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The purpose of this review is to summarize the literature on safety and efficacy of minimally invasive thulium laser procedures for benign prostatic hypertrophy (BPH). Recent studies have confirmed long-term safety and efficacy of thulium laser prostatectomy. There has been recent literature published from around the world confirming safety and efficacy in treatment of large prostates, obese patients, and in patients taking oral anticoagulation. Newer thulium laser systems use a wavelength of 1.9μm instead of 2 μm. Thus far, no clinical differences have been seen in outcomes of thulium laser procedures done with this wavelength. The high-power thulium laser was first introduced in 2005 for treatment of BPH [1]. Thulium vapoenucleation (ThuVEP), thulium laser resection of the prostate-tangerine technique (TmLRP), thulium laser enucleation (ThuLEP), and thulium vaporization (ThuVP) are techniques for thulium laser prostatectomy that have been described. Studies using the 70W to 200W thulium laser systems demonstrated good efficacy of these procedures with low morbidity and few complications in prostates of small to medium sizes [2]. Comparative studies have been published comparing thulium laser prostatectomy to monopolar transurethral resection of prostate (TURP), bipolar TURP, and holmium laser enucleation of prostate (HoLEP) [1]. In general, thulium laser prostatectomy appears to have longer operative times, shorter catheterization times, shorter hospital stay, and lower transfusion rates compared to standard and bipolar TURP. Outcomes of HoLEP and thulium enucleation techniques appear to be similar. Overall, thulium laser prostatectomy appears to be very safe and effective with low morbidity [3].

In this review, we examine the current literature regarding the use of cranberry and other complimentary methods for the prevention of catheter-associated urinary tract infections (CAUTIs). Some studies have suggested cranberry products may have a positive effect in reducing the incidence of CAUTIs in patients with normal bladder function receiving short-term catheterization, while other studies have failed to show the benefits of cranberry products for the reduction of CAUTIs. While there is some data suggesting cranberry-derived products may reduce CAUTIs in specific patient populations, there is currently overall insufficient clinical data to recommend broad usage of cranberry products for the reduction of CAUTIs. Many of the studies reviewed have significant limitations in size, design, and lack standardization.

Aim Female urethral stricture disease is rare and has several surgical approaches including endoscopic dilations (ENDO), urethroplasty with local vaginal tissue flap (ULT) or urethroplasty with free graft (UFG). This study aims to describe the contemporary management of female urethral stricture disease and to evaluate the outcomes of these three surgical approaches. Methods This is a multi-institutional, retrospective cohort study evaluating operative treatment for female urethral stricture. Surgeries were grouped into three categories: ENDO, ULT, and UFG. Time from surgery to stricture recurrence by surgery type was analyzed using a Kaplan-Meier time to event analysis. To adjust for confounders, a Cox proportional hazard model was fit for time to stricture recurrence. Results Two-hundred and ten patients met the inclusion criteria across 23 sites. Overall, 64% (n = 115/180) of women remained recurrence free at median follow-up of 14.6 months (IQR, 3-37). In unadjusted analysis, recurrence-free rates differed between surgery categories with 68% ENDO, 77% UFG and 83% ULT patients being recurrence free at 12 months. In the Cox model, recurrence rates also differed between surgery categories; women undergoing ULT and UFG having had 66% and 49% less risk of recurrence, respectively, compared to those undergoing ENDO. When comparing ULT to UFG directly, there was no significant difference of recurrence. Conclusion This retrospective multi-institutional study of female urethral stricture demonstrates that patients undergoing endoscopic management have a higher risk of recurrence compared to those undergoing either urethroplasty with local flap or free graft.

Aims The aim is to assess whether subjects with diabetes mellitus (DM) have greater urinary retention and increased post-void residual volume (PVR) following mid-urethral sling (MUS) surgery. Methods This multi-center retrospective study included patients who underwent MUS (2012-2016). Baseline data included demographics, comorbidities, urinary symptoms, urodynamics data, PVR, and responses to validated questionnaires (UDI6 and IIQ7). Intraoperative data, postoperative voiding trial results, postop questionnaires, and complications were also noted. Patients with and without DM were compared. Significance was defined as P Results A total of 605 MUS were included, 538(89%) without DM and 67(11%) with DM, of which 69% were transobturator and 31% retropubic. No differences were seen in urinary retention and passing void trial(79% DM vs 81% non-DM; P = .72). Mean PVR at discharge was similar between groups (136 mL DM vs 139 mL non-DM; P = .922). There were no differences between groups in UDI6 and IIQ7 sum scores at baseline and 1 month. DM subjects reported more bother at baseline on certain UDI-6 and IIQ-7 items including frequent urination, leakage related to urgency, and feeling frustrated. At 3 months postop, all subjects demonstrated improvement in scores. Interestingly, patients with DM reported worse quality of life on the IIQ7 sum. Conclusions Among subjects with well-controlled diabetes and more comorbidities who underwent MUS there were few differences in postoperative voiding dysfunction or PVR compared to nondiabetic women. DM patients were more bothered at baseline by urge-related symptoms. Quality of life following sling surgery appears to be worse in patients with DM at 3 months based on IIQ7. This data suggests that diabetic women with lower HbA1C can be counseled similarly to these complication rates and voiding dysfunction after MUS.

INTRODUCTION AND OBJECTIVE:Suprapubic tube insertion (SPT) is a commonly performed urologic procedure. However, few studies address its morbidity, and no studies address risk factors for complicati...

Neurogenic bladder due to spinal cord injury has significant consequences for patients’ health and quality of life. Regular surveillance is required to assess the status of the upper and lower urinary lower urinary tracts and prevent their deterioration. In this review, we examine surveillance techniques in neurogenic bladder, describe common complications of this disease, and address strategies for their management. This work represents the efforts of SIU-ICUD joint consultation on Urologic Management of the Spinal Cord injury. For this specific topic, a workgroup was formed and comprehensive literature search of English language manuscripts regarding neurogenic bladder management was performed using key words of neurogenic bladder. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for Levels of Evidence (LOEs) and Grades of Recommendation (GORs). At a minimum, patients should undergo an annual history and physical examination, renal functional testing (e.g., serum creatinine), and upper tract imaging (e.g., renal ultrasonography). The existing evidence does not support the use of other modalities, such as cystoscopy or urodynamics, for routine surveillance. Urologic complications in neurogenic bladder patients are common and often more complex than in the general population. There is a shortage of high-quality evidence to support any particular neurogenic bladder surveillance protocol. However, there is consensus regarding certain aspects of regular genitourinary system evaluation in these patients. Proper surveillance allows the clinician to avoid or address common urological complications, and to guide, alter, or maintain appropriate therapeutic regimens for individual patients.

Sling procedures, which have become the dominant method of surgical management of stress urinary incontinence, are frequently performed by urologists and gynecologists. Few studies investigating trends in surgical management have focused on differences in provision of care between the specialties. In this study we compared national practice patterns of sling procedures by provider type.We analyzed the 2006 to 2013 ACS (American College of Surgeons) NSQIP (National Surgical Quality Improvement Program) database. CPT-4 codes were used to identify patients who underwent sling procedures and any concomitant pelvic floor procedures. Patient and operative characteristics were compared between urologists and gynecologists using bivariate and multivariate analysis.Our analytical cohort included 22,192 sling procedures, of which 5,718 (25.8%) and 16,474 (74.2%) were performed by urologists and gynecologists, respectively. Urologists performed a greater percent of autologous fascial sling procedures than gynecologists (1.16% vs 0.06%, p0.001). Concomitant prolapse repair was performed in 8,664 patients (44.1%), including 954 (16.7%) of urologists and 7,710 (46.8%) of gynecologists. On multivariable analysis urology patients were less likely to undergo concomitant prolapse repair or hysterectomy. Urology patients were more likely to have hypertension and be older, have a higher ASA® (American Society of Anesthesiologists®) class and be current smokers.Gynecologists perform the majority of sling procedures for stress urinary incontinence. While gynecologists perform more concomitant procedures, urologists tend to operate on older patients with more comorbidities. Urologists also perform a greater proportion of autologous fascial sling procedures. These findings demonstrate that, although gynecologists perform a greater number of surgeries, urologists treat a unique population of patients who require operative management of stress urinary incontinence.

Historically, patients failing treatment with anti-muscarinic medications were subjected to bladder augmentation or urinary diversion, invasive procedures with significant complications. The approval of botulinum toxin A (BTX-A) intravesical injections revolutionized the treatment of neurogenic bladder (NGB). Ongoing research efforts to find even less invasive methods of treatments are exploring the possibility of intravesical botulinum toxin instillations for the treatment of neurogenic bladder. This paper reviews BTX-A in the treatment of neurogenic bladder, intravesical instillation of other medications in the treatment of this disease, available research on intravesical instillation of BTX-A for neurogenic bladder, and other forms of voiding dysfunction. Initial research has been done on rodents and human subjects. Some studies on BTX-A intravesical instillations have shown preliminary success and others have shown no improvement compared to placebo. Research groups have used a variety of mechanisms to overcome the low permeability of the bladder wall, including protamine sulfate, DMSO, and liposomes. While studies have shown improvements in markers of bladder pain response, a variety of urodynamic study (UDS) parameters, and patient satisfaction scores, none have shown a decrease in contraction amplitude. The most recent development is the use of liposomes as a delivery system for intravesical instillation of BTX. They have seen some preliminary success as some endpoints were met, others not. There is limited research on intravesical instillation of BTX-A for neurogenic detrusor overactivity. While available data suggests some degree of success in modulating symptoms, the data does not show an increase in bladder capacity or decreased voiding pressure. Further research is needed on the impact of BTX-A intravesical instillations in the NGB patient population.

Introduction: We aimed to assess safety and efficacy of incobotulinumtoxinA for the treatment of neurogenic detrusor overactivity (DO). Methods: We identified patients with neurogenic DO confirmed on urodynamics (UDS) and reported urgency incontinence (UI) in those who received intravesical incobotulinumtoxin A injection for neurogenic bladder between November 2013 and May 2017. Parameters studied were daytime frequency, daily incontinence episodes, daily pad use, clean intermittent catheterization (CIC) volumes, symptom scores (UDI6, IIQ7, PGII), and complications. Results: We examined 17 male patients who met inclusion criteria and underwent incobotulinumtoxinA injection. Mean age was 61.2±15.4 years. Fourteen patients (82%) were taking oral antimuscarinics prior to the incobotulinumtoxin A injection. There were improvements in the following parameters: average daily pads (4.5 to 3.3, p=0.465), daily urinary frequency (9.4 to 4.6, p=0.048), daily incontinent episodes (2.5 to 0.4, p=0.033), CIC volumes (400 to 550 mL, p=0.356), hours in between CIC (3.6 to 5.2, p=0.127), and the validated questionnaires UDI6 (30.6 to 7.4, p=0.543) and IIQ7 (52.4 to 6.8, p=0.029). There were no documented symptomatic urinary tract infections (UTIs) within 30 days of injection or reports of de novo urinary retention. Nine of 17 patients (53%) reported being dry at their first postoperative visit. Conclusions: In this preliminary pilot study of a small cohort of males with neurogenic DO and UI, significant improvements were seen following incobotulinumtoxinA injection in daily frequency, incontinence episodes, hours in between CIC, and quality of life. Larger-scale and long-term studies are required to confirm these results, but initial findings are promising for wider use of this formulation.

INTRODUCTION AND OBJECTIVES:Nocturia, waking ≥1 time to void during sleep with each void preceded by sleep, negatively impacts quality of life. Nocturia patients are a heterogeneous cohort due to its multifactorial causes, both urologic and systemic. Urodynamic (UDS) findings in patients with noctur

Objective We hypothesized that instruments of pelvic floor dysfunction would yield similar responses on web-based and smartphone administration compared with paper. Methods Subjects presenting with pelvic floor disorders were prospectively enrolled at 5 sites and invited to complete 4 validated pelvic floor disorder questionnaires (Pelvic Floor Distress Inventory 20, Pelvic Floor Impact Questionnaire 7, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire 12, Bristol Stool Scale) on both paper and electronic formats, 2 weeks apart, with the order of administration being randomized. Participants completed the questionnaires electronically on the internet via REDCap or using the PelvicTrack App on a smartphone or tablet. Results Two hundred thirty-four subjects were enrolled, and 132 subjects (56%) completed both sets of questionnaires with no intervening treatment. This group was 58 (±15) years old with body mass index 28 (±6) kg/m and parity 2 (1, 3) and was 77% white, 6% African American, 7% Asian, and 10% other. Presenting complaints were classified as 58% urinary, 37% prolapse, and 5% defecatory. There was no difference in overall demographic information between those who completed the second round of questionnaires and those who did not. There was no difference in age between those who chose to complete the questionnaires via REDcap and those who chose to complete the questionnaires via smartphone. Correlation coefficients between questionnaire administration range from 0.5 to 0.8. There was no significant difference in the responses for each total scale and individual scale between the first or second administration. Conclusions We demonstrated moderate to strong reliability between scales of pelvic floor dysfunction administered electronically compared with paper version. Our results strongly suggest that it is feasible and reliable to administer pelvic floor questionnaires in an electronic format on REDCap and on smartphones.

AIMS To analyze patient characteristics, complications, and surgical trends in vesicovaginal fistulas (VVF) from a national database. METHODS Current Procedural Terminology was used to identify patients undergoing VVF repair from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database. Characteristics and treatments were identified. Logistic regression was used to identify characteristics associated with complications. RESULTS From 2006 to 2013, 200 patients underwent VVF repair. Mean age was 50.3 ± 12.3 years. A large proportion of patients were overweight (72%) and recent smokers (30%). Predominant comorbidities were heart disease (29%) and type 2 diabetes (9.5%). Of all VVF repairs, 65% were repaired vaginally. Concomitant procedures included hysterectomy (n = 6), reconstructive flaps (n = 13), and slings (n = 2). Post-operative complications occurred in 15% of patients. The most common complication was urinary tract infection (8%) followed by blood transfusion (3%). Compared to the vaginal approach, abdominal VVF repairs had higher overall morbidity (22% vs 7% P = 0.003), longer length of stay (3.5 ± 2.3 vs 1.6 ± 2 days P = 0.00) and were more likely to be associated with sepsis (4.3% vs 0% P = 0.02), blood transfusion (7.1% vs 0.8% P = 0.017), and readmission (10.1% vs 0.8% P = 0.003). In multivariate analysis, abdominal approach was a significant predictor of complications within 30 days (P = 0.03, P = 0.02). CONCLUSIONS In the US VVF remains a rare entity. Over half of VVFs were repaired vaginally. The occurrence of serious complications is low. A vaginal approach appears to be associated with fewer complications.

INTRODUCTION AND OBJECTIVE:Overactive bladder (OAB) and its treatment options can often be confusing for patients. Increasingly patients with OAB turn to the internet for education material. With a...

Discussion and management of incontinence in a patient with spina bifida by four international experts followed by a literature review.

Objectives Few contemporary studies exist regarding urodynamic (UDS) findings in patients with diabetes mellitus (DM), and data are conflicting. Our aim was to compare UDS findings in women with and without DM. Methods Data from female patients in a prospectively maintained UDS database (2010-2014) were reviewed. Studies were performed according to International Continence Society standards. Clinical data, presenting symptoms, and UDS findings were compared in women with and without DM, controlling for demographic and pertinent variables. Results There were 384 patients who met the inclusion criteria, of whom 88 (26%) had DM. Symptoms at presentation were not statistically different in women with and without DM. Women with DM had larger bladder capacity (mean, 493 mL vs 409 mL; P = 0.005) and had more detrusor underactivity (30% vs 18%, P = 0.042) when compared with nondiabetic women. Diabetic women were more frequently diagnosed as having impaired sensation, or lack of desire to void, at 75% of capacity (17% vs 5%, P = 0.001). In women with diabetes, a serum hemoglobin A1c level of at least 7.5% was associated with delayed first sensation and first urge. Diagnosis of DM of more than 10 years was associated with greater volume at first urge, and maximal capacity, lower detrusor pressures, and higher postvoid residual. Conclusions In this contemporary series, women with DM demonstrated similar presenting complaints to women without DM but had significantly altered UDS findings. Among diabetic female patients, diabetes control and duration of diabetes seem to impact bladder sensation and contractility. Urodynamics may be helpful in diabetic female patients to diagnose underlying concealed bladder dysfunction before initiation of treatment.

The high-power thulium laser was first introduced in 2005 for the treatment of benign prostatic hyperplasia (BPH) ( Barbalat et al., 2016 ). The thulium laser has several properties that confer some theoretical advantages over other lasers used for the treatment of BPH. In ex-vivo animal studies comparing the potassium-titanyl-phosphate and thulium lasers, similar hemostatic properties were observed with a shallower coagulation zone for thulium lasers ( Wendt-Nordahl et al., 2008 ). Thulium vapoenucleation, thulium laser resection - tangerine technique, thulium laser enucleation, and thulium vaporization are techniques for thulium laser prostatectomy that have been described. Studies using the 70–150-W thulium laser systems demonstrated good efficacy of these procedures with low morbidity and few complications in prostates of small to medium sizes ( Gross et al., 2013 ). More recent studies show safety and efficacy in treatment of large prostates and in patients taking oral anticoagulation ( 4 , 5 , 6 ). Comparative studies have been published comparing thulium laser prostatectomy to monopolar transurethral resection of prostate (TURP), bipolar TURP, and holmium laser enucleation of prostate (HoLEP) ( Barbalat et al., 2016 ). In general, thulium laser prostatectomy appears to have longer operative times, but shorter catheterization times, shorter hospital stay, and lower transfusion rates compared to standard and bipolar TURP. Outcomes of HoLEP and thulium enucleation techniques appear to be similar. Overall, thulium laser prostatectomy appears to be very safe and effective with low morbidity ( Gilling, 2013 ).

OBJECTIVE To examine the effects of trainee involvement on fundamental urology procedures. METHODS Current Procedural Terminology codes were used to identify patients within the National Surgical Quality Improvement Program database who underwent a selection of fundamental general urology procedures (2005-2013). Operative time and perioperative complications (30-day) were compared between cases with and without trainee involvement. RESULTS 29,488 patients had general urology procedures with information regarding trainee involvement, 13,251 (44.9%) with trainee involvement, and 16,237 (55.1%) without. Overall patients who underwent procedures with trainee involvement were younger and had fewer comorbidities (Table 1). Trainee involvement showed significant increase in operative time in all procedures included in the study (Table 2). On multivariate analysis trainee involvement increased the risk of complications (Odds Ratio (OR) 1.61, 95% CI 1.45-1.78, P < .001). Other factors that increased the risk of complications were: American Society of Anesthesiologists (ASA) class 3-4 (OR 2.01, 95% CI 1.46-2.77, P < .001), partially or totally dependent functional status (OR 2.22, 95% CI 1.68-2.94, P < .001), diabetes mellitus (OR 1.21, 95% CI 1.05-1.39, P = .008), heart disease (OR 1.19, 95% CI 1.02-1.38, P = .027), and respiratory disease (OR 1.33, 95% CI 1.09-1.63, P = .027). CONCLUSION While trainees are valuable members of the urology team at teaching hospitals and training is necessary, their involvement in urologic surgery appears to increase operative time for all procedures and complications in certain procedures. Further research needs to be done on how to mitigate these effects while preserving surgical education quality.

AIMS To evaluate the utility of catheterized samples in reducing overdiagnosis of UTI based on voided specimens among patients presenting with a range of urinary symptoms. We also aimed to determine variables that may modify the predictive value of the voided midstream urine culture. METHODS Patient charts were reviewed to identify female patients referred to our voiding dysfunction clinic with a range of complaints warranting urine studies (5/2014-8/2016). Patients with a positive voided urine culture who also had a catheterized urine culture in our system were included. Multiple logistic regression analysis was performed to identify patient characteristics associated with a negative catheterized specimen despite a positive voided specimen. RESULTS One hundred and seven women were included in the study. Eighty percent of the cohort was post-menopausal. Although all patients had positive voided specimens, only 53 (49.5%) had positive catheterized specimens. On multivariate analysis negative nitrites on clean catch UA was a significant predictor of a negative catheterized sample (adjusted OR 8.9, 95%CI 2.2-43.7, P = 0.003). WBC/HPF

Pelvic organ prolapse (POP) is a significant problem with many options for surgical correction. Following prolapse surgery, de novo lower urinary tract symptoms (LUTS) are not uncommon. We review the current literature on de novo lower urinary tract symptoms following POP repair and discuss the role of urodynamics in the evaluation of the prolapse patient. Patients with occult stress urinary incontinence (SUI) appear to be at higher risk of developing de novo SUI after POP repair. Prolapse reduction in patients undergoing urodynamic evaluation is important. Different types of POP repair influence rates of de novo SUI. Also, prophylactic anti-incontinence procedures at time of POP repair appear to lower the incidence of de novo SUI, but at the cost of increased risk of complications and morbidity. Pre-existing overactive bladder (OAB) symptoms may either improve or persist, and de novo OAB can develop. The specific role of urodynamic study testing for POP is still being determined. Increasingly, women are seeking surgical treatment for POP. Aside from complications related to surgery in general, proper patient counseling is important regarding the risk of development of de novo voiding problems following surgery. Despite a growing body of literature looking at de novo voiding symptoms after prolapse repair, more studies are still needed.

Objective To explore patient characteristics and complications of simple cystectomy for benign disease. A secondary objective was to compare these parameters to those in radical cystectomy. Methods Current Procedural Terminology codes were used to identify patients within the National Surgical Quality Improvement Program who underwent cystectomy (2005-2014). International Classification of Disease, Ninth Revision, codes were used to classify patients with benign or malignant diagnoses. Perioperative complications (30 days) were identified and logistic regression analysis was used to identify factors associated with morbidity. Results We identified 389 patients who had a cystectomy for benign diagnosis. A total of 235 patients (60.4%) had complications. The most frequently reported complication was bleeding (requiring a transfusion within 72 hours) in 150 patients (38.6%). Other complications were wound infection (63, 16.2%), respiratory complication (29, 7.5%), wound dehiscence (8, 2.1%), renal complication (9, 2.3%), cardiovascular complication (6, 1.5%), and postoperative deep vein thrombosis (8; 2.1). On multivariate analysis, diabetes (odds ratio 1.9, P = .04) and smoking (odds ratio 1.8, P = .03) were associated with increased odds of any complication. Compared with those with cystectomy for malignancy, this cohort was younger, with higher American Society of Anesthesiologists scores, and chronic kidney disease stages, and the complication risk was similar (60.4% vs 57.7%, P = .3). Conclusion Our data suggest that the benign and radical cystectomy patients are different patient populations, with benign patients being younger with a higher American Society of Anesthesiologists class. Even in benign disease, cystectomy is not without risk, and patients should be counseled accordingly.

The use of mesh in vaginal cystocele repair has decreased. We analyzed the ACS NSQIP® (American College of Surgeons National Surgical Quality Improvement Project) database to compare outcomes of repairs with and without mesh.CPT was used to identify patients who underwent cystocele repair with and without mesh from 2006 to 2013. Patient characteristics and complications were analyzed.We identified 6,849 patients, of whom 5,667 (82.5%) underwent native tissue repair and 1,182 (17.5%) underwent repair with mesh. Patients who received mesh were older (mean ± SD age 64 ± 11 vs 60 ± 12 years, p0.001) and more had comorbidities (56% vs 47%, p0.001). Mean mesh vs nonmesh operative time (97 ± 67 vs 95 ± 53 minutes, p = 0.2) and mean length of stay (1.3 ± 2.4 vs 1.4 ± 1.3 days, p = 0.2) were similar in the 2 groups. Urinary tract infection was the most common complication in cases without vs with mesh (3.8% vs 3.5%). Mesh procedure rates of mortality (0% vs 0.3%, p = 0.04) and overall surgical complications (1.8% vs 3.9% p0.001) were higher. On multivariate analysis ASA® class 3 or greater (OR 1.4, p = 0.01), longer operative time (OR 1.004, p0.001) and mesh (OR 1.32, p = 0.05) were associated with greater morbidity. Patient comorbidities, surgeon specialty and concomitant procedures did not confer an increased risk of complications.Native tissue repair is performed more commonly than mesh repair. ASA class, operative time and mesh use are associated with an increased risk of postoperative morbidity. These results suggest an increased risk of complications when using mesh in vaginal anterior repair, although the overall risk in each procedure was low.

The thulium laser was introduced in 2005 for the treatment of benign prostatic hyperplasia (BPH). Enucleation studies from outside North America show comparable efficacy and lower morbidity to transurethral resection of the prostate. A few studies exist describing outcomes of vaporization, the most commonly used technique for urologists. We present our 3-month outcomes of thulium laser vaporization of the prostate (ThuVP).From December 2010 to October 2013, 68 men underwent ThuVP using the 150 W CyberTM(®). Data were collected on demographics, comorbidities, intraoperative measures, complications, serum parameters, maximum flow rate (Qmax), postvoid residual (PVR), International Prostate Symptom Score (IPSS), quality-of-life (QoL) score, and prostate-specific antigen. Patients were evaluated at 1 week, 1 month, and 3 months postoperatively. Nine patients were excluded for known prostate cancer.The mean age was 66±10 years, with a mean prostate size of 57±30 mL. At baseline, the mean IPSS was 19.9±8.0, QoL score was 4.5±1.1, Qmax was 5.2±4.5 mL/sec, and PVR was 220±397 mL. The mean laser time was 35±18 minutes, and energy used was 234±139 kJ. Forty-seven (78%) patients were discharged the day of surgery. No blood transfusions were administered with a mean drop in hemoglobin of 0.7±0.8 g/dL (p0.05). There were no Clavien grade≥III complications within 30 days of surgery. Six (10%) patients were diagnosed with urinary tract infection. Significant improvements from baseline were seen in Qmax, PVR, IPSS, and QoL score. All 15 patients who were in retention were voiding at the last follow-up.Thulium laser vaporization of the prostate appears to be a safe and effective outpatient technique for the treatment of BPH with durable outcomes at 3 months.

In 2005, the high power thulium laser was introduced for the surgical treatment of benign prostatic obstruction. It has several properties that confer theoretical advantages over other lasers used for the same indication, such as technical versatility and a relatively small zone of thermal damage. Studies using the 70–150 W thulium laser systems demonstrate good efficacy of these procedures with low morbidity and few complications even in higher risk patients. Different techniques have been employed to treat the prostate with this technology, including enucleation, vapoenucleation, vaporization and resection. Comparative studies have been published comparing thulium laser prostatectomy to monopolar transurethral resection of prostate (TURP), bipolar TURP and holmium laser enucleation of prostate (HoLEP). In this review we discuss the current literature on the safety and efficacy of various thulium techniques for the treatment of benign prostatic hyperplasia and examine comparative studies.

Purpose: Decision-making regarding surgery for post-prostatectomy incontinence (PPI) is challenging. The 24-hour pad weight test is commonly used to objectively quantify PPI. However, pad weight may vary based upon activity level. We aimed to quantify variability in pad weights based upon patient-reported activity. Materials and Methods: 25 patients who underwent radical prostatectomy were prospectively enrolled. All patients demonstrated clinical stress urinary incontinence without clinical urgency urinary incontinence. On three consecutive alternating days, patients submitted 24-hour pad weights along with a short survey documenting activity level and number of pads used. Results: Pad weights collected across the three days were well correlated to the individual (ICC 0.85 (95% CI 0.74–0.93), p

We examined the effect of 5α-reductase inhibitor therapy on prostate cancer detection in men with persistently increased or fluctuating prostate specific antigen and prior negative prostate cancer biopsy.A total of 276 men with prostate specific antigen greater than 4 ng/ml (208) or a prostate specific antigen velocity change of 0.75 ng/ml (68) and a normal digital rectal examination who had previously undergone biopsy a minimum of 2 times with prostate cancer not detected were given 5 mg finasteride (154) or dutasteride (122) daily. In phase 1, 97 patients had prostate specific antigen measured at 6 and 12 months with repeat transrectal ultrasonography and biopsy (12 cores) performed at 1 year. In phase 2, 179 patients underwent biopsy triggered by a change in nadir prostate specific antigen of more than 0.4 ng/ml.In phase 1 at 1 year prostate specific antigen had decreased by 2.4 ng/ml (-46.7%), and prostate volume had decreased 7.1 ml (-17.9%). Prostate cancer was detected in 27 of 97 (27.8%) patients and the mean minimum prostate specific antigen velocity from a nadir of 0.4 ng/ml was 0.6 ng/ml. In phase 2, 48 of 179 (26.8%) men underwent repeat biopsy at a mean of 14.6 months. Of these 48 men 26 (54.1%) were found to have prostate cancer. Of the 26 men in whom prostate cancer was detected 20 (76.9%) were found to have Gleason score 7 or greater disease.The magnitude of change in serum prostate specific antigen after 5α-reductase inhibitor therapy may be useful in diagnosing prostate cancer in patients with persistently increased or fluctuating prostate specific antigen and prior negative prostate biopsy.

The International Continence Society definition of overactive bladder syndrome (OAB) is “urgency, with or without urge incontinence, usually with frequency and nocturia.” OAB syndrome is a very common condition, estimated to affect 12% to 22% of women and men in Europe and 16% to 17% in the United States. The muscarinic receptor antagonists are first-line pharmacotherapy in treatment of OAB. In North America, six antimuscarinic drugs are marketed for treating OAB: oxybutynin, tolterodine, fesoterodine, trospium, darifenacin, and solifenacin. In our review, we summarize the pharmacology, efficacy, and adverse events of commonly used anticholinergic agents.

Patients on anticoagulation are at high risk for bleeding after electrocautery transurethral resection of the prostate or open prostatectomy and they are often denied surgery for symptomatic benign prostatic hyperplasia. Using photoselective vaporization of the prostate, patients at high risk may safely undergo surgery. We explored outcomes and complications after photoselective vaporization of the prostate in an anticoagulated, high risk cohort.Between 2002 and 2008, 162 men on systemic anticoagulation underwent photoselective vaporization of the prostate. Data were collected on demographics, comorbidities, complications, serum sodium, hematocrit, maximum flow rate, post-void residual urine, International Prostate Symptom Score and complications.Mean±SD age was 72±8 years, mean baseline prostate volume was 91±49 gm and mean prostate specific antigen was 4.1±5 ng/ml. Of the patients 31 (19%) were on warfarin, 101 (62%) were on acetylsalicylic acid, 19 (12%) were on clopidogrel and 11 (7%) were on 2 or more anticoagulants. Median American Society of Anesthesiologists class was 3 and mean Charlson comorbidity index was 5. Median operative time was 105 minutes and mean energy use was 280±168 kJ. The immediate mean hematocrit decrease was 1.94%±2.42%. One patient who received excessive intravenous fluids experienced heart failure. Complications within 30 days included urinary tract infection in 4 patients (2.5%) and delayed bleeding in 6 (4%). Three of these patients (50%) required blood transfusion and 1 (17%) required reoperation. In 2 years of followup 3 patients (2%) required repeat photoselective vaporization of the prostate. No incontinence or urethral stricture developed. Significant improvements occurred in International Prostate Symptom Score, maximum flow rate and post-void residual urine.Results support using 532 nm photoselective vaporization of the prostate in patients at high risk on systemic anticoagulation, even those on 2 or more anticoagulation agents and with a large prostate requiring longer operative time. Few complications developed and significant durable clinical improvement was seen.

The mainstays of treatment for overactive bladder are antimuscarinic medications. Oral formulations are limited by low patient adherence secondary to anticholinergic side effects (eg, dry mouth). The transdermal oxybutynin formulations oxybutynin transdermal patch (OXY-TD) and oxybutynin transdermal gel (OXY-TGEL) were developed to decrease levels of N-desethyloxybutynin and potentially limit anticholinergic adverse events. Both are efficacious in decreasing urge incontinence compared with placebo. The pharmacokinetics of OXY-TD and OXY-TGEL are similar. Compared with oral oxybutynin, OXY-TD evokes a lower proportion of N-desethyloxybutynin, likely translating to decreased dry mouth. Another advantage of OXY-TD is ease of administration (twice weekly). Unfortunately, application site reactions limit patient adherence. In 12-week studies, OXY-TGEL is effective in decreasing urinary incontinence and urinary frequency. Incidence of application site reactions appear lower than for OXY-TD. Future studies are required to evaluate the impact of OXY-TGEL on quality of life, and long-term studies are needed to confirm its safety and efficacy.

Objectives To assess safety and efficacy of 4 mg tolterodine extended release (TER) with 0.5 mg dutasteride (DUT) in men with persistent overactive bladder (OAB) symptoms and lower urinary tract symptoms (LUTS) unsuccessfully treated with DUT alone. TER is indicated for OAB and DUT is indicated for LUTS from benign prostatic hyperplasia. Methods A total of 51 men treated with DUT for ≥6 months with persistent OAB symptoms enrolled in a 12-week, open-label study, and given TER (4 mg q.h.s.). Inclusion criteria were international prostate symptom score (IPSS) ≥12, IPSS quality-of-life item ≥3, significant bother, frequency (≥8 voids/24 h), and urgency (≥3 episodes/24 h). Visits occurred at 4, 8, and 12 weeks. Efficacy was assessed by changes in diary endpoints and IPSS (total, storage, and voiding). Safety was assessed by changes in postvoid residual, peak flow rate (Qmax.), adverse events, and retention. Results Baseline prostate volume was 54.3 mL. TER significantly reduced frequency and urgency: 24-hour micturition frequency (−3.2, P

PURPOSE OF REVIEW Traditionally, the gold standard for treatment of benign prostatic hyperplasia was the electrocautery-based transurethral resection of the prostate. The number of laser techniques performed is rapidly increasing. Advantages of laser include decreased morbidity and shorter hospitalization. Our purpose is to review current status of the high-power 532 nm laser prostatectomy. RECENT FINDINGS The 120 W, 532 nm laser differs from the 80 W, 532 nm laser in higher power, better beam collimation, and greater efficiency. Animal studies suggested that slower sweep speed might increase vaporization efficiency. However, we believe that this may not correctly guide clinical recommendations in humans due to differences in tissue composition, instrumentation, and techniques utilized. Studies demonstrated that 532 nm laser prostatectomy is safe and effective in patients with large prostates, high comorbidity, and in those taking oral anticoagulation. There is a short learning curve, reported to be less than five cases in urologists, with previous transurethral resection experience. Several studies have compared these two techniques with transurethral resection of the prostate. Frequently reported advantages of holmium laser enucleation of the prostate over the 532 nm laser prostatectomy are the availability of a pathology specimen and ability to remove a higher percentage of prostate tissue. However, the transurethral laser enucleation of the prostate addresses these concerns and has shown durable outcomes at 2-year follow-up. SUMMARY Laser prostatectomy has proven to be a safe, efficacious, and durable surgical intervention to relieve symptomatic bladder outlet obstruction.

Traditionally, the gold standard for treatment of BPH has been the electrocautery-based TransUrethral Resection of the Prostate (TURP). However, the number of laser techniques being performed is rapidly increasing. Potential advantages of laser therapy over traditional TURP include decreased morbidity and shorter hospital stay. There are several techniques for laser prostatectomy that continue to evolve. The main competing techniques are currently the Holmium Laser Enucleation of the Prostate (HoLEP) and the 80W 532nm laser prostatectomy. The HoLEP, using the Holmium:YAG laser, has been shown to have clinical results similar to TURP and is suitable for patients on anticoagulation as well as those with large prostates. Disadvantages of this technique are the high learning curve and requirement of a morcellator. When used to treat BPH, studies have demonstrated that, like the HoLEP, the 80W KTP laser is safe and effective in patients with large prostates and in those taking oral anticoagulation. Several studies have compared these two techniques to TURP. Frequently reported advantages of the HoLEP over the 80W laser prostatectomy are the availability after the procedure of a pathology specimen and ability to remove a higher percentage of prostate tissue during resection. However, the transurethral laser enucleation of the prostate addresses these concerns and has shown to have durable outcomes at 2-year follow-up. Two new laser systems and techniques, the thulium laser and the 980nm laser, have emerged recently. However, clinical data from these procedures are in their infancy and large long-term studies are required.

Objective To compare outcomes after retropubic sling (RPS) in women with and without Valsalva voiding. Methods Women who underwent RPS for stress incontinence from 2010 to 2014 were identified and their baseline characteristics were examined. Valsalva voiding was defined as abdominal straining throughout voiding on preoperative urodynamics. Sub-analysis of those with Valsalva included a subset with detrusor underactivity on urodynamics. Follow-up was at 1, 3, 6, and 12 months. Primary outcomes were rates of subjective success, revisions, complications, and voiding dysfunction. Secondary measures were Urogenital Distress Inventory (UDI-6) score, Incontinence Impact Questionnaire (IIQ-7) score, post-void residual, and pad use. Results Subjects (n = 141) analyzed included 75 Valsalva voiders (VV) and 66 non-Valsalva voiders. At baseline, there were no differences in age, race, comorbidity, post-void residual, pad use, UDI-6, or capacity. Postoperatively, there were no differences in rates of passing initial void trial, need for clean intermittent catheterization, revisions, complications, or voiding dysfunction. No differences in pad use, UDI-6, or IIQ-7 were seen at 6 or 12 months. Within VV, no differences between patients with and without detrusor underactivity were seen for any primary or secondary outcomes (all P > .05). Conclusion In patients who void with Valsalva, RPS appears to be safe and effective. Between VV and non-Valsalva voiders, there were no differences in rates of subjective success, revisions, or complications, even in patients with Valsalva voiding without appreciable detrusor contraction.

The thulium laser has several properties that confer some theoretical advantages over other lasers used for the treatment of BPH such as a relatively small zone of thermal damage. In ex vivo animal studies comparing the KTP and thulium lasers, similar hemostatic properties were observed with a shallower coagulation zone (Wendt-Nordahl et al. J Endourol. 2008;22:1041). Two main techniques for laser resection and vapoenucleation have been described: ThuVEP and TmLRP (Xia et al. Eur Urol. 2008;53:383, Bach et al. World J Urol. 2007;25:257). Studies using the 70–120-W thulium laser systems demonstrate good efficacy of these procedures with low morbidity and few complications in mostly small- and medium-sized prostates (Gross et al. Eur Urol. 2012;63:859). Safety and efficacy has also been demonstrated in patients taking oral anticoagulation (Macchione et al. Int Urol Nephrol. 2013;45:1545–51). Comparative studies have been published comparing thulium laser prostatectomy to monopolar TURP, bipolar TURP, and HoLEP. Compared to all these techniques, thulium laser prostatectomy had a longer operative time and demonstrated superior blood loss compared to TURP techniques. Short- and intermediate-term improvements in IPSS, QoL, Qmax, and PVR were similar across techniques. Overall thulium laser resection and vapoenucleation, and enucleation techniques appear safe and effective with low morbidity. Further comparative and long-term studies are needed for this promising technology, particularly in larger prostates.

The high-power thulium laser was introduced in 2005 for the treatment of BPH. So far the vast majority of published studies using the thulium laser for BPH have employed enucleation, vapoenucleation, or laser resection techniques with very few describing pure vaporization. Studies using the 70–120 W thulium laser systems demonstrate good efficacy of these procedures with low morbidity and few complications. Our technique for thulium laser vaporization of the prostate (ThuVP) is simple, systematic, and is fully described in this chapter. Short-term data demonstrate significant improvements in IPSS, QoL, Qmax, and PVR. The procedure may be done on an outpatient basis, and low morbidity is experienced.

This chapter will focus on the highly prevalent condition of pelvic organ prolapse (POP). POP is a leading cause of morbidity in aging female adults and has a variety of clinical presentations. Unfortunately, there is a lack of uniformity in the approaches to POP and there is much misinformation among patients and in the lay media. Recent concerns about some of the surgical treatments of POP with synthetic mesh have heightened awareness and drawn attention to this condition. This chapter will look at the epidemiology of POP and associated risk factors. The etiology of these conditions and diagnostic criteria will also be explored. Finally, the clinical evaluation will be outlined followed by a thorough analysis of both conservative therapies and surgical options in older women.

Metastatic papillary renal cell carcinoma (RCC) to the heart has never been reported. We report the case of a 73-year-old patient with papillary RCC metastatic to the left and right ventricles, found during a triple vessel coronary artery bypass graft surgery

Introduction: The objective was to determine the prevalence of, and factors that predict, detrusor underactivity (DU) in patients presenting with incontinence or lower urinary tract symptoms (LUTS) following radical prostatectomy (RP). We also determined the prevalence of bladder outlet obstruction (BOO) and detrusor overactivity (DO) in this population. Methods: Patients who underwent urodynamics post-RP were identified. Detrusor underactivity was defined as a maximum flow rate (Qmax) of ≤15 mL/s and detrusor pressure (Pdet) Qmax