Enhancing continence post holmium laser enucleation of the prostate: assessment of novel technique through randomized clinical trial.

BACKGROUND: Transient urinary incontinence (UI) is distressing event following holmium laser enucleation of the prostate (HoLEP). Novel technique namely, veil sparing HoLEP (VS-HoLEP), was proposed to improve early continence outcome. In this trial (NCT03494049), VS-HoLEP was compared to standard HoLEP (St-HoLEP). METHODS: VS-HoLEP entails early apical separation with sparing of ventral apical mucosal veil proximal to the verumontanum. Eligible symptomatic BPH patients were randomly allocated to St-HoLEP (91) and VS-HoLEP (89). The primary outcome was UI as depicted by one-hour pad test at one month postoperatively. Other outcome measures include all perioperative parameters, complications, and urinary outcome measures at different follow-up points. RESULTS: Median preoperative prostate size was 138 (50:282) and 128 (50:228) mL in St-HoLEP and VS-HoLEP groups respectively. At one month the number of patients with positive one-hour pad test was 21 (23.1%) and 10 (11.4%) in St-HoLEP and VS-HoLEP groups respectively (P 0.047). The difference was significantly in favor of VS-HoLEP considering the number of patients reporting UI, the number of patients with positive one-hour pad test as well as the grade of UI reported at one and 4 months. The difference was not statistically significant at 12 months. The median time to patients' reported continence was 8 (1-52) and 1.5 (1-52) weeks in St-HoLEP and VS-HoLEP groups respectively (P≤0.005). The technique independently predicted positive one-hour pad test at one and four months respectively. At twelve months presence of DM (diabetes mellitus) and more percent PSA reduction independently predicted positive one-hour pad test. CONCLUSIONS: Veil sparing HoLEP enhances significantly early postoperative urine continence both subjectively and objectively. Optimization of the surgical technique could cut short the number of leaking patients and reduce the degree as well as the duration of transient postoperative urine leak.

The headache of the post transurethral prostate surgery pyuria: Pursuit for evidence.

• Objective To prospectively assess early post-TUPS (transurethral prostate surgery) urinalysis changes and bacteriuria with its clinical relevance. • Methods Patients with BPO enrolled for TUPS were prospectively assessed. Patients were assessed at 2, 4, 8, 12, and 24-weeks postoperatively by DVAS (dysuria-visual-analogue-scale), IPSS-QOL, uroflow, and PVR. Routine urinalysis was performed before discharge and at all visits. MSUC (midstream urine culture) was performed before discharge, 4 and 12-weeks postoperatively. • Results At final analysis 152 patients were evaluable. Significant pyuria was reported in 52%, 96.1%, 94.1%, 71.7%, 78.9% and 52.5% in before discharge, 2-, 4-, 8-, 12-, and 24-weeks urinalysis postoperative respectively. The mean time to non-significant-pyuria (95%CI) was 19.1(17.5-20.7), 20.1(17.3-22.9), 15.8(12.8-18.8) and 14(10.3-17.8) weeks after prostate resection, vaporization, enucleation, and incision respectively, (P0.03). Regardless of the TUPS technique, half of the patients had significant pyuria at 24-weeks postoperative. MSUC was positive in 37/152(24.3%), 3/152(2%), 23/152(15.1%), and 5/152(3.3%) preoperatively, before discharge, 4 and 12-weeks postoperative respectively. Only positive preoperative urine leucocyte esterase independently predicted positive 4-weeks MSUC (OR3.8, 95%CI1.3-11.1, P0.013). No significant correlation was found between IPSS or DVAS and positive MSUC nor between IPSS and postoperative pyuria at different follow-up points (P>0.05). However, the degree of postoperative dysuria was significantly correlated with postoperative pyuria count by urinalysis at 2-Weeks (r0.69, P0.03), 8-Weeks (r0.26, P0.001) and 12-Weeks (r0.23, P0.004). • Conclusion There is a persistent but gradually declining pyuria and microhematuria following TUPS up to 6 months postoperative. An earlier resolution was noted following prostate incision and enucleation. While routine urine analyses screening in these months would be of no clear clinical value, a routine urine culture would be of a reasonable significance at 1 month post-operatively.

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.

Greenlight laser (XPS-180watt) prostatectomy for treatment of benign prostate obstruction, Pursuit of durability.

Objectives: To report 5-year outcomes, need and predictors of retreatment post greenlight laser photoselective vaporization (GL.PVP) and vapo-enucleation (GL.PVEP), as long-term data on safety and efficacy of GL.PVP and GL.PVEP and on the prostate using XPSTM system are still pending. Patients and methods: Primary outcome was the need for retreatment (medical treatment and reintervention) for recurrent BOO. Time-to-event (retreatment) analysis, perioperative events, change in the urinary outcome measures at different follow-up visits, early and late complications and PSA kinetics were reported. Results: Between September 2014 and April 2017, 248 patients underwent GL/XPS procedures. GL.PVP and GL.PVEP were carried out for 157 (63.3%) and 91 (36.7%) patients with mean prostate sizes of 60 ± 18 and 100 ± 22 cc, respectively. After a mean duration of 62 ± 9-month follow-up, overall retreatment rate (medical and interventional) was 23% (57 patients). It was comparable between both GL.PVP and GL.PVEP cases: 38 (24.2%) and 19 (20.9%) patients, P = 0.5, respectively. Significantly more surgical reintervention rate was reported after GL.PVP compared to GL.PVEP (P = 0.03). In retreatment group, more intraoperative bleeding (P = 0.02), early postoperative hematuria (P = 0.03), higher median preoperative PSA (P = 0.02) and less postoperative one-year percent PSA reduction (P = 0.02) were detected. Lower postoperative one-year percent PSA reduction independently predicts retreatment with a cut-off point of 64.2% (58.2% sensitivity, 73.4% specificity, AUC 0.647, 95% CI 0.52-0.76).Median (range in months) time to event was 20 (1-60) for all cases and 13.5 (1-42) and 30 (18-60), P = 0.7, for GL.PVP and GL.PVEP groups, respectively. Conclusion: Greenlight laser XPS is an effective, durable and versatile tool in treating benign prostatic obstruction. Durability of the outcome is predictable with more postoperative PSA reduction.

Greenlight laser (XPSTM) 180W prostatectomy for treatment of benign prostate hyperplasia in patients with uncorrectable bleeding tendency.

Objectives: Safety of GreenLight™ laser prostatectomy (GL-LP) in patients with ongoing blood thinners has been proven. Yet, the possibility of drug manipulation makes it a less challenging situation compared to treating patients with uncorrectable bleeding tendency. Herein, we aim at evaluating the outcomes of XPS™-180 W GL-LP for treatment of BPH in patients who had uncorrectable bleeding tendency due to hepatic dysfunction. Methods: A prospectively maintained database for all patients who underwent GL-LP for symptomatic BPH was reviewed. Patients were divided into two groups based on the degree of hepatic dysfunction using Fib-4 index: Group 1 (indexed patients; low-risk Fib-4) and Group 2 (non-indexed patients; intermediate-high-risk Fib-4) included those who had chronic liver disease associated with either thrombocytopenia and/or hypoprothrombinemia. Primary outcome was the difference in perioperative bleeding complications between the two groups. Other outcome measures included all perioperative findings and complications as well-functional outcome measures. Results: The study included 140 patients (93 indexed patients and 47 non-indexed). There were no significant differences between both groups in operative time, laser time and energy, auxiliary procedures, catheter time, hospital stay, and hemoglobin deficit. The need for blood transfusion was significantly more in group 2 (two patients (4.3%) versus no patients in group 1, P = 0.045). Perioperative and late postoperative complications were comparable for both groups (P = 0.634 and 0.858, respectively). There were no significant differences in the postoperative uroflow, symptoms score, and PSA reduction between the two groups (P = 0.57, 0.87, and 0.05, respectively). Conclusions: XPS™-180 W GL-LP is a safe and effective technique for treatment of BPH in patients with uncorrectable bleeding tendency due to hepatic dysfunction.

Hormonal and molecular characterization of calcium oxalate stone formers predicting occurrence and recurrence.

The purpose of the study is to investigate the role of sex hormones, androgen receptors (ARs) and miRNA/CSF-1 in occurrence and recurrence of calcium oxalate (CaOx) renal urolithiasis. In this prospective study, 74 patients with CaOx stones; stone formers group (SFG) and 40 healthy subjects; control group were compared. SFG includes both de novo and recurrent cases. Steroid sex hormone plasma assay including testosterone, free testosterone, dihydrotestosterone, estradiol, and sex hormone binding globulin was analyzed. ARs, miRNA-185-5p and CSF-1 expression were compared between the groups. SFG showed significant higher ARs and miRNA-185-5p expression (3.7 ± 1.3, 1.8 ± 0.4, respectively) than control group (1 ± 0.08 and 1 ± 0.07, respectively) (p < 0.05). However, CSF-1 expression was significantly lower in stone formers than control group (0.4 ± 0.19 vs 1 ± 0.1, respectively) (p < 0.05). No differences were detected between de novo and recurrent SFG regarding sex hormones, AR, miRNA or CSF-1 expression. Our data suggest the important role of AR, miRNA and CSF-1 signaling in human nephrolithiasis pathogenesis.

Validation of the Arabic linguistic version of the Danish Prostatic Symptom Score for benign prostatic hyperplasia associated with lower urinary tract symptoms.

Objective: To validate an Arabic version of the Danish Prostatic Symptom Score (DAN-PSS), a self-administered quality-of-life questionnaire. Patients and methods: The reliability of the Arabic DAN-PSS was assessed by determining the internal consistency (Cronbach's α coefficient) and by assessing the test-retest reliability (Kappa [κ] test). Inter-domain associations were examined using Spearman's correlation coefficient (r). The discrimination validity was evaluated using receiver operating characteristic (ROC) curves. The sensitivity to change of the questionnaire and its individual items was assessed before and after intervention using a paired t-test. Results: In all, 106 men (55 patients with BPH and 51 without BPH symptoms) were included. A high level of internal consistency amongst the three domains of the answered Arabic DAN-PSS questionnaire was observed (Cronbach's α > 0.70). Also, there was a good correlation between storage and voiding (r = 0.75; P < 0.001) and post-micturition symptoms domains (r = 0.51; P < 0.001). Voiding and post-micturition symptoms domains also had a good correlation (r = 0.51; P < 0.001). The agreement between the test and retest scores had a κ value of 0.83 (P < 0.001). The ROC curve had an area under the curve of 0.98. The sensitivity to change comparing patients with BPH who received medical or surgical intervention revealed Arabic DAN-PSS mean (SD) scores of 34.7 (17.7) and 17 (8.7) before and after the intervention, respectively (P < 0.001). Conclusion: The Arabic DAN-PSS is a clear questionnaire, valid, reliable, and responsive that can be used for BPH associated with lower urinary tract symptoms assessment and follow-up in clinical practice and research in Arabic-speaking patients. Abbreviations: AUC: area under the curve; BPH: benign prostatic hyperplasia; CI: confidence interval; DAN-PSS: Danish Prostatic Symptom Score; DRE: digital rectal examination; ICIQ-MLUTS: International Consultation on Incontinence Male LUTS Questionnaire; ICS: international continence society; IPSS: international Prostatic Symptom Score; IPSS-Arb: Arabic version of the IPSS; LUTS: lower urinary tract symptoms; PSA: prostatic specific antigen; PSS: prostatic symptom score; QoL: quality of life; ROC: receiver operating characteristic; UTI: urinary tract infection.

Repurposing metformin as anticancer drug: Randomized controlled trial in advanced prostate cancer (MANSMED).

BACKGROUND: The proposal of metformin as an anticancer drug has been explored in many types of cancers. Metformin may act synergistically with standard prostate cancer therapies. However, there is still a debate about the effect of metformin on hormone sensitive prostate cancer (HSPC). PATIENTS AND METHODS: randomized controlled trial. Eligible patients were high risk locally advanced or metastatic HSPC. Patients were randomly assigned to receive either metformin plus standard of care or standard of care alone. The primary endpoint was castration-resistant prostate cancer-free survival (CRPC-FS). The secondary endpoints were overall survival, PSA level and adverse events. RESULTS: A total number of 124 patients underwent randomization where 62 patients were allocated in each arm. Over a median follow up of 22 months, the CRPC-FS was significantly improved with metformin (29 months, 95% CI 25-33 vs. 20 months 95% CI 16-24; P = 0.01). After subgroup analysis, the addition of metformin improved the CRPC-FS in patients with high risk localized disease (median not reached vs. 25 months, 95% CI 18-31; P = 0.02) and in patients with metastatic low tumor volume disease (median not reached vs. 15 months, 95% CI 5-25; P = 0.009). No significant difference in overall survival or PSA response in both treatment arms (P = 0.1 and 0.5, respectively). Metformin was not associated with significant adverse events apart from grade II diarrhea. CONCLUSION: Metformin is a safe and low-cost drug. Combining with androgen deprivation therapy improves the outcome in locally advanced or metastatic prostate cancer. Patients with low volume metastatic prostate cancer seem to drive more benefit.

Holmium Laser En-bloc Resection Versus Conventional Transurethral Resection of Bladder Tumors for Treatment of Non-muscle-invasive Bladder Cancer: A Randomized Clinical Trial.

BACKGROUND: En-bloc resection of bladder tumors achieves complete tumor removal, improves the quality of resection, decreases perioperative complication, and potentially improves recurrence rates. OBJECTIVE: To assess the efficacy and safety of holmium laser en-bloc resection (HolERBT) versus conventional transurethral resection of bladder tumor (cTURBT). DESIGN, SETTING, AND PARTICIPANTS: Between September 2015 and September 2018, 100 patients with non-muscle-invasive bladder cancer were randomly allocated to cTURBT or HolERBT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was detection of residual tumor in reTURBT specimens at 4 wk after the primary resection. Operative parameters, specimen quality, perioperative complications, and recurrence-free survival (RFS) were compared. Independent sample t tests, χ2 tests, and Kaplan-Meier curves were used, as appropriate. RESULTS AND LIMITATIONS: The patient and tumor baseline characteristics were comparable between the groups. Residual tumors were detected in 7% and 27.7% of cases after HolERBT and cTURBT, respectively (p=0.01). Detrusor muscle was sampled in 98% of HolERBT and 62% of cTURBT cases (p<0.001). Lamina propria invasion substaging was feasible in only 68.2% of HolERBT and 18.4% of cTURBT cases (p<0.001). Following HolERBT, catheterization time (p<0.001) and hospital stay (p=0.001) were shorter when compared to cTURBT. Immediate postoperative instillation of chemotherapy in indicated cases was feasible for 100% of the HolERBT group and 91.5% of the cTURBT group (p=0.04). After follow-up of 20 ± 9.9 mo (13-36), RFS was 31.76 mo (95% confidence interval [CI] 28.67-34.86) in the HolERBT group and 28.25 mo (95% CI 24.87-31.64) in the cTURBT group (hazard ratio 0.43, 95% CI 0.17-1.1; p=0.07). However, this study was not powered to detect a difference in RFS. CONCLUSIONS: Compared to cTURBT, HolERBT is a safer procedure for bladder tumor resection. It fulfills the oncological criteria of optimized resection with less residual tumor and better specimen quality. PATIENT SUMMARY: En-bloc resection of bladder cancer tumors using a holmium laser is safer than the conventional technique. It has the advantages of less residual tumor and better specimen quality, with a similar tumor recurrence rate. This study is registered at ClinicalTrials.gov as NCT02555163.

Randomised trial of bipolar resection vs holmium laser enucleation vs Greenlight laser vapo-enucleation of the prostate for treatment of large benign prostate obstruction: 3-years outcomes.

OBJECTIVE: To compare transurethral resection in saline (TURIS), Greenlight laser vapo-enucleation of the prostate (GL.PVEP), and holmium laser enucleation of the prostate (HoLEP), for controlling lower urinary tract symptoms secondary to large benign prostatic hyperplasia (BPH) and to assess non-inferiority of 3-year re-treatment rates. PATIENTS AND METHODS: Eligible patients with BPH (prostate size 80-150 mL) were randomly assigned to one of the intervention groups. Non-inferiority of re-treatment rate was evaluated using a one-sided test at 5% level of significance. RESULTS: At the time of analysis, 60 GL.PVEP, 60 HoLEP and 62 TURIS procedures were included. Perioperative parameters were comparable between groups; however, the operative time was longer in GL.PVEP vs HoLEP and TURIS, at a mean (SD) of 92 (32) vs 73 (30) and 83 (28) min (P = 0.005); and was less effective with a mean (SD) removal of 1.2 (0.4) vs 1.7 (0.7) and 1.4 (0.6) g/min (P < 0.001), respectively. Perioperative complications and need for auxiliary procedures were similar in the three groups; however, there was a significantly higher rate of capsular perforation in TURIS group (five, 8%) compared to one (1.6%) in the GL.PVEP group and none in the HoLEP group (P = 0.01). There was a significantly longer hospital stay, catheter-time and higher rate of blood transfusion in the TURIS group. There was significant but comparable improvements in the International Prostate Symptom Score in three groups at different follow-up points. At 3 years, re-treatment for recurrent bladder outlet obstruction was required more after GL.PVEP and TURIS. More re-do surgeries for recurrent obstructing prostate adenoma was reported after GL.PVEP (four, 6.7%) and TURIS (six, 9.7%) than for HoLEP (none) (P = 0.04). CONCLUSION: The perioperative outcomes of GL.PVEP and HoLEP surpassed that of TURIS for the treatment of large prostates, but with a significantly prolonged operative time with GL.PVEP. The three techniques achieve good functional outcomes; however, 3-year re-treatment rates following TURIS and GL.PVEP were inferior to HoLEP.

A randomized trial comparing bipolar transurethral vaporization of the prostate with GreenLight laser (xps-180watt) photoselective vaporization of the prostate for treatment of small to moderate benign prostatic obstruction: outcomes after 2 years.

OBJECTIVE: To test the non-inferiority of bipolar transurethral vaporization of the prostate (TUVP) compared to GreenLight laser (GL) photoselective vaporization of the prostate (PVP) for reduction of benign prostatic hyperplasia-related lower urinary tract symptoms in a randomized trial. METHODS: Eligible patients with prostate volumes of 30-80 mL were randomly allocated to GL-PVP (n = 58) or bipolar TUVP (n = 61). Non-inferiority of symptom score (International Prostate Symptom Score [IPSS]) at 24 months was evaluated. All peri-operative variables were recorded and compared. Urinary (IPSS, maximum urinary flow rate and post-void residual urine volume) and sexual (International Index of Erectile Function-15) outcome measures were evaluated at 1, 4, 12 and 24 months. Need for retreatment and complications, change in PSA level and health resources-related costs of both procedures were recorded and compared. RESULTS: Baseline and peri-operative variables were similar in the two groups. At 1, 4, 12 and 24 months, 117, 116, 99 and 96 patients, respectively, were evaluable. Regarding urinary outcome measures, there was no significant difference between the groups. The mean ± sd IPSS at 1 and 2 years was 7.1 ± 3 and 7.9 ± 2.9 (P = 0.8), respectively, after GL-PVP and 6.3 ± 3.1 and 7.2 ± 2.8, respectively, after bipolar TUVP (P = 0.31). At 24 months, the mean difference in IPSS was 0.7 (95% confidence interval -0.6 to 2.3; P = 0.6). The median (range) postoperative PSA reduction was 64.7 (25-99)% and 65.9 (50-99)% (P = 0.006) after GL-PVP, and 32.1 (28.6-89.7)% and 39.3 (68.8-90.5)% (P = 0.005) after bipolar TUVP, at 1 and 2 years, respectively. After 2 years, retreatment for recurrent bladder outlet obstruction was reported in eight (13.8%) and 10 (16.4%) patients in the GL-PVP and bipolar TUVP groups, respectively (P = 0.8). The mean estimated cost per bipolar TUVP procedure was significantly lower than per GL-PVP procedure after 24 months (P = 0.01). CONCLUSIONS: In terms of symptom control, bipolar TUVP was not inferior to GL-PVP at 2 years. Durability of the outcome needs to be tracked. The greater cost of GL-PVP compared with bipolar TUVP is an important concern.

Ejaculatory Hood Sparing versus Standard Laser Photoselective Vaporization of the Prostate: Sexual and Urodynamic Assessment through a Double Blinded, Randomized Trial.

PURPOSE: In a preliminary clinical trial we assessed the efficacy of ejaculatory hood sparing GreenLight™ Laser prostate photoselective vaporization to preserve antegrade ejaculation and urodynamic relief of obstruction compared to standard GreenLight prostate photoselective vaporization. MATERIALS AND METHODS: Standard prostate photoselective vaporization was classically performed in 24 patients. Ejaculatory hood sparing vaporization was performed with preservation of the paracollicular and supracollicular tissue proximal to the verumontanum in 25 patients. Patients were assessed at baseline, and 1, 3, 6 and 12 months postoperatively using the Ej-MSHQ (Ejaculatory Domain of Male Sexual Health Questionnaire) and the IIEF-15 (International Index of Erectile Function-15). The I-PSS (International Prostate Symptom Score), uroflowmetry and post-void residual urine volume were reported at each followup visit. A standard urodynamic study was performed at 6 months. RESULTS: Antegrade ejaculation was reported in 85% and 31.6% of patients after hood sparing and standard prostate vaporization, respectively (p=0.001). A significant reduction in the EJ-MSHQ score was reported after standard vaporization at 6 and 12 months (each p <0.001) with no significant difference after hood sparing vaporization (p=0.18 and 0.078, respectively). The median EJ-MSHQ score was 28.5 (range 1 to 33) and 27 (range 1 to 33) for hood sparing vaporization, and 9.5 (range 1 to 35) and 9 (range 0 to 33) for standard vaporization at 6 (p=0.005) and 12 months (p <0.001), respectively. Each group showed a decline in the mean total IIEF-15 score at 1 year but it was statistically significant only after standard vaporization (p=0.001). All urinary outcome measures revealed comparable significant improvement at all followups. Postoperative urodynamic assessment demonstrated a significant comparable decrease in the Bladder Outlet Obstruction Index from a median of 64 (range 21 to 207) to 23.5 (range 10 to 53) after hood sparing vaporization (p=0.005) and from 87 (range 38 to 186) to 19.5 (range 7 to 51) after standard vaporization (p=0.001). At 1 year the overall re-treatment rate was comparable in the 2 groups (p=0.26). CONCLUSIONS: In well informed, sexually interested patients ejaculatory hood sparing GreenLight prostate photoselective vaporization is feasible and effective treatment of small to moderate sized benign prostatic hyperplasia with a superior sexual function related outcome. Short-term relief of obstruction is objectively comparable to that of standard prostate photoselective vaporization.

Can We Predict the Outcome of Oral Dissolution Therapy for Radiolucent Renal Calculi? A Prospective Study.

PURPOSE: We prospectively assessed the efficacy and the predictors of the success of oral dissolution therapy by alkalization for lucent renal calculi. MATERIALS AND METHODS: Patients with radiolucent renal stones were counseled to undergo oral dissolution therapy, which entails oral potassium citrate 20 mEq 3 times daily, 3 L daily fluid intake and a dietary regimen. The study primary end point was the achievement of a 6-month stone-free rate with oral dissolution therapy. The other end point was a change in stone surface area as measured by noncontrast computerized tomography at 3 and 6 months. RESULTS: Between February 2015 and January 2016 only 182 of the 212 eligible patients who agreed to participate were compliant with oral dissolution therapy and included in the final analysis. Mean stone surface area at enrollment was 1.3 cm (range 0.16 to 11.84). At 3 months 97 (53.2%), 65 (35.7%) and 20 (11.1%) patients were oral dissolution therapy responders (stone-free), partial responders and nonresponders, respectively. Oral dissolution therapy achieved a 6-month stone-free rate of 83%, including 97 and 54 patients after 3 and 6 months of oral dissolution therapy, respectively. On regression analysis the initial 3-month response to oral dissolution therapy (p = 0.001), lower stone density (p = 0.03) and higher urine pH 12 weeks after treatment (p = 0.01) independently predicted the oral dissolution therapy response at 6 months. CONCLUSIONS: Regardless of stone size, oral dissolution therapy was an effective treatment approach for lucent renal stones. The initial response to oral dissolution therapy after 3 months was the key factor in determining the potential oral dissolution therapy response after 6 months. In addition, treatment compliance in achieving the targeted urine pH and low stone density has an independent role in the oral dissolution therapy response.

Erectile and ejaculatory functions changes following bipolar versus monopolar transurethral resection of the prostate: a prospective randomized study.

OBJECTIVES: To compare monopolar and bipolar transurethral resection of the prostate (M-TURP and B-TURP, respectively) focusing on erectile and ejaculatory functions in a randomized trial. METHODS: Between January 2013 and December 2014, all consecutive TURP candidates with benign prostatic hyperplasia (BPH) were prospectively randomized 1:1 into M-TURP/B-TURP arms and followed up at 2, and 4 weeks, 6 and 12 months after surgery. All patients were assessed using IIEF-15 (International index of erectile function-15) and Ej-MSHQ (ejaculatory domain-male sexual-health inventory). Changes in IIEF-15, its subdomains and Ej-MSHQ scores were compared between both intervention groups. RESULTS: Following M.TURP and B.TURP; 122 and 124 patients were included respectively and were considered for analysis at 1 year. Sexual function did not differ significantly between arms during follow-up (erectile function, P = 0.82; orgasmic function, P = 0.46; sexual desire, P = 0.29; intercourse satisfaction, P = 0.18; overall satisfaction, P = 0.92). There were no differences between arms in the distribution of EF evolution at any time compared with base line (at 12 months: M-TURP vs. B-TURP = improved, 24.5 vs. 26.6%; stable, 66.4 vs. 64.5%; deteriorated, 9.1 vs. 8.9%; P = 0.41). Newly developed erectile dysfunction (ED) was present in 8.2 and 7.3% of patients following M.TURP and B.TURP respectively and was related to presence of DM and obesity. Orgasm perception significantly reduced following M.TURP and B.TURP (P < 0.001). Newly reported ejaculatory dysfunction (Ej-MSHQ < 22) was significantly associated with low orgasm perception. CONCLUSIONS: There were no differences between M-TURP/B-TURP in any aspect of sexual function.

Low-Power Vs High-Power Holmium Laser Enucleation of the Prostate: Critical Assessment through Randomized Trial.

OBJECTIVE: To assess the non-inferiority of Low-power Holmium laser enucleation of the prostate (LP-HoLEP) to high-power (HP-HoLEP) for enucleation efficiency pertaining to the advantages of lower cost and minimal postoperative dysuria, storage symptoms, and negative sexual impact. PATIENTS AND METHODS: HoLEP was performed using 100W Versapulse, Luminis Inc., with 2J/25Hz for LP-HoLEP (61 patients) and 2J/50Hz for HP-HoLEP (60 patients). Two surgeons with different experience performed equal number of both procedures. Non-inferiority of enucleation efficiency (enucleated weight/min) was evaluated. All perioperative parameters were recorded and compared. Dysuria was assessed at 2 weeks by dysuria visual analog scale, urinary (Q.max and IPSS) and sexual (sexual health inventory for men score) outcome measures were evaluated at 1, 4, and 12 months. RESULTS: Baseline and perioperative parameters were comparable between the two groups. Mean enucleation efficiency was 1.42±0.6 vs 1.47±0.6 gm/min, P = .6 following LP-HoLEP and HP-HoLEP, respectively. Patients reported postoperative dysuria similarly in both groups as per dysuria visual analog scale. There was significant comparable improvement in IPSS (international prostate symptom score) and Q.max in both groups at different follow-up points. At one year, median IPSS and Q.max were comparable in both groups (P = .4 and .7 following LP-HoLEP and HP-HoLEP, respectively). Median postoperative reduction in prostate specific antigen was 89% (42:99) following LP-HoLEP vs 81% (62:94) after HP-HoLEP, P = .92. Both groups showed comparable perioperative and late postoperative complications. There were no statistically significant changes in the last follow-up sexual health inventory for men score in comparison to baseline score. CONCLUSION: LP-HoLEP is non-inferior to HP-HoLEP in terms of all efficiency parameters regardless level of surgeon experience.

Chemoprophylaxis during transrectal prostate needle biopsy: critical analysis through randomized clinical trial.

PURPOSE: To compare the efficacy of three chemoprophylaxis approaches in prevention of post-transrectal biopsy infectious complications (TBICs). METHODS: Patients were randomly assigned to receive ciprofloxacin 3 days 500 mg B.I.D 3 days starting the night prior to biopsy (standard prophylaxis), augmented prophylaxis using ciprofloxacin and single preprocedure shot of 160 mg gentamicin IM (augmented prophylaxis) and rectal swab culture-based prophylaxis (targeted prophylaxis). Patients were assessed 2 weeks prior to biopsy, at biopsy and 2 weeks after. Primary end point was occurrence of post-TBICs that included simple UTI, febrile UTI or sepsis. Secondary end points were post-biopsy change in the inflammatory markers (TLC, ESR and CRP), unplanned visits, hospitalization and occurrence of fluoroquinolones resistance (FQ-R; bacterial growth on MacConkey agar plate with 10 µg/ml ciprofloxacin) in the fecal carriage of screened men. RESULTS: Between April/2015 and January/2017, standard, augmented and targeted prophylaxes were given to 163, 166 and 167 patients, respectively. Post-TBICs were reported in 43 (26%), 13 (7.8%) and 34 (20.3%) patients following standard, augmented and targeted prophylaxes protocols, respectively (P = 0.000). Post-TBICs included UTI in 23 (4.6%), febrile UTI in 41 (8.2%) and sepsis in 26 (5.2%) patients. Significantly lower number of post-biopsy positive urine culture was depicted in the augmented group (P = 0.000). The number of biopsy cores was statistically different in the three groups (P = 0.004). On multivariate analysis, augmented prophylaxis had independently lower post-TBICs (OR 0.2, 95% CI 0.1-0.4, P = 0.000) when compared with the other two groups regardless of the number of biopsy cores taken (OR 1.07, 95% CI 0.95-1.17, P = 0.229). Post-biopsy hospitalization was needed in four (2%), one (0.6%) and ten (6%) patients following standard, augmented and targeted prophylaxes, respectively (P = 0.014). However, sepsis-related hospitalization was not statistically different. Post-biopsy changes in the inflammatory markers were significantly less in augmented prophylaxis (P < 0.05). FQ-R was depicted in 139 (83.2%) of the screened men. CONCLUSION: Augmented prophylaxis with single-dose gentamicin is an effective and practical approach. Targeted prophylaxis might be reserved for cases with contraindication to gentamicin.

Prospective controlled assessment of men's sexual function changes following Holmium laser enucleation of the prostate for treatment of benign prostate hyperplasia.

OBJECTIVES: To assess how much Holmium laser enucleation of the prostate (HoLEP) is detrimental on men sexuality. METHODS: Between January and December 2013, all patients presented for BPH surgery were assessed using IIEF-15 (international index of erectile function-15) and Ej-MSHQ (ejaculatory domain-male sexual health questionnaire). Changes in men's sexuality following HoLEP in relation to control procedure were prospectively assessed. Intervention group included legible consecutive patients treated by HoLEP. Control group included legible patients presented for diagnostic cystoscopy. Changes in IIEF-15, its subdomains and Ej-MSHQ scores were compared between HoLEP group and control. RESULTS: At one year 80 and 70 subjects were included for final analysis following HoLEP and control groups, respectively. Regardless of the baseline erectile function (EF/IIEF) score, there was an increase in EF score similar to control following HoLEP (P = 0.6). However, among subjects with normal preoperative EF (score >25), in comparison with control, there was similar decline in EF score following HoLEP (P = 0.07). Regarding the orgasm domain, there was a significant reduction in orgasm perception following HoLEP in relation to control (P = 0.01). Patients reported desire changes, intercourse satisfaction and overall satisfaction scores similar to control following HoLEP. Using Ej-MSHQ score, there was no statistically significant difference between HoLEP and control groups in percentage of subjects reporting ejaculatory dysfunction at baseline. However, at 12 months, there was statistically significant more ejaculatory dysfunction reporting following HoLEP. The most common ejaculatory abnormality was volume abnormality. Orgasm perception was significantly decreased among subjects with newly reported ejaculatory dysfunction (5.3 ± 1.4 vs. 8.6 ± 1.3, P = 0.001). CONCLUSIONS: Controlled short-term assessment of HoLEP showed potential negative impact on EF in patients with normal preoperative EF. Apart from orgasm perception, sexual function changes following HoLEP were similar to control. High prevalence of postoperative ejaculatory dysfunction following HoLEP remained notable finding.

Acute kidney injury after percutaneous nephrolithotomy for stones in solitary kidneys.

OBJECTIVES: The aim of this study was to report the incidence, severity, outcome and risk factors of acute kidney injury (AKI) following percutaneous nephrolithotomy (PNL) in solitary kidneys. METHODS: The study included consecutive adult patients who underwent PNL for treatment of calculi in a solitary kidney between May 2012 and July 2015. Patients with congenital renal anomalies or with stages 4 and 5 chronic kidney disease (CKD) were excluded. Serum creatinine levels were measured the day before PNL, daily after PNL for 2-5 days and after 3 months. AKI was depicted according to changes in early postoperative serum creatinine levels and its severity was determined based on the Acute Kidney Injury Network (AKIN) classification. The outcome of AKI was evaluated after 3 months by changes in the stage of CKD. Univariate and multivariate statistical analyses were conducted to determine risk factors for developing AKI. RESULTS: The study included 100 patients (62 males) with a mean ± SD age of 50 ± 11.7 years. Complications were reported for 27 patients. AKI developed in 25 patients; at the 3 month follow-up, 23 of them (92%) had completely recovered from AKI and two (8%) had developed stage 4 CKD. Independent risk factors for developing AKI were multiple PNL tracts and postoperative ureteric obstruction (relative risks were 14 and 22, respectively). CONCLUSIONS: The incidence of AKI was 25% after PNL for a solitary kidney. The likelihood of renal function recovery was 92%. Multiple PNL tracts and postoperative ureteric obstruction were risk factors for developing AKI.

Prospective Assessment of Learning Curve of Holmium Laser Enucleation of the Prostate for Treatment of Benign Prostatic Hyperplasia Using a Multidimensional Approach.

PURPOSE: Despite being endorsed in most guidelines, wide adoption of holmium laser enucleation of the prostate is hindered by learning difficulties. We prospectively assessed the learning curve using a multidimensional approach. MATERIALS AND METHODS: We prospectively report all perioperative safety and efficacy outcome measures as well as the need for reoperation and continence status. Case difficulty and learning curve characterization variables were considered, looking for predictors of different outcome measures. Our analysis included the first 313 procedures done by a total of 3 surgeons. RESULTS: Prostate volume and the number of previously performed cases independently predicted operative and enucleation efficiency (mean ± SD 0.76 ± 0.36 and 1.2 ± 0.6 gm per minute, respectively). Both measures plateaued only after the first 40 procedures. The mean percent reduction in postoperative prostate specific antigen was 80% ± 19%. A significantly lower decrease was independently predicted by the transrectal ultrasound depiction of a grossly multinodular prostate (p = 0.000, R2 = 0.59). Perioperative safety measures showed significant improvement after the first and second 20 procedures apart from hospital stay and catheter time. Urinary incontinence was reported in 89 (28.5%), 26 (8.3%) and 7 cases (2.2%) at 1, 4 and 12 months, respectively. Only the number of previously performed cases predicted urinary incontinence at 1 month, which was significantly reduced following the first 20 procedures (plateau) (OR 0.99, 95% CI 0.98-0.999, p = 0.03). The I-PSS (International Prostate Symptom Score) preoperative storage subdomain (OR 0.7, 95% CI 0.4-0.9, p = 0.04), case density (OR 0.3, 95% CI 0.2-0.6, p = 0.01) and number of previously performed cases (OR 0.97, 95% CI 0.98-0.999, p = 0.02) predicted urinary incontinence at 4 months, which was significantly reduced after the first and second 20 procedures. Persistent urinary incontinence at 12 months was significantly associated with fewer previously performed cases (median 60, range 0 to 211 vs 20, range 0 to 99, p = 0.04) with no plateauing through the curve. CONCLUSIONS: Plateauing through the learning curve of holmium laser enucleation of the prostate is a moving target. Looking at different outcome measures, different levels of experience are needed to reach the plateau. Preoperative prostate volume, the number of previously performed cases and case density are the main influential factors in the curve. Urinary incontinence is the most relevant clinical outcome that was significantly affected by learning, although its transient nature is assuring.