Objective: To evaluate using an inanimate model the thermal injury and laser efficiency on high frequency, high energy and its combination in hands of junior and experienced urologists during holmium YAG (Ho:YAG) and Thulium fiber laser (TFL) lithotripsy. Methods: Cyber: Ho 150 WTM and Fiber Dust TFL (Quanta System) with 200µm core-diameter laser fibers (LF) were used in a saline in vitro ureteral model. Each participant (5 junior -5 experienced urologist) performed 32 sessions of 5 minutes lasering (125 mm3 phantom BegoStonesTM), comparing four modes (3J/5Hz (1.5W), 0.3J/20Hz (6W), 1.2 J/5Hz (6W), and 1.2J/20Hz (24W)). Transparent tip and cleaved LF, and digital and fiberoptic ureteroscopes were also compared. Ureteral damage was classified in a scale (0-5) according to the burns and holes seen in the ureteral model’s surface. Results: High-power setting (24W) was associated with higher delivered energy and higher ablation rates in both lasers (p<0.001). For the same power setting (6W), there were no differences in delivered energy nor stone ablation rates. Regardless the settings, higher ablation rate was observed with TFL than with Ho:YAG ((0.5Δmg/s ± 0.33 vs 0.39 Δmg/s ± 0.31, p:0.002) laser. Higher mean ablation rate was found with cleaved tip vs transparent tip (p:0.03) in TFL. For both lasers, higher ureteral damage was observed in the 24W group (p: 0.006) and in the junior urologists (p: 0.03). Between 6W groups, different type of lesions were found and junior urologist have more lesions when high frequency was used, for both Ho:YAG (p=0.05) and TFL (p=0.04). Conclusion: High-power settings have more stone ablation rate and may reduce the operative time; however, more ureteral thermic-related damage is produced. When comparing the same power, higher energy or frequency does not modify the ablation rate. Nonetheless, more ureteral thermic-related thermal damage is observed in high frequency settings in unexperienced hands.

Objective: The aim of this review is to summarize the existing suction systems in flexible ureteroscopy (fURS) and to evaluate their effectiveness and safety. Methods: A narrative review was performed using the Pubmed and Web of Science Core Collection (WoSCC) databases. Additionally, we conducted a search on the Twitter platform. Studies including suctions systems in fURS were included. Editorials, letters and studies reporting intervention with semirigid ureteroscopy, PCNL and mPCNL were excluded. Results: A total of 12 studies were included in this review. These studies comprised one in vitro study, one ex vivo study, one experimental study and eight cohort studies. The Pubmed and WoSCC searches identified three suction techniques (Irrigation/Suctioning system with control of pressure, suction ureteral access sheath (sUAS) and direct in scope suction (DISS)), and the Twitter search identified four of them. The overall results showed that suction is an effective and safe technique that improves stone-free rates, reduces operative time and limits complication rates after fURS. Conclusions: The use of suctioning during common endourological procedures has been shown to improve safety and efficacy in several indications. However, randomized controlled trials are needed to confirm this.

Background: Benign prostatic hyperplasia (BPH) is commonly responsible for lower urinary tract symptoms (LUTS) in men aged 50 or over. Sexual dysfunctions, such as ejaculatory disorders (EjD), go along with LUTS but are frequently overlooked in the initial evaluation. This review aimed to detail BPH-related EjD, as well as their modifications by medical, surgical, and interventional treatments. Methods: We conducted a narrative review looking for publications between 1990 and 2020, regarding physiopathology, epidemiology, evaluation, and therapeutic management (medical, surgical, and interventional) of BPH-related EjD. Results: Sixty-five articles were included in our final analysis. Forty-six percent of men presenting with LUTS reported EjD. If the prevalence increases with age and LUTS severity, the functional impairment is not correlated with age. Several self-questionnaires evaluated the sexual function, but only four approaches are specific to EjD. Medical therapies were exposed to anejaculation, rather than retrograde ejaculation (RE) (4–30% (alpha-blockers), 4–18% (5-alpha-reductase inhibitors)). Regarding surgical therapies, trans-urethral resection of the prostate (TURP) and incision of the prostate (TUIP) are associated with 50–70% and 21–35% of RE. The RE rate is important after open simple prostatectomy but can be reduced with robotic approaches and urethral sparing techniques (19%). Anatomic endoscopic enucleation of the prostate (AEEP) with or without a laser source is associated with an 11–36% RE rate, according to supramontanal preservation. Recent surgical techniques (Rezum©, Aquablation©, or Urolift©) were developed to preserve antegrade ejaculation with promising short-term results. Regardless of the surgical approach, anatomic studies suggest that the preservation of peri-montanal tissue (7.5 mm laterally; 10 mm proximally) is primordial to avoid post-operative RE. Finally, prostate artery embolization (PAE) limits the RE rate but exposes it to a 12 months 10% re-intervention rate. Conclusion: EjD concerns almost half of the patients presenting BPH-related LUTS. Initial evaluation of EjD impairment is primordial before medical or surgical therapy. Peri-montanal tissue preservation represents a key point for antegrade ejaculation preservation, regardless of the surgical option.