Characterizing the biofilm of artificial urinary sphincters (AUS).

Background: There is a paucity of data regarding the bacterial colonization on artificial urinary sphincter (AUS) devices following revision surgery. We aim to evaluate the microbial compositions of explanted AUS devices identified on standard culture at our institution. Methods: Twenty-three AUS devices explanted were included in this study. During revision surgery, aerobic and anaerobic culture swabs are taken from the implant, capsule, fluid surrounding the device, and biofilm, if present. Culture specimens are sent to the hospital laboratory for routine culture evaluation immediately upon case completion. Differences in number of microorganism species detected across samples (richness) against demographic variables were determined through backwards selection of all variables using analysis of variance (ANOVA). We assessed the prevalence (how many times each species occurred) of microbial culture species. Statistical analyses were performed using the statistical package in R (version 4.2.1). Results: Cultures reported positive results in 20 (87%) cases. Coagulase-negative staphylococci were the most commonly identified bacteria among explanted AUS devices (n=16, 80%). Among two of the four infected/eroded implants, more virulent organisms such as Escherichia coli and fungal species such as Candida albicans were identified. The mean number of species identified amongst culture positive devices was 2.15±0.49. The number of unique bacteria identified per sample was not significantly associated with demographic variables including race, ethnicity, age at revision, smoking history, duration of implantation, etiology for explantation, and concomitant medical comorbidities. Conclusions: The majority of AUS devices removed for non-infectious reasons harbor organisms on traditional culture at the time of explantation. The most commonly identified bacteria in this setting is coagulase-negative staphylococci, which may be a result of bacterial colonization introduced at the time of implant. Conversely, infected implants may harbor microorganisms with higher virulence including fungal elements. Bacterial colonization or biofilm formation on implants may not necessarily equate to clinically infected devices. Future studies with more sophisticated technology, such as next-generation sequencing or extended cultures, may evaluate microbial compositions of biofilm at a more granular level to understand its role in device infections.

Urinary undiversion by conversion of the incontinent ileovesicostomy to augmentation ileocystoplasty in spinal cord injured patients.

Context: Spinal cord injury (SCI) patients with neurogenic bladder and the inability to self-catheterize may require incontinent diversion to provide low-pressure drainage while avoiding the use of indwelling catheters. We demonstrate that in patients with significant functional improvement, the ileovesicostomy can be a reversible form of diversion, with simultaneous bladder augmentation using the same segment of ileum utilized for the ileovesicostomy. Multidisciplinary management should be utilized to assure mastery of intermittent catheterization before urinary undiversion. This technique allows for transition to a regimen of intermittent self-catheterization with excellent functional and urodynamic outcomes.Design: Case Series.Setting: Tertiary care hospital, Philadelphia, Pennsylvania.Participants: Three individuals with an SCI.Interventions: Conversion of bladder management from an incontinent ileovesicostomy to an augmentation ileocystoplasty, with intermittent catheterization.Outcome Measures: Ability to regain urinary continence with preservation of renal function as determined by serum creatinine and renal ultrasound.Results: Three SCI patients who had an incontinent ileovesicostomy developed sufficient functional improvement to intermittently self-catheterize reliably and underwent conversion of ileovesicostomy to ileocystoplasty. For each, the ileovesicostomy channel was taken down and detubularized, then used to create an ileal patch for augmentation ileocystoplasty. Intermittent catheterization was then used for periodic bladder drainage. All achieved large capacity, low-pressure bladders with complete continence and stable creatinine.Conclusion: In motivated SCI patients, it is possible to regain continence by converting the ileovesicostomy into augmentation ileocystoplasty, avoiding the disadvantages of a urostomy. A multidisciplinary collaborative approach facilitates the optimal rehabilitation of SCI individuals.

Incidental prostate cancer at holmium laser enucleation of prostate.

INTRODUCTION: The purpose of this study was to describe the current incidence, risk factors, and management of incidental diagnosis of prostate cancer (iPCa) among patients who underwent holmium laser enucleation of prostate (HoLEP) and have no history of prostate cancer. MATERIALS AND METHODS: We conducted a retrospective review of all patients who underwent HoLEP in our institution between 2013-2020. All patients were offered a PSA screening according to the latest guidelines. We gathered demographic data, perioperative information, and pathologic evaluation. For patients diagnosed with iPCa, we gathered work up, management, and oncologic outcome. We then conducted a univariate and multivariate analysis to find predictive factors for the diagnosis of incidental cancer. RESULTS: The cohort included 777 patients, among them 55 (7.1%) patients with iPCa. The median age of the entire cohort was 71 years, median PSA was 3.9 mg/dL, and median prostate volume of 96 mL. Of those with iPCa, 34 (61.8%) patients had grade-group (GG) 1. Larger prostate size was found to be protective against iPCa, with a 13% risk reduction for every increment of 10 mL in prostate size. For prostates smaller than 100 mL, iPCa rate was 12.6%. Older age and smaller prostate volume were found to predict GG2-and-above iPCa. CONCLUSIONS: iPCa at HoLEP is rare, with clinically significant cancer being even rarer. Smaller preoperative prostate was found to be a predictive factor for iPCa. Our results provide an insight into the current risk and predictive factors to iPCa and can be used to guide surgeons and patients in the preoperative recommendations and informed consent process.

UroLift and Rezum: minimally invasive surgical therapies for the management of benign prostatic hyperplasia.

INTRODUCTION Minimally invasive surgical therapies for benign prostatic hyperplasia (BPH) are popular alternatives to the gold standard transurethral resection of the prostate (TURP). These procedures have fewer discernable side effects on urinary and sexual function, when compared to TURP, making it a desirable option for many patients. MATERIALS AND METHODS: We provide an updated literature review on the current landscape of minimally invasive modalities, specifically the prostatic urethral lift (UroLift) and water vapor thermal therapy (Rezum), for the surgical treatment of BPH. RESULTS: Both UroLift and Rezum have demonstrated excellent efficacy and durability in relieving lower urinary tract symptoms (LUTS) in the BPH patient. When compared to TURP, these minimally invasive therapies can be performed in an outpatient setting, with decreased hospitalization, operative and catheterization times, which minimizes overall healthcare costs. Moreover, these therapies have no discernable adverse effects on sexual function (both ejaculatory and erectile) or sexual satisfaction, making it a desirable option for many patients. CONCLUSIONS: Both the UroLift and Rezum are office-based, minimally invasive techniques capable of providing durable, and significant relief of LUTS secondary to BPH. In select patients, they demonstrate comparable efficacy to TURP with the added advantage of preserving sexual function and minimizing patient morbidity and healthcare cost. An individualized, shared decision-making approach is essential in selecting the optimal treatment option for each patient.

HoLEP: the new gold standard for surgical treatment of benign prostatic hyperplasia.

INTRODUCTION Transurethral resection of the prostate (TURP) was considered the "gold standard" surgical treatment for medication-refractory benign prostatic hyperplasia (BPH) for decades. With the desire to reduce hospital stay, complications, and cost, less invasive procedures gained usage in the 1990's. With the advent of a soft tissue morcellator, holmium laser enucleation of the prostate (HoLEP) was introduced as an efficacious alternative to TURP and due to its advantageous side effect profile compared to TURP, has grown in popularity ever since. HoLEP has become a size-independent guideline endorsed procedure of choice for the surgical treatment of BPH. MATERIALS AND METHODS: We provide a review on the evolution of HoLEP as a gold standard compared to the historical reference procedures for BPH, and provide a review of emerging laser technologies. RESULTS: A growing body of literature has shown HoLEP to be a safe and efficient procedure for the treatment of BPH for all prostate sizes. Long term studies have proven the durability of HoLEP, as a first line surgical therapy for BPH. CONCLUSIONS: HoLEP is a proven modality for the surgical treatment of BPH. It can be performed on patients with high risk for postoperative bleeding, or after previous prostate reducing procedures. HoLEP is the only procedure that is AUA guideline-endorsed for all prostate sizes for the surgical treatment of BPH. Given these considerations, HoLEP has become the new gold-standard for the surgical treatment of BPH.

HoLEP techniques - lessons learned.

INTRODUCTION Holmium laser enucleation of the prostate (HoLEP) with mechanical tissue morcellation is one of the most effective surgical modalities for the treatment of symptomatic BPH. HoLEP has many advantages over the historical gold standards open prostatectomy (OP) and transurethral resection of the prostate (TURP). HoLEP is an AUA guideline endorsed surgical treatment for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), independent of prostate size. MATERIALS AND METHODS: We provide a detailed presentation of our experience in performing HoLEP in a teaching university hospital, with an emphasis on the surgical technique and its evolution. RESULTS: HoLEP is an efficient and durable procedure, although it is very equipment sensitive and has a relatively long learning curve. HoLEP can be performed by several surgical approaches that can be used according to the specific anatomy of the patient. Advances in laser technology, endoscopic morcellators, and surgical technique has improved the HoLEP procedure in efficiency, hemostasis, and safety. CONCLUSIONS: The HoLEP procedure, first introduced in 1998, has undergone significant changes including advancements in laser technology, endoscopic morcellation devices, and modifications to the surgical technique. These advancements have made HoLEP a more effective, more efficient, easier to perform, and easier to learn technique for the surgical management of BPH. The modified 2-lobe and the en-bloc techniques are a natural progression from the classic 3-lobe technique.

Aquablation of the prostate: a review and update.

INTRODUCTION Historically, transurethral resection of the prostate (TURP) was considered the endoscopic "gold standard" surgical treatment of benign prostatic hyperplasia (BPH). Over the years, several other endoscopic procedures emerged, including the size-independent holmium laser enucleation of the prostate (HoLEP). In an effort to reduce the cost and morbidity associated with traditional endoscopic techniques, novel minimally invasive techniques have been developed, one of which is Aquablation. This review is an update of a previously published review article looking at the most recently published available data on Aquablation. MATERIALS AND METHODS: This review article covers the technical aspects of Aquablation and provides an update on the recently published literature regarding Aquablation compared to TURP and HoLEP. RESULTS: At up to 3 years of follow up, Aquablation performs favorably when compared to TURP in terms of alleviation of lower urinary tract symptoms (LUTS) and preservation of sexual function compared to TURP. Safety profile was similar between Aquablation and TURP. CONCLUSIONS: Aquablation is a safe and effective method of treating LUTS associated with BPH. At up to 3 years of follow up, it has shown a durable with efficacy similar to TURP.

Management of neurogenic detrusor overactivity.

INTRODUCTION Neurogenic lower urinary tract dysfunction (NLUTD) refers to altered function of the urinary bladder, bladder outlet, and external urinary sphincter related to a confirmed neurologic disorder. Neurogenic detrusor overactivity (NDO) is a subset of NLUTD that frequently results in incontinence and may be associated with elevated bladder storage and voiding pressures resulting in upper urinary tract damage. MATERIALS AND METHODS: This article provides an update on the evaluation and management of patients with NDO. Basic bladder physiology as well as classification of NLUTD, initial urologic evaluation, and management options ranging from the most conservative to surgical interventions will be covered. RESULTS: NDO may be managed by conservative, pharmacologic, and surgical methods. Untreated or inadequately managed NDO may result in significant urologic morbidity and mortality, making careful evaluation and lifelong management necessary to optimize quality of life and prevent secondary complications. CONCLUSIONS: Patients with NDO should have life-long urologic surveillance and follow up. The extent of regular evaluation and testing should be based on the principal of risk stratification. Treatment for NDO should be considered not only for clinical symptoms such as incontinence, but also aimed at preserving renal function.

Management of urinary incontinence following treatment of prostate disease.

INTRODUCTION Men who undergo treatment for prostate disease are at increased risk of urinary incontinence (UI). UI has a known negative impact on patient quality of life. Once a thorough evaluation has been performed, there are effective modalities for treatment that can be tailored to the patient. MATERIALS AND METHODS: This review article provides the most recent evidence-based work up and management for men with incontinence after prostate treatment (IPT). Etiology, prophylactic measures, work up, surgical treatments, and patient considerations will be covered. The more recent adjustable balloon device is included in this publication as well as more traditional treatments like the artificial urinary sphincter (AUS) and male urethral sling. RESULTS: IPT can result from treatment of either benign or malignant prostate disease whether surgery or radiotherapy are utilized. Stress urinary incontinence (SUI), urge urinary incontinence (UUI), or mixed urinary incontinence (MUI) are all possibilities. SUI after radical prostatectomy (RP) is the most common form of IPT. Patient education and implementation of pelvic therapy as well as modern surgical techniques have greatly improved continence results. AUS remains the gold standard of SUI treatment with the broadest category of patient eligibility. Patients experiencing UUI should be treated according to the overactive bladder guidelines. CONCLUSIONS: For men with IPT, it is crucial to first take a thorough patient history and delineate the exact nature of UI symptoms which will determine the options for management. Patient factors and preferences must also be taken into consideration when ultimately choosing the appropriate intervention.

Next-generation DNA sequencing for infected genitourinary implants: How I do it.

Infection of artificial urinary sphincters or inflatable penile prostheses is one of the most devastating complications after prosthetic surgery and can have a significant impact on a quality of life. Patients undergoing revision surgery with or without device replacement may have increased risk for infection when compared to initial primary surgery. As such, surgeons may utilize traditional culture results to direct antimicrobial therapy for these patients. Unfortunately, culture results can be inconclusive in up to one-third of the time even in the setting of active device infection. Next-generation sequencing (NGS) of DNA is an emerging technology capable of sequencing entire bacterial genomes and has the potential to identify microbial composition in explanted devices. Herein, we describe our institutional experience on NGS utilization in patients with genitourinary prostheses. We also highlight our methods and techniques to inform readers on the potential practices that can enhance the utility and diagnostic yield of this new and upcoming technology.

Peyronie's disease: what do we know and how do we treat it?

INTRODUCTION: Peyronie's disease is a common, benign condition characterized by an acquired penile abnormality due to fibrosis of the tunica albuginea. This may lead to penile curvature, deformity, discomfort, pain, and erectile dysfunction, resulting in emotional and psychosocial effects on patients. Therefore, it is important for urologists to thoroughly evaluate the extent of the patient's bother and discuss treatment goals, therapeutic options, and expectations. MATERIALS AND METHODS: We provide a review of the current landscape for the diagnosis, management, and treatment of Peyronie's disease, including oral, topical, intralesional, external energy, and surgical therapies. RESULTS: The hallmark of managing Peyronie's disease is attentive patient counseling. Patients may be hesitant to discuss their symptoms unless inquired directly and may not be aware that treatments exist. It is not uncommon for Peyronie's disease to be diagnosed incidentally during a routine or unrelated healthcare visit, with reported rates of incidental diagnosis as high as 16%. Treatment options are stratified by disease phase which is defined by whether symptoms (e.g. penile deformity and discomfort) are actively changing or have stabilized. Conservative therapy is the most common recommendation during the active phase with more invasive treatments reserved for the passive phase. Conservative therapy may include oral or topical medication, intralesional injection, and external energy therapy. These treatments may also have a role in improving symptoms during the passive phase prior to undergoing more definitive surgical treatment. Surgical interventions include tunical plication, plaque incision or excision with or without grafting, and penile prosthesis implantation. Despite the variety of treatment options available to patients, each has a distinct efficacy and adverse effect profile, warranting thorough discussion to meet patients' goals and manage expectations. CONCLUSION: Peyronie's disease is a common condition that is underdiagnosed and undertreated. Patients with Peyronie's disease will benefit from a comprehensive evaluation and in-depth counseling so that they may become familiar with the natural disease course and have appropriate expectations of each treatment option.

Benign prostatic hyperplasia: an update on minimally invasive therapy including Aquablation.

INTRODUCTION: Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is a common condition affecting older men. New interventional treatments have emerged and evolved over the years, each with their own distinct efficacy and safety profiles. While some have fallen out of favor, new options continue to be explored. MATERIALS AND METHODS: We provide a review and update on minimally invasive treatment modalities for BPH, including prostatic artery embolization (PAE), Aquablation, convective water vapor thermal therapy (Rezum), and prostatic urethral lift (Urolift). RESULTS: While current urologic guidelines recommend against PAE outside of the context of clinical trials, Aquablation, Rezum, and Urolift have demonstrated excellent efficacy and durability in relieving LUTS in the BPH patient. When compared to the gold standard, transurethral resection of the prostate (TURP), these novel therapies yield equivalent or superior objective outcomes, with the additional benefit of significantly reduced sexual side effects. Additionally, Rezum and Urolift may be performed as outpatient procedures under local anesthesia, allowing for decreased hospitalizations, operative times, catheterization duration, and financial burden on the health care system. CONCLUSIONS: Aquablation, Rezum and Urolift are minimally invasive surgical treatment options capable of providing rapid, significant, and durable relief of LUTS secondary to BPH. Each technique demonstrates comparable efficacy to TURP with the added advantages of preserving sexual function, decreasing patient morbidity, and limiting healthcare costs.

Male urinary incontinence after prostate disease treatment.

INTRODUCTION: Incontinence after prostate treatment (IPT) is an important and common problem for men and can lead to decreased quality of life. The proper evaluation and management of IPT requires both knowledge of the mechanisms for its development and of multiple evolving therapy types. MATERIALS AND METHODS: An update is provided on the evaluation and management for IPT. The underlying pathophysiology of the contributing conditions is explored along with the appropriate assessment prior to therapy. Surgical techniques including the artificial urinary sphincter (AUS) and male urethral sling are detailed specifically and compared. RESULTS: IPT can result from radical prostatectomy (RP), prostate radiation, and surgery for benign prostatic hyperplasia. All of these may increase the risk for stress urinary incontinence (SUI), urge urinary incontinence (UUI), or mixed incontinence. SUI after RP remains the largest component of IPT. Perioperative pelvic floor muscle therapy and advances in surgical technique have helped to prevent and treat post-RP SUI. The AUS and male urethral sling are both excellent surgical options for SUI with the AUS being currently indicated for a broader set of patients. Predominant UUI should be treated in a stepwise manner based upon guidelines for overactive bladder. CONCLUSIONS: Evaluation of men with IPT should include determining components of SUI and UUI as these will direct medical and surgical therapy. While advances in surgical technique and technology have reduced prevalence of SUI after RP, many men still require treatment. Surgical treatments with AUS and male urethral sling provide excellent outcomes in well selected patients.

Holmium laser enucleation of the prostate (HoLEP): size-independent gold standard for surgical management of benign prostatic hyperplasia.

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) has become an increasingly common surgical management option for treatment of symptomatic benign prostatic hyperplasia (BPH). Transurethral resection of the prostate (TURP) has long been considered the gold standard, contemporary literature and newer guidelines indicate that HoLEP has become the new size-independent endoscopic gold standard for surgical BPH treatment. MATERIALS AND METHODS: We provide a review and update on current HoLEP surgical techniques, outcomes, safety, and durability according to the growing body of literature. RESULTS: The current body of literature and guidelines indicate HoLEP as a safe and effective surgical treatment for symptomatic BPH regardless of prostate size. Durable long term subjective and objective outcomes have been demonstrated in previous studies, extending beyond 10 years. CONCLUSIONS: HoLEP continues to demonstrate durable long term efficacy for treating patients suffering from lower urinary tract symptoms (LUTS) due to BPH. The American Urological Association (AUA) guidelines recommend its use as a size-independent endoscopic treatment option. HoLEP has proven itself to be the new gold standard in surgical treatment for LUTS secondary to BPH with the ability to endoscopically treat prostates independent of size, with durable long term outcomes.

Stress Urinary Incontinence post-Holmium Laser Enucleation of the Prostate: a Single-Surgeon Experience.

PURPOSE: To identify incidence and predictors of stress urinary incontinence (SUI) following Holmium laser enucleation of the prostate (HoLEP). MATERIALS AND METHODS: We performed a retrospective review of 589 HoLEP patients from 2012-2018. Patients were assessed at pre-operative and post-operative visits. Univariate and multivariate regression analyses were performed to identify predictors of SUI. RESULTS: 52/589 patients (8.8%) developed transient SUI, while 9/589 (1.5%) developed long-term SUI. tSUI resolved for 46 patients (88.5%) within the first six weeks and in 6 patients (11.5%) between 6 weeks to 3 months. Long-term SUI patients required intervention, achieving continence at 16.4 months on average, 44 men (70.9%) with incontinence were catheter dependent preoperatively. Mean prostatic volume was 148.7mL in tSUI patients, 111.6mL in long-term SUI, and 87.9mL in others (p < 0.0001). On univariate analysis, laser energy used (p < 0.0001), laser "on" time (p=0.0204), resected prostate weight (p < 0.0001), overall International Prostate Symptom Score (IPSS) (p=0.0005), and IPSS QOL (p=0.02) were associated with SUI. On multivariate analysis, resected prostate weight was predictive of any SUI and tSUI, with no risk factors identified for long-term SUI. CONCLUSION: Post-HoLEP SUI occurs in ~10% of patients, with 1.5% continuing beyond six months. Most patients with tSUI recover within the first six weeks. Prostate size >100g and catheter dependency are associated with increased risk tSUI. Larger prostate volume is an independent predictor of any SUI, and tSUI.

Stress urinary incontinence post-holmium laser enucleation of the prostate: a single-surgeon experience

ABSTRACT Purpose To identify incidence and predictors of stress urinary incontinence (SUI) following Holmium laser enucleation of the prostate (HoLEP). Materials and Methods We performed a retrospective review of 589 HoLEP patients from 2012-2018. Patients were assessed at pre-operative and post-operative visits. Univariate and multivariate regression analyses were performed to identify predictors of SUI. Results 52/589 patients (8.8%) developed transient SUI, while 9/589 (1.5%) developed long-term SUI. tSUI resolved for 46 patients (88.5%) within the first six weeks and in 6 patients (11.5%) between 6 weeks to 3 months. Long-term SUI patients required intervention, achieving continence at 16.4 months on average, 44 men (70.9%) with incontinence were catheter dependent preoperatively. Mean prostatic volume was 148.7mL in tSUI patients, 111.6mL in long-term SUI, and 87.9mL in others (p <0.0001). On univariate analysis, laser energy used (p <0.0001), laser "on" time (p=0.0204), resected prostate weight (p <0.0001), overall International Prostate Symptom Score (IPSS) (p=0.0005), and IPSS QOL (p=0.02) were associated with SUI. On multivariate analysis, resected prostate weight was predictive of any SUI and tSUI, with no risk factors identified for long-term SUI. Conclusion Post-HoLEP SUI occurs in ~10% of patients, with 1.5% continuing beyond six months. Most patients with tSUI recover within the first six weeks. Prostate size >100g and catheter dependency are associated with increased risk tSUI. Larger prostate volume is an independent predictor of any SUI, and tSUI.