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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: 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]

To compare perioperative outcomes between Holmium laser enucleation of the prostate (HoLEP), open simple prostatectomy (OSP), and robotic simple prostatectomy (RSP) for large prostates (> 80 cc). A retrospective study of 340 patients who underwent HoLEP (n = 209), OSP (n = 66), or RSP (n = 65) at a large academic medical center between January 2013 – September 2021 was performed. Length of stay (LOS), operative time, catheter duration, estimated blood loss (EBL), blood transfusion, and 30-day ED visits and readmissions were compared between the three groups. Univariate analyses consisted of ANOVA with Tukey's corrections and Chi-square tests. Linear and multivariate logistic regression was also performed. All tests were two-sided and a p-value <0.05 was pre-determined to be statistically significant. Analyses were performed with SAS v9.4. HoLEP was found to have the shortest: operative time (1.4 vs 2.7 vs 3.8h), LOS (0.65 vs 4.2 vs 2.6d), and catheter duration (0.38 vs 9.9 vs 11.2d) compared to OSP and RSP, respectively (all P <.0001). HoLEP also had the lowest EBL (66 vs 795 vs 326 mL, P <.0001). HoLEP and RSP had a lower risk of blood transfusion compared to OSP (P <.0001). These associations remained significant on multivariable analyses. HoLEP is a minimally invasive treatment option for large prostates that was found to have shorter operative time, LOS, and catheter duration as well as lower EBL compared to OSP and RSP. [ABSTRACT FROM AUTHOR]

Introduction: Tranexamic acid (TXA) is a clot promoting agent utilized during orthopedic procedures to decrease bleeding. Urologists have demonstrated the benefits of TXA in percutaneous surgery. Our objective was to assess the safety and efficacy of single-dose TXA on same-day holmium laser enucleation of the prostate (HoLEP) outcomes. Methods: From September 2021 to January 2022, we prospectively randomized 110 patients undergoing HoLEP to either 1 g of TXA after induction or no treatment. Institutional Review Board (IRB) approval (STU00215134) and registry with ClinicalTrials.gov (NCT05082142) were obtained before enrollment. Primary outcome was the rate of effective same-day discharge (SDD). Secondary outcomes included transfusion rate, same-day catheter removal, length of stay (LOS), and 90-day complications. Power analysis determined that 110 patients should be enrolled to detect a 25% difference in SDD rate. Results: There was no difference in patient demographic and prostate features between the control (n = 55) and TXA groups (n = 55; all p > 0.05). The overall rate of effective SDD was not different between the control and TXA groups (49/55 [89%] vs 51/55 [93%], p = 0.74). Median LOS (hh:mm) was not different between groups (03:07 vs 02:50, p = 0.23) with only 3/110 (2.7%) having an LOS >24 hours. Effective same-day catheter removal occurred in 99/110 (90%) patients with no difference between groups (49/55 vs 50/55, p = 0.99). There was no difference in operative parameters (time, energy, specimen weight) and postoperative complications between groups (all p > 0.05). No patients required transfusions and there were no major 90-day complications related to surgery (Clavien–Dindo ≥IIIb). Conclusion: TXA administration is safe but did not impact SDD after HoLEP. [ABSTRACT FROM AUTHOR]

Purpose: We sought to objectively compare laser fiber degradation for holmium laser enucleation of the prostate (HoLEP) cases performed with 550 μm standard fibers versus 550 μm Moses 2.0 fiber in BPH mode on a macroscopic and microscopic level. Methods: We prospectively collected outcomes for 50 standardized HoLEP cases using 550 μm Moses fiber with 2.0 BPH mode compared to our historical cohort of 50 patients using 550 μm standard fibers on regular mode. Macroscopic degradation length was the difference in length of exposed fiber at the start and end of each case. Five consecutive 550 μm standard fibers, five 550 μm Moses fibers and their respective controls underwent novel utilization of three objective corroborating imaging techniques: Brightfield high resolution microscopy, high resolution 3-D microCT and Confocal Reflection Surface Analysis. Mann–Whitney U, 2-tailed T tests and Chi-squared tests were used. Results: Standard fibers demonstrated greater degradation than the Moses fibers with 2.0 BPH mode [2.9 cm (IQR 1.7–4.3 cm) vs 0.2 cm (IQR 0.1–0.4 cm), p < 0.01]. This difference remained significant when comparing degradation per energy used, per minute enucleation and per gram enucleated (all p < 0.05). None of the cases with Moses fiber and 2.0 BPH mode required intraoperative interruption to re-strip the fiber. Objective fiber degradation by three microscopic techniques confirmed more damage to the standard fibers with regular mode. Conclusion: Overall, use of the 550 μm Moses fiber with 2.0 BPH mode resulted in less fiber degradation compared to a standard 550 μm fiber with regular mode as confirmed using 4 corroborating macroscopic and microscopic techniques. [ABSTRACT FROM AUTHOR]

Introduction: Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for the management of benign prostatic hypertrophy. Although advancements in laser technology have led to clinical improvements in the enucleation portion of HoLEP, the morcellation aspect of HoLEP is often the rate-limiting step. We sought to compare efficiency and surgeon satisfaction in four commercial morcellators. Methods: This was an ex vivo study comparing four commercial morcellators: the Wolf Piranha™, the Lumenis VersaCut™, the JenaSurgical MultiCut Solo™, and the Hawk™ Morcellator. Four surgeons with significant experience performing HoLEPs participated. Surgeons tested each device to morcellate two different prostate models (1) morcellating as much microwave-cooked chicken breast in 10 minutes and (2) timed morcellation of bull testicles. Surgeons completed subjective surveys after each morcellator trial. Objective outcomes included the following: morcellation efficiency (g/min morcellated) and aspiration power (time to aspirate 1 L of saline). Means of continuous variables were compared using analysis of variance. Categorical variables were compared using chi-square tests. Statistical analyses were performed using SAS 9.4 (2019). Results: Comparing subjective outcomes, the Piranha™ was chosen as the safest morcellator (p = 0.0058). The least safe morcellator was thought to be the MultiCut by 75% of surgeons (p = 0.046). The Piranha™ was chosen as the most effective morcellator by 75% of surgeons (p = 0.046). Comparing objective parameters between the morcellators, the Piranha™ had the fastest aspiration time (43.50 ± 10.34 seconds, p = 0.0116). There were no significant differences in morcellation efficiency when using chicken breast (p = 0.3096). However, when comparing the morcellation efficiency using bull testicles, the Piranha™ had the highest efficiency at 39.68 ± 3.57 g/min (p = 0.0268). Conclusion: In this ex vivo study comparing four different commercially available morcellators, the Piranha™ had the highest aspiration power. No significant differences were found in morcellation efficiency using microwave-cooked chicken breast. The Piranha™ was felt to be the safest and most effective morcellator. [ABSTRACT FROM AUTHOR]

Objective: To investigate perceived barriers to successful same-day discharge (SDD) after holmium laser enucleation of the prostate (HoLEP) from the perspective of surgical and nursing staff members.Methods: A 17-question survey was administered to intraoperative and postoperative surgical staff in June 2021 after a six-month period of implementing a SDD HoLEP pathway with same-day catheter removal. McNemar's and Stuart-Maxwell tests were performed for statistical analysis.Results: Surveys were completed by 30 respondents. The majority of respondents had less than 5 years of surgical experience (63%). Almost all respondents (96%) felt that HoLEP patients could be discharged safely on day of surgery. Overall, 60% felt that HoLEP had a lower risk of post-operative bleeding compared to other transurethral surgeries. There was a significant decrease in number of respondents that felt apprehensive when comparing initiation of SDD HoLEP pathway to 6-months post-implementation (43% vs 7%, P = .003). The most common factors causing apprehension both pre- and post-implementation included: degree of hematuria (43% vs 40%, P = .56), risk of failure of trial of void (40% vs 30%, P = .26), and risk of readmission or unplanned emergency department (ED) visit (33% vs 30%, P = .48). There was a significant decrease in the number of respondents who were apprehensive about lack of experience with SDD after HoLEP comparing pre- and post-implementation (20% vs 0%, P = .01).Conclusion: While staff report initial apprehension regarding implementation of a SDD HoLEP pathway, adequate support to intraoperative and postoperative teams helps build experience that alleviates these concerns. [ABSTRACT FROM AUTHOR]

Introduction: Although holmium laser enucleation of the prostate (HoLEP) is a highly effective surgery, there is a variable recovery period where patients may experience hematuria, dysuria, or urinary incontinence (UI). Despite preoperative consultation, there is a paucity of literature examining the effectiveness of physician-patient communication in preparing the patient for the postoperative recovery period. We sought to examine recovery expectations as a patient-reported outcome (PRO) metric for HoLEP. Methods: With institutional review board approval, we queried our electronic medical record and retrospective clinical registry to identify 50 consecutive patients that underwent HoLEP from November 2019 to March 2020 by two endourologists. Patients were provided questionnaires via Twistle© ≥6 months postoperatively. Patient demographics and perioperative course was examined in the context of responses. Our primary objective was determining whether patients felt they had a reasonable understanding of the recovery process. Results: We observed a 92% (46/50) response rate, with an average patient age of 69.4 years (range 55-88). Overall, 91.3% (42/46) felt they had a reasonable understanding of the recovery. Additionally, 97.8% (45/46) were aware of temporary UI, with 87% having ≥1 episodes of UI after catheter removal. We found 47.8% (22/46) of patients expected UI to resolve within 30 days, while 8.6% expected >90 days of UI. All patients were aware of the risk of hematuria, with 93.5% (43/46) expecting resolution within 30 days (<7 days: 47.8%; 7-14 days: 28.3%; 15-30 days: 17.4%). Conclusions: Although surgical technique continues to improve HoLEP, ensuring adequate physician-patient communication to optimize expectations is crucial. We report patient understanding of HoLEP recovery and areas for future improvement. [ABSTRACT FROM AUTHOR]

Objectives: To determine if patients were obtaining opioids after HoLEP from other sources - despite our opioid-free postoperative pathway - we utilized a national prescription drug monitoring program (PDMP) to review all patients who underwent HoLEP at our institution.Methods: We performed a retrospective review of all HoLEPs completed by two fellowship-trained surgeons. We utilized a national PDMP to determine the true rate of postoperative opioid use. The primary outcome was filling of an opioid prescription within 31 postoperative days. Student t-tests and chi-square tests were used to compare continuous and categorical variables, respectively.Results: From July 2018-July 2020, 284 men underwent HoLEP. Despite our opioid-free pathway, 35 men (12.4%) received postoperative opioids. Unfortunately, 41.2% of opioids were prescribed by our inpatient physician assistant on his own accord. To prevent confounding, these patients were excluded from primary analyses. Thus, only 7.4% of patients received postoperative opioids. On univariate analysis, surgeon experience, chronic opioid use, any opioid exposure, benzodiazepine use, and chronic pain were associated with postoperative opioid use. On multivariate analysis, only preoperative opioid exposure (OR 41.9, P = 0.0383) was identified as a significant variable.Conclusion: 92.6% of patients did not obtain postoperative opioids on our opioid-free post-HoLEP pathway, but 7.4% of patients did obtain opioids from outside sources. Proper education of the surgical team is key to prevent inappropriate opioid prescribing. On multivariate analysis, we identified that any preoperative opioid exposure was associated with an increased risk of obtaining postoperative opioids. [ABSTRACT FROM AUTHOR]

Purpose: To perform a global survey to identify contemporary practice patterns of transurethral therapies for benign prostatic hypertrophy. Methods: A REDCap survey was distributed to the ~ 3500 members of the Endourological Society. Surgeons completed demographic information and then selected the BPH therapies they perform 10 cases/year. There were four categories of BPH therapies: ablation, enucleation, resection/vaporization, and MIST (minimally invasive surgical technique). Within each category, there were subcategories to account for different energy modalities. All statistical analyses were performed using SAS 9.4. Results: A total of 175 surgeons responded to our survey. Prostate resection/vaporization remained the most commonly utilized technique (51.9%, n = 147/283) followed by enucleation (22.6%, n = 64/283). Bipolar TURP (bTURP) was the most common modality for prostate resection (69.4%, n = 102/147). Holmium laser enucleation (HoLEP) was the most common modality for enucleation (46.9%, n = 30/64). Urolift® was performed more often than Rezūm™ (55.9% vs. 44.1%, n = 19/34 vs. 15/34, respectively). Among surgeons performing ablation, country of practice was a significantly associated with length of stay (LOS), p < 0.0001. For surgeons performing enucleation, academic institution and completion of a fellowship were associated with postoperative day (POD) 1 catheter removal (p = 0.0240 and p = 0.020, respectively). Conclusions: In this contemporary, global survey of the Endourology Society, resection/vaporization techniques were the most commonly performed. Rates of MISTs remained relatively low at 12.1%. Academic institution and fellowship status were associated with shorter catheterization times and LOS for certain surgical categories. [ABSTRACT FROM AUTHOR]

Background: Holmium laser enucleation of the prostate (HoLEP) is a highly effective and durable minimally invasive surgery for benign prostatic hyperplasia. Historically, alternative treatments for large glands (≥175 cc) are associated with prolonged length of stay (LOS) and postoperative catheterization. However, advances in laser technology combined with surgical technique optimization have early evidence supporting same-day discharge. We look to examine contemporary same-day discharge outcomes for large glands. Materials and Methods: With Institutional Review Board (IRB) approval we queried our electronic medical record and retrospective clinical registry to examine perioperative outcomes of large gland (≥175 cc) prostates that underwent HoLEP with consideration for same-day discharge. Results: From December 10, 2019 to September 29, 2020 we identified 55 patients with a preoperative prostate size ≥175 cc (39 CT, 12 MRI, 4 transrectal ultrasound), of which 45 were scheduled for same-day discharge and 10 for admission. Mean preoperative prostate size was 229.9 cc (range 175–535 cc) and 36 (65.5%) were in urinary retention. Mean preoperative prostate-specific antigen (PSA) was 8.58 ng/mL, American Urological Association Symptom Score (AUASS) 22.3, and Qmax 8.8 mL/second. At 3 months postoperative follow-up mean AUASS was 6.7, PSA 0.87 ng/mL and Qmax 20.4 mL/second. All comer same-day discharge rate was 70% (38/55). Of patients planned for same-day discharge 38/45 (84%) were effective. Average LOS for all patients was 11.8 hours with catheterization of 21.2 hours. When compared with 2010 published large gland outcomes, our current LOS represents a 220% reduction. Looking specifically at patients planned for same-day discharge, average LOS and catheter duration was 8.8 and 17.0 hours, whereas LOS and catheter duration for patients planned for admission was 25.7 and 39.4 hours, respectively. Conclusions: We report the first outcomes of preoperatively planned same-day discharge for HoLEP in large glands (≥175 cc). A combination of technologic advances and optimization of technique have allowed for a safe adoption of same-day discharge, providing additional advantages over alternative large gland treatments. [ABSTRACT FROM AUTHOR]

Background: Outcomes of holmium laser enucleation of the prostate (HoLEP) for benign prostatic hyperplasia has been well studied. As comfort with the procedure has improved, the number of concurrent surgeries performed with HoLEP has increased. Technology and technique optimization have safely transitioned HoLEP toward same-day catheter removal and discharge. We aim to assess the success and safety of transitioning toward a same-day care pathway for patients undergoing concurrent surgeries with HoLEP. Materials and Methods: With institutional review board approvals, we queried the electronic medical record and retrospective clinical registry to examine perioperative characteristics and outcomes of patients who underwent HoLEP performed by two endourologists at two centers between July 1, 2016, and June 1, 2021, in which ≥1 concurrent surgical procedure was performed. Results: There were 188 patients with an average age of 72.3 years, who underwent HoLEP with ≥1 concurrent surgical procedure within the study period. In total, 221 non-HoLEP procedures were performed with 30/188 (16.0%) undergoing ≥3 total procedures in a single operation. The four-most common concurrent procedures were cystolitholapaxy 86/221 (38.9%), ureteroscopy 57/221 (25.8%), transurethral resection of bladder tumor 14/221 (6.3%), and percutaneous nephrolithotomy 14/221 (6.3%). Postoperatively, 3 (1.6%) patients required transfusion. After transitioning to a same-day care path, the proportion of patients who had successful same-day catheter removal and same-day discharge increased (all p < 0.05). Median length of stay decreased (from 23 hours 11 minutes to 3 hours 49 minutes, p = 0.008). Our 90-day readmission rate for urology complication was 7.9%, and only 3.6% of patients undergoing concurrent stone surgery required an additional stone surgery within 90 days. The overall Clavien–Dindo ≥3b rate was 4.8% (9-3b, 0-4, 0-5). Conclusions: Advances in HoLEP technique and technology allow for safe same-day discharge for concurrent surgery performed at the time of HoLEP. Few patients were readmitted within 90 days and no patients experienced Clavien–Dindo ≥4 complications. [ABSTRACT FROM AUTHOR]