High-Risk Patients Undergoing Holmium Laser Enucleation of the Prostate Have Fewer Infections with a Longer Course of Preoperative Antibiotics.

Introduction: There are minimal data to guide antibiotic management of patients undergoing holmium laser enucleation of the prostate (HoLEP) for benign prostatic hyperplasia. Specifically, management of high-risk patients who are catheter dependent or have positive preoperative urine cultures varies widely. We aimed to evaluate the effect of preoperative antibiotic duration on infectious complications in high-risk patients undergoing HoLEP. Methods: A multi-institutional retrospective review of patients undergoing HoLEP between 2018 and 2023 at five institutions was performed. Patients were defined as high risk if they were catheter-dependent (indwelling urethral catheter, self-catheterization, or suprapubic tube) or had a positive preoperative urine culture. These patients were categorized into long course (>3 days) or short course (≤3 days) of preoperative antibiotics. The primary outcome was 30-day infectious complications defined as a positive urine culture with symptoms. A t-test or Wilcoxon rank-sum test was used for continuous variables and Fisher's exact test was used for categorical variables. Logistic regression analysis was conducted to identify associations with infectious complications. Results: Our cohort included 407 patients, of which 146 (36%) and 261 (64%) were categorized as short course and long course of preoperative antibiotics, respectively. Median preoperative antibiotic duration was 1 day (interquartile range [IQR]: 0, 3 days) and 7 days (IQR: 5, 7 days) in the short and long cohorts, respectively. Thirty-day postoperative infectious complications occurred in 11 (7.6%) patients who received a short course of antibiotics and 5 (1.9%) patients who received a long course of antibiotics (odds ratio 0.24, 95% confidence interval 0.07-0.67; p = 0.009). Variables such as age, positive urine culture, and postoperative antibiotic duration were not significantly associated with postoperative infection after propensity score weighting. Conclusion: In high-risk patients undergoing HoLEP, infectious complications were significantly lower with a long course vs short course of antibiotics. Further prospective trials are needed to identify optimal preoperative antibiotic regimens.

Tamsulosin 0.8 mg daily dose in management of BPH patients with failed tamsulosin 0.4 mg monotherapy and unfit for surgical intervention.

AIM: This study aims to evaluate the effectiveness and safety of administering double-dose tamsulosin (0.8 mg) for treating patients with benign prostatic hyperplasia (BPH) who have not responded to the standard single dose of tamsulosin (0.4 mg) and are deemed unsuitable for transurethral resection (TUR) intervention. MATERIALS AND METHODS: Between November 2022 and July 2023, we prospectively analyzed 111 patients who were experiencing severe BPH symptoms. These patients received a double dose of tamsulosin for one month. We collected baseline characteristics such as age, body mass index, and underlying medical conditions. Various parameters including the International Prostate Symptom Score (IPSS), prostate-specific antigen (PSA) levels, prostate volume, peak urinary flow rate (Qmax), voided volume, and post-void residual volume were evaluated before and after treatment. RESULTS: All 111 patients completed the study. The mean age, PSA level, and prostate volume were 63.12 ± 4.83 years, 3.42 ± 0.93 ng/ml, and 50.37 ± 19.23 ml, respectively. Of these patients, 93 showed improvement in Qmax, post-void residual volume, and IPSS score (p-value = 0.001). The total IPSS score and total Qmax improved from 24.03 ± 2.49 and 7.72 ± 1.64 ml/sec to 16.41 ± 3.84 and 12.08 ± 2.37 ml/sec, respectively. CONCLUSION: Double-dose 0.8mg tamsulosin as an alpha-blocker therapy appears to be a viable temporary management option for BPH patients who have not responded to the standard single dose 0.4mg tamsulosin and are not suitable candidates for TUR intervention.

Impact of age and anterior fibromuscular stroma preservation on post-enucleation voided volume.

PURPOSE: This study is centered on the critical role of anterior fibromuscular stroma (AFS) preservation in prostate enucleation, an emerging strategy aimed at minimizing postoperative urinary incontinence-a common concern in benign prostatic hyperplasia (BPH) surgeries. By focusing on postoperative voiding volumes (VV), our research investigates the efficacy of AFS preservation. This approach, distinct in its methodology, is hypothesized to improve urinary function post-surgery, thereby offering a potentially significant advancement in BPH surgical treatments. MATERIALS AND METHODS: A retrospective analysis was conducted, comparing patients who underwent prostate enucleation in 2017 without intentional AFS preservation to those in 2019 with this technique. We examined variables including age, BMI, diabetes, hypertension, and preoperative VV to assess their effect on post-catheter removal VV. The study's methodology includes a thorough review of the primary statistical analysis methods employed. RESULTS: Our analysis indicates that while the 2017 and 2019 cohorts were similar in most preoperative parameters, the 2019 group that underwent AFS-preserved surgery showed a significant improvement in postoperative VVs. This was less pronounced in the patient group aged over 70, underscoring the importance of this demographic in our study. CONCLUSIONS: The study concludes that intentional preservation of AFS during prostate enucleation positively impacts early postoperative VVs, with limited improvement in older patients. These findings highlight the potential of AFS preservation not only in enhancing urinary outcomes post-surgery but also in shaping future BPH surgical procedures and research directions.

Predictive factors of post-HoLEP incontinence: differences between stress and urgency urinary incontinence.

INTRODUCTION: The analysis of post-HoLEP urinary incontinence (UI) has traditionally focused on stress UI. Our aim is to evaluate the factors associated with stress and urgency UI in the first month after the surgery. METHODS: Data were obtained from patients who underwent HoLEP by the same experienced surgeon. UI was evaluated at one month and at 6 months after the surgery. Three groups were defined: continent patients, patients with pure urgency UI and patients with stress or mixed UI. Preoperative, intraoperative, urodynamic and clinical variables were analyzed and compared between the three groups. RESULTS: In total, 235 subjects were included. One month after the surgery, 156 (66.5%) were continent (group 1), 49 (20.8%) reported pure urgency UI (group 2), and 30 (12.7%) reported some level of stress UI (group 3). In Group 2, the factors associated with urgency UI in the univariate analysis were age, presurgical urgency UI, having diabetes or hypertension. In Group 3, age, prostatic volume, preoperative PSA, time of enucleation, weight of the resection in grams, having an IDC or being diabetic were significant in the univariate analysis. In the multivariate analysis, age predicts both types of UI, while prostatic volume and having an IDC predict stress or mixed UI. CONCLUSION: In the first month post-HoLEP, age is a predictive factor of urgency UI and stress UI. In addition, prostatic volume and the presence of an indwelling urinary catheter are predictive factors of stress UI.

Minimally invasive interventions for lower urinary tract symptoms: What sits between medical therapy and transurethral resection of the prostate.

BACKGROUND: There are a variety of medical and surgical treatment options available today for the management of lower urinary tract symptoms (LUTS) secondary to bladder outlet obstruction due to benign prostatic hyperplasia (BPH). OBJECTIVE: The aim of this paper is to highlight the various treatment options available for the management of bladder outlet obstruction secondary to BPH and discuss the benefits and potential drawbacks of each. DISCUSSION: Lifestyle and dietary modification and medical therapies, such as an alpha-1 blocker as monotherapy, should be considered as first-line when initially counselling a patient for LUTS secondary to bladder outlet obstruction due to BPH. If bothersome LUTS persist despite medical management, or if medical management is not suitable or preferable, then surgical interventions can be considered. The mainstay of surgical intervention has traditionally been transurethral resection of the prostate (TURP); however, the treatment landscape is rapidly evolving with the development of minimally invasive procedures.

Analysis of urinary retention after endoscopic prostate enucleation and its subsequent impact on surgical outcomes.

PURPOSE: Postoperative urinary retention (PUR) is a common complication after prostate enucleation, which leads to an increased length of hospital stay and decreased postoperative satisfaction. This study determined the predictive factors of postoperative urine retention within 1 month after prostate enucleation and investigated whether PUR influences surgical outcomes at the 2-week, 3-month, and 6-month follow-up time points. METHODS: Data were collected from the electronic medical records of 191 patients with benign prostatic obstruction (BPO) during October 2018 to September 2021. Of them, 180 patients who underwent thulium laser or plasma kinetic enucleation of the prostate (ThuLEP, PKEP) were separated into the PUR group (n = 24) and the non-PUR (NPUR) group (n = 156). Uroflowmetry and the International Prostate Symptom Score (IPSS) questionnaire were followed up at 2 weeks, 3 months, and 6 months postoperatively. RESULTS: The PUR group had a significantly higher percentage of patients with type 2 diabetes mellitus (DM) than the NPUR group. Postoperatively, compared with the NPUR group, the PUR group had significantly less improvement in changes in the IPSS Quality of Life scores at 2 weeks, the total IPSS(International Prostate Symptom Score) at all follow-up times, the IPSS-S(IPSS storage subscores) at 2 weeks and 3 months, and the IPSS-V(IPSS voiding subscores) at all follow-up times. Predictive factors for PUR include lower preoperative maximum urinary flow (Qmax), lower preoperative total IPSS, and higher operation time. CONCLUSION: Lower preoperative Qmax, lower IPSS scores, and longer operation time were risk factors for PUR. Furthermore, PUR could be a prognostic factor for prostatic enucleation surgical outcomes.

Real world propensity score matched analysis evaluating the influence of en-bloc vs. non en-bloc techniques, energy and instrumentation on enucleation outcomes for large and very large prostates.

PURPOSE: The primary aim of the study was to evaluate if en-bloc vs. non en-bloc made a difference to intra-, peri- and post-operative surgical outcomes of anatomical endoscopic enucleation (AEEP) in large (> 80 cc) and very large prostates (> 200 cc). The secondary aim was to determine the influence of energy and instruments used. METHODS: Data of patients with > 80 cc prostate who underwent surgery between 2019 and 2022 were obtained from 16 surgeons across 13 centres in 9 countries. Propensity score matching (PSM) was used to reduce confounding. Logistic regression was performed to evaluate factors associated with postoperative urinary incontinence (UI). RESULTS: 2512 patients were included with 991 patients undergoing en-bloc and 1521 patients undergoing non-en-bloc. PSM resulted in 481 patients in both groups. Total operation time was longer in the en-bloc group (p < 0.001), enucleation time was longer in the non en-bloc group (p < 0.001) but morcellation times were similar (p = 0.054). Overall, 30 day complication rate was higher in the non en-bloc group (16.4% vs. 11.4%; p = 0.032). Rate of late complications (> 30 days) was similar (2.3% vs. 2.5%; p > 0.99). There were no differences in rates of UI between the two groups. Multivariate analysis revealed that age, Qmax, pre-operative, post-void residual urine (PVRU) and total operative time were predictors of UI. CONCLUSIONS: In experienced hands, AEEP in large prostates by the en-bloc technique yields a lower rate of complication and a slightly shorter operative time compared to the non en-bloc approach. However, it does not have an effect on rates of post-operative UI.

A novel technique for thulium laser enucleation of the prostate: anterior releasing with ThuLEP (ARTh technique).

Thulium laser enucleation of the prostate (ThuLEP) is a highly effective approach to the treatment of benign prostatic hyperplasia. We present here a description of the "ARTh Technique" and the benefits it offers in terms of improved visualization, short operation times, and easy recognition of the dissection plane, describing specifically the anterior release (AR) technique using ThuLEP(Th). Included in this retrospective study were 32 consecutive patients operated on between January 2022-November 2022. Parameters were measured before and after the procedure: the International Prostate Symptom Score(IPSS), maximum flow rate(Qmax), post-void residual urine(PVR) prostate-specific antigen(PSA), prostate volume, operation-time, morcellation-time, catheterization-time and presence of transient urinary incontinence, and compared. The median age of patients undergoing enucleation of the prostate using the ARTh technique was 64 years (range: 44-83). The median prostate volume of the patients was 83.5 ml(50-128 ml), preoperative-IPSS was 24.8(15-33), postoperative-IPSS was 7(5-11), preoperative-Qmax was 8.1 ml/Sects. (5-11.5 ml/sec), postoperative-Qmax was 26.9 ml/Sect. (20.8-34 ml/sec), preoperative-PVR was 145 ml(75-258 ml), postoperative-PVR was 36.2 ml(0-66 ml), total operation time was 51.4 min(28-82 min), enucleation time was 36.9 min(19-51 min) and morcellation time was 15.3 min(8-27 min). The ARTh technique is a safe procedure that allows the surgeon to easily recognize and adhere to the defined dissection plane, thus decreasing operation times, significantly reducing the rate of postoperative transient urinary incontinence (TUI).

Aquablation versus HoLEP in patients with benign prostatic hyperplasia: a comparative prospective non-randomized study.

PURPOSE: The question of best surgical treatment for lower urinary tract symptoms (LUTS) due to benign prostate hyperplasia (BPH) remains controversial. We compared the outcomes of aquablation and holmium laser enucleation of the prostate ("HoLEP") in a prospective cohort. METHODS: Patients with BPH underwent aquablation or HoLEP according to their preference between June 2020 and April 2022. Prostate volume ("PV"), laboratory results, postvoid residual volume, uroflowmetry, IPSS, ICIQ-SF, MSHQ-EjD, EES and IIEF were evaluated preoperatively and at three, six and 12 months postoperatively. We also analyzed perioperative characteristics and complications via the Clavien Dindo ("CD") classification. RESULTS: We included 40 patients, 16 of whom underwent aquablation and 24 HoLEP. Mean age was 67 years (SD 7.4). Baseline characteristics were balanced across groups, except the HoLEP patients' larger PV. IPSS fell from 20.3 (SD 7.1) at baseline to 6.3 (SD 4.2) at 12 months (p < 0.001) without differences between aquablation and HoLEP. HoLEP was associated with shorter operation time (59.5 (SD 18.6) vs. 87.2 (SD 14.8) minutes, p < 0.001) and led to better PV reduction over all timepoints. At three months, aquablation's results were better regarding ejaculatory (p = 0.02, MSHQ-EjD) and continence function (p < 0.001, ICIQ-SF). Beyond three months, erectile, ejaculatory, continence function and LUTS reduction did not differ significantly between aquablation and HoLEP. CD ≥ grade 3b complications were noted in six patients in aquablation group while only one in HoLEP group (p = < 0.01). CONCLUSIONS: While aquablation revealed temporary benefits regarding ejaculation and continence at three months, HoLEP was superior concerning operation time, the safety profile and volumetric results.

What happens to orgasmic function after surgical benign prostate hypertrophy (BPH) treatments?

INTRODUCTION: The increasing number of subjects with benign prostate obstruction (BPO) has become a worldwide concern. The sexual problem after benign prostate enlargement (BPE) surgery that has received the most attention in the literature is ejaculation disorder. However, there appears to be a change in orgasmic sensation independent of ejaculation retention. The objective of our study is to explore the influence of BPE surgery on orgasmic function. METHODS: We evaluated the prospective, multicenter clinical data of 104 patients undergoing BPE surgery who reported maintaining sexual activity from January 2016 to November 2020. The endpoint of this study was to decipher the percentage of patients with an orgasm disorder as assessed by the difference between pre-and-postoperative question 10 of the IIEF 15 questionnaire. RESULTS: Orgasm function was stable, improved, and degraded in 34% (n=35), 30% (n=31), and 36% (n=38) respectively. A deterioration in orgasm was statistically significant in men who maintained quality ejaculation with retained force preoperatively and a high IIEF15 scale values preoperative of orgasmic function, overall and intercourse patient satisfaction. CONCLUSION: To enable the patient to maintain a satisfying and healthy sex life after any BPE surgery, urologist physicians should know the prevalence of orgasmic side effects after surgical treatment to provide appropriate counseling to patients. LEVEL OF EVIDENCE: Grade 4.

Is there a best timing for benign prostatic hyperplasia surgery?

INTRODUCTION: Treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH) has shifted over the last decades, with medical therapy becoming the primary treatment modality while surgery is being reserved mostly to patients who are not responding to medical treatment or presenting with complications from BPH. Here, we aim to to discuss the optimal timing of surgical management of LUTS/BPH. MATERIALS AND METHODS: A literature search was conducted on Pub-Med/MEDLINE database to identify reports published from January 1990 until January 2022 by combining the following MeSH terms: "Lower Urinary Tract Symptoms"; "Prostatic Hyperplasia"; "Prostatic Hyperplasia/therapy"; "Prostatic Hyperplasia/complications"; "Treatment Outcome"; "Time-to-Treatment". Evidence supporting or not early surgical treatment of BPH was examined and reported in a pros and cons form. RESULTS: The "pro early surgery" highlighted the superior efficacy and cost-effectiveness of surgery over medical treatment for BPH, as well as the possibility of worse postoperative outcomes for delayed surgical treatment. The "con early surgery" considered that medical therapy is efficient in well-selected patients and can avoid the serious risks inherent to surgical treatment of BPH including important sexual side effects. CONCLUSIONS: Clinical trials comparing the outcomes for prolonged medical therapy versus early surgical treatment could determine which approach is more beneficial in the long-term in context of the aging population. Until then, both approaches have their advantages and patients should be involved in the treatment decision.

Prostatic stromal tumor of uncertain malignant potential: a case report and literature review.

Prostatic stromal tumors, encompassing prostatic sarcoma and stromal tumors of uncertain malignant potential (STUMP), represent an exceedingly rare category of prostatic diseases, with a prevalence of less than 1%. We present a rare case involving a man in his early 40s diagnosed with STUMP. Despite presenting with normal prostate-specific antigen (PSA) concentrations, the patient experienced persistent dysuria and gross hematuria for >7 months, leading to an initial misdiagnosis of benign prostatic hyperplasia. Persistent symptoms prompted further investigation, with magnetic resonance imaging (MRI) revealing a suspicious lesion on the left side of the prostate, initially thought to be malignant. Transrectal prostatic biopsy subsequently confirmed the presence of mucinous liposarcoma, with no medical history of diabetes, coronary heart disease, or hypertension. The treatment approach comprised robot-assisted laparoscopic radical prostatectomy, culminating in a postoperative pathological definitive diagnosis of STUMP. This case underscores the indispensable role of early MRI in the diagnostic process, highlighting the necessity of detailed pathological examination for a conclusive diagnosis. Our report aims to illuminate the diagnostic challenges and potential treatment pathways for STUMP, emphasizing its consideration in the differential diagnosis of prostatic tumors to advance clinical outcomes in this rare but important condition.

Enhancing continence post holmium laser enucleation of the prostate: assessment of novel technique through randomized clinical trial.

BACKGROUND: Transient urinary incontinence (UI) is distressing event following holmium laser enucleation of the prostate (HoLEP). Novel technique namely, veil sparing HoLEP (VS-HoLEP), was proposed to improve early continence outcome. In this trial (NCT03494049), VS-HoLEP was compared to standard HoLEP (St-HoLEP). METHODS: VS-HoLEP entails early apical separation with sparing of ventral apical mucosal veil proximal to the verumontanum. Eligible symptomatic BPH patients were randomly allocated to St-HoLEP (91) and VS-HoLEP (89). The primary outcome was UI as depicted by one-hour pad test at one month postoperatively. Other outcome measures include all perioperative parameters, complications, and urinary outcome measures at different follow-up points. RESULTS: Median preoperative prostate size was 138 (50:282) and 128 (50:228) mL in St-HoLEP and VS-HoLEP groups respectively. At one month the number of patients with positive one-hour pad test was 21 (23.1%) and 10 (11.4%) in St-HoLEP and VS-HoLEP groups respectively (P 0.047). The difference was significantly in favor of VS-HoLEP considering the number of patients reporting UI, the number of patients with positive one-hour pad test as well as the grade of UI reported at one and 4 months. The difference was not statistically significant at 12 months. The median time to patients' reported continence was 8 (1-52) and 1.5 (1-52) weeks in St-HoLEP and VS-HoLEP groups respectively (P≤0.005). The technique independently predicted positive one-hour pad test at one and four months respectively. At twelve months presence of DM (diabetes mellitus) and more percent PSA reduction independently predicted positive one-hour pad test. CONCLUSIONS: Veil sparing HoLEP enhances significantly early postoperative urine continence both subjectively and objectively. Optimization of the surgical technique could cut short the number of leaking patients and reduce the degree as well as the duration of transient postoperative urine leak.

[Prostate Surgery for Benign Prostatic Syndrome >200 ml: Endoscopic, Robotic, or Open Approach]. / Prostatachirurgie beim benignen Prostatasyndrom >200 ml: Endoskopisch, robotisch oder doch offen?

Surgical approaches for benign prostatic hyperplasia have evolved and diversified over the past decades. While numerous studies document the efficacy of surgical procedures for moderate prostate sizes, there remains insufficient data for large prostate volumes >200 ml, leaving important questions unanswered regarding their effectiveness and safety. Consequently, selecting and adapting suitable therapeutic options for this specific patient group often poses a significant challenge. In this context, this review comprehensively summarizes and discusses current insights into surgical treatment options for large prostate volumes (>200 ml) following an extensive literature review.In summary, the surgical treatment of prostate volumes >200 ml is a challenge regardless of the chosen surgical method. Minimally invasive approaches should be considered standard practice today. Anatomical endoscopic enucleation of the prostate is a size-independent method and has the lowest morbidity. As it may be performed in spinal anaesthesia, endoscopic enucleation is feasible in patients with an increased anaesthetic risk. In extremely large prostate glands, the procedure poses challenges even for highly experienced surgeons. Especially in obese patients, the surgeon should be familiar with different exit strategies. Robot-assisted simple prostatectomy provides a minimally invasive alternative that may also treat pathologies such as diverticula or large bladder stones in the same surgical session. Due to its transabdominal approach, the morbidity and anaesthetic risk is comparatively higher. Each centre and surgeon should individually decide in which method they have the greatest expertise and which option is best suited for the specific case. In cases of limited expertise, it is advisable to refer patients to a centre with appropriate specialization.

Impact of kidney disease on perioperative outcomes of endoscopic BPH surgery: a propensity score matched analysis from the NSQIP database.

INTRODUCTION: To assess the impact of kidney function in patients with BPH undergoing surgery prior to Transurethral resection of prostate (TURP), Laser enucleation of the prostate (LEP), and Laser Vaporization of the prostate (LVP) on operative and post-operative outcomes using the ACS-NSQIP database. METHODS: The ACS-NSQIP database was reviewed for patients that underwent TURP, LEP and LVP for treatment of patients with BPH between the years of 2008 and 2021. Demographics, comorbidities, bleeding disorders, operative time, and surgical procedure performed were collected for comparison between Kidney function groups: G1, normal/high function; G2-G3, mild/moderate kidney disease; and G4-G5, severe kidney disease. The 30-day peri-operative complications were measured and a multivariate logistic regression analysis was performed while adjusting for all confounding variables. Propensity score matching was performed between the G1 and G4-G5 cohorts. RESULTS: A total of 83,020 patients were included. On multivariable regression, in the G2-G3 cohort, patients were at significantly increased risk for renal complications with OR = 2.43[1.56-3.79]. After propensity score matching, the G4-G5 cohort showed increased odds of pneumonia OR = 4.02[1.343-12.056], renal complications with OR = 7.62[2.283-25.411], cardiac complications OR = 4.53[1.531-13.411], and sepsis/septic shock OR = 1.76[1.091-2.834]. They also had a higher need for blood transfusion OR = 3.58[2.242-5.714], and prolonged hospital stay with OR = 1.49[1.296-1.723]. CONCLUSION: Pre-operative kidney disease may pose an increased risk of complications for patients undergoing endoscopic BPH surgery. The literature lacks information on the effect of pre-operative kidney disease on endoscopic BPH surgeries. Further studies are required to compare post-operative outcomes of LEP and LVP as compared to TURP across kidney function status.

Thulium fiber laser enucleation of the prostate: a systematic review of the current outcomes.

INTRODUCTION: One recent addition to different lasers used for endoscopic enucleation of the prostate is the thulium fiber laser (TFL). The purpose of this systematic review is to present the feasibility, safety and efficacy of TFL Enucleation of the Prostate (ThuFLEP). EVIDENCE ACQUISITION: PubMed®, Scopus® and Cochrane® primary databases were systematically screened. The search strategy used the PICO (Patients, Intervention, Comparison, Outcome) criteria. Patients should be adults with benign prostatic obstruction (BPO) undergoing ThuFLEP. While comparative studies reporting comparison of ThuFLEP to other BPO treatments were included, cohort studies with no comparison group were also accepted. Outcomes including enucleation time and complication rates were reported. EVIDENCE SYNTHESIS: Twelve studies met all the predefined criteria and were included in the final qualitative synthesis. Mean operative time and enucleation time ranged from 46.6±10.2 to 104.5±33.6 and from 38.8±17.9 to 66.0±24.9 minutes, respectively. Most of the complications were Grade I or Grade II ones. Although TFL was found to present some advantages over older BPO treatments, its outcomes were comparable with other endoscopic enucleation approaches. CONCLUSIONS: ThuFLEP seems to be a feasible, safe and efficient approach for BPO symptoms management. Limited evidence showed that although ThuFLEP was associated with a reduced total operative time, it was also associated with worse IPSS improvement at 1-year follow-up, when compared with MOSESTM Holmium Laser Enucleation of the Prostate (HoLEP). These findings confirm the well-established opinion that the enucleation technique itself is more important than the technology which is used.

Modified holmium laser enucleation for benign prostatic obstruction to preserve sexual and ejaculatory function.

INTRODUCTION: To report ejaculatory and urinary results in patients who underwent holmium laser enucleation of the prostate (HoLEP) with selective laser enucleation of the median lobe (MLHoLEP). METHODS: Patients with lower urinary tract symptoms (LUTS)/benign prostatic obstruction (BPO) who underwent MLHoLEP to preserve ejaculatory function in a single center were retrospectively identified. Urinary function was assessed using International Prostate Score Symptom (IPSS), IPSS-Quality of Life index (IPSS-QoL), peak urinary flow (Qmax) and postvoid residual (PVR). Erectile function was assessed using International Index of Erectile Function (IIEF-5). In patients with preoperative antegrade ejaculation, retrograde ejaculation was routinely screened at each follow-up visit. Sexual and urinary functions at 3 and 12 months were compared with baseline values. RESULTS: A total of 55 patients met our inclusion criteria. A significant improvement in the IPSS, IPSS-QoL, PVR and Qmax was found at 3 and 12 months, compared with baseline (all P<0.05). Eight patients (14.5%) required surgical reintervention due to persistant LUTS/BPO. No significant changes in the erectile function were found at 3 (P=0.3) and 12 months (P>0.9). In patients with preoperative antegrade ejaculation (n=32), only four cases of de novo retrograde ejaculation were recorded postoperatively. CONCLUSION: MLHoLEP represents a new alternative for men with LUTS/BPO who wish to preserve their ejaculatory function. Patients should be aware that improvement in urinary function may be inferior to the traditional technique, with a higher reintervention rate due to persistent LUTS. LEVEL OF EVIDENCE: Grade 4.

Predictors of postoperative storage symptoms in male patients with lower urinary tract symptoms: A retrospective analysis of prostate surgery for benign prostatic enlargement.

OBJECTIVES: This study investigated the effects of prostate surgery on storage symptoms in male patients with lower urinary tract symptoms (LUTS) from benign prostatic enlargement (BPE). This study aimed to identify patient characteristics associated with improved, unchanged, and deteriorated post-surgical storage symptoms and to identify the risk factors for non-improvement or deterioration. METHODS: A retrospective analysis of 586 prostate surgeries performed between 2016 and 2022 at Yokosuka Kyosai Hospital was conducted on patients with LUTS and at least one storage symptom preoperatively. Patients with active urinary tract infection, prostate/bladder cancer, urethral strictures, or dementia were excluded. The study enrolled 230 patients and assessed storage symptoms using the International Prostate Symptom Score (IPSS). RESULTS: Overall, storage symptoms improved, remained unchanged, and deteriorated in 87.0%, 5.7%, and 7.4% of patients, respectively. The patients in the deteriorated group were significantly older, whereas those in the no-change group had smaller prostate volumes. Patient-reported outcome scores (IPSS, IPSS-QoL, and BII) were significantly higher in the improved group. The predictors of non-improvement included low IPSS storage score, cardiovascular disease, and diabetes mellitus. Predictors of deterioration included advanced age and low IPSS storage score. CONCLUSIONS: Patients with severe LUTS showed greater postoperative improvement in storage symptoms. A low IPSS storage score predicted non-improvement and deterioration. Advanced age, low IPSS storage score, and a history of cardiovascular disease and diabetes mellitus were identified as key predictors. Awareness of these factors may guide preoperative counseling and improve decision-making in prostate surgery, ensuring more personalized and effective treatment strategies.

How I Do It: Teaching holmium laser enucleation of the prostate (HoLEP).

Holmium laser enucleation of the prostate (HoLEP) is considered a size-independent technique to treat benign prostatic hyperplasia. This safe and effective procedure is increasingly being adopted in urology training programs worldwide, yet limited teaching strategies have been described. Endoscopic handling during HoLEP allows for a simultaneous interaction between the surgeon and trainee, facilitating a guided teaching strategy with increasing difficulty as experience grows. In this article, we describe our stepwise approach for teaching HoLEP as part of a structured surgical training curriculum. We also evaluate the association of our method with intraoperative efficiency parameters and immediate postoperative surgical outcomes of 200 HoLEP procedures.