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

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

Corrigendum to "RPN (Radius, Position of tumour, iNvasion of renal sinus) Classification and Nephrometry Scoring System: An Internationally Developed Clinical Classification To Describe the Surgical Difficulty for Renal Masses for Which Robotic Partial Nephrectomy Is Planned" [Eur. Urol. Open Sci. 54 (2023) 33-42].

[This corrects the article DOI: 10.1016/j.euros.2023.05.007.].

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.

Robot-Assisted Radical Prostatectomy by Lateral Approach: Technique, Reproducibility and Outcomes.

BACKGROUND: Radical prostatectomy by lateral approach allows performing a prostatectomy through a buttonhole, with direct access to the seminal vesicle and fully sparing the anterior pubovesical complex. Our aim is to show the results of reproducing the technique of robotic radical prostatectomy by lateral approach, in terms of intraoperative, postoperative, oncological and functional parameters. METHODS: We analyzed 513 patients submitted to robotic radical prostatectomy by lateral approach from January 2015 to March 2021, operated on by two surgeons in our institution. The oncological and functional results of both surgeons were compared. RESULTS: When comparing both surgeons, the rate of positive surgical margins (PSM) was 32.87% and 37.9% and significant surgical margins (PSM > 2 mm) were 5.88% and 7.58% (p = 0.672) for surgeon 1 and surgeon 2, respectively. Immediate continence was 86% and 85% and sexual potency at one year 73% and 72%, with a similar rate of complications for surgeon 1 and 2. CONCLUSIONS: Radical prostatectomy by the lateral approach technique with preservation of the anterior pubovesical complex is reproducible and offers good oncological and functional results.

Results from a global multicenter registry of 6193 patients to refine endoscopic anatomical enucleation of the prostate (REAP) by evaluating trends and outcomes and nuances of prostate enucleation in a real-world setting.

PURPOSE: To collect a multicentric, global database to assess current preferences and outcomes for endoscopic enucleation of the prostate (EEP). METHODS: Endourologists experienced in EEP from across the globe were invited to participate in the creation of this retrospective registry. Surgical procedures were performed between January 2020 and August 2022. INCLUSION CRITERIA: lower urinary tract symptoms not responding to or worsening despite medical therapy and absolute indication for surgery. EXCLUSION CRITERIA: prostate cancer, concomitant lower urinary tract surgery, previous prostate/urethral surgery, pelvic radiotherapy. RESULTS: Ten centers from 7 countries, involving 13 surgeons enrolled 6193 patients. Median age was 68 [62-74] years. 2326 (37.8%) patients had large prostates (> 80 cc). The most popular energy modality was the Holmium laser. The most common technique used for enucleation was the 2-lobe (48.8%). 86.2% of the procedures were performed under spinal anesthesia. Median operation time was 67 [50-95] minutes. Median postoperative catheter time was 2 [1, 3] days. Urinary tract infections were the most reported complications (4.7%) followed by acute urinary retention (4.1%). Post-operative bleeding needing additional intervention was reported in 0.9% of cases. 3 and 12-month follow-up visits showed improvement in symptoms and micturition parameters. Only 8 patients (1.4%) required redo surgery for residual adenoma. Stress urinary incontinence was reported in 53.9% of patients and after 3 months was found to persist in 16.2% of the cohort. CONCLUSION: Our database contributes real-world data to support EEP as a truly well-established global, safe minimally invasive intervention and provides insights for further research.

Holmium laser with MOSES technology (MoLEP) vs Thulium fiber laser enucleation of the prostate (ThuFLEP) in a real-world setting. Mid-term outcomes from a multicenter propensity score analysis.

PURPOSE: To compare Holmium laser with MOSES technology (MoLEP) and Thulium fiber laser enucleation of the prostate (ThuFLEP) in terms of surgical and functional outcomes. METHODS: We performed a retrospective analysis of all patients who underwent either procedure in five centers (January 2020-January 2022). EXCLUSION CRITERIA: previous urethral/prostatic surgery, radiotherapy, concomitant surgery. Propensity score matching (PSM) analysis was performed to adjust for the bias inherent to the different characteristics at baseline. Differences between procedures were estimated using Firth Penalized Likelihood regression for International prostate symptom score (IPSS), quality of life (QL), maximum flow rate (Qmax). RESULTS: PSM retrieved 118 patients in each group. Baseline characteristics were similar except for PSA and number of men on indwelling catheter (higher in MoLEP group). Median surgical time was significantly longer in the MoLEP group despite the enucleation and morcellation times being similar. Median catheter dwelling time and postoperative length of stay were similar. Most of the early complications were Clavien ≤ 2 grade. There were only two Clavien grade 3 complications (one for each group), one grade 4 in MoLEP group. Rate and type of early and persistent incontinence (> 3 months) were similar. At 12-month, proportion of patients reaching a decrease (Δ) of IPSS ≥ 18 from baseline was significantly larger in MoLEP group, with no significant difference in ΔQmax > 12 ml/sec and ΔQL ≥ -3. CONCLUSION: MoLEP and ThuFLEP were safe and efficacious procedures with similar short-term operative and functional outcomes. At 1-year, MoLEP patients had a sustained reduction of IPPS score.

Correlation Between Transurethral Interventions and Their Influence on Type and Duration of Postoperative Urinary Incontinence: Results from a Systematic Review and Meta-Analysis of Comparative Studies.

Objective: To perform a systematic review to assess the incidence of transient (<6 months) and persistent (>6 months) stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence (MUI) after transurethral surgeries for benign prostatic hyperplasia. Materials and Methods: A systematic literature search was performed using Embase, PubMed, and Web of Science. We included studies comparing monopolar (M)/bipolar (B) transurethral resection of the prostate (TURP) vs ablation vs enucleation procedures. Incidence of incontinence was assessed using Cochran-Mantel-Haenszel Method and reported as odds ratio (OR), 95% confidence interval (CI), and p-values. Statistical significance was set at p < 0.05 Evidence Synthesis: Twenty-eight studies were included. Incidence of transient SUI was 4.6%, 6.0%, 3.0%, and 2.4% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent SUI was 1.1% after ablation, 1.7% after enucleation and M-TURP, and 1.0% after B-TURP. Incidence of transient UUI was 2.0%, 7.3%, 4.4%, and 2.8% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent UUI was 2.2% after M-TURP. The incidence of transient MUI was 5.1%, 0.8%, 5.4%, and 0.9% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent MUI was 3.1% after ablation and 4.8% after M-TURP. Incidence of transient and persistent SUI and UUI did not differ after TURP vs enucleation. Incidence of transient (OR 3.32, 95% CI 0.41-26.65, p = 0.26) and persistent SUI (OR 4.79, 95% CI 0.52-43.89, p = 0.17) was not significantly higher after ablation. Incidence of transient UUI was not significantly higher after ablation (OR 2.62, 95% CI 0.04-166.01, p = 0.65), whereas persistent UUI did not differ. Incidence of transient MUI was significantly higher after enucleation (OR 3.26, 95% CI 1.51-7.05, p = 0.003). Incidence of transient and persistent MUI did not differ after TURP vs ablation. Conclusions: Ablation, enucleation, and TURP have an impact on all forms of incontinence, but this is transient in most cases with no difference between the groups, except for MUI, which was higher after enucleation vs M-TURP.

Optimization of prostate biopsy - Micro-Ultrasound versus MRI (OPTIMUM): A 3-arm randomized controlled trial evaluating the role of 29 MHz micro-ultrasound in guiding prostate biopsy in men with clinical suspicion of prostate cancer.

BACKGROUND: Micro-ultrasound (microUS) is a novel ultrasound-based imaging modality which has demonstrated the ability to visualize prostate cancer. Multiparametric MRI/ultrasound (mpMRI/US) fusion has recognized advantages for the performance of prostate biopsy, however, it encompasses additional cost, time and technical expertise to performing prostate biopsy in comparison to conventional trans-rectal ultrasound biopsy. MicroUS may simplify and optimize this pathway. METHODS: OPTIMUM is a 3-arm randomized controlled trial comparing microUS guided biopsy with MRI/US fusion and MRI/MicroUS "contour-less" fusion. This trial will investigate whether microUS alone, or in combination with mpMRI, provides effective guidance during prostate biopsy for the detection of clinically significant prostate cancer (csPCa) for biopsy naïve subjects. 1200 subjects will be randomized. The economic impact will be evaluated. RESULTS: The rate of csPCa (defined as Grade Group 2 and above) in each arm will be compared. The primary hypothesis is non-inferiority of csPCa rate between the MRI/US fusion arm and the microUS-only arm (including the blinded microUS-only portion of the MRI/MicroUS arm). As a secondary objective, the csPCa rate between MRI/MicroUS fusion and MRI/US fusion arms will also be compared. Other secondary objectives include the increase in rate of patients diagnosed with csPCa due to each type of sample (mpMRI targeted, microUS targeted, systematic), the negative predictive value of each imaging modality, and a health economic analysis of the procedures in each arm. CONCLUSIONS: OPTIMUM will determine whether microUS can be used as an alternative to MRI/US fusion biopsy. The trial will also evaluate the efficacy of the simplified "contour-less" MRI/MicroUS fusion procedure. The adoption of the microUS technique will increase the proportion of men who can benefit from modern imaging-centric diagnostic strategies, and may help reduce variability, complexity, waiting time and cost within the diagnostic pathway.

The constant search for the greater good: evolving from TURP to anatomic enucleation of the prostate is a safe bet.

PURPOSE: In a troubling moment in history with an ongoing world pandemic and the impending economic crises, there is today a plethora of commercially available options for the minimally invasive treatment of BPH. New industry-driven evaluation criteria of these treatments, the logical marketing hype, a short follow-up for many of them, make challenging to interpret the role they will finally adopt in the armamentarium to treat BPH. METHOD: The author comments on recently published literature based in own experience and insight. RESULTS AND CONCLUSIONS: In this situation, choosing to evolve from TURP to the next step of endoscopic treatment, the size-independent anatomic endoscopic enucleation of the prostate is a safe bet. It is now exceedingly feasible when the paradigm of AEEP has changed, due to better learning opportunities and technological and surgical technique modifications that have refined this procedure significantly since its inception.

En bloc MoLEP (MOSES HoLEP) with early apical dissection and preservation of the sphincter's mucosa. Surgical technique and technology developments that allow a new paradigm of endoscopic prostate enucleation. / MoLEP (MOSES HoLEP) en bloque con liberación apical precoz y preservación de la mucosa esfinteriana. Evolución de la técnica quirúrgica y la tecnológica que permiten un nuevo paradigma de enucleación endoscópica anatómica de próstata.

Endoscopic enucleation of the prostate was first described by Hiraoka in 1986, using a monopolar resectoscope. His contribution was largely ignored until Gilling and Fraundorfer published their three-lobe enucleation technique with the Holmium laser in 1998 ,that ended establishing itself as a reliable option for the treatment of HBP, backed by ample scientific evidence. Later on, enucleation performed with other lasers, as well as bipolar energy, have shown concordance in their clinical results. As a result, the term AEEP (anatomic endoscopic enucleation of the prostate) emerged to encompass all these techniques. During the last few years there have been significant advances in two areas: first, technology, with the development of pulse modulation for Holmium generators (MOSES) as well as high-speed morcellators. Second, the development of new surgical techniques that recognize the importance of the early release of the sphincter from the apex of the adenoma during the operation as well as the careful preservation of the external sphincter's mucosa, to avoid early stress incontinence. In this paper,we review the recent evolution of both technology and surgical technique. AEEP has been risen to a new level, reducing operative time significantly, usually under one hour, and radically reducing the incidence of early temporary stress incontinence, and maybe also facilitating the learning curve of AEEP.

La enucleación endoscópica de próstata fue descrita por primera vez por Hiraoka en 1986, usando un resector monopolar. Su aportación pasó desapercibida hasta que Gilling y Fraundorfer publicaron su técnica de enucleación en tres lóbulos con láser de Holmio en 1998, que se estableció como una opción de tratamiento de la obstrucción prostática benigna ampliamente respaldada por la evidencia científica. Posteriormentes e ha estudiado el uso de otros láseres así como de la energía bipolar para realizar enucleación  endoscópica y se ha observado una concordancia en los resultados de estas técnicas, independientemente de la fuente de energía utilizada, que ha conducido a englobarlas bajo el acrónimo EEAP (enucleación endoscópica anatómica de próstata). En los últimos años se han producido avances muy relevantes en dos ámbitos: Uno, el ámbito tecnológico, con el desarrollo de la tecnología de modulación del pulso del láser de Holmio (MOSES) y de los morceladores de alto rendimiento. Otro, el desarrollo de nuevas técnicas quirúrgicas, que reconocen la importancia de liberar precozmente el esfínter del ápex del adenoma en la intervención y de preservar escrupulosamente la mucosa del esfínter externo, para evitar la incontinencia urinaria precoz postoperatoria. En este artículo se revisa la evolución reciente de la tecnología y de la técnica quirúrgica que han elevado a la enucleación endoscópica de próstata a otro nivel, reduciendo significativamente el tiempo operatorio, normalmente inferior a una hora, disminuyendo radicalmente la incontinencia precoz postoperatoria y probablemente, facilitando el aprendizaje de la técnica.

Molep (moses Holep) en bloque con liberación apical precoz y preservación de la mucosa esfinteriana. Evolución de la técnica quirúrgica y la tecnológica que permiten un nuevo paradigma de enucleación endoscópica anatómica de próstata / In block Molep (moses Holep), including early apical dissection and sphincter mucous preservation. Surgical technique and technology development that allow a new paradigm of endoscopic prostate enucleation

La enucleación endoscópica de próstata fue descrita por primera vez por Hiraoka en 1986, usando un resector monopolar. Su aportación pasó desapercibida hasta que Gilling y Fraundorfer publicaron su técnica de enucleación en tres lóbulos con láser de Holmio en 1998, que se estableció como una opción de tratamiento de la obstrucción prostática benigna ampliamente respaldada por la evidencia científica. Posteriormente se ha estudiado el uso de otros láseres así como de la energía bipolar para realizar enucleación endoscópica y se ha observado una concordancia en los resultados de estas técnicas, independientemente de la fuente de energía utilizada, que ha conducido a englobarlas bajo el acrónimo EEAP (enucleación endoscópica anatómica de próstata). En los últimos años se han producido avances muy relevantes en dos ámbitos: Uno, el ámbito tecnológico, con el desarrollo de la tecnología de modulación del pulso del láser de Holmio (MOSES) y de los morceladores de alto rendimiento. Otro, el desarrollo de nuevas técnicas quirúrgicas, que reconocen la importancia de liberar precozmente el esfínter del ápex del adenoma en la intervención y de preservar escrupulosamente la mucosa del esfínter externo, para evitar la incontinencia urinaria precoz postoperatoria. En este artículo se revisa la evolución reciente de la tecnología y de la técnica quirúrgica que han elevado a la enucleación endoscópica de próstata a otro nivel, reduciendo significativamente el tiempo operatorio, normalmente inferior a una hora, disminuyendo radicalmente la incontinencia precoz postoperatoria y probablemente, facilitando el aprendizaje de la técnica

Endoscopic enucleation of the prostate was first described by Hiraoka in 1986, using a monopolar resectoscope. His contribution was largely ignored until Gilling and Fraundorfer published their three-lobe enucleation technique with the Holmium laser in 1998, that ended establishing itself as a reliable option for the treatment of HBP, backed by ample scientific evidence. Later on, enucleation performed with other lasers, as well as bipolar energy, have shown concordance in their clinical results. As a result, the term AEEP (anatomic endoscopic enucleation of the prostate) emerged to encompass all these techniques. During the last few years there have been significant advances in two areas: first, technology, with the development of pulse modulation for Holmium generators (MOSES) as well as high-speed morcellators. Second, the development of new surgical techniques that recognize the importance of the early release of the sphincter from the apex of the adenoma during the operation as well as the careful preservation of the external sphincter's mucosa, to avoid early stress incontinence. In this paper, we review the recent evolution of both technology and surgical technique. AEEP has been risen to a new level, reducing operative time significantly, usually under one hour, and radically reducing the incidence of early temporary stress incontinence, and maybe also facilitating the learning curve of AEEP

En-bloc endoscopic enucleation of the prostate: a systematic review of the literature.

INTRODUCTION: Transurethral resection of the prostate (TURP) remains the gold standard for treatment of benign prostatic hyperplasia (BPH). Yet, the introduction of lasers for the treatment of LUTS due to BPO has dramatically changed the surgical landscape of benign prostatic obstruction (BPO) treatment. Recently, "en-bloc" techniques have shown to prove advantageous in terms of better visualization, more prompt identification of the surgical capsule and the correct plane to dissect. Herein we provide a comprehensive overview of available series of en-bloc enucleation of the prostate, focusing on surgical techniques, perioperative and functional outcomes. EVIDENCE ACQUISITION: A systematic review of the literature was performed according to PRISMA recommendations and was conducted on surgical techniques and perioperative outcomes of minimally invasive en-bloc surgery for prostate adenoma detachment. EVIDENCE SYNTHESIS: Overall, 16 studies with 2750 patients between 2003 and 2019 were included. Specific technical nuances have been described to maximize perioperative outcomes of en-bloc prostatic enucleation, including early apical release, horse-shape incisions, inverted U-shape tractions and low power. Overall, regardless of the energy employed, en-bloc prostatic enucleation achieved favorable outcomes including low risk of major complications and quality of life improvement. However, a great heterogeneity of study design, patients' inclusion criteria, prostate volume and en-bloc surgical strategy was found. CONCLUSIONS: En-bloc endoscopic enucleation of the prostate has been shown to be technically feasible and safe, with potential technical advantages over the classic three-lobe technique. Larger comparative studies are needed to evaluate the ultimate impact of the en-bloc approach on postoperative outcomes, in light of the surgeon's learning curve.

The surgical learning curve for endoscopic GreenLight™ laser enucleation of the prostate: an international multicentre study.

OBJECTIVES: To investigate the effect of surgical experience on the perioperative outcomes of endoscopic GreenLight™ (Boston Scientific Corporation, Marlborough, MA, USA) laser enucleation of the prostate (GreenLEP). SUBJECTS/PATIENTS AND METHODS: A multicentre retrospective study of the first patients treated with GreenLEP by six surgeons was conducted. For each patient, surgical experience was coded as the total number of procedures performed by the surgeons before the patient's operation. The learning curve was analysed in terms of changes over time for the following variables: enucleation time, morcellation time, occurrence of intraoperative complications (IOCs), 3-month postoperative International Prostate Symptom Score (IPSS) reduction, and the rate of Pentafecta achievement. RESULTS: In total, 922 patients were analysed. At multivariable regression analyses adjusted for case mix, surgical experience was associated with shorter enucleation and morcellation time (P < 0.001), lower IOC rate (P < 0.001), higher 3-month postoperative reduction in IPSS (P = 0.004), and higher probability of Pentafecta achievement (P < 0.001). The relationship between surgical experience and enucleation time/IOCs appeared as non-linear, with a steep slope reduction within the first 100 cases and a plateau observed after 200 cases, whilst the IPSS improved rapidly early in the learning curve process and plateaued after ~100 procedures. Finally, there was a linear improvement in Pentafecta achievement, with a plateau observed after 270 cases. CONCLUSION: Surgical experience has a significant impact on the perioperative outcomes for GreenLEP procedures. After adjusting for patient and prostate characteristics, plateau results were achieved after a long learning curve. A more intensely mentored and structured training schedule might allow quicker and safer adoption of the procedure.

'En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia.

PURPOSE: HoLEP represents an excellent treatment option for benign prostatic hyperplasia. Recently, 'en bloc' techniques resulting in improved visualization, shorter surgical times, and easier recognition of the dissection plane have been described. In this paper we describe the 'En bloc' HoLEP technique with early apical release. MATERIALS AND METHODS: Between January 2015 and March 2017, 137 consecutive patients were subjected to this technique by a single surgeon. The following parameters were measured pre- and post-procedure: International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), post-void residual urine (PVR) and PSA. Complications were recorded. RESULTS: Mean (SD; range) age was 66 years (8.0; 51-84), mean PSA was 4.8 ng/ml (7.0; 0.3-70), mean prostate volume was 75.63 ml (42.1; 37-253), mean volume of prostatic tissue removed was 65.9 ml (35.8; 30-217). Mean surgical duration was 47.58 min (21.3; 15-120 min): enucleation 31.5 min (14.9; 5-80 min), morcellating 6.9 min (6.6; 1-60 min). Mean hospitalization duration was 1.2 days (range 1-3), mean catheterization time was 1.2 days (range 1-5). The rate of stress urinary incontinence (SUI) was 5.8, 1.5 and 0.7% at 1, 3, and 6 months post-operation, respectively. Compared to pre-operative values, IPSS, Qmax, and PVR showed significant improvements at 1, 3, 6, and 12 months following the operation (p < 0.05). CONCLUSIONS: 'En Bloc' HoLEP with early apical release is a safe technique that allows for easier recognition of the surgical plane and preserves the external sphincter's mucosa to provide low rates of post-operative stress incontinence and significant functional results.

Vapoenucleation of the Prostate Using 180 W GreenLight Laser.

INTRODUCTION: The vapoenucleation of the prostate using green laser is an alternative hybrid technique between vaporization and enucleation. It consists of vaporizing the lateral lobes and enucleating the median lobe. The advantages compared with photoselective vaporization of the prostate (PVP) are: a fairly fast operation, low reoperation rates, it is suitable for large glands and provides pathology specimen. The aim of this video is to demonstrate the vapoenucleation technique step-by-step. METHODS: The surgery was performed with a 532-nm lithium triborate laser (GreenLight XPS 180W, American Medical Systems, Minnetonka, Minnesota), MoXy side-fire laser fiber at power settings: 180 W for cutting, 35 W for coagulation and a Piranha morcellation system (Richard Wolf GmbH, Germany). CASE REPORT: A 68-year-old patient presented with lower urinary tract symptoms secondary to benign prostatic obstruction. The prostate volume was 88 mL, PSA of 3.4 ng/mL, the peak urinary flow rate (Qmax) was 7 mL/s, the postvoid residual volumen was 160 mL and international prostate symptom score was 22. RESULTS: The total operative time was 72 minutes, total energy employed was 354 kJ and the pathology report showed no evidence of prostate cancer (35 g). The bladder catheter was removed at 24 hours postsurgery and the patient was discharged 48 hours postoperative without complications. Three months later all the parameters showed significant improvement (PSA: 1.02 ng/mL, international prostate symptom score: 4, Qmax: 43 mL/seg and postvoid residual volumen: 15 mL). CONCLUSION: Green laser vapoenucleation of the prostate represents a safe alternative technique for the complete removal of adenomatous prostate tissue, regardless of gland size, and it is particularly advantageous for the treatment of large prostates. This technique can also be used as an intermediate step during the learning curve of "en bloc" green laser enucleation of the prostate (GreenLEP). These promising results warrant further studies to assess long-term outcomes.

Aquablation of the prostate: single-center results of a non-selected, consecutive patient cohort.

PURPOSE: Aquablation of the prostate using the AquaBeam™ system promises equivalent functional outcomes, reduced learning curve, and improved sexual function compared to transurethral prostate resection as shown in prospective randomized trials. This prospective cohort study aims to evaluate if published results can be transferred into the clinical routine in a non-selected patient collective. METHODS: This study includes all patients treated between September 2017 and June 2018 with Aquablation of the prostate. Patients have been evaluated prospectively for the perioperative course and early follow-up. Besides voiding parameter and symptom score, TRUS-volume change, ejaculatory function, and adverse events have been recorded. RESULTS: 118 consecutive patients have been treated in the given time. Aquablation could be carried out successfully in all patients. IPSS, QoL, Qmax, and PVR improved significantly after the procedure and continued to improve during 3-month follow-up. Mean OR time was 20 min, TRUS volume decreased by 65%, and 73% of the patients retained antegrade ejaculation. Thirteen adverse events (> Clavien-Dindo I) occurred in 10 patients. CONCLUSION: The surgical ablation of the prostate using Aquablation achieved significant and immediate improvement of functional voiding parameters Qmax and PVR as well as symptomatic improvement of IPSS and QoL. Aquablation seems to be safe and effective with a low perioperative complication profile even in a non-selected group of patients.

Comparison of Outcomes Obtained After Regular Surgery Versus Live Operative Surgical Cases: Single-centre Experience with Green Laser Enucleation of the Prostate.

BACKGROUND: Live surgery remains controversial. Although it may improve surgical training and accelerate the dissemination of technical steps of surgical procedures, controversy exists regarding patient safety in live surgery. OBJECTIVE: To compare the perioperative outcomes of "en bloc" green laser enucleation of the prostate (GreenLEP) performed in workshops during live case demonstration (LCD) and in standard conditions (SCs). DESIGN, SETTING, AND PARTICIPANTS: Between June 2015 and January 2017, all consecutive patients who underwent GreenLEP for benign prostatic obstruction performed by a single surgeon were prospectively enrolled. Perioperative data and early postoperative complications according to Clavien-Dindo classification were collected. Workshop programmes started locally according to the European Association of Urology policy on live surgical events in June 2015 to enrol small groups of urologists in the GreenLEP technique. INTERVENTION: Endoscopic enucleation of the prostate using a GreenLight fibre. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Outcomes were compared between the LCD and SC groups. RESULTS AND LIMITATIONS: Of the 126 performed procedures, 37 were performed live during 17 LCDs with a median attendee number of 3. The patients' baseline characteristics were similar in both groups. Intraoperative parameters were comparable: total energy of 62 [53; 77] versus 56kJ [44; 69] (p=0.068), operative time of 61 [53; 71] versus 55min [45; 66] (p=0.1), and morcellating time of 3 [3; 5] versus 4min [2; 6] (p=0.82) in the LCD versus SC group. The catheterisation time (2d [1; 2]) and length of hospital stay (2d [2; 3]) were similar. The overall complication rate was comparable in the LCD (18.9%) and SC (24.7%) groups (p=0.64). Preoperative parameters significantly improved from baseline without any significant differences between the two groups. Limitations included a small number of attendees/workshop, and case selections were made by the surgeon himself. CONCLUSIONS: GreenLEP was safe and provided satisfactory functional outcomes in both conditions. From this preliminary study, it seems that LCD did not jeopardise the surgeon's skill or technique. Similar studies are required to further assess patient safety and outcomes associated with live surgical events. PATIENT SUMMARY: According to the surgeon expertise, endoscopic enucleation of the prostate performed during live case demonstration provided similar functional outcomes to that performed in standard condition and could therefore be considered a safe potential educational tool.

Recommendations for Safe and Efficient Morcellation After Endoscopic Enucleation of the Prostate.

OBJECTIVE: Background:After EEP (HoLEP, ThuLEP, GreenLEP or bipolar) the enucleated tissue is removed through a process of mechanical morcellation. Morcellation is the last, and very important, step in EEP procedures. It introduces additional time, and the possibility for complications exists. Although this is not a difficult procedure, it requires a learning curve that can pose a challenge for inexperienced surgeons. There are two types of morcellation systems: oscillating and reciprocating (depending on blade movement). OBJECTIVE: To demonstrate tips and tricks for safe and efficient morcellation after EEP and to share our experience with the oscillating morcellation system. MATERIAL AND METHODS: Four hundred and thirty-six patients were treated with green laser enucleation of the prostate by 3 surgeons with the en bloc technique between June 2013 and November 2016. After completing the enucleation procedure we removed the adenoma with an oscillating mechanical morcellator (Piranha, Richard Wolf, Germany). We have reported our experience (including the learning curve) and collected multiple videos exemplifying not only proper techniques for safe morcellation, but also possible problems and their solutions. The authors have compiled their collective experience to offer tips and tricks as well as a practical approach to trouble shooting and problem solving of the morcellation procedure. RESULTS: The median morcellation time was 5.00 minutes (3.00; 10.0) and the median morcellation efficiency was 11.0 g/min (7.70; 16.0). Complications included 2 cases of superficial bladder injuries and no bladder perforations. CONCLUSION: Morcellation is a safe and appropriate procedure to remove the adenoma after endoscopic enucleation of the prostate. However, without taking proper precautions major complications can occur. This video serves as a guide for safe morcellation after EEP and also offers practical advice to help avoid the most common complications in this procedure.

From "gold standard" resection to reproducible "future standard" endoscopic enucleation of the prostate: what we know about anatomical enucleation.

BACKGROUND: Open prostatectomy (OP) and transurethral resection of the prostate (TURP) have traditionally been the most common surgical approaches for the treatment of benign prostatic hyperplasia causing bladder outlet obstruction and have certainly passed the test of time. In time, many endoscopic surgical procedures have been described as an alternative mini-invasive treatment. Holmium laser enucleation (HoLEP) guaranteed functional outcomes similar to OP and TURP with lower perioperative complication rates for any prostate size. With the development of different kinds of lasers (such as thulium, "green light" and diode) and bipolar energy, the feasibility of endoscopic enucleation using these energies has been explored. EVIDENCE ACQUISITION: In this paper, recent techniques to perform true prostate enucleation have been reviewed through a search of PubMed and Web of Science, including articles published in the last 20 years in clinical journals. The review is based on a peer-review process of the authors after a structured data search. Search terms included "Thulium prostate enucleation, THULEP, TmLEP/Tm Yag enucleation" OR "Greenlight enucleation/prostate enucleation/vapo-enucleation/KTP prostate enucleation, PVP prostate enucleation, GreenLep/" OR "bipolar prostate enucleation" OR "HoLEP, Holmium prostate enucleation" OR "monopolar prostate enucleation" OR "Diode prostate enucleation" OR "DiLEP" OR "Eraser prostate enucleation" OR "ELEP". EVIDENCE SYNTHESIS: Following the example of HoLEP, many techniques have been described in the literature using a variety of energy sources and instruments either in a pure enucleative or a hybrid (mixed) fashion. However, the levels of evidence are too low and follow-up still too short to offer solid recommendations. CONCLUSIONS: HoLEP has become the conceptual and practical paradigm for the wide spread of enucleation thanks to the evidence provided by the literature and excellent outcomes. Higher level of evidence is required to assess efficacy of alternative enucleative techniques.