Objectives: Prostatic artery embolization (PAE) is a minimally invasive alternative to surgical benign prostatic obstruction (BPO) interventions, but durability is variable, and some patients ultimately require definitive surgery. Holmium laser enucleation of the prostate (HoLEP) is a size-independent, durable option with established efficacy in salvage settings. We evaluated outcomes of HoLEP in patients with prior PAE and compared them with surgery-naïve patients and those with prior transurethral BPO procedures to contextualize where PAE falls along the prior-intervention spectrum. Materials and Methods: We retrospectively reviewed a prospectively maintained HoLEP registry (July 2017 to August 2025) at a tertiary academic center. Patients undergoing HoLEP after prior PAE were compared with prostate procedures-naïve patients and those with prior transurethral BPO procedures. Outcomes and complications were compared among groups. Results: Among 856 HoLEP patients, 70 had prior PAE, 137 had prior transurethral BPO procedures, and 649 were surgery naïve. Baseline characteristics were largely comparable, although the prior transurethral cohort was older and had worse flow. All cohorts demonstrated marked postoperative improvement in functional outcomes. However, patients with prior transurethral surgery exhibited significantly lower postoperative flow. On linear regression, prior PAE was not independently associated with postoperative functional outcomes. Overall complication rates were low; major complications occurred in approximately 5% to 6%, and minor complications were largely driven by transient incontinence. Prior PAE was independently associated only with higher urinary tract infection (UTI) risk on multivariable analysis. Conclusions: HoLEP after prior PAE appears safe and effective with functional improvements comparable to primary HoLEP. Prior PAE was not associated with worse functional outcomes. The increased UTI risk in the prior PAE cohort warrants optimized perioperative care and further study.
Introduction: Conventional flexible ureteroscopy (fURS) remains technically demanding, requiring substantial endourologic expertise and optimal ergonomics. We report our initial clinical experience evaluating the feasibility and safety of Zamenix P, a novel robot-assisted platform for renal calculus management. Methods: Medical records were reviewed for patients who underwent fURS with Zamenix P during June 1 to June 30, 2024. A single-use flexible ureteroscope (LithoVue) was used with a robotic platform. After docking, the procedure was conducted from a remote console with bedside assistance. Stone disintegration was performed with a Holmium:YAG laser system, as in conventional retrograde intrarenal surgery, and fragments were extracted with a robot-controlled nitinol basket. Respiratory motion compensation, automated driving assistance, and stone size estimation were used. Stone-free status (residual fragments ≤2 mm) was assessed by noncontrast computed tomography 1 month postoperatively. Results: Nine patients underwent 10 robotic fURS procedures. The median stone diameter was 18.0 mm; stones were located in the renal pelvis (40.0%), lower calyx (30.0%), upper calyx (10.0%), or multiple locations (20.0%). Median robot docking time was 4.0 (3.0–5.0) min. Median total operative time and stone removal time were 144.0 (93.0–160.0) and 90.0 (73.0–132.0) min, respectively. Ureteral balloon dilation was required in 20.0% of cases. Intraoperative ureteral injury occurred in 50.0% of patients (grade 1, 20.0%; grade 2, 20.0%; and grade 3, 10.0%). The 1-month stone-free rate was 80.0%. Median hospitalization was 3.0 (2.0–3.0) days, with one postoperative perirenal hematoma and one ipsilateral pleural effusion case. Conclusion: Robotic fURS using Zamenix P appeared technically feasible in this cohort, including patients with relatively large stone burdens. The platform’s ergonomic and assistive features appear promising for expanding fURS to larger, more complex stones. Prospective comparative trials in larger cohorts with objective ergonomic assessments are warranted to evaluate efficacy, refine surgical techniques, and define optimal patient selection criterion.
Objective: To develop and evaluate machine-learning models for predicting postoperative bleeding after mini-percutaneous nephrolithotomy (mini-PCNL) using preoperative clinical parameters only. Materials and Methods: We retrospectively analyzed 1515 patients who underwent mini-PCNL between January 2014 and January 2026. Postoperative bleeding and a postoperative day-1 hemoglobin decrease ≥2 g/dL occurred in 273 patients (18%). All intra- and postoperative variables were excluded to preserve a genuinely preoperative tool, leaving 15 preoperative predictors. Penalized logistic regression, random forest, Extreme Gradient Boosting (XGBoost), and light gradient boosting machine (LightGBM) were developed under a strictly patient-level scheme with nested cross-validation; all preprocessing and categorical-aware oversampling (SMOTENC) were fitted within training folds only. Discrimination (AUC: with 95% confidence intervals [CIs]), calibration (Brier score, calibration slope), and decision-curve analysis were assessed on an untouched hold-out set, with a sensitivity analysis excluding preoperative hematocrit (HCT). Results: In the patient-isolated hold-out set (303 patients, 52 events), random forest achieved the best discrimination (AUC: 0.856, 95% CI: 0.787–0.925), followed by XGBoost (0.838) and LightGBM (0.825); all three significantly outperformed penalized logistic regression (0.722; DeLong p ≤ 0.013). Random forest was well calibrated (slope 1.099, Brier 0.098) and showed positive net benefit across clinically relevant thresholds. Discrimination remained high after removing preoperative HCT (AUC: 0.828), indicating a multivariable signal. Preoperative HCT, caliceal access site, and stone size were the most influential predictors. Conclusion: Ensemble machine-learning models can predict postoperative bleeding after mini-PCNL with good, well-calibrated discrimination from preoperative variables alone, outperforming conventional logistic regression. External, temporal, and prospective validation are required before routine clinical use.
PURPOSE Endoureterotomy is an established surgical method for children with symptomatic or progressive primary obstructive megaureter (POM). The aim of this study is to evaluate the long-term outcomes and complications associated with endoureterotomy in children with POM. MATERIAL AND METHODS In this retrospective single-center study, pediatric patients with POM who underwent endoureterotomy were evaluated for long-term complications and outcomes, including ultrasonographic and diuretic-enhanced renal scintigraphic findings. RESULTS Among 178 megaureter cases, 41 POM patients (48 ureterovesical junction units) underwent surgery, including seven patients with bilateral involvement. The mean age of included patients was 26.67 months, with an average follow-up duration of 65.49 months. According to the predefined study endpoint, four units (8.33%) required secondary surgical intervention: two underwent re-endoureterotomy, one required ureterostomy, and one underwent pyeloplasty for persistent ureteropelvic junction obstruction. The long-term success rate after the initial endoureterotomy was 91.67%. CONCLUSION This study suggests that endoureterotomy, as a minimally invasive surgical approach, provides favorable long-term ultrasonographic and scintigraphic outcomes with a high success rate in selected children with POM.
