Current Practice Patterns in the Surgical Management of Benign Prostatic Hyperplasia

OBJECTIVE

To use American Board of Urology (ABU) case log data to elucidate practice patterns for benign prostatic hyperplasia (BPH) surgery. Several surgical modalities have been introduced in recent decades causing significant practice variation.

MATERIALS AND METHODS

We retrospectively analyzed ABU case logs from 2008-2021 to assess trends in BPH surgery. We created logistic regression models to identify surgeon-sided factors associated with utilization of each surgical modality.

RESULTS

We identified 6,632 urologists who logged 73,884 surgeries for BPH. Transurethral resection of the prostate (TURP) was the most commonly performed BPH surgery in all but 1 year, and odds of performing a TURP increased year-over-year (OR 1.055, 95% CI [1.013,1.098], P = .010). The use of holmium laser enucleation of the prostate (HoLEP) did not change over time. HoLEP was more likely to be performed by urologists with higher BPH surgical volume (OR 1.017, CI [1.013, 1.021], P < .001) and with endourology subspecialization (OR 2.410, CI [1.45, 4.01], P = .001). Prostatic urethral lift (PUL) utilization increased significantly since its introduction in 2015 (OR 1.663, CI [1.540, 1.796], P < .001). PUL currently comprises over one third of all BPH surgeries logged.

CONCLUSION

In the face of newer technologies, TURP remains the most common surgery for BPH in the United States. PUL has been rapidly adopted while HoLEP comprises a consistent minority of cases. Surgeon age, patient age, and urologist subspecialization were associated with use of certain BPH surgical approaches.

Enterococcal Urinary Tract Infections: A Review of the Pathogenicity, Epidemiology, and Treatment

Urinary tract infections (UTIs) are among the most common causes of infections worldwide and can be caused by numerous uropathogens. Enterococci are Gram-positive, facultative anaerobic commensal organisms of the gastrointestinal tract that are known uropathogens. Enterococcus spp. has become a leading cause of healthcare associated infections, ranging from endocarditis to UTIs. In recent years, there has been an increase in multidrug resistance due to antibiotic misuse, especially in enterococci. Additionally, infections due to enterococci pose a unique challenge due to their ability to survive in extreme environments, intrinsic antimicrobial resistance, and genomic malleability. Overall, this review aims to highlight the pathogenicity, epidemiology, and treatment recommendations (according to the most recent guidelines) of enterococci.

The role of quantitative MRI-based prostate zonal parameters in predicting clinically significant prostate cancer: A U.S. cohort

INTRODUCTION

We aimed to investigate the clinical utility of quantitative prostatic zonal measurements on in multiparametric magnetic resonance imaging (mpMRI) for the predication of clinically significant prostate cancer (csPCa).

METHODS

A retrospective, single-institution study included 144 men who underwent mpMRI from 2015- 2017. Prostate zone parameters were measured on mpMRI. Correlation and multivariable analysis evaluated relationship between prostate zone parameters and the presence of csPCa.

RESULTS

The mean age was 66.9±7.8 years old. The median (interquartile range [IQR]) prostate volume and prostate-specific antigen (PSA) were 51.6 ml (37.1-74.5) and 6.1 ng/ml (4.5-8.2), respectively. Men with csPCa had significantly smaller total prostate volume (TPV), transitional zone volume (TZV), and transitional zone thickness (TZT), and larger transitional zone density (TZD) compared to those without PCa; however, on multivariate variable analysis, only TZD maintained significance. TZD had a comparable area under the curve to PSA density (PSAD) and PSA (0.74 vs. 0.73 vs. 0.60, respectively). Subgroup analysis of men with PCa, PSAD and TZD were significantly higher in men with Gleason grade group (GG) ≥2 compared to those with GG <2 (p=0.002); however, this significance is not maintained on logistic regression in predicting GG.

CONCLUSIONS

Quantitative features of prostate zones on MRI may aid in identifying better predictors of csPCa. Zonal-based PSA density (TZD) may be a useful marker in identifying csPCa. Further exploration is needed to understand the clinical application of larger TZV in men with csPCa compared to those with insignificant disease.

Cost-utility of minimally invasive therapies vs. pharmacotherapy as initial therapy for benign prostatic hyperplasia A Canadian healthcare payer perspective

INTRODUCTION

Recently, minimally invasive surgical therapies (MIST s) have become an alternative to surgery or pharmacotherapy to manage benign prostatic hyperplasia (BPH ). This study evaluated the cost-utility of water vapor thermal therapy (WVTT ) and prostatic urethral lift (PUL) compared to pharmacotherapy as initial treatment for patients with moderate-to-severe BPH.

METHODS

In this model-based economic evaluation, we simulated BPH progression in men (mean age 65 years, average International Prostate Symptom Score 16.6) over their lifetime and estimated healthcare costs (from the Canadian healthcare payer perspective) per quality-adjusted life year (QALY), discounted at 1.5% annually. In the model, men could receive up to three lines of therapy: 1) initial pharmacotherapy with MIST as second-line, and TURP or pharmacotherapy as third-line; 2) initial MIST (WVTT or PUL) with MIST again, TURP, or pharmacotherapy as second-line, and TURP as third-line. The model was populated using data from the published literature.

RESULTS

The expected lifetime QALYs and costs were 15.50 QALYs and $14 626 for initial treatment with WVTT, 15.35 QALYs and $11 795 for pharmacotherapy followed by WVTT, 15.29 QALYs and $13 582 for pharmacotherapy followed by PUL, and 15.29 QALYs and $19 151 for initial treatment with PUL. Strategies involving PUL procedures were dominated by strategies involving WVTT. The incremental cost per QALY gained was $18 873 for initial WVTT compared to initial pharmacotherapy followed by WVTT.

CONCLUSIONS

WVTT appears to be a cost-effective procedure and may be an appropriate first-line alternative to pharmacotherapy for patients with BPH and prostate volume less than 80 cm3 who seek faster improvement and no lifelong commitment to daily medications.

The impact of 5-ARI on perioperative and functional outcomes of GreenLight PVP: an analysis of the Global GreenLight Group database

INTRODUCTION

  In this study, we sought to investigate the impact of 5-alpha reductase inhibitors (5-ARI) on the perioperative and functional outcomes of 180-Watt XPS GreenLight photovaporization of the prostate (PVP) using a large international database.

MATERIALS AND METHODS

  Data were obtained from the Global GreenLight Group (GGG) database, which includes eight high-volume, experienced surgeons from seven international centers.  All men with established benign prostatic hyperplasia (BPH) with known 5-ARI status who underwent GreenLight PVP using the XPS-180W system between 2011 and 2019 were eligible for the study.  Patients were assigned to two groups based on the preoperative use of 5-ARI.  Analyses were adjusted for patient age, prostate volume, and American Society of Anesthesia (ASA) score.

RESULTS

  We included 3,500 men, of which 1,246 (36%) had preoperative 5-ARI use.  Patients in both groups were similar with regards to age and prostate size.  On multivariable analysis, total operative time was slightly shorter (-3.26 min 95% CI: 1.20 - 5.32, p < 0.01) and required 35.6kJ less laser energy (95% CI: -48.0kJ - -23.3kJ, p < 0.01) for patients on 5ARI compared to those without 5-ARI.  However, no clinically significant difference was appreciated regarding postoperative transfusion rates [OR 0.048 (95% CI -0.82-0.91; p = 0.91)], hematuria rates [OR 0.96 (95% CI 0.72-1.3; p = 0.81)], 30-day readmission rates [OR 0.98 (95% CI 0.71-1.4; p = 0.90)], or overall functional outcomes.

CONCLUSION

  Our findings suggest that preoperative 5-ARI is not associated with any clinically significant different perioperative or functional outcomes for GreenLight PVP using the XPS-180W system.  There is no role for the initiation or discontinuation of 5-ARI prior to GreenLight PVP.

Pharmacotherapy vs. minimally invasive therapies as initial therapy for moderate-to-severe benign prostatic hyperplasia: a cost-effectiveness study

BACKGROUND

Recently, minimally invasive therapies (MITs), such as water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL) have become an alternative to surgery or pharmacotherapy to manage benign prostatic hyperplasia (BPH), offering symptom relief with a favorable safety profile. The objective of this study was to evaluate the cost-utility of MITs (WVTT and PUL) compared to pharmacotherapy as initial treatment for patients with moderate-to-severe BPH.

METHODS

In this model-based economic evaluation we simulated BPH progression in men (mean age 65 years, average International Prostate Symptom Score 16.6) over their lifetime and estimated healthcare costs (from the US public payer perspective) per quality-adjusted life year (QALY), discounted at 3% annually. Various clinical scenarios were evaluated given that most men undergo several lifelong therapies up to surgical intervention and potentially thereafter. As such, in the study model men could receive up to three lines of therapy: (1) initial pharmacotherapy with MIT as second-line, and transurethral resection of the prostate (TURP) or pharmacotherapy as third-line; (2) initial MIT (WVTT or PUL) with MIT again, TURP or pharmacotherapy as second-line, and TURP as third-line. Model was populated using data from the published literature. Probabilistic analyses were performed.

RESULTS

Initial treatment with WVTT led to the highest QALYs (13.05) and the lowest cost ($15,461). The cumulative QALYs and lifetime costs were 12.92 QALYs and $20,280 for pharmacotherapy followed by WVTT, 12.87 QALYs and $22,424 for pharmacotherapy followed by PUL, 12.86 QALYs and $20,930 for initial treatment with PUL. In the cost-utility analysis, WVTT as initial treatment dominated all three strategies, i.e., generated more QALYs at a lower cost.

CONCLUSION

WVTT is an effective and cost-saving procedure, and may be an appropriate first-line alternative to pharmacotherapy for moderate-to-severe BPH patients who seek faster improvement and no lifelong commitment to daily medications.

The patient burden of nocturnal polyuria in the United States: Results from the epidemiology of nocturnal polyuria (EpiNP) study

OBJECTIVES

To explore the impact of nocturnal polyuria (NP) on health-related quality of life (HRQoL), work productivity, mental health, fatigue, bother, and daytime sleepiness.

MATERIALS AND METHODS

This large-scale, US population-representative epidemiologic study was conducted in two parts: a web-based survey and 3-day bladder diary. Consenting participants completed the baseline Epidemiology of NP (EpiNP) survey online (Lower Urinary Tract Symptoms [LUTS] Tool, comorbidities, burden, and multiple HRQoL measures). Participants who reported ≥2 voids/night, and a random sample of 100 respondents each reporting 0 or 1 void/night, were sent urine measurement containers and asked to complete the 3-day bladder diary. NP was defined as Nocturnal Polyuria Index >0.33 (NPI33) or nocturnal urine production >90 ml/h (NUP90). Five subgroups were created: Idiopathic NP (NP with no underlying cause), NP associated with symptoms of overactive bladder (NPOAB) or bladder outlet obstruction (NPBOO; men only), NP associated with other comorbidities (NPCOM; e.g., diabetes, hypertension, heart disease, sleep apnea), and no NP (did not meet NP criteria).

RESULTS

A total of 4893 men and 5297 women completed the EpiNP survey; mean age was 54.4 (SD = 14.7). Significantly greater patient burden (p < 0.0001) was evidenced in the nocturia group (≥2 voids/night) versus no nocturia group (0-1 void/night) on daily impact of nocturia, LUTS Bother, prostate symptoms (men only), work productivity, physical and mental health component scores, depression, fatigue, and daytime sleepiness. NP subgroup analyses showed men in the NPBOO group and women in the NPOAB group reported the greatest impact on LUTS bother, fatigue, physical health, work productivity impairment, daytime sleepiness, and depression (women only).

CONCLUSION

This was the first large-scale, epidemiologic study to explore the impact of different forms of NP on patients' HRQoL. Findings demonstrate that NP associated with other urologic or comorbid conditions appears to have greater patient burden than idiopathic NP, in particular for women.

Safety and efficacy of GreenLight PVP in octogenarians: evaluation of the Global GreenLight Group database

INTRODUCTION

The present study analyzes the largest international GreenLight database, the Global GreenLight Group (GGG), to evaluate the functional and safety profile of GreenLight photoselective vaporization of the prostate (PVP) in octogenarians.

METHODS

The GGG is a database comprised of patients that underwent GreenLight PVP from 2011 to 2019 performed by 8 experienced urologists at 7 international hospitals. Patients 80 years or older at the time of surgery were categorized as octogenarians. They were compared to a similar group of PVP patients below the age of 80.

RESULTS

Among 3,648 patients, 586 men were above the age of 80. Compared to patients under the age of 80, octogenarians had larger prostates (76.0 vs 71.9 ml, p = 0.02) and a lower BMI (25.6 vs 26.7, p = 0.045). Operative time was not significantly longer in octogenarians. The improvement in functional outcomes between 80-year-old patients and control patients was not significantly different at one-year follow-up, with the exception of maximum urinary flow (Q_max) that favoured younger patients (10.3 vs 12.6 ml/s, p = 0.02). The odds of transfusion were greater for older patients [OR 8.2 (95% CI 3.6-18.9, p < 0.01)], but they were not at increased risk of hematuria. Octogenarians had higher readmission rates (23.0 vs 11.9%, p < 0.01).

CONCLUSIONS

GreenLight PVP is a safe option in well-selected octogenarians in a cohort of patients treated by surgeons experienced with the technology. The odds of transfusion were higher in patients over 80, but the absolute risk remains low. The 30-day hospital readmission rate was higher in octogenarians.

Feasibility and preliminary clinical tolerability of low-field MRI-guided prostate biopsy

OBJECTIVE

We evaluate the clinical feasibility of a portable, low-field magnetic resonance imaging (MRI) system for prostate cancer (PCa) biopsy.

METHODS

A retrospective analysis of men who underwent a 12-core systematic transrectal ultrasound-guided prostate biopsy (SB) and a low-field MRI guided transperineal targeted biopsy (MRI-TB). Comparison of the detection of clinically significant PCa (csPCa) (Gleason Grade [GG] ≥ 2) by SB and low field MRI-TB, stratified by Prostate Imaging Reporting & Data System (PI-RADS) score, prostate volume, and prostate serum antigen (PSA) was performed.

RESULTS

A total of 39 men underwent both the MRI-TB and SB biopsy. Median (interquartile range [IQR]) age was 69.0 (61.5-73) years, body mass index (BMI) was 28.9 kg/m² (25.3-34.3), prostate volume was 46.5 cc (32-72.7), and PSA was 9.5 ng/ml (5.5-13.2). The majority (64.4%) of patients had PI-RADS ≥ 4 lesions and 25% of lesions were anterior on pre-biopsy MRII. Cancer detection rate (CDR) was greatest when combining SB and MRI-TB (64.1%). MRI-TB detected 74.3% (29/39) cancers. Of which, 53.8% (21/39) were csPCa while SB detected 42.5% (17/39) csPCa (p = 0.21). In 32.5% (13/39) of cases, MRI-TB upstaged the final diagnosis, compared to 15% (6/39) of cases in which SB upstaged the final diagnosis (p = 0.11).

CONCLUSION

Low-field MRI-TB is clinically feasible. Although future studies on the accuracy of MRI-TB system are needed, the initial CDR is comparable to those seen with fusion-based prostate biopsies. A transperineal and targeted approach may be beneficial in patients with higher BMI and anterior lesions.

Characterization of the histological response to the Butterfly Prostatic Retraction Device in patients with benign prostatic hyperplasia

PURPOSE

The Butterfly Prostatic Retraction Device ("Butterfly") is a permanent nitinol implant for benign prostatic hyperplasia. This study examines the chronic response of prostate tissue to the Butterfly in histological specimens from patients in the Butterfly pilot clinical study.

METHODS

Retrospective qualitative and semi-quantitative review of histological specimens of seven (7) patients who participated in the Butterfly pilot clinical study. Patients had at least 1-month implantation with the Butterfly prior to implant removal and TURP. Tissue samples were graded by two pathologists.

RESULTS

Four out of six patients had IPSS decreased from baseline. All seven patients' samples had signs of chronic inflammation; one demonstrated acute inflammation and one demonstrated fibrosis. In three cases, intraglandular calcification was identified. There was no ischemic necrosis induced by the implant, and no encrustation, urethral edema, or cellular atypia was noted.

CONCLUSION

The Butterfly demonstrated an overall favorable safety profile in terms of tissue response. This study demonstrates that there is no significant tissue reaction in the prostatic urethra due to presence of Butterfly device.

Patients' perspectives on attributes while choosing minimally invasive surgery for benign prostatic hyperplasia procedures: Experience from men undergoing water vapor thermal therapy

Objective To understand which attributes patients consider important when selecting treatment options for benign prostatic hyperplasia (BPH) given differences in clinical and economic outcomes. Methods Men (n=170) with lower urinary tract symptoms due to BPH who underwent water vapor thermal therapy (WVTT) between April 2019 and November 2020 in a Toronto urological clinic were invited to participate in an online survey. The survey included eight attributes of BPH surgical procedures and five attributes of WVTT. Patients were asked how important each attribute was to them before they selected a BPH procedure and decided to undergo WVTT. Results In total, 128 respondents (75%) completed the survey. A majority of the respondents were White (88%), married (83%), and aged 60-69 years old (45%). Approximately 97% of respondents rated the ability to avoid further BPH treatments as "very important" or "extremely important", followed by duration to return to normal activities (79%), and wait times to receive the procedure (57%). Only 47% of patients reported post-procedural catheterization was important. For WVTT, 98% of the respondents rated avoiding more invasive surgical treatments and 88% rated a quick recovery as important attributes. Conclusions Among men with moderate-to-severe BPH undergoing WVTT, the most important attributes for selecting a BPH surgical procedure were avoiding further BPH treatments, returning quickly to normal activities, and reducing treatment wait times. The majority of men chose WVTT to avoid more invasive procedures and had a quick recovery.

Prostatic zonal parameters and lower urinary tract symptoms as quantified via magnetic resonance imaging

INTRODUCTION

Benign prostatic hyperplasia (BPH) is a common diagnosis among aging males; however, the relationship between prostate volume and lower urinary tract symptoms (LUTS) severity is imperfect. The goal of this study was to comprehensively investigate the relationship between various prostate zone-based parameters measured using magnetic resonance imaging (MRI) and LUTS.

METHODS

Data were retrospectively collected for 144 patients who underwent MRI between 2015 and 2017 at a single institution. Prostate volumes were measured on sagittal and axial T2 weighted using the prostate ellipsoid formula.

RESULTS

Only transition zone thickness (TZT) correlated with International Prostate Symptom Score (IPSS) (Pearson's=0.33; p=0.007). The intraprostatic protrusion (IPP) component (rho 0.261; p=0.036), transitional zone volume (TZV) (rho 0.264; p=0.034), and TZT (Pearson's correlation 0.422; p<0.001) all correlated with worsening QoL scores. In total, 97.9% of men had the presence of an IPP (>0 mm) and larger IPPs were found in older men with higher postvoid residual volumes. Larger peripheral zone volume (PZV) (odds ratio [OR] 3.62, 95% confidence interval [CI] 1.07-12.30, p<0.05), TZV (OR 6.00, 95% CI 1.69-21.35, p<0.05), and TZT (OR 4.00, 95% CI 1.17-13.69, p<0.05) were predictive of developing severe LUTS; however, IPP (p=0.122) was not.

CONCLUSIONS

TZV, TZT, and IPP all demonstrated a role in the evaluation of LUTS with predictive capabilities. IPP is very common but not always clinically significant. Clarifying more precise zonal parameters and their relationship with LUTS may ultimately help clinicians guide the need for surgical intervention more precisely.

Surgical treatment for BPH refractory to medication: robotic water jet ablation vs. TURP functional outcomes from two FDA clinical trials

INTRODUCTION

A common indication for benign prostate hyperplasia (BPH) therapies is failure to improve with medical therapy. However, pivotal Federal Drug Administration (FDA) registered randomized clinical trials (RCTs) for minimally invasive surgical therapies (MISTs) are designed to be compared to either sham or placebo while off medical therapy at baseline, and as an alternative to medical therapy. There are few if any RCTs reporting the MISTS efficacy in patients with true medical therapy failure. We report on the efficacy of robotic water jet ablation therapy (RWT) and TURP in patients who have failed to improve with medical therapy.

MATERIALS AND METHODS

Data was obtained from the WATER and WATER II clinical trials. Both clinical trials did not implement a drug washout period. Only patients with reported BPH medical therapy such as alpha-blockers (AB) and 5-alpha-reductase inhibitors (5-ARIs) usage were included. Functional outcomes as post-void residual volume (PVR), peak urinary flow rate (Qmax), internal prostate symptom score (IPSS), and quality of life score (QoL) were analyzed.

RESULTS

AB and/or 5-ARIs usage at baseline were reported in 146 and 39 patients who underwent RWT (prostate sizes up to 150 cc) and transurethral resection of the prostate (TURP, prostate sizes up to 80 cc) respectively. Baseline median (IQR) IPSS, QoL, Qmax and PVR were 24 (18,28), 5 (4,5), 8.9 (6.4,11.5), and 95 (36,172), respectively. Functional outcomes did not statistically differ between Aquablation and TURP at baseline and at 36-month. In cohort of true medical failure, both RWT and TURP demonstrated group statistical improvements in PVR, Qmax, IPSS, and QoL at 36-month compared to baseline.

CONCLUSIONS

RWT and TURP are effective BPH therapy in patients who truly failed medical therapy, and RWT demonstrated this in a much broader prostate size range.

Effect of Surgeon and Facility Volume on Outcomes of Benign Prostatic Hyperplasia Surgery: Implications of Disparities in Access to Care at High-Volume Centers

OBJECTIVE

To report the effect of surgeon and facility volume on outcomes of transurethral resection of the prostate (TURP) and laser treatment of benign prostatic hyperplasia (BPH). We also investigate disparities in access to care by identifying demographic predictors of receipt of treatment at high-volume facilities.

METHODS

We used New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) data. We included 18,041 (41.4%) and 25,577 (58.6%) adult patients that underwent TURP and laser procedures in the outpatient setting between January 2005 and December 2018, respectively. Average annual surgeon and facility volumes were broken down by tertile. The effect of volume on short-term outcomes (30-day and 90-day readmission) was examined using mixed-effect logistic regression models. Cox-proportional-hazard models were used to assess the association between volume and long-term stricture development and reoperation. Demographic predictors of treatment at high-volume facilities were assessed using multinomial logistic regression.

RESULTS

High-volume facilities were more likely to offer laser procedures compared to low-volume facilities. Higher facility and surgeon volume were associated with lower odds of 30 and 90-day readmissions compared to low-volume facilities. There was no difference in reoperation and stricture development between surgeon volume groups. Medicaid insurance, Hispanic ethnicity, and Black race were inversely associated with treatment at high-volume facilities.

CONCLUSION

Higher surgeon and facility volumes were associated with lower odds of readmission. Higher facility volume was associated with lower hazards of reoperation and developing strictures. Medicaid insurance and non-white race were associated with lower odds of treatment at high-volume facilities, highlighting racial and socioeconomic disparities in access to high-volume BPH surgery facilities.

Top Ten Tips Palliative Care Clinicians Should Know About Urological Care

Patients receiving palliative care (PC) can present with or develop a host of urological needs or complications. These needs can include attention to sexual health, urinary incontinence, genitourinary bleeding, and urinary tract obstruction by benign, malignant, or urinary stone diseases. These varied conditions require that PC clinicians understand invasive and noninvasive medical, surgical, and radiation options for treatment. This article, written by a team of urologists, geriatricians, and PC specialists, offers information and guidance to PC teams in an accessible "Top Ten Tips" format to increase comfort with and skills around assessment, evaluation, and specialist referral for urological conditions common in the PC setting.

How I Do It: Penthrox in Urology

Penthrox is a portable handheld inhaler that delivers a low dose of methoxyflurane - an anesthetic with analgesic effects, rapid onset of action, and a favorable side-effect profile. It has been widely used for acute pain management in Australia for the past 40 years. Currently, it is approved for use in over 55 countries, including Canada. Prospective randomized studies highlight Penthrox analgesic effectiveness and safety profile for emergency, prehospital and outpatient settings. In addition, the use of multimodal analgesia, specifically Penthrox, can play an important role in the analgesic management of urological procedures, such as prostatic biopsies and office-based minimally invasive surgical therapies. Herein readers will familiarize themselves with Penthrox, significant studies, and technique used for outpatient urological procedures.

Prostatic artery embolization compared to transurethral resection of the prostate and prostatic urethral lift: a real-world population-based study

BACKGROUND

There are growing interests for minimally invasive surgical techniques (MISTs) for the treatment of benign prostatic hyperplasia (BPH)-associated lower urinary tract symptoms (LUTS). Prostatic artery embolization (PAE) uses selective angioembolization of prostatic arteries, thereby reducing size to improve LUTS/BPH. However, real-world data comparing surgical outcomes between MISTs and tissue resective techniques are lacking. We assessed the differences in surgical outcomes between PAE, transurethral resection of the prostate (TURP), and prostatic urethral lift (PUL) in a real-world population for LUTS/BPH.

METHODS

We present an observational population-based study of 12,902 men with BPH in New York State who received PAE, TURP, and PUL in outpatient and ambulatory surgery settings from 2014 to 2018. For short-term outcomes, we report 30-day and 90-day risks of readmission to inpatient and emergency room (ER) with/without complications and compared them across groups using χ² tests and mixed-effect logistic regressions. For long-term outcomes, we report surgical retreatment and stricture rates using Kaplan-Meier failure curves and compared them using Log rank tests and Cox regression models.

RESULTS

Of 12 902 men, 335 had PAE, 11,205 had TURP, and 1362 had PUL. PAE patients had the highest 30-day (19.9%) and 90-day (35.6%) risks of readmission to inpatient or ER (p < 0.01). Non-specific abdominal pain was the main diagnosis associated with 30-day and 90-day readmissions to inpatient or ER after PAE (14.3% and 26.8%, respectively). After 2 years of follow-up, PAE patients had the highest retreatment rate of 28.5% (95%CI 23.7-34.2%) compared to TURP (3.4% (95%CI 3.1-3.8%)) and PUL (8.5% (95%CI 5.6-12.9%)) (p < 0.001).

CONCLUSION

In a real-world population, PAE was associated with the most frequent 30-day and 90-day readmission to inpatient or ER and the highest retreatment rate among all surgical techniques even when controlled for individual patient comorbidities and surgical volume.

An Evaluation of Sexual Function in the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia in Men Treated with the Temporarily Implanted Nitinol Device

Purpose: To document the effect of the temporarily implanted nitinol device (iTind; Medi-Tate Ltd, Israel) on sexual function from a multicenter, randomized, single-blinded, sham-controlled trial. Materials and Methods: Men were randomized 2:1 between iTind and sham procedure arms. The iTind was placed for 5-7 days and an 18F Foley catheter was inserted and removed for the iTind and sham group, respectively. Patients were assessed at baseline, 3, and 12 months postoperatively using the Sexual Health Inventory for Men (SHIM) and International Index of Erectile Function (IIEF). Unblinding occurred at 3 months. Results: We studied 185 men with a mean age of 61.1 ± 6.5 years. There was no difference in SHIM or total IIEF between iTind and sham at 3 months or in the iTind arm at 12 months compared with baseline. Men in the iTind arm without erectile dysfunction at baseline showed an improvement in total IIEF score of +6.07 ± 21.17 points (p = 0.034) at 12 months, in addition to an improvement in ejaculatory function. SHIM scores remained unchanged in all groups, regardless of age, prostate volume, or baseline erectile function. Conclusion: No changes were observed in sexual and ejaculatory function of patients with iTind regardless of a man's age, prostate volume, and baseline sexual function. Clinicaltrials.gov: NCT02506465.

Simulation-based prostate enucleation training: Initial experience using 3D-printed organ phantoms

INTRODUCTION

Anatomical endoscopic enucleation of the prostate (AEEP) is an effective treatment for benign prostatic hyperplasia (BPH); however, there is controversy regarding the difficulty of learning such a technique. Simulation-based training can mimic real-life surgeries and help surgeons develop skills they can transfer to the operating room, thereby improving patient safety. This study aimed to evaluate the validity of a novel organ phantom for use in AEEP simulation training.

METHODS

Participants performed AEEP on organ phantom simulators during a Masterclass using one of three energy modalities: holmium:YAG laser, thulium fiber laser, or bipolar energy. The organ phantom is composed of hydrogels and uses 3D molds to recreate prostatic tissue. Participants completed a questionnaire assessing content validity, face validity, feasibility, and acceptability of using the prostate organ phantom.

RESULTS

The novice group consisted of 13 urologists. The median number of AEEP previously performed was 0 (interquartile range [IQR] 0-2). Two experts in AEEP (surgeons having performed over 100 AEEP interventions) also participated. All participants agreed or strongly agreed that there is a role for simulators in AEEP training. Participants positively rated the overall operative experience (7.3/10). Morcellation (4.7/10) and hemostasis (3.1/10) were deemed the least realistic steps. All participants considered it feasible to incorporate this organ phantom into training programs and 92.9% agreed that it teaches skills transferrable to the operating room.

CONCLUSIONS

This study has established content and face validity for AEEP with three different energy sources for an organ phantom. Participants considered its use both feasible and appropriate for AEEP training purposes.

Efficacy and safety of methoxyflurane (Penthrox) for pain control during water vapor thermal therapy (Rezum) for benign prostatic enlargement

INTRODUCTION

The safety and efficacy of low dose methoxyflurane disposable inhaler (Penthrox) was assessed in this study of men undergoing Rezum water vapor thermal therapy (WVTT).

MATERIAL AND METHODS

An open-labeled, single-center study was conducted to demonstrate the safety and efficacy of using methoxyflurane inhaler during a Rezum procedure. Patients assessed current pain intensity using a 10-point Visual Analog Scale (VAS) of Pain at 4 timepoints including (1) before any medication, (2) initially after insertion of the rigid cystoscope and before any Rezum treatment, (3) immediately after final injection of Rezum treatment and (4) at discharge. Patients were asked to fill out the Treatment Satisfaction Questionnaire for Medication (TSQM 1.4) and one question about pain relief at discharge. Treating physician also completed the TSQM 1.4.

RESULTS

Ten patients were recruited. Median prostate volume was 53.4 cc (range 24-158 cc). Patients received a median of 10.5 Rezum injections, with a median procedure time of 4.5 minutes. Median VAS scores were 0, 0.1, 0 (primary efficacy outcome) and 0 (out of scale of 10) at the 4 timepoints, respectively. TSQM scores on effectiveness, side effects, convenience and global median satisfaction rated by patients were respectively 69.4, 100.0, 77.8 and 82.1 (out of scale of 100). Treatment satisfaction on pain relief was rated as 4.0 (very good). There were no observed adverse events.

CONCLUSIONS

Methoxyflurane inhaler (Penthrox) was low cost, rapid, feasible and easy to administer as a pain management strategy for Rezum therapy. Further data from a larger comparative study will be conducted.

Development of a coordinated registry network for pelvic organ prolapse technologies

Objectives

The accumulation of data through a prospective, multicenter Coordinated Registry Network (CRN) could be a robust and cost-effective way to gather real-world evidence on the performance of pelvic organ prolapse (POP) technologies for device-based and intervention-based studies. To develop the CRN, a group of POP experts consisting of representatives from professional societies, the Food and Drug Administration, academia, industry, and the patient community, was convened to discuss the role and feasibility of the CRN and to identify the core data elements important to assess POP technologies.

Design

A Delphi method approach was employed to achieve consensus on a core minimum dataset for the CRN. A series of surveys were sent to the panel and answered by each expert anonymously and individually. Results from the surveys were collected, collated, and analyzed by the study design team from Weill Cornell Medicine. Questions for the next round were based on the analysis process and discussed with group members via conference call. This process was repeated twice over a 6-month time period during which consensus was achieved.

Results

Twenty-one experts participated in the effort and proposed 120 data elements. Participation rates in the first and second round of the Delphi survey were 95.2% and 71.4%, respectively. The working group reached final consensus among responders on 90 data elements capturing relevant general medical and surgical history, procedure and discharge, short-term and long-term follow-up, device factors, and surgery and surgeon factors.

Conclusions

The CRN successfully developed a set of core data elements to support the study of POP technologies through convening an expert panel on POP technologies and using the Delphi method. These standardized data elements have the potential to influence patient and provider decisions about treatments and include important outcomes related to efficacy and safety.