ABSTRACT Introduction: Thulium laser VapoEnucleation of the prostate (ThuVEP) is an evolving surgical technique for BPH. Most studies have focused on outcomes in small to medium sized prostates and have originated from Europe and Asia. We sought to describe our experience with ThuVEP for very large prostates in a North American cohort. Materials and Methods: From December 2010 to October 2014, 25 men underwent ThuVEP using the CyberTM® (Quantastem, Italy) thulium laser, all with prostate volume >75mL. Data collected included patient demographics, comorbidities, intraoperative parameters, complications, and post-operative outcomes including maximum flow rate (Qmax), post-void residual (PVR), International Prostate Symptom Score (IPSS), and quality of life score (QoL) in one year of follow-up. Statistical analysis was done using Wilcoxon signed-rank test. Results: At baseline, mean age was 70±9 years and prostate size was 163±62g. Most patients (84%) were in retention and 10 (40%) patients were on anticoagulation. Seven (28%) patients went home the day of surgery (mean hospital stay: 1.2±1.2d). There were 2 intraoperative complications (8%), both cystotomies related to morcellation. Nine patients (36%) experienced a complication, all within 30 days. There were no Clavien ≥III complications. Significant improvements were seen in Qmax, PVR, IPSS, and QoL score at each time interval to 12-months following surgery (all p<0.05). Of 21 patients initially in retention, all were voiding at last follow-up. Conclusions: Our findings suggest that ThuVEP is an effective treatment for BPH in patients with large prostates with sustained results for one year.

ABSTRACT Purpose: Decision-making regarding surgery for post-prostatectomy incontinence (PPI) is challenging. The 24-hour pad weight test is commonly used to objectively quantify PPI. However, pad weight may vary based upon activity level. We aimed to quantify variability in pad weights based upon patient-reported activity. Materials and Methods: 25 patients who underwent radical prostatectomy were prospectively enrolled. All patients demonstrated clinical stress urinary incontinence without clinical urgency urinary incontinence. On three consecutive alternating days, patients submitted 24-hour pad weights along with a short survey documenting activity level and number of pads used. Results: Pad weights collected across the three days were well correlated to the individual (ICC 0.85 (95% CI 0.74–0.93), p<0.001). The mean difference between the minimum pad weight leakage and maximum leakage per patient was 133.4g (95% CI 80.4–186.5). The mean increase in 24-hour leakage for a one-point increase in self-reported activity level was 118.0g (95% CI 74.3–161.7, p<0.001). Pad weights also varied significantly when self-reported activity levels did not differ (mean difference 51.2g (95% CI 30.3–72.1), p<0.001). Conclusions: 24-hour pad weight leakage may vary significantly on different days of collection. This variation is more pronounced with changes in activity level. Taking into account patient activity level may enhance the predictive value of pad weight testing.

Treatment of LUTS from BPH has evolved from surgical therapy to medical monotherapy to combination therapy. First-line medical therapy for men with LUTS remains agents that decrease outlet resistance: α-adrenergic antagonists and 5α-reductase inhibitors. Alpha-adrenergic agents decrease smooth muscle tone in the prostate and bladder neck. The mechanism of action of 5α-reductase inhibitor is reduction in prostate volume. First-line therapy for OAB symptoms are antimuscarinic agents. There has been reluctance to prescribe these agents to men with BPH due to the perceived risk of precipitating urinary retention. Alpha-adrenergic antagonists, 5α-reductase inhibitors, and antimuscarinic agents have all been shown to be safe and effective when administered to men with BPH and LUTS. The combination of 5α-reductase inhibitors with α-adrenergic antagonists is effective in men with LUTS secondary to BPH. The combination of α-adrenergic antagonists plus antimuscarinic agents and the combination of 5α-reductase inhibitors with antimuscarinic agents are safe and effective in patients with LUTS, evidence of BPH, and OAB symptoms. At present only combination therapy with 5areductase inhibitors with α-adrenergic antagonists is recommended in clinical practice guidelines. MTOPS and ComBAT have demonstrated superiority of combination therapy over monotherapy in preventing disease progression. Further studies are required to elucidate which specific patient population benefits most from particular combination therapies.

El tratamiento de los síntomas tracto urinario inferior (STUI) secundarios a hiperplasia benigna de la próstata (HBP) ha evolucionado desde el tratamiento médico quirúrgico a la monoterapia y a la terapia combinada. La terapia de primera línea médica para los hombres con STUI siguen siendo los agentes que disminuyen la resistencia de salida: α-adrenérgicos y los inhibidores de la 5α-reductasa. Los agentes alfa-adrenérgicos disminuyen el tono del músculo liso de la próstata y cuello vesical. El mecanismo de acción del inhibidor de la 5α- reductasa es la reducción en el volumen de la próstata. La terapia de primera línea para los síntomas de vejiga hiperactiva (VH) son los agentes antimuscarínicos. Ha habido renuencia a prescribir estos fármacos a hombres con HBP, debido a la percepción de riesgo de precipitar la retención urinaria. Alfa-antagonistas adrenérgicos, inhibidores de la 5α-reductasa, y los agentes antimuscarínicos, han demostrado ser seguros y eficaces cuando se administran a los hombres con HBP y STUI. La combinación de los inhibidores de la 5α-reductasa con a-antagonistas adrenérgicos es eficaz en varones con STUI secundarios a HBP. La combinación de los antagonistas α-adrenérgicos más antimuscarínicos y la combinación de inhibidores 5α-reductasa con antimuscarínicos son seguros y eficaces en pacientes con STUI, evidencia de la HBP y síntomas de vejiga hiperactiva. En la actualidad los inhibidores de la 5α y los antagonistas α-adrenérgicos se recomiendan en la práctica clínica. Los estudios de "Medical Therapy Of Prostatic Symptoms" (MTOPS) y "COMBinación de Avidart y Tamsulosina" (comBAT), han demostrado la superioridad de la terapia combinada sobre la monoterapia en la prevención de la progresión de la enfermedad. Se requieren más estudios para aclarar qué población específica de pacientes, se beneficiaría más de las terapias de combinación particular.