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Alia J Codelia-Anjum,1,* Mohamad Baker Berjaoui,2,* Adree Khondker,2 Dean Elterman,2 Kevin C Zorn,3 Naeem Bhojani,3 Lori B Lerner,4 Bilal Chughtai1 1Department of Urology, Weill Cornell Medical College/New York Presbyterian, New York, NY, USA; 2Division of Urology, Department of Surgery, University Health Network, University of Toronto, Toronto, ON, Canada; 3Division of Urology, Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada; 4Department of Urology, VA Boston Healthcare System, Boston, MA, USA*These authors contributed equally to this workCorrespondence: Bilal Chughtai, Weill Cornell Medical Center, Department of Urology, 425 East 61st Street, 12th Floor, New York, NY, 10065, USA, Tel +1 646 962-4811, Email bic9008@med.cornell.eduObjective: We set out to review studies reporting on the use of surgical intervention to treat Benign Prostatic Hyperplasia in elderly men ≥ 70 years of age.Methods: A systematic literature search was conducted using Scopus, PubMed-MEDLINE, Cochrane, and Wiley Online Library databases including studies published between January 2012 through December 2022. This 10-year interval was chosen given the recent plethora of new modalities that have entered the BPH armamentarium, many of which have been marketed as appropriate for older and high-risk patients. The following database search words were used either individually or in conjunction: “BPH”, “elderly”, “surgical”, “ablation”, “resection”, “embolization”, and “aging”.Results: We identified 28 studies for inclusion in this review. The pros and cons of these modalities are presented, specifically as applicable to an older and higher risk population.Conclusion: There are a wide variety of surgical procedures available for surgically treating BPH in elderly men with varying states of health. Each of these comes with different risks and benefits, supporting that individualized approaches are important. Long-term data and further studies comparing modalities, specifically as regards the elderly and frail, would enhance our approaches to BPH treatment in this patient population.Keywords: benign prostatic hyperplasia, aging, elderly, surgical

The epidemiology of infectious causes of meningitis in sub-Saharan Africa is not well understood, and a common cause of meningitis in this region, Mycobacterium tuberculosis (TB), is notoriously hard to diagnose. Here we show that integrating cerebrospinal fluid (CSF) metagenomic next-generation sequencing (mNGS) with a host gene expression-based machine learning classifier (MLC) enhances diagnostic accuracy for TB meningitis (TBM) and its mimics. 368 HIV-infected Ugandan adults with subacute meningitis were prospectively enrolled. Total RNA and DNA CSF mNGS libraries were sequenced to identify meningitis pathogens. In parallel, a CSF host transcriptomic MLC to distinguish between TBM and other infections was trained and then evaluated in a blinded fashion on an independent dataset. mNGS identifies an array of infectious TBM mimics (and co-infections), including emerging, treatable, and vaccine-preventable pathogens including Wesselsbron virus, Toxoplasma gondii, Streptococcus pneumoniae, Nocardia brasiliensis, measles virus and cytomegalovirus. By leveraging the specificity of mNGS and the sensitivity of an MLC created from CSF host transcriptomes, the combined assay has high sensitivity (88.9%) and specificity (86.7%) for the detection of TBM and its many mimics. Furthermore, we achieve comparable combined assay performance at sequencing depths more amenable to performing diagnostic mNGS in low resource settings.

Ofer N Gofrit,1 Amos Shapiro,1 Ran Katz,1 Mordechai Duvdevani,1 Vladimir Yutkin,1 Ezekiel H Landau,1 Kevin C Zorn,2 Guy Hidas,1 Dov Pode1 1Department of Urology, Hadassah Hebrew University Hospital, Jerusalem, Israel; 2Department of Surgery, Section of Urology, Montreal, Canada Background: Partial cystectomy provides oncological results comparable with those of radical cystectomy in selected patients with invasive bladder cancer without the morbidity associated with radical cystectomy and urinary diversion. We describe a novel technique of partial cystectomy that allows accurate identification of tumor margins while minimizing damage to the rest of the bladder. Methods: During the study period, 30 patients underwent partial cystectomy for invasive high-grade cancer. In 19 patients, the traditional method of tumor identification was used, ie, identifying the tumor by palpation and cystotomy. In eleven patients, after mobilization of the bladder, flexible cystoscopy was done and the light of the cystoscope was pointed toward one edge of the planned resected ellipse around the tumor, thus avoiding cystotomy. Results: Patients who underwent partial cystectomy using the novel method were similar in all characteristics to patients operated on using the traditional technique except for tumor diameter which was significantly larger in patients operated on using the novel method (4.3±1.5 cm versus 3.11±1.18 cm, P=0.032). Complications were rare in both types of surgery. The 5-year local recurrence-free survival was marginally superior using the novel method (0.8 versus 0.426, P=0.088). Overall, disease-specific and disease-free survival rates were similar. Conclusion: The use of a flexible cystoscope during partial cystectomy is a simple, low-cost maneuver that assists in planning the bladder incision and minimizes injury to the remaining bladder by avoiding the midline cystotomy. Initial oncological results show a trend toward a lower rate of local recurrence compared with the standard method. Keywords: bladder cancer, partial cystectomy, cystoscopic-assisted partial cystectomy

Background: The standard surgical procedure for polar renal tumors is nephron-sparing surgery, currently performed laparoscopically in most cases. This technically challenging surgery involves clamping of the hilar vessels and warm kidney ischemia. This study tested the feasibility of performing polar nephrectomy using a cable tie without hilar clamping or any other hemostatic procedure.Methods: General anesthesia and pneumoperitoneum were induced in four farm pigs, and three trocars were inserted intraperitoneally. A kidney pole (either a lower or an upper pole of either the left or right kidney) was exposed and encircled with a plastic cable tie. The pole then was transected sharply with scissors, opening the urinary collecting system and major blood vessels. Neither tissue sealants nor any form of energy was used throughout the cases. The animals were killed 3 weeks later.Results: All the pigs tolerated the surgery well. The renal part of the surgery required less than 12 min, and blood loss was minimal (<30 ml) for all the animals. The postoperative course was benign. Laparotomy performed 3 weeks later showed no peritoneal or retroperitoneal abnormalities. The plastic cable tie remained in the same position covered with a thin layer of mesothelial cells. A thin sector of coagulation necrosis was found under the pressure of the cable.Conclusions: In a porcine model, polar nephrectomy using a plastic cable tie is a very easy and rapid procedure. Cheap and bloodless, it eliminates the need for renal reconstruction. Hilar dissection and renal ischemia are avoided. "Cable-tie partial nephrectomy" may become a method for removing a tumor-bearing renal pole. [ABSTRACT FROM AUTHOR]

Competing Interests: Declaration of Competing Interest Dr Zorn is a paid consultant for Boston Scientific, Procept, Olympus, Zenflow, Clarius and Laborie Dr Chakraborty declares no conflict of interest Dr. Chughtai is a paid consultant for Boston Scientific, Olympus, Zenflow, Proden Medical Dr. Mehan is a paid consultant for Boston Scientific, Procept, Olympus, Laborie, Promaxo, and Marius Pharmaceuticals, CMO for HIFU Prostate Services, Dr. Elterman is a paid consultant for Boston Scientific, Procept, Olympus, Zenflow, Clarius and Laborie Dr Nguyen declares no conflict of interest Dr Bouhadana declares no conflict of interest Dr. Glaser is a paid consultant for Procept Biorobotics Dr. Marhamati declares no conflict of interest Mr Barber is a paid consultant for Procept Biorobotics, Olympus Keymed and Teleflex. Dr. Helfand is a paid consultant for Procept Biorobotics and a medical advisory board member for Emano Metrics, Inc. I accept the responsibility for the completion of this document and attest to its validity on behalf of the co-authors.

Purpose of Review: The prevalence of benign prostatic hyperplasia (BPH) is rising, however, current treatment options present severe complications and limit patient's quality of life. Accordingly, advancements in prostatic catheter and stent designs for use in treating lower urinary tract symptoms (LUTS) in BPH patients have largely expanded in the past five years and we aim to provide an exhaustive summary of recent outcomes., Recent Findings: The dual dilation and paxlitaxel eluting Optilume BPH Catheter System enhances promise in catheter-based treatments, providing the longest sustained increase in max urinary flow rate and decrease in post-void residual volume compared to alternative MISTs. Additionally, use of iTiND, along with recent advancements in temporary (EXIME, Prodeon Urocross) and permanent (Zenflow Spring, Butterfly, and ClearRing) stent designs, have demonstrated rapid, lasting, and low-cost LUTS relief with sustained sexual function. Minimally invasive solutions that offer in-office treatment, rapid symptom relief, shorter recovery times, and preservation of sexual function hold great promise in improving outcomes in managing BPH patients with LUTS., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Ataxia with anti-regulator of G-protein signaling 8 autoantibodies (RGS8-Abs) is an autoimmune disease recently described in four patients. The present study aimed to identify other patients with RGS8-Abs, describe their clinical features, including the link between RGS8-related autoimmune cerebellar ataxia (ACA) and cancer. Patients with RGS8-Abs were identified retrospectively in the biological collections of the French Reference Center for Paraneoplastic Neurological Syndrome and the University of California San Francisco Center for Encephalitis and Meningitis. Clinical data were collected, and cerebrospinal fluid, serum, and tumor pathological samples were retrieved to characterize the autoantibodies and the associated malignancies. Only three patients with RGS8-Abs were identified. All of them presented with a pure cerebellar ataxia of mild to severe course, unresponsive to current immunotherapy regimens for ACA. Two patients presented with a Hodgkin lymphoma of the rare specific subtype called nodular lymphocyte-predominant Hodgkin lymphoma, with very mild extension. Autoantibodies detected in all patients enriched the same epitope on the RGS8 protein, which is an intracellular protein physiologically expressed in Purkinje cells but also ectopically expressed specifically in lymphoma cells of patients with RGS8-related ACA. The present results and those of the four cases previously described suggest that RGS8-Abs define a new paraneoplastic neurological syndrome of extreme rarity found mostly in middle-aged males that associates pure cerebellar ataxia and a particular lymphoma specifically expressing the RGS8 antigen. As in other paraneoplastic ACA with intracellular antigen, the disease course is severe, and patients tend to exhibit a poor response to immune therapy., (© 2024. The Author(s).)

Purpose of Review: Benign prostatic hyperplasia (BPH) is prevalent in nearly 70% of men over the age of 60, leading to significant clinical challenges due to varying symptom presentations and treatment responses. The decision to undergo surgical intervention is not straightforward; the American Urological Association recommends consideration of surgical treatment after inadequate or failed response to medical therapy. This review explores the role of artificial intelligence (AI), including machine learning and deep learning models, in enhancing the decision-making processes for BPH management., Recent Findings: AI applications in this space include analysis of non-invasive imaging modalities, such as multiparametric Magnetic Resonance Imaging (MRI) and Ultrasound, which enhance diagnostic precision. AI models also concatenate serum biomarkers and histopathological analysis to distinguish BPH from prostate cancer (PC), offering high accuracy rates. Furthermore, AI aids in predicting patient outcomes post-treatment, supporting personalized medicine, and optimizing therapeutic strategies. AI has demonstrated potential in differentiating BPH from PC through advanced imaging and predictive models, improving diagnostic accuracy, and reducing the need for invasive procedures. Despite promising advancements, challenges remain in integrating AI into clinical workflows, establishing standard evaluation metrics, and achieving cost-effectiveness. Here, we underscore the potential of AI to improve patient outcomes, streamline BPH management, and reduce healthcare costs, especially with continued research and development in this transformative field., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Benign prostatic hyperplasia (BPH) is a condition that affects over 50% of men as they enter their fifth decade of life, often leading to lower urinary tract symptoms (LUTS). Primary treatment options include alpha blockers, 5-alpha reductase inhibitors, and phosphodiesterase-5 inhibitors. However, these medications can have some side effects, and there is a noticeable dearth of information addressing the long-term use of these medications. Thus, the exploration of all treatment modalities helps ensure patients receive personalized and effective care. Consequently, the primary objective of this review is to identify potential emerging medications for the treatment of BPH., Areas Covered: We conducted an extensive review of articles discussing pharmacotherapy for BPH spanning the last 15 years. Our information gathering process involved Scopus, PubMed-MEDLINE, Cochrane, Wiley Online Library Google Scholar, ClinicalTrials.gov, and the PharmaProjects database. This approach ensures that readers gain an in-depth knowledge of the existing therapeutic agents as well as promising avenues for managing BPH., Expert Opinion: BPH treatment targets a patient's specific constellation of symptoms. Therefore, a broad knowledge base encompassing various treatment options is paramount in ensuring optimal treatment. Looking forward, the emphasis on personalization promises to reshape the landscape of BPH treatment and improve patient outcomes.

Introduction: With more than 60% of urological procedures performed in ambulatory settings, it is imperative to understand the current trends in postoperative narcotic prescriptions and their adherence to the guidelines. We studied postoperative opioid-prescribing patterns after selected common urology ambulatory procedures., Methods: A retrospective cohort was derived from a 10% random sample of enrollees within the IQVIA PharMetrics Plus for Academics database from 2015 to 2021. Patient-level baseline characteristics were collected in the year preceding the index date. Descriptive and bivariate analyses were used to compare patient characteristics from opioid and nonopioid cohorts and those who utilized opioids ≤ 7 days and > 7 days postprocedurally. Trends of opioid and nonopioid use were also investigated and compared., Results: Between 2015 to 2021, 17,817 patients underwent urological ambulatory procedures, of which the majority (90.9%) were endoscopic procedures. Of those, 4077 (22%) were prescribed opioids and 978 (5.4%) patients were given prescription nonopioid (ie, ketorolac) medication. From 2015 to 2021, there was an overall decrease in prescription of opioids from 32% to 19%. The acute fulfillment (within 7 days of the procedure) of opioids had notably declined; however, there is a slight increase in the fulfillment of opioids beyond 7 days., Conclusions: Within the 7-day postsurgical period after ambulatory procedures, narcotic prescribing habits among urologists are congruent with current initiatives to reduce narcotic use in the setting of the opioid pandemic. However, beyond the 7-day postsurgical period, further guidelines are needed to guide narcotic prescribing habits.

Objective: To investigate the feasibility, safety, and efficacy of same-day discharge (SDD) after Aquablation specifically in an ambulatory surgery center (ASC)., Methods: A prospective cohort of men with significant BPH underwent Aquablation at a single ASC. Comprehensive preoperative assessments were conducted, including uroflowmetry, IPSS, and PVR. Aquablation was performed as morning cases by a single experienced surgeon. Following the procedure, men were assessed for immediate postoperative outcomes, including pain levels, hematuria, and voiding efficiency. Patients meeting discharge criteria were allowed to return home on the same calendar day., Results: A total of 60 consecutive men with a mean prostate size of 115 mL underwent Aquablation, 59 (98%) of whom were discharged the same day. No transfusions or return to the OR occurred. The procedure demonstrated a significant improvement in urinary flow rates and a substantial reduction in IPSS scores at the 1-month post-operative period. Pain scores were found to be minimal, and the incidence of postoperative complications, including hematuria and urinary retention was low and comparable to previously published outcomes. Despite more meticulous focal cautery, no differences in erectile, ejaculatory or adverse outcomes were observed., Conclusion: Aquablation for BPH at an ASC appears to be a safe and effective approach. Morning procedures and attentive cautery and streamlined patient pathways seem essential for SDD. Despite electrosurgical hemostasis, ejaculatory, sexual, and post-operatively pain were not compromised., Competing Interests: Declaration of Competing Interest Dr Zorn is a paid consultant for Boston Scientific, Procept, Olympus, Zenflow, Clarius, and Laborie; Dr. Chughtai is a paid consultant for Boston Scientific, Olympus, Zenflow, Proden Medical; Dr. Mehan is a paid consultant for Boston Scientific, Procept, Olympus, Laborie, Promaxo, and Marius Pharmaceuticals, CMO for HIFU Prostate Services; Dr. Elterman is a paid consultant for Boston Scientific, Procept, Olympus, Zenflow, Clarius, and Laborie; Dr. Glaser is a paid consultant for Procept Biorobotics; Mr Barber is a paid consultant for Procept Biorobotics, Olympus Keymed, and Teleflex; Dr. Helfand is a paid consultant for Procept Biorobotics and a medical advisory board member for Emano Metrics, Inc; the remaining authors declare that they have no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Despite the growing body of literature on sacral neuromodulation (SNM) outcomes, research focusing on male patients remains limited and often represented by small cohorts nested within a larger study of mostly women. Herein, we evaluated the outcomes of SNM in a male-only cohort with overactive bladder (OAB), fecal incontinence (FI), chronic bladder pain, and neurogenic lower urinary tract dysfunction (NLUTD)., Materials and Methods: This retrospective cohort study included 64 male patients who underwent SNM insertion between 2013 and 2021 at a high-volume tertiary center. Indications for SNM therapy included OAB, FI, chronic pelvic pain, and NLUTD. Descriptive statistics, Fisher's and t-test were used in analysis., Results: The mean age was 57.7 ± 13.4 years, and the most frequent reason for SNM insertion was idiopathic OAB (72%), FI (16%), pelvic pain (11%), and NLUTD (11%). A majority (84%) of men received treatment prior to SNM insertion. 84% reported satisfaction and 92% symptom improvement within the first year, and these improvements persisted beyond 1 year in 73% of patients. Mean follow up was 52.7 ± 21.0 months. The complication rate was 23%, and the need for adjunct treatments was significantly reduced (73% to 27%, p < 0.001). Treatment outcomes did not differ significantly between various indications for SNM therapy or the presence of benign prostatic hyperplasia (BPH)., Conclusion: SNM is an effective and safe procedure for male patients with neurogenic and non-neurogenic OAB, pelvic pain, and FI. Over 70% of patients experienced symptomatic improvement and remained satisfied in the mid to long term follow up. BPH does not seem to hinder treatment outcomes.

Introduction: A variety of procedures for the endoscopic surgical treatment of symptomatic benign prostatic hyperplasia (BPH) refractory to medical therapy have existed for decades. The present study examined trends in surgeon compensation for these treatments within Canada., Methods: The physician fee schedule for BPH surgery across 10 Canadian provinces for the years 2010 and 2023 were obtained. A descriptive study examined first the provincial reimbursement for transurethral resection of prostate (TURP) and laser ablative/enucleation surgery; second, the difference in TURP reimbursement between 2010 and 2023; and third, the annual change in TURP reimbursement juxtaposed with the annual change in the provincial Consumer Price Index (CPI) and annual salary for the working population aged 35-44., Results: Seven of 10 Canadian provinces reimburse laser BPH surgery equally to TURP. The average provincial TURP reimbursement is $545, ranging from $451 in Ontario to $688 in Saskatchewan. Since 2010, TURP reimbursement has varied by province from a 0% net change in Ontario to an increase of 21% in Nova Scotia. Reimbursement for TURP has increased at a slower pace than the local CPI, and for half of the provinces at a slower pace than the annual salary for people aged 35-44., Conclusions: The compensation model for endoscopic BPH surgery does not have a unified structure in Canada that is consistent across provinces, nor does it keep up with inflation, possibly impacting future recruitment, increasing geographic disparities, and most importantly, limiting the adoption of new BPH therapies.

Vitamin B12 is critical for hematopoiesis and myelination. Deficiency can cause neurologic deficits including loss of coordination and cognitive decline. However, diagnosis relies on measurement of vitamin B12 in the blood, which may not accurately reflect the concentration in the brain. Using programmable phage display, we identified an autoantibody targeting the transcobalamin receptor (CD320) in a patient with progressive tremor, ataxia, and scanning speech. Anti-CD320 impaired cellular uptake of cobalamin (B12) in vitro by depleting its target from the cell surface. Despite a normal serum concentration, B12 was nearly undetectable in her cerebrospinal fluid (CSF). Immunosuppressive treatment and high-dose systemic B12 supplementation were associated with increased B12 in the CSF and clinical improvement. Optofluidic screening enabled isolation of a patient-derived monoclonal antibody that impaired B12 transport across an in vitro model of the blood-brain barrier (BBB). Autoantibodies targeting the same epitope of CD320 were identified in seven other patients with neurologic deficits of unknown etiology, 6% of healthy controls, and 21.4% of a cohort of patients with neuropsychiatric lupus. In 132 paired serum and CSF samples, detection of anti-CD320 in the blood predicted B12 deficiency in the brain. However, these individuals did not display any hematologic signs of B12 deficiency despite systemic CD320 impairment. Using a genome-wide CRISPR screen, we found that the low-density lipoprotein receptor serves as an alternative B12 uptake pathway in hematopoietic cells. These findings dissect the tissue specificity of B12 transport and elucidate an autoimmune neurologic condition that may be amenable to immunomodulatory treatment and nutritional supplementation.

Purpose: To investigate safety and feasibility of performing water vapor thermal therapy (WVTT; Rezum, Boston Scientific, Marlborough, MA, USA) without postoperative catheterization among men with benign prostatic hyperplasia., Methods: This is a prospective, single arm, unblinded pilot study of 20 consecutive male patients ages 40-80 who underwent WVTT at a single academic institution. All patients underwent 1 injection per lobe at the point of maximal obstruction based on visualization. Primary outcome was evaluation of voiding parameters, symptom scores, and need for catheterization at 3 day, 1, 3, and 6 month follow up compared to baseline visit 30 days prior to surgery., Results: Mean age was 65 years (range 55-75). Mean prostate volume and PVR were 43 cc (range 30-68) and 89 cc, with 30% (n = 6) having median lobes. Patients received 2-3 treatments based on presence of bilobar versus trilobar hyperplasia. One patient (55 cc prostate, no median lobe) required catheterization for acute urinary retention on postoperative day 2. No patients required antibiotics for urinary tract infection or inpatient readmission within 30 days. Qmax significantly increased from 6 mL/s to 8, 13, 12, and 14 at 3 days, 1, 3, and 6 months (p < 0.05). IPSS decreased from 17 preoperatively to 10, 6, 7, and 8 (p < 0.05). No significant differences were noted in PVR, IIEF, MSHQ-EjD, or SF-12., Conclusions: In well-selected men, catheter-free WVTT is feasible and improved voiding parameters and symptom scores. No changes in sexual function, infectious complications, or readmission were noted. Only 1 patient (5%) required postoperative catheterization within 30 days., (© 2024. The Author(s).)

Introduction: Most robot-assisted surgery (RAS) systems in Canada are donor-funded, with constraints on implementation and access due to significant costs, among other factors. Herein, we evaluated the impact of the growing multispecialty use of RAS on urologic RAS access and outcomes in the past decade., Methods: We conducted a retrospective review of all RAS performed by different surgical specialties in two high-volume academic hospitals between 2010 and 2019 (prior to the COVID pandemic). The assessed outcomes included the effect of increased robot access over the years on annual robotic-assisted radical prostatectomy (RARP) volumes, surgical waiting times (SWT), and pathologically positive surgical margins (PSM). Data were collected and analyzed from the robotic system and hospital databases., Results: In total, six specialties (urology, gynecology, general, cardiac, thoracic, and otorhinolaryngologic surgery) were included over the study period. RAS access by specialty doubled since 2010 (from three to six). The number of active robotic surgeons tripled from seven surgeons in 2010 to 20 surgeons in 2019. Moreover, there was a significant drop in average case volume, from a peak of 40 cases in 2014 to 25 cases in 2019 (p=0.02). RARP annual case volume followed a similar pattern, reaching a maximum of 166 cases in 2014, then declining to 137 cases in 2019. The mean SWT was substantially increased from 52 days in 2014 to 73 days in 2019; however, PSM rates were not affected by the reduction in surgical volumes (p<0.05)., Conclusions: Over the last decade, RAS access by specialty has increased at two Canadian academic centers due to growing multispecialty use. As there was a fixed, single-robotic system at each of the hospital centers, there was a substantial reduction in the number of RAS performed per surgeon over time, as well as a gradual increase in the SWT. The current low number of available robots and unsustainable funding resources may hinder universal patient access to RAS.

Although B cells are implicated in multiple sclerosis (MS) pathophysiology, a predictive or diagnostic autoantibody remains elusive. In this study, the Department of Defense Serum Repository (DoDSR), a cohort of over 10 million individuals, was used to generate whole-proteome autoantibody profiles of hundreds of patients with MS (PwMS) years before and subsequently after MS onset. This analysis defines a unique cluster in approximately 10% of PwMS who share an autoantibody signature against a common motif that has similarity with many human pathogens. These patients exhibit antibody reactivity years before developing MS symptoms and have higher levels of serum neurofilament light (sNfL) compared to other PwMS. Furthermore, this profile is preserved over time, providing molecular evidence for an immunologically active preclinical period years before clinical onset. This autoantibody reactivity was validated in samples from a separate incident MS cohort in both cerebrospinal fluid and serum, where it is highly specific for patients eventually diagnosed with MS. This signature is a starting point for further immunological characterization of this MS patient subset and may be clinically useful as an antigen-specific biomarker for high-risk patients with clinically or radiologically isolated neuroinflammatory syndromes., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Background: Shared decision-making (SDM) is recommended for prostate-specific antigen (PSA) testing but appears underutilized. This population-based study assessed the prevalence and determinants of SDM for PSA testing among US men., Methods: We assessed PSA testing rates and SDM engagement in men aged 40 and older without prostate cancer history using the 2019 National Health Interview Survey. SDM was defined as discussing the advantages and disadvantages of PSA testing with a physician. We used multivariable logistic regression with machine learning to identify factors associated with lack of SDM., Results: Among 9723 eligible participants (mean age 58 years), lifetime PSA testing prevalence was 45.9% and the 1-year testing incidence was 29.1%. Only 24.1% reported engaging in SDM with a physician, while 62.9% never discussed PSA testing. Younger age and lower education levels were the primary determinants of decreased SDM engagement. Men with less education engaged in SDM less than half as often as those with higher education levels across all age groups., Conclusions: Societal guidelines recommend SDM for PSA testing. However, most men, regardless of age, have never engaged in SDM conversations with a healthcare provider about PSA testing, especially those with less education. More efforts are needed to improve patient-provider conversations about the potential benefits and harms of PSA testing., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Introduction: Benign prostatic hyperplasia (BPH) is one of the most common diseases affecting men and can present with bothersome lower urinary tract symptoms (LUTS). Historically, transurethral resection of the prostate (TURP) has been considered the gold standard in the treatment of LUTS due to BPH. However, TURP and other traditional options for the surgical management of LUTS secondary to BPH are associated with high rates of sexual dysfunction. In the past decade, several novel technologies, including Aquablation therapy, convective water vapor therapy (Rezum), and transperineal prostate laser ablation (TPLA), have demonstrated promising evidence to be safe and effective while preserving sexual function., Methods: In this review, we discuss three ablative minimally invasive surgeries: Aquablation, Rezum, and TPLA. We review their techniques, safety, as well as perioperative and functional outcomes. We go into further detail regarding sexual function after these ablative minimally invasive surgical therapies., Results: Aquablation is a surgeon-guided, robot-executed, heat-free ablative waterjet procedure with sustained functional outcomes at 5 years while having no effect on sexual activity. Rezum is an innovative office-based, minimally invasive surgical option for BPH that delivers convective water vapor energy into prostate adenoma to ablate obstructing tissue. Rezum leads to significant improvements in Qmax, IPSS while preserving sexual function. TPLA is another office-based technology which uses a diode laser source to produce thermoablation. It leads to improvement in Qmax, IPSS, and QoL while preserving ejaculatory function., Conclusions: Overall, ablative minimally invasive surgical therapies have demonstrated excellent safety and efficacy profiles while preserving sexual function. These modalities should be discussed with patients to ensure informed and shared decision-making. Ablative minimally invasive surgical therapies may be particularly interesting to patients who value the preservation of their sexual function., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Minimally invasive surgery techniques (MIST) have become newly adopted in urological care.  Given this, new analgesic techniques are important in optimizing patient outcomes and resource management. Rezūm treatment (RT) for BPH has emerged as a new MIST with excellent patient outcomes, including improving quality of life (QoL) and International Prostate Symptom Scores (IPSSs), while also preserving sexual function.  Currently, the standard analgesic approach for RT involves a peri-prostatic nerve block (PNB) using a transrectal ultrasound (TRUS) or systemic sedation anesthesia.  The TRUS approach is invasive, uncomfortable, and holds a risk of infection.  Additionally, alternative methods such as, inhaled methoxyflurane (Penthrox), nitric oxide, general anesthesia, as well as intravenous (IV) sedation pose safety risks or mandate the presence of an anesthesiology team.  Transurethral intraprostatic anesthesia (TUIA) using the Schelin Catheter (ProstaLund, Lund, Sweden) (SC) provides a new, non-invasive, and efficient technique for out-patient, office based Rezūm procedures.  Through local administration of an analgesic around the prostate base, the SC has been shown to reduce pain, procedure times, and bleeding during MISTs.  Herein, we evaluated the analgesic efficacy of TUIA via the SC in a cohort of 10 patients undergoing in-patient RT for BPH.

Introduction: Despite high prevalence and increased severity and burden of overactive bladder (OAB) and fecal incontinence (FI) in the elderly, sacral neuromodulation (SNM) is often overlooked as a potential treatment option for this demographic. In this study, we report the outcomes of SNM in patients aged 75 years or older at the time of surgery., Methods: We conducted a retrospective cohort study of patients who underwent SNM implantation between 2013 and 2022 performed by a single, high-volume urologist at a tertiary center. Success, complication, and adjunct therapy rates were analyzed by Fisher's or Wilcox rank-sum test as appropriate. We compared outcomes between patients aged 75-79 years and octogenarians., Results: Of 632 patients, 50 were ≥75 years. Patients had a mean age of 78.4±2.6 years and were predominantly female (84%). The indications for SNM were 66% OAB, 16% FI, 16% non-obstructive urinary retention, and 4% pelvic pain. Within the first year, 94% of patients reported satisfaction and improvement in symptoms, while 76% continued to experience improvement beyond one year. SNM insertion led to reduced oral medication use from 68% to 24% (p<0.0001). The complication rate was 16% and mostly included device pain. No significant difference was observed in treatment success, complication, or adjunct therapy rate between age groups., Conclusions: SNM is a safe and effective option in well-selected patients over the age of 75 years. Treatment success rate is comparable to younger cohorts. Advanced age should not preclude third-line therapy options in this population.

Background: To summarize current evidence to report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) with transurethral resection of the prostate (TURP) and open simple prostatectomy (OSP) for the treatment of benign prostatic hyperplasia (BPH)., Methods: A systematic literature search was performed to identify studies published from inception until August 2021. The search terms used were (prostate embolization OR prostatic embolization) AND (prostatic hyperplasia OR prostatic obstruction) as well as the abbreviations of PAE and BPH. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool for observational studies. Random-effects meta-analysis was performed using Revman 5.4., Results: Seven studies were included with 810 patients: five RCTs and one observational study compared PAE with TURP, and one observational study compared PAE with OSP. The included studies had considerable risk of bias concerns. TURP and OSP were associated with more statistically significant improvements in urodynamic measures and BPH symptoms compared to PAE. However, PAE seems to significantly improve erectile dysfunction compared to OSP and improve other outcome measures compared to TURP, although not significantly. PAE appeared to reduce adverse events and report more minor complications compared with TURP and OSP, but it is unclear whether PAE is more effective in the long-term., Conclusion: PAE is an emerging treatment option for patients with symptomatic BPH who cannot undergo surgery or have undergone failed medical therapy. Overall, PAE groups reported fewer adverse events. Future ongoing and longer-term studies are needed to provide better insight into the benefit of PAE compared to other treatment options., (© 2024. The Author(s).)

Transrectal ultrasound (TRUS) is a common modality used during urological procedures that require real-time visualization of the prostate, such as prostate biopsy and peri-prostatic nerve blocks (PNB) for surgical procedures. Current practice for TRUS-guided PNB requires use of costly, fixed, and non-portable ultrasound machinery that can often limit workflow. The Clarius endocavity EC7 probe, a digital, handheld and pocket-sized endocavity ultrasound (US) device, is an alternative, portable technology which was recently shown to accurately visualize and measure prostate dimensions and volume. Moreover, in recent years, there has been a renaissance of office-based treatments for minimally invasive surgical therapies (MIST) for the treatment of benign prostate hyperplasia (BPH). More specifically, the Rezūm procedure has been demonstrated to offer men a short, outpatient therapy with excellent 5-year outcomes in durability and preservation of antegrade ejaculation. While other anesthetic techniques have been described for Rezūm, including inhaled methoxyflurane (Penthrox), nitrous oxide, IV sedation and general anesthesia (which often mandate the presence of an anesthesiology team), US-guided local blocks offer the urologist an independent method for pain management. While most urologists may not have direct access to expensive, cart-based ultrasound systems, point of care ultrasound (POCUS) technology, such as Clarius (Vancouver, BC, Canada) and Butterfly (Butterfly Network, Inc, Guilford, CT, USA), can provide high-resolution imaging in combination with smart phone technology. Herein, we sought to describe the technique for using Clarius EC7 for TRUS-guided PNB and its use in urological application with the Rezūm BPH procedure.

Objective: Co-occurring anti-tripartite motif-containing protein 9 and 67 autoantibodies (TRIM9/67-IgG) have been reported in only a very few cases of paraneoplastic cerebellar syndrome. The value of these biomarkers and the most sensitive methods of TRIM9/67-IgG detection are not known., Methods: We performed a retrospective, multicenter study to evaluate the cerebrospinal fluid and serum of candidate TRIM9/67-IgG cases by tissue-based immunofluorescence, peptide phage display immunoprecipitation sequencing, overexpression cell-based assay (CBA), and immunoblot. Cases in which TRIM9/67-IgG was detected by at least 2 assays were considered TRIM9/67-IgG positive., Results: Among these cases (n = 13), CBA was the most sensitive (100%) and revealed that all cases had TRIM9 and TRIM67 autoantibodies. Of TRIM9/67-IgG cases with available clinical history, a subacute cerebellar syndrome was the most common presentation (n = 7/10), followed by encephalitis (n = 3/10). Of these 10 patients, 70% had comorbid cancer (7/10), 85% of whom (n = 6/7) had confirmed metastatic disease. All evaluable cancer biopsies expressed TRIM9 protein (n = 5/5), whose expression was elevated in the cancerous regions of the tissue in 4 of 5 cases., Interpretation: TRIM9/67-IgG is a rare but likely high-risk paraneoplastic biomarker for which CBA appears to be the most sensitive diagnostic assay. ANN NEUROL 2023;94:1086-1101., (© 2023 The Authors. Annals of Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.)

Purpose: To conduct a scoping review of the existing literature and recent developments on prostatic stents for the treatment of benign prostatic hyperplasia (BPH)., Methods: A comprehensive search was performed on Embase, MEDLINE, and Web of Science to identify English literature on prostatic stents for the treatment of BPH. Additional studies and upcoming devices were identified through grey literature search and expert consultation. Study characteristics and stent information were extracted and tabulated narratively., Results: Of the 1171 search results, 64 studies were included in this review. iTiND was the prostatic stent with the most long-term evidence. iTiND is a safe and effective minimally invasive treatment for BPH that preserves sexual function. Adverse events are mild and transitory. Emerging stents (e.g. Zenflow, Butterfly, Urocross, and Exime) had 7/64 eligible studies, where no studies had long-term follow-up. These newer stents show promising results for quality of life and BPH symptom management; however, long-term monitoring and head-to-head comparisons are needed., Conclusion: Over the last 50 years, prostatic stents have evolved and demonstrated improved clinical efficacy. iTiND provides a safe and effective outpatient treatment of LUTS secondary to BPH preserving erectile and ejaculatory function. Emerging prostatic stents are a promising, effective, and safe intervention in well-selected patients interested in its benefits., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To analyze the impact of perioperative antithrombotic use on the bleeding outcomes following Aquablation., Methods: One hundred sixteen men with who underwent Aquablation as part of the WATER prospective trial (NCT02505919) were assigned to 2 groups based on perioperative antithrombotic status. Antithrombotic cessation and restart timing were based on the surgeon's discretion. Methods of achieving intraoperative hemostasis consisted of no-cautery balloon tamponade or cautery. Primary endpoints included immediate postoperative hematuria rates and changes in hemoglobin. Secondary endpoints included 90-day bleeding complications and nonbleeding postoperative adverse events., Results: Forty-one men took antithrombotic medications in the perioperative period while 75 men had no antithrombotic medication. Preoperative hemoglobin levels were comparable between both groups. Postoperative hemoglobin change from baseline (drop of 1.8 ± 1.5 g/dL among the antithrombotic group vs 1.8 ± 1.7 g/dL among the antithrombotic-naïve group) did not differ between both groups (P = .896). In total, 4 (9.8%) men in the antithrombotic group and 4 (5.3%) patients in the antithrombotic-naïve group experienced a Clavien-Dindo grade 1 complication (P = .451) in the 3-month postoperative period. Eight (19.5%) patients in the antithrombotic group and 11 (14.7%) patients in the antithrombotic-naïve group experienced a Clavien-Dindo grade 2 complication (P = .601), none of which is associated with bleeding in both groups. No men in either group demonstrated de novo erectile dysfunction. One patient (2.4%) in the antithrombotic group and none in the antithrombotic-naïve group required blood products (P = .353)., Conclusion: Aquablation demonstrates comparable postoperative bleeding outcomes and other adverse effects for men with benign prostatic hypertrophy who are on antithrombotic therapy., Competing Interests: Declaration of Competing Interest Neil Barber – Proctor/Advisor to Procept Biorobotics. Kussil Oumedjbeur -- consulting agreement with Procept-BioRobotics for travel expenses. Naeem Bhojani Received paid training session at the AUA 2018. Dean Elterman Paid consultant to Procept Biorobotics. Alexis E. Te Paid consultant to Procept Biorobotics. Claus Roehrborn Paid consultant to Procept Biorobotics. Kevin Zorn Paid consultant to Procept Biorobotics/Received paid training session at the AUA 2018. The other authors have no conflict of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Neurological opportunistic infections cause significant morbidity and mortality in people with human immunodeficiency virus (HIV) but are difficult to diagnose., Methods: One hundred forty people with HIV with acute neurological symptoms from Iquitos, Peru, were evaluated for cerebral toxoplasmosis with quantitative polymerase chain reaction (qPCR) of cerebrospinal fluid (CSF) and for cryptococcal meningitis with cryptococcal antigen test (CrAg) in serum or CSF. Differences between groups were assessed with standard statistical methods. A subset of samples was evaluated by metagenomic next-generation sequencing (mNGS) of CSF to compare standard diagnostics and identify additional diagnoses., Results: Twenty-seven participants were diagnosed with cerebral toxoplasmosis by qPCR and 13 with cryptococcal meningitis by CrAg. Compared to participants without cerebral toxoplasmosis, abnormal Glasgow Coma Scale score ( P = .05), unilateral focal motor signs ( P = .01), positive Babinski reflex ( P = .01), and multiple lesions on head computed tomography (CT) ( P = .002) were associated with cerebral toxoplasmosis. Photophobia ( P = .03) and absence of lesions on head CT ( P = .02) were associated with cryptococcal meningitis. mNGS of 42 samples identified 8 cases of cerebral toxoplasmosis, 7 cases of cryptococcal meningitis, 5 possible cases of tuberculous meningitis, and incidental detections of hepatitis B virus (n = 1) and pegivirus (n = 1). mNGS had a positive percentage agreement of 71% and a negative percentage agreement of 91% with qPCR for T gondii . mNGS had a sensitivity of 78% and specificity of 100% for Cryptococcus diagnosis., Conclusions: An infection was diagnosed by any method in only 34% of participants, demonstrating the challenges of diagnosing neurological opportunistic infections in this population and highlighting the need for broader, more sensitive diagnostic tests for central nervous system infections., Competing Interests: Potential conflicts of interest. M. R. W. is a co-founder and a member of the board of directors for Delve Bio. All other authors report no potential conflicts., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Introduction: To report the 5-year efficacy and safety of Aquablation compared with transurethral resection of the prostate for the management of lower urinary tract symptoms secondary to benign prostatic hyperplasia in men with prostate volumes 50-80 mL., Materials and Methods: In a large double-blinded, multicenter, and prospective randomized controlled trial, 96 randomized men with 50-80 mL prostates who underwent Aquablation or transurethral prostate resection were prospectively identified for subgroup analysis. Follow up was performed for up to 5 years. The primary efficacy endpoint was the reduction in International Prostate Symptom Score (IPSS) at 6 months. The primary safety endpoint was the occurrence of Clavien-Dindo (CD) postoperative complications grade 1 persistent and grade 2 or higher at 3 months., Results: Both groups had comparable baseline characteristics. Reduction in IPSS score was significantly higher in the Aquablation group across 5 years of follow up (-14.1 vs. -10.8, p = 0.02). The Aquablation group achieved a significantly lower rate of CD1P and CD2 or higher events at 3 months follow up (risk difference of -23.1%). Among recorded adverse events, de novo postoperative ejaculatory dysfunction was notably lower in Aquablation (risk difference of -21.9%), while the risk of bleeding remained similar after 6 months. The surgical and medical retreatment rate at 6 months was also lower in Aquablation (risk difference of -14.4%)., Conclusions: In the 50-80 mL prostate volume subgroup, Aquablation yields superior long-term symptom relief and lower complication rates than standard transurethral resection, with notably lower rates of ejaculatory dysfunction. This further supports the adoption of Aquablation for men with medium-sized prostates.

Introduction: In line with Canadian provincial directives due to the COVID-19 pandemic, certain elective urologic surgical cases that are normally performed as inpatient procedures were performed as same-day discharge procedures to reduce hospitalization and the usage of scarce healthcare resources. Since the pandemic, we began performing laser enucleation of the prostate (LEP), robotic-assisted radical prostatectomy (RARP), and percutaneous nephrolithotomy (PCNL ) as outpatient surgeries. This was supported by recent evidence demonstrating the safety and feasibility of performing these minimally invasive surgeries as same-day procedures. As such, we sought to retrospectively evaluate the clinical outcomes and safety during the COVID-19 era at our institution for same-day discharge LEP, RARP, and PCNL procedures., Methods: All patients operated for LEP, RARP, or PCNL between May 2020 and March 2022 at two academic institutions were included. Surgeries were classified as planned same-day discharge or inpatient surgery. Same-day discharge patients were compared to inpatients for each procedure type. This comparison assessed the occurrence of same-day failure, postoperative complications, and re-admission rates at 30 days. This study was approved by the scientific ethics committee of the Centre de Recherche de l'Université de Montréal (CRCHUM)., Results: A total of 413 subjects were included in this study. Among LEP patients (n=169), 104 (62%) were identified as same-day procedures and 65 (38%) were inpatient. Among RARP patients (n=194), 46 (24%) were identified as same-day procedures and 148 (76%) inpatient. Among PCNL patients (n=50), 38 (76%) were identified as same-day procedures and 12 (24%) were inpatient. Of the patients who underwent planned same-day LEP, RARP, and PCNL, 77.9%, 73.9%, and 71.1% were successfully discharged home, respectively. Patients who underwent LEP as inpatients had a higher incidence of overall postoperative complications compared to same-day LEP (23.1% vs. 8.7%, p=0.017). The rates of 30-day emergency department (ED ) visits and hospital re-admission were similar between inpatient and same-day LEP (9.2% vs. 3.8%, p=0.27; and 4.6% vs. 1.0%, p=0.32, respectively). Inpatient RARP, however, was associated with more 30-day ED visits compared to same-day procedures (17.4% vs. 4.1%, p<0.01). No statistically significant differences were found for postoperative complications (15.2% vs. 6.1%, p=0.097) and re-admission rates (1.4% vs. 4.3%, p=0.51). There were no significant differences on overall postoperative complications, 30-day ED visits, and re-admission rates in inpatient vs. same-day PCNL., Conclusions: Our results suggest that same-day discharge for LEP, RARP, and PCNL is safe and feasible in select patients, with an acceptable complication rate. These results should be validated in a larger, prospective clinical trial comparing same-day and inpatient procedures.

Benign prostatic obstruction (BPO) is a prevalent condition that affects men, primarily toward their old age. The condition is often accompanied by lower urinary tract symptoms (LUTS), which can significantly impair a patient's quality of life and lead to other medical complications. Accurate diagnosis of BPO is essential for effective management of complications secondary to BPO, and treatment plans should be tailored patients, and occasionally according to surgeon experience. As such, this literature review aims to analyze the current available data on male LUTS secondary to BPO by providing a comprehensive overview of relevant studies, as well as the surgical and medical management guidelines from the Canadian Urological Association (CUA), American Urological Association (AUA), and European Association of Urology (EAU). By synthesizing the existing literature, this review purports to summarize the current body of knowledge surrounding BPO and male LUTS, and support healthcare providers in making informed decisions about the management of male LUTS secondary to BPO, ultimately improving patient outcomes and quality of life., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose: We report 5-year safety and efficacy outcomes of the Aquablation procedure for the treatment of men with symptomatic benign prostatic hyperplasia and large-volume prostate glands., Materials and Methods: A total of 101 men with moderate to severe benign prostatic hyperplasia symptoms and prostate volumes between 80 and 150 mL underwent a robotic-assisted Aquablation procedure in a prospective multicenter international trial (NCT03123250). Herein we report the final 5-year results., Results: The study successfully met its safety and efficacy performance goal, which was based upon transurethral resection of the prostate outcomes typically done in smaller prostates, at 3 months. Mean prostate volume was 107 mL (range 80-150) at baseline. Patient symptoms showed a significant improvement where the mean (SD) International Prostate Symptom Score of 22.6 (6.4) at baseline to 6.8 (4.6) at 5 years, resulting in a change score of 15.9 (7.7, P < .001). Uroflowmetry measurements also demonstrated improvement where the mean maximum urinary flow rate increased from 8.6 (SD 3.4) to 17.1 (9.8) mL/s at 5 years, resulting in a change score of 9.2 (11.1) mL/s at 5 years ( P < .001). A regression analysis evaluating change in PSA as a function of baseline PSA across all time points out to 5 years resulted in a 50% reduction. A prespecified subgroup analysis using a baseline prostate volume cutoff of 100 mL showed no difference in efficacy outcomes through 5 years. Freedom from a secondary benign prostatic hyperplasia procedure at 5 years was 96.3% based on Kaplan-Meier., Conclusions: At 5-years of prospective follow-up, the Aquablation procedure was shown to be safe with durable efficacy and low rates of retreatment in men with large prostates (80-150 mL).