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IntroductionIt has been shown that endoscopic enucleation of the prostate (EEP) allows for similar efficacy and safety, no matter what energy and type of instruments we use, but the length of learning may differ greatly. The aim of this systematic review is to verify if there is any significant difference between EEP methods in learning.Evidence acquisitionWe performed a systematic literature search in three databases and included only the articles containing their own data on the EEP learning curve assessment during the last 10 years. The primary endpoint was to determine the necessary experience needed to achieve a plateau. The secondary endpoints were to review methods used to evaluate a learning curve.Evidence synthesisThe final sample included 17 articles, containing a total of 4615 EEPs performed by 76 surgeons, the most common method was HoLEP (9/17). The majority of articles studying HoLEP report a learning curve of experience level achievement in roughly 30–40 (min 20; max 60) cases. The studies of GreenLight laser showed high heterogeneity in the results with minimum of 20 cases and maximum of 150–200 cases. TUEB required roughly 40–50 cases to reach the plateau.ConclusionAlthough EEP is considered challenging, it shows a steep learning curve with a plateau after 30–50 cases. Proper criteria are critical for accurate assessment of the learning curve. The Trifecta and Pentafecta criteria are currently the most appropriate method to evaluate EEP learning.

PurposeTo perform a review on the latest evidence related to intrarenal pressures (IRPs) generated during upper-tract endourology, and present different tools to maintain decreased values, to decrease complication rates.MethodsA literature search was performed using PubMed, restricted to original English-written articles, including animal, artificial model and human studies. Different keywords were: percutaneous nephrolithotomy, PCNL, ureteroscopy, URS, RIRS, irrigation flow, irrigation pressure, intrarenal pressure, intrapelvic pressure and renal-pelvic pressure.ResultsIRPs reported during retrograde intrarenal surgery (RIRS), PCNL, miniPCNL, and microPCNL range 40.8–199.35, 3–40.8, 10–45 and 15.37–41.21 cm H2O, respectively. By utilizing ureteral access sheaths (UASs) IRPs usually remain lower than 30 cm H2O at an irrigation pressure (IP) of ≤ 100 cm H2O but could increase to > 40 cm H2O at an IP of 200 cm H2O. By utilizing the minimally invasive PCNL system, IRPs remain low at 20 cm H2O even at high IPs. Utilizing endoluminal isoproterenol during RIRS, could reduce IRP increases with a rate of 27–107%, and maintain low IRPs values, usually below 50 cm H2O.ConclusionsIncreased IRP values have been reported during RIRS and UASs constitute the most efficient tool for decreasing them. IRPs during mini-PCNL can be decreased utilizing the vacuum-cleaner and purging effects but might remain uncontrolled during micro- and ultra-mini PCNL. Intraluminal pharmacological treatment could play a role in IRP decrease, with isoproterenol being the most studied agent.

PurposeTo perform a review on the latest evidence related to normal and pathological intrarenal pressures (IRPs), complications of incremented values, and IRP ranges during endourology.MethodsA literature search was performed using PubMed, restricted to original English-written articles, including animal, artificial model, and human studies. Different keywords were: percutaneous nephrolithotomy, PCNL, ureteroscopy, URS, RIRS, irrigation flow, irrigation pressure, intrarenal pressure, intrapelvic pressure and renal pelvic pressure.ResultsNormal IRPs range from zero to a few cm H2O. Pyelovenous backflow may occur at pressure range of 13.6–27.2 cm H2O. During upper tract endourology, complications such as pyelorenal backflow, sepsis, and renal damage are directly related to increased IRPs. Duration of increased IRPs and concomitant obstruction are independent predictors of complication development.ConclusionsIRP increase remains a neglected predictor of upper tract endourology complications and its intraoperative monitoring should be taken into consideration. Further research is necessary, to quantify pressures generated during upper tract endourology, and introduce means of controlling them.

PurposeWe looked into the Thulium: yttrium-aluminum-garnet (TM:YAG), Thulium Fibre laser (TFL) and Holmium: yttrium-aluminum-garnet (Ho:YAG) thermal laser tissue effect during lithotripsy and tissue ablation.MethodsWe performed a PubMed, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) search.ResultsDuring lithotripsy, the Ho:YAG generated temperatures from 24 to 68.7 °C at powers < 20 W, the Tm:YAG from 43.7 °C at 30 W to 68 °C at powers < 20 W, and the TFL from 33 to 40.46 °C. During ablation, the Ho:YAG and continuous wave (cw) Tm:YAG tissue incision depths ranged from 0.08 to 2.26 mm, and from 0.28 to 3.22 mm. The Ho:YAG and Tm:YAG vaporization areas ranged from 0.044 to 0.078 mm2 and from 0.050 to 0.078 mm3 and their coagulation zones were 0.075 mm2 and 0.125 mm3 respectively. Ho:YAG and Tm:YAG laser damage zones ranged from 0.093 to 2.6 mm3 and from 0.207 to 0.98 mm3 respectively. The TFL incision depth ranged from 0.04 to 5.7 mm. The cw and SuperPulsed (SP) vaporization volumes ranged from 8 to 28.2 mm3/s and from 4 to 11 mm3/s. TFL coagulation depth and coagulation zone ranged from zero to 1.1 mm, 2.2 to 5.1 mm3 in SP mode and from 7.7 to 18.1 mm3 in cw mode.ConclusionDuring lithotripsy all lasers caused similar temperature changes and had a safe temperature profile at < 40 W. During tissue ablation, Ho:YAG has a deeper incision depth, while cwTm:YAG and cwTFL have broader coagulation and total laser areas.

PurposeTo perform a review on the latest evidence related to generated temperatures during Ho:YAG laser use, and present different tools to maintain decreased values, and minimize complication rates during endourological procedures. MethodsWe performed a literature search using PubMed, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials-CENTRAL, restricted to original English-written articles, including animal, artificial model, and human studies. Different keywords were URS, RIRS, ureteroscopy, percutaneous, PCNL, and laser. ResultsThermal dose (t43) is an acceptable tool to assess possible thermal damage using the generated temperature and the time of laser exposure. A t43 value of more than 120 min leads to a high risk of thermal tissue injury and at temperatures higher than 43 °C Ho:YAG laser use becomes hazardous due to an exponentially increased cytotoxic effect. Using open continuous flow, or chilled irrigation, temperatures remain lower than 45 °C. By utilizing high-power (> 40 W) or shorter laser pulse, temperatures rise above the accepted threshold, but adding a ureteral access sheath (UAS) helps to maintain acceptable values. ConclusionsOpen irrigation systems, chilled irrigation, UASs, laser power < 40 W, and shorter on/off laser activation intervals help to keep intrarenal temperatures at accepted values during URS and PCNL.

While the study observed a higher rate of bladder perforations in the ERBT group, previous studies report conflicting outcomes (Table 2) [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15–16]. In Gallioli et al., perforation rates were 17% for cTURBT and 20% for ERBT, showing no significant difference in outcomes such as operative time or hospital stay [13]. A few studies presented mixed outcomes, highlighting the importance of achieving both safe resection and optimal pathological evaluation, particularly in maintaining accurate staging (Table 3). Summary of Randomized studies reporting bladder perforation outcomes in ERBT compared to cTURBT, highlighting inclusion criteria, outcomes, Perforation Rates, and EBRUC II Trial results for comparison Author (year) Inclusion criteria Energy source Patients, n Tumor size(cm), mean (SD) Number of lesions, mean (SD) Irrigation time (h), mean (SD) Bladder perforation, n (%) Muscle sampling Follow up (mo) Total ERBT/cTURBT ERBT cTURBT ERBT cTURBT ERBT cTURBT ERBT cTURBT ERBT cTURBT Liu (2013) [2] Primary NMIBC, not MIBC or CIS Thulium 120 64/56 1.3 (0.2) 1.3 (0.3) 2.8 (1.2) 2.7 (1.5) 8.2 (1.3) 14.5 (2.1) 0 5 (8.9) NA NA 36 Zhang (2015) [4] Primary NMIBC Thulium 292 149/143 NA NA Single: 52% Single: 55% 0 6 (4.2) NA NA 36 Huang (2016) [5] Primary NMIBC Holmium 140 70/70 1.6 (0.5) 1.5 (0.2) 2.4 (1.3) 2.5 (1.2) 14 (20) 6 (8.6) 0 5 (7.1) NA NA 24 Gakis (2020) [6] Primary or recurrent NMIBC, > 0.5 cm, ≤cT1, < 5 tumors HybridKnife 115 56/59 NA NA NA NA NA NA 1 (1.8) 1 (1.7) 41 (77.4) 36 (66.7) 12 Lu (2020) [7] Primary NMIBC Holmium 218 109/109 NA NA NA NA NA NA 0 8 (7.3) NA NA 24 Fan (2021) [8] Primary NMIBC, < 3 cm Green-light 233 116/117 1.5 (1.2–1.5) 1.5 (1–2) 1 (1–1.7) 1 (1–1) b NA NA 0 1 (0.9) 104 (89.7) 84 (71.8) 48 Razzaghi (2021) [9] Primary NMIBC Holmium 79 40/39 2 (1.1) 2.2 (0.8) Single: 63% Single: 59% NA NA 0 3 (7.7) NA NA 18 Mohamed Samy Shahin (2021) [10] Primary papillary NMIBC, single lesion, 1–3 cm Holmium 52 26/26 NA NA NA NA 7.6 (2.5) 1 (3.8) 1 (3.8) 3 (11.5) NA NA NA Tripathi (2021) [11] Primary or recurrent NMIBC, ≤ 3 lesions, and/or ≤ 3 cm Green light 83 40/43 1.7 (0.6) 1.7 (0.6) Single: 87.5% Single: 83.7% NA NA 0 0 22 (55) 24 (55.8) NA Badawy (2023) [12] Pr NMIBC < 4 cm, not the anterior wall or bladder dome tm Thulium 120 60/60 1.8 (0.5) 1.8 (0.6) Single: 96.7% Single: 91.7% NA NA 2 (3.3) 9 (15) 57 (95) 44 (73.3) 12 Gallioli (2022) [13] primary or recurrent tm, ≤ 3 cm, max 3 lesions, Monopolar Bipolar Thulium 248 140/108 NA NA NA NA 12 (12–24) 28 (20) 28 (20) 18 (17) 133 (95) 101 (94) 15 D’Andrea (2023) [14] Primary tm, stage, 1–3 cm, maximum of 3 tumors Monopolar Bipolar Laser 384 178/179 1.9 (1–2) 1.7 (1–2.5) NA NA NA NA 12 (5.6) 28 (12) 177 (81) 166 (71) 13 Wu (2023) [15] Primary or recurrent Tm, ≤ 4 lesions, and/or ≤ 2 cm Blue laser 174 85/89 1.4 (0.6) 1.3 (0.6) 1 (1–3) 1 (1–3) NA NA 0 1 (1.1) NA NA NA Yuen-Chun Teoh (2024) [16] Tm < 3 cm, not detected during intravesical BCG therapy Bipolar 276 143/133 1.5 (1–2) 2 (1–2) Single: 68% Single: 65% 26 (18) 18 (14) 0 0 112 (84) 119 (83) 12 Struck (2024) [1] Tumour size > 4.3 mm, no restrictions on number of tumours, tumour location, or tumour size Bipolar Monopolar Holmium 97 57/40 2.01 (1.13) 2.6(1.2) Single 72.7% Number 2.3 (0.7) Single 78% Number 2 (0) 21.

The latest update of the EAU Guidelines on Management of Non - Neurogenic Male Lower Urinary Tract Symptoms, incl. Benign Prostatic Obstruction in 2016 announced a novel acronym for transurethral Endoscopic Enucleation of the Prostate (EEP). This was inspired by a meta-analysis on randomized controlled trials on Holmium Laser Enucleation of the Prostate (HolEP) and bipolar enucleation versus open simple prostatectomy. EEP codes for the common ground of both techniques: “anatomical enucleation.” Although study quality with regard to the availability of long-term randomized controlled trials is at the moment mostly available for HoLEP, and bipolar enucleation, the existing data of all other enucleating techniques that have been demonstrated to perform anatomical enucleation as well should also been summarized under the same term. This editorial is a call for embracing this acronym of EEP for all anatomical enucleating techniques in order to serve for the transition from the age of TURP and open prostatectomy toward the age of EEP.

PurposeTo evaluate and provide a comprehensive literature review of Prostate specific antigen (PSA) dynamics after various surgical procedures for benign prostatic hyperplasia (BPH).MethodsA thorough PubMed database search was performed over last 30 years including terms “PSA” and various surgical procedures for BPH. PSA nadir after various procedure was evaluated. The post-operative improvement in International Prostate Symptom Score, maximum void rates and post-void residue after surgeries were recorded. An indirect correlation was made between PSA nadir and outcome of various BPH surgical procedures.ResultsEnucleation procedures like simple prostatectomy and endoscopic enucleation of prostate (EEP) produced maximum drop in PSA level after surgery and were associated with the highest improvement in post-operative parameters. The PSA nadir following resection techniques like transurethral resection of prostate and Holmium laser resection of prostate and vaporization technique was variable and less robust when compared to EEP. Newer techniques like Aquablation, Rezum, Urolift, Prostate artery embolization and Temporary implantable nitinol devices (iTIND) produce relatively less reduction in PSA and lesser percentile improvement in post-operative parameters.ConclusionsVarious surgical procedures for BPH result in varying PSA nadirs level. Enucleation procedures and simple prostatectomy produce the most drastic and sustained decrease in PSA. There is a possible indirect evidence suggesting that the level of PSA nadir corresponds closely with the degree of post-operative improvement and durability of the procedure. Establishing the new PSA nadir at 3–6 months after the procedure is recommended as a part of routine surveillance for prostate cancer in eligible patients.

PurposeTo evaluate the risk of urinary incontinence (UI) after various prostate enucleation procedures (PEP).MethodsPubMed was searched from January 2000 to July 2021 for studies investigating UI after PEP. The articles were divided into 5 subgroups: holmium, thulium, greenlight laser, electrocautery, and simple prostatectomy. Meta-analysis was performed to examine rate of stress (SUI), urge (UUI) or unspecified UI at short (< 3 months), intermediate (3–6 months), and long-term (> 6 months). The impact of age, prostate size, surgery time, laser time, postoperative nadir PSA level and technical modifications on UI was analyzed.ResultsMost (69.4%) of 49 articles included employed holmium laser. There was no significant difference in incidence of short-, intermediate-, and long-term UI, SUI and UUI between five sub-groups and within different technical modifications. Although not statistically significant, the incidence of UI was higher (15%) at short-term with green-light and simple prostatectomy (95% CI 9–23 and 1–84), and higher (4%) at intermediate-term with holmium laser (95% CI 2–8). SUI was more prevalent at short-term with holmium laser (4%; 95% CI 2–5%), and at intermediate term with simple prostatectomy (3%; 95% CI 1–14). UUI was higher in the thulium group (10%, 95% CI 7–16). Increased age, surgery time, laser time and prostate size up to 80 cc were associated with higher UI. There was no correlation between postoperative PSA and UI.ConclusionsThere is no significant difference in incidence of UI, SUI and UUI after various PEP. Patients age, prostate size, surgery and laser time are linearly associated with UI.