Influence of Early Apical Release on Outcomes in Endoscopic Enucleation of the Prostate: Results From a Multicenter Series of 4392 Patients.

OBJECTIVE: To evaluate outcomes after laser endoscopic enucleation of the prostate (EEP) stratified by whether early apical release (EAR) was performed or not. METHODS: We retrospectively reviewed patients with clinical benign prostatic hyperplasia who underwent EEP with holmium or thulium fiber laser in 8 centers (January 2020-January 2022). EXCLUSION CRITERIA: previous prostate/urethral surgery, prostate cancer, pelvic radiotherapy, concomitant lower urinary tract surgery. One-to-one propensity score-matching was performed between patients with EAR vs no EAR, with covariates including age, prostate volume, diabetes mellitus, hypertension, preoperative indwelling catheter, IPSS, Qmax, enucleation, and laser types. Multivariable logistic regression analyses were performed to evaluate independent predictors of 30-day postoperative complications and urinary incontinence. RESULTS: EAR was performed in 2094 of 4392 included patients. The matched cohort consisted of 787 patients per arm. Total operation time was significantly longer in the EAR group (median 75 vs 67 minutes, P = .004). Early complications were higher in the EAR group (18.6% vs 12.5%, P = .001), while postoperative incontinence rates were similar (14.1% vs 13.1%, P = .61). Multivariable regression analysis showed that 3-lobe enucleation and operation time were significant predictors of postoperative complications; preoperative indwelling catheterization, higher prostate volume, and en-bloc enucleation were associated with higher odds of postoperative incontinence. LIMITATION: retrospective nature. CONCLUSION: Performing EAR during EEP is associated with a greater incidence of early complications, which was mainly driven by higher rates of postoperative hematuria and perioperative transfusion. The risk of postoperative incontinence and its duration are not affected by EAR.

Incidence of urinary incontinence following endoscopic laser enucleation of the prostate by en-bloc and non-en-bloc techniques: a multicenter, real-world experience of 5068 patients.

ABSTRACT: We aim to evaluate the incidence of incontinence following laser endoscopic enucleation of the prostate (EEP) comparing en-bloc (Group 1) versus 2-lobe/3-lobe techniques (Group 2). We performed a retrospective review of patients undergoing EEP for benign prostatic enlargement in 12 centers between January 2020 and January 2022. Data were presented as median and interquartile range (IQR). Univariable and multivariable logistic regression analysis was performed to evaluate factors associated with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI). There were 1711 patients in Group 1 and 3357 patients in Group 2. Patients in Group 2 were significantly younger (68 [62-73] years vs 69 [63-74] years, P = 0.002). Median (interquartile range) prostate volume (PV) was similar between the groups (70 [52-92] ml in Group 1 vs 70 [54-90] ml in Group 2, P = 0.774). There was no difference in preoperative International Prostate Symptom Score, quality of life, or maximum flow rate. Enucleation, morcellation, and total surgical time were significantly shorter in Group 1. Within 1 month, overall incontinence rate was 6.3% in Group 1 versus 5.3% in Group 2 (P = 0.12), and urge incontinence was significantly higher in Group 1 (55.1% vs 37.3% in Group 2, P < 0.001). After 3 months, the overall rate of incontinence was 1.7% in Group 1 versus 2.3% in Group 2 (P = 0.06), and SUI was significantly higher in Group 2 (55.6% vs 24.1% in Group 1, P = 0.002). At multivariable analysis, PV and IPSS were factors significantly associated with higher odds of transient SUI/MUI. PV, surgical time, and no early apical release technique were factors associated with higher odds of persistent SUI/MUI.

Real-world Global Outcomes of Retrograde Intrarenal Surgery in Anomalous Kidneys: A High Volume International Multicenter Study.

OBJECTIVE: To analyze the trends and outcomes of retrograde intrarenal surgery for treatment of urolithiasis in anomalous kidneys in a large international multicenter series. MATERIALS AND METHODS: We designed a multicentric retrospective study. Nineteen high-volume centers worldwide were included. Pre-, peri- and postoperative data were collected, and a subgroup analysis was performed according to renal anomaly. RESULTS: We analyzed 414 procedures: 119 (28.7%) were horseshoe kidneys, 102 (24.6%) pelvic ectopic kidneys, 69 (16.7%) malrotated kidneys and 50 (12.1%) diverticular calculus. The average size (SD) of the stone was 13.9 (±6) millimeters and 193 (46.6%) patients had a pre-operative stent. In 249 cases (60.1%) a disposable scope was used. A UAS (ureteral access sheath) was used in 373 (90%) patients. A Holmium laser was used in 391 (94.4%) patients. The average (SD) operating time was 65.3 (±24.2) minutes. Hematuria, caliceal perforation and difficulty in stone localisation were mostly seen in diverticular stones and difficulty in UAS placement and lithotripsy in the cases of renal malrotation. The overall complication rate was 12%. Global stone-free rate was 79.2%. Residual fragments (RF) were significantly lesser in the pre-stented group (P <.05). Diverticular calculi was the group with more RF and needed ancillary procedures (P <.05). CONCLUSION: Retrograde intrarenal surgery in patients with anomalous kidneys is safe and effective with a high single-stage stone-free rate and low complication rate. There is a trend toward using smaller and disposable scopes and smaller UAS. Diverticular stones can still be challenging with higher rates of intraoperative hematuria, caliceal perforation and RF.