Benedikt Becker

A Feasibility Study Utilizing the Thulium and Holmium Laser in Patients for the Treatment of Recurrent Benign Prostatic Hyperplasia after Previous Prostatic Surgery

Background: Transurethral resection of the prostate (TURP) is considered to be the standard treatment for patients with benign prostatic obstruction (BPO) ≤80 mL. However, up to 14.7% of the patients require secondary TURP due to recurrent BPO. The aim of our study was to describe specific features of holmium laser enucleation of the prostate (HoLEP) and thulium laser enucleation of the prostate (ThuLEP) in patients with recurrent BPO after previous prostate surgery. Materials and Methods: A total of 768 consecutive patients from our prospective collected database were retrospectively reviewed and divided into 4 groups: group A (489 patients) and group C (253 patients) underwent primary HoLEP and ThuLEP treatment, while group B (17 patients) and D (9 patients) included patients with recurrent BPO who were treated with HoLEP and ThuLEP, respectively. Results: There were no significant differences in preoperative parameters between the groups at primary (A and C) and secondary (B and D) treatment except their age. At 6-month follow-up, voiding parameters and symptom scores showed statistically significant improvements compared to baseline without differences between the groups. The mean operative time was comparable between the groups and did not differ significantly (p > 0.05). Conclusions: Laser enucleation for the treatment of recurrent BPO is feasible and seems to be a safe and effective procedure.

MP24-10 WAVELENGTH AND PULSE SHAPE EFFECTS ON STONE FRAGMENTATION OF LASER LITHOTRIPTERS

34 and 2, respectively. Compare to direct sequence, 9 patients were reclassified into the novel genotype. However, overall 19.6% of patients still not fit into an autosomal recessive inheritance, with 2 patients possessed no mutation. CONCLUSIONS: Among 51 patients, 8 novel mutations were identified and 9 patients were reclassified into a novel genotype. However, 20% of patients did not fit into autosomal recessive genotype. Current data may suggest the potential contribution of another factor in the pathogenesis of Cystinuria.

Old wine in new bottles

I read the above-mentioned article with interest to learn something “new” about a “novel” technique of a procedure which has initially been described 20 years ago by Peter Gilling and Mark Fraundorfer [1]. Ever since, the three-lobe holmium laser enucleation of the prostate (HoLEP) procedure has been well established for the treatment of benign prostatic obstruction (BPO) as a size-independent method with excellent long-term results [1, 2]. Meanwhile, a lot of technical modifications have been described for the HoLEP procedure: high power [1, 3], low power (total low power, low power at the apex and bladder neck) [4], en bloc [5], en bloc “no touch” techniques [6], or the anteroposterior dissection HoLEP technique [7]. The only issue that is not “new” is the 3 horse shoe-like incision HoLEP (3 HSI HoLEP) [8]. The described approach is a fundamental part of the HoLEP procedure and can be seen in mostly all of the videos published in this field, but has not been labelled with a specific “name” so far. The goals of these technical modifications of the HoLEP technique are to shorten the learning curve, to decrease the risk of early transient stress/urge incontinence and to decrease the incidence of early postoperative dysuria. However, none of these technical modifications have been critically evaluated and validated (by other experts in HoLEP) in larger multicentric studies with regard to the expected outcomes of these modifications so far. Despite these descriptions in technical papers, which of course, also gain the author’s reputation in endourology, the most important issue in HoLEP as in any other transurethral endoscopic enucleation technique (EEP) is still to find the right plane: the layer of enucleation between the prostatic pseudocapsule and the adenoma. After reviewing the technical HoLEP papers [3–8], the initial description of HoLEP in 1998 must be correctly named holmium vapoenucleation of the prostate (HoVEP), because the energy source, the Ho:YAG laser, is used to find the correct plane and for dissecting the adenoma from the pseudocapsule [1]. Contrary to that, in the current papers [3–7], as in the study by Miernik and Schoeb, a blunt dissection (with the beak of the resectoscope) of the prostate with holmium laser support is being more or less performed [3–8]. As a special feature, Miernik and Schoeb omit the longitudinal 5, 7, and 12 o’clock incisions made in the classic three-lobe HoLEP technique [8]. However, the article lacks a clear scientific explanation of the disadvantages of longitudinal incisions during EEP. The main drawback of the paper by Miernik and Schoeb is the aspect of the learning curve as a surgical bias [8]. All surgeries were carried out by one surgeon (A.M.) who had performed initially, 94 classic three-lobe HoLEPs, and secondly, the en bloc 3 HSI HoLEP in 114 patients. The operative time was significantly lower in the latter group compared to the classic three-lobe HoLEP group (which was prior performed). Is this difference in the operative time based upon the “new” 3 HSI HoLEP technique or the completion of the individual HoLEP-learning curve in larger prostates (mean prostate size 88.3 ml classic threelobe HoLEP and 86.3 ml 3 HSI HoLEP)? The reoperation rate (13.8% vs. 4.4%), the transfusion rate (3.2% vs. 0%), as well as the recatheterization rate (12.8% vs. 6.1%) was not only higher in the three-lobe HoLEP group compared to the 3 HSI group, but also higher than in the HoLEP literature [2], which supports the assumption of completion of an individual HoLEP-learning curve. Another drawback of 3 HSI HoLEP is step 4 of the technique which describes a regular monopolar or bipolar coagulation of the prostate fossa. Experienced EEP surgeons would assess this rather as an unwanted argument against the use of lasers for EEP but for the use of electric current (bipolar, monopolar or plasmakinetic) for EEP. As Thomas Herrmann mentioned in his editorial, “Enucleation is enucleation is enucleation is enucleation”, the This letter refers to the article avaliable at https ://doi.org/10.1007/ s0034 5-018-2418-0.inson recently said, referring specifically to die works of Flannery O’Connor, another religious writer with a connection to the Iowa Writers’ Workshop, “but virtually none with a loving heart.” Robinson, pouring her love into the objects o f her creation, allows her characters to be transformed by goodness and by grace. At a time when so much in our culture brings people down, Robinson, in telling the story of Lila’s struggle from fear and loneliness to love and grace, writes to inspire and elevate the human soul—and this, to readers, is infectious.

Thulium Vaporesection of the Prostate and Thulium Vapoenucleation of the Prostate: A Retrospective Bicentric Matched-Paired Comparison with 24-Month Follow-Up

Introduction: To evaluate the intermediate-term outcomes of thulium vapoenucleation of the prostate (ThuVEP) and thulium vaporesection of the prostate (ThuVaRP) in patients with benign prostate obstruction (BPO). Materials and Methods: A bicentric retrospective matched-paired comparison of patients treated by ThuVEP (n = 80) or ThuVaRP (n = 80) was performed. The patients were preoperatively assessed with International Prostate Symptom Score (IPSS), quality of life (QoL), post-void residual urine (PVR), maximum urinary flow rate (Qmax), prostatespecific antigen (PSA) and re-evaluated at 12- and 24-month follow-up. Results: Median prostate volume was 65 mL and not different between the groups. The immediate re-operation rate was significantly different between ThuVEP and ThuVaRP (5 vs. 0%, p ≤ 0.0434). IPSS, QoL, Qmax and PVR had improved significantly compared to preoperative assessment in both groups at 12- and 24-month follow-up (p ≤ 0.001). Median Qmax (18.2 vs. 21.0 mL/s) and PVR (29.4 vs. 0 mL) were significantly different between ThuVEP and ThuVaRP at 24-month follow-up (p ≤ 0.001), while IPSS and QoL showed no differences between the groups. However, the PSA reduction was significantly higher after ThuVEP compared to ThuVaRP (78.93 vs. 23.39%, p ≤ 0.006) at 24-month follow-up. Conclusions: ThuVEP and ThuVaRP are safe and efficacious procedures for patients with BPO. Although the peri-operative re-intervention rates were lower after ThuVaRP, the low PSA reduction rate after ThuVaRP at 24-month follow-up favours the ThuVEP procedure.

MP24-13 A NEW MOBILE APPLICATION FOR KIDNEY STONE PATIENTS

INTRODUCTION AND OBJECTIVES: Our recent studies have revealed that adipocytokines secreted by adipocytes are important for the formation of kidney stones. b3-adrenergic receptor agonist is reported to differentiate white adipocytes into beige cells, which improves metabolic syndrome via the specific protein uncoupling protein 1 (UCP1) expression. In this study, we investigated the effect of transdifferentiation from white adipocytes to beige cells on kidney stone formation. METHODS: Mice were administered daily intra-abdominal injection of saline (control group) or 1.0 mg/kg b3-agonist CL316243 (b3 group) for 12 days. From days 6 to 12, we induced renal crystal deposits by daily intra-abdominal injection of 80 mg/kg glyoxylate. Fat tissues and kidneys were extracted at days 0, 6, and 12. We examined the morphology as well as histology of fat tissues. Total RNA of fat tissue and kidneys were isolated and reverse-transcribed into double-stranded cDNA. Then, the expression of UCP1, adipocytokines, and stonerelated genes was assessed using quantitative real-time polymerase chain reaction (PCR). The formation of renal crystal deposits was observed using polarized light microscopy, and percentages of the depots as the total tissue area of the renal cross-section were expressed using the Image Pro software. RESULTS: b3-agonist treatment reduced lipid droplets in adipocytes and provided differentiation from white adipocytes into beige cells. The expression levels of UCP1 and adiponectin in the adipose tissue in the b3 group increased by 8.1-fold and 4.2-fold compared with those in the control group at day 12 (P < 0.01, P 1⁄4 0.01). The expression levels of IL-6 and osteopontin decreased by 0.3-fold and 0.1-fold (p 1⁄4 0.03, p 1⁄4 0.02). In the kidneys, the expression levels of SOD1 increased by 2.3-fold, and EMR1 decreased by 0.4-fold (P 1⁄4 0.04). The formation of renal crystal deposits decreased to 17.0% in the b3 group (P 1⁄4 0.03). CONCLUSIONS: Our results showed that transdifferentiation from white adipocytes into beige cells suppressed renal crystal formation by reducing pro-inflammatory adipocytokine secretion and improving antioxidant action. This is the first report on the therapeutic role of beige cells for kidney stone formation.

Iatrogenic hypospadias classification: A new way to classify hypospadias caused by long-term catheterization

DOI: 10.1111/iju.13791 IH is an injury of the ventral male urethra caused by long-term catheterization. Pathomechanistically, a downward directed pressure of the transurethral catheter leads to compression of the ventral urethra and the development of pressure necrosis. Its incidence constantly increases due to the aging of the population and age-related indications, such as neurological and/or musculoskeletal disorders impairing movement, urinary retention, or the need to measure input and output of a patient. IH is virtually unknown to a high number of medical staff. Referral diagnosis is often one of the following: “cleft of the penis,” “penis injury,” “unknown penile condition,” “broken urethra” or “surgery required – penis looks weird.” This unawareness of the physiological process among nursing staff and medical doctors leads to tremendous costs of the healthcare system due to recurrent consultations of patients requesting therapy in urological departments. Therapeutically, a suprapubic catheter is mostly inserted at an early stage after development of IH. The hypothesis is that complications, especially higher rates of infection, can thereby be prevented. However, there is no standardized measure as to when to apply this treatment. Because of urinary leakage outside the catheter, a larger urethral catheter is often inserted. Conversely, an increase in the catheter size leads to a higher downward pressure, resulting in a vicious cycle of further necrosis of the urethral mucosa. The aim of the present study was to develop a classification system to enhance the awareness of IH, and set a standard for assessment of complications and treatment. The “IHC” was designed as follows (Fig. 1): IHC grade 1: Penile cleavage ranges from the meatus to the proximal part of the corona glans penis. IHC grade 2: Penile cleavage ranges from the meatus to the subcoronal part of the penis. IHC grade 3: Penile cleavage ranges from the meatus to the scrotum. IHC grade 4: The meatus is not affected, but pressure necrosis is seen along the penis shaft. The IHC was tested prospectively for accuracy using an online survey designed using SurveyMonkey (SurveyMonkey Inc., San Mateo, CA, USA). First, the participants were asked to memorize different drawings showing IH of different grades. Second, the drawings had to be assigned to the respective grade. It was only possible to assign exactly one picture to each grade. Each rater assessed four pictures. Furthermore, all participants had to assign one of the ranks “excellent,” “very good,” “good,” “fair” and “poor” to the properties “simplicity,” “clinical utility,” “applicability” and “comprehensibility” regarding the IHC. All answers were analyzed for mean values and standard deviations. The survey was sent to all active members of the national Society for Urology and to nonurological doctors from several hospitals in Germany. A total of 317 (256 urologists and 42 non-urologists) doctors participated in the survey. Out of these 317 medical doctors, 79.7% (n = 244), 82% (n = 251), 86.3% (n = 264) and 82% (n = 251) assigned the grades 1–4 according to the pictures correctly. The interrater reliability between urologists and non-urologists was high, with a j of 0.831, 1.0, 0.725 and 0.562 according to the grades 1–4 (P < 0.001), respectively. This shows an equivalent agreement rate among the participants. Regarding simplicity, the IHC was evaluated with “excellent” or “very good” in 71.8% (n = 214), with “good” in 25.2% (n = 75) and with “fair” or “poor” in 3.0% (n = 9; Fig. S1). Regarding clinical utility, the classification was evaluated with “excellent” or “very good” in 60.1% (n = 179), with “good” in 31.9% (n = 95) and with “fair” or “poor” in 8% (n = 24; Fig. S1). Regarding applicability, the classification was evaluated with “excellent” or “very good” in 63.1% (n = 188), with “good” in 30.5% (n = 91) and with “fair” or “poor” in 6.4% (n = 19; Fig. S1). Regarding comprehensibility, the classification was evaluated with “excellent” or “very good” in 62.7% (n = 187), with “good” in 30.5% (n = 91) and with “fair” or “poor” in 6.7% (n = 20; Fig. S1). Urological Notes

MP02-15 PSA-CHANGES AND MICTURITION IMPROVEMENT 5-YEARS AFTER THULIUM VAPOENUCLEATION OF THE PROSTATE FOR SYMPTOMATIC BENIGN PROSTATIC OBSTRUCTION

METHODS: Our study included 141 patients who underwent HoLEP. Enrolled patients were divided into two groups according to the presence of UI. Independent t test was used to compare between two groups. Logistic regression was performed to analyze a correlation between de novo UI and other factors such as age, prostate volume, retrieved tissue weight, operative time, and the first post-void residual (PVR) urine volume immediately after removing postoperative urethral catheter. Urethral catheter was removed after bladder instillation with a 200 ml normal saline via urethral catheter, and PVR urine volume was estimated immediately after the first postoperative self-voiding. All definitions of UI corresponded to recommendations of the International Continence Society. RESULTS: After HoLEP, 44 patients (31.2%) had de novo UI, most of which resolved within 1-6 months; 34 had stress UI, 6 had urgency UI, and 4 had mixed UI. Age and PVR urine volume were significantly higher in UI group than non-UI group (75.09 6.82 vs 72.01 8.04 years; P 1⁄4 0.029, 81.88 67.13 vs 30.15 23.56 ml, P < 0.001). In a logistic linear regression analysis, only PVR urine volume was an independent predictor of de novo UI after HoLEP. The most optimal cut-off value of PVR urine volume for predicting de novo UI was defined as 39.5 ml in the receiver operating characteristics curve analysis (sensitivity, 75.0%; specificity, 74.2%; AUC, 0.815; P < 0.001). CONCLUSIONS: About one-third of patients might undergo de novo UI following HoLEP, and most of them might have been resolved within 1-6 months. High PVR urine volume after removal of postoperative urethral catheter is associated with de novo UI after HoLEP, and could be used as a practical tool to predict postoperative de novo UI.

PD23-06 THULIUM VAPOENUCLEATION OF THE PROSTATE VERSUS HOLMIUM LASER ENUCLEATION OF THE PROSTATE: 6-MONTH SAFETY AND EFFICACY RESULTS OF A PROSPECTIVE RANDOMIZED TRIAL

IPSS, Qmax, residual volume) were recorded preoperatively and at each follow-up visit. RESULTS: Median initial prostate volume was not significantly different between the groups (LV: 44.1ml, TURP: 44.8ml; p1⁄40.47). After catheter removal, the relative prostate volume reduction (RVR) was significantly lower following LV (table). Six weeks and six months after LV RVR increased significantly (both p<0.001). However, RVR remained significantly lower after LV throughout the entire 3-year observation period (table). All clinical outcome parameters improved significantly and remained so for 3 years without relevant differences between the groups. No significant differences in overall re-treatment rates were observed (LV: 5 (5.1%), TURP: 5 (6.5%), p1⁄40.75) CONCLUSIONS: After 3 years, prostate volume reduction remained inferior after 120W greenlight LV compared to TURP. However, as yet the lower volume reduction did not translate into inferior functional outcome or higher retreatment rates. Further follow-up of our cohort will reveal if the extent of tissue ablation impacts the long-term outcome of the procedures.