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Objective: To perform a systematic review to assess the incidence of transient (<6 months) and persistent (>6 months) stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence (MUI) after transurethral surgeries for benign prostatic hyperplasia. Materials and Methods: A systematic literature search was performed using Embase, PubMed, and Web of Science. We included studies comparing monopolar (M)/bipolar (B) transurethral resection of the prostate (TURP) vs ablation vs enucleation procedures. Incidence of incontinence was assessed using Cochran-Mantel-Haenszel Method and reported as odds ratio (OR), 95% confidence interval (CI), and p -values. Statistical significance was set at p  < 0.05 Evidence Synthesis: Twenty-eight studies were included. Incidence of transient SUI was 4.6%, 6.0%, 3.0%, and 2.4% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent SUI was 1.1% after ablation, 1.7% after enucleation and M-TURP, and 1.0% after B-TURP. Incidence of transient UUI was 2.0%, 7.3%, 4.4%, and 2.8% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent UUI was 2.2% after M-TURP. The incidence of transient MUI was 5.1%, 0.8%, 5.4%, and 0.9% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent MUI was 3.1% after ablation and 4.8% after M-TURP. Incidence of transient and persistent SUI and UUI did not differ after TURP vs enucleation. Incidence of transient (OR 3.32, 95% CI 0.41-26.65, p  = 0.26) and persistent SUI (OR 4.79, 95% CI 0.52-43.89, p  = 0.17) was not significantly higher after ablation. Incidence of transient UUI was not significantly higher after ablation (OR 2.62, 95% CI 0.04-166.01, p  = 0.65), whereas persistent UUI did not differ. Incidence of transient MUI was significantly higher after enucleation (OR 3.26, 95% CI 1.51-7.05, p  = 0.003). Incidence of transient and persistent MUI did not differ after TURP vs ablation. Conclusions: Ablation, enucleation, and TURP have an impact on all forms of incontinence, but this is transient in most cases with no difference between the groups, except for MUI, which was higher after enucleation vs M-TURP.

Background: Micro-ultrasound (microUS) is a novel ultrasound-based imaging modality which has demonstrated the ability to visualize prostate cancer. Multiparametric MRI/ultrasound (mpMRI/US) fusion has recognized advantages for the performance of prostate biopsy, however, it encompasses additional cost, time and technical expertise to performing prostate biopsy in comparison to conventional trans-rectal ultrasound biopsy. MicroUS may simplify and optimize this pathway., Methods: OPTIMUM is a 3-arm randomized controlled trial comparing microUS guided biopsy with MRI/US fusion and MRI/MicroUS "contour-less" fusion. This trial will investigate whether microUS alone, or in combination with mpMRI, provides effective guidance during prostate biopsy for the detection of clinically significant prostate cancer (csPCa) for biopsy naïve subjects. 1200 subjects will be randomized. The economic impact will be evaluated., Results: The rate of csPCa (defined as Grade Group 2 and above) in each arm will be compared. The primary hypothesis is non-inferiority of csPCa rate between the MRI/US fusion arm and the microUS-only arm (including the blinded microUS-only portion of the MRI/MicroUS arm). As a secondary objective, the csPCa rate between MRI/MicroUS fusion and MRI/US fusion arms will also be compared. Other secondary objectives include the increase in rate of patients diagnosed with csPCa due to each type of sample (mpMRI targeted, microUS targeted, systematic), the negative predictive value of each imaging modality, and a health economic analysis of the procedures in each arm., Conclusions: OPTIMUM will determine whether microUS can be used as an alternative to MRI/US fusion biopsy. The trial will also evaluate the efficacy of the simplified "contour-less" MRI/MicroUS fusion procedure. The adoption of the microUS technique will increase the proportion of men who can benefit from modern imaging-centric diagnostic strategies, and may help reduce variability, complexity, waiting time and cost within the diagnostic pathway., (Copyright © 2021. Published by Elsevier Inc.)

Objectives: To investigate the effect of surgical experience on the perioperative outcomes of endoscopic GreenLight™ (Boston Scientific Corporation, Marlborough, MA, USA) laser enucleation of the prostate (GreenLEP)., Subjects/patients and Methods: A multicentre retrospective study of the first patients treated with GreenLEP by six surgeons was conducted. For each patient, surgical experience was coded as the total number of procedures performed by the surgeons before the patient's operation. The learning curve was analysed in terms of changes over time for the following variables: enucleation time, morcellation time, occurrence of intraoperative complications (IOCs), 3-month postoperative International Prostate Symptom Score (IPSS) reduction, and the rate of Pentafecta achievement., Results: In total, 922 patients were analysed. At multivariable regression analyses adjusted for case mix, surgical experience was associated with shorter enucleation and morcellation time (P < 0.001), lower IOC rate (P < 0.001), higher 3-month postoperative reduction in IPSS (P = 0.004), and higher probability of Pentafecta achievement (P < 0.001). The relationship between surgical experience and enucleation time/IOCs appeared as non-linear, with a steep slope reduction within the first 100 cases and a plateau observed after 200 cases, whilst the IPSS improved rapidly early in the learning curve process and plateaued after ~100 procedures. Finally, there was a linear improvement in Pentafecta achievement, with a plateau observed after 270 cases., Conclusion: Surgical experience has a significant impact on the perioperative outcomes for GreenLEP procedures. After adjusting for patient and prostate characteristics, plateau results were achieved after a long learning curve. A more intensely mentored and structured training schedule might allow quicker and safer adoption of the procedure., (© 2019 The Authors BJU International © 2019 BJU International Published by John Wiley & Sons Ltd.)

Purpose: Aquablation of the prostate using the AquaBeam™ system promises equivalent functional outcomes, reduced learning curve, and improved sexual function compared to transurethral prostate resection as shown in prospective randomized trials. This prospective cohort study aims to evaluate if published results can be transferred into the clinical routine in a non-selected patient collective., Methods: This study includes all patients treated between September 2017 and June 2018 with Aquablation of the prostate. Patients have been evaluated prospectively for the perioperative course and early follow-up. Besides voiding parameter and symptom score, TRUS-volume change, ejaculatory function, and adverse events have been recorded., Results: 118 consecutive patients have been treated in the given time. Aquablation could be carried out successfully in all patients. IPSS, QoL, Qmax, and PVR improved significantly after the procedure and continued to improve during 3-month follow-up. Mean OR time was 20 min, TRUS volume decreased by 65%, and 73% of the patients retained antegrade ejaculation. Thirteen adverse events (> Clavien-Dindo I) occurred in 10 patients., Conclusion: The surgical ablation of the prostate using Aquablation achieved significant and immediate improvement of functional voiding parameters Qmax and PVR as well as symptomatic improvement of IPSS and QoL. Aquablation seems to be safe and effective with a low perioperative complication profile even in a non-selected group of patients.

Background: Live surgery remains controversial. Although it may improve surgical training and accelerate the dissemination of technical steps of surgical procedures, controversy exists regarding patient safety in live surgery., Objective: To compare the perioperative outcomes of "en bloc" green laser enucleation of the prostate (GreenLEP) performed in workshops during live case demonstration (LCD) and in standard conditions (SCs)., Design, Setting, and Participants: Between June 2015 and January 2017, all consecutive patients who underwent GreenLEP for benign prostatic obstruction performed by a single surgeon were prospectively enrolled. Perioperative data and early postoperative complications according to Clavien-Dindo classification were collected. Workshop programmes started locally according to the European Association of Urology policy on live surgical events in June 2015 to enrol small groups of urologists in the GreenLEP technique., Intervention: Endoscopic enucleation of the prostate using a GreenLight fibre., Outcome Measurements and Statistical Analysis: Outcomes were compared between the LCD and SC groups., Results and Limitations: Of the 126 performed procedures, 37 were performed live during 17 LCDs with a median attendee number of 3. The patients' baseline characteristics were similar in both groups. Intraoperative parameters were comparable: total energy of 62 [53; 77] versus 56kJ [44; 69] (p=0.068), operative time of 61 [53; 71] versus 55min [45; 66] (p=0.1), and morcellating time of 3 [3; 5] versus 4min [2; 6] (p=0.82) in the LCD versus SC group. The catheterisation time (2d [1; 2]) and length of hospital stay (2d [2; 3]) were similar. The overall complication rate was comparable in the LCD (18.9%) and SC (24.7%) groups (p=0.64). Preoperative parameters significantly improved from baseline without any significant differences between the two groups. Limitations included a small number of attendees/workshop, and case selections were made by the surgeon himself., Conclusions: GreenLEP was safe and provided satisfactory functional outcomes in both conditions. From this preliminary study, it seems that LCD did not jeopardise the surgeon's skill or technique. Similar studies are required to further assess patient safety and outcomes associated with live surgical events., Patient Summary: According to the surgeon expertise, endoscopic enucleation of the prostate performed during live case demonstration provided similar functional outcomes to that performed in standard condition and could therefore be considered a safe potential educational tool., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: Background:After EEP (HoLEP, ThuLEP, GreenLEP or bipolar) the enucleated tissue is removed through a process of mechanical morcellation. Morcellation is the last, and very important, step in EEP procedures. It introduces additional time, and the possibility for complications exists. Although this is not a difficult procedure, it requires a learning curve that can pose a challenge for inexperienced surgeons. There are two types of morcellation systems: oscillating and reciprocating (depending on blade movement)., Objective: To demonstrate tips and tricks for safe and efficient morcellation after EEP and to share our experience with the oscillating morcellation system., Material and Methods: Four hundred and thirty-six patients were treated with green laser enucleation of the prostate by 3 surgeons with the en bloc technique between June 2013 and November 2016. After completing the enucleation procedure we removed the adenoma with an oscillating mechanical morcellator (Piranha, Richard Wolf, Germany). We have reported our experience (including the learning curve) and collected multiple videos exemplifying not only proper techniques for safe morcellation, but also possible problems and their solutions. The authors have compiled their collective experience to offer tips and tricks as well as a practical approach to trouble shooting and problem solving of the morcellation procedure., Results: The median morcellation time was 5.00 minutes (3.00; 10.0) and the median morcellation efficiency was 11.0 g/min (7.70; 16.0). Complications included 2 cases of superficial bladder injuries and no bladder perforations., Conclusion: Morcellation is a safe and appropriate procedure to remove the adenoma after endoscopic enucleation of the prostate. However, without taking proper precautions major complications can occur. This video serves as a guide for safe morcellation after EEP and also offers practical advice to help avoid the most common complications in this procedure., (Copyright © 2018. Published by Elsevier Inc.)

Background: Open prostatectomy (OP) and transurethral resection of the prostate (TURP) have traditionally been the most common surgical approaches for the treatment of benign prostatic hyperplasia causing bladder outlet obstruction and have certainly passed the test of time. In time, many endoscopic surgical procedures have been described as an alternative mini-invasive treatment. Holmium laser enucleation (HoLEP) guaranteed functional outcomes similar to OP and TURP with lower perioperative complication rates for any prostate size. With the development of different kinds of lasers (such as thulium, "green light" and diode) and bipolar energy, the feasibility of endoscopic enucleation using these energies has been explored., Evidence Acquisition: In this paper, recent techniques to perform true prostate enucleation have been reviewed through a search of PubMed and Web of Science, including articles published in the last 20 years in clinical journals. The review is based on a peer-review process of the authors after a structured data search. Search terms included "Thulium prostate enucleation, THULEP, TmLEP/Tm Yag enucleation" OR "Greenlight enucleation/prostate enucleation/vapo-enucleation/KTP prostate enucleation, PVP prostate enucleation, GreenLep/" OR "bipolar prostate enucleation" OR "HoLEP, Holmium prostate enucleation" OR "monopolar prostate enucleation" OR "Diode prostate enucleation" OR "DiLEP" OR "Eraser prostate enucleation" OR "ELEP"., Evidence Synthesis: Following the example of HoLEP, many techniques have been described in the literature using a variety of energy sources and instruments either in a pure enucleative or a hybrid (mixed) fashion. However, the levels of evidence are too low and follow-up still too short to offer solid recommendations., Conclusions: HoLEP has become the conceptual and practical paradigm for the wide spread of enucleation thanks to the evidence provided by the literature and excellent outcomes. Higher level of evidence is required to assess efficacy of alternative enucleative techniques.

Purpose: To compare the learning curves, perioperative and early functional outcomes after HoLEP and GreenLEP., Methods: Data from the first 100 consecutive cases treated by GreenLEP and HoLEP by two surgeons were prospectively collected from dedicated databases and analysed retrospectively. En-bloc GreenLEP and two-lobar HoLEP enucleations were conducted using the GreenLight HPS™ 2090 laser and Lumenis™ holmium laser. Patients' characteristics, perioperative outcomes and functional outcomes after 1, 3 and 6 months were compared between groups., Results: Total energy delivered and operative times were significantly shorter for GreenLEP (58 vs. 110 kJ, p < 0.0001; 60 vs. 90 min, p < 0.0001). Operative time reached a plateau after 30 procedures in each group. Length of catheterization and hospital stay were significantly shorter in the HoLEP group (2 vs. 1 day, p < 0.0001; 2 vs. 1 day, p < 0.0001). Postoperative complications were comparable between GreenLEP and HoLEP (19 vs. 25 %; p = 0.13). There was a greater increase of Q max at 3 months and a greater IPSS decrease at 1 month for GreenLEP, whereas decreases in IPSS and IPSS-Q8 at 6 months were greater for HoLEP. Transient stress urinary incontinence was comparable between both groups (6 vs. 9 % at 3 months; p = 0.42). Pentafecta was achieved in four consecutive patients after the 18th and the 40th procedure in the GreenLEP and HoLEP group, respectively. Learning curves ranged from 14 to 30 cases for GreenLEP and 22 to 40 cases for HoLEP., Conclusion: Learning curves of GreenLEP and HoLEP provided roughly similar peri-operative and short-term functional outcomes.

Background: To compare baseline characteristics and outcomes of patients undergoing GreenLight laser vaporization (GL) or transurethral resection of the prostate (TURP) in a real life setting., Methods: In this prospective observational cohort, the Clinical Research Office of the Endourological Society (CROES) collected data of consecutive GL or TURP treated patients. Treatment involved one of three GL laser powers (80 W, 120 W or 180 W) based on availability in each participating centre, or TURP. Data on baseline characteristics as well as functional measures were collected at three time points: 6-12 weeks, 6, and 12months after surgery. Functional measures included urinary flow parameters, perceived prostate function (IPSS), perceived erectile function (IIEF-5) and complications., Results: Seven hundred thirteen patients underwent GL, and 234 patients underwent TURP. Overall, patients treated with GL show higher BMI, IIEF and medication use, together with lower urinary function (voided volume, incontinence, urinary retention) at baseline. After the procedure, despite higher antibiotic and antimuscarinic use and shorter hospital stay, readmission rates, PVR, PSA were higher, but Qmax, and IIEF were lower in the GL group. The rate of post-operative complications was 10.3% and 5.2% for the TURP and GL group, respectively (P=0.006)., Conclusions: We were unable to categorically state which procedure is superior. This observational study confirms that treatment decision for either TURP or GL is not based on patient characteristics.

Background: Transurethral laser prostatectomy has evolved as a viable alternative for the management of benign prostate enlargement. Since the renaissance of laser prostatectomy with the advent of the holmium:yttrium-aluminum-garnet laser in the 1990s, various lasers and subsequent procedures have been introduced. These techniques can be categorized as vaporizing, resecting, and enucleating approaches. Photoselective vaporization of the prostate (PVP) is dominated by high-power lithium triborate (LBO) crystal lasers (GreenLight XPS). The mainstay of this technique is for the treatment of small to medium prostate volumes whereas enucleating techniques, such as holmium laser enucleation of the prostate and thulium enucleation of the prostate, focus on large-volume glands. In order to perspectively "delimit" LBO into the field of large-volume prostates, we developed LBO en bloc enucleation to render it as a competing transurethral enucleating approach., Materials and Methods: We present a detailed stepwise progressive technique developed in Madrid, Spain, for the complete removal of the transitional zone by vapoenucleation. The steps include exposition of the prostatic capsule by PVP toward the peripheral zone, thereby identifying the anatomical limits of enucleation. Subsequently, the transitional zone is excised in a single bloc and morcellated after its placement into the bladder., Conclusion: This new GreenLight en bloc enucleation technique allows to treat larger prostates than those previously treated with the PVP technique.

Purpose of Review: To determine that GreenLight laser therapy is now an established treatment option for men with lower urinary tract symptoms (LUTS) associated with benign prostatic enlargement (BPE)., Recent Findings: The three generations of the GreenLight laser, 80, 120 and 180 W, have been studied for efficacy and safety in the treatment of men with LUTS associated with BPE. Studies have also been conducted that compare outcome with transurethral resection of the prostate, historically considered the gold-standard treatment for this patient group., Summary: GreenLight is an established therapeutic option for LUTS associated with BPE. It can be used safely and effectively in men on anticoagulants, in retention and with prostates of size greater than 80 ml. The safety and efficacy of this treatment are comparable to transurethral resection of the prostate.

The objective was to know the principal risk factors that influence in the development of surgical would infection, and the economical saving achieved with the control of a single variable, that is, right prophylaxis. A prospective study was carried out at the Traumatology Department of La Paz Hospital. A total of 5260 patients operated during 1990-1993 are included. Active epidemiological surveillance was used to check patients; logistic regression was used in the multivariant analysis. The principal risk factors found were: immunodeficiency (OR = 8.67), incorrect healing (OR = 14.42), reoperated patient (patients who needed more than one surgical procedure while they are admitted; reoperations) (OR = 3.57), type of surgery (OR = 4.71) and wrong prophylaxis (OR = 6.36). Making constant all the variables except for prophylaxis, we calculated the percentage of infections prevented by a right prophylaxis, and the cost was calculated starting from the number of extra days of infection. The number of infections prevented during the four years was 310, saving a total of 194 million pesetas (1.5 million dollars), due to right prophylaxis. Cost-benefice ratio = 1/17. We consider of special importance to control this manipulable risk factor, in order to avoid the development of infections.

We carried out a four-year prospective study in the rehabilitation and traumatology center of the Hospital La Paz, where a total of 5260 patients were included. The objective of the study was to know the main risk factors that could influence the development of an infection of surgical wound, and get a predictive equation of infection of surgical wound in our patients. We utilized logistic regression for it, following the patient by means of active epidemiological surveillance; the main risk factors found were: immunodeficiency (OR = 8.3) wrong scaring (OR = 14.4), more than one intervention (OR = 3.5), type of surgical intervention (OR = 4.8) and incorrect use of prophylaxis (OR = 6.3). We considered that this knowledge could permit us to diminish the incidence of infections, specially if there is some of these factors, like the antimicrobial prophylaxis, that could be easily modified. Finally, upon applying to our patients the gotten equation, we get a ROC curve with 85% of the area under it, and if we take the point of cut of greater sensibility and specificity in this situation of very low prevalence of illness, it determines we could use it better in order to mark patients that don't suffer infection (high negative predictive value), making this possible to improve the efficacy of our work.