Purpose: Holmium laser enucleation of the prostate (HoLEP) represents the current standard procedure for size-independent surgical therapy of benign prostatic obstruction (BPO). With advent of the novel laser technology thulium fiber laser (TFL), we hypothesized that the functional outcome of TFL enucleation of the prostate (ThuFLEP) is non-inferior compared to HoLEP. Methods: From October 2021 to October 2022, 150 patients with BPO were recruited for the prospective randomized trial in accordance with CONSORT. Stratified randomization into the arms ThuFLEP (n = 74) or HoLEP (n = 76) was carried out. The primary endpoint was non-inferior international prostate symptom score (IPSS) and quality of life (QoL) at three months after treatment. Secondary endpoints were rates of complications, peak flow, residual urine and operation times. Results: Preoperative characteristics showed no significant differences. Overall IPSS and QoL improved from 21 to 8 and 4 to 1.5, respectively, after three months of follow-up. No statistically significant differences between ThuFLEP and HoLEP were observed regarding median postoperative IPSS (8.5 vs. 7, p > 0.9), QoL (1 vs. 2, p = 0.6), residual urine (48 vs. 30ml, p = 0.065) and peak flow (19 vs. 17ml/s, p > 0.9). Similarly, safety profile was comparable with no statistically significant differences regarding rate of major complications (5.3 vs. 5.4%, p = 0.5), laser hemostasis time (3 vs. 2min, p = 0.2), use of additive electric coagulation (74 vs. 87%, p = 0.06) or electric coagulation time (8 vs. 8min, p = 0.4). Conclusions: In this prospective, randomized trial ThuFLEP showed non-inferior results compared to HoLEP in terms of functional outcomes measured by IPSS and QoL as primary endpoint. Trial registration number: DRKS00032699 (18.09.2023, retrospectively registered).

Purpose: Whether racial/ethnic differences exist in time to nephrectomy (TTN) and whether prolonged TTN differentially affects cancer-specific mortality (CSM) remains unclear. We evaluated race/ethnicity as a predictor of prolonged TTN and assessed race/ethnicity-specific associations between TTN and CSM in localized renal cell carcinoma (RCC). Methods: Patients were identified within the Surveillance, Epidemiology and End Results database (2010–2021) and stratified according to race/ethnicity and TTN ≤ 3 vs. > 3 months. Multivariable logistic regression models, propensity score matching (PSM) and multivariable competing risks regression models were used. Results: In 11,058 T1b–2 N0 M0 clear-cell RCC patients, TTN > 3 months was recorded in 1168 (15.6%) of 7506 Caucasians, in 505 (23.6%) of 2138 Hispanics, in 180 (26.6%) of 676 African Americans, and in 118 (16.0%) of 738 Asians and Pacific Islanders (API). Hispanic (OR 1.80, p < 0.001) and African American (OR 2.10, p < 0.001) race/ethnicity independently predicted higher proportions of TTN > 3 months, compared to Caucasian. Over the study span, the proportion of patients with TTN > 3 months increased significantly in all four racial/ethnic groups (all p < 0.01). After PSM, TTN > 3 months was associated with higher CSM in Caucasians (sHR 1.57, p < 0.001) and in Hispanics (sHR 1.55, p = 0.046), but not in African Americans or APIs. Conclusion: In localized RCC patients treated with nephrectomy, TTN > 3 months became more prevalent over time in all four examined racial/ethnic groups. In Hispanics and African Americans, TTN > 3 months proportions were higher than in Caucasians and APIs. TTN > 3 months was independently associated with higher CSM in Caucasians and Hispanics, but not in African Americans and APIs.

Introduction: It is unknown whether marital status affects years of life lost (YLL) in metastatic prostate cancer (mPCa) according to race/ethnicity. Methods: Within the SEER database (2004–2021), unmarried and married mPCa patients aged 40–80 years were identified. Age‐ and sex‐matched controls were generated (Social Security Administration life tables and Monte Carlo simulation). YLL were quantified for unmarried and married mPCa patients and controls according to race/ethnicity. Subsequently, multivariable competing risks regression (CRR) models were fitted to assess cancer‐specific mortality (CSM) and other‐cause mortality (OCM). Results: Among 34,202 mPCa patients, the distribution of unmarried patients according to race/ethnicity was as follows: 7267 (34.0%) in Caucasians; 3680 (57.0%) in African Americans; 1659 (37.0%) in Hispanics; and 478 (24.0%) in Asians/Pacific Islanders. YLL values in unmarried vs. married patients relative to age‐ and sex‐matched population simulated controls, were as follows: 7.7 vs. 5.8 in Caucasians (Δ: 1.9), 9.6 vs. 7.9 in African Americans (Δ: 1.7), 7.9 vs. 6.7 in Hispanics (Δ: 1.2), and 6.3 vs. 4.7 in Asians/Pacific Islanders (Δ: 1.6). In multivariable CRR models, unmarried status independently predicted higher CSM (1.2‐fold, p < 0.001) and OCM (1.2‐fold, p < 0.001) in Caucasians, only higher CSM in African Americans (1.1‐fold, p = 0.008) and in Asians/Pacific Islanders (1.2‐fold, p = 0.02), but only higher OCM in Hispanics (1.5‐fold, p < 0.001). Conclusion: Unmarried mPCa patients exhibited higher YLL values than their married counterparts, relative to age‐ and sex‐matched population simulated controls, across all races/ethnicities. Interestingly, the YLL detriments originated from both CSM and OCM in Caucasians, only CSM in African Americans and Asians/Pacific Islanders, and only OCM in Hispanics.

Background: The effect of insulin-dependence in type 2 diabetes mellitus (T2DM) on adverse in-hospital outcomes after partial (PN) or radical nephrectomy (RN) is unknown. Patients and Methods: Descriptive statistics, propensity score matching (PSM), and multivariable logistic regression were applied to the National Inpatient Sample (2004–2019) patients with kidney cancer who underwent nephrectomy. T2DM was stratified between insulin-dependent (ID) and noninsulin-dependent (NID) subtypes. Results: In 31,909 patients treated with PN, rates of ID-T2DM versus NID-T2DM were 3.5% versus 20.0%, and 3.4% versus 20.9% in 57,029 patients treated with RN. During the study period, ID-T2DM rates increased from 0.02% to 5.4% (270-fold) in PN and from 0.3% to 6.3% (21-fold) in RN. NID-T2DM rates increased from 17.4% to 20.2% (1.2-fold) in PN and from 17.0% to 21.6% (1.3-fold) in RN. After PSM, patients with ID-T2DM who underwent PN (1109 versus 5545 nondiabetic controls) exhibited higher rates of adverse in-hospital outcomes with significant increases in six examined categories (7.9–2.3%; OR 1.6–1.3). ID-T2DM had a weaker effect (6.0–0.6%; OR 3.0–1.2) in patients treated with RN (1961 versus 3922 controls). Finally, NID-T2DM exerted a modest effect (3.5–2.5%, OR 1.4–1.2) in patients treated with PN (6400 versus 6400 controls) and the weakest effect (2.6–0.8%, OR 1.2–1.1) in patients treated with RN (11,924 versus 11,924 controls). Conclusions: Although ID-T2DM is relatively rare, its rates increased drastically over time. ID-T2DM was most strongly associated with adverse in-hospital outcomes in patients treated with PN, both in absolute and relative terms. Therefore, patients with ID-T2DM undergoing PN may represent a particularly relevant target population for perioperative management optimization with respect to surgical risk.

Pathological T4 (pT4) renal cell carcinoma (RCC) is defined by adjacent organ invasion. The rate of pT4 and its associated clinicopathological characteristics received little attention in non-metastatic (M0) RCC. Within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2022), we identified M0 RCC nephrectomy patients and assessed pT4 rates. Of 129,075 M0 RCC nephrectomy patients, 733 (0.6%) harbored pT4 stage. Annual pT4 rates decreased from 1.4% in 2004 to 0.4% in 2022 (p < 0.001). According to tumor size, the pT4 rate was 0.1% in tumors <7 cm and increased from 0.7% in 7-7.9 cm tumors to 6.4% in ≥15 cm tumors (p < 0.001). In patients undergoing radical nephrectomy for tumors ≥7 cm, pT4 rate was 2.5% (578/22,981). According to histology, pT4 rates were 2.3% (376/16,703) in clear-cell RCC, 3.0% (81/2682) in papillary RCC, 1.2% (27/2274) in chromophobe RCC, 6.7% (75/1119) in sarcomatoid dedifferentiated tumors, 13.2% (7/53) in collecting duct carcinomas, and 8.0% (12/150) in other variant histologies (p < 0.001). Compared to pT2-3 patients, pT4 patients more frequently underwent lymphadenectomy (63.3% [366/578] vs. 30.0% [6724/22,403], p < 0.001). Among patients who underwent lymphadenectomy, lymph node invasion was more common in pT4 than in pT2-3 stage (83.6% [298/366] vs. 54.8% [3901/6724], p < 0.001). In M0 RCC, pT4 is rare. It is virtually non-existent in tumors <7 cm. The highest pT4 rates are observed in variant histologies. Compared to pT2-3, pT4 is associated with higher lymphadenectomy use and lymph node invasion rates. Collectively, these findings provide descriptive population-level benchmarks.

Purpose: To compare 24-month outcomes of Thulium fiber laser enucleation of the prostate (ThuFLEP) and Holmium laser enucleation of the prostate (HoLEP). Methods: A 24-month follow-up analysis of a prospective randomized trial including 150 patients (ThuFLEP n = 74, HoLEP n = 76) was conducted. Primary outcome was non-inferior International Prostate Symptom Score (IPSS) and quality of life (QoL) reduction. Secondary outcomes included urinary continence, medication use reduction, erectile and ejaculatory function, and late adverse events. Results: At 24 months, non-inferiority of ThuFLEP regarding IPSS and QoL was confirmed ( p = 0.03). Median IPSS improved from 21 preoperatively to 3 after ThuFLEP and from 20 to 4 after HoLEP ( p < 0.001), with no significant intergroup differences at any time point (all p > 0.1). Median QoL improved from 4 to 1 in both groups ( p < 0.001), likewise without significant differences at any time point (all p > 0.3). Continence rates improved from 74.0% preoperatively to 90.0%, pad usage decreased from 89.8% to 25.4% and ICIQ-SF decreased from 5 to 3 points (all p < 0.001), without intergroup differences (all p > 0.1). Use of medication for lower urinary tract symptoms decreased from 89.4% to 7.7% ( p < 0.001). Ejaculatory function declined, while ejaculation-related bother remained unchanged and erectile function improved modestly, all without intergroup differences (all p > 0.1). Three late adverse events occurred exclusively in the ThuFLEP group, without statistical significance ( p > 0.1). Conclusion: ThuFLEP remains non-inferior to HoLEP for patient-reported functional outcomes at 24 months and demonstrates comparable safety, continence, medication use reduction, and sexual function results over time. Both techniques represent effective, durable and safe surgical options for treating benign prostatic obstruction. Trial Registration Number: DRKS00032699 (18.09.2023, retrospectively registered).