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INTRODUCTION: We sought to identify predictors of failed retrograde ureteric stent (FRS) placement in the setting of obstructing ureteric calculi. In addition to patient- and stone-specific characteristics, we also considered computed tomography (CT) measures of ureteric wall thickness (UWT), as it has shown clinical potential in predicting outcomes of shockwave lithotripsy, ureteroscopy, and spontaneous stone passage. METHODS: We performed a retrospective, case-control study comparing patients who had successful retrograde stent (SRS) insertions with those who failed stent placement and ultimately required nephrostomy tube (NT) insertion (2013--2019). Patients were identified using administrative data from a shared electronic medical record (capturing all urology patients in our geographic area) and a prospective database capturing all institutional interventional radiology procedures. Patient demographics, as well as clinical and stone characteristics, were then collected, and imaging manually reviewed. Statistical analysis was performed using univariate and multivariate logistic regression analysis in collaboration with a statistician. RESULTS: A total of 109 patients met inclusion for analysis (34 FRS, 75 SRS). The most common indication for stent insertion included sepsis (79%). On multivariate analysis, both acute kidney injury as primary indication for stent insertion (odds ratio [OR] 9.16, 95% confidence interval [CI] 1.91--44.00, p=0.006) and UWT (OR 0.34, 95% CI 0.15--0.74, p=0.007) were found to be significantly associated with FRS placement. A receiver operator characteristic curve analysis demonstrates an optimal UWT cutoff of 3.2 mm (sensitivity 60.6%, specificity 83.3%). CONCLUSIONS: Elevated UWT and acute kidney injury as an indication for urgent urinary decompression in the setting of obstructing ureteric stones are predictive of FRS placement. These patients may benefit from upfront nephrostomy tube insertion. [ABSTRACT FROM AUTHOR]

Background: Until recently, Holmium laser enucleation of the prostate (HoLEP) utilisation has been limited despite its perceived benefits over alternative surgical and minimally invasive benign prostatic hyperplasia (BPH) treatments. Objective: The purpose of this review is to highlight our experience with recent advances in laser and morcellator technologies that have made it easier for urologists to consistently offer HoLEP as a safe, efficient, and effective in an ambulatory (day surgery) setting. Methods: Our narrative review focused on contemporary studies published within the last five years. Conclusions: Technological advances coupled with increasing availability of training opportunities has and will continue to improve patients' accessibility to the gold standard in BPH surgical treatment. Furthermore, we will describe refinements in laser enucleation techniques that have improved procedural efficiencies, rates of temporary post-operative urinary incontinence, and preservation of sexual function. The effects of technical modifications on functional and durability outcomes are to be seen in further prospective studies. Level of Evidence: Level 7 (Expert Opinion) [ABSTRACT FROM AUTHOR]

Introduction: Holmium laser enucleation of the prostate (HoLEP) is routinely performed with a 24F, 26F, or a 28F scope. Proponents of the larger scopes propose that a bigger sheath size allows for superior flow and visibility leading to a more efficient operation and better hemostasis. Those utilizing the smaller scopes suggest that the smaller sheath is less traumatic, resulting in lower stricture rates and temporary incontinence. We sought to compare outcomes of ambulatory HoLEP using the 24F and 28F laser scope. Materials and Methods: From May 2022 to March 2023, we randomized patients undergoing HoLEP (<200 cm3 in size) 1:1 to either a 24F or 28F scope. The primary outcome was differences in surgical duration between groups (minutes). Secondary outcomes included surgeon scope evaluation and postoperative patient results. Results: There was no difference in patient characteristics in those randomized to 28F (n = 76) vs 24F (n = 76) (p > 0.05) scopes. Procedural duration and efficiencies were not different between groups (all p > 0.05). The 28F scope was associated with improved surgeon-graded irrigation flow and visibility (p < 0.001). Patients treated with the 28F scope were more likely to achieve effective same-day trial of void (SDTOV) (28F 94.3% vs 24F 82.1%, p = 0.048) and have a shorter length of stay (LOS) (28F 7.0 vs 24F 11.9 hours, p = 0.014), however, rates of same-day discharge (SDD) were not statistically different (28F 87.8% vs 24F 78.4%, p = 0.126). There was no difference between the cohorts in rates of 90-day emergency room presentations, re-admissions, complications, or functional ouctomes (p > 0.05). Conclusions: We identified no clear advantage of scope size with regard to intraoperative or postoperative outcomes at 3-month follow-up due to scope size. However, if SDD is part of your postoperative pathway, the 28F scope may shorten LOS and increase rates of effective SDTOV. Clinicaltrials.gov: NCT05308017. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Prostatic urethral lift (PUL) accounts for approximately one-quarter of all surgical benign prostatic hyperplasia (BPH) procedures performed in the U.S.1 Within five years of a patient's PUL procedure, approximately 1/7 patients will require surgical BPH retreatment.2 We aimed to highlight the evidence of surgical BPH retreatment modalities after PUL, with a focus on safety, short-term efficacy, durability, and relative costs. METHODS: A literature review was performed using PubMed, and an exhaustive review of miscellaneous online resources was completed. The search was limited to English, human studies. Citations of relevant studies were reviewed. RESULTS: No study has examined the efficacy, safety, or durability of transurethral resection of the prostate (TURP) or repeat PUL in the post-PUL setting. Recently, groups have examined laser enucleation (n=81), water vapor thermal therapy (WVTT) (n=5), robotic simple prostatectomy (SP) (n=2), and prostatic artery embolization (PAE) (n=1) in the post-PUL setting. Holmium enucleation of the prostate (HoLEP) after PUL appears to be safe and has similar functional outcomes to HoLEP controls. Other treatment modalities examined appear safe but have limited efficacy evidence supporting their use. Photo-selective vaporization of the prostate (PVP) and robotic waterjet treatment (RWT) have no safety or efficacy studies to support their use in the post-PUL setting. CONCLUSIONS: Despite increasing numbers of patients expected to require surgical retreatment after PUL in North America, there is currently limited evidence and a lack of recommendations guiding the evaluation and management of these patients. HoLEP is associated with the strongest evidence to support its use in the post-PUL setting. [ABSTRACT FROM AUTHOR]

Introduction: Holmium laser enucleation of the prostate (HoLEP) has evidenced-based advantages in treating benign prostatic hyperplasia (BPH) relative to other interventions. Unfortunately, the adoption of HoLEP has remained relatively low in Medicare and the National Surgical Quality Improvement Program populations. HoLEPs role as an inpatient surgical intervention is changing as advancements in the technique and systems have demonstrated the feasibility of same-day discharge. Thus, our objective was to evaluate national HoLEP trends in ambulatory surgery settings from 2016 to 2019. Materials and Methods: The Nationwide Ambulatory Surgery Sample (NASS) is the largest national all-payer database of ambulatory surgical encounters, managed by the Agency for Healthcare Research and Quality. A cross-sectional retrospective analysis of the 2016 and 2019 NASS was performed. Rates of BPH surgeries were calculated and stratified by age, census region, and primary payer to compare across time points for trends. Chi-squared tests and two-sample t-tests were completed for categorical and continuous variables, respectively. Results: The total number of ambulatory BPH surgeries fell 20% between 2016 (n = 124,538) and 2019 (n = 100,593). In 2016, HoLEP lagged behind photoselective vaporization of the prostate (PVP) and transurethral resection of prostate (TURP) with 4.7% of surgeries but rose to the second most common procedure in 2019 with 8.3% of total surgeries. TURP was the most common intervention (62.6% in 2016, 90.7% in 2019). Simple prostatectomy was the most expensive intervention. By U.S. census region, more HoLEPs were carried out in the South (43.1% in 2016, 37.5% in 2019) and Midwest (26.8% in 2016, 31.7% in 2019). Conclusions: Overall, HoLEP uptake is increasing. HoLEP has replaced greenlight PVP as the second most frequently used intervention. The rate of ambulatory HoLEPs has nearly doubled despite a general decrease in the number of surgeries. [ABSTRACT FROM AUTHOR]

Introduction: The effect of prophylactic bladder neck incision (BNI) at time of holmium laser enucleation of the prostate (HoLEP) is unknown. The aim of our study was to examine HoLEP outcomes with a specific focus on rates of bladder neck contractures (BNCs), with and without utilizing prophylactic BNI. Materials and Methods: We performed a retrospective review of HoLEP patients from January 2021 until January 2022. Outcomes of patients who underwent BNI at time of HoLEP were compared with those who underwent standard HoLEP alone. Student's t-tests, chi-square tests, and logistic regressions were performed using SAS Studio. Results: In total, 421 patients underwent HoLEP. BNI was concurrently performed in 74 (17.6%) HoLEP patients. BNI patients were younger (67.5 ± 9.0 years vs 71.1 ± 8.2 years, p = 0.00007) and had smaller prostates (60.7 ± 30.3 cc vs 133.2 ± 64.5 cc, p < 0.0001). Procedure, enucleation, and morcellation times were shorter in the BNI group (all p < 0.0001). There was no statistical difference in same-day discharge rates (90.4% vs 87.7%, p = 0.5), short-term functional outcomes, emergency department (ED) visits, or readmission rates between the two groups. At 14 months mean follow-up, two BNCs occurred in patients in the control group (0.6%), and no BNCs occurred in patients who underwent BNI (0.0%, p = 0.5). Conclusions: BNI at time of HoLEP did not decrease the ability to achieve same-day discharge or increase 90-day complications, ED visits, or readmission rates. No BNCs occurred in patients who underwent prophylactic BNI (0.0%) despite a smaller gland size and lower specimen weight in this cohort. Further prospective studies are required to conclude if concurrent BNI at time of HoLEP is protective against BNC. [ABSTRACT FROM AUTHOR]

Introduction: Intradetrusor onabotulinumtoxinA (OTA) injection is a well-established treatment option for refractory overactive bladder; however, its use at the time of holmium laser enucleation of the prostate (HoLEP) for men with bladder outlet obstruction (BOO) and severe storage symptoms has not been previously reported. Materials and Methods: We retrospectively identified men with BOO and severe storage symptoms who underwent treatment with 200 U of intradetrusor OTA (Botox®) at the time of HoLEP. Patients were propensity score matched to a cohort of HoLEP-only patients based on age, Michigan Incontinence Symptom Index (M-ISI) score, preoperative urinary retention, urge incontinence, and prostate size. Perioperative, postoperative, and patient-reported outcomes were examined between groups. Results: We identified 82 men who underwent HoLEP, including 41 patients in the OTA group and 41 patients in the control group. There was no difference in operative times (59 minutes OTA vs 55 minutes control, p = 0.2), rates of same-day trial of void (TOV) (92% OTA vs 94% control, p = 0.7), or rates of same-day discharge (88% OTA vs 85% control, p = 0.6) between groups. There was no difference in temporary postoperative urinary retention (7% OTA vs 2% control, p = 0.3) between groups. Patients who received OTA injections had a significant reduction in their incontinence scores at 3-month follow-up (M-ISI −8, interquartile range [IQR]: −13 to 0, p < 0.001), whereas control patients did not (M-ISI −5, IQR: −8 to −1, p = 0.2). There was no difference in rates of 90-day complications between groups (OTA 10% vs control 5%, p = 0.7). Conclusions: Intradetrusor OTA at the time of HoLEP is safe and is associated with improved urinary incontinence scores and AUA Symptom Score. Rates of same-day discharge and same-day TOV after HoLEP were not affected by OTA. These findings support the role of OTA as an adjunct to surgical intervention in men with incontinence in the presence of BOO. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to compare holmium laser enucleation of the prostate (HoLEP) outcomes in patients with and without neurologic diseases (ND). Methods: A prospectively maintained database of patients undergoing HoLEP from January 2021 to April 2022 was reviewed. The following NDs were included: diabetes-related neuropathy/neurogenic bladder, Parkinson’s disease, dementia, cerebrovascular accident, multiple sclerosis, traumatic brain injury, transient ischemic attack, brain/spinal tumors, myasthenia gravis, spinal cord injury, and other. Statistical analysis was performed using t-tests, Chi-squared, and binomial tests (p<0.05). Results: A total of 118 ND patients were identified with 135 different neurologic diseases. ND patients were more likely to have indwelling catheters (57% vs. 39%, p=0.012) and urinary tract infections (UTIs) preoperatively (32% vs. 19%, p=0.002). Postoperatively, ND patients were more likely to fail initial trial of void (20% vs. 8.1%, p<0.001) and experience an episode of acute urinary retention (16% vs. 8.5%, p=0.024). Within 90 days postoperative, the overall complication rate was higher in the ND group (26% vs. 13%, p=0.001). Within the ND group, 30/118 (25%) had ≥1 UTI within 90 days preoperative, which decreased to 10/118 (8.7%) 90 days postoperative (p<0.001). At last followup (mean 6.7 months [ND] vs. 5.4 months [nonND], p=0.03), four patients (4.4%) in the ND group required persistent catheter/clean intermittent catheterization compared to none in the non-ND group (p=0.002). Conclusions: Patients with ND undergoing HoLEP are more likely to experience postoperative retention and higher complication rates compared to non-ND patients. While UTI rates are higher in this population, HoLEP significantly reduced three-month UTI and catheterization rates. [ABSTRACT FROM AUTHOR]

Abbreviations Used BPH benign prostatic hyperplasia HoLEP holmium laser enucleation of the prostate QOL quality of life OTA onabotulinumtoxinA UTI urinary tract infection References 1 Creta M, Collà Ruvolo C, Longo N, et al. Patients within our study were offered OTA concurrently at time of HoLEP if they had severe storage symptoms in the setting of benign prostatic hyperplasia (BPH). Thank you Dr. Masheshwari for your interest in our proof-of-concept study performed to assess the safety and efficacy of intradetrusor onabotulinumtoxinA (OTA) at time of holmium laser enucleation of the prostate (HoLEP) for men with severe preoperative urinary storage symptoms. [Extracted from the article]

Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Disclosures: Amy Krambeck is a consultant for Richard Wolf, Storz, Boston Scientific, and on the DSMB for Uriprene.

Objective: To compare the outcomes between those who held or continued antiplatelet or anticoagulation therapy (APAC) for holmium laser enucleation of the prostate (HoLEP)., Methods: We retrospectively reviewed patients on APAC who underwent HoLEP between January 2021 and August 2023 by a single surgeon at a high-volume center. APAC was further categorized to the specific medication: clopidogrel, apixaban, warfarin, rivaroxaban. Preoperative, intraoperative, and postoperative characteristics and outcomes were then compared. SPSS was used for statistical analysis with significance defined as P <.05., Results: One hundred thirty-nine patients were on APAC, of which 82 held and 57 continued APAC: 38 on clopidogrel (21 held), 20 on warfarin (11 held), 57 on apixaban (34 held), 24 on rivaroxaban (16 held). Overall, there were no significant differences between those who held versus those who continued APAC. On sub-analysis, controlling for age and prostate size, patients who held clopidogrel had shorter length of stays (11.3 hours vs 27.3 hours, P = .016), higher likelihood for same-day catheter removal (90.5% vs 47.1%, P = .002) and same-day discharge (90.5% vs 35.3%, P = .002). Patients who held warfarin had shorter procedure (61.3 minutes vs 92.2 minutes, P = .025) and morcellation time (7.36 minutes vs 18 minutes, P = .048)., Conclusion: HoLEP is safe and efficacious in patients whether APAC is held or continued through surgery. Holding APAC in those on clopidogrel may decrease length of stay and improve rates of same-day Foley removal and discharge. Patients who held warfarin had shorter morcellation and procedure times., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Ureteral stone impaction is associated with unfavorable endourological outcomes; however, reliable predictors of stone impaction are limited. We aimed to assess the performance of ureteral wall thickness on noncontrast computed tomography as a predictor of ureteral stone impaction and failure rates of spontaneous stone passage, shock wave lithotripsy, and retrograde guidewire and stent passage., Materials and Methods: This study was completed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A search was conducted in April 2022 for all adult, human, and English language studies investigating ureteral wall thickness using PROSPERO, OVID Medline, OVID EMBASE, Wiley Cochrane Library, Proquest Dissertations & Theses Global, and SCOPUS. A systematic review and meta-analysis using random effects model was conducted. Risk of bias was assessed using the MINORS (Methodological Index for Non-randomized Studies) score., Results: Fourteen studies with a pooled population of 2,987 patients were included for quantitative analysis, and 34 studies were included in our qualitative review. Meta-analysis findings suggest that a thinner ureteral wall thickness is associated with more favorable subgroup stone outcomes. Thinner ureteral wall thickness suggests a lack of stone impaction and was associated with improved rates of spontaneous stone passage, successful retrograde guidewire and stent placement, and improved shock wave lithotripsy outcomes. Studies lack a standardized ureteral wall thickness measurement protocol., Conclusions: Ureteral wall thickness is a noninvasive measure that predicts ureteral stone impaction, and thin measurements are predictive of successful outcomes. Variability in measurement methods confirms that a standardized ureteral wall thickness protocol is needed, and the clinical utility of ureteral wall thickness is yet to be determined.