Laser fiber degradation following holmium laser enucleation of the prostate utilizing Moses technology versus regular mode.

PURPOSE: We sought to objectively compare laser fiber degradation for holmium laser enucleation of the prostate (HoLEP) cases performed with 550 µm standard fibers versus 550 µm Moses 2.0 fiber in BPH mode on a macroscopic and microscopic level. METHODS: We prospectively collected outcomes for 50 standardized HoLEP cases using 550 µm Moses fiber with 2.0 BPH mode compared to our historical cohort of 50 patients using 550 µm standard fibers on regular mode. Macroscopic degradation length was the difference in length of exposed fiber at the start and end of each case. Five consecutive 550 µm standard fibers, five 550 µm Moses fibers and their respective controls underwent novel utilization of three objective corroborating imaging techniques: Brightfield high resolution microscopy, high resolution 3-D microCT and Confocal Reflection Surface Analysis. Mann-Whitney U, 2-tailed T tests and Chi-squared tests were used. RESULTS: Standard fibers demonstrated greater degradation than the Moses fibers with 2.0 BPH mode [2.9 cm (IQR 1.7-4.3 cm) vs 0.2 cm (IQR 0.1-0.4 cm), p < 0.01]. This difference remained significant when comparing degradation per energy used, per minute enucleation and per gram enucleated (all p < 0.05). None of the cases with Moses fiber and 2.0 BPH mode required intraoperative interruption to re-strip the fiber. Objective fiber degradation by three microscopic techniques confirmed more damage to the standard fibers with regular mode. CONCLUSION: Overall, use of the 550 µm Moses fiber with 2.0 BPH mode resulted in less fiber degradation compared to a standard 550 µm fiber with regular mode as confirmed using 4 corroborating macroscopic and microscopic techniques.

Determining the threshold of acute renal parenchymal damage for intrarenal pressure during flexible ureteroscopy using an in vivo pig model.

PURPOSE: To identify a threshold for intrarenal pressure (IRP), that if exceeded, will result in renal parenchymal damage. Herein, we attempt to identify an IRP threshold by subjecting in vivo porcine kidneys to various levels of extreme pressurized irrigation. Our objective was not to simulate ureteroscopy treatment, but to attempt identify a threshold of IRP injury. METHODS: Ten female pigs were intubated and sedated. The abdomen was opened; the ureters were isolated and incised. A LithoVue™ (Boston Scientific) ureteroscope was inserted. A 0-silk tie was then used to tie the ureter around the scope to create a closed system (to achieve a constant level of pressure). Real-time IRPs were measured using the Comet™ Pressure guidewire (Boston Scientific). Kidneys were exposed to pressurized, saline for 36 min (at control, 50, 100, 150 mmHg and higher pressures). Kidneys were then immediately harvested. Two expert histologists independently analyzed kidney slides to identify areas of renal damage. RESULTS: The two kidneys exposed to IRPs > 185 mmHg resulted in forniceal rupture and large areas of hematoma. The other IRP groups (control, 50, 100, and 150 mmHg) had no identifiable gross or histologic renal parenchymal damage. CONCLUSIONS: No differences in renal parenchymal morphology were identified between pressure groups of control, 50, 100, or 150 mmHg. However, IRPs > 185 mmHg did result in forniceal rupture in this closed-system in vivo porcine model. Further study is required to elucidate the damage threshold.

The IDENTIFY study: the investigation and detection of urological neoplasia in patients referred with suspected urinary tract cancer - a multicentre observational study.

OBJECTIVE: To evaluate the contemporary prevalence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC] and renal cancer) in patients referred to secondary care with haematuria, adjusted for established patient risk markers and geographical variation. PATIENTS AND METHODS: This was an international multicentre prospective observational study. We included patients aged ≥16 years, referred to secondary care with suspected urinary tract cancer. Patients with a known or previous urological malignancy were excluded. We estimated the prevalence of bladder cancer, UTUC, renal cancer and prostate cancer; stratified by age, type of haematuria, sex, and smoking. We used a multivariable mixed-effects logistic regression to adjust cancer prevalence for age, type of haematuria, sex, smoking, hospitals, and countries. RESULTS: Of the 11 059 patients assessed for eligibility, 10 896 were included from 110 hospitals across 26 countries. The overall adjusted cancer prevalence (n = 2257) was 28.2% (95% confidence interval [CI] 22.3-34.1), bladder cancer (n = 1951) 24.7% (95% CI 19.1-30.2), UTUC (n = 128) 1.14% (95% CI 0.77-1.52), renal cancer (n = 107) 1.05% (95% CI 0.80-1.29), and prostate cancer (n = 124) 1.75% (95% CI 1.32-2.18). The odds ratios for patient risk markers in the model for all cancers were: age 1.04 (95% CI 1.03-1.05; P < 0.001), visible haematuria 3.47 (95% CI 2.90-4.15; P < 0.001), male sex 1.30 (95% CI 1.14-1.50; P < 0.001), and smoking 2.70 (95% CI 2.30-3.18; P < 0.001). CONCLUSIONS: A better understanding of cancer prevalence across an international population is required to inform clinical guidelines. We are the first to report urinary tract cancer prevalence across an international population in patients referred to secondary care, adjusted for patient risk markers and geographical variation. Bladder cancer was the most prevalent disease. Visible haematuria was the strongest predictor for urinary tract cancer.

Initially Asymmetrical Function on MAG3 Renography Increases Incidence of Adverse Outcomes.

PURPOSE: To discriminate pathological from physiological hydronephrosis (99m)Tc-mercaptoacetyltriglycine (MAG3) diuretic renography is a fundamental imaging modality. Initial asymmetrical differential function or decreasing function on serial MAG3 scans is a classic surgical indication. However, prognostic evidence supporting this is limited. Therefore, we examined the association between initial function and outcomes. We hypothesized that patients with initially asymmetrical function would have higher odds of functional decline, and experience symptoms and surgical intervention compared to patients with initially symmetrical scans. MATERIALS AND METHODS: We retrospectively reviewed the charts of 1,124 pediatric patients with hydronephrosis seen at Stollery Children's Hospital from 2000 to 2014. A total of 387 cases of unilateral ureteropelvic junction obstruction were grouped by initial postnatal differential function with asymmetrical defined as a greater than 10% difference in relative function. Postnatal surveillance, followup MAG3 results, pyeloplasty rates and post-pyeloplasty outcomes were compared. RESULTS: Of 387 patients 143 (37%) had initially asymmetrical function. Of those undergoing MAG3 scan surveillance 17% experienced a 10% or greater decline in ipsilateral differential function vs a 6% rate of function loss in the initially symmetrical group (OR 3.2, 95% CI 1.6-6.4, p = 0.0008). The overall pyeloplasty rate in patients with asymmetrical and symmetrical function was 27% and 16%, respectively (OR 1.9, 95% CI 1.1-3.2, p = 0.013). Patients with initially asymmetrical function had an increased rate of pyeloplasty secondary to symptoms compared to those with initially symmetrical function (16% vs 8%, OR 2.1, 95% CI 1.1-4.0, p = 0.019). Mean time to functional decline and pyeloplasty was 19 and 17 months, respectively. CONCLUSIONS: Patients with initially asymmetrical differential function had increased ORs for subsequent renal decline, symptom onset and pyeloplasty.

Comparison of outcomes in patients with and without neurologic diseases undergoing holmium laser enucleation of the prostate.

INTRODUCTION: We aimed to compare holmium laser enucleation of the prostate (HoLEP) outcomes in patients with and without neurologic diseases (ND). METHODS: A prospectively maintained database of patients undergoing HoLEP from January 2021 to April 2022 was reviewed. The following NDs were included: diabetes-related neuropathy/neurogenic bladder, Parkinson's disease, dementia, cerebrovascular accident, multiple sclerosis, traumatic brain injury, transient ischemic attack, brain/spinal tumors, myasthenia gravis, spinal cord injury, and other. Statistical analysis was performed using t-tests, Chi-squared, and binomial tests (p<0.05). RESULTS: A total of 118 ND patients were identified with 135 different neurologic diseases. ND patients were more likely to have indwelling catheters (57% vs. 39%, p=0.012) and urinary tract infections (UTIs) preoperatively (32% vs. 19%, p=0.002). Postoperatively, ND patients were more likely to fail initial trial of void (20% vs. 8.1%, p<0.001) and experience an episode of acute urinary retention (16% vs. 8.5%, p=0.024). Within 90 days postoperative, the overall complication rate was higher in the ND group (26% vs. 13%, p=0.001). Within the ND group, 30/118 (25%) had ≥1 UTI within 90 days preoperative, which decreased to 10/118 (8.7%) 90 days postoperative (p<0.001). At last followup (mean 6.7 months [ND] vs. 5.4 months [non-ND], p=0.03), four patients (4.4%) in the ND group required persistent catheter/clean intermittent catheterization compared to none in the non-ND group (p=0.002). CONCLUSIONS: Patients with ND undergoing HoLEP are more likely to experience postoperative retention and higher complication rates compared to non-ND patients. While UTI rates are higher in this population, HoLEP significantly reduced three-month UTI and catheterization rates.

Tranexamic Acid Does Not Improve Outcomes of Holmium Laser Enucleation of the Prostate: A Prospective Randomized Controlled Trial.

Introduction: Tranexamic acid (TXA) is a clot promoting agent utilized during orthopedic procedures to decrease bleeding. Urologists have demonstrated the benefits of TXA in percutaneous surgery. Our objective was to assess the safety and efficacy of single-dose TXA on same-day holmium laser enucleation of the prostate (HoLEP) outcomes. Methods: From September 2021 to January 2022, we prospectively randomized 110 patients undergoing HoLEP to either 1 g of TXA after induction or no treatment. Institutional Review Board (IRB) approval (STU00215134) and registry with ClinicalTrials.gov (NCT05082142) were obtained before enrollment. Primary outcome was the rate of effective same-day discharge (SDD). Secondary outcomes included transfusion rate, same-day catheter removal, length of stay (LOS), and 90-day complications. Power analysis determined that 110 patients should be enrolled to detect a 25% difference in SDD rate. Results: There was no difference in patient demographic and prostate features between the control (n = 55) and TXA groups (n = 55; all p > 0.05). The overall rate of effective SDD was not different between the control and TXA groups (49/55 [89%] vs 51/55 [93%], p = 0.74). Median LOS (hh:mm) was not different between groups (03:07 vs 02:50, p = 0.23) with only 3/110 (2.7%) having an LOS >24 hours. Effective same-day catheter removal occurred in 99/110 (90%) patients with no difference between groups (49/55 vs 50/55, p = 0.99). There was no difference in operative parameters (time, energy, specimen weight) and postoperative complications between groups (all p > 0.05). No patients required transfusions and there were no major 90-day complications related to surgery (Clavien-Dindo ≥IIIb). Conclusion: TXA administration is safe but did not impact SDD after HoLEP.

Benign prostatic hyperplasia surgical re-treatment after prostatic urethral lift A narrative review.

INTRODUCTION: Prostatic urethral lift (PUL) accounts for approximately one-quarter of all surgical benign prostatic hyperplasia (BPH) procedures performed in the U.S. Within five years of a patient's PUL procedure, approximately 1/7 patients will require surgical BPH retreatment. We aimed to highlight the evidence of surgical BPH retreatment modalities after PUL, with a focus on safety, short-term efficacy, durability, and relative costs. METHODS: A literature review was performed using PubMed, and an exhaustive review of miscellaneous online resources was completed. The search was limited to English, human studies. Citations of relevant studies were reviewed. RESULTS: No study has examined the efficacy, safety, or durability of transurethral resection of the prostate (TURP) or repeat PUL in the post-PUL setting. Recently, groups have examined laser enucleation (n=81), water vapor thermal therapy (WVTT) (n=5), robotic simple prostatectomy (SP) (n=2), and prostatic artery embolization (PAE) (n=1) in the post-PUL setting. Holmium enucleation of the prostate (HoLEP) after PUL appears to be safe and has similar functional outcomes to HoLEP controls. Other treatment modalities examined appear safe but have limited efficacy evidence supporting their use. Photo-selective vaporization of the prostate (PVP) and robotic waterjet treatment (RWT) have no safety or efficacy studies to support their use in the post-PUL setting. CONCLUSIONS: Despite increasing numbers of patients expected to require surgical retreatment after PUL in North America, there is currently limited evidence and a lack of recommendations guiding the evaluation and management of these patients. HoLEP is associated with the strongest evidence to support its use in the post-PUL setting.

Quality Improvement of Surgical Team Communication of Required Percutaneous Nephrolithotomy Equipment.

OBJECTIVE: To evaluate if implementation of a percutaneous nephrolithotomy (PCNL) equipment whiteboard can improve communication accuracy of surgical equipment, streamline operative efficiency, and decrease unnecessary case equipment costs. METHODS: A real-time editable equipment whiteboard was designed and implemented for all PCNL cases between October and December 2021. The relative difference in pre- and post-intervention surgical equipment accuracy as well as overall case costing was compared from 90 days prior to implementation to the period after intervention. RESULTS: Quality assessment surveys were completed prior to whiteboard implementation (N = 25) and cost implementation (n = 15). Pre- and postoperative assessment of equipment communication, assessed on a 10-point scale, improved after implementation of the communication whiteboard (Pre-op: 6.7/10 vs. 8.9/10, P < .001. Post-op: 7.0/10 vs. 9.3/10, P < .001). On average 64% (3.2/5) of items were accurate on preintervention cases. Postintervention accuracy improved to 88% (4.4/5 items) (P = .049). There was a significant relative case cost improvement after implementing the PCNL equipment whiteboard with an average of $436.81 USD savings per case (P = .001) and $488.22 USD per renal moiety (P = .002). CONCLUSION: Our baseline quality assessment of surgical team communication regarding PCNL equipment identified an area for improvement. Multidisciplinary feedback resulted in the development of a real-time editable PCNL equipment whiteboard which improved team perception of equipment communication, case item accuracy and resulted in a relative average cost savings for PCNL.

Trends of Benign Prostatic Hyperplasia Procedures in Ambulatory Surgery Settings.

Introduction: Holmium laser enucleation of the prostate (HoLEP) has evidenced-based advantages in treating benign prostatic hyperplasia (BPH) relative to other interventions. Unfortunately, the adoption of HoLEP has remained relatively low in Medicare and the National Surgical Quality Improvement Program populations. HoLEPs role as an inpatient surgical intervention is changing as advancements in the technique and systems have demonstrated the feasibility of same-day discharge. Thus, our objective was to evaluate national HoLEP trends in ambulatory surgery settings from 2016 to 2019. Materials and Methods: The Nationwide Ambulatory Surgery Sample (NASS) is the largest national all-payer database of ambulatory surgical encounters, managed by the Agency for Healthcare Research and Quality. A cross-sectional retrospective analysis of the 2016 and 2019 NASS was performed. Rates of BPH surgeries were calculated and stratified by age, census region, and primary payer to compare across time points for trends. Chi-squared tests and two-sample t-tests were completed for categorical and continuous variables, respectively. Results: The total number of ambulatory BPH surgeries fell 20% between 2016 (n = 124,538) and 2019 (n = 100,593). In 2016, HoLEP lagged behind photoselective vaporization of the prostate (PVP) and transurethral resection of prostate (TURP) with 4.7% of surgeries but rose to the second most common procedure in 2019 with 8.3% of total surgeries. TURP was the most common intervention (62.6% in 2016, 90.7% in 2019). Simple prostatectomy was the most expensive intervention. By U.S. census region, more HoLEPs were carried out in the South (43.1% in 2016, 37.5% in 2019) and Midwest (26.8% in 2016, 31.7% in 2019). Conclusions: Overall, HoLEP uptake is increasing. HoLEP has replaced greenlight PVP as the second most frequently used intervention. The rate of ambulatory HoLEPs has nearly doubled despite a general decrease in the number of surgeries.

An Outcomes Comparison Between Holmium Laser Enucleation of the Prostate, Open Simple Prostatectomy, and Robotic Simple Prostatectomy for Large Gland Benign Prostatic Hypertrophy.

OBJECTIVE: To compare perioperative outcomes between Holmium laser enucleation of the prostate (HoLEP), open simple prostatectomy (OSP), and robotic simple prostatectomy (RSP) for large prostates (> 80 cc). MATERIALS AND METHODS: A retrospective study of 340 patients who underwent HoLEP (n = 209), OSP (n = 66), or RSP (n = 65) at a large academic medical center between January 2013 - September 2021 was performed. Length of stay (LOS), operative time, catheter duration, estimated blood loss (EBL), blood transfusion, and 30-day ED visits and readmissions were compared between the three groups. Univariate analyses consisted of ANOVA with Tukey's corrections and Chi-square tests. Linear and multivariate logistic regression was also performed. All tests were two-sided and a p-value <0.05 was pre-determined to be statistically significant. Analyses were performed with SAS v9.4. RESULTS: HoLEP was found to have the shortest: operative time (1.4 vs 2.7 vs 3.8h), LOS (0.65 vs 4.2 vs 2.6d), and catheter duration (0.38 vs 9.9 vs 11.2d) compared to OSP and RSP, respectively (all P <.0001). HoLEP also had the lowest EBL (66 vs 795 vs 326 mL, P <.0001). HoLEP and RSP had a lower risk of blood transfusion compared to OSP (P <.0001). These associations remained significant on multivariable analyses. CONCLUSION: HoLEP is a minimally invasive treatment option for large prostates that was found to have shorter operative time, LOS, and catheter duration as well as lower EBL compared to OSP and RSP.

Relationships between holmium laser enucleation of the prostate and prostate cancer.

Holmium laser enucleation of the prostate (HoLEP) is a size-independent surgical option for treating benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) with excellent, durable functional outcomes. The prevalence of LUTS secondary to BPH and prostate cancer both increase with age, although the two diseases develop independently. Urologists often face a diagnostic dilemma, as men with LUTS secondary to BPH might also present with an elevated PSA and, therefore, need a diagnostic work-up to exclude prostate cancer. Nevertheless, ~15% of men with a negative elevated PSA work-up will undergo HoLEP and will be diagnosed with incidental prostate cancer at the time of HoLEP. Indeed, prostate cancer is often found in men undergoing HoLEP, and this situation can be challenging to manage. Variables associated with the detection of incidental prostate cancer, strategies to reduce incidental prostate cancer, as well as the natural history and management of this condition have been extensively studied, but further work in this area is still needed.

Short-Term Clinical Outcomes of Bladder Neck Incision at Time of Holmium Laser Enucleation of the Prostate.

Introduction: The effect of prophylactic bladder neck incision (BNI) at time of holmium laser enucleation of the prostate (HoLEP) is unknown. The aim of our study was to examine HoLEP outcomes with a specific focus on rates of bladder neck contractures (BNCs), with and without utilizing prophylactic BNI. Materials and Methods: We performed a retrospective review of HoLEP patients from January 2021 until January 2022. Outcomes of patients who underwent BNI at time of HoLEP were compared with those who underwent standard HoLEP alone. Student's t-tests, chi-square tests, and logistic regressions were performed using SAS Studio. Results: In total, 421 patients underwent HoLEP. BNI was concurrently performed in 74 (17.6%) HoLEP patients. BNI patients were younger (67.5 ± 9.0 years vs 71.1 ± 8.2 years, p = 0.00007) and had smaller prostates (60.7 ± 30.3 cc vs 133.2 ± 64.5 cc, p < 0.0001). Procedure, enucleation, and morcellation times were shorter in the BNI group (all p < 0.0001). There was no statistical difference in same-day discharge rates (90.4% vs 87.7%, p = 0.5), short-term functional outcomes, emergency department (ED) visits, or readmission rates between the two groups. At 14 months mean follow-up, two BNCs occurred in patients in the control group (0.6%), and no BNCs occurred in patients who underwent BNI (0.0%, p = 0.5). Conclusions: BNI at time of HoLEP did not decrease the ability to achieve same-day discharge or increase 90-day complications, ED visits, or readmission rates. No BNCs occurred in patients who underwent prophylactic BNI (0.0%) despite a smaller gland size and lower specimen weight in this cohort. Further prospective studies are required to conclude if concurrent BNI at time of HoLEP is protective against BNC.

Intradetrusor OnabotulinumtoxinA Injections at the Time of Holmium Laser Enucleation of the Prostate for Men with Severe Storage Symptoms.

Introduction: Intradetrusor onabotulinumtoxinA (OTA) injection is a well-established treatment option for refractory overactive bladder; however, its use at the time of holmium laser enucleation of the prostate (HoLEP) for men with bladder outlet obstruction (BOO) and severe storage symptoms has not been previously reported. Materials and Methods: We retrospectively identified men with BOO and severe storage symptoms who underwent treatment with 200 U of intradetrusor OTA (Botox®) at the time of HoLEP. Patients were propensity score matched to a cohort of HoLEP-only patients based on age, Michigan Incontinence Symptom Index (M-ISI) score, preoperative urinary retention, urge incontinence, and prostate size. Perioperative, postoperative, and patient-reported outcomes were examined between groups. Results: We identified 82 men who underwent HoLEP, including 41 patients in the OTA group and 41 patients in the control group. There was no difference in operative times (59 minutes OTA vs 55 minutes control, p = 0.2), rates of same-day trial of void (TOV) (92% OTA vs 94% control, p = 0.7), or rates of same-day discharge (88% OTA vs 85% control, p = 0.6) between groups. There was no difference in temporary postoperative urinary retention (7% OTA vs 2% control, p = 0.3) between groups. Patients who received OTA injections had a significant reduction in their incontinence scores at 3-month follow-up (M-ISI -8, interquartile range [IQR]: -13 to 0, p < 0.001), whereas control patients did not (M-ISI -5, IQR: -8 to -1, p = 0.2). There was no difference in rates of 90-day complications between groups (OTA 10% vs control 5%, p = 0.7). Conclusions: Intradetrusor OTA at the time of HoLEP is safe and is associated with improved urinary incontinence scores and AUA Symptom Score. Rates of same-day discharge and same-day TOV after HoLEP were not affected by OTA. These findings support the role of OTA as an adjunct to surgical intervention in men with incontinence in the presence of BOO.

Does Resectoscope Sheath Size Influence Holmium Laser Enucleation of the Prostate Outcomes? A Prospective Randomized Controlled Trial.

Introduction: Holmium laser enucleation of the prostate (HoLEP) is routinely performed with a 24F, 26F, or a 28F scope. Proponents of the larger scopes propose that a bigger sheath size allows for superior flow and visibility leading to a more efficient operation and better hemostasis. Those utilizing the smaller scopes suggest that the smaller sheath is less traumatic, resulting in lower stricture rates and temporary incontinence. We sought to compare outcomes of ambulatory HoLEP using the 24F and 28F laser scope. Materials and Methods: From May 2022 to March 2023, we randomized patients undergoing HoLEP (<200 cm3 in size) 1:1 to either a 24F or 28F scope. The primary outcome was differences in surgical duration between groups (minutes). Secondary outcomes included surgeon scope evaluation and postoperative patient results. Results: There was no difference in patient characteristics in those randomized to 28F (n = 76) vs 24F (n = 76) (p > 0.05) scopes. Procedural duration and efficiencies were not different between groups (all p > 0.05). The 28F scope was associated with improved surgeon-graded irrigation flow and visibility (p < 0.001). Patients treated with the 28F scope were more likely to achieve effective same-day trial of void (SDTOV) (28F 94.3% vs 24F 82.1%, p = 0.048) and have a shorter length of stay (LOS) (28F 7.0 vs 24F 11.9 hours, p = 0.014), however, rates of same-day discharge (SDD) were not statistically different (28F 87.8% vs 24F 78.4%, p = 0.126). There was no difference between the cohorts in rates of 90-day emergency room presentations, re-admissions, complications, or functional ouctomes (p > 0.05). Conclusions: We identified no clear advantage of scope size with regard to intraoperative or postoperative outcomes at 3-month follow-up due to scope size. However, if SDD is part of your postoperative pathway, the 28F scope may shorten LOS and increase rates of effective SDTOV. Clinicaltrials.gov: NCT05308017.

Improving communication of post-holmium laser enucleation of the prostate recovery using a surgeon-patient handout.

INTRODUCTION: To improve surgeon-patient communication of postoperative expectations, a multidisciplinary team created and evaluated a holmium laser enucleation of the prostate (HoLEP) expectations handout. Although an effective benign prostatic hyperplasia (BPH) surgery, it is crucial that patients understand the HoLEP recovery. A quality assessment previously performed at our center revealed 11% of patients were not aware of potential ejaculate volume changes. METHODS: Patients presenting for consultation prior to HoLEP were assessed with post-procedure patient-reported outcomes (PRO) questionnaires before (n=50) and after (n=50) the implementation of a surgeon-patient expectations handout. Patient demographics and perioperative course were examined in the context of responses. Comparisons were made with a Chi-squared test (p<0.05). RESULTS: We observed a response rate of 96% (pre-handout: 46/50 vs. post-handout: 50/50). Overall, 89/96 (93%) patients felt they had a reasonable understanding of HoLEP expectations, with no difference between cohorts (45/46 vs. 48/50, p=0.71). There was no difference in reporting an understanding of post-HoLEP hematuria (p=0.12) or urinary incontinence (UI) (p=0.99). The implementation of the handout improved understanding of retrograde ejaculation (pre-handout: 41/46 vs. post-handout: 50/50, p=0.022) and dysuria (pre-handout: 35/46 vs. post-handout: 46/50, p=0.048). Fifty-five patients experienced any dysuria postoperatively, with 89% reporting less than or equal to what they expected. Close to 30% (28/94) of respondents offering ways to improve communication suggested an educational website. CONCLUSIONS: The implementation of a surgeon-patient handout during HoLEP consultation improved understanding of postoperative retrograde ejaculation and dysuria at our center. We identified areas for future technology-aided improvements in post-HoLEP communication.

Understanding holmium laser enucleation of the prostate (HoLEP) recovery: Assessing patient expectations and understanding.

INTRODUCTION: Although holmium laser enucleation of the prostate (HoLEP) is a highly effective surgery, there is a variable recovery period where patients may experience hematuria, dysuria, or urinary incontinence (UI). Despite preoperative consultation, there is a paucity of literature examining the effectiveness of physician-patient communication in preparing the patient for the postoperative recovery period. We sought to examine recovery expectations as a patient-reported outcome (PRO) metric for HoLEP. METHODS: With institutional review board approval, we queried our electronic medical record and retrospective clinical registry to identify 50 consecutive patients that underwent HoLEP from November 2019 to March 2020 by two endourologists. Patients were provided questionnaires via Twistle© ≥6 months postoperatively. Patient demographics and perioperative course was examined in the context of responses. Our primary objective was determining whether patients felt they had a reasonable understanding of the recovery process. RESULTS: We observed a 92% (46/50) response rate, with an average patient age of 69.4 years (range 55-88). Overall, 91.3% (42/46) felt they had a reasonable understanding of the recovery. Additionally, 97.8% (45/46) were aware of temporary UI, with 87% having ≥1 episodes of UI after catheter removal. We found 47.8% (22/46) of patients expected UI to resolve within 30 days, while 8.6% expected >90 days of UI. All patients were aware of the risk of hematuria, with 93.5% (43/46) expecting resolution within 30 days (<7 days: 47.8%; 7-14 days: 28.3%; 15-30 days: 17.4%). CONCLUSIONS: Although surgical technique continues to improve HoLEP, ensuring adequate physician-patient communication to optimize expectations is crucial. We report patient understanding of HoLEP recovery and areas for future improvement.

Cost-Effectiveness of 90-day Single-use Flexible Cystoscope Trial: Single Center Micro-Costing Analysis and User Satisfaction.

OBJECTIVE: To evaluate cost-effectiveness and user satisfaction of a single-use flexible cystoscope at a tertiary care center we conducted a 90-day trial. Single-use flexible cystoscope advancements have introduced alternative options to reusable scopes. However, there is a paucity of cost-effectiveness and provider satisfaction studies examining the implementation of a hospital-based transition to single-use cystoscopes. METHODS: Following institutional device-approval we initiated a 90-day trial period (November 1, 2020-January 29, 2021) where all flexible, transurethral, and percutaneous, urologic care was provided with a disposable AMBU aScope. We performed a micro-costing analysis examining payor per case cost of the reusable flexible cystoscope (including servicing and processing) to the disposable units. Provider surveys assessed visual quality, deflection, ease of working channel and overall satisfaction on a 10-point Likert scale. RESULTS: Over the 90-day period, we encountered 84 cases (78 operative, 5 inpatient, 1 emergency department) where flexible cystoscopy was required. One disposable flexible cystoscope was successfully used in 78 of 84 (93%) cases. Of the 6 failures, 2 were due to an inability to access a disposable scope/monitor. Per use cost of the reusable flexible cystoscope at our center was $272.41 versus $185.00 for the single use. Extrapolating our average case volume and conservative failure rate (3 single use failures/month, requiring reusable), transitioning to predominately single use scopes results in $39,142.84 annual cost savings. CONCLUSIONS: This single center 90-day trial of disposable flexible cystoscopy identified per-use costs to be less when a single-use flexible cystoscope was utilized at a high-volume tertiary care center.

Concurrent placement of SpaceOAR gel and gold fiducials during HoLEP: a case report.

Herein, we describe a case of a patient diagnosed with prostate cancer (PCa) who presented with lower urinary tract symptoms (LUTS) and elevated Prostate Specific Antigen (PSA). He underwent Holmium Laser Enucleation of the Prostate (HoLEP) for his severe LUTS with concurrent placement of SpaceOAR gel and gold fiducials in preparation for radiation therapy (RT). After a successful operation, the patient underwent same-day discharge and catheter removal. He regained continence at 2 weeks and started RT at 9 weeks post-HoLEP. We present that concurrent placement of fiducials and SpaceOAR during HoLEP appears to be feasible, well tolerated and effective for PCa patients who elect RT.

Ambulatory Percutaneous Nephrolithotomy May Be Cost-Effective Compared to Standard Percutaneous Nephrolithotomy.

Background: Coronavirus disease 2019 (COVID-19) changed the practice of medicine in America. During the March 2020 lockdown, elective cases were canceled to conserve hospital beds/resources resulting in financial losses for health systems and delayed surgical care. Ambulatory percutaneous nephrolithotomy (aPCNL) has been shown to be safe and could be a strategy to ensure patients receive care that has been delayed, conserve hospital resources, and maximize cost-effectiveness. We aimed to compare the safety and cost-effectiveness of patients undergoing aPCNL against standard PCNL (sPCNL). Materials and Methods: Ninty-eight patients underwent PCNL at Indiana University Methodist Hospital, a tertiary referral center, by three expert surgeons from January 2020 to September 2020. The primary outcome of the study was to compare the 30-day rates of emergency department (ED) visits, readmissions, and complications between sPCNL and aPCNL. Secondary outcomes included cost analysis and stone-free rates (SFRs). Propensity score matching was performed to ensure the groups were balanced. Statistical analyses were performed using SAS 9.4 using independent t-tests for continuous variables and chi-square analyses for categorical variables. Results: Ninety-eight patients underwent PCNL during the study period (sPCNL = 75 and aPCNL = 23). After propensity score matching, 42 patients were available for comparison (sPCNL = 19 and aPCNL = 23). We found no difference in 30-day ED visits, readmissions, or complications between the two groups. aPCNL resulted in cost savings of $5327 ± 442 per case. SFRs were higher for aPCNL compared with sPCNL. Conclusions: aPCNL appears safe to perform and does not have a higher rate of ED visits or readmissions compared with sPCNL. aPCNL may also be cost-effective compared with sPCNL.

Developing a Diagnostic Multivariable Prediction Model for Urinary Tract Cancer in Patients Referred with Haematuria: Results from the IDENTIFY Collaborative Study.

BACKGROUND: Patient factors associated with urinary tract cancer can be used to risk stratify patients referred with haematuria, prioritising those with a higher risk of cancer for prompt investigation. OBJECTIVE: To develop a prediction model for urinary tract cancer in patients referred with haematuria. DESIGN, SETTING, AND PARTICIPANTS: A prospective observational study was conducted in 10 282 patients from 110 hospitals across 26 countries, aged ≥16 yr and referred to secondary care with haematuria. Patients with a known or previous urological malignancy were excluded. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcomes were the presence or absence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC], and renal cancer). Mixed-effect multivariable logistic regression was performed with site and country as random effects and clinically important patient-level candidate predictors, chosen a priori, as fixed effects. Predictors were selected primarily using clinical reasoning, in addition to backward stepwise selection. Calibration and discrimination were calculated, and bootstrap validation was performed to calculate optimism. RESULTS AND LIMITATIONS: The unadjusted prevalence was 17.2% (n = 1763) for bladder cancer, 1.20% (n = 123) for UTUC, and 1.00% (n = 103) for renal cancer. The final model included predictors of increased risk (visible haematuria, age, smoking history, male sex, and family history) and reduced risk (previous haematuria investigations, urinary tract infection, dysuria/suprapubic pain, anticoagulation, catheter use, and previous pelvic radiotherapy). The area under the receiver operating characteristic curve of the final model was 0.86 (95% confidence interval 0.85-0.87). The model is limited to patients without previous urological malignancy. CONCLUSIONS: This cancer prediction model is the first to consider established and novel urinary tract cancer diagnostic markers. It can be used in secondary care for risk stratifying patients and aid the clinician's decision-making process in prioritising patients for investigation. PATIENT SUMMARY: We have developed a tool that uses a person's characteristics to determine the risk of cancer if that person develops blood in the urine (haematuria). This can be used to help prioritise patients for further investigation.