Ejaculatory and erectile function outcomes following holmium laser enucleation of the prostate.

PURPOSE: Holmium laser enucleation of the prostate (HoLEP) is a surgical treatment option for benign prostatic hyperplasia (BPH). Many men develop retrograde ejaculation postprocedure, but there is conflicting evidence regarding sexual function outcomes post-HoLEP. We sought to examine significant variations in patient-reported erectile and ejaculatory function within 12 months post-HoLEP. MATERIALS AND METHODS: We conducted a retrospective study for patients who underwent HoLEP between Nov 2018 and Feb 2022. Of the reviewed patients, 277 patients met inclusion criteria and completed pre and postoperative questionnaires, which included the Male Sexual Health Questionnaire- Ejaculatory Dysfunction (MSHQ-EJD) and the International Index of Erectile Function/Sexual Health Inventory for Men (IIEF-5/SHIM). Surveys were provided to patients up to 12 months postprocedure. Demographics and comorbidities associated with sexual dysfunction were collected. Responses to each question were analyzed to detect sub-categorical variations in sexual function as the secondary objective. Data was analyzed by using a linear mixed model. RESULTS: There was a significant decline in total scores for the MSHQ-EJD (8.70 pre-HoLEP vs. 6.58 post HoLEP, p ≤ 0.001) including a significant decline (p < 0.005) in questions 1-3 which assess ejaculatory ability, strength, and volume. There was not a significant decline in question 4 which assesses bother (2.552 pre-HoLEP vs. 3.119 post-HoLEP, p = 0.526). There was not a significant decline in the IIEF-5/SHIM postoperatively (11.51 pre-HoLEP vs. 13.327 post-HoLEP, p = 0.498). CONCLUSIONS: Patients undergoing HoLEP do not experience a decline in erectile function. Patients do experience a decline in ejaculatory function but did not find this bothersome.

Evaluation of Renal Function Recovery After Holmium Laser Enucleation of the Prostate in Patients with Chronic Kidney Disease.

Introduction: Holmium laser enucleation of the prostate (HoLEP) has become a new surgical gold standard treatment for benign prostatic hyperplasia (BPH). It is known that untreated BPH can lead to bladder outlet obstruction (BOO). A positive correlation exists between BOO and chronic kidney disease (CKD), but stability or recovery of renal function after HoLEP remains unknown. We sought to describe changes in renal function after HoLEP in men with CKD. Methods: A retrospective study was conducted of patients who underwent HoLEP with glomerular filtration rates (GFRs) <60, CKD stages III to V. Pre- and postoperative GFRs were selected within 3 months before the operation and within 1 year postoperatively. The presence of an indwelling catheter, preoperative hydronephrosis, history of kidney stones, and prostate size were also reviewed. Data were analyzed in accordance with preoperative CKD stage. Results: Of the reviewed patients, 138 met inclusion criteria with CKD stages III to V. Each CKD group was without significant postoperative complications. There was a significant increase between pre- and postoperative GFR for patients in CKD stages III (n = 116) and IV (n = 17) (p < 0.0001 and p = 0.010, respectively). The mean increase between pre- and postoperative GFR for the CKD stages III and IV patients were 6.4 and 6.49, respectively. There was no correlation between presence of preoperative hydronephrosis, history of kidney stones, catheter dependency, nor prostate size on change in postoperative GFR (p > 0.05). Conclusion: These findings suggest that patients in CKD stages III or IV undergoing HoLEP experience an increase in GFR. It is noteworthy that there appears to be no decline in renal function postoperatively in any group. HoLEP represents an excellent surgical option for patients with preoperative CKD and may prevent further renal decline.

Mini-Percutaneous Nephrolithotomy Outcomes in the Obese Population: A Retrospective Review.

Introduction and Objectives: Mini-percutaneous nephrolithotomy (PCNL) has gained popularity over the last decade due to its stone-free rate comparable to traditional PCNL but with decreased risk of complications. While the data on mini-PCNL has been favorable thus far, no study today has evaluated outcomes in obese patients. Methods: All patients undergoing mini-PCNL at our institution since we began its use in 2019 were included in this study. Mini-PCNL was defined as access sheath ≤22F in size. An obese group with body mass index (BMI) ≥30 was compared to a nonobese group with BMI <30. A patient was considered relatively stone free if residual fragments were <4 mm on follow-up CT with ≤3 mm cuts. Fisher exact test was used to compare dichotomous differences between variables, and t-test to compare continuous variables. Results: We identified 67 patients who underwent mini-PCNL during the study period with 33 patients in the obese group. Median BMI in the obese group was 36.4 kg/m2 compared to 25.05 kg/m2 in nonobese. There were no blood transfusions in either group during the study period. There was no statistical difference between the obese vs nonobese group for age, access sheath size, change in hemoglobin, same day discharge, percent relatively stone free, emergency department visit within 30 days, and median largest single stone diameter. There was a significant difference in the sum of all treated stone diameter in the obese group (median 15 mm) vs nonobese (median 18 mm, p = 0.02) (Table 1). Conclusion: Mini-PCNL appears to be equally safe and effective in obese and nonobese patients alike. While there was a statistically significantly higher amount of overall stone burden in the nonobese groups, the overall difference is not clinically significant. Further research is needed to validate our experience.

Impact of American Society of Anesthesiologists score on postoperative holmium enucleation of the prostate outcomes and complications.

INTRODUCTIONS: The American Society of Anesthesiologists Physical Status Classification System (ASA) is a validated risk stratification method for patients undergoing surgery. There is an increased prevalence of benign prostatic hyperplasia and comorbidities in our aging population. The role of ASA related to postoperative complications in patients undergoing holmium laser enucleation of the prostate (HoLEP) has not been described. METHODS: A review of our database was performed for patients who underwent HoLEP from July 2018 to December 2020. Patients were stratified based on ASA score. Preoperative, perioperative, and complication data were analyzed using SAS analytics software. RESULTS: Of 472 patients undergoing HoLEP, 320 (67.8%) were ASA 3-4 patients. There was a statistically significant difference found in age (72.3 ± 9.8 vs. 69.1 ± 9.0 years, p < 0.001), body mass index (BMI) (29.0 ± 5.9 vs. 27.3 ± 4.2, p = 0.004), and use of antiplatelet/anticoagulant medications (14.6% vs. 2.6%, p < 0.001) in the ASA 3-4 group. There was no significant difference between prostate volume (p = 0.158) or catheter-dependent urinary retention (p = 0.376). No difference was found in enucleation time (52.76 ± 24.8 vs. 54.16 ± 23.7 min, p = 0.587), OR specimen weight (70.24 ± 58.5 vs. 81.53 ± 65.9, p = 0.094). or intraoperative complications (2.8% vs. 1.3%, p = 0.330). There were higher postoperative complications in the ASA 3-4 group (12.8% vs. 7.9%, p = 0.03), but no difference in Clavien ≥3 complications (p = 0.068). ASA 3-4 patients had similar postoperative international prostate symptom score (p = 0.159). CONCLUSION: HoLEP is feasible and effective in patients who are ASA 3-4. The high-risk cohort had an increased rate of low-grade complications. Patients with an ASA score of 3-4 should be counseled regarding a higher rate of low-grade complications.

Holmium Laser Enucleation of Prostate in Patients with Pre-Existing Localized Prostate Cancer, Dual Center Study.

Background: Holmium laser enucleation of the prostate (HoLEP) has been used as an effective minimally invasive technique for management of enlarged prostates. We aimed to report the role of HoLEP in prostate cancer (PCa) patients either on active surveillance with bothersome lower urinary tract symptoms (LUTS) or for prostate debulking before radiation therapy and the impact on PCa management plans. Methods: Prospectively maintained database in two institutions was reviewed for patients with localized PCa managed by HoLEP with at least a follow-up of 1 year. We assessed prostate-specific antigen (PSA) trends, effect on international prostate symptom score (IPSS) and further management of PCa. Results: Out of >2000 HoLEP patients, 117 patients with a median follow-up of 30 months were included. Mean (standard deviation) age was 72.3 (±8.3) years with median (interquartile range, IQR) IPPS of 22 (16-28) and median (IQR) PSA at 7.6 (5.3-14.9) ng/mL. Gleason grade group was 1, 2, 3, and 4 in 47 (73.2%), 32 (27.35%), 7 (5.9%), and 4 (3.4%) patients, respectively. Median (IQR) PSA has significantly dropped to 1.3 (0.6-3.1), 1.4 (0.75-2.9), and 1.7 (0.86-2.75) ng/mL at 6-week, 3-month, and 1-year follow-up, respectively (p < 0.001). IPSS scores post-HoLEP obviously improved with mean (IQR) IPSS of 10 (5-13), 7 (3-12), and 3 (2-5) at 6-week, 3-month, and 1-year, respectively (p < 0.001). Eighty-eight (72%) patients stayed on active surveillance, whereas 27 (23%) patients had radiotherapy ± androgen deprivation therapy for persistently high or relapsing PSA. Within 36 intermediate-risk patients, 15 (41.6%) and patients had radiotherapy, whereas 21 (58.3%) patients continued active surveillance. Conclusions: HoLEP is beneficial in debulking large prostate in PCa patients with bothersome LUTS on active surveillance or before radiotherapy. HoLEP reduces the contribution of large adenoma to PSA level, thus reflecting PSA level better and helping reduce overtreatment.

Evaluation of the Cost-Effectiveness of Surgical Treatment Options for Benign Prostatic Hyperplasia.

OBJECTIVE: To compare the cost-effectiveness of surgical interventions for BPH. METHODS: Using a Markov model, a cost-utility analysis was performed comparing HoLEP, B-TURP, WVTT, and PUL for prostate size <80cc (index patient 1) and HoLEP and SP for prostate size >80cc (index patient 2). Model probabilities and utility values were drawn from the literature. Analysis was performed at a 5-year time horizon with extrapolation to a lifetime horizon. Primary outcomes included quality-adjusted life years (QALYs), 2021 Medicare costs, and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100,000/QALY. Univariate and probabilistic sensitivity analyses were performed. RESULTS: At 5 years, costs per patient for index patient 1 were $3292 (WVTT), $6532 (HoLEP), $6670 (B-TURP), and $10,257 (PUL). HoLEP resulted in the highest QALYs (4.66), followed by B-TURP (4.60), PUL (4.38), and WVTT (4.38). This translated to HoLEP being most cost-effective (ICER $11,847). For index patient 2, HoLEP was less costly ($6,585 vs $15,404) and more effective (4.654 vs 4.650) relative to SP. On sensitivity analysis for index patient 1, B-TURP became most cost-effective if cost of HoLEP increased two-fold or chronic stress incontinence following HoLEP increased ten-fold. When follow-up time was varied, WVTT was preferred at very short follow up (<1 year), and HoLEP became more strongly preferred with longer follow up. CONCLUSION: At 5 years follow up, HoLEP is a cost-effective surgical treatment for BPH- independent of gland size.

Expanded Criteria Same Day Catheter Removal After Holmium Laser Enucleation of the Prostate.

Abstract Introduction and Objectives: Holmium laser enucleation of the prostate (HoLEP) is a highly effective treatment of benign prostatic hyperplasia (BPH). Technical advances and improved hemostatic properties of holmium lasers have allowed for increased efficiency and outcomes. Same day catheter removal after HoLEP was described at our institution in 2020 after a 30-patient pilot trial. We now present an expanded update after widespread adoption at our facility. Methods: We reviewed patients who underwent same day catheter removal after HoLEP between January 1, 2020 and March 21, 2021. Unlike previous trials, there were no limitations to prostate size. Other changes included catheter removal in phase two of recovery when nursing was available rather than the urology clinic. Descriptive statistics are presented of preoperative, operative, and postoperative data. Univariate and multivariate analysis was performed to assess associations with failure of same day void trial. Results: The success rate of same day catheter removal for the 114 identified patients was 87.7%. Mean age was 69.1 ± 8.6 years and prostate volume was 109.2 ± 61.5 cc, 35% were dependent on catheterization for urinary retention preoperatively and 9% were on antiplatelet/anticoagulant therapy. A total of 26.5% of patients with American Society of Anesthesiology score (ASA) 3 or 4 failed catheter removal compared with 3.9% of patients with ASA 1 or 2 (likelihood ratio 9.32, p = 0.002), ASA status lost significance on multivariate analysis (p = 0.076). Effective catheter removal was not significantly associated with age, body mass index, prostate size, catheter dependency, anticoagulation/antiplatelet therapy, American Urologic Association symptom score, prior BPH surgery, or prostate cancer in final pathology report. Conclusion: Regardless of prostate size, same day catheter removal is a safe and reliable method of post-HoLEP patient management. Patients with an ASA 3 or 4 should be counseled regarding potential risks of temporary re-catheterization. Given ongoing nationwide shortages in hospital beds and staffing, same day discharge and catheter removal may allow for wider availability of surgical treatment for BPH.

Stretched penile length and its associations with testosterone and infertility.

BACKGROUND: Male infertility can be associated with secondary sexual characteristics, hypogonadism, and several findings in the examination of external genitalia. We sought to identify if stretched penile length (SPL) is associated with infertility or baseline testosterone. METHODS: We performed a retrospective review of all males age 18-59 presenting to a Men's health clinic from 2014 to 2017. SPL of patients with infertility were compared to patients with any other complaint. Patients with Peyronie's disease, prior penile surgery, prostatectomy, on testosterone replacement, clomiphene or ß-hCG were excluded from our study. Baseline characteristics were compared between the two groups (infertile vs. other). Linear regression was used to assess the association between infertility and testosterone with SPL after adjusting for patient age, BMI, and race. Scatterplot was used for correlation between testosterone and SPL. RESULTS: Six hundred and sixty-four men were included in our study (161 infertile, 503 other). The unadjusted mean SPL in the infertile group was 12.3 cm compared to 13.4 cm in the other group (P<0.001). The significance remained when adjusted for age, BMI, testosterone and race (12.4 vs. 13.3, P<0.001). Mean total testosterone in the infertile group was not significantly different than the other group (414 vs. 422, P=0.68). Infertile men were younger than the other group (33.2 vs. 42.1 years, P<0.001). BMI did not significantly differ (28.9 vs. 28.9 kg/m2, P=0.57). There was a weak positive correlation between testosterone and penile size in both the infertile group (r=0.20, P=0.01) and the other group (r=0.24, P<0.001). CONCLUSIONS: Though SPL differed amongst our groups, adult testosterone levels did not. If developmental levels of testosterone exposure accounted for some of the differences in SPL between our two groups, these variations did not persist into adulthood. It remains unknown if reduced length is a result of genetic or congenital factors associated with infertility. Further investigation is needed to better understand the association of shorter SPL with male infertility.

Feasibility of wearable activity trackers in cystectomy patients to monitor for postoperative complications.

BACKGROUND: To determine the feasibility of using wearables in patients undergoing radical cystectomy to monitor postoperative heart rate and activity and attempt to correlate these factors to complications and readmissions. MATERIALS AND METHODS: We conducted a prospective study of 20 patients undergoing radical cystectomy for bladder cancer between June 2017 and March 2018. Each patient was provided with a Garmin Vívofit heart rate (HR) activity tracker and instructed to wear it on their wrist for 30 days postoperatively. Heart rate, steps, and sleep data were collected during this time. Patients were called at 10-day intervals and surveyed for complications and device compliance. Univariable mixed effects logistic regression models were used to compare daily activity tracker measures with occurrence of an adverse event. Odds ratios, 95% confidence intervals, and p-values were reported. RESULTS: Median age was 65 (interquartile range 61-74) years. Patients had usable data for a median of 59.3% (interquartile range 25-71.7%) of the time. Five patients experienced a postoperative event (1 readmission for sepsis from urinary tract source, 1 inpatient rapid response called for tachycardic event, 3 unscheduled visits related to dehydration), where event data was recorded over a total of 17 days. Higher step count was associated with reduced odds of an adverse event (odds ratio 0.31, 95% confidence interval 0.10-0.98 per 1000 steps, p = 0.047). CONCLUSIONS: Postoperative activity and heart rate monitoring in cystectomy patients is feasible though current wearables are not well suited for this task.

Post-hypospadias urethrocutaneous fistulae: no difference in repair success between proximal and distal fistulae.

INTRODUCTION Urethrocutaneous fistulae are the most common complication after hypospadias repair. We sought to compare outcomes of proximal versus distal urethrocutaneous fistula repair and hypothesized that patients with proximal fistulae would have lower rates of success than those with distal fistulae. We also aimed to evaluate factors that affected these outcomes. MATERIAL AND METHODS: Current procedural terminology codes were used to identify patients undergoing urethrocutaneous fistula repair after hypospadias surgery between 2014 and 2017 at an academic, pediatric urology referral center. Characteristics for each initial hypospadias repair and each fistula repair were noted, including location of meatus, location of fistula, type of magnification, suture type, interposition layer and post-operative stenting. The primary outcome was successful fistula repair. Univariate and multivariate analysis was performed. RESULTS: During the study period, 416 hypospadias repairs were performed. Thirty-one of these later presented with a fistula (8% fistula rate). Sixty-eight percent of fistulae were successfully closed with a single repair. There were 17 distal fistulae and 14 proximal fistulae. There was no difference in success between distal (71%) and proximal (64%) fistulae (p = 0.73). There was no statistically significant association between the primary outcome (successful fistula repair) and fistula location (p = 0.71), magnification (p = 0.38), suture type (p = 0.49), interposition coverage layer (0.43), or postoperative stenting (p = 0.92) on univariate or multivariate analysis. CONCLUSION: There is no difference in success when repairing distal versus proximal urethrocutaneous fistulae. Neither fistula location, type of magnification, suture type, interposition layer nor stenting affected outcomes.

Scoping Review and Meta-analysis of Hyperbaric Oxygen Therapy for Radiation-Induced Hemorrhagic Cystitis.

PURPOSE OF REVIEW: To critically review and summarize existing literature assessing the effectiveness of hyperbaric oxygen therapy (HBOT) for the treatment of radiation-induced urologic injury. RECENT FINDINGS: Though 5 of the included 13 studies were published in the last 2-3 years, the only randomized controlled study was performed in 2012. Recent studies have confirmed the safety and efficacy of HBOT as well as identified risk factors for success vs. failure of HBOT for hemorrhagic radiation cystitis (HRC). Of the 602 patients that received HBOT for HRC, 84% had a partial or complete resolution. In the 7 studies that utilized RTOG/EORTC, 75% of patients saw an improvement in hematuria of at least one grade (out of possible 5 total). Of the 499 patients with documented follow-up, 14% experienced recurrence, with a median time to recurrence of 10 months (6 to 16.5 months).

Surgical Feeding Tubes in Pediatric and Adolescent Cancer Patients: A Single-institution Retrospective Review.

The purpose of our study was to evaluate surgical enteric access in pediatric cancer patients to determine factors associated with postoperative complications. We performed a single-institution retrospective review of all patients below 21 years old with a primary cancer diagnosis who underwent surgical procedures for enteral access between 2004 and 2014. Multivariate logistic regression was performed to determine independent predictors of postoperative complications. During the study period, 122 patients had surgically placed feeding tubes, of whom 58% developed ≥1 complication(s) and 16% experienced a major complication. No single factor was significantly associated with developing any complication or major complication. Several trends were noted including increased complications associated with jejunostomy tubes, percutaneous endoscopic gastrostomy tubes, and abdominal radiation. Surgically placed enteric access in pediatric and adolescent cancer patients is associated with an extremely high complication rate emphasizing the importance of careful evaluation of these patients before embarking on surgical feeding access. Future work should evaluate mechanisms to decrease complications and/or explore alternative methods to provide supplemental nutrition in children and adolescents with cancer.

Effect of concurrent metastatic disease on survival in children and adolescents undergoing lung resection for metastatic osteosarcoma.

PURPOSE: To evaluate the impact of treated extra-pulmonary metastatic disease on overall (OS) and event-free survival (EFS) for pediatric osteosarcoma patients undergoing pulmonary metastatectomy. METHODS: We retrospectively reviewed pediatric patients who were treated for osteosarcoma at our institution from 2001 to 2011 and received pulmonary metastatectomy (n=76). We compared OS and EFS between patients with metastases limited to the lungs (Group A, n=58) to those with treated extra-pulmonary metastases (Group B, n=18) at the time of first pulmonary metastatectomy. RESULTS: The estimated median OS and EFS from first pulmonary metastatectomy were 2.0years (95% CI 1.5-2.8years) and 5.5months (95% CI 3.0-8.1months), respectively. Median OS was significantly greater for Group A (2.6years, 95% CI 1.9-3.8) compared to Group B (0.9years, 95% CI 0.6-1.5) (log rank p=0.0001). Median EFS was significantly greater for Group A (7.9months, 95% CI 5.0-10.7) compared to Group B (1.6months, 95% CI 0.8-2.7) (log rank p<0.0001). Independent predictors of OS included extra-pulmonary metastatic disease at the time of first thoracotomy, bilateral pulmonary metastases, and >4 nodules resected at first thoracotomy (all p<0.001). CONCLUSIONS: Osteosarcoma patients with treated extra-pulmonary metastatic disease at the time of pulmonary metastatectomy have significantly worse survival compared to those with disease limited to the lungs.

Childhood melanoma: an increasingly important health problem in the USA.

PURPOSE OF REVIEW: To inform pediatricians of the challenges of detection of melanoma in children and adolescents as well as to instruct on proper biopsy technique of suspicious lesions. RECENT FINDINGS: The incidence of melanoma in children and adolescents is on the rise with an average increase of 2% per year. Rates of change are higher in adolescent girls and locations with low UV-B exposure. Standard Amelanotic, Bleeding, Bump, Color uniformity, De novo, any Diameter (ABCD) detection criteria fail to detect most childhood melanomas. Tumor thickness and sentinel lymph node status are the most important prognostic factors. Artificial tanning use is prevalent among adolescent girls and likely contributes to the growing incidence of melanoma in this group. SUMMARY: Childhood melanoma is often amelanotic and may also appear as raised or ulcerated lesions commonly mistaken for warts or other benign skin conditions. Excision and full-thickness punch biopsies are indicated for suspicious lesions, whereas shaves and small punch biopsies are to be avoided. Pediatric patients more frequently have positive sentinel lymph nodes and increased tumor thickness, yet similar survival compared with adults.

A zyxin-nectin interaction facilitates zyxin localization to cell-cell adhesions.

Cell-cell junction remodeling is associated with dramatic actin reorganizations. Several actin regulatory systems have been implicated in actin remodeling events as cell-cell contacts are assembled and disassembled, including zyxin/LPP-VASP complexes. These complexes facilitate strong cell-cell adhesion by maintaining actin-membrane connections. It has been proposed that zyxin and LPP localize to cell-cell junctions via a well-defined interaction with alpha-actinin. This was recently confirmed for LPP, but zyxin localization at cell-cell contacts occurs independently of alpha-actinin binding. Here we seek to map the zyxin sequence responsible for localization to cell-cell contacts and identify the protein that docks zyxin at this cellular location. Previous results have shown that a zyxin fragment excluding the alpha-actin binding site and the LIM domains (amino acids 51-392) can independently localize to cell-cell contacts. Here, expression of smaller zyxin fragments show that zyxin localization requires amino acids 230-280. A yeast-two-hybrid screen, using the central region of zyxin as bait, resulted in the identification of the cell-cell adhesion receptor nectin-4 as a zyxin binding partner. Further demonstrating zyxin-nectin interactions, zyxin binds the intracellular domain of nectin-2 in vitro. Depletion of nectin-2 from L cells expressing E-cadherin results in a loss of zyxin localization to cell-cell contacts, demonstrating that the zyxin-nectin interaction plays a critical role in zyxin targeting to these sites.