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Objective: To assess outcomes following Holmium Laser Enucleation of Prostate (HoLEP) in men with prostate volumes ≥150cc and compare this to men with prostate volumes ≤150 cc., Patients & Methods: We analyzed our prospective database of consecutive patients undergoing HoLEP in a single tertiary public hospital between October 2016 and January 2019. We excluded patients with clinically significant prostate cancer or neurogenic bladders. Preoperative prostate volume was measured on MRI or ultrasonography. Perioperative variables and functional outcomes were recorded., Results: Of 304 HoLEPs performed, we included 97 patients with prostate volume of ≥150 cc and 186 patients with prostate volume <150 cc. Comparing both cohorts (≥150 cc vs <150 cc): mean age was 71.5 vs 68.3 years, prostate volume 195 cc vs 93 cc, preoperative Qmax 9.6mL/s vs 10mL/s, American Urology Association Symptom Score (IPSS) 21 points vs 20.5 points; mean PSA 13.2µg/L vs 8.8µg/L; laser duration 86 vs 59 minutes; morcellation duration 29 vs 14 minutes; enucleated weight was 124 g vs 60 g. One patient (1%) from the ≥150 cc cohort required a surgical procedure for stress urinary incontinence, and none from the <150 cc cohort, but this did not achieve statistical significance (P = .12). There were no statistically significant differences in postoperative Qmax (32.3 vs 26.4 mL/s; P = .12), IPSS (5.9 points vs 7.3points; P = .23), mean PSA (3.9 µg/L vs 2.2 µg/L; P = .60), stricture incidence (1% vs 2.7%; P = .63), or significant stress urinary incontinence (4.1% vs 0.5%; P = .08)., Conclusion: Our large series demonstrates that HoLEP is safe and effective in patients with massive prostates (≥150 cc), with similar outcomes compared to patients with prostates <150 cc., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To assess and quantify the surgical learning curve of holmium laser enucleation of the prostate (HoLEP) of a single surgeon., Methods: A retrospective analysis of 253 consecutive cases performed by the same surgeon from 2006 to 2013 was conducted. Primary outcomes included enucleation ratio and morcellation efficiencies and complication rates. Three-month postoperative prostate-specific antigen values were used as secondary measures. Cases were divided into cohorts of 20 cases to assess changes in means analyzed through Analysis of Variance (ANOVA) tests. Scatter plots of cases with a best-fit line were drawn to analyze the learning curve., Results: The mean age of patients across the cases was 69.21 years with an average transrectal ultrasound prostate volume of 95.84 cc. Enucleation ratio efficiency was significantly different between cohorts (P = .02) plateau after 50-60 cases conducted. Similarly, a significant difference is shown for morcellation efficiency (P = .01) with stabilization in performance after 60 cases. Complication rates decreased through the caseload but did not show a statistical difference (P = .62) or plateauing on the graph. Finally, no difference between 3-month postoperative prostate-specific antigen values was seen (P = .083); however, a learning curve of 50 cases was observed graphically., Conclusion: Within our single-surgeon cohort, we experienced a learning curve of 40-60 cases for the HoLEP procedure. Large variability in performance late into the caseload demonstrates the technical difficulty of HoLEP. Owing to this, adjuncts to training such as simulation-based training may be of use for the new surgeon to shorten the initial phase of learning., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To evaluate the face, content, and construct validity of a novel virtual reality simulator for holmium laser enucleation of the prostate (HoLEP) and to assess its feasibility and acceptability as a training model., Methods: This prospective observational study recruited 53 participants, comprising of 3 groups: HoLEP experts (n = 11), intermediates (n = 24), and novices (n = 18). All participants received an educational package and a 15-minute familiarization exercise with the simulator. All participants then carried out a full enucleation on an identical 60 cm(3) virtual prostate. Performance was assessed using in-built simulator metrics, and a questionnaire was distributed assessing face and content validity, as well as feasibility, and acceptability. Novice, intermediate, and expert groups were compared using the Mann-Whitney U test., Results: Construct validity data revealed significant differences in enucleation efficiency (grams enucleated per hour) when comparing experts to intermediates (P = .003), experts to novices (P <.001), and intermediates to novices (P = .001). Face validity was rated by experts as acceptable, with a mean score of 5.6 out of 10 when asked to rate the overall realism. Content validity questions showed that 85% of participants agreed that simulator-based assessment is essential for patient safety and 87% agreed that there was a role for a validated virtual reality simulator for use in HoLEP training., Conclusion: This study established face, content, and construct validity for this novel virtual reality HoLEP simulator. The majority of participants also thought that it is a feasible and acceptable model for HoLEP training., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To describe our technique and determine the feasibility and tolerability of transperineal template prostate (TP) biopsies under local anesthesia (LA)., Methods: Fifty consecutive patients underwent TP biopsies under LA for investigation of an elevated prostate-specific antigen level or risk stratification as part of our active surveillance protocol. Tolerability was evaluated with a visual analog scale assessing probe discomfort, LA infiltration, and the biopsy procurement. Patients were also asked if they would have the procedure again, and in those who had undergone previous transrectal biopsies, how the TP technique compared. Pathologic data, clinical outcomes, and complications were recorded at 2 weeks., Results: Mean age was 62.8 years (standard deviation [SD], 6.34 years) and the mean prostate-specific antigen level was 8.49 ng/mL (SD, 6.36 ng/mL). Mean prostate volume was 48.2 mL (SD, 19.4 mL). Mean visual analog scale scores for discomfort caused by the ultrasound probe, LA injections, and biopsies were 3.08 (SD, 1.64), 3.29 (SD, 1.13), and 2.88 (SD, 1.28), respectively. Thirty-four of 50 men (68%) had positive histology, 26 men had Gleason score≤3+4, 5 men had Gleason score≥4+3, and 3 had recurrent adenocarcinoma after radiotherapy. There were 2 complications: 1 Clavien score 1 and 1 Clavien score 3a., Conclusion: LA TP biopsies are well tolerated, acceptable, and feasible when carried out within an outpatient setting., (Copyright © 2014 Elsevier Inc. All rights reserved.)

We describe the first case of salvage robotic-assisted radical prostatectomy for local recurrence after external beam radiotherapy. A 50-year-old man initially underwent combined external beam radiotherapy and hormonal treatment for Stage T2a prostate adenocarcinoma. The prostate-specific antigen level was 10.5 ng/mL, and the Gleason score was 3+3. Two years later, he developed biopsy-proven recurrent disease. He underwent salvage robotic-assisted radical prostatectomy. The patient was discharged on day 1 postoperatively. The histologic analysis revealed an organ-confined tumor. His prostate-specific antigen at 3 months was <0.03 ng/mL, and he was continent. Salvage robotic-assisted radical prostatectomy is a safe and technically feasible salvage treatment for prostate cancer for which primary radiotherapy has failed.

Intraoperative penile tumescence during endoscopic surgery is a troublesome complication and a challenge to the urologist. We describe a novel, convenient, safe, and readily available technique. We used an intracavernosal injection of epinephrine using a standard dental syringe and a cartridge of lidocaine 2% and epinephrine 1:80,000 to induce detumescence reliably.