Holmium Laser Enucleation Of The Prostate Patients Research Articles

Propensity Score Matching Analysis of Differential Outcomes in Holmium Laser Enucleation of the Prostate vs. Robotic-Assisted Simple Prostatectomy.

Background & Objectives: Patients with bladder outlet obstruction (BOO) due to massive prostate enlargement have several surgical treatment options, such as robot-assisted simple prostatectomy (RASP) and holmium laser enucleation of the prostate (HoLEP). Postoperative outcomes may differ between those undergoing RASP and HoLEP. RASP has been associated with a lower incidence of transient stress urinary incontinence (SUI), while HoLEP allows for shorter catheterization times. Here, we report on our experience with both surgical modalities. Methods: Data were collected from prospectively maintained databases for 37 RASP patients and 181 HoLEP patients treated from July 2021 to November 2023. To control for selection bias, propensity score matching (PSM) was utilized based on age and prostate size. We compared patients' preoperative, perioperative, and postoperative outcomes both before and after applying PSM. Results: Before the PSM, the median prostate size was significantly lower in the HoLEP group (p < 0.001). The HoLEP group also had significantly shorter operative times (p ≤ 0.001) and lower weights of resected adenoma (p ≤ 0.001). After the PSM of 31 RASP and 31 HoLEP patients, all baseline patient characteristics were comparable. No significant differences were observed in operation time (p = 0.140) or in the weight of resected adenoma (p = 0.394) between the modalities. The median (IQR) length of catheterization was significantly shorter in the HoLEP group (1 [1-4] days) compared to the RASP group (7 [7-8] days), in both pre- and post-matching analyses (p ≤ 0.001 for both), reflecting the standard of practice. In contrast, in both pre- and post-PSM analyses, the average hospital stay was significantly shorter in the RASP cohort, as same-day discharge is standard in our center, whereas the HoLEP cohort required overnight stays due to routine continuous bladder irrigation before discharge (p < 0.001 for all). Notably, the SUI rates and American Urological Association (AUA) symptom scores were comparable at 3 months within both matched and unmatched cohorts (pre-PSM: p = 0.668, p = 0.083; post-PSM: p = 1, p = 0.152, respectively). Conclusions: Our comparative analysis indicates that both RASP and HoLEP yield similar outcomes, including SUI rates, at 3 months. While HoLEP provided shorter durations of postoperative catheterization, RASP offered shorter hospital stays.

Clinical Outcomes in Patients With Hypocontractile Bladders Undergoing Holmium Laser Enucleation of the Prostate

To compare post-operative outcomes in patients who underwent holmium laser enucleation of the prostate (HoLEP) for benign prostatic hyperplasia (BPH) and had urodynamic evidence of bladder hypocontractility versus those with normocontractile bladders. We retrospectively reviewed HoLEP patients with pre-operative urodynamic studies at a single institution, categorizing them into normocontractile and hypocontractile groups based on the bladder contractility index (BCI) (hypocontractile defined as BCI < 100). Post-void residual (PVR) volume was measured at 6 weeks and 6 months. Secondary outcomes included maximum flow rate (Qmax) and catheterization status. Among 114 HoLEP patients with pre-operative urodynamic data, 49 had hypocontractile bladders. The median pre-operative PVR was 305 (202-446) ml in the hypocontractile group, higher than the median PVR of 190 (60-361) ml in the normocontractile group (p=.013). At 6 weeks post-op, the median PVR was higher in the hypocontractile compared to normocontractile group [38 (3-61) vs. 5 (0-44) ml, p=.016], but at 6 months post-op there was no significant difference [18 (0-39) vs. 12 (0-70) ml, p=.97]. Among men who were catheter-dependent pre-operatively, 98% of hypocontractile and 100% of normocontractile patients were catheter-free postoperatively. Qmax and symptom scores were similar at both follow-up time points. HoLEP can be an effective surgical option for BPH patients with hypocontractile bladders, including those who are catheter-dependent, with minimal differences in post-operative voiding parameters compared to those with normal bladder function.

Incidental Prostate Cancer Diagnosis Is Common After Holmium Laser Enucleation of the Prostate

ObjectiveTo determine the incidence of incidental prostate cancer detection (iPCa) after holmium laser enucleation of the prostate (HoLEP). The published rate of iPCa after HoLEP is widely variable from 7-23% and we aim to define preoperative risk factors for iPCa to inform risk adjusted preoperative evaluation for prostate cancer. MethodsConsecutive patients undergoing HoLEP from 2018-2022 were included and comprehensive clinical data abstracted from a prospectively maintained database. iPCa was defined as a diagnosis of PCa on pathologic examination of the HoLEP specimen. Patients with and without iPCa were compared with respect to pre-operative clinical variables. ResultsOf 913 HoLEP patients, 183 (20%) were diagnosed with iPCa. Most patients (95%) had a pre-operative PSA, 9% had negative MRI, and 30% had negative prostate biopsy. On multivariable analysis, PSA density (OR 1.06; 95% CI 1.03, 1.10; p<0.001), preoperative biopsy status (OR 0.47, CI 0.30, 0.75; p=0.002), and current 5-alpha reductase inhibitor (5-ARI) use (OR 0.64, CI 0.43, 0.97; p=0.034), were associated with iPCa diagnosis. ConclusionsIn a significantly pre-screened population, we identified a 20% rate of iPCa after HoLEP. Preoperative characteristics associated with iPCa diagnosis included increasing age, increasing PSA density, and current 5-ARI use. However, these factors alone may be of limited clinical utility to prospectively identify patients at high risk of iPCa diagnosis. We suggest and advocate for development of a standardized, risk adapted evaluation focused on expanded use of imaging and selective biopsy to prioritize identification of clinically significant prostate cancers prior to non-oncologic surgery.

Efficacy and safety of transurethral thulium laser enucleation versus robot-assisted prostatectomy for large-volume benign prostatic hyperplasia: a systematic review and meta-analysis.

To compare perioperative outcomes between Holmium laser enucleation of the prostate (HoLEP) and robotic-assisted simple pasta-ectomy (RASP)for large-volume benign prostatic hyperplasia(> 80ml). In August 2023, we undertook a comprehensive search of major global databases including PubMed, Embase, and Google Scholar, focusing solely on articles written in English. Studies that were merely reviews or protocols without any specific published data were omitted. Furthermore, articles that comprised conference abstracts or content not pertinent to our subject of study were also disregarded. To calculate the inverse variances and 95% confidence intervals (CIs) for categorical variables' mean differences, we employed the Cochran-Mantel-Haenszel approach along with random-effects models. The findings were denoted in the form of odds ratios (ORs) and 95% CIs. A p-value less than 0.05 was deemed to indicate statistical significance. Our finalized meta-analysis incorporated six articles, including one randomized controlled trial (RCT) and five cohort studies. These studies accounted for a total of 1218 patients, 944 of whom underwent Holmium Laser Enucleation of the Prostate (HoLEP) and 274 who underwent Robotic-Assisted Simple Prostatectomy (RASP). The pooled analysis from these six papers demonstrated that compared to RASP, HoLEP had a shorter hospital stay, shorter catheterization duration, and a lower blood transfusion rate. Moreover, HoLEP patients exhibited a smaller reduction in postoperative hemoglobin levels. Statistically, there were no significant differences between the two procedures regarding operative time, postoperative PSA, the weight of prostate specimens, IPSS, Qmax, PVR, QoL, and postoperative complications. (HoLEP) and (RASP) are both effective and safe procedures for treating large-volume benign prostatic hyperplasia. HoLEP, with its benefits of shorter catheterization and hospitalization duration, lesser decline in postoperative hemoglobin, and reduced blood transfusion needs, stands as a preferred choice for treating extensive prostate enlargement. However, further validation through more high-quality clinical randomized trials is required.

Holmium Laser Enucleation of the Prostate vs Transvesical Single-port Robotic Simple Prostatectomy for Large Prostatic Glands

To compare the perioperative outcomes of transvesical single-port robotic simple prostatectomy (SP-RASP) and holmium laser enucleation of the prostate (HoLEP). A retrospective review was performed of patients undergoing SP-RASP and HoLEP from 2019 to 2022 with preoperative prostatic volume (PPV) >80cm3. Percent of prostate adenoma removed (%PAR) was estimated by specimen weight normalized by PPV. Univariate analysis was performed using chi-square, Fisher exact, and Wilcoxon rank-sum tests. A subgroup analysis with 1:1 matching for PPV was also performed. A total of 50 SP-RASP and 90 HoLEP cases were analyzed. The median (interquartile range) PPV was 169 (128-244)cm3 for SP-RASP and 129 (100-150)cm3 for HoLEP, (P<.01). The median (interquartile range) %PAR was 57(44-68) for SP-RASP vs 51(42-62) for HoLEP (P=.10). Overall, 11(12%) HoLEP and 5(10%) SP-RASP patients experienced complications (P=.51). Same-day discharge occurred in 24(48%) SP-RASP vs 7(8%) HoLEP patients (P<.01). Median foley catheter duration was longer in SP-RASP (6 vs 1day, P<.01) and trial of void was successful at first attempt in >94% (P=.68). Transient de novo incontinence was reported in 24(28%) HoLEP vs 2(5%) SP-RASP (P<.01). No differences in voiding parameters were observed at latest follow up. Subgroup postmatched analysis revealed analogous findings. SP-RASP and HoLEP have similar favorable perioperative outcomes for management of large prostatic adenomas. SP-RASP may be considered in patients unwilling to accept the risk of transient incontinence and in those with unfavorable urethral access, large bladder stone burden, or diverticula.

Holmium laser enucleation of prostate in nonagenarians and octogenarians Impact of age and frailty on surgical outcomes.

Holmium laser enucleation of the prostate (HoLEP) is a well-established technique for management of benign prostatic hyperplasia (BPH). With the growing aging population, a considerable percentage of octogenarians (80-90 years old) and nonagenarians (>90 years old) require surgical management for BPH. We aimed to assess the outcomes of HoLEP in those age groups. We reviewed a maintained database for HoLEP patients in a tertiary center. Patients were assigned to two groups: above (group A) and below (group B) 80 years old. Perioperative outcome and postoperative followup data were compared between both groups. The study included 1090 patients, 201 and 889 in groups A and B, respectively. Median age was 83 and 70 years in groups A and B, respectively. Group A showed longer operative time, longer catheterization time, and higher 30-day emergency room visits and readmission rates. Hemoglobin drop was comparable, although associated with higher rate of blood transfusion in group A. Overall, 30-day postoperative complications were higher in group A (20.8% vs. 9.3%, p=0.008), although the majority of complications in both groups were grade I and II. The rate of complications over Clavien-Dindo grade II were statistically comparable (3.4% vs. 1.79%, p=0.133). Followup at six weeks, three months, and one year showed comparable functional outcomes in both groups. HoLEP is a safe and effective option in the geriatric population of octogenarians and even nonagenarians. HoLEP is associated with higher overall complication rate in older age groups; however, most complications were minor.

Tranexamic Acid Was Not Associated With a Reduction in Bleeding Complications Related to Holmium Laser Enucleation of the Prostate

To compare outcomes in males given perioperative tranexamic acid (TXA) during holmium laser enucleation of the prostate (HoLEP) to a historical cohort that did not receive TXA. Our cohort included HoLEP patients (N=1037) from August 2018 through November 2022. Exclusion criteria included history of stroke, transient ischemic attack, or coronary stent placed within 18 months. The primary predictor was TXA during HoLEP. The primary outcome variable was a return to the operating room (RTOR) for bleeding. Secondary outcomes included catheter reinsertion, transfusion, and clotting complications. Multivariable models evaluating associations of TXA with outcomes were adjusted for potential confounders. In our cohort, 214/1035 had one or more complications with 81 having a Clavien-Dindo Grade of 3a or higher, 114/1037 with catheter reinsertion, 36/1037 RTOR for bleeding, and 15/1035 had a transfusion. TXA use was not associated with 30-day RTOR. 3.7% of those without TXA had a RTOR, and 3.1% of those with TXA had a RTOR (adjusted odds ratio 0.63, 95% CI 0.28-1.38, P=.25). Transfusion rates were higher for those without TXA (2.0%) compared to with (0.5%). This was statistically significant after adjustment (adjusted odds ratio 0.13, 95% CI 0.03-0.69, P=.016) and after correction for multiple testing (corrected P=.048). TXA use was not associated with catheter reinsertion or clotting complications. Routine perioperative intravenous TXA in HoLEP patients was not associated with a reduction of RTOR for bleeding, catheter reinsertion, or clotting complications. TXA was associated with decreased transfusions with a low overall event rate of 1.4%.

Short-Term Clinical Outcomes of Bladder Neck Incision at Time of Holmium Laser Enucleation of the Prostate.

Introduction: The effect of prophylactic bladder neck incision (BNI) at time of holmium laser enucleation of the prostate (HoLEP) is unknown. The aim of our study was to examine HoLEP outcomes with a specific focus on rates of bladder neck contractures (BNCs), with and without utilizing prophylactic BNI. Materials and Methods: We performed a retrospective review of HoLEP patients from January 2021 until January 2022. Outcomes of patients who underwent BNI at time of HoLEP were compared with those who underwent standard HoLEP alone. Student's t-tests, chi-square tests, and logistic regressions were performed using SAS Studio. Results: In total, 421 patients underwent HoLEP. BNI was concurrently performed in 74 (17.6%) HoLEP patients. BNI patients were younger (67.5 ± 9.0 years vs 71.1 ± 8.2 years, p = 0.00007) and had smaller prostates (60.7 ± 30.3 cc vs 133.2 ± 64.5 cc, p < 0.0001). Procedure, enucleation, and morcellation times were shorter in the BNI group (all p < 0.0001). There was no statistical difference in same-day discharge rates (90.4% vs 87.7%, p = 0.5), short-term functional outcomes, emergency department (ED) visits, or readmission rates between the two groups. At 14 months mean follow-up, two BNCs occurred in patients in the control group (0.6%), and no BNCs occurred in patients who underwent BNI (0.0%, p = 0.5). Conclusions: BNI at time of HoLEP did not decrease the ability to achieve same-day discharge or increase 90-day complications, ED visits, or readmission rates. No BNCs occurred in patients who underwent prophylactic BNI (0.0%) despite a smaller gland size and lower specimen weight in this cohort. Further prospective studies are required to conclude if concurrent BNI at time of HoLEP is protective against BNC.

Incidence and predictors of urinary incontinence rates post-holmium laser enucleation of prostate.

One of the main adverse outcomes following Holmium laser enucleation of the prostate (HoLEP) is the development of transient de novo urinary incontinence (UI). We aimed to evaluate the correlation of multiple risk factors to UI rates post-HoLEP. A review of prospectively maintained 7 year database for HoLEP patients in a single center was performed. UI data at 6 week, 3 month, and 1 year follow-up intervals were assessed with bivariate and multivariate analysis of multiple potential risk factors. The study included 666 patients with median (IQR) age of 72 (66-78) years old and median (IQR) preoperative prostate volume of 89 (68-126) gm. UI was seen in 287 (43%), 100 (15%) and 26 (5.8%) at 6 week, 3 month, and 1 year follow up occasions respectively. At 6 weeks follow up, UI type was stress, urge and mixed in 121 (18.16%), 118 (17.72) and 48 (7.21%) patients respectively. Using a multivariate regression analysis, obesity and pre-operative UI were associated with postoperative UI rate at both 6 week (p = .0065, .031) and 3 month (p = .0261, .044) follow up encounters respectively. Also, larger specimen weight was another predictor for 6 week UI (p = .0399) while higher frailty score was a predictor for UI at 3 month occasion (p = .041). Patients with preoperative UI, obesity, frailty, and large prostate volume are at higher risk of short-term UI post-HoLEP up to 3 months. Patients with one or more of these risk factors should be counseled regarding the higher risk of UI.

The outcomes of same-day discharge following holmium laser enucleation of the prostate (HoLEP) surgeries: our experience during the COVID-19 pandemic.

To describe the outcomes of Same-Day Discharge (SDD) following Holmium Laser Enucleation of the Prostate (HoLEP) in patients during the COVID-19 pandemic. A retrospective review of HoLEP surgeries at a single institution between January 2021 and March 2022 was performed. Patient demographic and operative data were collected, and postoperative outcomes were evaluated in terms of safety and efficacy and compared in both groups using a t-test and chi-square test. Logistic regression was also performed to identify factors that correlate with the failure of SDD. A total of 155 patients were identified; 135 patients were successfully discharged on the same day and 20 were admitted (87% SDD rate). Admitted HoLEP patients had a significantly higher median prostate-specific antigen (5.7 vs 3.9ng/dL, P < 0.001), prostate volume (152.3 vs 100.6mL, P < 0.001), and enucleated tissue weight (90.3 vs 56.9g, P = 0.04) compared to the SDD group. The SDD group had a 2.9% (n = 4) readmission rate and a 5.2% (n = 7) Emergency Department (ED) visit rate. There was no significant difference in the rate of postoperative ED visits (P = 0.64), readmissions (P = 0.98), complications, and catheterization time (P = 0.98) between both groups. Preoperative predictors of SDD failure included prostate gland volume > 150mL (OR = 7.17; CI 2.01-25.67; P < 0.01) and history of antiplatelet/anticoagulation use (OR = 6.59; CI 2.00-21.67; P < 0.01). Same-day discharge following HoLEP is a safe and effective approach that can be performed in most patients using a liberal discharge criteria and relying on postoperative findings only.

MP13-08 HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HOLEP) OUTCOMES AFTER MINIMALLY INVASIVE SURGICAL THERAPIES (MIST) FOR BPH

You have accessJournal of UrologyCME1 Apr 2023MP13-08 HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HOLEP) OUTCOMES AFTER MINIMALLY INVASIVE SURGICAL THERAPIES (MIST) FOR BPH Mark Assmus, Nick Dean, Matthew Lee, Jenny Guo, and Amy Krambeck Mark AssmusMark Assmus More articles by this author , Nick DeanNick Dean More articles by this author , Matthew LeeMatthew Lee More articles by this author , Jenny GuoJenny Guo More articles by this author , and Amy KrambeckAmy Krambeck More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003233.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The 2021 American Urologic Association benign prostate hyperplasia (BPH) guideline recommends several minimally invasive surgical therapies (MIST). We look to describe outcomes of individuals undergoing holmium laser enucleation of the prostate (HoLEP) after failing prior minimally invasive BPH procedures, specifically prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), robotic waterjet treatment (RWT) or prostatic artery embolization (PAE). METHODS: We retrospectively examined patients within our IRB approved clinical database that underwent HoLEP over a 19-month period (March 2021 – Oct 2022). Patient demographics, surgical BPH treatments, operative variables, and perioperative courses were examined. Patients with a prior neurological diagnosis or prior bladder cancer were excluded from the analysis. Descriptive statistics, two-tailed T-Tests, and ANOVA were performed with SPSS (p<0.05). Although PAE is not an office-based procedure, due to its minimally invasive nature we included it in the MIST category. RESULTS: We identified 600 HoLEP patients who met inclusion criteria, with 24.2% (n=145) of patients having undergone a prior BPH procedure. Of these procedures, 31.7% (n=46) were MISTs including PUL (n=22), WVTT (n=11), RWT (n=3), and PAE (n=10) and the remaining 68.3% (n=99) of procedures were TURP (n=63) and photo-selective vaporization of the prostate (PVP) (n=36). Time from original treatment to HoLEP did not differ between MIST procedures (p>0.05), but was significantly shortened comparing MISTs to TURP and PVP (2.9 versus 6.8 years, p<0.01). Patients with a prior BPH procedure were older (72.4 versus 69.7 years, p<0.01) than those without a history of BPH procedures; however, there were no other differences in pre-operative patient variables or post-operative functional outcomes including catheter free status, anti-cholinergic requirements, and continence rates, or 90-day complications (all p>0.05). Patients with a prior PUL had a significantly worse morcellation efficiency (7.3 vs 9.0 grams/min, p=0.03) and required more sets of morcellator blades per case (1.3 vs 1.0, p=0.03) compared to other prior BPH treatments. CONCLUSIONS: Patients undergoing HoLEP after prior failed BPH surgery experienced equivalent outcomes to patients without prior BPH surgery. Patient functional outcomes after HoLEP were maintained regardless of prior treatment modality. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e176 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mark Assmus More articles by this author Nick Dean More articles by this author Matthew Lee More articles by this author Jenny Guo More articles by this author Amy Krambeck More articles by this author Expand All Advertisement PDF downloadLoading ...

Holmium Laser Enucleation of Prostate in Patients with Pre-Existing Localized Prostate Cancer, Dual Center Study.

Background: Holmium laser enucleation of the prostate (HoLEP) has been used as an effective minimally invasive technique for management of enlarged prostates. We aimed to report the role of HoLEP in prostate cancer (PCa) patients either on active surveillance with bothersome lower urinary tract symptoms (LUTS) or for prostate debulking before radiation therapy and the impact on PCa management plans. Methods: Prospectively maintained database in two institutions was reviewed for patients with localized PCa managed by HoLEP with at least a follow-up of 1 year. We assessed prostate-specific antigen (PSA) trends, effect on international prostate symptom score (IPSS) and further management of PCa. Results: Out of >2000 HoLEP patients, 117 patients with a median follow-up of 30 months were included. Mean (standard deviation) age was 72.3 (±8.3) years with median (interquartile range, IQR) IPPS of 22 (16-28) and median (IQR) PSA at 7.6 (5.3-14.9) ng/mL. Gleason grade group was 1, 2, 3, and 4 in 47 (73.2%), 32 (27.35%), 7 (5.9%), and 4 (3.4%) patients, respectively. Median (IQR) PSA has significantly dropped to 1.3 (0.6-3.1), 1.4 (0.75-2.9), and 1.7 (0.86-2.75) ng/mL at 6-week, 3-month, and 1-year follow-up, respectively (p < 0.001). IPSS scores post-HoLEP obviously improved with mean (IQR) IPSS of 10 (5-13), 7 (3-12), and 3 (2-5) at 6-week, 3-month, and 1-year, respectively (p < 0.001). Eighty-eight (72%) patients stayed on active surveillance, whereas 27 (23%) patients had radiotherapy ± androgen deprivation therapy for persistently high or relapsing PSA. Within 36 intermediate-risk patients, 15 (41.6%) and patients had radiotherapy, whereas 21 (58.3%) patients continued active surveillance. Conclusions: HoLEP is beneficial in debulking large prostate in PCa patients with bothersome LUTS on active surveillance or before radiotherapy. HoLEP reduces the contribution of large adenoma to PSA level, thus reflecting PSA level better and helping reduce overtreatment.

PD45-10 OUTCOMES AFTER HOLMIUM LASER ENUCLEATION OF THE PROSTATE, OPEN SIMPLE PROSTATECTOMY, AND ROBOTIC SIMPLE PROSTATECTOMY: EXPERIENCE FROM A LARGE ACADEMIC MEDICAL CENTER

You have accessJournal of UrologyCME1 May 2022PD45-10 OUTCOMES AFTER HOLMIUM LASER ENUCLEATION OF THE PROSTATE, OPEN SIMPLE PROSTATECTOMY, AND ROBOTIC SIMPLE PROSTATECTOMY: EXPERIENCE FROM A LARGE ACADEMIC MEDICAL CENTER Matthew Lee, Meera Ganesh, Joshua Han, Quan Mai, Mark Assmus, Jessica Helon, Briana Kaplunov, and Amy Krambeck Matthew LeeMatthew Lee More articles by this author , Meera GaneshMeera Ganesh More articles by this author , Joshua HanJoshua Han More articles by this author , Quan MaiQuan Mai More articles by this author , Mark AssmusMark Assmus More articles by this author , Jessica HelonJessica Helon More articles by this author , Briana KaplunovBriana Kaplunov More articles by this author , and Amy KrambeckAmy Krambeck More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002613.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Per AUA guidelines, large prostates (defined as ≥80g in size) can be managed with Holmium Laser Enucleation of the Prostate (HoLEP), Open simple prostatectomy (OSP) or robotic simple prostatectomy (RSP). While these modalities have been previously compared to one another, one study only compared 32 RSPs to 600 HoLEPs. To our knowledge, the three modalities have never been compared against each other in the same cohort. Furthermore, in any published studies, the authors were not performing same-day catheter removal and discharge after HoLEP, indicating the studies must be updated. Herein, we present our experience performing HoLEP, OSP, and RSP for large prostates at a large academic medical center. METHODS: The Northwestern Enterprise Data Warehouse (EDW) is a system-wide electronic medical record based data platform. We queried the EDW for all patients undergoing HoLEP, OSP, and RSP from Jan 2011 to Oct 2021 for prostates ≥80g. Patients were identified by CPT code (52649, 55831/ 55821, 55899, respectively). Variables were abstracted from the EDW and medical record. Statistical analysis was performed using SAS studio (2021). Multiple comparisons for continuous variables were performed using ANOVA with Tukey’s corrections. Chi-square tests were used for categorical variables. P-value <0.05 was determined to be statistically significant. RESULTS: The three cohorts were similar in age, BMI, and Carlson comorbidity index. There was no difference in preoperative Hgb, Cr or prostate volume. PSA was higher in the OSP group (p=0.0077). Surgery duration, estimated blood loss (EBL), length of stay (LOS) and catheter duration were all shortest in the HoLEP group (p<0.0001). OSP had the highest EBL and HoLEP had the lowest EBL (P<0.0001) which also translated into less RBC transfusions for HoLEP and RSP compared to OSP (p<0.0001). There were no differences in ED visits, but RSP had the highest readmission rate (p<0.0001). CONCLUSIONS: In this cohort where HoLEP patients underwent same-day catheter removal and discharge, despite similar preoperative characteristics, HoLEP was associated with shorter surgery duration, LOS and catheter duration. HoLEP also had the lowest EBL and RBCs transfused with an increase in ED visits or readmissions. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e786 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Lee More articles by this author Meera Ganesh More articles by this author Joshua Han More articles by this author Quan Mai More articles by this author Mark Assmus More articles by this author Jessica Helon More articles by this author Briana Kaplunov More articles by this author Amy Krambeck More articles by this author Expand All Advertisement PDF DownloadLoading ...

Barriers to Implementation of a Same-Day Discharge Pathway for Holmium Laser Enucleation of the Prostate

ObjectiveTo investigate perceived barriers to successful same-day discharge (SDD) after holmium laser enucleation of the prostate (HoLEP) from the perspective of surgical and nursing staff members. MethodsA 17-question survey was administered to intraoperative and postoperative surgical staff in June 2021 after a six-month period of implementing a SDD HoLEP pathway with same-day catheter removal. McNemar's and Stuart-Maxwell tests were performed for statistical analysis. ResultsSurveys were completed by 30 respondents. The majority of respondents had less than 5 years of surgical experience (63%). Almost all respondents (96%) felt that HoLEP patients could be discharged safely on day of surgery. Overall, 60% felt that HoLEP had a lower risk of post-operative bleeding compared to other transurethral surgeries. There was a significant decrease in number of respondents that felt apprehensive when comparing initiation of SDD HoLEP pathway to 6-months post-implementation (43% vs 7%, P = .003). The most common factors causing apprehension both pre- and post-implementation included: degree of hematuria (43% vs 40%, P = .56), risk of failure of trial of void (40% vs 30%, P = .26), and risk of readmission or unplanned emergency department (ED) visit (33% vs 30%, P = .48). There was a significant decrease in the number of respondents who were apprehensive about lack of experience with SDD after HoLEP comparing pre- and post-implementation (20% vs 0%, P = .01). ConclusionWhile staff report initial apprehension regarding implementation of a SDD HoLEP pathway, adequate support to intraoperative and postoperative teams helps build experience that alleviates these concerns.

A Cost Comparison of Holmium Laser Enucleation of the Prostate with and without Moses™.

Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for the treatment of benign prostatic hyperplasia. HoLEP has been shown to have excellent improvements in prostate symptom scores and maximum flow rates that have been durable for 2 decades. However, the steep learning curve associated with HoLEP has prevented its widespread adoption. New advancements in lasers, specifically the Moses™ pulse-modulation technology, have resulted in improvements in hemostasis and achieving same-day discharges and catheter removals. We aimed to perform a cost-comparison to analyze if Moses-augmented HoLEP (m-HoLEP) resulted in cost-savings. A retrospective review was performed of a single expert surgeon's experience from May 2018 to November 2020, comparing m-HoLEP with HoLEP. Perioperative and postoperative variables were abstracted from the medical record. Univariate and multivariate analyses were performed using SAS® 9.4. Two-sided significance was set at p <0.05. A total of 312 men underwent HoLEP during the study period (192 in m-HoLEP group and 120 in HoLEP group). The m-HoLEP group had more same-day discharges (p <0.001) and emergency department visits (6.3% vs 1.7%, p=0.0071). m-HoLEP resulted in hospital cost savings of $840 for the initial surgical episode (p=0.0297). When factoring in emergency department visits/readmissions, the cost savings decreased to $747 per case (p=0.0574). m-HoLEP was associated with same-day discharge and hospital cost savings of $840 for the initial surgical episode. Further study in other institutions with surgeons of varying experience levels will need to be performed to see if these findings can be replicated.

Sexual and ejaculatory function after holmium laser enucleation of the prostate and bipolar transurethral enucleation of the prostate: a single-center experience.

Currently available surgical treatments for Lower Urinary Tract Symptoms (LUTS) due to Benign Prostatic Obstruction (BPO) are associated with an increased risk of sexual dysfunction. The aim of our study is to compare sexual and ejaculatory function after Holmium Laser Enucleation of the Prostate (HoLEP) and Bipolar Transurethral Enucleation of the Prostate (B-TUEP). We performed a retrospective analysis of data prospectively collected from 62 (44.9%) and 76 (55.1%) patients who underwent HoLEP and B-TUEP, respectively. Erectile function and ejaculation characteristics were assessed with the International Index of Erectile Function-Erectile Function (IIEF-EF) domain and the Male Sexual Health Questionnaire-Ejaculatory function (MSHQ-EJ) questionnaires. Our study recorded no change in erectile function and no significant difference in rates of preserved antegrade ejaculation after both surgeries. One month after surgery, rates of physical pain/discomfort and perceived decreased physical pleasure during ejaculation were higher in HoLEP than B-TUEP patients (all p < 0.03). Moreover, HoLEP patients were more bothered by their ejaculatory difficulties than B-TUEP men (p = 0.03). At 3- and 12-months follow-up, all ejaculation-related differences disappeared. In conclusion, both procedures are valid alternatives for BPO treatment as they offer comparable urinary and sexual outcomes in the long term. However, in the first month after surgery, HoLEP patients present with more ejaculatory difficulties.

Stress Urinary Incontinence post-Holmium Laser Enucleation of the Prostate: a Single-Surgeon Experience.

ABSTRACTPurpose To identify incidence and predictors of stress urinary incontinence (SUI) following Holmium laser enucleation of the prostate (HoLEP).Materials and Methods We performed a retrospective review of 589 HoLEP patients from 2012-2018. Patients were assessed at pre-operative and post-operative visits. Univariate and multivariate regression analyses were performed to identify predictors of SUI.Results 52/589 patients (8.8%) developed transient SUI, while 9/589 (1.5%) developed long-term SUI. tSUI resolved for 46 patients (88.5%) within the first six weeks and in 6 patients (11.5%) between 6 weeks to 3 months. Long-term SUI patients required intervention, achieving continence at 16.4 months on average, 44 men (70.9%) with incontinence were catheter dependent preoperatively. Mean prostatic volume was 148.7mL in tSUI patients, 111.6mL in long-term SUI, and 87.9mL in others (p <0.0001). On univariate analysis, laser energy used (p <0.0001), laser “on” time (p=0.0204), resected prostate weight (p <0.0001), overall International Prostate Symptom Score (IPSS) (p=0.0005), and IPSS QOL (p=0.02) were associated with SUI. On multivariate analysis, resected prostate weight was predictive of any SUI and tSUI, with no risk factors identified for long-term SUI.Conclusion Post-HoLEP SUI occurs in ~10% of patients, with 1.5% continuing beyond six months. Most patients with tSUI recover within the first six weeks. Prostate size >100g and catheter dependency are associated with increased risk tSUI. Larger prostate volume is an independent predictor of any SUI, and tSUI.

Holmium laser enucleation of the prostate: efficacy, safety and preoperative management in patients presenting with anticoagulation therapy

PurposeWe evaluated efficacy and safety profile of patients with anticoagulation therapy (AT) undergoing holmium laser enucleation of the prostate (HoLEP).MethodsWithin our prospective institutional database (11/2017 to 11/2019), we analyzed functional outcomes and 30-day complication rates of HoLEP patients according to Clavien–Dindo classification (CLD), stratified according to specific AT vs. no AT. Further analyses consisted of uni- and multivariate logistic regression models (LRM) predicting complications.ResultsOf 268 patients undergoing HoLEP, 104 (38.8%) received AT: 25.7% were treated with platelet aggregation inhibitors (PAI), 8.2% with new oral anticoagulants (NOAC) and 4.9% with AT-combinations or coumarins bridged with low molecular weight heparins (LMWH/combination). Patients receiving AT were significantly more comorbid (p < 0.01). Pre- and postoperative maximal flow rates, residual void urine and IPSS at 3 months after surgery were invariably improved after HoLEP for patients with/ without AT. Overall complication rate was 19.5% in patients with no AT vs. 26.1% vs. 27.3 vs. 46.2%, respectively, in patients with PAI, NOAC and LMWH/combination (p < 0.01). Major complications (CLD ≥ 3b) occurred in 6.1% of no AT patients vs. 4.3% vs. 4.5 vs. 0% in patients with PAI, NOAC and LMWH/combination, respectively (p < 0.01). In multivariate LRM, AT was not significantly associated with higher complication rates, whereas high ASA status (OR 2.2, p = 0.04), age (OR 1.04, p = 0.02) and bioptical or incidental prostate cancer (OR 2.5, p = 0.01) represented independent risk factors.ConclusionDespite higher overall complication rates in AT patients, major complications were not more frequent in AT patients. HoLEP is safe and effective in anticoagulated patients.

PD56-01 PROSTATE SPECIFIC ANTIGEN KINETICS PREDICT INCIDENTAL PROSTATE CANCER PROGRESSION FOLLOWING HOLMIUM LASER ENUCLEATION OF THE PROSTATE

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology III (PD56)1 Apr 2020PD56-01 PROSTATE SPECIFIC ANTIGEN KINETICS PREDICT INCIDENTAL PROSTATE CANCER PROGRESSION FOLLOWING HOLMIUM LASER ENUCLEATION OF THE PROSTATE Kyle Rose*, Kassem Faraj, Anojan Navaratnam, Marlene Girardo, Amihay Nevo Pima, Karan Arora, Scott Cheney, and Mitchell Humphreys Kyle Rose*Kyle Rose* More articles by this author , Kassem FarajKassem Faraj More articles by this author , Anojan NavaratnamAnojan Navaratnam More articles by this author , Marlene GirardoMarlene Girardo More articles by this author , Amihay Nevo PimaAmihay Nevo Pima More articles by this author , Karan AroraKaran Arora More articles by this author , Scott CheneyScott Cheney More articles by this author , and Mitchell HumphreysMitchell Humphreys More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000966.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Holmium laser enucleation of the prostate (HoLEP) allows for the definitive management of benign prostatic hyperplasia and histopathologic analysis. The complete adenomectomy of HoLEP allows for the diagnosis of incidental prostate cancer (PCA). Outcomes data regarding the clinical progression of PCA following HoLEP is lacking. The objective of this study is to describe the clinical course of patients diagnosed with PCA after HoLEP, and identify predictors for clinical progression in this population. METHODS: HoLEP cases performed at our institution by a single surgeon from 2008-2018 were reviewed and monitored for incidentally diagnosed PCA. Clinical progression of PCA was defined as the need for additional therapeutic intervention or the development of metastatic disease. Univariate analysis was conducted using Chi-squared and T-tests when appropriate. Kaplan Meier estimates were used to evaluate survival. RESULTS: Of 1,288 HoLEP patients, 133 patients were diagnosed with incidental PCA. Seventeen (12.7%) patients met criteria for clinical progression at a median of 20 months postoperatively. On univariate logistic regression, predictors of clinical progression included preoperative prostate specific antigen density (PSAD) >0.15 (OR 3.4, 95% CI 1.7-6.6, p<0.01), T1b vs. T1a (OR 2.9, 95% CI 1.6-5.2), first postoperative PSA >1 (OR 2.1, 95% CI 1.9-2.3, p<0.01), PSADT <36 months (OR 9.2, 95% CI 1.15-74.8, P=0.01) and PSA velocity >0.75 (OR 14.6, 95% CI 3.5-60.7, p<0.01). When predicting clinical progression, the sensitivity of PSADT <36 months was 94%, the negative predictive values for first postop PSA >1 was 94%, PSA velocity >0.75 ng/mL/year was 95%, and PSA DT <36 months was 97%. Progression-free survival was 101.9 months in T1a vs. 61.5 months in T1b disease (p<0.01). CONCLUSIONS: PSA kinetics are informative in predicting clinical progression following HoLEP. These parameters can be used to risk stratify patients diagnosed with incidental PCa after HoLEP. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1188-e1188 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kyle Rose* More articles by this author Kassem Faraj More articles by this author Anojan Navaratnam More articles by this author Marlene Girardo More articles by this author Amihay Nevo Pima More articles by this author Karan Arora More articles by this author Scott Cheney More articles by this author Mitchell Humphreys More articles by this author Expand All Advertisement PDF downloadLoading ...

Super early detailed assessment of lower urinary tract symptoms after holmium laser enucleation of the prostate (HoLEP): a prospective study.

To prospectively investigate early and consecutive changes of lower urinary tract symptoms (LUTS), specifically storage symptoms after holmium laser enucleation of the prostate (HoLEP). Patients referred for HoLEP completed the International Prostatic Symptom Score (IPSS) the day before, at discharge, and 1, 2, 3, 4, 6, 8, 12, 16, 20, 24, and 52weeks after HoLEP. Total IPSS was stratified into mild (score 0-7), moderate (8-19), and severe (20-35) LUTS. Storage symptoms were sub-stratified into storage "negative" and "positive". IPSS changes served as the main postoperative outcome. Mixed linear models identified risk factors affecting postoperative recovery of LUTS. Between December 2010 and 2012, 144 consecutive HoLEP patients were prospectively included in the study. Preoperatively 57.6% of the cohort reported severe storage symptoms (mean total IPSS: 22.6 ± 5.0). Total IPSS decreased significantly immediately after surgery (p < 0.001). Patients with severe LUTS, storage-positive sub-score, and high maximum urinary flow rate were affected by a rebound of mainly storage symptoms 6-8weeks after HoLEP and prolonged recovery from LUTS. Of these, about 7.4% presented persisting urge complaints. Finally, 12weeks following HoLEP, the vast majority of patients were symptom-free. Limitations of this study include missing urodynamic workup and a comparative patient cohort. Immediately after HoLEP, patients experience a significant decrease of LUTS. Continuous symptom recovery seems to be hampered in patients with severe and storage-positive baseline symptoms. (De-novo) storage symptoms slightly affect postoperative recovery. Quality of life is restored to a stable and significantly improved status 3months after surgery.