Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Amy Krambeck. She's the Chief of Endourology and Stone Disease and a Professor of Urology at Northwestern Medicine. She's here today to highlight resectoscope sheath size influence on outcomes of holmium laser enucleation of the prostate or HOLEP.

Dr. Krambeck, thank you for joining us again today. And I'd like you to start by providing us a bit of an overview of your experience and expertise in performing HOLEP procedures.

Dr Amy Krambeck: Well, thank you again for having me on. It's always a delight to speak with you. I have been doing HOLEPs since 2008, so almost 16 years. It has really changed significantly over that time. When I first started, it was a difficult procedure to perform, more blood loss, much longer surgery. But as the technology has improved, as laser technology, morcellator technologies improved, it's become a much faster procedure with fewer complications and better patient outcomes.

Melanie Cole, MS: Well, thank you for that. And as we're talking about this sheath size influence on outcomes, provide us a little bit of an overview of the study design and what motivated you to design this clinical trial.

Dr Amy Krambeck: So, the motivation was really set forth by the movement across the globe to go to smaller and smaller scopes. Traditionally, HOLEP has been performed with a 28-French or a 26-French resectoscope. But recently, there's been a movement towards miniaturization. So, individuals are trying to do the procedure with 24, 21-French scopes.

The limitation with HOLEP is that the morcellator requires a five-millimeter working channel. So in the United States, the smallest scope size that can be used with the morcellator is 24-French. So, I wanted to see if the scope size influenced patient outcomes or surgical outcomes or surgeon satisfaction in the HOLEP procedure?

Melanie Cole, MS: Were there any differences in the procedural duration and operative efficiencies between the two, 24F and 28Fs? Explain a little bit about the potential implications of using larger or smaller sheath sizes.

Dr Amy Krambeck: Yes. So in order to assess scope size, we thought the best thing to do would be a prospective randomized trial. So, we took 152 men who had prostates under 200 grams or 200 cc's preoperative volume measurement. We wanted to stick with smaller prostates, even though 100 cc prostate's big, we thought limiting 200 as the upper size was reasonable.

And then, the patients were randomized to either receive the surgery with a 28-French scope or a 24-French scope. And then, the surgeon, which was essentially me, I rated my satisfaction with the procedure and we recorded surgical time. We also assessed if the patient could be discharged home the same day, their degree of bleeding, complications, and then the patients received a survey at one week, two weeks, one month, and three months to assess how they were doing after the surgery.

And essentially, we really found no difference. There was no increased rate of complications in patients who either underwent a 28-French scope or a 24-French scope. There was no improvement with burning or temporary incontinence. We really just found that if you used a larger scope, the patient was more likely to be able to go home that day and get their catheter out that day, as opposed to a smaller scope where we had a little bit more bleeding. So, this trend of going smaller has not realized into a benefit to the patient at this point.

Melanie Cole, MS: Well, then expanding on that a minute, you just said that patients were maybe able to go home earlier and without a catheter. What about patient-reported outcomes such as urinary symptoms? I mean, obviously, quality of life if they're going home without a cath is going to be better, but what about any other symptoms from the patient.

Dr Amy Krambeck: Yes. So, we did query the patients about dysuria or burning and temporary urinary incontinence. There was no difference in permanent incontinence, which was less than 1% in either group. And with the temporary urinary incontinence right after surgery, there was also no difference between the larger scope or smaller scope.

We really just found that with the larger scopes, the patients were more likely to be able to get their catheter out the same day of surgery and to pass their voiding trial than compared to the smaller scopes. And we're talking about a 94% same-day trial of void passage rate versus an 82%. So, still very good in the smaller scope group, but just not as good as the larger scopes.

Melanie Cole, MS: If you had to look at patient selection and specific populations or clinical scenarios where one scope size may be preferred over the other, do you have any advice for other providers about that?

Dr Amy Krambeck: So, I use both scopes. I use a smaller scope and a larger scope, but I would say if you are just new to HOLEP have not done thousands of the procedure, you would be better served by using a larger scope. Visualization is subjectively better with that and it's just easier to manipulate. So, my go-to is really the larger scope, but I will use the smaller scope if the patient has certain conditions, like a very small prostate, a narrow urethra, or if they have a history of a penile prosthesis, you don't want to damage that prosthesis with a big scope, so you would use a smaller scope, or if they have a history of urethral stricture repair. All of those patients are ideal for the 24-French or smaller scope.

Melanie Cole, MS: This is such an interesting episode and so informative, Dr. Krambeck. As we look at bench to bedside and potential implications of your study findings for practice, as well as future research, in your opinion, how might these findings of your research contribute to the optimization of HOLEP?

Dr Amy Krambeck: Well, I think we should always be asking ourselves why we do what we do, and is there a way to make it better? You know, we have the initial findings from this study. The next step is to do a two-year follow up on these patients and see if there's any difference in the long-term outcomes, because maybe we didn't realize much difference in the short term, but maybe over a two-year period, there's less scar tissue formation in the patients who had a smaller scope. So, I'm continuing to ask this question to see where we can find small benefits for this procedure to make it better than it was yesterday.

Melanie Cole, MS: Great information, Dr. Krambeck. Thank you so much for joining us. You are a great guest. Great guest as always. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/urology to get connected with one of our providers. That concludes this episode of BetterEdge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.