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Abstract Introduction Holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation represents the latest refinement of holmium:YAG surgical treatment for benign prostatic hyperplasia (BPH). Utilizing this technique, even the largest of glands can be effectively treated with minimal morbidity. The learning curve remains an obstacle, preventing more widespread adoption of this procedure. This paper provides an outline of the HoLEP technique as is currently used at two centers in hopes of easing the initial learning curve. Technical considerations Detailed descriptions of the major steps of the HoLEP procedure are provided with attention to critical steps such as identification of the surgical capsule, median and lateral lobe enucleation, and morcellation of enucleated tissue. Conclusions HoLEP is a promising alternative for the surgical treatment of BPH which allows complete removal of intact lobes of the prostate. Obstruction is relieved immediately with superior hemostasis, no risk of TUR syndrome, and a minimal hospital stay.

Abbreviations AUA, American Urological Association; BPH, benign prostatic hyperplasia; CUA Canadian Urological Association EAU European Association of Urology; HRQoL, health-related quality of life; IPSS, International Prostate Symptom Score LUTS lower urinary tract symptoms PtDA patient decision aid PVP photovaporisation SMOG Simple Measure of Gobbledygook TURP transurethral resection of the prostate Introduction There are several surgical options to treat lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). This allows patients to have the chance to explore treatment options not offered by their urologist and at the same time encourages urologists that do not offer all of the presented treatments to use the PtDA effectively, while still educating their patients about all possible options. For one, the Dutch BPH PtDA is not specific to surgical treatments; only four out of the nine surgical treatments described in our PtDA are included in the Dutch PtDA. Acceptability and validation testing will ensure that the finalised PtDA is acceptable with all stakeholders, including patients and urologists, and is improving quality of decision-making by BPH surgery patients. [Extracted from the article]

Until now, the pre-Miocene fossil record of mustelids in North America has been restricted to specimens attributable to oligobunine taxa and isolated remains tentatively allocated to the genus Plesictis. In the present study, we report on a nearly complete cranium and a referred dentary of a new genus and species of mustelid. The specimens were recovered from the Turtle Cove and Kimberly Members of the John Day Formation, Oregon, USA. These excellently preserved specimens more confidently confirm the presence of mustelids in the Early and Late Oligocene (Early and Late Arikareean) of North America. Like the holotype specimen of ' Plesictis ' julieni , the new species lacks an alisphenoid canal and a postprotocrista on the M1 (synapomorphies of Mustelidae), but retains a dorsally deep suprameatal fossa (a feature occasionally suggested to be unique to Procyonidae). Phylogenetic analyses, applying parsimony and Bayesian inference to combined molecular (five genes totalling 5490 bp) and morphological data, recover this new species of mustelid as sister-species to ' Plesictis ' julieni. The results of these analyses reveal that the new genus is a close relative of other species of Plesictis and several taxa traditionally allied with Oligobuninae, thereby rendering Oligobuninae paraphyletic. We further discuss the significance of the relatively small size of this new mustelid as it relates to predictions based on increased aridification of the palaeoclimate and the expansion of open habitats in the Oligocene. [ABSTRACT FROM AUTHOR]

The early synapsid Echinerpeton intermedium from Florence, Nova Scotia, was first described as a basal ophiacodontid 'pelycosaur', displaying the oldest record of hyper-elongated neural spines in an amniote. Since its initial discovery, the systematic placement of Echinerpeton intermedium has been less clear than that of its contemporary Archaeothyris florensis. The difficulty in assigning the remains of Echinerpeton firmly to any broader clade is largely the result of the incomplete nature of specimens, particularly the lack of diagnostic cranial material. The most recent large-scale phylogenies of basal synapsid interrelationships do not consistently recover Echinerpeton in a stable position. Despite being one of the earliest known synapsids, the volatility of the phylogenetic position of Echinerpeton has resulted in its exclusion from many large-scale phylogenetic analyses. Here, we describe the first new remains of Echinerpeton since its initial discovery. RM 206866 includes substantial new cranial material, and we provide the first comprehensive description of its skull. Informative remains include a relatively complete parabasisphenoid complex. Additionally, we revisit the phylogenetic position of Echinerpeton using Bayesian inference and parsimony-based methods, confirming the taxon as a member of Ophiacodontidae. [ABSTRACT FROM AUTHOR]

Objective: To compare the outcomes of Aquablation in 30–80 mL prostates with those in 80–150 mL prostates. Surgical options, especially with short learning curves, are limited when treating large prostates for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Aquablation (AquaBeam System, PROCEPT BioRobotics Inc., Redwood City, CA, USA) could solve this issue with global reproducibility, independent of prostate volume. Patients and Methods: Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue (WATER [W‐I]; NCT02505919) is a prospective, double‐blind, multicentre, international clinical trial comparing Aquablation and transurethral resection of the prostate (TURP) for the treatment of LUTS/BPH in prostates between 30 and 80 mL. WATER II (W‐II; NCT03123250) is a prospective, multicentre, single‐arm international clinical trial of Aquablation in prostates between 80 and 150 mL. We compare baseline parameters and 12‐month outcomes in 116 W‐I and 101 W‐II study patients. Students' t‐test or Wilcoxon tests were used for continuous variables and Fisher's test for binary variables. Results: The mean (SD) operative time was 33 (17) and 37 (13) min in W‐I and W‐II, respectively. Actual treatment time was 4 and 8 min in W‐I and W‐II, respectively. The mean change in the International Prostate Symptom Score was substantial averaging (at 12 months) 15.1 in W‐I and 17.1 in W‐II (P = 0.605). By 3 months, Clavien–Dindo grade ≥II events occurred in 19.8% of W‐I patients and 34.7% of W‐II patients (P = 0.468). Conclusion: Aquablation clinically normalises outcomes between patients with 30–80 mL prostates and patients with 80–150 mL prostates treated for LUTS/BPH, with an expected increase in the risk of complications in larger prostates. Long‐term outcomes of procedure durability are needed. [ABSTRACT FROM AUTHOR]

Objectives: To present early safety and feasibility data from a multicentre prospective study (WATER II) of aquablation in the treatment of symptomatic men with large‐volume benign prostatic hyperplasia (BPH). Methods: Between September and December 2017, 101 men with moderate‐to‐severe BPH symptoms and prostate volume of 80–150 mL underwent aquablation in a prospective multicentre international clinical trial. Baseline demographics and standardized postoperative management variables were carefully recorded in a central independently monitored database. Surgeons answered analogue scale questionnaires on intra‐operative technical factors and postoperative management. Adverse events up to 1 month were adjudicated by an independent clinical events committee. Results: The mean (range) prostate volume was 107 (80–150) mL. The mean (range) operating time was 37 (15–97) min and aquablation resection time was 8 (3–15) min. Adequate adenoma resection was achieved with a single pass in 34 patients and with additional passes in 67 patients (mean 1.8 treatment passes), all in a single operating session. Haemostasis was achieved using either a Foley balloon catheter placed in the bladder under traction (n = 98, mean duration 18 h) or direct tamponade using a balloon inflated in the prostate fossa (n = 3, mean duration 15 h). No patient required electrocautery for haemostasis at the time of the primary procedure. The mean length of stay after the procedure was 1.6 days (range same day to 6 days). The Clavien–Dindo grade ≥2 event rate observed at 1 month was 29.7%. Bleeding complications were recorded in 10 patients (9.9%) during the index procedure hospitalization prior to discharge, and included six (5.9%) peri‐operative transfusions. Conclusions: Aquablation is feasible and safe in treating men with men with large prostates (80–150 mL). The 6‐month efficacy data are being accrued and will be presented in future publications (ClinicalTrials.gov number, NCT03123250). [ABSTRACT FROM AUTHOR]