One-Year Outcomes of Transurethral Treatment of Bladder Neck Stenosis Following Transurethral Resection of the Prostate. Results from a Large, Multicenter Series.

Purpose: To assess management and outcomes of bladder neck stenosis (BNS) post-transurethral resection of the prostate (TURP) in 12 centers. Patients and Methods: A retrospective analysis of patients who underwent transurethral BN incision for stenosis following TURP from January 2015 and January 2023 was performed. Inclusion criteria included endoscopic diagnosis of BNS associated with obstruction and/or lower urinary tract symptoms. Data are presented as median and interquartile range. Two distinct univariable logistic regression analyses were performed to identify factors associated with overall urinary incontinence and recurrent stenosis. Results: Three hundred and seventy-two men were included. 95.2% of patients developed BNS following bipolar TURP. 21.0% of patients were on an indwelling catheter before BNS incision. Bipolar electrocautery was the most commonly employed energy for incision (66.5%). Collings knife was the most commonly employed (61.2%) instrument for incision, followed by end-firing holmium lasering (35.3%). Median operation time was 30 (25-45) minutes. The overall complication rate was 12.4%, with 19 (5.1%) patients suffering from acute urinary retention, 6 (1.6%) patients requiring prolonged irrigation due to persistent hematuria, and a surgical hemostasis was necessary in 8 cases (2.2%). Overall postoperative incontinence rate was 17.2%, with urge incontinence accounting for the most common type (45.3%). Incontinence lasted more than 3 months in 9/46 (14.3%) patients. Recurrent BNS occurred in 29 (7.8%) patients and was managed by re-endoscopic incision in 21 (5.6%) patients and dilatation only in 6 (1.6%) patients. Two (0.5%) patients underwent urethroplasty for recalcitrant stenosis. Logistic regression analysis showed that Collings knife was associated with higher odds of having postoperative incontinence (OR 3.93 95% CI 1.45-11.13, p=0.008) and BN recurrence (OR 3.589 95% CI 1.157-15.7, p=0.047). Conclusion: Transurethral BN incision provides satisfactory short-term results with an acceptable rate of complications.

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.

Influence of Prostate Volume on the Incidence of Complications and Urinary Incontinence Following Thulium Fiber Laser Enucleation of the Prostate: Results from Multicenter, Real-world Experience of 2732 patients.

Background: The use of the new thulium fiber laser in enucleation of the prostate (ThuFLEP) has been introduced recently. Objective: To evaluate complications and urinary incontinence (UI) after ThuFLEP in small and large prostate volume (PV). Design setting and participants: We retrospectively reviewed patients who underwent ThuFLEP in six centers (from January 2020 to January 2023). The exclusion criteria were concomitant lower urinary tract surgery, previous prostate/urethral surgery, prostate cancer, and pelvic radiotherapy. Outcome measurements and statistical analysis: Patients were divided into two groups: group 1: PV ≤80 ml; group 2: PV >80 ml. Univariable and multivariable logistic regression analyses were performed to evaluate the independent predictors of overall UI. Results and limitations: There were 1458 patients in group 1 and 1274 in group 2. There was no significant difference in age. The median PV was 60 (61-72) ml in group 1 and 100 (90-122) ml in group 2. En bloc enucleation was employed more in group 1, while the early apical release technique was used more in group 2. The rate of prolonged irrigation for hematuria, urinary tract infection, and acute urinary retention did not differ significantly. Blood transfusion rate was significantly higher in group 2 (0.5% vs 2.0%, p = 0.001). There was no significant difference in the overall UI rate (12.3% in group 1 vs 14.7% in group 2, p = 0.08). A multivariable regression analysis showed that preoperative postvoiding urine residual (odds ratio 1.004, 95% confidence interval 1.002-1.007, p < 0.01) was the only factor significantly associated with higher odds of UI. A limitation of this study was its retrospective nature. Conclusions: Complications and UI rates following ThuFLEP were similar in patients with a PV up to or larger than 80 ml except for the blood transfusion rate that was higher in the latter. Patient summary: In this study, we looked at outcomes after thulium fiber laser in enucleation of the prostate stratified by PV. We found that blood transfusion was higher in men with PV >80 ml, but urinary incontinence was similar.

High-power holmium laser versus thulium fiber laser for endoscopic enucleation of the prostate in patients with glands larger than 80 ml: Results from the Prostate Endoscopic EnucLeation study group.

Background: Endoscopic enucleation of the prostate (EEP) has gained acceptance as an equitable alternative to transurethral resection of the prostate for benign prostate hyperplasia (BPH). Our primary aim is to compare peri-operative outcomes of EEP using thulium fiber laser (TFL) against high-power holmium laser (HPHL) in hands of experienced surgeons for large prostates (≥80 ml in volume). Secondary outcomes were assess complications within 1 year of follow up. Materials and Methods: We retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with TFL or HPHL in 13 centers (January 2019-January 2023). Patients with prostate volume ≥80 ml were included, while those with concomitant prostate cancer, previous prostate/urethral surgery, and pelvic radiotherapy were excluded. Results: Of 1,929 included patients, HPHL was utilized in 1,459 and TFL in 470. After propensity score matching (PSM) for baseline characteristics, 247 patients from each group were analyzed. Overall operative time (90 [70, 120] vs. 52.5 [39, 93] min, P < 0.001) and enucleation time (90 [70, 105] vs. 38 [25, 70] min, P < 0.001) were longer in the TFL group, with comparable morcellation time (13 [10, 19.5] vs. 13 [10, 16.5] min, P = 0.914). In terms of postoperative outcomes, there were no differences in 30-day complications such as acute urinary retention, urinary tract infection or sepsis. In the PSM cohort, univariable analyses showed that higher age, lower preoperative Qmax, higher preoperative PVRU, and longer operation time were associated with higher odds of postoperative incontinence, while 2-lobe enucleation had lower odds of incontinence compared to 3-lobe enucleation. Conclusions: This real-world study reaffirms that HPHL and TFL in large prostates are equally efficacious in terms of 30-day complications. TFL with the en-bloc technique has a shorter operative time which significantly improves short- and medium-term functional outcomes.

Influence of Early Apical Release on Outcomes in Endoscopic Enucleation of the Prostate: Results From a Multicenter Series of 4392 Patients.

OBJECTIVE: To evaluate outcomes after laser endoscopic enucleation of the prostate (EEP) stratified by whether early apical release (EAR) was performed or not. METHODS: We retrospectively reviewed patients with clinical benign prostatic hyperplasia who underwent EEP with holmium or thulium fiber laser in 8 centers (January 2020-January 2022). EXCLUSION CRITERIA: previous prostate/urethral surgery, prostate cancer, pelvic radiotherapy, concomitant lower urinary tract surgery. One-to-one propensity score-matching was performed between patients with EAR vs no EAR, with covariates including age, prostate volume, diabetes mellitus, hypertension, preoperative indwelling catheter, IPSS, Qmax, enucleation, and laser types. Multivariable logistic regression analyses were performed to evaluate independent predictors of 30-day postoperative complications and urinary incontinence. RESULTS: EAR was performed in 2094 of 4392 included patients. The matched cohort consisted of 787 patients per arm. Total operation time was significantly longer in the EAR group (median 75 vs 67 minutes, P = .004). Early complications were higher in the EAR group (18.6% vs 12.5%, P = .001), while postoperative incontinence rates were similar (14.1% vs 13.1%, P = .61). Multivariable regression analysis showed that 3-lobe enucleation and operation time were significant predictors of postoperative complications; preoperative indwelling catheterization, higher prostate volume, and en-bloc enucleation were associated with higher odds of postoperative incontinence. LIMITATION: retrospective nature. CONCLUSION: Performing EAR during EEP is associated with a greater incidence of early complications, which was mainly driven by higher rates of postoperative hematuria and perioperative transfusion. The risk of postoperative incontinence and its duration are not affected by EAR.

The Utility and Safety of Ureteral Access Sheath During Retrograde Intrarenal Surgery in Children.

OBJECTIVE: To compare retrograde intrarenal surgery (RIRS) with and without ureteral access sheath (UAS) in different pediatric age groups. METHODS: The data of RIRS for kidney stone in children were obtained from 9 institutions. Demographic characteristics of patients and stones, intraoperative and postoperative results were recorded. While analyzing the data, patients who underwent RIRS without UAS (group 1) (n = 195) and RIRS with UAS (group 2) (n = 194) were compared. RESULTS: Group 1 was found to be young, thin, and short (P <.001, P = .021, P <.001), but there was no gender difference and similar symptoms were present except hematuria, which was predominant in group 2 (10.6% vs 17.3%, P <.001). Group 1 had smaller stone diameter (9.91 ± 4.46 vs 11.59 ± 4.85 mm, P = .001), shorter operation time (P = .040), less stenting (35.7% vs 72.7%, P = .003). Re-intervention rates and stone-free rates (SFR) were similar between groups (P = .5 and P = .374). However, group 1 had significantly high re-RIRS (P = .009). SFR had a positive correlation with smaller stone size and thulium fiber laser usage compared to holmium fiber laser (HFL) (P <.001 and P = .020), but multivariate analysis revealed only large stone size as a risk factor for residual fragments (P = .001). CONCLUSION: RIRS can be performed safely in children with and without UAS. In children of smaller size or younger age (<5 years), limited use of UAS was observed. UAS may be of greater utility in stones larger than 1 cm, regardless of the age, and using smaller diameter UAS and ureteroscopes can decrease the complications.

Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. METHODS: An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). RESULTS: Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. CONCLUSION: This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.

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.

Comparing Same-Sitting Bilateral vs Unilateral Retrograde Intrarenal Surgery in the Elderly.

OBJECTIVE: To compare same-sitting bilateral vs unilateral retrograde intrarenal surgery (RIRS) in elderly patients, focusing on postoperative complications and stone-free rates (SFR). METHODS: Data from 2 multicenter databases, FLEXible ureteroscopy Outcomes Registry (FLEXOR) (unilateral RIRS) and same sitting bilateral-retrograde intrarenal surgery (SSB-RIRS) (bilateral RIRS), were analyzed, considering only patients aged 70+ with preoperative computed tomography. Patients were categorized into Group 1 (bilateral RIRS) and Group 2 (unilateral RIRS). Follow-up included imaging assessments and secondary treatments as needed. RESULTS: Group 1 included 146 patients, while group 2 had 495. Group 1's patients were slightly older and had a higher prevalence of recurrent stone formation. Group 2 often underwent RIRS for incidental stones. Group 1 had larger and more pelvic stones. Laser lithotripsy and total operation times were significantly longer in Group 1. Group 2 had significantly higher overall stone-free rates, although there were no significant differences in ancillary procedures for residual fragments. Group 1 experienced more pelvicalyceal injuries needing stenting, postoperative fever, and post-op hematuria not requiring transfusion. CONCLUSION: In conclusion, bilateral RIRS can be carefully considered in elderly patients. Preoperative counseling is essential for both primary and repeat RIRS procedures, and further research is needed to optimize instrument and laser strategies for better outcomes in elderly RIRS patients.

Artificial Intelligence-Guided Segmentation and Path Planning Software for Transthoracic Lung Biopsy.

PURPOSE: To validate the sensitivity and specificity of a 3-dimensional (3D) convolutional neural network (CNN) artificial intelligence (AI) software for lung lesion detection and to establish concordance between AI-generated needle paths and those used in actual biopsy procedures. MATERIALS AND METHODS: This was a retrospective study using computed tomography (CT) scans from 3 hospitals. Inclusion criteria were scans with 1-5 nodules of diameter ≥5 mm; exclusion criteria were poor-quality scans or those with nodules measuring <5mm in diameter. In the lesion detection phase, 2,147 nodules from 219 scans were used to develop and train the deep learning 3D-CNN to detect lesions. The 3D-CNN was validated with 235 scans (354 lesions) for sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) analysis. In the path planning phase, Bayesian optimization was used to propose possible needle trajectories for lesion biopsy while avoiding vital structures. Software-proposed needle trajectories were compared with actual biopsy path trajectories from intraprocedural CT scans in 150 patients, with a match defined as an angular deviation of <5° between the 2 trajectories. RESULTS: The model achieved an overall AUC of 97.4% (95% CI, 96.3%-98.2%) for lesion detection, with mean sensitivity of 93.5% and mean specificity of 93.2%. Among the software-proposed needle trajectories, 85.3% were feasible, with 82% matching actual paths and similar performance between supine and prone/oblique patient orientations (P = .311). The mean angular deviation between matching trajectories was 2.30° (SD ± 1.22); the mean path deviation was 2.94 mm (SD ± 1.60). CONCLUSIONS: Segmentation, lesion detection, and path planning for CT-guided lung biopsy using an AI-guided software showed promising results. Future integration with automated robotic systems may pave the way toward fully automated biopsy procedures.

Retrograde intrarenal surgery for asymptomatic incidental renal stones: a retrospective, real-world data analysis.

OBJECTIVE: To determine surgical outcomes and stone-free rates (SFRs) when offering upfront retrograde intrarenal surgery (RIRS) to patients with asymptomatic incidental renal stones (AIRS), as active surveillance, shockwave lithotripsy or upfront intervention in patients with AIRS is still a debate among urologists. PATIENTS AND METHODS: This retrospective FLEXible Ureteroscopy Outcomes Registry (FLEXOR), supported by the Team of Worldwide Endourological Researchers (TOWER), examines adult patients who underwent RIRS. We analysed a subset of asymptomatic patients with renal stones on imaging who were treated with RIRS. Data includes patient characteristics, stone specifications, anaesthesia type, perioperative details, complications, and SFR. A multivariable logistic regression analysis was performed to assess factors associated with the SFR. RESULTS: Among 679 patients with AIRS, 640 met the inclusion criteria. The median age was 55 years, with 33.4% being female. In all, 22.1% had positive urine cultures. The median stone diameter was 12 mm, commonly in lower and interpolar locations. RIRS was preferentially performed under general anaesthesia using a reusable scope in 443 cases. Prophylactic antibiotics were administered to 314 patients. The median operation time was 58 min and the median laser time was 24 min. The SFR was 68.8%. The use of holmium laser (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.06-0.63; P < 0.01) and multiple stones (OR 0.38, 95% CI 0.19-0.76; P < 0.01) were factors associated with lower odds of being stone free. Overall complications were minimal, with sepsis in 1.6% of patients. Re-interventions were performed in 76 cases (11.8%), with RIRS being the most common in 67 cases (10.6%). CONCLUSION: Our multicentre real-world study is the first of its kind that highlights the pros and cons of offering RIRS to patients with AIRS and demonstrates a favourable SFR with acceptable complications. Pre-emptively discussing potential re-intervention helps patients make informed decisions, particularly in cases involving large and multiple stones.

Incidence of urinary incontinence following endoscopic laser enucleation of the prostate by en-bloc and non-en-bloc techniques: a multicenter, real-world experience of 5068 patients.

ABSTRACT: We aim to evaluate the incidence of incontinence following laser endoscopic enucleation of the prostate (EEP) comparing en-bloc (Group 1) versus 2-lobe/3-lobe techniques (Group 2). We performed a retrospective review of patients undergoing EEP for benign prostatic enlargement in 12 centers between January 2020 and January 2022. Data were presented as median and interquartile range (IQR). Univariable and multivariable logistic regression analysis was performed to evaluate factors associated with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI). There were 1711 patients in Group 1 and 3357 patients in Group 2. Patients in Group 2 were significantly younger (68 [62-73] years vs 69 [63-74] years, P = 0.002). Median (interquartile range) prostate volume (PV) was similar between the groups (70 [52-92] ml in Group 1 vs 70 [54-90] ml in Group 2, P = 0.774). There was no difference in preoperative International Prostate Symptom Score, quality of life, or maximum flow rate. Enucleation, morcellation, and total surgical time were significantly shorter in Group 1. Within 1 month, overall incontinence rate was 6.3% in Group 1 versus 5.3% in Group 2 (P = 0.12), and urge incontinence was significantly higher in Group 1 (55.1% vs 37.3% in Group 2, P < 0.001). After 3 months, the overall rate of incontinence was 1.7% in Group 1 versus 2.3% in Group 2 (P = 0.06), and SUI was significantly higher in Group 2 (55.6% vs 24.1% in Group 1, P = 0.002). At multivariable analysis, PV and IPSS were factors significantly associated with higher odds of transient SUI/MUI. PV, surgical time, and no early apical release technique were factors associated with higher odds of persistent SUI/MUI.

Off-clamp vs on-clamp robot-assisted partial nephrectomy: a systematic review and meta-analysis.

OBJECTIVE: To compare intra- and postoperative outcomes between off-clamp and on-clamp robot-assisted partial nephrectomy (RAPN), using data from randomised controlled trials (RCTs) or covariate-matched studies (propensity score-matched or matched-pair analysis). METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature review was conducted on PubMed, EMBASE, Scopus and CENTRAL for relevant studies comparing off-clamp to on-clamp RAPN. Primary outcomes were estimated blood loss, postoperative percentage decrease in estimated glomerular filtration rate (eGFR), and margin positive rate. Secondary outcomes were operative time, postoperative eGFR, length of stay, all postoperative complications, major complications, and need for transfusion. Random-effects meta-analyses were performed to generate mean differences (MDs) or odds ratios (ORs). RESULTS: A total of 10 studies (2307 patients) were shortlisted for analysis. There was no significant difference in estimated operative blood loss between off-clamp and on-clamp RAPN (MD 21.9 mL, 95% confidence interval [CI] -0.9 to 44.7 mL; P = 0.06, I2 = 58%). Off-clamp RAPN yielded a smaller postoperative eGFR deterioration (MD 3.10%, 95% CI 1.05-5.16%; P = 0.008, I2 = 13%) and lower odds of margin positivity (OR 0.62, 95% CI 0.40-0.94; P = 0.03, I2 = 0%). No significant differences were found for all secondary outcomes. CONCLUSIONS: Off-clamp and on-clamp RAPN are similarly effective approaches for selected renal masses. Within the classic trifecta of PN outcomes, off-clamp RAPN yields similar rates of perioperative complications and may possibly offer better preservation of renal function and reduced margin-positive rates.

Comparison Between Thulium Fiber Laser and High-power Holmium Laser for Anatomic Endoscopic Enucleation of the Prostate: A Propensity Score-matched Analysis from the REAP Registry.

BACKGROUND: Different lasers have been developed for treatment of benign prostatic hyperplasia, with no definitively superior technique identified to date. OBJECTIVE: To compare surgical and functional enucleation outcomes in real-world multicentre practice using high-power holmium laser (HP-HoLEP) and thulium fiber laser enucleation of the prostate (ThuFLEP) for different prostate sizes. DESIGN, SETTING, AND PARTICIPANTS: The study included 4216 patients who underwent HP-HoLEP or ThuFLEP at eight centers in seven countries between 2020 and 2022. Exclusion criteria were previous urethral or prostatic surgery, radiotherapy, or concomitant surgery. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: To adjust for the bias arising from different characteristics at baseline, propensity score matching (PSM) was used to identify 563 matched patients in each cohort. Outcomes included the incidence of postoperative incontinence, early complications (30-d), and delayed complications, and results for the International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and postvoid residual volume (PVR). RESULTS AND LIMITATIONS: After PSM, 563 patients in each arm were included. Total operative time was similar between the arms, but enucleation and morcellation times were significantly longer for ThuFLEP. The rate of postoperative acute urinary retention was higher in the ThuFLEP arm (3.6% vs 0.9%; p = 0.005), but the 30-d readmission rate was higher in the HP-HoLEP arm (22% vs 8%; p = 0.016). There was no difference in postoperative incontinence rates (HP-HoLEP:19.7%, ThuFLEP:16.0%; p = 0.120). Rates of other early and delayed complications were low and comparable between the arms. The ThuFLEP group had higher Qmax (p < 0.001) and lower PVR (p < 0.001) than the HP-HoLEP group at 1-yr follow-up. The study is limited by its retrospective nature. CONCLUSIONS: This real-world study shows that early and delayed outcomes of enucleation with ThuFLEP are comparable to those with HP-HoLEP, with similar improvements in micturition parameters and IPSS. PATIENT SUMMARY: As lasers become readily available for the treatment of enlarged prostates causing urinary bother, urologists should focus on performing good anatomic removal of prostate tissue, with the choice of laser not as important for good outcomes. Patients should be counseled about long-term complications, even when the procedure is being performed by an experienced surgeon.

Radiomics in Kidney Transplantation: A Scoping Review of Current Applications, Limitations, and Future Directions.

Radiomics is increasingly applied to the diagnosis, management, and outcome prediction of various urological conditions. The purpose of this scoping review is to evaluate the current evidence of the application of radiomics in kidney transplantation, especially its utility in diagnostics and therapeutics. An electronic literature search on radiomics in the setting of transplantation was conducted on PubMed, EMBASE, and Scopus from inception to September 23, 2022. A total of 16 studies were included. The most widely studied clinical utility of radiomics in kidney transplantation is its use as an adjunct to diagnose rejection, potentially reducing the need for unnecessary biopsies or guiding decisions for earlier biopsies to optimize graft survival. Technology such as optical coherence tomography is a noninvasive procedure to build high-resolution optical cross-section images of the kidney cortex in situ and in real time, which can provide histopathological information of donor kidney candidates for transplantation, and to predict posttransplant function. This review shows that, although radiomics in kidney transplants is still in its infancy, it has the potential for large-scale implementation. Its greatest potential lies in the correlation with conventional established diagnostic evaluation for living donors and potential in predicting and detecting rejection postoperatively.

Graft retrieval incisions in minimally invasive donor nephrectomy: Systematic review and network meta-analysis.

BACKGROUND: Various incisions are employed for graft extraction during minimally invasive donor nephrectomy, but an overarching synthesis of associated short-term donor outcomes is lacking. METHODS: An electronic literature search was conducted on PubMed, EMBASE and Scopus for studies comparing ≥2 graft extraction incisions in laparoscopic or robotic donor nephrectomy with ≥10 patients per arm. Eligible study designs included randomized trials, case-control, and cohort studies. Primary outcomes were donor length of stay (LOS); in-hospital analgesic requirement; and postoperative complications. Secondary outcomes were warm ischemia time (WIT), total operation time (TOT), and estimated blood loss (EBL). Random-effects Frequentist network meta-analyses were conducted for all outcomes. RESULTS: Twenty-nine studies (4702 patients) were shortlisted. Six incisions were analyzed: iliac, Pfannenstiel, midline hand-assisted laparoscopic (HAL), midline umbilical, flank and transvaginal natural orifice transluminal endoscopic surgery (NOTES). The flank incision had significantly longer LOS than all other incisions. LOS was significantly longer in Pfannenstiel than iliac incision (mean difference [MD] = 0.29, 95%CI = 0.002-0.58 days). Midline HAL had significantly shorter TOT than most other incisions. Midline umbilical incisions had significantly higher WIT than midline HAL and Pfannenstiel incisions. Midline HAL had shorter WIT than transvaginal NOTES (MD = 0.80, 95%CI = 0.05-1.56 min). No major differences were seen in analgesia requirement, postoperative complications and EBL. CONCLUSION: Six different incisions for graft retrieval are broadly comparable across most short-term outcomes although long-term outcomes remain to be elucidated. Iliac and Pfannenstiel incisions yielded similar outcomes besides marginally lower LOS for the former. Midline incision for HAL may be associated with shorter TOT, and transvaginal NOTES is an effective technique for selected female donors. TRIAL REGISTRATION: PROSPERO CRD42023445407.

Dementia Risk of Direct Oral Anticoagulants Versus Warfarin for Atrial Fibrillation: Systematic Review and Meta-Analysis.

Background: Direct-acting oral anticoagulants (DOACs) have demonstrated superior efficacy in preventing stroke and death compared with warfarin in patients with atrial fibrillation (AF), but their influence on dementia risk remains unclear. Objectives: The purpose of this study was to evaluate the relative risks of dementia in DOAC vs warfarin in patients with AF. Methods: An electronic literature search was conducted to retrieve studies reporting comparisons of dementia incidence between patients treated with DOACs and warfarin for AF. HRs and 95% CI were pooled in a random-effects meta-analysis. Meta-regression was performed to identify prognostic baseline variables. Network meta-analysis was performed to determine dementia risk between individual DOACs and warfarin. Results: Ten studies (n = 342,624) were retrieved. DOAC was associated with a significantly lower risk of developing dementia compared with warfarin (HR: 0.88; 95% CI: 0.80-0.98; P = 0.017; I2 = 75%); significance was also seen in Asian patients (HR: 0.81; 95% CI: 0.68-0.86) but not non-Asian patients. Subgroup analyses of propensity score-matched studies and patients aged 65-75 years showed similar significance, but not for patients aged ≥75 years. Meta-regression found that a lower mean age corresponded to significantly greater favoring of DOAC over warfarin. Network meta-analysis found significant reductions in dementia risk over warfarin for rivaroxaban (HR: 0.854; 95% CI: 0.763-0.955), apixaban (HR: 0.881; 95% CI: 0.778-0.997), and dabigatran (HR: 0.871; 95% CI: 0.770-0.987); the highest-ranked treatment based on P scores was edoxaban. Conclusions: The use of DOAC in AF significantly reduces dementia risk compared with warfarin, particularly in Asian patients. The possible reversal of this effect with increasing age merits further randomized trials with long-term follow-up. (Dementia Risk of Direct Oral Anticoagulants Versus Warfarin for Atrial Fibrillation: A Systematic Review and Meta-Analysis; CRD42022365634).

Outcomes of Localized Renal Cell Carcinoma Across Different Races.

Introduction: Epidemiological outcomes of renal cell carcinoma (RCC) remain sparse. This study aims to compare preoperative characteristics, surgical outcomes, and oncological outcomes of RCC patients at a urology unit in Singapore.Methods: A retrospective cohort analysis of 137 RCC patients in the National University Hospital of Singapore who had undergone partial nephrectomy between 2009 and 2020 was conducted. χ2 tests (Chi-Square Test, Fisher's Exact Test) and one-way analysis of variance (ANOVA) were used for comparing categorical and continuous variables respectively. Kaplan-Meier estimates were used for survival analysis.Results: In total, 137 patients were identified (Chinese [n=82], Malay [n=19], Indian [n=15], Others [n=21]). Indian patients were diagnosed at an earlier age (52.13±10.52 years, P=0.018). A larger percentage of Malay patients (78.9%, P<0.001) were operated on before 2016, prior to the center's adoption of the robotic surgical technique. More Malay and Indian patients underwent laparoscopic surgery (36.8% and 46.7%, P=0.008), experiencing higher rates of intra-operative conversions compared to the Chinese and other ethnicities (5.3% and 13.3% vs. 0%, P=0.011). They also had longer post-operative stays compared to Chinese (7.42±6.46 days; 7.40±7.69 days vs. 4.88±2.87 days, P=0.036). Malays were much less likely to undergo robotic partial nephrectomy compared to Chinese patients (OR=0.295, 95% CI=0.102-0.856) and had the highest rate of metastatic recurrence (10.5%, P=0.023).

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.

PCNL vs RIRS in management of stones in calyceal diverticulum: outcomes from a global multicentre match paired study that reflects real world practice.

INTRODUCTION: Calyceal diverticulum (CD) is the outpouching of a calyx into the renal parenchyma, connected by an infundibulum. Often associated with recurrent stones, common surgical options include percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS). We aim to present the real-world practises and outcomes comparing both approaches and the technical choices made. MATERIALS AND METHODS: Retrospective data including 313 patients from 11 countries were evaluated. One hundred and twenty-seven underwent mini-PCNL and one hundred and eighty-six underwent RIRS. Patient demographics, perioperative parameters, and outcomes were analysed using either T test or Mann-Whitney U test. Categorical data between groups were analysed using the Chi-squared test. Propensity score matching (PSM) was performed matching for baseline characteristics. Subgroup analyses for anomalous/malrotated kidneys and difficult diverticulum access were performed. RESULTS: After PSM, 123 patients in each arm were included, with similar outcomes for stone-free rate (SFR) and complications (p < 0.001). Hospitalisation was significantly longer in PCNL. Re-intervention rate for residual fragments (any fragment > 4 mm) was similar. RIRS was the preferred re-intervention for both groups. Intraoperative bleeding was significantly higher in PCNL (p < 0.032) but none required transfusion. Two patients with malrotated anatomy in RIRS group required transfusion. Lower pole presented most difficult access for both groups, and SFR was significantly higher in difficult CD accessed by RIRS (p < 0.031). Laser infundibulotomy was preferred for improving diverticular access in both. Fulguration post-intervention was not practised. CONCLUSION: The crux lies in identification of the opening and safe access. Urologists may consider a step-up personalised approach with a view of endoscopic combined approach where required.