Although ureteral stenting is widely used in kidney transplantation (KTx) to prevent major urological complications (MUC), important uncertainties remain regarding its impact on infectious outcomes, optimal dwell time, preferred removal technique, and whether routine or selective stenting is most appropriate. This scoping review synthesizes contemporary evidence to clarify best practices and identify future directions for stent use in KTx recipients. A scoping review with systematic synthesis was conducted following PRISMA methodology. PubMed, Embase, and CENTRAL were searched for studies published between 1 January 2000 and 25 July 2025. Fifty-five eligible studies—including systematic reviews, randomized controlled trials, prospective and retrospective series—were included and organized according to key clinical questions. Evidence on whether ureteric stenting independently increases urinary tract infection (UTI) risk is inconclusive, largely due to heterogeneity in definitions, stent durations, and prophylactic approaches. However, the association between dwell time and UTI risk is clear: stent removal between 14 and 21 days consistently reduces UTI rates without increasing MUCs. Uncertainty regarding the clinical course of stent colonization and asymptomatic bacteriuria continues to challenge evidence-based management in stented KTx recipients. Emerging removal methods—such as stent-on-string techniques, single-use cystoscopy, and magnetic stents—demonstrate reduced costs and improved patient tolerability. Internal double-J (DJ) stents show superior outcomes to external stents, and although evidence remains limited, selective stenting may be appropriate for carefully selected low-risk recipients. Current evidence supports DJ stent insertion in KTx recipients, with removal at 14–21 days using minimally invasive, office-based techniques. Personalized selection of stent strategy, alongside evaluation of novel stent designs, represents an important direction for improving outcomes and patient experience.

Introduction Anatomical endoscopic enucleation of the prostate (AEEP) techniques, including bipolar enucleation (B-TUEP), holmium laser enucleation (HoLEP), thulium laser enucleation (ThuLEP), and thulium fibre laser enucleation (ThuFLEP), demonstrate comparable clinical outcomes for benign prostatic hyperplasia. As clinical equivalence is increasingly established, cost becomes a key determinant of modality selection. We performed a cost minimisation analysis comparing index procedural costs across AEEP modalities from an institutional perspective. Methods A cost minimisation model was developed from the institutional perspective, incorporating amortised capital costs, maintenance, and consumables. In addition to the base-case scenario of 180 cases per year, we modelled two additional case volume scenarios: low (50 cases/year) and high (500 cases/year) volume. Thu:YAG laser fibres were modelled on two scenarios: disposable single-use, and reusable fibres (up to 10 cases per fibre). Breakeven analysis determined the threshold volume at which each laser modality achieves cost parity with B-TUEP, and one-way sensitivity analysis was performed on key cost parameters. Analysis was limited to index procedural costs calculated in Singapore dollars. Results At the base case of 180 cases per year, B-TUEP had the lowest index procedure cost (SGD 1,018), followed by ThuFLEP (SGD 1,584), ThuLEP (1,599), and HoLEP (SGD 1,655). Breakeven analysis demonstrated that HoLEP, ThuLEP, and ThuFLEP can never achieve cost parity with B-TUEP when laser fibres are single-use, as laser modalities carry higher costs on both capital and per-case dimensions. ThuLEP with reusable fibres (10 uses per fibre) was the only modality to cross below B-TUEP, at a breakeven volume of 198 cases per year. At 500 cases per year with reusable fibres, ThuLEP achieved the lowest cost (SGD 847), representing a 15.4% saving over B-TUEP. Sensitivity analysis identified annual case volume and B-TUEP loop cost as the most influential parameters. Conclusion Index procedural costs in AEEP are strongly influenced by case volume and consumable strategy. While B-TUEP remains cost-efficient at low volume, high-volume practice combined with reusable Thu:YAG fibre technology enables cost parity and potential cost advantage for laser enucleation. These findings highlight the importance of economies of scale and device utilisation in technology adoption.

INTRODUCTION:Despite kidney transplantation being the gold-standard treatment for end-stage renal disease, organ donation rates remain low. This study examined public perceptions and barriers to kidney donation to guide future efforts in Singapore. METHODS:An online survey on kidney donation knowledge and attitudes was distributed via FormSG. Categorical data were presented as counts and percentages, and chi-square tests were used for categorical comparisons. RESULTS:Of the 633 respondents, 91% were Singaporeans, 55.8% were female, 20.7% had medical background, 81.6% had university education and 59.5% had a household income >SGD 8000. While 94.3% were familiar with the term 'kidney transplantation', only 70% knew about Human Organ Transplant Act (HOTA), with higher awareness among older adults (P < 0.01), those with a medical background (P < 0.01) and higher-income groups (P = 0.01). Only 25.1% correctly identified organs covered by HOTA and 82.8% incorrectly believed the next of kin could refuse donation after brain death. Overall, 66.7% of respondents were willing to donate, with greater willingness among postgraduates (P = 0.02) and Hindus (P < 0.01); the strongest motivator was the relationship to the recipient (80.5%), while key deterrents were health concerns (49.6%) and financial impact (25.9%). Most (75.2%) incorrectly thought donor surgery was open rather than laparoscopic. Willing donors perceived higher transplant success rates (73.2% vs. 65.7%, P < 0.01) but underestimated actual success (85%-99%, P < 0.01). CONCLUSION:Our study identified several knowledge gaps about kidney transplantation, including HOTA provisions, donor nephrectomy approach, recovery period and long-term donor health outcomes. Sociocultural and economic factors influence the willingness to donate, necessitating targeted interventions to improve awareness and address misconceptions.

Background Bladder cancer in the setting of previous a kidney transplant (KT) is challenging to manage due to complex medical and surgical considerations. Objective To provide a comprehensive evaluation of the scope of management of bladder cancer in KT patients, and describe the controversies surrounding these management options. Methods A systematic review of studies reporting management of KT patients with bladder cancer and involving ≥3 patients was performed. A narrative review was also performed for various aspects of management such as pathophysiology, surgical considerations, intravesical therapy, immunosuppression and oncological surveillance. Results Bladder cancer incidence in KT recipients is 2.8–4.1 times higher than the general population, and there is a notable association with aristolochic acid nephropathy as well as BK virus oncogenesis. Regarding surgical treatment, transurethral resection is preferred for non-muscle invasive tumors, and intravesical BCG for intermediate- and high-risk patients appears to be underutilized despite its safety and associated reduction in recurrence. Radical cystectomy with limited pelvic lymph node dissection, urinary diversion, and consideration of bilateral nephroureterectomy appears to be the safest method of oncological control in muscle-invasive tumors. A switch in immunosuppressive regimens to mTOR inhibitors may be considered in lieu of its antitumor effects. Routine surveillance in KT patients with risk factors for bladder cancer is challenging and may be warranted especially in the Asian population which has a higher rate of urothelial malignancy. Conclusions This review provides a thorough summary of management strategies for bladder cancer in the setting of previous KT.

Background: This study aimed to evaluate the impact of preoperative prostate artery embolization (PAE) on intraoperative blood loss during transurethral resection of the prostate (TURP) in glands larger than 80 cc. Material and methods: A prospective, surgeon-blinded randomized controlled clinical trial was conducted at a single tertiary center. Patients with a prostate volume of more than 80 cc with indications for TURP were randomized (1:1) to the following groups: preoperative prostatic artery embolization followed by TURP (Group Adintervention arm) and TURP alone (Group Bdcontrol arm). The primary outcome studied was blood loss measured as the drop in hemoglobin level postoperatively, and the secondary outcome measured was resection efficiency (resected weight per min) and postoperative complication rate. Results: Our study included 10 patients each in group, A and B. The median prostate volume was 119 mL and 140 mL and the median preoperative hemoglobin was 13.3 g/dL (interquartile range: 12.5 e 14.3 g/ dL) and 14.4 g/dL (interquartile range: 10.1e15.2 g/dL) in groups A and B, respectively. Change in postoperative hemoglobin was significantly greater in Group B than in Group A (-1.4 g/dL versus +0.5 g/dL, P = 0.015). There were no significant differences in the weight of resected prostate chips (52 g versus 73 g, P = 0.089) and resection efficiency (0.7 g/min versus 0.6 g/min, P = 0.853) between groups A and B. Two patients in Group B received one unit of red blood cell transfusion compared to only 1 patient in Group A (P = 1.000). One patient from each group had to be brought back to the operation room for hemostasis. Conclusion: Our study demonstrated that preoperative prostate artery embolization reduces intraoperative blood loss in men with large prostates undergoing TURP but did not impact resection efficiency or complication rate. (c) 2025 The Asian Pacific Prostate Society. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction:Anatomical endoscopic enucleation of the prostate (AEEP) is a guideline-recommended treatment for benign prostatic hyperplasia (BPH). We aimed to analyze postoperative complications and outcomes within a large real-world database. Material and methods:The Refinement in Endoscopic Anatomical enucleation of Prostate (REAP) registry includes patients who received AEEP for BPH in 8 centers worldwide from January 2020 to January 2022. Exclusion criteria included previous prostate/urethral surgery, prostate cancer, pelvic radiotherapy, and concomitant lower urinary tract surgery (internal urethrotomy, cystolithotripsy, or transurethral resection of bladder tumor). The primary outcome was postoperative incontinence; secondary outcomes included early complications (<30 days) and late complications (>30 days). Results:We analyzed 6,193 patients; the mean age was 68 years. Thulium laser was used in 37% and high-power holmium laser in 32%. Median operation time was 67 min [IQR 50-95 min]. The 2-lobe enucleation technique was utilized in 49%, and en-bloc resection was utilized in 39%. Early postoperative complications included urinary tract infection (4.7%), acute urinary retention (4.1%), post-operative bleeding requiring additional intervention (0.9%), and sepsis requiring intensive care admission (0.1%). The incidence of postoperative incontinence was 14.8%, of which 54% were stress incontinence; 84% cases resolved by 3 months. On univariate and multivariate analysis, prostate volume >100 ml was a significant predictor of postoperative incontinence. Late complications such as bulbar urethral stricture, bladder neck sclerosis, and need for redo BPH surgery each occurred in <1% of patients. Conclusions:Analysis of the real-world REAP database shows favorable safety outcomes for AEEP, with a low incidence of serious complications and postoperative incontinence beyond 3 months.

BACKGROUND:Machine learning (ML) and artificial intelligence (AI) have demonstrated powerful functionality in the healthcare setting thus far. We aimed to construct an AI model to predict postoperative incontinence after enucleation surgery for benign prostatic hyperplasia (BPH). METHODS:Data were taken from two BPH registries and split into training and validation datasets. The following characteristics were used as predictors of incontinence: age, prostate volume, preoperative IPSS, QoL score, Qmax and post-void residual; presence of preoperative indwelling catheter, early apical release (EAR), enucleation type (2-lobe, 3-lobe, or en-bloc), and laser energy type. Six types of ML models were constructed using the training dataset and applied to the validation dataset to assess their accuracy. RESULTS:3828 patients from both databases were analyzed. Median age was 68, median prostate volume was 85.5 cc. 5.4% had a preoperative indwelling catheter. The commonest enucleation type was 2-lobe, the commonest energy type was Thulium fiber laser, and EAR was performed in 34.0%. Of the six ML models tested, extreme gradient boosting with manual fine tuning was the best-performing with an accuracy of 86.2%, sensitivity of 96.8%, specificity of 23.7%, PPV of 88.2%, and NPV of 55.9%. CONCLUSIONS:We hereby present an ML model for incontinence prediction post-surgery for BPH. Its main strengths are high sensitivity and PPV, meaning that if a patient is predicted to be incontinent using this model, this is likely to reflect the eventual outcome. This allows clinicians to pay closer attention on follow-up to detect and manage postoperative incontinence expediently.

BACKGROUND AND OBJECTIVE:Natural language processing (NLP) is a subfield of artificial intelligence that enables computers to process human language. As most human interactions today involve the internet and electronic devices, NLP tools quickly become indispensable to modern life. The use of NLP tools in medical practice and research is growing fast. This scoping review evaluates the current and potential future applications of NLP in kidney transplantation medicine. DESIGN:We conducted an electronic literature search on NLP in the setting of kidney transplantation on PubMed, EMBASE, and Scopus from inception to August 26, 2024. Two independent investigators conducted the search strategy and reviewed abstracts and full texts; conflicts were resolved after discussion with a third and fourth author. A total of ten studies were included in the study. RESULTS:The most commonly studied clinical applications of NLP in kidney transplantation are its use as an adjunct tool to facilitate early diagnosis of renal disease and as an effective predictor of graft loss and complications among kidney transplant recipients. Some researchers were able to predict organs at risk of delayed implant or discard by analyzing donors' EHR; this has the potential to improve organ utilization significantly. In clinical research, NLP tools can be tailored to perform specific tasks of interest on unstructured text. By studying n comments from social media and news websites, 1 group was able to gauge public perception of transplant policies and identify potential actions to improve access to transplant care. CONCLUSIONS:NLP tools have only recently been introduced into medical research, but they are already significantly impacting kidney transplantation medicine. The literature demonstrates the potential to improve early diagnosis of renal failure, predict renal transplantation outcomes, improve organ utilization, and support advocacy and policymaking. With more widespread use of EHR globally and the continued development of NLP technology, these tools are poised to revolutionize the practice of renal transplantation.

Background:Reduction of immunosuppression (ROI) remains the mainstay of treatment for BK virus infection (BKVI) in kidney transplantation (KT). This review explored the role of intravenous immunoglobulin (IVIG) and mammalian target of rapamycin inhibitor (mTORi) regimens as alternative therapies for KT recipients with BKVI, focusing on viral clearance and graft-related outcomes. Methods:An electronic search was conducted for articles examining IVIG or mTORi use in treating BKVI among adult and/or pediatric KT recipients. Meta-analyses of proportions were performed for relevant outcomes. Results:Twenty-seven studies (13 evaluating IVIG and 14 evaluating mTORi) were included; all but three enrolled only adult participants. In IVIG studies, the pooled viral clearance rate was 76.4% (95% confidence interval [CI], 64.2%-85.5%), with numerically higher clearance for IVIG after ROI compared to IVIG with ROI (87.0% vs. 66.1%). Overall graft survival was 84.7% (95% CI, 70.7%-92.7%), with numerically higher survival in IVIG after ROI than in IVIG with ROI (93.6% vs. 78.4%). Pooled histological clearance and graft rejection rates were 82.8% and 14.5%, respectively. In mTORi studies, the pooled viral clearance rate was 68.0% (95% CI, 58.0%-76.7%) and overall graft survival was 89.1% (95% CI, 82.7%-93.4%), with no significant difference between patients with and without prior ROI. Histological clearance and graft rejection rates were 59.8% and 8.6%, respectively. Conclusions:IVIG and mTORi regimens appear to be feasible alternatives to ROI in KT recipients with BKVI, achieving viral clearance while maintaining graft survival. Future randomized controlled trials are needed to further define their role and strengthen current evidence with higher-quality data.

Background:Renal allograft lithiasis (RAL) is a rare but potentially serious complication following kidney transplantation. Traditionally, ureteroscopy (URS) has been considered a second-line treatment for stones <15 mm, typically after failed extracorporeal shock wave lithotripsy (ESWL), due to concerns over challenging ureteral access. This study reviews Singapore General Hospital (SGH)'s experience and compares outcomes with published literature to evaluate efficacy and safety. Methods:Retrospective review was conducted on RAL cases treated with URS at SGH from January 2015 to December 2023. Data collected included demographics, end-stage renal failure etiology, preoperative biochemistry, stone characteristics, and surgical details. Stone-free status and complications were assessed. Additionally, a systematic literature review was performed using five databases (PubMed, Embase, Web of Science, SCOPUS, Cochrane Library) from inception up to August 13, 2023. We included all primary studies with no restriction on study design, published in English, including conference abstracts and excluded articles on ex-vivo or pre-transplant URS. Risk of bias assessment was performed using Joanna Briggs Institute Critical Appraisal Tools. Results:Five URS procedures were performed at SGH for RAL during the study period, yielding a stone-free rate (SFR) of 71.4%. One case involved an encrusted double-J (DJ) stent. The systematic review included 30 studies (10 case reports, 20 case series) totaling 145 URS procedures. The overall SFR was 82.3%. Thirteen complications (9.0%) were reported, including ureteral perforation (n=3), urinary tract infections (n=3), and nephrocutaneous fistula (n=2). No graft loss was reported. These rates are comparable to those seen in non-transplant URS. Conclusions:URS appears to be a safe and effective treatment for RAL, with outcomes comparable to non-transplant populations. Increasing evidence supports URS as a first-line option in select transplant patients. The current evidence is limited by small case numbers, retrospective study designs, and lack of standardisation in defining and assessing stone-free outcomes.

BackgroundAs the incidence of urological malignancies after renal transplantation (RT) is observed to be greater than in the general population, a better understanding of them is important. We present our experience with urological tumors in RT recipients at our transplant center, and analyze their incidence, management and outcomes.Materials and MethodsA retrospective analysis of 2177 RT recipients on follow-up at our center between 1990 and 2022 was conducted for de novo genitourinary malignancy. Patients diagnosed with malignancy before transplantation were excluded. Clinicopathological data at diagnosis and follow-up were collected and analyzed. Kaplan-Meier estimates were used to evaluate overall survival (OS) and cancer-specific survival (CSS). Statistical analysis was performed using IBM SPSS v.24 (IBM Corp., Armonk, NY, USA).ResultsThe overall incidence of Urological malignancies was 3.9%, with 89 cancers diagnosed in 85 patients. Renal cell carcinoma was most common (n = 61, 68.5%), followed by prostate cancer (n = 10, 11.2%), urothelial carcinoma (n = 10, 11.2%), squamous cell carcinoma of the penis/scrotum (n = 7, 7.9%), and testicular cancer (n = 1, 1.1%). Mean duration between transplantation and diagnosis of malignancy was 9.9 (0.4-20.7) years. At a median follow-up of 4.6 (018.2) years, 27 deaths were seen; 7(25.9%) were due to urological malignancy. CSS rates were 86% and 78% at five and ten years, respectively, after diagnosis.ConclusionWe present one of the largest series of de novo urological malignancies observed over an extended 30-year follow-up of RT recipients, demonstrating an elevated risk in line with other studies. Regular surveillance for malignancies is advised, in order to ensure early diagnosis and management.

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology III (MP46)1 May 2024MP46-05 HOW DOES REZUM WATER VAPOR THERMAL THERAPY COMPARE WITH THE GOLD STANDARD TRANSURETHRAL RESECTION OF PROSTATE FOR TREATMENT OF BENIGN PROSTATIC HYPERPLASIA?–AN ANALYSIS OF PERIOPERATIVE OUTCOMES Yi Ling Chua, Ee Jean Lim, Mark Chan, Jin Yong, Tze Kiat Ng, and Edwin Jonathan Aslim Yi Ling ChuaYi Ling Chua , Ee Jean LimEe Jean Lim , Mark ChanMark Chan , Jin YongJin Yong , Tze Kiat NgTze Kiat Ng , and Edwin Jonathan AslimEdwin Jonathan Aslim View All Author Informationhttps://doi.org/10.1097/01.JU.0001008668.53858.38.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Rezum water vapor thermal therapy (WVTT) for benign prostatic hyperplasia (BPH) utilises targeted thermal energy delivered in the form of water vapor to ablate excess prostate tissue, thereby debulking the prostate and alleviating obstructive urinary symptoms. No study has directly compared the outcomes of Rezum WVTT and transurethral resection of prostate (TURP), the gold standard surgical treatment for BPH. The aim of our study was to analyze the perioperative outcomes of Rezum WVTT versus TURP in patients with BPH. METHODS: Patients who underwent Rezum WVTT and TURP at our institution from January 2022 to June 2023 were identified using standardised surgical codes. Baseline BPH history, operative time and duration of hospital stay were extracted. Those with prostate volume more than 80 milliliters were excluded. A prospective registry was established with preoperative and follow-up uroflowmetry outcomes (maximum urinary flow rate, Qmax and post-void residual volume, PVR), as well as duration to successful voiding trial. Change in Qmax and PVR from baseline was calculated for each patient and compared between the groups. RESULTS: 260 patients who underwent Rezum WVTT (n=69) and TURP (n=191) for BPH were included. Average follow-up was 7.2 months (range, 6-81 weeks) for Rezum and 6.5 months (range, 6-84 weeks) for TURP group (p=0.352). Results are summarised in Table 1. Patients who underwent Rezum WVTT were discharged 46.1±5.3 hours earlier (95% CI: 35.8 to 56.5) and had urinary catheters for 6.6±1.0 days longer (95% CI: 4.6 to 8.6) prior to successful voiding trial than those who had TURP. Both groups showed significant improvements in Qmax at 6 months compared to preoperative (Rezum: 9.9 to 13.0 mL/s, p=0.002; TURP 7.9 to 15.8 mL/s, p<0.0001). Patients who underwent Rezum WVTT had less improvement in Qmax from baseline compared to TURP cohort (mean difference -4.8 mL/s, 95% CI: -6.8 to -2.8). PVR reduced significantly in both cohorts at 6 months compared to baseline (Rezum: 50.2 to 10.4 mL, p=0.0007; TURP 102.1 to 21.1 mL, p<0.0001). TURP cohort had greater reduction in PVR from preoperative than Rezum group (mean difference 36.0 mL, 95% CI: 6.3 to 65.7). CONCLUSIONS: Compared to TURP, Rezum WVTT is a shorter procedure with reduced hospital stay, longer time to successful voiding trial and smaller improvements in Qmax and PVR achieved at 6 months follow-up. Source of Funding: Not applicable © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e754 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Yi Ling Chua More articles by this author Ee Jean Lim More articles by this author Mark Chan More articles by this author Jin Yong More articles by this author Tze Kiat Ng More articles by this author Edwin Jonathan Aslim More articles by this author Expand All Advertisement PDF downloadLoading ...

Radiomics is increasingly applied to the diagnosis, management, and outcome prediction of various urological conditions. The purpose of this scoping review is to evaluate the current evidence of the application of radiomics in kidney transplantation, especially its utility in diagnostics and therapeutics. An electronic literature search on radiomics in the setting of transplantation was conducted on PubMed, EMBASE, and Scopus from inception to September 23, 2022. A total of 16 studies were included. The most widely studied clinical utility of radiomics in kidney transplantation is its use as an adjunct to diagnose rejection, potentially reducing the need for unnecessary biopsies or guiding decisions for earlier biopsies to optimize graft survival. Technology such as optical coherence tomography is a noninvasive procedure to build high-resolution optical cross-section images of the kidney cortex in situ and in real time, which can provide histopathological information of donor kidney candidates for transplantation, and to predict posttransplant function. This review shows that, although radiomics in kidney transplants is still in its infancy, it has the potential for large-scale implementation. Its greatest potential lies in the correlation with conventional established diagnostic evaluation for living donors and potential in predicting and detecting rejection postoperatively.

Abstract Background Minimally invasive surgical therapies, such as water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL), are typically second-line options for patients in whom medical management (MM) failed but who are unwilling or unsuitable to undergo invasive transurethral resection of the prostate (TURP). However, the incremental cost-effectiveness of WVTT or PUL as first- or second-line therapy is unknown. We evaluated the incremental cost-effectiveness of alternative first- and second-line treatments for patients with moderate-to-severe benign prostatic hyperplasia (BPH) in Singapore to help policymakers make subsidy decisions based on value for money. Methods We considered six stepped-up treatment strategies, beginning with MM, WVTT, PUL or TURP. In each strategy, patients requiring retreatment advance to a more invasive treatment until TURP, which may be undergone twice. A Markov cohort model was used to simulate transitions between BPH severity states and retreatment, accruing costs and quality-adjusted life-years (QALYs) over a lifetime horizon. Results In moderate patients, strategies beginning with MM had similar cost and effectiveness, and first-line WVTT was incrementally cost-effective to first-line MM (33,307 SGD/QALY). First-line TURP was not incrementally cost-effective to first-line WVTT (159,361 SGD/QALY). For severe patients, WVTT was incrementally cost-effective to MM as a first-line treatment (30,133 SGD/QALY) and to TURP as a second-line treatment following MM (6877 SGD/QALY). TURP was incrementally cost-effective to WVTT as a first-line treatment (48,209 SGD/QALY) in severe patients only. All pathways involving PUL were dominated (higher costs and lower QALYs). Conclusion Based on the common willingness-to-pay threshold of SGD 50,000/QALY, this study demonstrates the cost-effectiveness of WVTT over MM as first-line treatment for patients with moderate or severe BPH, suggesting it represents good value for money and should be considered for subsidy. PUL is not cost-effective as a first- nor second-line treatment. For patients with severe BPH, TURP as first-line is also cost-effective. PLAIN LANGUAGE SUMMARY Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate, common among older men. Its symptoms include difficulties with starting and completing urination, incontinence, frequent and urgent need to urinate. Minimally invasive procedures, such as water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL), are typically offered as second-line options to patients for whom medication has failed but who are unwilling or unsuitable to undergo invasive surgery (transurethral resection of the prostate, TURP). However, whether offering these procedures as first-line options represents good value for money (i.e. cost-effectiveness) is an open question. To address this question and inform subsidy decisions in Singapore, we investigated six stepped-up treatment strategies which differ in first- and second-line treatments. For each strategy, we simulated healthcare costs and quality of life for a cohort of moderate and severe BPH patients over their lifetime, considering the possibility of treatment-related adverse effects and multiple rounds of retreatment. The incremental cost of a unit improvement in quality of life for a strategy relative to the next most expensive one was compared against a willingness-to-pay threshold to determine cost-effectiveness. We found that WVTT was cost-effective relative to medication as a first-line treatment for patients with moderate or severe BPH, suggesting it represents good value for money and should be considered for subsidy. PUL was not cost-effective as first- nor second-line treatment. TURP is cost-effective as first-line for severe BPH patients only.

ABSTRACT Aim The objective of this study was to evaluate the cost-effectiveness of an upfront minimally invasive surgical procedure, the prostatic urethral lift (PUL), as an initial treatment for patients with moderate benign prostatic hyperplasia (BPH), against current first-line pharmacotherapy with combination medical therapy. Method A micro-simulation model was developed using TreeAge Pro to compare two treatment strategies – initial treatment with combination medical therapy (alpha-blocker + 5-ARI) versus an upfront prostatic urethral lift procedure. The impact on disease progression, costs, and quality-adjusted life-years (QALYs) was analyzed. A Markov model and probabilistic sensitivity analysis were used to estimate the costs and effects of the different strategies. The cost-effectiveness of the strategies at different willingness-to-pay (WTP) thresholds was then examined. Results Incremental costs (versus no prostatic urethral lift) were S$13,600 (1 year) and S$8,700 (5 years). Incremental QALYs were 0.07 (1 year) and 0.22 (5 years). An upfront PUL procedure was more expensive but also more effective than pharmacotherapy, with an incremental cost per QALY gain of approximately S$39,400. It is a cost-effective treatment option at the willingness-to-pay threshold of S$50,000. Conclusion Prostatic urethral lift is a cost-effective initial treatment option for men with moderate symptoms of benign prostatic hyperplasia.

Objective To compare intra‐ and postoperative outcomes between off‐clamp and on‐clamp robot‐assisted partial nephrectomy (RAPN), using data from randomised controlled trials (RCTs) or covariate‐matched studies (propensity score‐matched or matched‐pair analysis). Methods A Preferred Reporting Items for Systematic Reviews and Meta‐Analyses‐compliant literature review was conducted on PubMed, EMBASE, Scopus and CENTRAL for relevant studies comparing off‐clamp to on‐clamp RAPN. Primary outcomes were estimated blood loss, postoperative percentage decrease in estimated glomerular filtration rate (eGFR), and margin positive rate. Secondary outcomes were operative time, postoperative eGFR, length of stay, all postoperative complications, major complications, and need for transfusion. Random‐effects meta‐analyses were performed to generate mean differences (MDs) or odds ratios (ORs). Results A total of 10 studies (2307 patients) were shortlisted for analysis. There was no significant difference in estimated operative blood loss between off‐clamp and on‐clamp RAPN (MD 21.9 mL, 95% confidence interval [CI] −0.9 to 44.7 mL; P = 0.06, I 2 = 58%). Off‐clamp RAPN yielded a smaller postoperative eGFR deterioration (MD 3.10%, 95% CI 1.05–5.16%; P = 0.008, I 2 = 13%) and lower odds of margin positivity (OR 0.62, 95% CI 0.40–0.94; P = 0.03, I 2 = 0%). No significant differences were found for all secondary outcomes. Conclusions Off‐clamp and on‐clamp RAPN are similarly effective approaches for selected renal masses. Within the classic trifecta of PN outcomes, off‐clamp RAPN yields similar rates of perioperative complications and may possibly offer better preservation of renal function and reduced margin‐positive rates.

BACKGROUND:Various incisions are employed for graft extraction during minimally invasive donor nephrectomy, but an overarching synthesis of associated short-term donor outcomes is lacking. METHODS:An electronic literature search was conducted on PubMed, EMBASE and Scopus for studies comparing ≥2 graft extraction incisions in laparoscopic or robotic donor nephrectomy with ≥10 patients per arm. Eligible study designs included randomized trials, case-control, and cohort studies. Primary outcomes were donor length of stay (LOS); in-hospital analgesic requirement; and postoperative complications. Secondary outcomes were warm ischemia time (WIT), total operation time (TOT), and estimated blood loss (EBL). Random-effects Frequentist network meta-analyses were conducted for all outcomes. RESULTS:Twenty-nine studies (4702 patients) were shortlisted. Six incisions were analyzed: iliac, Pfannenstiel, midline hand-assisted laparoscopic (HAL), midline umbilical, flank and transvaginal natural orifice transluminal endoscopic surgery (NOTES). The flank incision had significantly longer LOS than all other incisions. LOS was significantly longer in Pfannenstiel than iliac incision (mean difference [MD] = 0.29, 95%CI = 0.002-0.58 days). Midline HAL had significantly shorter TOT than most other incisions. Midline umbilical incisions had significantly higher WIT than midline HAL and Pfannenstiel incisions. Midline HAL had shorter WIT than transvaginal NOTES (MD = 0.80, 95%CI = 0.05-1.56 min). No major differences were seen in analgesia requirement, postoperative complications and EBL. CONCLUSION:Six different incisions for graft retrieval are broadly comparable across most short-term outcomes although long-term outcomes remain to be elucidated. Iliac and Pfannenstiel incisions yielded similar outcomes besides marginally lower LOS for the former. Midline incision for HAL may be associated with shorter TOT, and transvaginal NOTES is an effective technique for selected female donors. TRIAL REGISTRATION:PROSPERO CRD42023445407.