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We aim to evaluate the incidence of incontinence following laser endoscopic enucleation of the prostate (EEP) comparing en-bloc (Group 1) versus 2-lobe/3-lobe techniques (Group 2). We performed a retrospective review of patients undergoing EEP for benign prostatic enlargement in 12 centers between January 2020 and January 2022. Data were presented as median and interquartile range (IQR). Univariable and multivariable logistic regression analysis was performed to evaluate factors associated with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI). There were 1711 patients in Group 1 and 3357 patients in Group 2. Patients in Group 2 were significantly younger (68 [62-73] years vs 69 [63-74] years, P = 0.002). Median (interquartile range) prostate volume (PV) was similar between the groups (70 [52-92] ml in Group 1 vs 70 [54-90] ml in Group 2, P = 0.774). There was no difference in preoperative International Prostate Symptom Score, quality of life, or maximum flow rate. Enucleation, morcellation, and total surgical time were significantly shorter in Group 1. Within 1 month, overall incontinence rate was 6.3% in Group 1 versus 5.3% in Group 2 ( P = 0.12), and urge incontinence was significantly higher in Group 1 (55.1% vs 37.3% in Group 2, P < 0.001). After 3 months, the overall rate of incontinence was 1.7% in Group 1 versus 2.3% in Group 2 ( P = 0.06), and SUI was significantly higher in Group 2 (55.6% vs 24.1% in Group 1, P = 0.002). At multivariable analysis, PV and IPSS were factors significantly associated with higher odds of transient SUI/MUI. PV, surgical time, and no early apical release technique were factors associated with higher odds of persistent SUI/MUI., (Copyright © 2024 Copyright: © The Author(s)(2024).)

Purpose: To evaluate complications and urinary incontinence (UI) after endoscopic enucleation of the prostate (EEP) stratified by prostate volume (PV)., Methods: We retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with different energy sources in 14 centers (January 2019-January 2023)., Inclusion Criteria: prostate volume ≥ 80 ml., Exclusion Criteria: prostate cancer, previous prostate/urethral surgery, pelvic radiotherapy., Primary Outcome: complication rate., Secondary Outcomes: incidence of and factors affecting postoperative UI. Patients were divided into 3 groups. Group 1: PV = 80-100 ml; Group 2 PV = 101-200 ml; Group 3 PV > 200 ml. Multivariable logistic regression analysis was performed to evaluate independent predictors of overall incontinence., Results: There were 486 patients in Group 1, 1830 in Group 2, and 196 in Group 3. The most commonly used energy was high-power Holmium laser followed by Thulium fiber laser in all groups. Enucleation, morcellation, and total surgical time were significantly longer in Group 2. There was no significant difference in overall 30-day complications and readmission rates. Incontinence incidence was similar (12.1% in Group 1 vs. 13.2% in Group 2 vs. 11.7% in Group 3, p = 0.72). The rate of stress and mixed incontinence was higher in Group 1. Multivariable regression analysis showed that age (OR 1.019 95% CI 1.003-1.035) was the only factor significantly associated with higher odds of incontinence., Conclusions: PV has no influence on complication and UI rates following EEP. Age is risk factor of postoperative UI., (© 2024. The Author(s).)

Introduction: Men with detrusor underactivity (DUA) and concomitant bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) may present poorer functional outcomes after surgical desobstruction. This study aimed to evaluate the safety and efficacy of BPE surgery in men with DUA compared with those with normal detrusor contractility (NC)., Materials and Methods: This review was performed according to the 2020 PRISMA framework. A comprehensive literature search was performed until May 7, 2023, using MEDLINE, EMBASE, and Cochrane Database. No date limits were imposed. Only comparative studies were accepted. The primary endpoint was to assess if there was any difference in short- and long-term functional outcomes after BPE surgery in men with DUA and NC. The secondary endpoint was to evaluate the differences in perioperative outcomes and postoperative complications between the two groups. Meta-analysis was performed using Review Manager (RevMan) software., Results: There were 5 prospective nonrandomized studies and 12 retrospective studies, including 1701 DUA and 1993 NC patients. Regarding surgical procedures, there were eight TURP (transurethral resection of the prostate) studies, four GreenLight PVP (photoselective vaporization of the prostate) studies, two HoLEP (Holmium laser enucleation of the prostate) studies, one GreenLight PVP/HoLEP study, one Holmium laser incision of the prostate study, and one study did not report the type of surgery. We did not find a statistically significant difference between the two groups in terms of perioperative outcomes, including postoperative catheterization time, hospitalization time, urinary retention, need to recatheterization, transfusion rate, or urinary tract infections. Also, we found no significant differences in long-term complications, such as bladder neck stenosis or urethral stenosis. Posttreatment bladder recatheterization and retreatment rate for BPE regrowth could not be evaluated properly, because only one study reported these findings. When we analyzed functional outcomes at 3 months, those with NC had lower International Prostatic Symptom Score (IPSS), lower quality-of-life (QoL) score, better maximum flow rate (Qmax), and lower post-voiding residual (PVR) of urine. These results were maintained at 6 months postoperatively, with exception of PVR that showed no difference. However, at 12 and more than 12 months the functional outcomes became similar regarding IPSS and QoL. There were few data about Qmax and PVR at longer follow-up., Conclusion: In this meta-analysis, data suggest that BOO surgical treatment in patients with concomitant BPE and DUA appears to be safe. Despite patients with DUA may present worse functional outcomes in the short postoperative term compared with the NC population, IPSS and QoL scores become comparable again after a longer follow-up period after surgery., (© 2023 Wiley Periodicals LLC.)

Purpose: To collect a multicentric, global database to assess current preferences and outcomes for endoscopic enucleation of the prostate (EEP)., Methods: Endourologists experienced in EEP from across the globe were invited to participate in the creation of this retrospective registry. Surgical procedures were performed between January 2020 and August 2022., Inclusion Criteria: lower urinary tract symptoms not responding to or worsening despite medical therapy and absolute indication for surgery., Exclusion Criteria: prostate cancer, concomitant lower urinary tract surgery, previous prostate/urethral surgery, pelvic radiotherapy., Results: Ten centers from 7 countries, involving 13 surgeons enrolled 6193 patients. Median age was 68 [62-74] years. 2326 (37.8%) patients had large prostates (> 80 cc). The most popular energy modality was the Holmium laser. The most common technique used for enucleation was the 2-lobe (48.8%). 86.2% of the procedures were performed under spinal anesthesia. Median operation time was 67 [50-95] minutes. Median postoperative catheter time was 2 [1, 3] days. Urinary tract infections were the most reported complications (4.7%) followed by acute urinary retention (4.1%). Post-operative bleeding needing additional intervention was reported in 0.9% of cases. 3 and 12-month follow-up visits showed improvement in symptoms and micturition parameters. Only 8 patients (1.4%) required redo surgery for residual adenoma. Stress urinary incontinence was reported in 53.9% of patients and after 3 months was found to persist in 16.2% of the cohort., Conclusion: Our database contributes real-world data to support EEP as a truly well-established global, safe minimally invasive intervention and provides insights for further research., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To compare Holmium laser with MOSES technology (MoLEP) and Thulium fiber laser enucleation of the prostate (ThuFLEP) in terms of surgical and functional outcomes., Methods: We performed a retrospective analysis of all patients who underwent either procedure in five centers (January 2020-January 2022)., Exclusion Criteria: previous urethral/prostatic surgery, radiotherapy, concomitant surgery. Propensity score matching (PSM) analysis was performed to adjust for the bias inherent to the different characteristics at baseline. Differences between procedures were estimated using Firth Penalized Likelihood regression for International prostate symptom score (IPSS), quality of life (QL), maximum flow rate (Qmax)., Results: PSM retrieved 118 patients in each group. Baseline characteristics were similar except for PSA and number of men on indwelling catheter (higher in MoLEP group). Median surgical time was significantly longer in the MoLEP group despite the enucleation and morcellation times being similar. Median catheter dwelling time and postoperative length of stay were similar. Most of the early complications were Clavien ≤ 2 grade. There were only two Clavien grade 3 complications (one for each group), one grade 4 in MoLEP group. Rate and type of early and persistent incontinence (> 3 months) were similar. At 12-month, proportion of patients reaching a decrease (Δ) of IPSS ≥ 18 from baseline was significantly larger in MoLEP group, with no significant difference in ΔQmax > 12 ml/sec and ΔQL ≥ -3., Conclusion: MoLEP and ThuFLEP were safe and efficacious procedures with similar short-term operative and functional outcomes. At 1-year, MoLEP patients had a sustained reduction of IPPS score., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Urologists may hesitate to offer transurethral resection of the prostate (TURP) because of increased morbidity in elderly patients., Aims: We aimed to compare data on postoperative outcomes of elderly men undergoing bipolar transurethral resection of the prostate (B-TURP) as compared to thulium laser vapoenucleation of the prostate (ThuVEP)., Methods: We retrospectively reviewed data of all patients aged ≥ 75 years who underwent benign prostatic hyperplasia surgery. Differences between interventions were estimated using propensity scores (PS) to adjust for different patients characteristics., Results: Between 2017 and 2020, 275 men were included in the analysis. Propensity score retrieved 65 patients in each group. Median age was 78 (4) years in B-TURP group and 78 (6) in ThuVEP group. Median prostate volume was 63 (35) ml and 54 (24) ml in B-TURP group and ThuVEP group, respectively. Only American Society of Anesthesiologists score was significantly higher in ThuVEP group (p = 0.006). Median operation time, catheterization time, and hospital stay were similar in both groups (55 min, 2 and 3 days). Overall, 84.6% of men had no complications, with no significant differences between the groups (p = 0.234). Only one patient in B-TURP group experienced a Clavien grade IIIb complication. By 1 year, there were a statistically significant differences in International Prostate Symptom Score (p = 0.000) in favor of B-TURP group and in maximal urine flow rate (p = 0.000) in favor of ThuVEP group., Discussion and Conclusions: Both procedures showed excellent functional improvements one year after surgery with a low rate of major complications in men aged ≥ 75 years with small-to-medium sized prostates.

Systemic fluid absorption frequently occurs during endoscopic surgery. When large volumes are absorbed, fluid overload is the result. The introduction of lasers allowed the use of normal saline (0.9% sodium chloride) in endoscopic prostatic surgery. This led to the disappearance of the transurethral resection syndrome; however, the fluid overload of normal saline can cause the onset of several catastrophic effects. The present study aimed to evaluate the incidence, sign and symptoms severity of fluid overload in a large series of men who underwent Thulium Laser Enucleation of the Prostate. Between December 2014 and February 2020, 633 men underwent the procedure. Seven patients (1.1%) had symptomatic fluid overload. Two patients developed severe pulmonary oedema, which required oral intubation and admission to the intensive care unit. Two patients required delayed morcellation. The analysis of our series highlighted that old age, large prostate volume, prolonged operative time and prostatic capsular perforation influenced the onset of fluid overload syndrome. Urologists should be aware that fluid overload might be a potentially life-threatening condition and should be early recognised. Surgery should be interrupted as soon as it occurs to avoid severe pulmonary oedema., (© 2020 Wiley-VCH GmbH.)

There is an increasing use of the procedure, anatomical endoscopic enucleation of the prostate, as an alternative to conventional transurethral resection of prostate for surgical treatment of benign prostatic hyperplasia. However, barriers to adoption of this procedure remain and no prior studies explored this important aspect till date. The aim of this study is to identify the predictors and barriers of surgeon-related practices in this area. The study findings may also provide valuable insight into current practice trends worldwide. To achieve the objectives, we conducted an online, cross-sectional, questionnaire-based study between 1st September 2019 and 5th October 2019 to investigate the knowledge, attitudes and practices among urologists worldwide. Our findings showed that the main barriers for adoption of the procedure were lack of mentorship, a steep learning curve, and unavailability of morcellator, bipolar or laser energy sources. Fear of urinary incontinence, bleeding and bladder injury were not major hindrance to adoption of this technique. The results also demonstrated that there will be continued increase in utility of the procedure in the future., (© 2020 Blackwell Verlag GmbH.)

Tm:YAG laser operates at a wavelength of 1940-2013 nm in a continuous wave mode, which enables smooth incision and rapid vaporization of prostatic tissue, with a shallow penetration of only 0.2 mm. These characteristics make Tm:YAG a versatile laser, allowing the surgeon to perform resection, vaporization, and vapoenucleation. This systematic review aims to summarize the current evidence of safety and efficacy, long-term durability, impact on sexual function following Tm:YAG laser enucleation and vapoenucleation of the prostate and to compare the outcomes of these procedures vs other surgical treatments of benign prostatic hyperplasia., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Thulium laser enucleation of the prostate is gaining popularity due to its short learning curve and low postoperative morbidity. The aim of Thulium laser enucleation of the prostate is the complete endoscopic enucleation of the adenoma. We report an unusual case of bladder outlet obstruction developed 6 weeks after Thulium laser enucleation of the prostate., Case Description: A 74-year-old man complained of severe voiding phase symptoms lasting 2 weeks, starting 6 weeks after Thulium laser enucleation of the prostate. He underwent a transrectal ultrasound, which showed a wide prostatic fossa. A cystoscopy revealed that the prostatic fossa was filled with whitish tissue arising from two tiny residual adenomas. The obstructing tissue was resected with the aid of Thulium laser and the histopathology report showed necrotic prostatic glands., Conclusion: Partially enucleated and left inside adenoma may become necrotic and cause bladder outlet obstruction several weeks after Thulium laser enucleation of the prostate. Transrectal ultrasound control at the end of enucleation may help reduce this complication.

Objective: To compare in daily practice efficacy and safety of standard 180-Watt GreenLight laser photoselective vaporization (PVP) and Thulium laser Vaporesection of the prostate (ThuVEP)., Materials and Methods: All men were evaluated with prostate volume, prostate-specific antigen, International Prostate Symptom Score, and maximum urinary flow. Patient global impression of improvement was evaluated with patient global impression of improvement scale for 6 months. Antiplatelet/anticoagulant therapy, operation time, 24-hour hemoglobin drop , length of catheterization, discharge day, early complications, and reoperation after 30 days were gathered. Differences between interventions were estimated using propensity scores to adjust for different patients characteristics. The propensity scores were estimated by fitting a stepwise logistic regression model with intervention type as the dependent variable and all the covariates., Results: Five hundred five men underwent the surgical procedures (291 PVP and 214 ThuVEP). Mean age was 69.6 years. Mean prostate volume was 54 mL. Median operation time was 55 minutes. Median catheterization time was 2 days in both series. After matching, the postoperative stay was similar in both groups (2 days). Hemoglobin drop for 24 hours was statistically significantly lower in PVP (-0.5 vs -0.8 g/dL, P .002). Most of the complications were mild-to-moderate and comparable among groups. Δ Maximum urinary flow was similar 6-month after surgery before and after matching, whereas PVP group had a better improvement 12-month after surgery. 96.4% of all patients had an improvement of their symptoms, with no difference between groups, before and after matching., Conclusion: Our study demonstrated that PVP and ThuVEP are similar in term of complications and outcomes, with high patients' satisfaction., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To evaluate whether 2 similar en bloc thulium laser enucleation of the prostate (ThuLEP) techniques can influence surgical complications and outcomes., Material: Within 2 institutional databases 164 men who underwent 2 different en bloc ThuLEP techniques were compared using propensity scores. With the first technique prostatic lobes were all enucleated en bloc, whereas, with the second the median lobe was enucleated first and the lateral lobes were enucleated en bloc thereafter. All patients were evaluated at baseline and 6 months after surgery with PSA, Qmax, and self-administrated IPSS. Operative data and 30-day postoperative complications were gathered., Results: Surgical time and 24-hour blood loss were similar between 2 groups (55 vs 55 minutes, P .97288; -0.9 vs -1.3 g/dL, P .112 respectively). Median hospital stay after surgery was 3 days in both groups (P .3251). IPSS and Qmax improved equally in both groups (median 3 vs 3, P .941; 19.17 vs 20.63 mL/s, P .8232 respectively). Early complications were mild to moderate (Clavien I 12.2% vs 12.2%; Clavien II 3.6% vs 4.84%; Clavien IIIb 1.2% vs 2.4%)., Conclusion: Our results show that en bloc ThuLEP approaches appear feasible, have similar complications and outcomes and can be considered surgeon-independent techniques. En bloc ThuLEP may be proposed even for laser-naïve urologists as an alternative to the original 3-lobe technique., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To present our 2-lobe technique of thulium laser transurethral enucleation of the prostate. Transurethral resection of prostate and open prostatectomy have been traditionally considered as the gold standard for benign prostatic enlargement surgical treatment. Laser has been recently made available for benign prostatic enlargement surgery to minimize morbidity of traditional surgery. 1 In 2009, Bach et al introduced the use of thulium laser, 2 describing the 3-lobe technique, which overlaps open prostatectomy but with a greater control of hemostasis. 3 Two techniques have been recently published that differ from the original one. 4,5 Kim et al described the "All-in-One" technique, 4 whereas Wolters et al described a 2-lobe enucleation (left lobe first, then combined enucleation of the right and median lobe). 5 We developed a different en block enucleation technique., Methods: In our 2-lobe enucleation technique, the median lobe is enucleated first, whereas the lateral lobes are dissected and enucleated en bloc. Once the medial lobe is moved into the bladder lumen, the dissection is carried out at 4-o'clock position toward the bladder neck, enucleating the left lobe in an anticlockwise direction. At 12-o'clock position, dissection keeps going beneath the right lobe toward the 9-o'clock position. At this point, an incision is made at 8-o'clock position and enucleation is completed in a clockwise direction toward the 9-o'clock position. The 2 enucleated tissues are finally morcellated., Results: Preoperative prostate volume was 55 cc. Operative time was 36 minutes. The decrease in hemoglobin was 1.1 g/dL 24 hours after surgery. Catheter was removed in first postoperative day and the patient was discharged home. Removed tissue weighed 45 g and showed <5% Gleason score 3 + 3 adenocarcinoma., Conclusion: Our enucleation technique may offer perioperative outcomes comparable with other approaches in medium-sized prostates (up to 100 mL), and we believe that is helpful in following correctly the surgical capsule plane. This technique speeds up the procedure and helps to leave no tissue behind., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Bleeding is the most common complication of transurethral resection of the prostate and simple open prostatectomy, especially in men on antiplatelet/anticoagulant therapy. The present study aimed to evaluate the safety and effectiveness of thulium laser vapoenucleation of the prostate (ThuVEP) for benign prostatic hyperplasia in patients on chronic antithrombotic medications. Between January 2015 and December 2019, 88 men underwent the procedure under antithrombotic agents in our center. The mean age was 74.7 ± 6.1 years. Median prostate volume was 66.5 mL. Patients on oral anticoagulants were bridged to low-molecular-weight heparin (n = 35). Aspirin (n = 39), clopidogrel (n = 10), and ticlopidine (n = 4) were maintained. Of the patients, 69.3% had an American Society of Anesthesiologists score ≥ 3. Blood loss at 24 h was comparable in all groups. Median catheterization length and postoperative stays were 2 and 3 days respectively. Acute cardiovascular events occurred in 2 patients (2.3%). Of the patients, 4 required prolonged bladder irrigation, 2 required blood transfusions, 1 required a cystoscopy for bleeding control, and 1 required a suprapubic cystostomy for blood clot evacuation. No patients died within 30 days of being discharged. Late complications occurred in 3 (3.8%) patients (1 optical urethrotomy and 1 bladder neck incision for stenosis; 1 acute myocardial infarction). All follow-up visits (1, 6, and 12-month) showed a significant improvement in all urinary parameters compared to baseline. ThuVEP appears to be a feasible surgical option in high-risk patients on antithrombotic regimens, with acceptable postoperative morbidity, good functional outcome, and low incidence of medium-term reoperation rate. [ABSTRACT FROM AUTHOR]