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Revisiting the issue of “beach balls” in holmium laser enucleation of prostate: clinical and histological characterization

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Abstract

Purpose

To clinically and histologically characterize prostatic nodules resistant to morcellation (“beach balls,” BBs).

Patients and methods

We reviewed a consecutive cohort of 559 holmium laser enucleation of the prostate (HoLEP) procedures performed between January 2020 and November 2023. The BBs group comprised 55 men (10%) and the control group comprised 504 men (90%). The clinical, intraoperative, outcome, and histologic data were statistically processed for the prediction of the presence of BBs and their influence on the perioperative course and outcome.

Results

The BBs group in comparison to the controls was older (75 vs 73 years, respectively, p = 0.009) and had higher rates of chronic retention (51 vs 29%, p = 0.001), larger prostates on preoperative abdominal ultrasound (AUS) (140 vs 80 cc, p = 0.006E−16), longer operating time (120 vs 80 min, p = 0.001), higher weights of removed tissue (101 vs 60 gr, p = 0.008E−10), higher complication rates (5 vs 1%, p = 0.03), and longer hospitalization (p = 0.014). A multivariate analysis revealed that larger prostates on preoperative AUS and older age independently predicted the presence of BBs which would prolong operating time. ROC analyses revealed that a threshold of 103 cc on AUS predicted BBs with 94% sensitivity and 84% specificity. BBs were mostly characterized histologically by stromal component (p = 0.005).

Conclusions

BBs are expected in older patients and cases of chronic retention. Prostatic volume is the most reliable predictor of their presence. They contribute to prolonged operating time and increased risk of complications. The predominantly stromal composition of the BBs apparently confers their resistance to morcellation.

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Abbreviations

AEEP:

Anatomic endoscopic enucleation of prostate

ASA:

American Society of Anesthesiologists

AUC:

Area under the curve

BB:

Beach ball

BPH:

Benign prostatic hyperplasia

CI:

Confidence interval

HoLEP:

Holmium laser enucleation of prostate

Ho:YAG:

Holmium:yttrium–aluminum–garnet

IRB:

Institutional Review Board

ISUP:

International Society of Urological Pathology

IQR:

Interquartile range

OR:

Odds ratio

PSA:

Prostatic-specific antigen

PSAD:

Prostatic-specific antigen density

ROC:

Receiving operating characteristic

RPM:

Rotations per minute

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Author information

Author notes

  1. Ziv Savin

    Present address: Department of Urology, Faculty of Medical & Health Sciences, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, 6 Weizmann St., 6423906, Tel-Aviv, Israel

Authors and Affiliations

  1. Department of Urology, Faculty of Medical & Health Sciences, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, 6 Weizmann St., 6423906, Tel-Aviv, Israel

    Haim Herzberg, Karin Lifshitz, Omri Schwarztuch Gildor, Yotam Veredgorn, Ron Marom, Ofer Yossepowitch & Mario Sofer

  2. Department of Pathology, Faculty of Medial & Health Sciences, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, Tel-Aviv, Israel

    Ibrahim Fahoum

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  1. Haim Herzberg
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Contributions

Haim Herzberg contributed to ethics approval, acquired the data, involved in the follow-up of the study, and drafted the data. Ziv Savin interpreted the data and involved in statistical analysis. Ibrahim Fahoum involved in histopathological assessment. Karin Lifshitz provided tabulations and designed the graphics. Omri Schwartztuch Gildor acquired the data and involved in the follow-up of the study. Yotam Veredgorn acquired the data and interpreted the data. Ron Marom provided postoperative care and involved in the follow-up of the study. Ofer Yossepowitch involved in general supervision and reviewed the data. Mario Sofer conceived the data, designed the methodology, performed the surgery, supervised the manuscript, and edited the data.

Corresponding author

Correspondence to Mario Sofer.

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No conflict financial interest exist.

Ethical approval

Institutional Review Board (IRB) approval was obtained for this study, and patient-informed consent was obtained before undergoing the procedures.

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Herzberg, H., Savin, Z., Fahoum, I. et al. Revisiting the issue of “beach balls” in holmium laser enucleation of prostate: clinical and histological characterization. World J Urol 42, 201 (2024). https://doi.org/10.1007/s00345-024-04902-9

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  • DOI: https://doi.org/10.1007/s00345-024-04902-9

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