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OBJECTIVE To determine if there is an association between patient body habitus as measured by body mass index (BMI), body surface area (BSA), preoperative prostate volume, postoperative specimen weight, and open conversion with cystotomy or perineal urethrotomy (PU) during holmium laser enucleation of the prostate (HoLEP). We attempt to provide meaningful criteria to assist in preoperative patient counseling. MATERIALS AND METHODS Three hundred consecutive patients underwent HoLEP between August 3, 2018 and February 20, 2020 by a single surgeon. Patient metrics were recorded in a database including age, height, weight, preoperative prostate volume, postoperative specimen weight, catheter dependence, and transfusion requirement. Nine patients were identified who had cystotomy (8) or PU (1) performed during HoLEP secondary to inability to complete the procedure using standard endoscopic technique. Univariate and multivariate statistical analysis was performed. RESULT Younger age, higher BMI, higher BSA, and higher estimated prostate volume were associated with increased risk of open conversion during HoLEP. No patient with a BMI under 30 required open conversion. CONCLUSION Men with BMI >30 kg/m2 or preoperative prostate volume >125 mL should be counseled on the possibility of open conversion with cystotomy or PU. Although the overall risk of conversion is low (3%), the risk may be as high as 10% for patients in the highest quartile of BMI (>30.5 kg/m2) and BSA (>2.2m2).

Objective To determine if preoperative catheter dependence or specimen weight is associated with failed trial without catheter (TWOC) following holmium laser enucleation of the prostate (HoLEP). Material and Methods The study population consisted of 143 consecutive men who underwent HoLEP by a single surgeon over 10 months. Ten were excluded from analysis because they did not have a TWOC on the morning following surgery. Preoperative catheter dependence and specimen weight as well as catheter reinsertions were analyzed. Results Of 133 men included in analysis, 23 (17.3%) required catheter reinsertion. Of the 23 requiring catheter reinsertion, 6 were catheter dependent preoperatively and 17 were not. Men who were catheter dependent had a lower overall rate of failed TWOC compared to those who were not catheter dependent (15.0% vs 18.3%, P = .647). Mean specimen weight for men requiring catheter reinsertion was significantly lower than men who passed their TWOC (49.9 gm vs 73.1 gm, P = .013). Conclusion Very few studies exist on factors associated with short-term catheter reinsertion following HoLEP or other prostatic hyperplasia procedures. We hypothesized that preoperative catheter dependence and small specimen weight would predispose to catheter reinsertion. Specimen weight was inversely related to risk of catheter reinsertion after HoLEP and preoperative catheter dependence was not associated with catheter reinsertion. In men with small prostates, consideration should be given to delayed TWOC to allow resolution of capsular edema and accumulation of clot in the prostatic fossa. Transition zone volume below which delayed TWOC should be considered is the subject of future studies.

To evaluate factors influencing fixed operating room time during holmium laser enucleation of the prostate.A prospective observational study was performed for all holmium laser enucleation of the prostate (HoLEP) cases performed by a single surgeon over a 24-month period. Operating room (OR) time was divided into fixed and variable time. The variable time was defined as cut-to-close time. Fixed time included in room time to anesthesia release time (IRAT), anesthesia release time to cut time (ARCT), and close time to wheels out (CTWO). The effects of time of day and anesthesia personnel (AP) changes on fixed operating room time were evaluated.A total of 406 HoLEPs were analyzed. There was no statistically significant difference in nonprocedural OR times between morning and afternoon surgeries (IRAT, P = .38, ARCT P = .10, CTWO P = .77). Median nonprocedural OR times accounted for 27% (IQR: 22%-31%) of the total procedure time in the AM group and 29% (IQR: 24%-33%) in the PM group (P = .005). Of the HoLEPs,78.1% (178/228) experienced one or more AP changes during the procedure. The median fixed OR time was not significantly different between procedures with 1 AP and procedures with ≥2 APs (IRAT, P = .53; ARCT, P = .71; CTWO, P = .98).Fixed operating room time makes up a significant portion of HoLEP procedures and should be considered when evaluating OR efficiency. The time of day and number of anesthesia personnel involved did not affect the fixed OR times.

OBJECTIVES To determine if transition zone (TZ) volume as measured by magnetic resonance imaging (MRI) correlates closely with specimen weight and postoperative prostate-specific antigen (PSA) and to determine if this correlation improved with increased experience. We hypothesize that information from a preoperative MRI can be leveraged to self-assess competency in HoLEP. METHODS From August 2018 to June 2021 567 men were identified who underwent HoLEP by a single surgeon and had their data entered into a database. Ninety seven men were identified who had an MRI in our image archives. A radiologist blinded to the specimen weight measured the transition zone (TZ) using image analysis software. TZ volume was then correlated with specimen weight for the entire study period and subdivided into four consecutive periods. Preoperative and Postoperative PSA data was analyzed. RESULTS Seventeen percent of men who underwent HoLEP at our institution had an MRI preoperatively. The TZ to total prostate volume ratio was 70%. The overall correlation coefficient between TZ volume and specimen weight was 0.914 (p-value

Objective To demonstrate the surgical considerations for managing retained UroLift implants when performing HOLEP. Prostatic Urethral Lift via the UroLift System has become a common treatment modality to manage symptoms associated with benign prostatic hyperplasia. The UroLift procedure uses non-absorbable implants to retract obstructing prostate lobes. Retreatment rates following UroLift have been reported at 13.6% over 5 years. 1 We anticipate an increasing number of men seeking definitive surgical management after failed Urolift. There have been reports in the literature of UroLift implants causing morcellator device jams when attempting holmium laser enucleation of the prostate (HOLEP). 2 Methods From August 2018 to April 2019, we reviewed 118 consecutive patients who underwent HOLEP by a single surgeon. Three men were identified who had previously undergone Urolift. Video footage was obtained. As demonstrated in the video, during enucleation the metallic clip of the UroLift implants were incorporated in the adenoma specimen. For morcellation, we use the Piranha morcellator (Richard Wolf, Knittlingen, Germany). Morcellation was carried out in a slow and controlled manner. When the metal clip comes into contact with the morcellator, a catch and release is performed by releasing the morcellator pedal and withdrawing the morcellator into the nephroscope to release the adenoma. Remnant clips and sutures can be retrieved with a grasper. We perform a 3 month follow-up cystoscopy in the office to exclude any remnant implant material in the prostatic urethra or bladder. Results Procedures were completed uneventfully. In developing this technique, we experienced jamming of the morcellator blades in 2 cases requiring replacement of the disposable blades. Follow up in-office cystoscopy did not reveal any remnant implant material that needed to be removed. Conclusion HOLEP can be performed safely in the UroLift failure patient population. Careful morcellation techniques can decrease the risk of costly morcellator blade replacement.

We investigated time dependent variations in tensile strength, stiffness, shrinkage and distortion in 6 materials commonly used for transvaginal anti-incontinence surgery.A total of 15 rabbits were randomized into 3 survival groups (2, 6 and 12 weeks, respectively). Each rabbit had human cadaveric fascia, porcine dermis, porcine small intestine submucosa, polypropylene mesh and autologous fascia implanted on the anterior rectus fascia. At harvest tensiometry and image analysis were performed on each sling. Results were compared to baseline for each sling type and the percent decrease from baseline was compared among sling types.Each type of human cadaveric fascia and porcine allografts showed a marked decrease (60% to 89%) in tensile strength and stiffness from baseline. Polypropylene mesh and autologous fascia did not differ in tensile strength from baseline. Polypropylene mesh increased in stiffness from baseline. Autologous fascia and small intestinal submucosa demonstrated a 41% and 50% decrease in surface area, respectively, at 12 weeks.To our knowledge the relative contribution of biomechanical properties of sling material to the success of anti-incontinence surgery is unknown. However, rapid loss of tensile strength and stiffness in porcine and cadaveric materials may contribute to the early re-emergence of symptoms following successful sling surgery. The results of this study add scientific validity to the increasing use of synthetics in anti-incontinence surgery. Urologists selecting a sling material should be aware of its time dependent biomechanical fate relative to other sling materials.

Objectives To provide pathologic evidence, using six different sling materials, of the findings from rabbit model studies demonstrating loss of tensile strength and stiffness in porcine and cadaveric sling materials. Methods Ten rabbits randomized into two survival groups (6 and 12 weeks of age) each had human cadaveric fascia, porcine dermis, porcine small intestine submucosa, polypropylene mesh, and autologous fascia implanted on their anterior rectus fascia. At harvest, hematoxylin-eosin and immunohistochemical staining for CD3, CD20, and MIB-I were performed. A pathologist unaware of the content of the slides quantified the degree of inflammation and fibrosis of each. Results Significant differences were found for inflammation (P = 0.016), eosinophil infiltrate (P = 0.035), and inflammatory rind (P = 0.027) at 12 weeks, with polypropylene mesh having the lowest degree. At 12 weeks, differences were found in the presence of fibrosis/scar formation (P = 0.010) and degree of fibrosis/scar (P = 0.009). Although polypropylene mesh, cadaveric fascia, and porcine dermis all demonstrated a high presence of fibrosis/scar, polypropylene mesh had the greatest overall degree of scar formation at 12 weeks. Conclusions The inflammation with the cadaveric fascia and porcine materials may cause rapid clinical deterioration compared with autologous fascia and polypropylene mesh. These data provide a possible explanation for prior biomechanical studies demonstrating variations in tensile strength and stiffness of the different materials. The fibrosis and scarring noted with polypropylene mesh may also contribute to a more lasting repair.

Intraspinal injection of the nonspecific inhibitor of nitric oxide synthase N-nitro-L-arginine methyl ester (L-NAME) results in a dose-dependent loss of neurons in the rat spinal cord. This effect is thought to result from a reduction in basal levels of nitric oxide (NO), thereby producing an ischemic reaction secondary to vasoconstriction and reduced spinal cord blood flow (SCBF). An important component of this ischemic reaction is the release of excitatory amino acids and the initiation of an excitotoxic cascade. In the present study, microinjections of adenosine A1 and A2 receptor agonists were made in the spinal cord to evaluate the neuroprotective effects of these drugs against neuronal loss produced by L-NAME. Animals were divided into six groups based on the composition of injected solutions: (a) L-NAME; (b) L-NAME + N6-cyclopentyladenosine (CPA, A1 agonist); (c) L-NAME + 5'-(N-cyclopropyl)-carboxamidoadenosine (CPCA, A2 agonist); (d) L-NAME + CPA + CPCA; (e) N-methyl D-aspartate (NMDA); and (f) NMDA + CPA. Injections of L-NAME or NMDA produced a unilateral loss of spinal neurons, a local inflammatory response, and darkly stained pyknotic nuclei surrounding the area of neuronal loss. CPA and CPCA significantly reduced the area of L-NAME-induced neuronal loss, and a synergistic effect was observed when ineffective doses of these agonists were co-injected with L-NAME. The excitotoxic effects of NMDA were not affected by CPA. The results have shown that A1 and A2 receptor agonists provide significant neuroprotection against L-NAME induced neuronal loss, presumably by inhibiting ischemia induced release of excitatory amino acids (A1 agonist), or by restoring SCBF secondary to vasodilation (A2 agonist). It is suggested by these results that the intraspinal injection of L-NAME is an effective model to study the pathological consequences of vasoconstriction, reduced SCBF, and ischemia secondary to decreased NO production in the rat spinal cord. Finally, the results provide support for the continued investigation of specific adenosine agonists as therapeutic agents directed against the ischemic and excitotoxic components of spinal injury.