Refining surgical strategies in ThuLEP for BPH: a propensity score matched comparison of En-bloc, three lobes, and two lobes techniques.

PURPOSE: This study compares the peri-operative and functional outcomes of three distinct surgical techniques in Thulium Laser Enucleation of the Prostate (ThuLEP) for benign prostatic hyperplasia (BPH). The main aim is to assess whether the En-bloc, Three-lobe, and Two-lobe techniques have differential effects on surgical efficacy and patient outcomes. METHODS: A retrospective analysis was conducted on patients undergoing ThuLEP for BPH between January 2019 and January 2024 at two tertiary centers. Propensity score matching was utilized to balance baseline characteristics among patients undergoing the different techniques. Surgical parameters, including operative time, enucleation time, morcellation time, energy consumption, and postoperative outcomes, were compared among the groups. RESULTS: Following propensity score matching, 213 patients were included in the analysis. Intraoperative analysis revealed significantly shorter enucleation, laser enucleation, morcellation and operative times and total energy delivered in the En-bloc and Two-lobe groups compared to the Three-lobe group. No significant differences were observed among the groups in terms of intraoperative and postoperative complications. There were no significant differences in functional outcomes at the 3-month follow-up among the groups. CONCLUSION: The findings of this study suggest that while the En-bloc and Two-lobe techniques may offer efficiency benefits and could be considered safe alternatives in ThuLEP procedures, the reduction in laser enucleation time and energy delivered did not necessarily translate into improvements in post operative storage symptoms or other functional outcomes for the patients. Surgeon preference and proficiency may play a crucial role in selecting the most suitable technique for individual patients. Future research should focus on larger-scale prospective studies to further validate these findings and explore potential factors influencing surgical outcomes.

Monopolar Transurethral Resection of the Prostate by a Single Surgeon in North-Central Nigeria: Surgical Results and Postoperative Complications.

BACKGROUND: There has been an upsurge in the use of electrocautery in the treatment of benign prostatic hyperplasia (BPH) in our environment. Monopolar transurethral resection of the prostate (M-TURP) still remains the gold standard in the surgical management of BPH. OBJECTIVES: To present our experience and the clinical outcome of M-TURP in north-central Nigeria. METHODS: Data on demographics, indications, comorbidities, duration of surgery, weight of resected tissue, outcome of surgery, and complications were collected. International Prostate Symptom Score (IPSS) and Quality of Life (QoL) scores were assessed pre- and post-operatively. Results were analyzed using descriptive statistics. Student t-test was used for the comparison of continuous data while categorical data were compared by using Chi-square. P-value was considered significant if <0.05. RESULTS: In this retrospective study, out of 227 men who met the inclusion criteria, two patients' procedures were converted to open surgery (conversion rate of 0.9%). The mean age of our patients was 65.2 + 7.5 years (44-90). The commonest indication for surgery was LUTS unresponsive to medical therapy (54.7%, n=123), followed by acute urinary retention (36.4%, n=82). The average weight of resected tissue was 36.5+12.1g (range 10-89) The weight of resected tissue correlated positively to prostate size measured by ultrasonography and it was also statistically significant (r = 0.568 and p-value <0.001). The early complications encountered were urinary tract infection (3.6%, n=8), clot retention (1.8%, n=4), and significant hematuria requiring blood transfusion (1.8%, n=4). CONCLUSION: In our setting, M-TURP demonstrates safety and efficacy in treating BPH. Skill and experience contribute to better outcomes, facilitating the management of larger prostates through refined techniques.

CONTEXTE: Il y a eu une augmentation de l'utilisation de l'électrocautérisation dans le traitement de l'hyperplasie bénigne de la prostate (HBP) dans notre environnement. La résection transurétrale monopolaire de la prostate (RTUP-M) reste néanmoins la référence en matière de gestion chirurgicale de l'HBP. OBJECTIFS: Présenter notre expérience et les résultats cliniques de la RTUP-M dans le centre-nord du Nigéria. MÉTHODES: Des données sur la démographie, les indications, les comorbidités, la durée de la chirurgie, le poids du tissu réséqué, les résultats de la chirurgie et les complications ont été collectées. Les scores de l'Indice International des Symptômes Prostatiques (IPSS) et de la Qualité de Vie (QoL) ont été évalués avant et après l'opération. Les résultats ont été analysés à l'aide de statistiques descriptives. Le test t de Student a été utilisé pour comparer les données continues tandis que les données catégorielles ont été comparées à l'aide du test du Chi-carré. La valeur p était considérée comme significative si elle était inférieure à 0,05. RÉSULTATS: Dans cette étude rétrospective, sur 227 hommes répondant aux critères d'inclusion, deux interventions ont été converties en chirurgie ouverte (taux de conversion de 0,9 %). L'âge moyen de nos patients était de 65,2±7,5 ans (44-90). L'indication la plus courante pour la chirurgie était les LUTS non réactifs au traitement médical (54,7 %, n =123), suivis de la rétention urinaire aiguë (36,4 %, n=82). Le poids moyen du tissu réséqué était de 36,5 ± 12,1 g (plage 10-89). Le poids du tissu réséqué était positivement corrélé à la taille de la prostate mesurée par échographie et était également statistiquement significatif (r=0,568 et p-value <0,001). Les complications précoces rencontrées étaient les infections des voies urinaires (3,6 %, n = 8), la rétention de caillot (1,8 %, n = 4) et une hématurie significative nécessitant une transfusion sanguine (1,8 %, n = 4). CONCLUSION: Dans notre cadre, la RTUP-M démontre sa sécurité et son efficacité dans le traitement de l'HBP. La compétence et l'expérience contribuent à de meilleurs résultats, facilitant la gestion de prostates plus grandes grâce à des techniques affinées. MOTS-CLÉS: Électrocautérisation; Référence; Hommes; Formation; Poids; Réséqué.

The Effect of Transurethral Holmium Laser Enucleation of the Prostate in the Treatment of High-Risk Elderly Patients with BPH and Its Influence on Quality of Life.

BACKGROUND: Transurethral holmium laser enucleation of the prostate (HoLEP) has a good therapeutic effect on benign prostatic hyperplasia (BPH). The purpose of this study was to investigate the clinical efficacy of HoLEP in the treatment of high-risk elderly patients with BPH and assess its impact on the inflammatory response, vascular endothelial function and quality of life (QoL). METHODS: Patients at high risk of BPH who were hospitalised in Chengde Central Hospital from February 2021 to December 2022 were retrospectively selected as the study objects, and a total of 100 cases were included. The control group underwent transurethral resection of the prostate, and the observation group underwent HoLEP. Perioperative indexes, urodynamic indexes, QoL 6 months after surgery and incidence of postoperative complications were compared between the two groups. Moreover, serum levels of inflammatory factors and vascular endothelial factors were detected in two groups. RESULTS: We found no significant difference in general data between the two groups of patients (p > 0.05). The operation time, perioperative bleeding, bladder flushing time and hospitalisation time of the observation group were significantly shorter than those of the control group (p < 0.05). On the 7th day after surgery, the serum levels of tumour necrosis factor alpha, interleukin-1ß, interleukin-6, vascular endothelial growth factor, basic fibroblast growth factor and endothelin-1 in the observation group were significantly lower than those in the control group (p < 0.05). Six months after surgery, the maximal urinary flow rate and QoL scores of the patients in the observation group were significantly higher than those of the control group (p < 0.05), and the residual urine volume and International Prostate Symptom Score of observation group were significantly lower than those of the control group (p < 0.05). The incidence of postoperative complications in the observation group was significantly lower than that in the control group (χ2 = 7.440, p = 0.006). CONCLUSIONS: HoLEP can effectively remove hyperplasia of the prostate and reduce the inflammatory response in the patient's body when treating BPH in high-risk elderly patients. It can also regulate the levels of vascular endothelial factors and effectively improve the patient's QoL.

Does previous transurethral resection of the prostate affect the outcomes in robotic assisted radical prostatectomy?

PURPOSE: Transurethral resection of the prostate (TURP) is one of the surgical options for treating enlarged prostates with lower urinary symptoms (LUTS). In this older group of patients, concomitant prostate cancer is not uncommon. However, the fibrosis and distortion of the prostate anatomy by prior TURP can potentially hinder surgical efficacy at robotic-assisted radical prostatectomy (RARP). We aim to evaluate functional, and oncologic outcomes of RARP in patients with and without previous TURP. METHODS: 231 men with previous TURP underwent RARP (TURP group). These men were propensity score matched using clinicopathological characteristics to men without previous TURP who underwent RARP (Control group). Perioperative and postoperative variables were analysed for significant differences in outcomes between groups. Variables analysed included estimated blood loss (EBL), operative time, catheter time, hospitalization time, postoperative complications, positive surgical margins (PSM) rates, cancer status, biochemical recurrence (BCR), potency, and continence rates. RESULTS: Patients in the TURP group showed no statistically significant differences in operative safety measures including median EBL, operative time, catheter time, hospitalization time or postoperative complications. No significant difference between the groups in terms of potency rates and continence rates. Furthermore, there were no statistically significant differences in oncological outcomes, including PSM rates (15% vs 18%, P = 0.3) and BCR. CONCLUSION: In RARP after TURP there is often noticeable distortion of the surgical anatomy. For an experienced team the procedure is safe and provides similar oncologic control and functional outcomes to RARP in patients without previous TURP.

Transurethral water vapour thermal therapy for benign prostatic hyperplasia under local anaesthesia alone: initial experience in Chinese patients.

INTRODUCTION: This study evaluated the perioperative and early postoperative outcomes of transurethral water vapour thermal therapy (WVTT) under local anaesthesia alone for benign prostatic enlargement in Chinese patients. METHODS: This retrospective review of transurethral WVTT for benign prostatic enlargement focused on 50 Chinese patients who exhibited clinical indications (acute retention of urine or symptomatic lower urinary tract symptoms due to benign prostatic enlargement) for surgical treatment between June 2020 and December 2021 in Hong Kong. Exclusion criteria included active urinary tract problems and urological malignancies. Follow-up was conducted at 3 months postoperatively. RESULTS: The median patient age was 71.5 years. The mean preoperative prostatic volume was 56.7 mL. The mean operation time was 25.1 minutes. All procedures were performed under local anaesthesia alone. The mean pain scores for transrectal ultrasound probe insertion, transperineal local anaesthesia injection, and transurethral WVTT were 2, 5, and 4, respectively. Forty-nine patients (98%) were discharged on the same day with a urethral catheter. Forty-eight patients (96%) successfully completed a trial without catheter within 3 weeks postoperatively. Five patients (10%) had unplanned hospital admission within 30 days postoperatively due to surgical complications (Clavien-Dindo grade 1). CONCLUSION: Transurethral WVTT, an advanced surgical treatment for benign prostatic enlargement, is a safe procedure that relieves lower urinary tract symptoms with minimal hospital stay. It can be performed in an office-based setting under local anaesthesia, maximising utilisation of the surgical theatre.

Minimally invasive interventions for lower urinary tract symptoms: What sits between medical therapy and transurethral resection of the prostate.

BACKGROUND: There are a variety of medical and surgical treatment options available today for the management of lower urinary tract symptoms (LUTS) secondary to bladder outlet obstruction due to benign prostatic hyperplasia (BPH). OBJECTIVE: The aim of this paper is to highlight the various treatment options available for the management of bladder outlet obstruction secondary to BPH and discuss the benefits and potential drawbacks of each. DISCUSSION: Lifestyle and dietary modification and medical therapies, such as an alpha-1 blocker as monotherapy, should be considered as first-line when initially counselling a patient for LUTS secondary to bladder outlet obstruction due to BPH. If bothersome LUTS persist despite medical management, or if medical management is not suitable or preferable, then surgical interventions can be considered. The mainstay of surgical intervention has traditionally been transurethral resection of the prostate (TURP); however, the treatment landscape is rapidly evolving with the development of minimally invasive procedures.

[Robot-assisted radical prostatectomy in patients after transurethral resection of the prostate].

Performing a radical treatment of prostate cancer in patients with a history of transurethral resection of the prostate (TURP) is a serious task even for an experienced surgeon, due to the anatomical and topographic changes that occur after endoscopic surgery. The technical possibilities of robotic technologies have great potential for obtaining the best treatment results for this category of patients. In order to review the intra- and postoperative outcomes of robot-assisted radical prostatectomy (RARP) in patients with a history of PCa and TURP, we selected relevant publications in the PubMed and Google Scholar databases for the period from 2008 to 2022. Based on the analysis of publications, there is no definite opinion on the efficacy and safety of RARP in patients after TURP compared with patients without a history of TURP. However, an experienced robotic surgeon with an appropriate level of expertise should perform surgical treatment of patients with a history of TURP. It has been shown that the choice of surgical approach when performing radical prostatectomy does not have a significant impact on treatment outcomes. At the same time, before performing radical treatment of prostate cancer in this category of patients, it is necessary to inform them about the possibly worse oncological and functional results of the operation.

Reoperation Rate for Residual/Regrowth Adenoma Following Transurethral Interventions for Benign Prostatic Enlargement: Results from a Systematic Review and Meta-Analysis of Comparative Randomized Studies.

Objective: To perform a systematic review to assess the incidence of reoperation rate for residual/regrowth adenoma after transurethral surgeries for benign prostatic enlargement. Materials and Methods: A systematic literature search was performed on November 12, 2023, using Cochrane Central Register of Controlled Trials, PubMed, and Scopus. We only included randomized studies comparing monopolar (M)/bipolar (B) transurethral resection of the prostate (TURP) vs ablation vs enucleation procedures. Incidence of reoperation was assessed using the Cochran-Mantel-Haenszel Method and reported as risk ratio (RR), 95% confidence interval (CI), and p-values. Statistical significance was set at p < 0.05. Evidence synthesis: Forty-eight studies were included. Six studies compared enucleation vs TURP, 41 ablation vs TURP, and 1 study enucleation vs ablation vs TURP, encompassing 457 patients in enucleation, 2259 in ablation, and 2517 in the TURP group. The pooled incidence of reoperation was 6.2%, 0.7%, 2.3%, and 4.3% after ablation, enucleation, M-TURP, and B-TURP, respectively. Meta-analysis showed that the incidence of reoperation was significantly lower in the enucleation group (RR 0.28, 95% CI 0.10-0.81, p = 0.02), but the difference accounted only in studies with follow-up between 1 and 3 years (RR 0.18, 95% CI 0.04-0.85, p = 0.03). The incidence of reoperation was significantly lower in the enucleation compared with the B-TURP group (RR 0.14, 95% CI 0.03-0.77, p = 0.02). Meta-analysis showed that the incidence of reoperation was significantly higher in the ablation group (RR 1.81, 95% CI 1.33-2.47, p = 0.0002), but there was no difference in studies with follow-up up to 1 year (odds ratio 1.78 95% CI 0.97-3.29, p = 0.06) longer than 5 years (RR 2.02, 95% CI 0.71-5.79, p = 0.19). The incidence of reoperation was significantly higher in the ablation compared with the M-TURP group (RR 1.91, 95% CI 1.44-2.54, p < 0.0001). Conclusions: In mid-term follow-up, reoperation rate for residual/regrowth adenoma was significantly lower after enucleation, although was significantly higher after ablation compared with TURP.

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

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

Surgical Advances in Treating Benign Prostatic Hyperplasia in Africa: What About the Endoscopic Approach?

OBJECTIVE: To assess the practices, trends, and challenges associated with the use of endoscopic techniques in Africa related to the surgical treatment of benign prostatic hyperplasia METHODS: The questionnaire, which was based on Google Forms, assessed several points related to the surgical management of benign prostatic hyperplasia. RESULTS: In 67.4% of the centers, BPH was the primary pathology requiring surgical management. In all 43 centers, approximately 1/3 of the urologists (n = 41) are able to perform an endoscopic procedure for the management of prostatic hypertrophy. Of the 43 centers, 30 had a block equipped with endourology equipment, and 56.6% (n = 17) performed endourological surgery exclusively for the surgical management of BPH. TURP is the most widely used endoscopic technique. Open prostatectomy was the only surgical technique used in 14 centers (32.5%). In the remaining centers, both procedures (endoscopy and open surgery) were used depending on the surgeon's skills. Twenty-six (60.5%) centers expressed the need for training in endoscopic management of BPH. CONCLUSION: The main challenges encountered relate to the lack of competent personnel, the unavailability of equipment and materials, and the high cost to patients. It is essential to develop modern urology in Africa, particularly in terms of endourological practices.

How I Do It: Teaching holmium laser enucleation of the prostate (HoLEP).

Holmium laser enucleation of the prostate (HoLEP) is considered a size-independent technique to treat benign prostatic hyperplasia. This safe and effective procedure is increasingly being adopted in urology training programs worldwide, yet limited teaching strategies have been described. Endoscopic handling during HoLEP allows for a simultaneous interaction between the surgeon and trainee, facilitating a guided teaching strategy with increasing difficulty as experience grows. In this article, we describe our stepwise approach for teaching HoLEP as part of a structured surgical training curriculum. We also evaluate the association of our method with intraoperative efficiency parameters and immediate postoperative surgical outcomes of 200 HoLEP procedures.

MR-Guided Transurethral Ultrasound Ablation (TULSA)-An Emerging Minimally Invasive Treatment Option for Localised Prostate Cancer.

The optimal treatment strategy for men with localised prostatic cancer of low and intermediate risk is an actively evolving field. It is important to strike a balance between maximal oncological control and minimal treatment-related complications, which helps preserve the patients' quality of life. MR-guided transurethral ultrasound ablation (TULSA) has emerged as a minimally invasive treatment option for this group of patients. This article aims to provide of a background on TULSA technology, a step-by-step procedural guide of MR-guided TULSA and to summarise the current evidence of TULSA in management of localised prostatic cancer, as well as other potential indications.

[Minimally-Invasive Surgical Techniques (MIST): Shedding Light on the Mist]. / Minimal Invasive Surgical Techniques (MIST): wie relevant ist der ganze Mist?

As life expectancy increases and there is growing demand for BPH treatments, innovative technologies have been developed, allowing for swift recovery, symptom relief, low complication rates, and the possibility of performing procedures on an outpatient basis, often under local anaesthesia. This review aims to describe the outcomes of newly developed minimally-invasive surgical therapies (MIST) for BPH treatment in terms of functional voiding parameters and sexual function. These therapies are categorized into primarily ablative (Aquablation [Aquabeam]), non-ablative (Prostatic Urethral Lift (PUL, Urolift), temporary implantable devices [iTind]), and secondarily ablative procedures (convective water vapor ablation, Rezum, Prostate Artery Embolization [PAE]). All MIST technologies have advanced the medical care of patients with BPH while preserving ejaculation. However, there is a shortage of long-term data specifically addressing re-intervention rates and the preservation of functional voiding parameters. Although there is promising data from regulatory trials and randomized studies, all MIST therapies are potentially associated with severe complications. Patients considering such methods must be thoroughly informed about their inferiority compared with established transurethral procedures like TUR-P and enucleation.

A randomized controlled trial evaluating low-intensity shockwave therapy for treatment of persistent storage symptoms following transurethral surgery for benign prostatic obstruction.

BACKGROUND: Low-intensity shockwave therapy (Li-SWT) can improve bladder function through enhancement of angiogenesis and nerve regeneration and suppression of inflammation and overactivity. In this trial, we aimed to evaluate the efficacy of Li-SWT on persistent storage symptoms after transurethral surgery (TUS) for benign prostatic obstruction (BPO). METHODS: Between July 2020 and July 2022, 137 patients with persistent storage symptoms; urgency episodes/24 h ≥ 1 and daytime frequency ≥8, for at least three months after TUS for BPO were randomly allocated to Li-SWT versus sham versus solifenacin 10 mg/day in 3:1:1 ratio. The primary end point was the percent reduction from baseline in overactive bladder symptom score (OABSS) at 3-month follow-up. The changes in 3-day voiding diary parameters, quality of life (QoL) score, peak flow rate and residual urine at 3 and 6-month follow-up were compared. Treatment-related adverse effects were also evaluated. RESULTS: Baseline data were comparable between groups. The percent reduction from baseline in OABSS at 3-month follow-up was significantly higher in Li-SWT compared to sham (-55% versus -11%), and it was comparable between Li-SWT and solifenacin-10 (-55% versus -60%). Li-SWT achieved significant improvement like solifenacin-10 in 3-day voiding diary parameters and QoL score at 3-month follow-up. This improvement remained comparable between Li-SWT and solifenacin-10 at 6-month follow-up. No adverse effects related to Li-SWT were noted apart from tolerable pain during the procedure. Solifenacin-10 was associated with bothersome adverse effects in 73% of the patients with 11.5% discontinuation rate. CONCLUSIONS: Li-SWT ameliorates persistent storage symptoms and promotes QoL after TUS for BPO, with comparable efficacy and better tolerance compared to solifenacin.

Propensity score-matched analysis comparing perioperative, functional, and safety outcomes between thulium fiber laser and bipolar enucleation of the prostate performed by a single surgeon with two years of follow-up.

PURPOSE: To compare perioperative, functional, and safety outcomes between thulium fiber laser enucleation of the prostate (ThuFLEP) and bipolar enucleation of the prostate performed by a single surgeon with use of propensity score (PS)-matched analysis. MATERIALS AND METHODS: Data were from 675 patients, 422 of whom underwent ThuFLEP and bipolar enucleation by a single highly experienced surgeon. ThuFLEP was performed with Fiberlase U1 (IRE Polus Ltd.). Perioperative parameters, safety, and functional outcomes, such as International Prostate Symptom Score (IPSS), quality of life (QoL), postvoid residual volume (PVR), and maximum urinary flow rate (Qmax) were assessed. To control for selection bias, a 1:1 PS-matched analysis was carried out using the following variables as covariates: total prostate volume, preoperative IPSS and early sphincter release. RESULTS: Of 422 patients, 370 (87.7%) underwent ThuFLEP and 52 (12.3%) underwent bipolar enucleation. Operation, enucleation, and morcellation time were comparable between groups before and after PS-matched analysis (p=0.954, p=0.474, p=0.362, respectively). Functional parameters (IPSS, QoL, PVR, Qmax) were also comparable between groups at every time point before and after PS matching. Significant improvements in IPSS, QoL score, Qmax, and PVR were observed during the 24-month follow-up period for both ThuFLEP and bipolar enucleation without any significant differences between groups. Early and late postoperative complications before and after PS-matched analysis were similar. CONCLUSIONS: ThuFLEP was comparable to bipolar enucleation in perioperative characteristics, improvement in voiding parameters, and complication rates. Both procedures were shown to be effective and safe in the management of benign prostatic hyperplasia.

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

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

Pulse modulation in En-Bloc HoLEP: does it really matter? A propensity score matched analysis.

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) is an established option in the surgical treatment of benign prostatic hyperplasia. Pulse modulation, such as MOSES® technology, has recently been introduced and may offer potential advantages in HoLEP. METHODS: Perioperative data from 117 patients who underwent MOSES® laser enucleation of the prostate (MoLEP) were collected. Propensity score matching using prostate volume, age, body mass index (BMI), and anticoagulant intake was performed using a database of 237 patients treated with HoLEP. In total, 234 patients were included in the analysis. RESULTS: Prostate volume (104 vs. 102 ml), age (70 vs. 71 years), BMI (27 vs. 27), and anticoagulant intake (34 vs. 35%) did not differ significantly between the groups. There were no significant differences in operation time (61.5 vs. 58.1 min, p = 0.42), enucleation efficiency (2.5 vs. 2.6 g/min, p = 0.74), hemostasis time (7.8 vs. 8 min, p = 0.75) and hemoglobin drop (0.9 vs. 0.7 mg/dl, p = 0.48). The complication rates were low in both groups (16.2% for HoLEP and 17.1% for MoLEP). No differences were noted in the Clavien-Dindo Classification (p = 0.63) and the Comprehensive Complication Index (p = 0.24). The rate of complications > CDC IIIa was 0.9% for HoLEP (endoscopic coagulation) and 1.7% for MoLEP (2 cases of endoscopic coagulation). No transfusions were administered. CONCLUSION: Overall, the enucleation efficiency was high in both groups and the procedure time was short. HoLEP is an efficient and safe treatment option in experienced hands, regardless of the use of pulse modulation technology.

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.

Transurethral bipolar enucleation using a TUEB loop for large benign prostatic hyperplasia: a retrospective cohort study.

PURPOSE: We aimed to assess the efficacy and safety of transurethral enucleation with bipolar system (TUEB) regardless of the prostate size using a specially developed TUEB loop. METHODS: A total of 251 patients who underwent TUEB were categorized into two groups depending on the prostate volume (PV): small-PV (≤ 80 mL) group, 133 patients; large-PV (> 80 mL) group, 118 patients. Comparisons of background information and treatment outcomes were performed between the groups. RESULTS: Operation (113.5 vs 166.4 min), enucleation (49.4 vs 68.1 min), and morcellation (11.4 vs 26.4 min) times were longer and hemoglobin decreased significantly (0.84 vs 1.30 g/dL) in the large PV group. However, the enucleation efficiency (enucleated weight per enucleation time; 0.71 vs 0.97 g/min) and prostate-specific antigen reduction rate (24.6% vs 16.1%) were significantly better in the large-PV group, with similar enucleation rates (enucleated weight per transitional zone volume; 82% vs 81%). The International Prostate Symptom Score, uroflowmetry maximum flow rate, and post-void residual urine in both groups improved at 3, 6, and 12 months compared with baseline. No patient underwent blood transfusion. There were no differences in the frequency of postoperative clot retention, urethral stricture, or stress incontinence at 3, 6, and 12 months. CONCLUSION: TUEB using a TUEB loop resulted in high levels of satisfaction regarding the enucleation efficiency, efficacy, and safety for BPH surgery regardless of the prostate size. TUEB should be considered one of the best treatment options for large BPH that is uncontrollable with medication.