLUSIONS: This study determined that patients benefit significantly from the removal of calyceal nonobstructing kidney stones for at least 12 weeks with a reduction in pain and an increase in quality of life. Therefore, surgical removal of these stones in this patient population should be offered as a treatment option.

Operative Time Accuracy in the Era of Electronic Health Records: Addressing the Elephant in the Room.

GOAL: Accurate prediction of operating room (OR) time is critical for effective utilization of resources, optimal staffing, and reduced costs. Currently, electronic health record (EHR) systems aid OR scheduling by predicting OR time for a specific surgeon and operation. On many occasions, the predicted OR time is subject to manipulation by surgeons during scheduling. We aimed to address the use of the EHR for OR scheduling and the impact of manipulations on OR time accuracy. METHODS: Between April and August 2022, a pilot study was performed in our tertiary center where surgeons in multiple surgical specialties were encouraged toward nonmanipulation for predicted OR time during scheduling. The OR time accuracy within 5 months before trial (Group 1) and within the trial period (Group 2) were compared. Accurate cases were defined as cases with total length (wheels-in to wheels-out) within ±30 min or ±20% of the scheduled duration if the scheduled time is ≥ or <150 min, respectively. The study included single and multiple Current Procedural Terminology code procedures, while procedures involving multiple surgical specialties (combo cases) were excluded. PRINCIPAL FINDINGS: The study included a total of 8,821 operations, 4,243 (Group 1) and 4,578 (Group 2), (p < .001). The percentage of manipulation dropped from 19.8% (Group 1) to 7.6% (Group 2), (p < .001), while scheduling accuracy rose from 41.7% (Group 1) to 47.9% (Group 2), (p = .0001) with a significant reduction of underscheduling percentage (38.7% vs. 31.7%, p = .0001) and without a significant difference in the percentage of overscheduled cases (15% vs. 17%, p = .22). Inaccurate OR hours were reduced by 18% during the trial period (2,383 hr vs. 1,954 hr). PRACTICAL APPLICATIONS: The utilization of EHR systems for predicting OR time and reducing manipulation by surgeons helps improve OR scheduling accuracy and utilization of OR resources.

The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP-tool): a Delphi consensus project on standardised evaluation of flexible ureterorenoscopes.

OBJECTIVE: To develop a standardised tool to evaluate flexible ureterorenoscopes (fURS). MATERIALS AND METHODS: A three-stage consensus building approach based on the modified Delphi technique was performed under guidance of a steering group. First, scope- and user-related parameters used to evaluate fURS were identified through a systematic scoping review. Then, the main categories and subcategories were defined, and the expert panel was selected. Finally, a two-step modified Delphi consensus project was conducted to firstly obtain consensus on the relevance and exact definition of each (sub)category necessary to evaluate fURS, and secondly on the evaluation method (setting, used tools and unit of outcome) of those (sub)categories. Consensus was reached at a predefined threshold of 80% high agreement. RESULTS: The panel consisted of 30 experts in the field of endourology. The first step of the modified Delphi consensus project consisted of two questionnaires with a response rate of 97% (n = 29) for both. Consensus was reached for the relevance and definition of six main categories and 12 subcategories. The second step consisted of three questionnaires (response rate of 90%, 97% and 100%, respectively). Consensus was reached on the method of measurement for all (sub)categories. CONCLUSION: This modified Delphi consensus project reached consensus on a standardised grading tool for the evaluation of fURS - The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP) tool. This is a first step in creating uniformity in this field of research to facilitate future comparison of outcomes of the functionality and handling of fURS.

Feasibility and clinical outcomes of ureteral stenting in the office procedural suite.

INTRODUCTION: Stent placement is a common procedure for addressing obstructive uropathy. However, lack of operating room (OR) availability can substantially delay this procedure. In this study, we sought to assess the feasibility, safety, and efficacy of this procedure in a clinical setting using nitrous oxide (N2O) and local anesthesia. MATERIALS AND METHODS: Patients included in this study included those who were determined to need management of urinary obstruction with a JJ ("double J") stent and had their procedure performed in the clinic procedure suite with N2O anesthesia. RESULTS: We present a case series of 565 patients undergoing ureteral stent placements in a clinic operative suite with N2O. In this cohort, complications occurred after 4.1% of procedures and unplanned admissions to the hospital occurred after 2.5% of procedures. Stent placements failed in 1.0% of procedures. Failures occurred due to pain in 2/565 patients. No anesthetic complications were encountered. CONCLUSION: We report the feasibility and clinical outcomes of ureteral stent placements for ureteral obstruction in a clinic setting with the use of local anesthetic or N2O anesthesia, with excellent results. A majority of patients tolerated the procedure well and only 2 of 565 had their procedures stopped due to discomfort. To our knowledge, this is the first report of the use of N2O anesthetic for conscious sedation for the placement of ureteral stents.

Wolf Piranha Versus Lumenis VersaCut Prostate Morcellation Devices: A Prospective Randomized Trial.

PURPOSE: Holmium laser enucleation of the prostate for the management of benign prostatic hyperplasia involves the 2 steps of enucleation and morcellation. Few prostate morcellation devices are available. In this study we compare the Wolf Piranha and Lumenis® VersaCut™ prostate morcellation devices. MATERIALS AND METHODS: After institutional review board approval and patient informed consent, a prospective, randomized trial was initiated for patients with symptomatic benign prostatic hyperplasia undergoing holmium laser enucleation of the prostate. All procedures were performed by a single surgeon (JEL) at Indiana University Health Methodist Hospital using the Piranha or VersaCut prostate morcellation device. Patient demographics, and preoperative, intraoperative and postoperative data for patients in the 2 treatment groups were analyzed and compared in a prospective fashion. RESULTS: A total of 74 patients were enrolled and randomized for the treatment device. Both groups were comparable in terms of age, prostate specific antigen and prostate size. There was no difference in patient demographic and preoperative characteristics. The Piranha achieved a slightly higher morcellation rate at 5.6 gm per minute (range 1.4 to 18), compared to the VersaCut at 4.8 gm per minute (range 1.3 to 9.5). However, the difference was not statistically significant (p = 0.14). Cost analysis (USD per patient) favored the VersaCut ($241 vs $471, p <0.001). CONCLUSIONS: Morcellation rates for the Piranha and VersaCut prostate morcellation devices are comparable, with the Piranha having a statistically significant increased cost. The Wolf Piranha also has a more complicated design, making it less user-friendly for the operating room staff and, therefore, more difficult to troubleshoot than the Lumenis VersaCut. Nevertheless, 75% of urology faculty, fellows and residents preferred the Piranha over the VersaCut, reporting that when working properly, it was more efficient in tissue removal.

Holmium laser enucleation of prostate in nonagenarians and octogenarians Impact of age and frailty on surgical outcomes.

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) is a well-established technique for management of benign prostatic hyperplasia (BPH). With the growing aging population, a considerable percentage of octogenarians (80-90 years old) and nonagenarians (>90 years old) require surgical management for BPH. We aimed to assess the outcomes of HoLEP in those age groups. METHODS: We reviewed a maintained database for HoLEP patients in a tertiary center. Patients were assigned to two groups: above (group A) and below (group B) 80 years old. Perioperative outcome and postoperative followup data were compared between both groups. RESULTS: The study included 1090 patients, 201 and 889 in groups A and B, respectively. Median age was 83 and 70 years in groups A and B, respectively. Group A showed longer operative time, longer catheterization time, and higher 30-day emergency room visits and readmission rates. Hemoglobin drop was comparable, although associated with higher rate of blood transfusion in group A. Overall, 30-day postoperative complications were higher in group A (20.8% vs. 9.3%, p=0.008), although the majority of complications in both groups were grade I and II. The rate of complications over Clavien-Dindo grade II were statistically comparable (3.4% vs. 1.79%, p=0.133). Followup at six weeks, three months, and one year showed comparable functional outcomes in both groups. CONCLUSIONS: HoLEP is a safe and effective option in the geriatric population of octogenarians and even nonagenarians. HoLEP is associated with higher overall complication rate in older age groups; however, most complications were minor.

Preoperative Frailty Scores Predict the Early Postoperative Complications of Holmium Laser Enucleation of Prostate.

Background: Frailty is a recent multidimensional concept of a contemporary growing interest for understanding the complex health status of elderly population. We aimed to assess the impact of frailty scores on the outcome and complication rate of holmium laser enucleation of prostate (HoLEP). Methods: A 7-year data of HoLEP patients in a single tertiary referral center were reviewed. The preoperative, operative, early, and late postoperative outcome data were collected and compared according to the preoperative frailty scores. Frailty was assessed preoperatively using the Modified Hopkins frailty score. Results: The study included 837 patients categorized into two groups: group I included 533 nonfrail patients (frailty score = 0), whereas group II included 304 frail patients (frailty score ≥1). The median (interquartile range) age was 70 (11) and 75 (11) years for groups I and II, respectively (<0.001). The 30-day perioperative complication rate (p = 0.005), blood transfusion (p = 0.013), failed voiding trial (p = 0.0015), and 30-day postoperative readmission (p = 0.0363) rates were significantly higher in frail patients of group II. The two groups were statistically comparable regarding postoperative international prostate symptom score (p = 0.6886, 0.6308, 0.9781), incontinence rate (p = 0.475, 0.592, 0.1546), postvoid residual (p = 0.5801, 0.1819, 0.593) at 6 weeks and 3 months, and 1-year follow-up intervals, respectively. Conclusion: In elderly patients undergoing HoLEP, the preoperative frailty scores strongly correlate with the risk of perioperative complications. Frail patients should be counseled regarding their relative higher risk of early perioperative complications although they gain the same functional profit of HoLEP as nonfrail patients.

Holmium Laser Enucleation of Prostate in Patients with Pre-Existing Localized Prostate Cancer, Dual Center Study.

Background: Holmium laser enucleation of the prostate (HoLEP) has been used as an effective minimally invasive technique for management of enlarged prostates. We aimed to report the role of HoLEP in prostate cancer (PCa) patients either on active surveillance with bothersome lower urinary tract symptoms (LUTS) or for prostate debulking before radiation therapy and the impact on PCa management plans. Methods: Prospectively maintained database in two institutions was reviewed for patients with localized PCa managed by HoLEP with at least a follow-up of 1 year. We assessed prostate-specific antigen (PSA) trends, effect on international prostate symptom score (IPSS) and further management of PCa. Results: Out of >2000 HoLEP patients, 117 patients with a median follow-up of 30 months were included. Mean (standard deviation) age was 72.3 (±8.3) years with median (interquartile range, IQR) IPPS of 22 (16-28) and median (IQR) PSA at 7.6 (5.3-14.9) ng/mL. Gleason grade group was 1, 2, 3, and 4 in 47 (73.2%), 32 (27.35%), 7 (5.9%), and 4 (3.4%) patients, respectively. Median (IQR) PSA has significantly dropped to 1.3 (0.6-3.1), 1.4 (0.75-2.9), and 1.7 (0.86-2.75) ng/mL at 6-week, 3-month, and 1-year follow-up, respectively (p < 0.001). IPSS scores post-HoLEP obviously improved with mean (IQR) IPSS of 10 (5-13), 7 (3-12), and 3 (2-5) at 6-week, 3-month, and 1-year, respectively (p < 0.001). Eighty-eight (72%) patients stayed on active surveillance, whereas 27 (23%) patients had radiotherapy ± androgen deprivation therapy for persistently high or relapsing PSA. Within 36 intermediate-risk patients, 15 (41.6%) and patients had radiotherapy, whereas 21 (58.3%) patients continued active surveillance. Conclusions: HoLEP is beneficial in debulking large prostate in PCa patients with bothersome LUTS on active surveillance or before radiotherapy. HoLEP reduces the contribution of large adenoma to PSA level, thus reflecting PSA level better and helping reduce overtreatment.

Predictors of postoperative urinary tract infection following holmium laser enucleation of the prostate.

INTRODUCTION: Storage urinary symptoms and urinary tract infection (UTI) are among the most common complications following holmium laser enucleation of the prostate (HoLEP). We aimed to study the incidence and risk factors for storage urinary symptoms and early UTI following HoLEP. METHODS: A prospectively maintained database was reviewed for patients who underwent HoLEP over a five-year period at a single tertiary center. Patient demographics, preoperative, operative, and postoperative characteristics, as well as infection rates, were obtained and analyzed using the appropriate statistical methods. RESULTS: Of a total 514 patients who underwent HoLEP, 473 patients with complete followup data were included. Mean (± standard deviation) age and median (interquartile range) prostate volume were 72±9.1 years and 89 (68-126) g, respectively. Preoperative positive urine culture and urine retention were seen in 28.5% (n=135) and 23.46 % (n=111) of patients, respectively. At six-week followup, irritative urinary symptoms were seen in 32.3% (n=153) of patients, while 13.5% (n= 64) of patients had positive urine culture. Bivariate and multivariate analysis showed that factors associated with significant higher rate of postoperative UTI at six weeks were high body mass index (BMI) (p= 0.023), weak grip strength within preoperative frailty assessment (p=0.042), positive preoperative urine culture (p=0.025), and postoperative incontinence (p=0.002). CONCLUSIONS: Storage urinary symptoms are common complaints post-HoLEP; however, it may be caused by an inflammatory rather than infective process in a significant percentage of patients. Possible predictors of UTI after HoLEP are high BMI, preoperative positive urine culture, higher frailty scale, and postoperative urinary incontinence.

Comparison of outcomes of holmium laser versus bipolar enucleation of prostates weighing >80 g with bladder outlet obstruction.

Transurethral enucleation of the prostate has been increasingly recognized as an effective minimally invasive technique for management of enlarged prostates. We aimed to compare holmium laser enucleation (HoLEP) and bipolar transurethral enucleation (B-TUEP) of large-volume prostates. A prospectively maintained database in two tertiary referral centers was reviewed for patients with HoLEP and B-TUEP for prostates >80 g. Operative data, perioperative complications, and early postoperative outcomes were compared. The study included 101 patients, 70 who underwent HoLEP and 31 who underwent B-TUEP. The operative enucleation rate (weight of adenoma enucleated in g/min) was higher in HoLEP compared to B-TUEP (P < 0.0001). The operative complication rate, hemoglobin drop, and readmission rate were comparable in both groups (P = 0.13, 0.35, 0.29, 0.59, respectively). The HoLEP arm had a shorter hospital stay and shorter catheterization time (P = 0.001, 0.012). Follow-up data showed a lower International Prostate Symptom Score and serum prostate-specific antigen level in the HoLEP group. The incontinence rate was comparable in both groups. In conclusion, both techniques were effective in managing a high-volume prostate, although HoLEP had a shorter enucleation time, better symptom score, lower postoperative prostate-specific antigen level, shorter catheterization time, and shorter hospital stay compared to B-TUEP.

The incidence of urethral stricture and bladder neck contracture with transurethral resection vs. holmium laser enucleation of prostate: A matched, dual-center study.

INTRODUCTION: Urethral strictures (US) and bladder neck contracture (BNC) are common, long-term complications of transurethral prostate surgery. We aimed to compare transurethral resection of the prostate (TURP) and holmium laser enucleation of the prostate (HoLEP) regarding incidence of US or BNC and identify possible risk factors. METHODS: A retrospective review of patients who underwent TURP and HoLEP with followup data of at least one year in two separate institutions was performed. The incidence of postoperative US or BNC in both groups was compared. Bivariate and multivariate analysis of risk factors in both cohorts with US or BNC were performed. RESULTS: The study included 208 patients: 101 and 107 patients in the TURP and HoLEP arms, respectively. The two groups were matched for age and prostate size. Eight (7.92%) and five (4.72%) patients in the TURP and HoLEP arms, respectively, developed US (p=0.3423), while two (1.87%) patients in the HoLEP arm had BNC (p=0.2634). Of the eight patients with the US in the TURP arm, six (9.8%) had bipolar TURP, while two (5%) had monopolar TURP. Multivariate analysis showed that larger prostate volume (hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.05, 1.41, p=0.0066) and longer operative time (HR 1.84, 95% CI 1.76, 1.93, p=0.0015) were associated with risk of US/BNC. CONCLUSIONS: There is no significant difference between TURP and HoLEP regarding incidence of US or BNC, although there is a tendency towards a higher rate of US associated with bipolar TURP. Increased prostate volume and operative time are possible risk factors.

Comparison of commonly utilized ureteral access sheaths: A prospective randomized trial.

OBJECTIVE: We aimed to evaluate and compare the functional characteristics, safety profile and effectiveness of two commonly used ureteral access sheaths (UAS) during flexible ureteroscopy. METHODS: After institutional review board approval, patients with proximal ureteral or kidney stones requiring flexible ureteroscopy and UAS were prospectively randomized to group I or group II according to the type of access sheath used. Primary outcome was incidence of intraoperative complications. RESULTS: Eighty-eight patients were enrolled in the study, 44 patients in each group. Sheath size 12/14 FR was used in both cohorts. Median (IQR) stone size was 10 mm (7-13.5) and 10.5 mm (7.37-14) in group I and II respectively (p = 0.915). Nineteen and twenty patients, in group I and II respectively, were pre-stented. Subjective resistance with insertion of the UAS was observed in 9 and 11 patients in group I and II respectively (p = 0.61) while failed insertion was encountered in one patient in group I. Traxer grade 1 ureteral injury was noted in 5 and 6 patients in group I and II respectively while grade 3 injury was seen in 1 patient for both cohorts (p = 0.338). There was less resistance for UAS placement in pre-stented patients (p = 0.0202) but without significant difference in ureteric injury incidence (p = 0.175). Emergency department visits were encountered in 7 (group I) and 5 patients (group II) (p = 0.534). CONCLUSIONS: The studied UASs were comparable regarding safety and efficacy in the current study. Pre-stented and dilated ureters had less resistance to insertion although this was not reflected on incidence of ureteric injury.

Urethral Complications Post-Holmium Laser Enucleation of the Prostate: A Seven-Year Experience.

Background: Urethral strictures (US) and bladder neck contracture (BNC) are troublesome complications of transurethral surgery. We aimed to report the incidence, risk factors, and management of US and BNC post-holmium laser enucleation of the prostate (HoLEP) together with review of literature. Patients and Methods: A retrospective review of prospectively managed HoLEP patients in one institution between 2015 and 2021 was performed. The study included patients with complete follow-up of at least 1-year. Multivariate regression analysis for risk factors of US or BNC was performed. Appropriate statistical analysis methods were used. Results: Out of total 1055 HoLEP patients, 566 patients were included. Eleven (1.94%), 8 (1.41%), and 1 (0.17%) patients developed US, BNC, and both, respectively, while 8 (1.41%) patients had postoperative recurrence of intraoperatively diagnosed US. With multivariate regression analysis, intraoperative US (p = 0.0055, odds ratio [OR] = 15.5, confidence interval [95% CI] = 2.2-37.7), intraoperative need for meatotomy (p = 0.0019, OR = 7.69, 95% CI = 2.12-27.8), and longer operative time (p = 0.0250, OR = 1.043, 95% CI = 1.005-1.083) were predictors of US/BNC. For US patients, urethral dilatation under local anesthesia was sufficient in 14 (70%) patients while 6 (30%) patients had visual urethrotomy. Patients with BNC were managed by endoscopic bladder neck incision. Conclusion: Although the US/BNC are annoying long-term sequalae that may complicate HoLEP, the incidence is still low and can be easily managed. Diagnosed intraoperative stricture, need for meatotomy, and longer operative time are the main predictors of urethral complications post-HoLEP.

Isolated penile corporeal cavernosal injury accompanying pelvic fracture after motor vehicle accident.

Pelvic fracture is a common cause of traumatic injury of the bladder and posterior urethra; however, isolated corporal injury is rare. We present a case of pelvic fracture associated with proximal injury of the penile corpora cavernosa sparing the urethra and bladder, together with a literature review of erectile dysfunction post-pelvic fracture.

Safety and efficacy of sequential balloon dilation prior to ureteral access sheath insertion in nonstented patients undergoing ureteroscopy.

Techniques such as ureteral access sheath placement and balloon dilation are utilized to facilitate ureteroscopy. A retrospective review was performed to evaluate the efficacy and complications from ureteral access sheath (UAS) placement with or without sequential ureteral balloon dilation (SBD) in non-prestented patients who underwent ureteroscopy with UAS with or without SBD for renal or proximal ureteral stones from February 2014 to April 2017. This was a two-surgeon series of 124 patients divided into groups of SBD + UAS or direct UAS placement. Postoperative complications included hematuria, fever, and flank pain. Successful UAS insertion rates and postoperative complication rates were statistically significantly higher in the SBD + UAS group (P = 0.01 and 0.023, respectively). The procedure time, emergency department return, and 6-week stone-free rates were not statistically different between the groups. In conclusion, SBD + UAS has a higher success rate of UAS insertion compared to direct UAS alone, allowing for same-setting ureteroscopy. However, SBD + UAS is associated with significantly higher rates of fever, flank pain, and hematuria. We conclude that SBD + UAS and direct UAS are equivalent.

Wolf Piranha vs Storz Prostate Morcellation Devices: A Retrospective Multi-Institutional Study.

Purpose: Holmium laser enucleation of the prostate (HoLEP) entails both enucleation and morcellation. Only three popular prostate morcellation devices are available for this procedure. In this study, a retrospective review was done to compare the Wolf® and Storz® morcellators. Materials and Methods: After Institutional Review Board approval, a multi-institutional retrospective chart review of prospectively collected data was performed at two institutions with a single surgeon at each center performing HoLEP. Thunder Bay Regional Health Sciences Center employed the Storz morcellator while Baylor Scott and White Medical Center used the Wolf. Preoperative, perioperative, postoperative, and demographic data for both sets of patients were analyzed and compared retrospectively. Results: A total of 506 patients in the Wolf cohort and 60 patients in the Storz cohort were analyzed. Morcellated pathologic weight was 52.3 g in the Wolf arm and 101.7 g on the Storz arm (p < 0.0001). Overall, average morcellation rates were faster in the Storz arm; morcellation rate was 5.8 g/min for Wolf, and 6.7 g/min in the Storz (p = 0.0015). Morcellator malfunction was significantly lower in Wolf cohort 0% vs 6.6% in the Storz (p = 0.0001), but this did not significantly slow morcellator efficiency times. The total number of mucosal bladder injuries was comparable with rates of 1.4% and 1.6% in the Wolf and Storz groups, respectively (p = 0.59). The duration of hospital stay and catheterization were <24 hours in both groups. Conclusions: In this retrospective study, the Storz DrillCut had higher efficacy in morcellation when compared with Wolf Piranha. However, it was associated with more malfunctions. Both morcellators have comparable rates of complications and perioperative outcomes.

Urethral Complications While Using 26F vs 28F Resectoscope Sheaths in Holmium Laser Enucleation of the Prostate: A Retrospective Observational Study.

Objective: To determine the rate of the urethral stricture (US) and bladder neck contracture (BNC) between patients who undergo Holmium Laser Enucleation of Prostate (HoLEP) surgery with 26F vs 28F resectoscope sheaths (RS). Studies report rates of 2.8-4.4% and 3.6-5.4% for US and BNC, respectively. To date, there are no studies that have shown the difference between RS size and urethral complications. Methods: We retrospectively reviewed charts of patients who had HoLEP surgery between August 2015 and June 2018, by a single surgeon. Those with a prior history of US or BNC were excluded. The operative set-up for an HoLEP includes Ho:YAG laser, urethral dilation, a 26F or 28F continuous flow RS, and a tissue morcellator. Primary endpoints include postoperative US or BNC. Secondary endpoints include postoperative catheterization time, success of voiding trial, and urinary incontinence. Statistical analysis was performed by using appropriate methods. Results: Out of 502 HoLEP patients, 339 consecutive patients had surgery with a 28F RS (Group A) and 163 consecutive patients had surgery with a 26F RS (Group B). Twelve patients (A) and three patients (B) had post-op US (p = 0.41). Eight (A) and zero (B) patients had post-op BNC (p = 0.0585). Stress urinary incontinence at 6 weeks, 3-6 months, and 1 year was present in 15.9% (both A & B), 6.5% (A) vs 6.1% (B) (p = 0.88), and 3.2% (A) vs 1.8% (B) (p = 0.564), respectively. Both blood loss and change in hemoglobin were higher in the 28F group with no significant difference in rate of transfusion. Conclusions: RS size had no impact on the rate of US or BNC; however, there was lower incidence in the 26F sheath cohort for both. The 28F sheath had a larger change in hemoglobin levels and estimated blood loss, but the higher rate of transfusion was not statistically significant. There was no difference in the stress incontinence rates, length of stay, and enucleation rates.

Safety and efficacy of male urethral slings for management of persistent stress urinary incontinence after holmium laser enucleation of the prostate.

Holmium laser enucleation of the prostate gland (HoLEP) is an alternative to the traditional transurethral resection of the prostate, especially for large-volume prostates. One complication is urinary incontinence, which is usually stress urinary incontinence (SUI). Little data exist on surgical interventions for SUI after HoLEP. This retrospective case series examined the safety and possible efficacy of a midurethral sling (MUS) following HoLEP. Between January 2016 and February 2019, 610 HoLEPs were performed at our institution. Three (0.5%) had persistent, overly bothersome symptoms of SUI. All three underwent MUS placement with a transobturator AdVance® male sling after failed pelvic floor rehabilitation. The degree of SUI was evaluated by pad use pre-HoLEP, post-HoLEP, and post-MUS placement. Surgical times for HoLEP and MUS were evaluated. No patients were using pads for incontinence before HoLEP. The average pad use was 7 post-HoLEP and 0.3 post-MUS. The average morcellated prostate was 48 g, and surgical time was 68 min (52 for enucleation and 15 for morcellation). No complications were reported with MUS placement intraoperatively or postoperatively. MUS for persistent and bothersome SUI after HoLEP shows promise as a safe and effective surgical option.