BACKGROUND:This study evaluated the feasibility and success of advancing a guidewire alongside the nephrostomy tube instead of through it in patients undergoing endourological procedures who had nephrostomy tubes. METHODS:33 patients with nephrostomy tubes in place underwent endourological procedures over a 2-year period (2023-2025). Under fluoroscopic guidance, a guidewire was advanced alongside the nephrostomy tube, and success was defined by the wire reaching the renal pelvis or ureter. Outcomes were compared to the conventional technique of inserting the guidewire through the nephrostomy tube, and the influence of time since nephrostomy placement on success was assessed. RESULTS:Guidewire passage alongside the nephrostomy tube succeeded in 27 of 33 cases (81.8%). Failures occurred in 6 cases (18.2%), mainly because of tortuous or calcified tracts requiring new access. The conventional through-tube approach succeeded in 32 of 33 cases (97%), but this difference was not statistically significant (p = 0.10). Notably, the alongside approach achieved ureteral/bladder access in a higher proportion of cases than the through-tube method (48.4% vs 12.1%, p = 0.003). Longer time intervals between nephrostomy placement and the procedure were associated with increased success (p = 0.002), with an optimal cutoff of ∼1.3 months identified. CONCLUSIONS:Guidewire passage alongside an existing nephrostomy tube proved to be a safe, effective, and feasible technique for establishing antegrade access. Performing the procedure more than ∼1.3 months after nephrostomy placement was associated with higher success, suggesting that a well-matured tract improves outcomes.

INTRODUCTION:The necessity of routinely combining bladder stone removal with surgical treatment for BPH remains debated. We compared the efficacy and safety of bladder stone removal with and without concomitant outlet surgery in patients with BPH. METHODS:We conducted a multicenter ambispective cohort study comparing bladder stone removal alone vs. removal with concomitant holmium laser enucleation of the prostate (HoLEP). BPH patients with bladder stones > 1 cm were included. Exclusion criteria ruled out alternative causes of bladder stones. The "stone removal-only" group (n = 63) underwent endoscopic removal at Mount Sinai, while the "HoLEP" group (n = 42) underwent a combined procedure at Sourasky Medical Center. Outcomes included 90-day complications, stone recurrence, IPSS scores, and decisional regret. RESULTS:At baseline, HoLEP patients had higher PVR, greater use of 5-ARI, and more frequent preoperative catheterization, while the stone removal-only group had greater stone burden. Compared to HoLEP, stone removal alone was associated with higher bladder stone recurrence (14% vs. 0%) and a slightly higher symptom burden (median IPSS: 8 vs. 4), but lower overall (13% vs. 31%) and major complication rates (0% vs. 5%). Despite these differences, 77% of patients managed by stone removal alone remained free of BPH surgery at 3 years and reported higher long-term satisfaction. Based on the results, we developed a shared decision-making tool and user-friendly app for clinical use (PreOp Decision). CONCLUSION:Bladder stone removal alone is a viable option for selected patients, and BPH surgery should be guided by obstruction severity, not stone presence. Shared decision-making is essential, and our proposed questionnaire may help guide treatment selection pending future validation.

Measurements of prostate volume and weight are essential for surgical planning, outcome assessment, clinical practice, research, and guideline development in holmium laser enucleation of prostate. Yet, the reporting of both features is not standardized. Our objective was to illustrate these inconsistencies by comparing the weight of the resected prostate tissue measured in the operating room with the weight reported by pathology. We conducted a prospective multicenter study of 409 holmium laser enucleation of prostate procedures performed across 4 medical centers. For each case, the two weight measurements were compared while the pathologists were blinded to the study, and the scales were well-calibrated. Statistical analyses were performed. The median operating room weight was 58 g (IQR 40–83), significantly lower than the median pathology weight of 71 g (IQR 50–100; p < 0.001). Pathology weight exceeded operating room measurements in 90

OBJECTIVE:PI-RADS 3 lesions on prostate multiparametric MRI (mpMRI) are indeterminate findings with debated management. We evaluated their radiologic evolution on follow-up mpMRI and correlated imaging changes with biopsy outcomes. METHODS:We retrospectively identified 166 men with at least one PI-RADS 3 lesion on initial mpMRI and at least one follow-up mpMRI without intervening treatment. Lesions were classified at follow-up as regressed (downgraded to PI-RADS ≤ 2), stable (remained PI-RADS 3), or progressed (upgraded to PI-RADS 4-5). Lesions were stratified by zonal location. MRI-targeted biopsy results were reviewed when available (n = 64). RESULTS:On follow-up, 52% of lesions regressed, 29% remained stable, and 19% progressed. Progression was significantly more common for peripheral-zone lesions (25%) than transition-zone lesions (6%); no central-zone lesions progressed. Of the biopsied lesions, most yielded benign or low-grade pathology: 44% were benign, 47% were ISUP 1, 6% had high-grade PIN or ASAP, and only 3% harbored clinically significant prostate cancer (csPCa; ISUP ≥ 2). Both csPCa cases occurred in lesions that had progressed radiologically. Lesions with imaging progression were significantly more likely to yield cancer on initial or follow-up biopsy than stable/regressed lesions (83% vs 40%; p = 0.037). CONCLUSIONS:In this real-world cohort, most PI-RADS 3 lesions remained indolent: over half regressed, and 19% progressed. Biopsied lesions had a very low rate of csPCa (3%). These results suggest that surveillance with interval MRI rather than immediate biopsy may be a safe strategy for selected men with PI-RADS 3 lesions.

Introduction:Data on holmium laser enucleation of the prostate (HoLEP) in men ≤60 are limited. This study aimed to characterize the clinical presentation and outcomes of this population. Material and methods:This retrospective study comprised 750 consecutive HoLEPs between 1/2020 and 11/2024. Patients were categorized by age: ≤60, 61-70, 71-80, and >80 years. The data retrieved from the medical records included age, International Prostate Symptom Scores (IPSS), uroflowmetry, preoperative prostate volume (via abdominal ultrasound), comorbidities, previous prostate surgery, presence of a preoperative indwelling urinary catheter or chronic retention, bladder stones, operative time, complications, hospital stay, and outcome. Results:Presentation with absolute indication (indwelling catheter and/or chronic retention) was more prevalent in the ≤60 and >80 age groups (p <0.001). The youngest group had smaller prostate volume (78 vs 90 ml, p = 0.004), fewer comorbidities, shorter surgery (70 vs 90 minutes, p <0.001), lower "beach balls" rate (2% vs 15%, p = 0.008), and shorter hospitalization (1 vs 1.5 days, p <0.001). Younger patients had lower postoperative IPSS (4 vs 7 points, p = 0.036), while the quality of life scores were similar. The overall rate of incidental prostate cancer increased with age, but not significantly. The youngest group presented with only International Society of Urological Pathology (ISUP) 1, while older groups had a higher rate of ISUP grade ≥2 (0 vs 18-25%, p <0.05). Complications were similar across age groups. Conclusions:HoLEP is an effective treatment for men of all ages. Men under 60 or over 80 were more frequently treated for absolute indications, while those aged 61-80 were more often treated for relative indications.

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.

Transient stress urinary incontinence (SUI) after holmium laser enucleation of prostate (HoLEP) is commonly linked to intraoperative injury of the external urethral sphincter (EUS). We assessed the reliability of the post-HoLEP endoscopic appearance of the membranous urethra mucosa (MUM) in predicting post-HoLEP continence. Forty HoLEPs were prospectively recorded by an artificial intelligence video platform capable of segmenting clips by surgical steps. The final clip was assessed for postoperative MUM integrity by 2 experts in HoLEP and 2 residents, all blinded to the clinical outcome. Their findings were scored as no injury, anterior injury, and lateral injury, and the results underwent statistical analyses. The referent rating was 72

The past three decades have witnessed continuing evolution and diversification of laser technologies used for the surgical treatment of benign prostatic obstruction (BPO). These advances resulted from a better understanding of laser-tissue interactions, technical refinements, and increasing clinical experience. To date, holmium and thulium lasers are most commonly used in BPO surgery owing to their intrinsic characteristics, such as strong absorption in water and minimal tissue penetration. These laser types have also been widely assessed in clinical studies that provided strong evidence for their efficiency. This mini review describes current trends for laser applications in the treatment of BPO. PATIENT SUMMARY: Our mini review describes the different types of lasers used to remove prostate tissue in patients with a benign enlarged prostate gland that is obstructing urine flow. We highlight the advantages and disadvantages of the different techniques.

Surgical masks have long been standard in operating rooms to reduce infection risks, though their effectiveness, especially in minimally invasive procedures, has been increasingly questioned. Endourological surgeries present a unique setting where contamination is more likely linked to instrumentation than airborne pathogens. To evaluate whether the routine use of surgical masks by scrubbed personnel reduces postoperative urinary tract infections (UTIs) in endourological procedures. A retrospective cohort study was conducted at a single institution, comparing patient outcomes during two periods: a non-COVID-19 era (no mask use) and a COVID-19 era (universal mask use). A total of 4442 patients who underwent endourological surgery between 2017 and 2024 were included. Data on demographics, perioperative factors, and infection outcomes were analyzed. The overall rate of postoperative UTIs was 2.3

To provide the outcomes from a multicentric series of men aged 80 years and above, understand the feasibility of endoscopic enucleation of the prostate (EEP), and compare different energy sources and techniques. We extracted data on patients who underwent EEP in 15 Centers (January 2019-January 2023). Continuous variables are expressed as medians and interquartile ranges while categorical variables as absolute numbers and percentages. A multivariable logistic regression analysis was performed to identify predictors of overall postoperative incontinence and reported as odds ratio (OR) and 95

Stress urinary incontinence (SUI) after holmium laser enucleation of the prostate (HoLEP) is traditionally explained by longitudinal overstretching of the external urethral sphincter (EUS) during enucleation. We propose extreme radial forces exerted on the EUS as a novel mechanism for post-HoLEP SUI. We assessed the resectoscope angles during enucleation as seen on external intraoperative pictures followed by fluoroscopically calibrated measurements and trigonometric calculations of EUS dilation as a function of the resectoscope angle and diameter and the membranous urethra length and width. Preoperative magnetic resonance imaging studies (n = 55) validated the trigonometric formula relative to SUI at one month post-HoLEP. The maximal median angles for the non-SUI (n = 28) and SUI (n = 27) groups were 54° vs. 57° (p = 0.002), and the calculated sphincter dilations were 39mm vs. 49mm (p < 0.001), respectively. The sphincter dilation and resectoscope angle were the only independent predictors of SUI post-HoLEP in the univariate and multivariate regression models. A receiver-operating characteristic analysis found an area under the curve (AUC) of 0.849 for our formula, 0.764 for sphincter dilation, and 0.745 for the resectoscope angle. These AUCs were significantly better than those for prostate volume and patient age (p < 0.05). The EUS dilation caused by radial forces exercised during resectoscope angulation is a plausible cause for post-HoLEP UI. It may also explain its temporality.

Background The use of the new thulium fiber laser in enucleation of the prostate (ThuFLEP) has been introduced recently. Objective To evaluate complications and urinary incontinence (UI) after ThuFLEP in small and large prostate volume (PV). Design, setting, and participants We retrospectively reviewed patients who underwent ThuFLEP in six centers (from January 2020 to January 2023). The exclusion criteria were concomitant lower urinary tract surgery, previous prostate/urethral surgery, prostate cancer, and pelvic radiotherapy. Outcome measurements and statistical analysis Patients were divided into two groups: group 1: PV ≤80 ml; group 2: PV >80 ml. Univariable and multivariable logistic regression analyses were performed to evaluate the independent predictors of overall UI. Results and limitations There were 1458 patients in group 1 and 1274 in group 2. There was no significant difference in age. The median PV was 60 (61-72) ml in group 1 and 100 (90-122) ml in group 2. En bloc enucleation was employed more in group 1, while the early apical release technique was used more in group 2. The rate of prolonged irrigation for hematuria, urinary tract infection, and acute urinary retention did not differ significantly. Blood transfusion rate was significantly higher in group 2 (0.5% vs 2.0%, p = 0.001). There was no significant difference in the overall UI rate (12.3% in group 1 vs 14.7% in group 2, p = 0.08). A multivariable regression analysis showed that preoperative postvoiding urine residual (odds ratio 1.004, 95% confidence interval 1.002-1.007, p < 0.01) was the only factor significantly associated with higher odds of UI. A limitation of this study was its retrospective nature. Conclusions Complications and UI rates following ThuFLEP were similar in patients with a PV up to or larger than 80 ml except for the blood transfusion rate that was higher in the latter. Patient summary In this study, we looked at outcomes after thulium fiber laser in enucleation of the prostate stratified by PV. We found that blood transfusion was higher in men with PV >80 ml, but urinary incontinence was similar.

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology I (MP20)1 May 2024MP20-11 Incidence of complications and urinary incontinence following endoscopic laser enucleation of the prostate in men with prostate volume 80ml and above: Results from a multicenter, real-world experience Khi Yung Fong, Vineet Gauhar, Daniele Castellani, Thomas R. W. Herrmann, Mehmet Gokce, Nariman Gadzhiev, Vigen Malkhasyan, Giacomo Pirola, Angelo Naselli, Abhay Mahajan, Pankaj Maheshwari, Sarvajit Biligere, Azimdjon Tursunkulov, Vladislav Petov, Marco Dellabella, Ee Jean Lim, Moises R. Socarrás, Marek Zawadzki, Luigi Cormio, Bhaskar K. Somani, Mario Sofer, and Fernando G. Sancha Khi Yung FongKhi Yung Fong , Vineet GauharVineet Gauhar , Daniele CastellaniDaniele Castellani , Thomas R. W. HerrmannThomas R. W. Herrmann , Mehmet GokceMehmet Gokce , Nariman GadzhievNariman Gadzhiev , Vigen MalkhasyanVigen Malkhasyan , Giacomo PirolaGiacomo Pirola , Angelo NaselliAngelo Naselli , Abhay MahajanAbhay Mahajan , Pankaj MaheshwariPankaj Maheshwari , Sarvajit BiligereSarvajit Biligere , Azimdjon TursunkulovAzimdjon Tursunkulov , Vladislav PetovVladislav Petov , Marco DellabellaMarco Dellabella , Ee Jean LimEe Jean Lim , Moises R. SocarrásMoises R. Socarrás , Marek ZawadzkiMarek Zawadzki , Luigi CormioLuigi Cormio , Bhaskar K. SomaniBhaskar K. Somani , Mario SoferMario Sofer , and Fernando G. SanchaFernando G. Sancha View All Author Informationhttps://doi.org/10.1097/01.JU.0001008732.80104.31.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Endoscopic enucleation of the prostate (EEP) has evolved considerably over the past few years, and urologists have strived to improve outcomes in large-volume prostates. We aimed to evaluate outcomes after EEP stratified by prostate volume using data from a large multicenter registry. METHODS: The PEEL registry is a retrospective database comprising patients with benign prostatic hyperplasia and prostate volume≥80 ml, who underwent EEP with different energy sources in 13 centers from January 2019-January 2023. Patients with prostate cancer, previous prostate/urethral surgery or pelvic radiotherapy were excluded. For this analysis, patients were divided into 3 groups according to prostate volume: Group 1 (80-100 ml); Group 2 (101-200 ml); and Group 3 (PV>200 ml). The main outcomes were early complication rate (within 30 days), late complication rate (>30 days), and postoperative urinary incontinence (UI). Multivariable logistic regression analysis was performed to evaluate independent predictors of overall UI. RESULTS: Of a total of 2512 patients in the PEEL registry, There were 486 patients in Group 1, 1830 in Group 2, and 196 in Group 3. The most commonly used energy was high-power Holmium laser followed by Thulium fiber laser in all groups. Enucleation, morcellation, and total surgical time were significantly longer in Group 2 than the other groups. Most procedures utilized en-bloc enucleation (75.1% in Group 1 vs. 57.5% in Group 2 vs. 52.6% in Group 3). There was no significant difference in early complication rate and 30-day readmission rate. UI incidence was similar (12.1% in Group 1 vs. 13.2% in Group 2 vs. 11.7% in Group 3, p=0.72). The rate of stress and mixed incontinence was higher in Group 1. Multivariable regression analysis showed that age (p=0.019) and preoperative post-void residual urine volume (p<0.001) were significantly associated with higher odds of UI. CONCLUSIONS: This real-world study shows that EEP in patients with large prostates is a safe, efficacious, and size-independent procedure. En-bloc EEP with Holmium or Thulium fiber were the predominant techniques utilized in our cohort. Although absolute prostate volume does not appear to influence postoperative UI, older men with high preoperative post-void residual urine volume should be counseled regarding an increased possibility of this adverse outcome. Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e323 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Khi Yung Fong More articles by this author Vineet Gauhar More articles by this author Daniele Castellani More articles by this author Thomas R. W. Herrmann More articles by this author Mehmet Gokce More articles by this author Nariman Gadzhiev More articles by this author Vigen Malkhasyan More articles by this author Giacomo Pirola More articles by this author Angelo Naselli More articles by this author Abhay Mahajan More articles by this author Pankaj Maheshwari More articles by this author Sarvajit Biligere More articles by this author Azimdjon Tursunkulov More articles by this author Vladislav Petov More articles by this author Marco Dellabella More articles by this author Ee Jean Lim More articles by this author Moises R. Socarrás More articles by this author Marek Zawadzki More articles by this author Luigi Cormio More articles by this author Bhaskar K. Somani More articles by this author Mario Sofer More articles by this author Fernando G. Sancha More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology I (MP20)1 May 2024MP20-14 Can post-HoLEP urinary incontinence be predicted by the endoscopic aspect of membranous urethra mucosa at the end of the procedure? – A prospective AI based video analysis Tomer Mendelson, Ziv Savin, Ron Marom, Yotam Veredgorn, Amihay Nevo, Ofer Yossepowitch, and Mario Sofer Tomer MendelsonTomer Mendelson , Ziv SavinZiv Savin , Ron MaromRon Marom , Yotam VeredgornYotam Veredgorn , Amihay NevoAmihay Nevo , Ofer YossepowitchOfer Yossepowitch , and Mario SoferMario Sofer View All Author Informationhttps://doi.org/10.1097/01.JU.0001008732.80104.31.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Postoperative urinary incontinence (UI) is a transient side effect of holmium laser enucleation of the prostate (HoLEP), ranging 15-27%. The common hypothesis is that UI is caused by damage of the external urethral sphincter (EUS). Integrity of mucosal membranous urethra circumference (MMUC) distal to verumontanum at the completion of HoLEP is traditionally considered a marker of EUS preservation and a prognosticator of maintaining postoperative continence. We aimed to assess the reliability of endoscopic identification and interpretation of the post-HoLEP MMUC integrity and its influence on the functional outcome. METHODS: A prospective cohort of 40 HoLEPs operated by a single dedicated surgeon was recorded by a video platform able to divide the surgical steps using AI (Theator, Palo Alto, Ca). MMUC images at completion of HoLEP were analyzed by the surgeon (as a referent) and another HoLEP expert as well as by 2 residents, all of them blinded to the clinical outcome. Findings were scaled as 0=non-damage, 1=anterior damage and 2=lateral damage. The results were statistically analyzed for inter-observer agreement and association with post-HoLEP UI 1 month after surgery. UI was defined as any drop on a ped as reported by the patient. RESULTS: The referent rated the MMUC condition as 71%, 23% and 6% for grades 0, 1 and 2, respectively. However, the overall inter-observer agreement was K=0.28, inter-experts agreement was K=0.13 and inter-residents agreement was K=0.39. These results reveal a low inter-observer reliability. The rate of UI by our strict definition was 27% at 1 month. Univariate analysis showed no association between the grade of MMUC injury and UI (OR 0.34, 95%CI 0.043 - 3.08). Multivariate analysis controlling for age, prostate size, resectoscope size (22 vs 26 FR), surgery time, and use of final fulguration did not show any statistically independent predictor. CONCLUSIONS: It appears that contrary to the traditional perception, the endoscopic assessment of MMUC as a marker of EUS location, function and injury is not reliable. To the best of our knowledge, despite a dogmatic acceptance, there is no high level of evidence in literature to support the significance of MMUC integrity. Further studies, including real time electro-physiological, anatomical and functional assessment, are needed to better understand the mechanism of post-HoLEP UI. Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e325 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Tomer Mendelson More articles by this author Ziv Savin More articles by this author Ron Marom More articles by this author Yotam Veredgorn More articles by this author Amihay Nevo More articles by this author Ofer Yossepowitch More articles by this author Mario Sofer More articles by this author Expand All Advertisement PDF downloadLoading ...

Background: Preoperative identification of the bowel on imaging is essential in planning renal access during percutaneous nephrolithotomy (PCNL) and avoiding colonic injury. We aimed this study to assess which noncontrast computed tomography (NCCT) window setting provides the optimal colonic identification for PCNL preoperative planning. Methods: Ten urologic surgeons (four seniors, six residents) reviewed 22 images of NCCT scans in both abdomen and lung window settings in a randomized blinded order. Colonic area delineation in each image was performed using a dedicated, commercially available area calculator software. A comparison of the marked colonic area between the abdomen and lung window settings was performed. Results: Overall, the mean marked colonic area was greater in the lung window compared with the abdomen window (8.82 cm2 vs 7.4 cm2, respectively, p < 0.001). Switching the CT window from abdomen to lung increased the identified colonic area in 50 cases (50%). Intraclass correlation showed good agreement between the senior readers and among all readers (0.92 and 0.87, respectively). Similar measurements of the colonic area in both abdomen and lung windows were observed in 26/44 (60%) of the seniors cases and in 7/66 (10%) of the resident cases (p = 0.002). Conclusion: Lung window solely or in combination with abdomen window appears to provide the most accurate colonic identification for preoperative planning of PCNL access and potentially reduce the risk of colonic injury. This pattern is more evident among young urologists, and we propose to introduce it as a standard sequence in PCNL preplanning.