Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART II-Surgical Evaluation and Treatment

Venous Thromboembolism and Bleeding after Transurethral Resection of the Prostate (TURP) in Patients with Preoperative Antithrombotic Therapy: A Single-Center Study from a Tertiary Hospital in China

BACKGROUND

Venous thromboembolism (VTE) and postoperative hemorrhage are unavoidable complications of transurethral resection of the prostate (TURP). At present, more and more patients with benign prostate hyperplasia (BPH) need long-term antithrombotic therapy before operation due to cardiovascular diseases or cerebrovascular diseases. The purpose of this study was to investigate the effect of preoperative antithrombotic therapy history on lower extremity VTE and bleeding after TURP.

METHODS

Patients who underwent TURP in the Department of Urology, Xiangya Hospital, Central South University, from January 2017 to December 2021 and took antithrombotic drugs before operation were retrospectively analyzed. The baseline data of patients were collected, including age, prostate volume, preoperative International Prostate Symptom Score (IPSS), complications, surgical history within one month, indications of preoperative antithrombotic drugs, drug types, medication duration, etc. Main outcome measures included venous thromboembolism after TURP, intraoperative and postoperative bleeding, and perioperative blood transfusion. Secondary outcome measures included operation duration and postoperative hospitalization days, the duration of stopping antithrombotic drugs before operation, the recovery time of antithrombotic drugs after operation, the condition of lower limbs within 3 months after operation, major adverse cardiac events (MACEs), and cerebrovascular complications and death.

RESULTS

A total of 31 patients after TURP with a long preoperative history of antithrombotic drugs were included in this study. Six patients (19.4%) developed superficial venous thrombosis (SVT) postoperatively. Four of these patients progressed to deep vein thrombosis (DVT) without pulmonary thromboembolism (PE). Only one patient underwent extra bladder irrigation due to blockage of their urinary catheter by a blood clot postoperatively. The symptoms of hematuria mostly disappeared within one month postoperatively and lasted for up to three months postoperatively. No blood transfusion, surgical intervention to stop bleeding, lower limb discomfort such as swelling, MACEs, cerebrovascular complications, or death occurred in all patients within three months after surgery.

CONCLUSION

Short-term preoperative discontinuation may help patients with antithrombotic therapy to obtain a relatively safe opportunity for TURP surgery after professional evaluation of perioperative conditions. The risks of perioperative bleeding, VTE, and serious cardiovascular and cerebrovascular complications are relatively controllable. It is essential for urologists to pay more attention to the perioperative management of these patients. However, further high-quality research results are needed for more powerful verification.

Prostatic arterial embolization versus holmium laser enucleation of the prostate: 1-year outcomes

PURPOSE

Holmium Laser Enucleation of the Prostate (HoLEP) and Prostatic Artery Embolization (PAE) are novel techniques for the treatment of benign prostatic hyperplasia lower urinary tract symptoms (BPH-LUTS). The objective of this study was to describe and compare the functional results and complications of these two techniques at one year follow-up.

MATERIALS AND METHODS

We performed a retrospective, monocentric study of all patients consecutively treated in our center with HoLEP or PAE for symptomatic or complicated BPH between January 2016 and December 2019. Data regarding patient and perioperative characteristics, follow-up biological results, functional questionnaires and uroflowmetry were collected from medical records.

RESULTS

A total of 490 and 57 patients were treated with HoLEP and PAE, respectively. The demographic and clinical characteristics of the two groups were similar. The operative time was significantly higher for PAE (p < 0.001) and hospitalization time longer after HoLEP (p = 0.0006). The urinary catheterization time was longer after PAE (p < 0.001). The prostatic volume treated was higher with HoLEP than with PAE (56% versus 26%, p < 0.001). The mean difference in IPSS from baseline to 12 months was significantly higher after HoLEP than after PAE: - 17.58 versus - 8 (p < 0.001). The mean difference in QoL-IPSS from baseline to 12 months was significantly higher after HoLEP: - 4.09 versus - 2.27 (p < 0.001). The rate of postoperative adverse events in the first three months was similar between the two groups:35% after HoLEP and 33% after PAE (p = 0.88).

CONCLUSIONS

HoLEP and PAE both significantly improved BPH-LUTS, with HoLEP having an advantage over PAE.

Prostatic arterial embolisation for men with benign prostatic hyperplasia: a Cochrane review

OBJECTIVES

To assess the effects of prostatic arterial embolisation (PAE) compared to other procedures for treatment of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH).

METHODS

We included randomised controlled trials (RCTs), as well as non-randomised studies (NRSs) enrolling men with BPH undergoing PAE vs other surgical interventions via a comprehensive search up until 8 November 2021. Two independent reviewers screened the literature, extracted data, assessed risk of bias, performed statistical analyses by using a random-effects model, and rated the certainty of evidence (CoE) of RCTs and NRSs.

RESULTS

We found data to inform two comparisons: PAE vs transurethral resection of prostate (TURP; six RCTs and two NRSs), and PAE vs sham (one RCT). This abstract focuses on the primary outcomes in a comparison of PAE vs TURP. Short-term follow-up: based on RCT evidence, there may be little to no difference in urological symptom score improvement (mean difference [MD] 1.72, 95% confidence interval [CI] -0.37 to 3.81; low CoE) and quality of life (QoL; MD 0.28, 95% CI -0.28 to 0.84; low CoE) measured by International Prostatic Symptom Score. We are very uncertain about the effects of PAE on major adverse events (risk ratio [RR] 0.75, 95% CI 0.19-2.97; very low CoE). Long-term follow-up: based on RCT evidence, PAE may result in little to no difference in urological symptom scores (MD 2.58, 95% CI -1.54 to 6.71; low CoE) and QoL (MD 0.50, 95% CI -0.03 to 1.04; low CoE). We are very uncertain about major adverse events (RR 0.91, 95% CI 0.20-4.05; very low CoE).

CONCLUSION

Compared to TURP, the impact on urological symptoms and QoL improvement as perceived by patients appears to be similar. This review did reveal major uncertainty as to how major adverse events compare.

Comparison of Cost and Perioperative Outcomes Among Patients Undergoing Simple Prostatectomy and Laser Enucleation of the Prostate

Introduction: Simple prostatectomy (SP) and laser enucleation of the prostate (LEP) are treatments for symptomatic benign prostatic hyperplasia (BPH) in men with large glands (e.g., >80 g). The decision between the two operations is often dependent on surgeon preference/experience and equipment availability. As the use of minimally invasive techniques, such as robotic-assisted simple prostatectomy, has increased for the treatment of large gland BPH, studies comparing the outcomes and cost of these modalities in a contemporary cohort are lacking. Methods: All-payer data from Healthcare Cost and Utilization Project State Databases from Florida, New York, California, and Maryland from 2016 to 2018 were used to identify adults who underwent SP or LEP for BPH. Patient demographics, facility characteristics, revisit rates, and cost of the index hospitalization were examined. Multivariable logistic and gamma generalized linear regression models were utilized to compare predictors of the operation performed, 30-day revisits, and index hospitalization cost among the two operations. Results: Of the 2032 patients in the cohort, 1067 (46.4%) underwent LEP and 965 (41.9%) underwent SP. On multivariable logistic regression analysis, SP patients were younger, had higher comorbidity scores, and were more likely to be uninsured compared with LEP patients. Thirty-day revisit rates among the operations were equivalent (odds ratio 0.89, 95% confidence interval 0.63-1.27, p = 0.05). The mean adjusted cost of the index hospital stay for LEP was significantly greater than that of SP ($7291 vs $6442, p = 0.04). However, our sub-group analysis examining high-volume centers revealed no significant differences in cost ($6184 vs $5353, p = 0.1). Conclusions: Across the four states examined, SP and LEP were performed with comparable volume and had similar rates of 30-day revisits. The SP was less expensive than LEP overall; however, among high-volume facilities, the cost of both operations was reduced, such that they were equivalent.

Risk Factors and Real-World Short-Term Outcomes of a Failed Trial of Void After Rezum Therapy in a Multiethnic Population

Background: Postoperative urinary retention is a common complication following surgery for benign prostatic hyperplasia. We aimed to identify risk factors for a failed trial of void (TOV) following treatment with the Rezum system and assess the impact of a failed TOV on short-term outcomes. Methods: A single-office retrospective study was conducted on patients treated with Rezum therapy between 2017 and 2019. A urinary catheter was placed in all patients following Rezum therapy. Demographic data and outcome measures, including the International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax), postvoid residual (PVR), and adverse events, were analyzed at baseline and 1, 3, and/or 6 months postoperatively. Risk factors were identified through multivariate logistic regression analysis. Results: A total of 289 patients were included. Thirty-five patients (12.1%) failed a TOV, while 254 (87.9%) had an effective TOV. All patients were given a TOV after a median of 5 days (4-5). Those who failed the TOV spent an additional mean of 13.7 ± 13.3 days with a catheter. Patients who failed the TOV were more likely to get a urinary tract infection compared with those who had an effective TOV (20.0% vs 4.7%, p < 0.001). All patients experienced significant improvements in IPSS, QoL, and Qmax at 1, 3, and/or 6 months. On multivariate analysis, a high baseline PVR was the only independent predictor of a failed TOV (odds ratio: 1.01, 95% confidence interval 1.00-1.01). A greater proportion of patients with a baseline PVR >200 mL failed the TOV (40.0%) compared with patients with a baseline PVR <200 mL (10.9%, p = 0.008). Conclusions: Approximately one in eight patients failed the TOV following Rezum therapy. Baseline PVR was the only independent risk factor for a failed TOV. Nevertheless, all patients experienced significant relief of urinary symptoms. Patients with high baseline PVR, particularly >200 mL, may require a catheter for an extended duration.

Evaluation of the Cost-Effectiveness of Surgical Treatment Options for Benign Prostatic Hyperplasia

OBJECTIVE

To compare the cost-effectiveness of surgical interventions for BPH.

METHODS

Using a Markov model, a cost-utility analysis was performed comparing HoLEP, B-TURP, WVTT, and PUL for prostate size <80cc (index patient 1) and HoLEP and SP for prostate size >80cc (index patient 2). Model probabilities and utility values were drawn from the literature. Analysis was performed at a 5-year time horizon with extrapolation to a lifetime horizon. Primary outcomes included quality-adjusted life years (QALYs), 2021 Medicare costs, and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100,000/QALY. Univariate and probabilistic sensitivity analyses were performed.

RESULTS

At 5 years, costs per patient for index patient 1 were $3292 (WVTT), $6532 (HoLEP), $6670 (B-TURP), and $10,257 (PUL). HoLEP resulted in the highest QALYs (4.66), followed by B-TURP (4.60), PUL (4.38), and WVTT (4.38). This translated to HoLEP being most cost-effective (ICER $11,847). For index patient 2, HoLEP was less costly ($6,585 vs $15,404) and more effective (4.654 vs 4.650) relative to SP. On sensitivity analysis for index patient 1, B-TURP became most cost-effective if cost of HoLEP increased two-fold or chronic stress incontinence following HoLEP increased ten-fold. When follow-up time was varied, WVTT was preferred at very short follow up (<1 year), and HoLEP became more strongly preferred with longer follow up.

CONCLUSION

At 5 years follow up, HoLEP is a cost-effective surgical treatment for BPH- independent of gland size.

The 10-item LURN Symptom Index (LURN SI-10) Detects Additional Symptoms and Shows Convergent Validity With the IPSS in Men Presenting With Lower Urinary Tract Symptoms

OBJECTIVE

To determine how the LURN-SI-10, a novel questionnaire developed by the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN), compares with the International Prostate Symptom Score (IPSS) in men with lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH). Specifically, to assess convergent validity and determine how frequently the LURN-SI-10 identifies symptoms not captured by the IPSS.

MATERIALS AND METHODS

Men presenting with BPH/LUTS were prospectively administered LURN-SI-10 and IPSS questionnaires. Urinary incontinence (UI) including post-void dribbling (PVD), urgency urinary incontinence (UUI), stress urinary incontinence (SUI), as well as bladder pain were considered present if the patient reported "about half the time or more" on LURN-SI-10. Correlations between LURN-SI-10 and IPSS were assessed as continuous and categorical variables. Multivariable linear regression analysis was performed to determine associations with symptom scores.

RESULTS

LURN-SI-10 and IPSS were highly correlated in men with BPH/LUTS (r = 0.82, n = 429), as were respective bother and quality of life scores (ρ = 0.74). The LURN-SI-10 identified additional symptoms including PVD (24%), UUI (13%), SUI (2%), and pain (8%). Men with any UUI, SUI, or PVD had on average a 7.6-point higher LURN-SI-10 score than those without UI (P<.001) and 8.0-point higher IPSS score than those without UI (P<.001).

CONCLUSION

The LURN-SI-10 correlates strongly with the IPSS, but the LURN-SI-10 identifies additional important symptomatology in men with LUTS. This additional information may improve the evaluation and treatment of men with BPH/LUTS. Further prospective studies of the LURN-SI-10 is warranted.

Efficiency and clinical outcomes of Moses technology for holmium laser enucleation of the prostate: An evidence-based analysis

BACKGROUND

To compare the safety and clinical efficacy of Moses laser enucleation of the prostate (MoLEP) with those of holmium laser enucleation of the prostate (HoLEP) for treating benign prostatic hyperplasia (BPH).

METHODS

We systematically searched PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang databases, and SinoMed databases. The retrieval period was from the establishment of the database to March 2022. Stata17.0 was used for calculations and statistical analyses.

RESULTS

This study included 12 articles comprising 1160 patients for meta-analysis. Compared with those of the HoLEP group, the hemostasis time (weighted mean difference [WMD] = -4.66, 95% confidence interval [CI] [-6.47, -2.84], p < 0.001), enucleation time (WMD = -7.23, 95% CI [-10.67, -3.79], p < 0.001), operative time (WMD = -15.02, 95% CI [-20.50, -9.53], p< 0.001), length of hospital stay (WMD = -15.02, 95% CI [-20.50, -9.53], p< 0.001), intraoperative blood loss (WMD = -11.19, 95% CI [-12.94, -9.44], p< 0.001), and total postoperative complications rate (OR = 0.51, 95% CI [0.32, 0.81], p = 0.004) were shorter in the MoLEP group. Postoperative quality of life (WMD = 0.30, 95% CI [0.00, 0.59], p = 0.047) was lower in the HoLEP group, and there were no statistically significant differences in the International Prostate Symptom Score, postoperative maximum urinary flow rate, and postoperative residual urine (p > 0.05).

CONCLUSION

MoLEP has more advantages than HoLEP in terms of safety, shorter operation time and hospital stay, and fewer complications. However, this conclusion needs to be verified with a larger sample size, longer follow-up time, and multicenter randomized controlled trial data.

Controversies in Prostate Artery Embolization: Future Best Practice

Prevalence of lower urinary tract symptoms secondary to benign prostatic hyperplasia is correlated with age. Men seeking treatment options with a low side effect profile often turn to prostate artery embolization (PAE). PAE continues to be refined with advanced tools and optimized techniques. Nonetheless, there exist controversies in terms of best practices for the management of lower urinary track symptoms (LUTS) with PAE. These controversies are essential for medical progress. Herein we suggest best practices moving forward based on currently available data. Given extensive safety data, we recommend PAE be considered alongside medical management and as a precursor to surgery. Given demonstrated efficacy across gland sizes, PAE can be performed in a single session, ideally in a hybrid angio-CT suite, without preoperative cross-sectional imaging. PAE should be initially performed with 300- to 500-μm size particles, and instead consider exploring other particles and sizes for repeat PAE. Finally, PAE can also be considered as first-line option for recurrent disease given the efficacy and excellent safety profile. This article is not meant to purport a dogma, but rather to serve as a guide to the experienced practitioner in challenging his or her own biases when performing PAE.

Medium-Term Real-World Outcomes of Minimally Invasive Surgical Therapies for Benign Prostatic Hyperplasia: Water Vapor Thermal Therapy (Rezum) vs Prostatic Urethral Lift (UroLift) in a High-Volume Urban Academic Center

Purpose: Water vapor thermal therapy (WVTT, i.e., Rezum^®) and prostatic urethral lift (PUL, i.e., Urolift^®) are minimally invasive surgical therapy (MIST) options for benign prostatic hyperplasia (BPH). Few studies have directly compared the two procedures. We examined the clinical characteristics and postoperative outcomes of patients undergoing WVTT and PUL at our high-volume urban academic center. Methods: We reviewed our institutional MIST database to identify patients with prostate sizes ≥30 and ≤80 cc who underwent WVTT or PUL for treatment of BPH between January 2017 and September 2021. Pre- and postoperative outcomes, including retreatment rates, American Urological Association symptom score (AUA-SS), maximum flow (Qmax), postvoid residual (PVR), medication usage, trial of void success rates, catheterization requirements, and postoperative complications within 90 days were extracted and compared between procedures. Results: Three hundred seven patients received WVTT and 110 patients received PUL with average follow-up times of 11.3 and 12.8 months, respectively. WVTT patients showed significant improvements in AUA-SS, Qmax, and PVR, whereas PUL patients showed improvements in only AUA-SS and Qmax. Both WVTT and PUL patients with longitudinal follow-up demonstrated improvements in AUA-SS, Qmax, and PVR. Postoperatively, alpha-blocker utilization was significantly decreased following both WVTT and PUL (WVTT: 73.9%-46.6%, PUL: 76.4%-38.2%, both p < 0.001). Compared to patients receiving PUL, WVTT patients more frequently reported postoperative dysuria (22.8% vs 8.3%, p = 0.001) and nonclot-related retention (18.9% vs 7.3%, p = 0.005); PUL patients more frequently experienced postoperative clot retention (7.3% vs 2.6%, p = 0.027). There were no differences in rates of postoperative bladder spasm, trial of void success, urinary tract infections, or emergency department visits. Postoperative erectile dysfunction and retrograde ejaculation were rare and occurred at similar rates. Conclusion: In the real-world setting, WVTT and PUL have similar medium-term efficacy in improving symptoms and decreasing medication utilization for patients with BPH. Differences in postoperative complication profiles should inform patient counseling.

Network Meta-Analysis of the Treatment Safety and Efficacy of Different Lasers in Prostate Enucleation

Purpose: This study aimed to compare different laser systems for the enucleation of benign prostate hyperplasia. Methods: Randomized controlled trials (RCTs) on different lasers for prostate enucleation were searched from PubMed, Embase, and CNKI databases. Pairwise and network meta-analyis (NMA) were performed to analyze the outcome regarding surgery time, complications, short-term postvoid residual (PVR), long-term PVR, and short-term international prostate symptom score (IPSS), long-term IPSS, short-term maximum urine flow rate (Qmax), and long-term Qmax. RevMan software was used for paired meta-analysis. Considering the variance uncertainty caused by the different source regions of RCTs and the different primary conditions of surgeons and patients, this study uses Bayesian NMA conducted with ADDIS software to compare different treatment methods indirectly. Node-splitting analysis was used to test inconsistency for closed-loop indirect comparison. Results: Nine studies were included in this study, involving four types of lasers: diode laser, holmium laser, thulium laser, and greenlight laser. In safety paired meta-analysis, holmium laser could bring more complication risk than thulium laser (odds ratio: 2.70, 95% confidential interval [CI]: 1.79-4.00, p < 0.001), and no other significant result was detected. In the efficacy comparisons, holmium laser could offer better postoperative long-term PVR (standardized mean difference [SMD]: -0.35, 95%CI: -0.62, -0.09, p = 0.011), better postoperative long-term IPSS (SMD: -0.30, 95%CI: -0.57, -0.04, p = 0.011), better postoperative short-term Qmax (SMD: 0.44, 95%CI: 0.17, 0.70, p = 0.001) compared with greenlight laser. According to the results of NMA, greenlight laser may bring more complication risks when applied to prostate enucleation than the other three lasers. Thulium laser may be the recommended laser system for prostate enucleation. Conclusion: Thulium laser may be the recommended laser system since it can bring less complication risk with comparable efficacy. More RCTs are still needed to validate this study.

Learning curve and functional outcomes after laser enucleation of the prostate for benign prostate hyperplasia according to surgeon's caseload

PURPOSE

To evaluate the impact of surgical caseload on safety, efficacy, and functional outcomes of laser enucleation of the prostate (LEP) applying a structured mentoring program.

METHODS

Patient characteristics, perioperative data, and functional outcomes were analyzed descriptively. Linear and logistic regression models analyzed the effect of caseload on complications, functional outcomes and operative speed. Within the structured mentoring program a senior surgeon was present for the first 24 procedures completely, for partial steps in procedures 25-49, and as needed thereafter.

RESULTS

A total of 677 patients from our prospective institutional database (2017-2022) were included for analysis. Of these, 84 (12%), 75 (11%), 82 (12%), 106 (16%), and 330 patients (49%) were operated by surgeons at (A) < 25, (B) 25-49, (C) 50-99, (D) 100-199, and (E) ≥ 200 procedures. Preoperative characteristics were balanced (all p > 0.05) except for prostate volume, which increased with caseload. There was no significant difference in change of IPSS, Quality of life, ICIQ, pad usage, peak urine flow, residual urine, and major complications (Group A: 8.3 to E: 7.6%, p = 0.2) depending on the caseload. Caseload was not associated (Odds ratio: 0.7-1.4, p > 0.2) with major complications in the multivariable logistic regression model. Only operating time was significantly shorter with increasing caseload in the multivariable analysis (111-55 min, beta 23.9-62.9, p < 0.001).

CONCLUSION

With a structured mentoring program, the safety and efficacy of LEP can be ensured even during the learning curve with very good outcome quality. Only the operating time decreases significantly with increasing experience of the surgeon.

A Scoping Review of the Management of Benign Prostate Hyperplasia in Africa

Benign prostatic hyperplasia (BPH) is a non-malignant prostate gland enlargement of unknown cause that affects more than 50% of men over 60 and is the most common cause of bladder outlet obstruction and voiding symptoms. BPH is treated primarily with watchful waiting, phytotherapy (herbs), and medical or surgical options. In this study, we sought to examine the different management practices in African urological centers, outcomes of management, and complications. A literature search was conducted using PubMed, African Journal Online, and Google Scholar regarding the management of BPH from inception till date. Articles were selected based on their relevance to the management of benign prostatic enlargement in Africa. Results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. The studies included were conducted from 1997 to 2022. They were from eight different African countries (Nigeria, Kenya, Togo, Ethiopia, Egypt, South Africa, Ghana, and Congo), with Nigeria contributing the most with 10 studies. Exactly 2999 patients were included in the study. Seventy-three (73.49%) percent of these patients totaling 2204, underwent surgical management of BPH, 124 (4.13%) patients were treated with phytomedicines or herbs, and 684 (22.80%) patients were treated with medical therapy. The complications and outcomes were studied and collated. A total of 808 patients opted for non-surgical treatment for BPH in the included studies. In this group, 124 were treated using phytochemicals or natural herbs, and 648 were treated with standard prescription medications. While surgical treatment for benign prostatic enlargement is shifting towards minimally invasive procedures in the developed world, open prostatectomy is still quite popular in Africa. Further research should focus not only on the reason for these disparities in management but also on the rationale for the selection of medical, surgical, or phytotherapy in African urological centres.

The global, regional, and national burden of benign prostatic hyperplasia in 204 countries and territories from 2000 to 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Benign prostatic hyperplasia is a common urological disease affecting older men worldwide, but comprehensive data about the global, regional, and national burden of benign prostatic hyperplasia and its trends over time are scarce. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we estimated global trends in, and prevalence of, benign prostatic hyperplasia and disability-adjusted life-years (DALYs) due to benign prostatic hyperplasia, in 21 regions and 204 countries and territories from 2000 to 2019.

METHODS

This study was conducted with GBD 2019 analytical and modelling strategies. Primary prevalence data came from claims from three countries and from hospital inpatient encounters from 45 locations. A Bayesian meta-regression modelling tool, DisMod-MR version 2.1, was used to estimate the age-specific, location-specific, and year-specific prevalence of benign prostatic hyperplasia. Age-standardised prevalence was calculated by the direct method using the GBD reference population. Years lived with disability (YLDs) due to benign prostatic hyperplasia were estimated by multiplying the disability weight by the symptomatic proportion of the prevalence of benign prostatic hyperplasia. Because we did not estimate years of life lost associated with benign prostatic hyperplasia, disability-adjusted life-years (DALYs) equalled YLDs. The final estimates were compared across Socio-demographic Index (SDI) quintiles. The 95% uncertainty intervals (UIs) were estimated as the 25th and 975th of 1000 ordered draws from a bootstrap distribution.

FINDINGS

Globally, there were 94·0 million (95% UI 73·2 to 118) prevalent cases of benign prostatic hyperplasia in 2019, compared with 51·1 million (43·1 to 69·3) cases in 2000. The age-standardised prevalence of benign prostatic hyperplasia was 2480 (1940 to 3090) per 100 000 people. Although the global number of prevalent cases increased by 70·5% (68·6 to 72·7) between 2000 and 2019, the global age-standardised prevalence remained stable (-0·770% [-1·56 to 0·0912]). The age-standardised prevalence in 2019 ranged from 6480 (5130 to 8080) per 100 000 in eastern Europe to 987 (732 to 1320) per 100 000 in north Africa and the Middle East. All five SDI quintiles observed an increase in the absolute DALY burden between 2000 and 2019. The most rapid increases in the absolute DALY burden were seen in the middle SDI quintile (94·7% [91·8 to 97·6]), the low-middle SDI quintile (77·3% [74·1 to 81·2]), and the low SDI quintile (77·7% [72·9 to 83·2]). Between 2000 and 2019, age-standardised DALY rates changed less, but the three lower SDI quintiles (low, low-middle, and middle) saw small increases, and the two higher SDI quintiles (high and high-middle SDI) saw small decreases.

INTERPRETATION

The absolute burden of benign prostatic hyperplasia is rising at an alarming rate in most of the world, particularly in low-income and middle-income countries that are currently undergoing rapid demographic and epidemiological changes. As more people are living longer worldwide, the absolute burden of benign prostatic hyperplasia is expected to continue to rise in the coming years, highlighting the importance of monitoring and planning for future health system strain.

FUNDING

Bill & Melinda Gates Foundation.

TRANSLATION

For the Amharic translation of the abstract see Supplementary Materials section.

Ejaculation Sparing Thulium Laser Enucleation of the Prostate: An Observational Prospective Study

Benign prostatic hypertrophy (BPH) is a condition that appears with advancing age and affects 1/3 of men over 50 years, resulting in filling and emptying symptoms. One of the main limitations of endoscopic techniques for BPH is the occurrence of retrograde ejaculation. The purpose of this prospective observational study is to evaluate the efficacy and feasibility of ejaculation-sparing thulium laser enucleation of the prostate (ES-ThuLEP) in the treatment of BPH-related LUTS and the preservation of ejaculation. Sexually active patients with BPH were enrolled and followed up with at 3, 6, and 12 months after surgery. Personal and pharmacological histories were collected, while three standardized questionnaires—the International Index of Erectile Function short form (IIEF-5), the International Consultation on Incontinence Questionnaire for Male Sexual Matters Associated with Lower Urinary Tract Symptoms Module (ICIQ—MLUTSsex), and the International Prostatic Symptom Score (IPSS)—were administered. In addition, all patients underwent uroflowmetry and an assessment of post-void residual volume (PVR). A total of 53 patients were enrolled. A statistically significant improvement in the IPSS score, maximum flow (Qmax), and post-void volume (PVR) at 3 months, 6 months, and 12 months after surgery was found (p < 0.05), while no statistically significant differences were reported between IIEF-5 scores before and after surgery. A total of 48 patients (88.6%) had preserved ejaculation at 3 months, while 92.4% and 94.3% of patients reported preserved ejaculation at 6 and 12 months, respectively. Nevertheless, some degree of hypoposia was referred, at 3, 6, and 12 months, by 43.7%, 30.6%, and 13.2% of patients, respectively. The ES-ThuLEP technique successfully preserved ejaculation in over 90% of patients, representing an ejaculation-sparing alternative in the treatment of BPH.

Improving Prostatic Preoperative Volume Estimation and Planning before Laser Enucleation

We aimed to validate a formula for improving the estimation of prostatic volume by abdominal ultrasound (AUS) prior to transurethral laser enucleation. A total of 293 patients treated for benign prostate hyperplasia (BPH) by laser enucleation from 2019−2022 were included. The preoperative AUS volume was adjusted by the formula 1.082 × Age + 0.523 × AUS − 53.845, which was based on specimens retrieved by suprapubic prostatectomy. The results were compared to the weight of the tissue removed by laser enucleation as determined by the intraclass correlation coefficient test (ICC). The potential impact of preoperative planning on operating time was calculated. The ICC between the adjusted volumes and the enucleated tissue weights was 0.86 (p < 0.001). The adjusted volume was more accurate than the AUS volume (weight-to-volume ratio of 0.84 vs. 0.7, p < 0.001) and even more precise for prostates weighing >80 g. The median operating time was 90 min. The adjusted volume estimation resulted in an overall shorter expected preoperative operating time by a median of 21 min (24%) and by a median of 40 min in prostates weighing >80 g. The adjustment formula accurately predicts prostate volume before laser enucleation procedures and may significantly improve preoperative planning, the matching of a surgeon’s level of expertise, and the management of patients’ expectations.

Development of a North American coordinated registry network for surgical treatment of benign prostatic hyperplasia

PURPOSE

To create a prospective, multicenter coordinated registry network (CRN) of robust "real world" data for benign prostatic hyperplasia (BPH) that links surgical practices to objective and subjective outcomes of patients who undergo surgery for the improvement in lower urinary tract symptoms (LUTS) secondary to BPH.

METHODS

We gathered a group of BPH experts from various institutions to identify the minimum core data elements needed to assess BPH procedures. To achieve consensus on the data elements, we used a Delphi method adaptation, in which a series of surveys were answered by the expert panel individually and anonymously. Survey results were collected and analyzed. Questions for the following round were based on response analysis from the prior survey. This process was repeated until consensus was achieved.

RESULTS

Participation rates in the first and second rounds were 100% and 90%, respectively. The expert panel reached consensus on 148 data elements out of the 182 proposed, capturing patient medical and surgical history, procedure, discharge, short- and long-term follow-up, device factors, surgery, and surgeon factors.

CONCLUSION

We have successfully developed a set of core data elements to support the study of BPH surgical therapies by gathering an expert panel on BPH and using the Delphi method. These data elements influence provider decisions about treatment and include important outcomes related to efficacy and safety.

A 40-Year Litigation Review of Transurethral Surgeries for Benign Prostatic Hyperplasia

OBJECTIVE

To describe litigation patterns of transurethral surgery in the treatment of benign prostatic hyperplasia including verdicts, types of lawsuits, plaintiff claims, and timing of the claims.

METHODS

Data was gathered by searching for litigation cases between January 1, 1980 and December 1, 2021 in the Westlaw legal database using keywords for transurethral surgeries for benign prostatic hyperplasia. Extracted data included case type, general description of the plaintiffs and defendants, plaintiff claims, and whether the claim involved preoperative, perioperative, or postoperative management, verdict, and indemnity awards.

RESULTS

The Westlaw search yielded 44 unique cases after removing duplicate and irrelevant cases. The most common surgery resulting in a lawsuit was transurethral resection of the prostate (70%) and urologists were the most frequently named defendant (80%). The most common plaintiff claims were sexual dysfunction (36%), irritative lower urinary tract symptoms (32%), and lack of consent (27%). Among malpractice cases, the verdict was in favor of the defendant in most cases (71%) and among Eighth Amendment violation cases, the verdict was in favor of the defendant in every case. The average indemnity payment was $565,845 and the highest indemnity payment was $1,020,000.

CONCLUSION

Complications of transurethral surgeries and lack of consent are common reasons for patient's filing a lawsuit. Healthcare providers should ensure patient understanding of surgical risks and thoroughly document the conversation. Providers should be aware of the causes for litigation among transurethral surgeries for benign prostatic hyperplasia and of the possibility of Eighth Amendment violation lawsuits when treating prison inmates.

Comparison of Emergency Room Visits and Rehospitalization for Bleeding Complications following Transurethral Procedures for the Treatment of Benign Prostatic Hyperplasia: A Population-Based Retrospective Cohort Study

Background: The postoperative bleeding complications associated with laser surgery of the prostate and transurethral resection of the prostate (TURP) were compared. Methods: We used the Taiwan National Health Insurance Research Database to conduct an observational population-based cohort study. All eligible patients who received transurethral procedures between January 2015 and September 2018 were enrolled. Patients who received laser surgery or TURP were matched at a ratio of 1:1 by using propensity score matching, and the association of these procedures with bleeding events was evaluated. Results: A total of 3302 patients who underwent elective transurethral procedures were included. The multivariable Cox regression analysis revealed that diode laser enucleation of the prostate (DiLEP) resulted in significantly higher emergency room risks within 90 days after surgery due to clot retention than the Monopolar transurethral resection of the prostate (M-TURP) (Hazard Ratio: 1.52; 95% Confidence Interval [CI], 1.06–2.16, p = 0.022). Moreover, GreenLight photovaporization of the prostate (PVP) (0.61; 95% CI, 0.38–1.00 p = 0.050) and thulium laser vaporesection of the prostate (ThuVARP) (0.67; 95% CI, 0.47–0.95, p = 0.024) resulted in significantly fewer rehospitalization due to clot retention than did M-TURP. No significant increase in blood clots were observed in patients using comedications and those with different demographic characteristics and comorbidities. Conclusions: Among the investigated six transurethral procedures for Benign prostatic hyperplasia, PVP and ThuVARP were safer than M-TURP because bleeding events and clot retention were less likely to occur, even in patients receiving anticoagulant or antiplatelet therapy. However, DiLEP and holmium laser enucleation of the prostate (HoLEP) did not result in fewer bleeding events than M-TURP.

Does the 5-item Frailty Index predict surgical complications of endoscopic surgical management for benign prostatic obstruction? An analysis of the ACS-NSQIP

PURPOSE

To assess whether the 5-item Frailty Index (5i-FI) predicts surgical complications of endoscopic surgery for benign prostatic obstruction (BPO) and examine the rates of these complications across BPO surgical modalities adjusting for patient frailty.

METHODS

The ACS-NSQIP registry was queried for patients who underwent transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), and laser enucleation of the prostate (LEP) between 2009 and 2019. Patients' frailties were estimated using the 5i-FI. We assessed the association between 5i-FI and the following endpoints: all complications, major complications (Clavien-Dindo ≥ 3), length of stay (LOS) ≥ 2 days, and 30-day postoperative readmission. Inverse probability of treatment weighting (IPTW) was used to account for selection bias in treatment allocation. IPTW-adjusted rates for 30-day complications were compared between surgical modalities.

RESULTS

The cohort included 38,399 (62.6%) TURP, 19,121 (31.2%) PVP, and 3797 (6.2%) LEP. Men with 5i-FI score ≥ 2 were more likely to receive TURP (22.7%) and PVP (22.5%) than LEP (18.8%). 5i-FI ≥ 2 was associated with higher odds of all complications (OR 1.50), major complications (OR 1.63), LOS ≥ 2 (OR 1.31), and readmission (OR 1.65). After IPTW, LEP had the lowest rates for all complications (6.29%; 95%CI 5.48-7.20), major complications (2.30%; 95%CI 1.83-2.89), and readmission (3.80%; 95%CI 3.18-4.53).

CONCLUSION

The 5i-FI score is an independent predictor of 30-day postoperative surgical complications after endoscopic BPO surgery. After IPTW, LEP and PVP were associated with lower rates of complications than TURP. However, frail patients were less likely to undergo PVP and LEP. Preoperative frailty assessment could improve risk stratification before BPO surgery.

The mechanism of Lingze tablets in the treatment of benign prostatic hyperplasia based on network pharmacology and molecular docking technology

Lingze tablets has been used as a drug in the treatment of kidney deficiency-dampnes shea-stasis type benign prostatic hyperplasia (BPH) in Traditional Chinese Medicine, and it was found effective for BPH treatment. We aimed to investigate the mechanism of the Lingze tablets in the treatment of BPH through the network pharmacology and molecular docking technology. The active compounds of Lingze tablets were retrieved from the TCMSP, BATMAN-TCM and ETCM databases. The ADME of active compounds was screened for Swiss target prediction, and the targets of the active compounds were predicted. DisGeNET, Genecards and OMIM were used to obtain the disease targets of BPH, and the targets of Lingze tablets in the treatment of BPH were obtained by venny2.1. String platform and cytoscape softwares were used to construct the PPI network. Go enrichment analysis and KEGG signal pathway analysis were analysed by mediascape. The 'component-target-pathway' networks diagram was constructed by the cytoscape software. Molecular docking was carried out by autodock software. Lingze tablets could serve as a drug for BPH treatment by regulating SRC, MAPK1, PIK3CA, JAK2 and other disease targets, intervening in biological processes such as cell migration, cell activity, cytokine secretion, protein phosphorylation, MAPK, transferase activity and PI3K/AKT signalling pathways.

PSA density is associated with BPH cellular composition

BACKGROUND

Current AUA guidelines recommend 5 alpha reductase inhibitor (5ARI) treatment for patients with obstructive benign prostatic hyperplasia (BPH) that display prostate volume ≥30 cc and total prostate specific antigen (PSA) ≥1.5 ng/ml. However, BPH is highly pleomorphic and response to 5ARIs is highly variable. An understanding of cellular composition based on a noninvasive PSA density test could lead to improved clinical decision making.

METHODS

The histological composition of 307 BPH specimens was scored by a pathologist for stromo-glandular content and associated with total PSA, prostate volume, PSA density and other clinical variables using univariate and multivariate linear regression.

RESULTS

The percentage of glandular composition in prostates of 5ARI-naïve men was positively and independently associated with PSA and PSA density. It was determined through statistical modeling that a PSA density ≤0.05 ng/ml2 associated with a glandular composition of ≤30% with 76% sensitivity.

CONCLUSIONS

PSA density could provide a decisive variable for estimating BPH cellular content and may eventually improve selection of patients for 5ARI treatment. Further work is needed to demonstrate that patients with higher glandular content are more responsive to 5ARI treatment.

Does MOSES Technology Enhance the Efficiency and Outcomes of Standard Holmium Laser Enucleation of the Prostate? Results of a Systematic Review and Meta-analysis of Comparative Studies

CONTEXT

Holmium laser enucleation of the prostate (HoLEP) is currently the size-independent gold standard for surgical treatment of benign prostate enlargement (BPE).

OBJECTIVE

To systematically review the current literature and compare perioperative parameters, early outcomes, and complications after HoLEP with MOSES technology LEP (MoLEP) for BPE.

EVIDENCE ACQUISITION

This study was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework using the PICOS (Patient, Intervention Comparison, Outcome, Study) model to frame the clinical question. The population was adults undergoing LEP for BPE, with standard HoLEP as the intervention and MoLEP as the comparison. The outcomes were enucleation time, surgical time, haemostasis time, energy used, hospital length of stay (LOS), recatheterisation, urethral stricture rate, and functional outcomes. The study type included randomised, prospective nonrandomised, and retrospective studies.

EVIDENCE SYNTHESIS

Seven studies were included for meta-analysis after screening. Mean enucleation time was significantly shorter for MoLEP (mean difference [MD] -7.27 min, 95% confidence interval [CI] -11.26 to -3.28; p = 0.0004). Postoperative LOS was significantly longer in the HoLEP group (MD 0.3 d, 95% CI -0.24-0.85,p<0.0001). Although not statistically significant, there was a trend for higher incidence of recatheterisation (odds ratio [OR] 1.39, 95% CI 0.47-4.09; p = 0.55) and urethral stricture (OR 1.81, 95% CI 0.45-7.37; p = 0.41) in the HoLEP group. The mean maximum peak flow favoured HoLEP (MD 0.95 ml/s, 95% CI -1.66 to 3.57; p = 0.47) and a lower mean postvoid residual volume was noted in the MoLEP group (MD -10.08 ml, 95% CI -53.54 to 33.37; p = 0.65).

CONCLUSIONS

MoLEP performed better in terms of intraoperative outcomes compared to standard HoLEP, resulting in shorter enucleation, haemostasis, and total surgical times for similar energy delivered. In addition, postoperative LOS with an early trial of catheter favours MoLEP, making it appealing as a day surgery procedure.

PATIENT SUMMARY

We reviewed the literature for early outcomes of laser treatment of the prostate for tissue removal using a MOSES system in comparison to standard treatment with a holmium laser for BPE. We found that the MOSES laser system can improve intraoperative performance, making prostate treatment a same-day discharge surgery.

Laser enucleation of the prostate in men with very large glands ≥175 ml: A systematic review

Background

Surgical treatment options for lower urinary tract symptoms can differ according to prostate size. There are few studies on the efficacy and safety of endoscopic enucleation of prostate (EEP) in patients with very large prostates focusing on laser as energy source. In this systematic review, we aimed to examine the efficacy and safety of laser-based EEP on prostate glands ≥150 ml.

Methods

A systematic search was conducted using Web of Science, PubMed-MEDLINE, Wiley Online Library and Cochrane Library databases with the following search terms solely or in combination: "large prostate", "laser enucleation", "laser prostatectomy"by combining PICO (population, intervention, comparison, and outcome) terms. Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed.

Results

We retrieved 6 studies included 375 patients with prostate sizes ≥175 ml treated with laser-based EEP for symptomatic benign prostatic obstruction. Three studies examined Holmium laser enucleation of prostate (HoLEP) outcomes with a prostate volume (PV) >200 ml, one evaluated HoLEP outcomes with a PV of 200–299 and ≥ 300 ml, two studies evaluated HoLEP outcomes with a PV > 175 ml. We observed improvement in postoperative functional outcomes in patients with a PV > 175, >200 and >300 ml. The retreatment rate was 0–1.3% in all studies involving prostate size ≥175 ml. Most of the complications were Clavien-Dindo I (%0–9) and II (%12.7–16.6).

Conclusions

Laser-based EEP is an efficient, safe and feasible procedure even in very large prostates with good functional outcomes, low perioperative complication and retreatment rates.

•

We observed better postoperative functional outcomes in prostates with a volume of ≥175, >200 and >300 ml in the present study.

•

The retreatment rate was 0–1.3% in all studies involving prostate size ≥175 ml.

•

Laser-based- endoscopic enucleation of the prostate is an efficient, safe and feasible procedure even in very large glands.

Salvage versus primary holmium laser enucleation of the prostate: trends, outcomes and safety analysis

PURPOSE

To study the safety, efficacy and trends in index procedures leading to salvage holmium laser enucleation of the prostate (S-HoLEP).

METHODS

This was a single-institution retrospective review of HoLEPs performed between 2006 and 2020. Patients who underwent S-HoLEP were compared to those undergoing primary holmium laser enucleation of the prostate (P-HoLEP). The endpoint of primary interest were functional outcomes. Changes in index procedures over the study period were analyzed.

RESULTS

A total of 633 HoLEPs were performed during the study, with 217 being S-HoLEP. The S-HoLEP cohort was older than P-HoLEP cohort, 71.2 years vs 68.8 years (p = 0.03). All other factors were well matched. The most common index procedures prior to S-HoLEP included transurethral resection of the prostate (TURP) (87, 40.1%), transurethral microwave thermotherapy (TUMT) (44, 20.3%), photoselective vaporization of the prostate (PVP) (24, 11.1%) and prostatic urethral lift (PUL) (24, 11.1%). Preoperative prostate volume, IPSS and Q_max were similar between groups. Intra-operatively, S-HoLEP had longer procedure and morcellation times (p = 0.01 and 0.007). Postoperatively, the S-HoLEP cohort had longer catheter duration and hospitalization (both p < 0.001). Postoperative Q_max, IPSS and 90-day complication rates were similar. On temporal analysis, minimally invasive surgical therapies (MIST) have become more prevalent as index procedures.

CONCLUSION

S-HoLEP is safe and efficacious for patients requiring additional BPH surgical intervention. S-HoLEP patients had longer operative times and hospital stays but equivalent postoperative functional outcomes compared to P-HoLEP. As MIST mature and gain traction, it is expected that rates of S-HoLEP will continue to rise.

Lasers for benign prostatic hyperplasia (hybrid, blue diode, TFL, Moses). Which one to choose?

PURPOSE OF REVIEW

To present the evidence of latest developments of lasers for the surgical treatment of benign prostatic hyperplasia (BPH). We focused on recent advancements in Ho:YAG laser such as Moses technology, the Thulium Fiber Laser (TFL), the blue diode laser, and hybrid laser.

RECENT FINDINGS

Laser enucleation of prostate techniques using either Ho:YAG laser with the Moses technology and Moses 2.0, or TFL seem efficient and safe compared with the standard enucleation using Ho:YAG laser. Only in vitro studies evaluated the blue diode laser and hybrid laser (combination of a continuous wave TFL and blue diode laser). Blue diode laser showed intermediate incision depth and minimal coagulation depth compared with Ho:YAG laser and Super Pulse TFL. Hybrid laser showed deep incision depth and small coagulation area compared with Ho:YAG laser and continuous wave TFL.

SUMMARY

Surgical treatment of BPH using Moses technology, Moses 2.0, and TFL shows encouraging results comparable to the standard enucleation using Ho:YAG laser. Only in vitro data are currently available for blue diode laser and hybrid laser. Future well-designed studies comparing these technologies and evaluating them on specific risk groups of patients as well as the long-term durability of outcomes are needed.

Using Haemocoagulase Agkistrodon in Patients Undergoing Transurethral Plasmakinetic Resection of the Prostate: A Pilot, Real-World, and Propensity Score-Matched Study

Objectives

To compare the clinical outcomes of using different hemostatic agents after transurethral plasmakinetic resection of the prostate (TUPKP) in benign prostatic hyperplasia (BPH) patients.

Methods

The patients were divided into 5 groups according to the hemostatic agents used after TUPKP, including the haemocoagulase agkistrodon for injection (HCA), hemocoagulase for injection (HC), hemocoagulase bothrops atrox for injection (HCB), ethylenediamine diaceturate injection (EDD), and tranexamic acid (TXA). Propensity score matching was performed based on age, body mass index, prostate volume, hypertension status, fasting blood glucose, smoking, and drinking history. The hospitalization time, bladder irrigation time, indwelling catheterization time, the patency of urine flow, and blood transfusion records were used as outcome indicators to compare the clinical effects of these five agents.

Results

We finally matched 65 pairs receiving HCA or HC, 71 pairs receiving HCA or HCB, 38 pairs receiving HCA or TXA, and 29 pairs receiving HCA or EDD. Compared with HC, HCA given during the perioperative period significantly reduced the median hospitalization time [7.00 days (5.00, 8.00) vs. 9.00 days (8.00, 10.00); p < 0.001] and median catheterization time (109.00 hours [88.00, 129.00] vs. 164.00 hours [114.00, 189.00], p < 0.001). Compared with EDD, the median hospitalization time (7.00 days [6.00, 8.00] vs. 10.00 days [8.00, 11.00]; p < 0.001) and median catheterization time (113.00 hours [95.00, 143.00] vs. 160.00 hours [139.00, 168.00]; p < 0.001) were also significant shorter in HCA group. Compared with HCB, median bladder irrigation time (45.00 hours [27.00, 71.00] vs. 49.00 hours [45.00, 72.00]; p = 0.04) was shorter in the HCA group. However, there were no statistical differences in outcomes between HCA and TXA.

Conclusions

HCA probably has an advantage over HC, HCB, and EDD in reducing the hospitalization time, catheterization time, and bladder irrigation time among BPH patients undergoing TUPKP.

Use of the penile cuff test to diagnose bladder outlet obstruction: A systematic review and meta-analysis

PURPOSE

Among noninvasive modalities for assessing bladder outlet obstruction (BOO), the penile cuff test (PCT) is the most used in clinical practice. The purpose of this review was to evaluate the performance of PCT in diagnosing and managing BOO.

MATERIALS AND METHODS

PubMed, Scopus, CINAHL, Embase, Cochrane Library, and Web of Science were searched for studies investigating use of PCT for BOO. Studies evaluating diagnostic parameters, inter-observer agreements, or treatment outcomes using PCT were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol was followed (PROSPERO ID: CRD42022300047). A proportional meta-analysis was done for diagnostic accuracy proportions. The Egger's and the Begg-Mazumdar rank-correlation tests were used to assess publication bias. Risk of bias was assessed using the Gradings of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria.

RESULTS

Of the 272 articles retrieved, 17 were included in qualitative synthesis and meta-analysis was performed on five studies (comprising 448 patients). Two studies evaluating inter-observer agreement demonstrated 95% agreement and five studies evaluating procedures reported a 66%-80% surgical success rate on obstructed patients using PCT. From the proportional meta-analysis, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 0.85 (95% CI 0.71-0.95) 0.78 (95% CI 0.67-0.87), 0.74 (95% CI 0.52-0.91), and 0.87 (95% CI 0.73-0.96), respectively. Publication bias was noted for PPV but not for sensitivity, specificity, or NPV. Based on the GRADE criteria, there were two low, six moderate, and nine high-quality studies.

CONCLUSIONS

PCT performs sufficiently in diagnosing and managing BOO. However, due to variability in obstruction criteria assessment, more studies comparing diagnostic criteria are warranted.

The Efficacy and Safety of Laser and Electrosurgical Transurethral Procedures for the Treatment of BPO in High-Risk Patients: A Systematic Review

Objective

To compare efficacy and safety outcomes of GreenLight, Holmium and Thulium laser  techniques with standard monopolar and bipolar transurethral resection of the prostate (TURP) in high-risk patients with lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO).

Methods

We conducted a systematic literature review of studies in patients undergoing BPO surgeries who may be considered high-risk for standard TURP, with higher risk defined as follows: large prostates (≥80 mL) and/or taking antithrombotic agents and/or urinary retention and/or age >80 years and/or significant comorbidity.  Outcomes summarised included bleeding complications, re-intervention rates, hospital length of stay, and standard measures of disease and symptom severity for all available timepoints.

Results

A total of 276 studies of 32,722 patients reported relevant data. Studies were heterogeneous in methodology, population and outcomes reported. IPSS reduction, Qmax improvement and PVR were similar across all interventions. Mean values at baseline and after 12 months across interventions were 13.2−29 falling to 2.3−10.8 for IPSS, 0−19 mL/s increasing to 7.5−34.1 mL/s for Qmax and 41.4−954 mL falling to 5.1−138.3 mL for PVR. Laser treatments show some advantages compared with monopolar and bipolar TURP for some adverse events and safety parameters such as bleeding complications. Duration of hospital stay, reinterventions and recatheterisations were lower with GreenLight, HoLEP, Thulium lasers, and bipolar enucleation than TURP.

Conclusions

Laser therapies are effective and well-tolerated treatment options in high-risk patients with BPO compared with monopolar or bipolar TURP. The advantageous safety profile of laser treatments means that patients with a higher bleeding risk should be offered laser surgery preferentially to mTURP or bTURP.

Standardization of the ethanolic extract of Crinum latifolium leaves by two bioactive markers with antiproliferative activity against TGF-β-promoted prostate stromal cells (WPMY-1)

BACKGROUND

Crinum latifolium L. (Amaryllidaceae) has been used in Southeast Asian traditional medicine to alleviate the symptoms of benign prostatic hyperplasia (BPH). The pathological mechanism of BPH is associated with the induction of prostate stromal cell proliferation through transforming growth factor-beta (TGF-β). Standardization as well as investigation of the potential anti-BPH activity of C. latifolium extract could benefit the further development of BPH-related analyses and provide evidence to support the application of this extract for BPH treatment. This study aimed to standardize and investigate the antiproliferative activity of the ethanolic extract of C. latifolium leaves. The major alkaloids isolated from C. latifolium were also explored for their potential use as bioactive markers.

METHODS

Two major alkaloids were isolated from the ethanolic extract of C. latifolium leaves by chromatographic techniques, identified by NMR and MS, and quantified by a validated UHPLC method. Their antiproliferative activity was studied in human prostate stromal cells (WPMY-1) induced by TGF-β. The synergistic effect of combining the two major isolated alkaloids was analyzed by the zero interaction potency (ZIP) model.

RESULTS

Two alkaloids, lycorine (1) and 6α-hydroxybuphanidrine (2), were isolated from the ethanolic leaf extract of C. latifolium. A UHPLC method for the quantification of (1) and (2) was developed and validated in terms of linearity, precision, and accuracy. The C. latifolium leaf extract contained 0.279 ± 0.003% (1) and 0.232 ± 0.004% (2). The crude extract was more potent than either (1) and (2) alone against TGF-β-treated WPMY-1 cell proliferation. The drug combination study revealed that the greatest synergistic effect of (1) and (2) was achieved at a 1:1 ratio.

CONCLUSIONS

The results of this study support the anti-BPH activity of C. latifolium in traditional medicine and suggest that these the two isolated alkaloids may promote the efficacy of the C. latifolium extract. Additionally, major alkaloids (1) and (2) can be used as bioactive markers for the standardization of C. latifolium extracts.

A Transition Towards A Faster Recovery in Single-Port Transvesical Simple Prostatectomy

Objectives To present the updated technique and evaluate the perioperative and postoperative outcomes of Single-port transvesical simple prostatectomy (SP TVSP) Patients and methods Forty-two consecutive patients with BPH indicated for surgery underwent SP TVSP in a single institution. Through direct suprapubic bladder access, the single-port (SP) robot was docked. Prostatic enucleation was performed using the prostatic capsule as a landmark. Then a complete vesicourethral mucosal advancement flap was accomplished. Demographics, perioperative and postoperative data were prospectively collected. Mean follow-up period was 12 months. Results All procedures were successfully performed with no conversion, additional port placement or intraoperative complication. The median prostatic volume was 170cc. 95% of the patients did not require opioids analgesia after discharge. Excluding planned admissions, 92% (21/23 patients) were discharged after a median (IQR) of 4.6 (4.1-5.7) hours after the surgery. The median Foley catheter duration for all cohort was 7 days, decreased to 3 days after technique adjustment for the last 19 consecutive patients. The median IPSS score decreased from 23 before the surgery to 2.5 after the surgery. All patients had a significant postoperative improvement in maximum flow rate with a 200% improvement over baseline (19 vs. 6.5 mL/sec). Conclusion In our initial series, SP TVSP allows for favorable perioperative and early postoperative outcomes including low complication same-day discharge, short Foley catheter stay, minimal opioids use and quick recovery.

Prostatic artery embolization in men with severe hemophilia a: a case report of two patients

Background

This is the first case report describing the peri- and postoperative hemostasis plans in two men with severe hemophilia A (HA) who underwent prostatic artery embolization (PAE) for symptomatic benign prostatic hyperplasia (BPH).

Case presentation

Two patients with severe HA and lower urinary tract symptoms (LUTS) not responding to medical therapy underwent PAE at our institution. In both patients, intermittent administration of decreasing doses of extended half-life recombinant factor VIII (EHL rFVIII) concentrate from 30 min before to 7 days after the PAE resulted in good hemostatic control. In addition to EHL rFVIII, tranexamic acid was administered in the same timeframe to augment the action of EHL rFVIII and to account for possible mucosal bleeding from the urinary tract. Both patients reported a minor localized hematoma at the femoral puncture site in the right groin, that resolved spontaneously. No other bleeding complications were observed.

Conclusions

The procoagulant effects of the chosen dosing of EHL rFVIII showed sufficient to perform a technically successful embolization. At 6 months follow-up, both patients had significant reduction in self-reported urinary symptoms and were content with the outcome.

A comprehensive analysis of clinical, quality of life, and cost-effectiveness outcomes of key treatment options for benign prostatic hyperplasia

Treatment options for men with moderate-to-severe lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) have variable efficacy, safety, and retreatment profiles, contributing to variations in patient quality of life and healthcare costs. This study examined the long-term cost-effectiveness of generic combination therapy (CT), prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), photoselective vaporization of the prostate (PVP), and transurethral resection of the prostate (TURP) for the treatment of BPH. A systematic literature review was performed to identify clinical trials of CT, PUL, WVTT, PVP, and TURP that reported change in International Prostate Symptom Score (IPSS) for men with BPH and a prostate volume ≤80 cm³. A random-effects network meta‐analysis was used to account for the differences in patient baseline clinical characteristics between trials. An Excel-based Markov model was developed with a cohort of males with a mean age of 63 and an average IPSS of 22 to assess the cost-effectiveness of these treatment options at 1 and 5 years from a US Medicare perspective. Procedural and adverse event (AE)-related costs were based on 2021 Medicare reimbursement rates. Total Medicare costs at 5 years were highest for PUL ($9,580), followed by generic CT ($8,223), TURP ($6,328), PVP ($6,152), and WVTT ($2,655). The total cost of PUL was driven by procedural ($7,258) and retreatment ($1,168) costs. At 5 years, CT and PUL were associated with fewer quality-adjusted life years (QALYs) than WVTT, PVP, and TURP. Compared to WVTT, the incremental cost-effectiveness ratios (ICERs) for both TURP and PVP were above a willingness-to-pay threshold of $50,000/QALY (TURP: $64,409/QALY; PVP: $87,483/QALY). This study provides long-term cost-effectiveness evidence for several common treatment options for men with BPH. WVTT is an effective and economically viable treatment in resource-constrained environments.

Does a 55-year-old Male with Lower Urinary Tract Symptoms and a 50-ml Gland Have To Decide Between Ejaculation and Voiding Function?

Treatment of lower urinary tract symptoms secondary to benign prostatic obstruction may affect ejaculatory function. However, preservation of ejaculation via minimally invasive surgical therapies might impair the long-term durability of voiding improvement.

Clinical practice guideline for transurethral plasmakinetic resection of prostate for benign prostatic hyperplasia (2021 Edition)

Benign prostatic hyperplasia (BPH) is highly prevalent among older men, impacting on their quality of life, sexual function, and genitourinary health, and has become an important global burden of disease. Transurethral plasmakinetic resection of prostate (TUPKP) is one of the foremost surgical procedures for the treatment of BPH. It has become well established in clinical practice with good efficacy and safety. In 2018, we issued the guideline "2018 Standard Edition". However much new direct evidence has now emerged and this may change some of previous recommendations. The time is ripe to develop new evidence-based guidelines, so we formed a working group of clinical experts and methodologists. The steering group members posed 31 questions relevant to the management of TUPKP for BPH covering the following areas: questions relevant to the perioperative period (preoperative, intraoperative, and postoperative) of TUPKP in the treatment of BPH, postoperative complications and the level of surgeons' surgical skill. We searched the literature for direct evidence on the management of TUPKP for BPH, and assessed its certainty generated recommendations using the grade criteria by the European Association of Urology. Recommendations were either strong or weak, or in the form of an ungraded consensus-based statement. Finally, we issued 36 statements. Among them, 23 carried strong recommendations, and 13 carried weak recommendations for the stated procedure. They covered questions relevant to the aforementioned three areas. The preoperative period for TUPKP in the treatment of BPH included indications and contraindications for TUPKP, precautions for preoperative preparation in patients with renal impairment and urinary tract infection due to urinary retention, and preoperative prophylactic use of antibiotics. Questions relevant to the intraoperative period incorporated surgical operation techniques and prevention and management of bladder explosion. The application to different populations incorporating the efficacy and safety of TUPKP in the treatment of normal volume (< 80 ml) and large-volume (≥ 80 ml) BPH compared with transurethral urethral resection prostate, transurethral plasmakinetic enucleation of prostate and open prostatectomy; the efficacy and safety of TUPKP in high-risk populations and among people taking anticoagulant (antithrombotic) drugs. Questions relevant to the postoperative period incorporated the time and speed of flushing, the time indwelling catheters are needed, principles of postoperative therapeutic use of antibiotics, follow-up time and follow-up content. Questions related to complications incorporated types of complications and their incidence, postoperative leukocyturia, the treatment measures for the perforation and extravasation of the capsule, transurethral resection syndrome, postoperative bleeding, urinary catheter blockage, bladder spasm, overactive bladder, urinary incontinence, urethral stricture, rectal injury during surgery, postoperative erectile dysfunction and retrograde ejaculation. Final questions were related to surgeons' skills when performing TUPKP for the treatment of BPH. We hope these recommendations can help support healthcare workers caring for patients having TUPKP for the treatment of BPH.

Prostatic arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia

BACKGROUND

A variety of minimally invasive surgical approaches are available as an alternative to transurethral resection of the prostate (TURP) for management of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). Prostatic arterial embolization (PAE) is a relatively new, minimally invasive treatment approach.

OBJECTIVES

To assess the effects of PAE compared to other procedures for treatment of LUTS in men with BPH.

SEARCH METHODS

We performed a comprehensive search the Cochrane Library, MEDLINE, Embase, three other databases, trials registries, other sources of grey literature, and conference proceedings with no restrictions on language of publication or publication status, up to 8 November 2021.

SELECTION CRITERIA

We included parallel-group randomized controlled trials (RCTs), as well as non-randomized studies (NRS, limited to prospective cohort studies with concurrent comparison groups) enrolling men over the age of 40 years with LUTS attributed to BPH undergoing PAE versus TURP or other surgical interventions.  DATA COLLECTION AND ANALYSIS: Two review authors independently classified studies for inclusion or exclusion and abstracted data from the included studies. We performed statistical analyses by using a random-effects model and interpreted them according to the Cochrane Handbook for Systematic Reviews of Interventions. We used GRADE guidance to rate the certainty of evidence of RCTs and NRSs.  MAIN RESULTS: We found data to inform two comparisons: PAE versus TURP (six RCTs and two NRSs), and PAE versus sham (one RCT). Mean age was 66 years, International Prostate Symptom Score (IPSS) was 22.8, and prostate volume of participants was 72.8 mL. This abstract focuses on the comparison of PAE versus TURP as the primary topic of interest. Prostatic arterial embolization versus transurethral resection of the prostate We included six RCTs and two NRSs with short-term (up to 12 months) follow-up, and two RCTs and one NRS with long-term follow-up (13 to 24 months).  Short-term follow-up: based on RCT evidence, there may be little to no difference in urologic symptom score improvement measured by the International Prostatic Symptom Score (IPSS) on a scale from 0 to 35, with higher scores indicating worse symptoms (mean difference [MD] 1.72, 95% confidence interval [CI] -0.37 to 3.81; 6 RCTs, 360 participants; I² = 78%; low-certainty evidence). There may be little to no difference in quality of life as measured by the IPSS-quality of life question on a scale from 0 to 6, with higher scores indicating worse quality of life between PAE and TURP, respectively (MD 0.28, 95% CI -0.28 to 0.84; 5 RCTs, 300 participants; I² = 63%; low-certainty evidence). While we are very uncertain about the effects of PAE on major adverse events (risk ratio [RR] 0.75, 95% CI 0.19 to 2.97; 4 RCTs, 250 participants; I² = 24%; very low-certainty evidence), PAE likely increases retreatments (RR 3.20, 95% CI 1.41 to 7.27; 4 RCTs, 303 participants; I² = 0%; moderate-certainty evidence). PAE may make little to no difference in erectile function measured by the International Index of Erectile Function-5 on a scale from 1 to 25, with higher scores indicating better function (MD -0.50 points, 95% CI -5.88 to 4.88; 2 RCTs, 120 participants; I² = 68%; low-certainty evidence). Based on NRS evidence, PAE may reduce the occurrence of ejaculatory disorders (RR 0.51, 95% CI 0.35 to 0.73; 1 NRS, 260 participants; low-certainty evidence). Long-term follow-up: based on RCT evidence, PAE may result in little to no difference in urologic symptom scores (MD 2.58 points, 95% CI -1.54 to 6.71; 2 RCTs, 176 participants; I² = 73%; low-certainty evidence) and quality of life (MD 0.50 points, 95% CI -0.03 to 1.04; 2 RCTs, 176 participants; I² = 29%; low-certainty evidence). We are very uncertain about major adverse events (RR 0.91, 95% CI 0.20 to 4.05; 2 RCTs, 206 participants; I² = 72%; very low-certainty evidence). PAE likely increases retreatments (RR 3.80, 95% CI 1.32 to 10.93; 1 RCT, 81 participants; moderate-certainty evidence). While PAE may result in little to no difference in erectile function (MD 3.09 points, 95% CI -0.76 to 6.94; 1 RCT, 81 participants; low-certainty evidence), PAE may reduce the occurrence of ejaculatory disorders (RR 0.67, 95% CI 0.45 to 0.98; 1 RCT, 50 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Compared to TURP, PAE may provide similar improvement in urologic symptom scores and quality of life. While we are very uncertain about major adverse events, PAE likely increases retreatment rates. While erectile function may be similar, PAE may reduce ejaculatory disorders. Certainty of evidence for the outcomes of this review was low or very low except for retreatment (moderate-certainty evidence), signaling that our confidence in the reported effect size is limited or very limited, and that this topic should be better informed by future research.

Efficacy and Safety of the Sandwich Method in Patients with Benign Prostate Hyperplasia: Bipolar Transurethral Resection with GreenLight Vaporization

Benign prostate hyperplasia (BPH) refers to the nonmalignant enlargement of the transition zone of the prostate gland. While holmium laser enucleation of the prostate and open simple prostatectomy are effective in the management of patients with large prostates, they have some limitations. Thus, this study aimed to analyze the efficacy and safety of the sandwich method of bipolar transurethral resection of the prostate (B-TURP) and GreenLight photoselective vaporization of the prostate (GLPVP) in patients with large prostates. Patients diagnosed with BPH who underwent the sandwich method with B-TURP and GLPVP from 2015 to 2020 were included. Efficacy analyses included the change in the uroflowmetry results in both group A (prostate volume < 80 g) and group B (prostate volume ≥ 80 g), and complication analyses included perioperative complications, early postoperative complications at three months and late postoperative complications at 12 months. The cohort comprised 188 and 44 patients in groups A and B, respectively. The prostate volume of groups A and B were 50.83 ± 14.14 g and 102.03 ± 19.36 g (p < 0.001), respectively. The peak (Qmax) and average (Qavg) flow rates were comparable between the two groups. The only significant difference noted was in the postoperative post-void residual (PVR) urine. Improvement was seen in all the variables including the Qmax, Qavg and PVR urine in each group. No patient experienced perioperative complications. Analysis of the overall one-year complication rate showed no significant difference between the two groups. The sandwich method of B-TURP and GLPVP may be feasible for the management of patients with large prostate.

Long-Term Risk of Surgery Following First Diagnosis of Benign Prostatic Hyperplasia in Middle-Aged Men

Objective

Pharmacotherapy is often used to relieve lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), yet surgery may be indicated for persistent bothersome symptoms. BPH is common among older men, yet the burden of BPH among middle-aged men may be under-recognized. This study examined the 5-year risk of BPH surgery among middle-aged men following the first BPH diagnosis.

Methods

Using the IBM MarketScan Commercial Claims and Encounters Database, males aged 35 to 64 years with a first-time primary diagnosis of BPH who were prescribed oral medication for LUTS were identified. The primary outcome was the risk of BPH surgery within five years of the first BPH diagnosis, which was analyzed using Kaplan-Meier methods. The influence of patient demographics, comorbidities, and medication use on the risk of BPH surgery was explored using a Cox proportional hazards model. 

Results

Four thousand five hundred ten eligible men, 460 underwent BPH surgery within five years of BPH diagnosis. The most common surgical procedures were transurethral resection of the prostate and laser enucleation. The risk of BPH surgery over five years following BPH diagnosis was 10.2% (95% CI: 9.4% to 11.1%). In a multivariable Cox proportional hazards regression analysis, patient age was the primary factor associated with higher surgery risk. Compared to men aged 35 to 44 years, the hazard ratio for BPH surgery was 3.9 (95% CI: 1.9 to 8.4; p<0.001) among men aged 45 to 54 years, and 5.0 (95% CI: 2.4 to 10.6; p<0.001) among men aged 55 to 64 years.

Conclusions

In middle-aged men prescribed oral medication for LUTS secondary to BPH, the risk of BPH surgery was 10.2% over five years. This risk may be underappreciated and highlights the clinical need for surgical procedures with favorable risk-to-benefit profiles.

Anatomical endoscopic enucleation of bladder outlet obstruction

Anatomical endoscopic enucleation of the prostate (AEEP) differs from other endoscopic modalities for bladder outlet obstruction (BOO) because it extracts the whole benign prostatic hyperplasia component. AEEP has been launched for almost 40 years as a first-line treatment method for BOO regardless of prostate size according to several guidelines. However, it remains underperformed worldwide. In this review article, we elaborate on the advantages and disadvantages of AEEP compared to other surgical modalities for BOO to investigate its efficacy and safety as a gold standard surgical management option for males with BOO.

Holmium Laser Enucleation of the Prostate Efficiency by Prostate Gland Size: Is There a Sweet Spot?

Holmium laser enucleation of the prostate (HoLEP) is one of only two AUA guideline-recommended prostate size-independent surgeries for benign prostate hyperplasia (BPH). The significant variation in gland size treated results in a wide range of enucleation and morcellation times. We sought to understand the effect of prostate size on HoLEP efficiency to better educate patients and improve operative room utilization. After IRB approval, we identified patients from 1 July 2016 to 1 January 2020 who underwent HoLEP by two endourologists. Our primary objectives were to assess the effects of increasing increments (25 g) of mean enucleated prostate tissue weight on enucleation and morcellation efficiency (g/min). One-way Kruskal–Wallis ANOVA with Dunn’s post hoc test was used, with significant p < 0.05. We included 675 HoLEPs with all comers mean tissue weight resected of 72.1 g (Range 1–448 g), energy used 110.00 kJ (10.73–340 kJ), enucleation time 48.6 min (5–151 min), and morcellation time 10.1 min (0.5–113 min). Average enucleation efficiency increased with increasing prostate size categories (e.g., <25 g–0.48 g/min, >325 g–3.91 g/min) (K-W ANOVA p = 0.004, Dunn’s post hoc p = 0.004). The combined average enucleation and morcellation efficiency was ≥5 g/min between 55 and 271 g. Inefficiency for cases <55 g was driven by enucleation, while >271 g case inefficiency was driven by morcellation. Increasing tissue weight at the time of HoLEP is associated with a linear relationship of increasing enucleation and decreasing morcellation efficiencies.

Effects of Cytochrome P450 and Transporter Polymorphisms on the Bioavailability and Safety of Dutasteride and Tamsulosin

Dutasteride and tamsulosin are one of the first-line combination therapies for the management of benign prostatic hyperplasia (BPH). Despite being more effective than monotherapies, they produce frequent adverse drug reactions (ADRs). Institutions such as Food and Drug Administration and European Medicines Agency recommend precaution with CYP2D6 poor metabolizers (PMs) that receive CYP3A4 inhibitors and tamsulosin. However, no specific pharmacogenetic guideline exists for tamsulosin. Furthermore, to date, no pharmacogenetic information is available for dutasteride. Henceforth, we studied the pharmacokinetics and safety of dutasteride/tamsulosin 0.5 mg/0.4 mg capsules according to 76 polymorphisms in 17 candidate pharmacogenes. The study population comprised 79 healthy male volunteers enrolled in three bioequivalence, phase-I, crossover, open, randomized clinical trials with different study designs: the first was single dose in fed state, the second was a single dose in fasting state, and the third was a multiple dose. As key findings, CYP2D6 PMs (i.e., *4/*4 and *4/*5 subjects) and intermediate metabolizers (IMs) (i.e., *1/*4, *1/*5, *4/*15 individuals) presented higher AUC (p = 0.004), higher t_1/2 (p = 0.008), and lower Cl/F (p = 0.006) when compared with NMs (*1/*1 individuals) and UMs (1/*1 × 2 individuals) after multiple testing correction. Moreover, fed volunteers showed significantly higher t_max than fasting individuals. Nominally significant associations were observed between dutasteride exposure and CYP3A4 and CYP3A5 genotype and between tamsulosin and ABCG2, CYP3A5, and SLC22A1 genotypes. No association between the occurrence of adverse drug reactions and genotype was observed. Nonetheless, higher incidence of adverse events was found in a multiple-dose clinical trial. Based on our results, we suggest that dose adjustments for PMs and UMs could be considered to ensure drug safety and effectiveness, respectively. Further studies are warranted to confirm other pharmacogenetic associations.

Prostatic arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia

BACKGROUND

A variety of minimally invasive surgical approaches are available as an alternative to transurethral resection of the prostate (TURP) for management of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). Prostatic arterial embolization (PAE) is a relatively new, minimally invasive treatment approach.

OBJECTIVES

To assess the effects of PAE compared to other procedures for treatment of LUTS in men with BPH.

SEARCH METHODS

We performed a comprehensive search using multiple databases (The Cochrane Library, MEDLINE, Embase, LILACS, Scopus, Web of Science, and Google Scholar), trials registries, other sources of grey literature, and conference proceedings with no restrictions on language of publication or publication status, up until 25 September 2020.

SELECTION CRITERIA

We included parallel-group randomized controlled trials (RCTs), as well as non-randomized studies (NRS, limited to prospective cohort studies with concurrent comparison groups) enrolling men over the age of 40 with LUTS attributed to BPH undergoing PAE versus TURP or other surgical interventions.  DATA COLLECTION AND ANALYSIS: Two review authors independently classified studies for inclusion or exclusion and abstracted data from the included studies. We performed statistical analyses by using a random-effects model and interpreted them according to the Cochrane Handbook for Systematic Reviews of Interventions. We used GRADE guidance to rate the certainty of evidence of RCTs and NRSs.  MAIN RESULTS: We found data to inform two comparisons: PAE versus TURP (six RCTs and two NRSs), and PAE versus sham (one RCT). Mean age, IPSS, and prostate volume of participants were 66 years, 22.8, and 72.8 mL, respectively. This abstract focuses on the comparison of PAE versus TURP as the primary topic of interest. PAE versus TURP We included six RCTs and two NRSs with short-term (up to 12 months) follow-up and one RCT with long-term follow-up (13 to 24 months).  Short-term follow-up: based on RCT evidence, there may be little to no difference in urologic symptom score improvement (mean difference [MD] 1.55, 95% confidence interval [CI] -0.40 to 3.50; 369 participants; 6 RCTs; I² = 75%; low-certainty evidence) measured by the International Prostatic Symptom Score (IPSS) on a scale from 0 to 35, with higher scores indicating worse symptoms. There may be little to no difference in quality of life (MD 0.16, 95% CI -0.37 to 0.68; 309 participants; 5 RCTs; I² = 56%; low-certainty evidence) as measured by the IPSS quality of life question on a scale from 0 to 6, with higher scores indicating worse quality of life between PAE and TURP, respectively. While we are very uncertain about the effects of PAE on major adverse events (risk ratio [RR] 0.71, 95% CI 0.16 to 3.10; 250 participants; 4 RCTs; I² = 26%; very low-certainty evidence), PAE may increase re-treatments (RR 3.64, 95% CI 1.02 to 12.98; 204 participants; 3 RCTs; I² = 0%; low-certainty evidence). Based on 18 re-treatments per 1000 men in the TURP group, this corresponds to 47 more (0 more to 214 more) per 1000 men undergoing PAE.   We are very uncertain about the effects on erectile function (MD -0.03, 95% CI -6.35 to 6.29; 129 participants; 2 RCTs; I² = 78%; very low-certainty evidence) measured by the International Index of Erectile Function at 5 on a scale from 1 to 25, with higher scores indicating better function. NRS evidence when available yielded similar results. Based on evidence from NRS, PAE may reduce the occurrence of ejaculatory disorders (RR 0.51, 95% CI 0.35 to 0.73; 260 participants; 1 NRS; low-certainty evidence). Longer-term follow-up: based on RCT evidence, we are very uncertain about the effects of PAE on urologic symptom scores (MD 0.30, 95% CI -3.17 to 3.77; 95 participants; very low-certainty evidence) compared to TURP. Quality of life may be similar (MD 0.20, 95% CI -0.49 to 0.89; 95 participants; low-certainty evidence). We are also very uncertain about major adverse events (RR 1.96, 95% CI 0.63 to 6.13; 107 participants; very low-certainty evidence). We did not find evidence on erectile function and ejaculatory disorders. Based on evidence from NRS, PAE may increase re-treatment rates (RR 1.51, 95% CI 0.43 to 5.29; 305 participants; low-certainty evidence); based on 56 re-treatments per 1000 men in the TURP group. this corresponds to 143 more (25 more to 430 more) per 1000 men in the PAE group.  AUTHORS' CONCLUSIONS: Compared to TURP up to 12 months (short-term follow-up), PAE may provide similar improvement in urologic symptom scores and quality of life. While we are very uncertain about major adverse events, PAE may increase re-treatment rates. We are uncertain about erectile function, but PAE may reduce ejaculatory disorders. Longer term (follow-up of 13 to 24 months), we are very uncertain as to how both procedures compare with regard to urologic symptom scores, but quality of life appears to be similar. We are very uncertain about major adverse events but PAE may increase re-treatments. We did not find longer term evidence on erectile function and ejaculatory disorders. Certainty of evidence for the main outcomes of this review was low or very low, signalling that our confidence in the reported effect size is limited or very limited, and that this topic should be better informed by future research.