Experts' recommendations in laser use for the endoscopic treatment of prostate hypertrophy: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group.

PURPOSE: To identify expert laser settings for BPH treatment and evaluate the application of preventive measures to reduce complications. METHODS: A survey was conducted after narrative literature research to identify relevant questions regarding laser use for BPH treatment (59 questions). Experts were asked for laser settings during specific clinical scenarios. Settings were compared for the reported laser types, and common settings and preventive measures were identified. RESULTS: Twenty-two experts completed the survey with a mean filling time of 12.9 min. Ho:YAG, Thulium fiber laser (TFL), continuous wave (cw) Tm:YAG, pulsed Tm:YAG and Greenlight™ lasers are used by 73% (16/22), 50% (11/22), 23% (5/22), 13.6% (3/22) and 9.1% (2/22) of experts, respectively. All experts use anatomical enucleation of the prostate (EEP), preferentially in one- or two-lobe technique. Laser settings differ significantly between laser types, with median laser power for apical/main gland EEP of 75/94 W, 60/60 W, 100/100 W, 100/100 W, and 80/80 W for Ho:YAG, TFL, cwTm:YAG, pulsed Tm:YAG and Greenlight™ lasers, respectively (p = 0.02 and p = 0.005). However, power settings within the same laser source are similar. Pulse shapes for main gland EEP significantly differ between lasers with long and pulse shape modified (e.g., Moses, Virtual Basket) modes preferred for Ho:YAG and short pulse modes for TFL (p = 0.031). CONCLUSION: Ho:YAG lasers no longer seem to be the mainstay of EEP. TFL lasers are generally used in pulsed mode though clinical applicability for quasi-continuous settings has recently been demonstrated. One and two-lobe techniques are beneficial regarding operative time and are used by most experts.

The good, the bad, and the ugly about surgical approaches for inflatable penile prosthesis implantation.

The penoscrotal (PS), infrapubic (IP), and subcoronal (SC) incisions are used for inserting an inflatable penile prosthesis (IPP). Each surgical approach has its advantages and disadvantages and experts continue to debate which technique has the best outcomes. We performed a critical review of the published English-language studies up to April 2020 investigating the PS, IP, or SC approach for IPP placement. The PS approach is the most frequently used incision. The available data do not suggest a difference between PS and IP approach in size of the implanted prostheses, achieved penile length, patient satisfaction, infection rate, and risk of urethral injury. The risk of dorsal nerve injury, even if low, seems to be greater for IP approach. IP technique is associated with shorter operative time and earlier use of IPP compared with PS approach. Despite limited available data it is reasonable to assume that SC approach, compared with other approaches, has longer operative time and similar infection rate. The time to device activation with SC technique could be similar to the IP approach, but there is only minimal data that can confirm this hypothesis.

Current practices regarding corporotomy localization during penoscrotal inflatable penile implant surgery: a multicenter cohort study.

Literature concerning corporotomy location in multicomponent inflatable penile prosthetic surgery via a penoscrotal approach is scarce if not nonexistent. Aim of our study was to report practices in low-, moderate-, and high-volume penile implant centers regarding corporotomy location and evaluate its potential impact on intraoperative and short-term postoperative complications. Data from 18 (13 European and 5 American) implant centers were collected retrospectively between September 1st, 2018 and August 31st, 2019. Variables included: intraoperative proximal and distal corpus cavernosum length measurement, total corporal length measurement, total penile implant cylinder length, and length of rear tip extenders. Eight hundred and nine virgin penile implant cases were included in the analysis. Mean age of participants was 61.5 ± 9.6 years old. In total, 299 AMS 700™ (Boston Scientific, USA) and 510 Coloplast Titan® (Minneapolis, MN USA) devices were implanted. The mean proximal/distal corporal measurement ratio during corporotomy was 0.93 ± 0.29 while no statistical difference was found among low-, moderate-, and high-volume penile implant centers. A statistically significant correlation between lower proximal/distal measurement ratio and higher age (p = 0.0013), lower BMI (p < 0.0001), lower use of rear tip extenders (RTE) (p = 0.04), lower RTE length (p < 0.0001), and absence of diabetes (p = 0.0004) was reported. In a 3-month follow up period, 49 complications and 37 revision procedures were reported. This is the first study reporting the current practices regarding corporotomy location during IPP placement in a multicenter cohort, particularly when including such a high number of patients. Nevertheless, the retrospective design and the short follow up period limits the study outcomes. Corporotomy location during penoscrotal IPP implantation does not correlate with intraoperative or short-term postoperative complication rates. Future studies with longer follow up are needed in order to evaluate the association of corporotomy location with long-term complications.

Prospective analysis of cultures from the Furlow insertion tool: a possible etiology for penile prosthesis infections.

The most dreaded complication of penile prosthesis (PP) implantation is device infection. We sought to assess whether inadequate cleaning and sterilization of the reusable Furlow inserter may represent one of the last etiologies of infection in PP patients. We performed a prospective analysis of cultures of the Furlow inserter used for PP surgeries from seven centers between May 1st and June 30th, 2019. Once the Furlow was received for surgery, the surgical team inspected the device for assembly status (disassembled or not) and the presence of visible stains, pieces of tissue or discoloration on either the interior of the barrel or the plunger. Swab aerobic and anaerobic bacterial and fungal cultures were then obtained from the internal component, after removal from the external component if assembled, and after introduction and immediate removal from the external component if disassembled. A total of 83 Furlow devices were cultured. Median age of surgical instrument was 4 years (2-10 years). Methods of sterilization included autoclave, wet autoclave, steam, and Sterad. Median time from sterilization was 3 days (1-22). On initial presentation, 79 devices were disassembled (95.1%) and 4 devices were still assembled (4.9%). Three external components were discolored (3.6%), while internal components demonstrated two stains (2.4%) indicative of improper cleaning which were thought to be residual blood products. Overall, 2/83 (2.4%) devices revealed positive swab cultures for Staphylococcus epidermidis. Swab cultures were negative for fungi and anaerobic bacteria. This patient cohort will continue to be followed to see if device infection occurs but it is unlikely to be meaningful since contaminated Furlows were discarded. Improper cleaning and/or sterilization of the Furlow Insertion Instrument may represent a source of infection for patients undergoing PP implantation.

Current evidence of ThuLEP for BPH: A review of literature.

Endoscopic enucleation of the prostate (EEP) techniques for the treatment of benign prostatic hyperplasia (BPH) have become increasingly popular among urologists over the past 23 years. Despite the energy source employed, the aim of all these procedures is to endoscopically remove the prostatic lobes by enucleating them from the prostate surgical capsule. The reasons for which EEP has gained popularity among urologists are the reduction in complications and hospital stay compared to endoscopic gold standard Transurethral Resection of the Prostate (TURP), but especially the possibility to treat large prostates, allowing to abandon open simple prostatectomy (OP) and to avoid the burden related to open surgery. Holmium laser enucleation of the prostate (HoLEP) sets the basic principles of all EEP techniques in 1998 and has become the treatment of reference for BPH. Since then, various lasers have been developed and applied to prostatic enucleation. The thulium laser has a slightly shorter wavelength compared to the holmium laser and a continuous wave output, which increase vaporization and reduce penetration depth. These features make it ideal for prostatic enucleation. A vapoenucleating technique called Thulium Laser Vapoenucleation of the Prostate was presented in 2009, followed by a blunt enucleating technique called Thulium Laser Enucleation of the Prostate in 2010. These techniques have become alternatives to HoLEP and TURP; however, the amount of literature and randomized controlled trials available are inferior compared to HoLEP. The aim of th describe, and discuss current evidence on thulium enucleating techniques.

Delaying Surgical Treatment of Penile Fracture Results in Poor Functional Outcomes: Results from a Large Retrospective Multicenter European Study.

BACKGROUND: Penile fracture is a rare clinical entity that represents a urologic emergency. It involves traumatic rupture of the tunica albuginea of the corpora cavernosa due to twisting or bending of the penile shaft during erection. OBJECTIVE: To determine the differences in preoperative diagnostic evaluation patterns and outcomes of penile fracture patients to investigate the impact of surgical delay on functional outcomes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was performed using data obtained from 137 patients presenting with penile fracture at seven different European academic medical centers between 1996 and 2013. Age, imaging modalities used, timing of surgical intervention, length of tunica albuginea defect, and surgical technique were recorded. Postoperative erectile function outcomes were assessed with the International Index of Erectile Function (IIEF-5), and the presence of postoperative penile curvature was noted. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The association between timing of surgical intervention and postoperative IIEF-5 results was evaluated with discriminant function analysis. RESULTS AND LIMITATIONS: The median age of the patients was 34.50 yr (interquartile range [IQR]: 28.0-46.5 yr). Of the 137 patients, 82 (59.85%) underwent penile Doppler ultrasound, and 5 patients (3.64%) were evaluated with magnetic resonance imaging. All patients were treated surgically, and the duration between emergency room admission and surgical intervention was 5.0h (IQR: 3.6-8.0h). The median length of tunica albuginea defect was 10mm (IQR: 8-20mm). Postoperative IIEF-5 scores were 21 (IQR: 12-23) and 23 (IQR: 15-24) at the first and third postoperative months, respectively. Discriminant function analysis revealed that if the surgical intervention was performed >8.23hours after emergency room admission, postoperative erectile function was significantly worse (p=0.0051 at first month and p=0.0057 at third month postoperatively). CONCLUSIONS: Our multicenter study showed that delaying surgical intervention results in significantly impaired erectile function. Surgical treatment must be planned as soon as possible to avoid postoperative erectile dysfunction. PATIENT SUMMARY: We looked at sexual outcomes following the repair of penile fracture in a large European population. We found that outcomes worsened if surgical repair was delayed.

Use of a lyophilized bovine pericardium graft to repair tunical defect in patients with Peyronie's disease: experience in a clinical setting.

Many different materials are available for grafting during surgery for Peyronie's disease (PD). To study the outcomes associated with the use of a lyophilized bovine pericardium graft (Peri-Guard®) to repair tunical defects in patients with PD, descriptive study of 43 patients with disabling penile curvature was performed. Curvature was measured before and after the intervention using a standardized procedure. Surgical technique was plaque excision and grafting of the tunical defect carried out by a single surgeon. A lyophilized bovine pericardium patch was used for grafting. We measured the change in penile curvature and length, the ability to perform successful sexual intercourse without further pharmacological or surgical treatment, and the satisfaction with treatment. Follow-up data were available for a total of 41 patients. Median age was 50 years (IQR 48-52); mean follow-up time was 14 ± 6 months. Complete penile straightening was achieved in 33 patients (80.5%) and five patients (12.2%) had curvature under 20°. Three months after surgery and stretching therapy, mean (s.d.) flaccid penile length increased from 11.2 ± 2.8 cm to 12.1 ± 2.9 cm (P = 0.062). Seventy-five percentage of patients reported being able to achieve successful intercourse without further treatment. Eighty-five percentage of patients reported to be satisfied with the treatment. There was no evidence of tissue rejection or infection, and only four patients suffered an adverse event. Plaque excision and grafting of the tunical defect with lyophilized bovine pericardium seems to be a safe and effective treatment for patients with PD.

Comparison of the patient and partner satisfaction with 700CX and Titan penile prostheses.

Most widespread three-component penile prosthesis models are 700CX™ and Titan ® . Our purpose is to assess patient and partner satisfaction after the first implant. This is a multicenter, retrospective, nonrandomized study in which all patients who met the inclusion criteria between 2009 and 2013 were included. In total, 248 patients agreed to participate. To evaluate patient satisfaction, a validated but modified 11-question questionnaire was completed (EDITS); and a nonvalidated two-item questionnaire was given to the partner. Statistical analysis used an ordinal logistic regression model. Two hundred and forty-eight patients (194 with 700CX™ vs 54 with Titan®) and 207 couples completed the questionnaire (165 with 700CX™ vs 42 with Titan®). Overall satisfaction was high. Both showed great reliability for sexual intercourse and high compliance with prior expectations. Most patients were able to manage the penile prosthesis correctly within 6 months. Postoperative penile shortening led to some dissatisfaction in 42% and 46% of cases (700CX™ /Titan®). Significant differences were found in three questions of patients' questionnaire. There were more patients satisfied with the 700CX™ (P = 0.0001). No patient with Titan® implant took longer than 6 months to optimal management. Only 4% of patients with 700CX™ implant were dissatisfied with the deflation, in contrast to 24% with the Titan® (P = 0.0031). Of the two partners' questions, one showed a statistically significant difference (P = 0.0026). It seems that group 700CX™ would recommend to re-implant the prosthesis with a greater tendency. The overall satisfaction was very high for both prostheses. The final aspect of the erected and flaccid penis was satisfactory, but both groups showed significant discontent with its final size. Partners' overall satisfaction was high.

[Hormonal treatment in biochemical recurrence after radical prostatectomy]. / Tratamiento hormonal en la recidiva bioquímica tras prostatectomía radical.

To date, the role of hormonal therapy (HT) after biochemical failure, when to initiate it, the therapeutic scheme and duration remains controversial due to the absence of well designed randomized trials analyzing the overall survival of patients. In clinical practice, the most widely spread treatment in this scenario is hormonal therapy with LH-RH analogues. However, the scientific support for this issue is very weak. We are extrapolating the benefits proven for early vs delayed HT in advanced prostate cancer, to asymptomatic patients presenting just an increase in PSA. These patients usually have a long time disease-history until development of metastasis. It should also be noticed the harmful secondary effects acquired with the time of employment of hormotherapy. Probably patients suffering a Gleason score >8 and PSA doubling time <12 months could obtain a benefit from an early castration treatment, even more if they are young (grade 2c). Except in selected cases of local treatment as radiotherapy, the decision for early or delayed hormonal therapy should be taken carefully with patient consensus. The alternatives for hormonal treatment to preserve sexual function, as intermittent treatment, antiandrogen monotherapy, or antiandrogen plus 5 alpha reductase inhibitors, are very attractive in this scenario. However due to the short time experience with these modalities of treatment should be evaluated with caution.

Recovery of urinary continence after radical prostatectomy: association with urethral length and urethral fibrosis measured by preoperative and postoperative endorectal magnetic resonance imaging.

BACKGROUND: Limited data on endorectal magnetic resonance imaging (MRI) features and urinary continence after radical prostatectomy (RP) are available. OBJECTIVE: To assess whether recovery of urinary continence after RP is associated with endorectal MRI findings regarding preoperative and postoperative membranous urethral length (MUL), percent change in MUL, and postoperative urethral and periurethral fibrosis. DESIGN, SETTING, AND PARTICIPANTS: Sixty-four patients who received an MRI scan before and after RP for localized prostate cancer were evaluated in a retrospective study at a single institution. INTERVENTION: All patients underwent RP. MEASUREMENTS: The postoperative scan was performed to detect local recurrence in patients with rising levels of prostate-specific antigen. Urinary continence was graded on a five-point scale. MUL was measured on T2-weighted images. Urethral and periurethral fibrosis was graded from 0 to III based on axial T2-weighted images. Univariate Cox proportional hazards regression was performed to assess variables associated with continence. RESULTS AND LIMITATIONS: Forty-eight patients regained continence following surgery. The median follow-up for patient who were incontinent at their last assessment was 7 mo. The median interval from RP to postoperative endorectal MRI was 10 mo. A longer preoperative or postoperative MUL was associated with superior continence (both p<0.01). The MUL loss ratio was significantly associated with postoperative continence (p=0.02). Patients with a high grade of postoperative periurethral fibrosis tended to have worse postoperative continence; nevertheless a statistical correlation was not reached (hazard ratio: 0.64, p=0.16). This is a retrospective study. CONCLUSIONS: Preoperative and postoperative MUL and the MUL loss ratio are related to the recovery time and level of urinary continence after RP. Therefore, preservation of urethral length during surgery is recommended. Periurethral fibrosis might impede the recovery of continence after RP by altering the elasticity of the external sphincter.

Standard versus limited pelvic lymph node dissection for prostate cancer in patients with a predicted probability of nodal metastasis greater than 1%.

PURPOSE: We determined the yield of standard vs limited pelvic lymphadenectomy in patients with a predicted risk of lymph node metastasis greater than 1% according to the Partin tables predicted probability of pathological stage. We also determined the feasibility of laparoscopic standard pelvic lymph node dissection. MATERIALS AND METHODS: Of 1,269 patients with clinically localized prostate cancer undergoing radical prostatectomy, 648 had a Partin's table predicted probability of lymph node invasion greater than 1%. Of the 648 patients 177 underwent limited pelvic lymph node dissection performed laparoscopically (group 1), and 471 underwent standard pelvic lymph node dissection performed open (367) or laparoscopically (104) (group 2). Templates of limited pelvic lymph node dissection included the external iliac lymph nodes whereas standard pelvic lymph node dissection included the external iliac, obturator and hypogastric lymph nodes. Multivariate logistic regression analyses were performed to compare the node positivity rate between groups 1 and 2. RESULTS: On multivariate logistic regression analysis controlling for prostate specific antigen, biopsy Gleason sum, clinical stage and surgical approach, the odds of node positivity were 7.15-fold higher (95% CI 2.49-20.5, p<0.001) for standard vs limited pelvic lymph node dissection. The median (mean) number of nodes retrieved was 9 (10) and 14 (15) after limited and standard pelvic lymph node dissection, respectively (p<0.001). A similar impact was observed in patients treated laparoscopically with standard vs limited pelvic lymph node dissection (odds ratio 15.6, 95% CI 3.7-66.4, p<0.001). CONCLUSIONS: Standard lymph node dissection yields positive nodes more frequently and retrieves a higher total nodal count than the often performed pelvic lymph node dissection limited to the external iliac nodes. Standard pelvic lymph node dissection is feasible through a transperitoneal laparoscopic approach.