Comparison between open simple prostatectomy and green laser enucleation of the prostate for treating large benign prostatic hyperplasia: a single-centre experience

Outcomes of holmium laser enucleation of the prostate (HoLEP) for very large-sized benign prostatic hyperplasia (over 150 mL): open simple prostatectomy is dead

INTRODUCTION

Our study aimed to describe the outcomes of transurethral enucleation of the prostate (HoLEP) for large-sized benign prostatic hyperplasia over 150 mL (bBPH).

METHODS

We conducted a retrospective, descriptive, and analytical study of patients undergoing HoLEP for bBPH. The primary endpoint was the success of the procedure, defined by a mixed criteria: complete endoscopic enucleation of the prostate, absence of blood transfusion or reoperation for bleeding, post-operative improvement of quality of life (assessed by a ≥ 2 points increase at in the 8th question of the IPSS test) and post-operative continence (no pads use) at 3 months.

RESULTS

Eighty-one patients were included with a mean age of 73.9 ± 7.3 and a mean measured prostate volume of 183.3 ± 34.5 cc. The mean operative time was 57.5 ± 29.7 min and the average wet weight of resected tissue removed was 151.8 ± 44.7 g. Mean hospitalization stay was 1.3 ± 0.7 days with a mean post-operative catheterization period of 1.9 ± 0.9 days. The success of the surgery was achieved in 77 patients (95%). Functional improvements were found at 1 and 6 months for Qmax, post-void residual, IPSS and QoL-IPSS. The 30-day complication rate was 9.9%. The average PSA level dropped from 14.8 ± 11.6 ng/mL at baseline to 0.8 ± 0.5 ng/mL at 6 months.

CONCLUSION

HoLEP for bBPH is both safe and efficient. Regarding the benefit/risk balance, it should be highlighted as the gold standard for the management of big BPH.

Photoselective sharp enucleation of the prostate with a front-firing 532-nm laser versus photoselective vaporization of the prostate in the treatment of benign prostatic hyperplasia: a randomised controlled trial with 1-year followup results

BACKGROUND

We designed a new surgical procedure to treat benign prostatic hyperplasia(BPH). In order to verify its effectiveness and safety, we constructed this randomized controlled trial to compare the efficacy of our innovative enucleation technique- photoselective sharp enucleation of the prostate (PSEP), with a front-firing 532-nm laser and the traditional technique-photoselective vaporization of the prostate (PVP) in the treatment of BPH.

METHODS

A total of 154 consecutive patients diagnosed with bladder outlet obstruction secondary to BPH in our center from June 2018 to April 2019 were randomly divided into the PSEP group (n = 77) and the PVP group (n = 77) and were treated surgically with either PSEP or PVP. All patients were assessed preoperatively and followed up at 1, 6, and 12 months postoperatively. The international prostate symptom score,quality-of-life score, postvoid residual urine volume, maximum urine flow rate, prostate volume, prostate-specific antigen, and adverse events were compared.

RESULTS

The lower urinary tract symptoms in both groups were significantly improved compared with the baseline at 1, 6, and 12 months postoperatively. The PSEP and PVP groups had an equivalent International Prostate Symptom Score, quality-of-life score, postvoid residual urine volume, maximum urine flow rate, prostate-specific antigen at each follow-up (P > 0.05). The median operative time in the PSEP group was significantly shorter than that in the PVP group (35 min vs. 47 min, P < 0.001). At 6 and 12 months after surgery, the median PV in the PSEP group was smaller than that in the PVP group (P < 0.05). Complication rates were comparable between the groups.

CONCLUSION

Both PSEP and PVP can achieve good efficacy and safety in the treatment of BPH. PSEP can remove more tissue than PVP and is associated with higher efficiency. In addition, PSEP eliminates the problem of lack of tissue samples associated with PVP.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, identifie:ChiCTR1800015867, date:25/04/2018.

Comparison of the efficacy and safety of transurethral laser versus open prostatectomy for patients with large-sized benign prostatic hyperplasia: A meta-analysis of comparative trials

PURPOSE

The selection of open prostatectomy (OP) over transurethral laser surgery is controversial for large volume prostates. Thus, we aim to compare the efficacy and safety of transurethral laser versus OP, and provide the latest evidence of clinical practice for large-sized benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

This meta-analysis used Review Manager V5.3 software and the systematic literature search of Cochrane Library, Embase, PubMed, and Web of Science datasets was performed for citations published from 2000 to 2020 that compared transurethral laser with OP for the treatment of large BPH. Variables of interest assessing the two techniques included clinical characteristics, and the perioperation-, effectiveness-, and complication-related outcomes.

RESULTS

The meta-analysis included twelve studies containing 1,514 patients, with 792 laser and 722 OP. The transurethral laser group was associated with shorter hospital stay and catheterization duration, and less hemoglobin decreased in the perioperative variables. There was no significant difference in the international prostate symptom score, post-void residual urine volume, maximum flow rate, and quality of life score. Transurethral laser group had a significantly lower incidence of blood transfusion than OP group (odds ratio, 0.10; 95% confidence interval, 0.05 to 0.19; p<0.001; I²=8%), and no statistical differences were found with respect to the other complications.

CONCLUSIONS

Both OP and transurethral laser prostatectomy are effective and safe treatments for large prostate adenomas. With these advantages of less blood loss and transfusion, and shorter catheterization time and hospital stay, laser may be a better choice for large BPH.

From open simple to robotic-assisted simple prostatectomy (RASP) for large benign prostate hyperplasia: the time has come

PURPOSE

Robotic-assisted simple prostatectomy (RASP) has recently been studied as an alternative to open simple prostatectomy or endoscopic treatment options. At present, there is no defined recommendation for a robotic procedure as a standard surgical technique to treat large benign prostate hyperplasia.

METHODS

Several robotic techniques have been described since 2007. Contemporaneously, multiple endoscopic enucleation techniques have been proposed. Nevertheless, open simple prostatectomy still remains a mainstay of therapy. We aimed to evaluate the development of robotic-assisted prostatectomy for large benign prostatic obstruction, thus comparing the technical aspects and clinical outcomes with open and endoscopic enucleation.

RESULTS

Robotic-assisted simple prostatectomy provides significantly less blood loss and shorter hospital stay but longer operative time compared to open simple prostatectomy. Compared to endoscopic treatments, robotic approaches have a similar perioperative outcome, but cause less urethral trauma or potential bladder neck strictures. Moreover, concomitant bladder pathologies can be treated within the same setting.

CONCLUSION

Robotic-assisted simple prostatectomy is an effective and safe technique, and can hence be considered to become the preferred first-line therapy to treat patients with obstructive large prostate glands.

Green Light laser enucleation of the prostate with early apical release is safe and effective: single center experience and revision of the literature

BACKGROUND

Green Light laser enucleation of the prostate (GreenLEP) is an endoscopic treatment to treat bladder outlet obstruction in men with large prostate (>100 cc). Herein, we describe our GreenLEP series and describe its safety and efficacy.

METHODS

Between February 2014 and April 2019, 120 patients from a single center underwent en-bloc GreenLEP with early apical release. All procedures were performed with the AMS XPS laser generator (set: 120 W for vaporization and 20 W for coagulation). Morcellation was carried out with the Wolf Piranha morcellator. Data concerning the pre-, intra- and postoperative outcomes were prospectively collected. The follow-up data at 6, 12 months and at the last control were collected.

RESULTS

The median age was 66.0 (IQR: 61.0-71.0) years; 37.5% of the patients were under antiplatelet/anticoagulant therapy, 15.0% had indwelling catheter history. The median prostate volume and the baseline PSA value were 98.5ml (IQR 83.0-130.0) and 4.2ng/ml (IQR: 3.2-6.8), respectively. The median operative and lasing time were 65.0 (IQR: 51.0-83.5) and 6.0 (IQR: 6.0-10.0) minutes, respectively. In the post-operative period 1 patient was transfused. The median follow-up was 18.0 (IQR: 12.0-39.5) months. All patients had significant improvement in terms of improvement of uroflowmetry [median from 9ml/sec (IQR 7.8, 11.0) to 20.0 (IQR 18.0, 22.0), p <0.001] and symptoms control [IPSS median score from 26.0ml/sec (IQR 22.0, 28.0) to 7.0 (IQR 6.0, 8.0), p <0.001]) over time. After 12 months 1 patient complained of stress incontinence (1 pad/day) and 1 of "de novo" wet urgency.

CONCLUSIONS

En-bloc GreenLEP with early apical release is a safe and effective procedure even for large volume prostates. It allows us to limit the use of laser energy and shorten the operating times with stable and satisfactory long-term outcomes.

Recent evidence for anatomic endoscopic enucleation of the prostate (AEEP) in patients with benign prostatic obstruction on antiplatelet or anticoagulant therapy

INTRODUCTION

Due to demographic changes in today's society, the number of patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) is increasing. Similarly, the proportion of patients with cardiovascular risk factors undergoing antiplatelet (AP) or anticoagulation (AC) therapy is growing as well.

METHODS

This review discusses the current literature on various techniques used for anatomic endoscopic enucleation of the prostate (AEEP) in patients on AC/AP therapy.

RESULTS

The large number of energy sources used for AEEP makes it difficult to compare them. Overall, fewer bleeding-associated complications arise in patients under AP compared to AC or bridging therapy with low molecular weight heparin. However, perioperatively both AP and AC therapy lead to a higher risk of bleeding complications compared to patients not taking anticoagulants.

CONCLUSIONS

The literature shows that AEEP is possible and efficacious in patients under AC/AP therapy, with only slight differences compared to patients not taking AC/AP drugs, on a short and long-term basis. Nevertheless, the sparse data, the retrospective nature of many studies and the inclusion of prostate sizes between 50 and 110 ml only, make it difficult to come to strong conclusions.

Propensity-score analysis comparing perioperative and functional outcomes between XPS 180 W-photovaporization and GreenLight laser enucleation of the prostate: reasons to discard vaporization and move to enucleation

PURPOSE

To compare the perioperative and functional outcomes between 180_W XPS GreenLight photoselective vaporization (PVP) and 532-nm GreenLight laser enucleation of the prostate (GreenLEP) in the surgical management of benign prostatic obstruction (BPO).

METHODS

Retrospective review of a prospectively maintained international database of patients managed with GreenLight laser surgery (PVP or GreenLEP) was performed. To adjust for potential baseline confounders, propensity-score matching (PSM) was applied at a ratio of 1:1 to compare the perioperative and functional outcomes between the groups.

RESULTS

A total of 2,420 patients were included. 1,491 (61.6%) underwent PVP and 929 (38.4%) underwent GreenLEP. Before PSM analysis, patients in the vaporization group were older (p < 0.001), had a lower PSA and prostate volume at baseline (p < 0.001). Using estimated propensity scores, 78 patients in the PVP group were matched 1:1 to the patients in the GreenLEP group. The incidence of overall postoperative complications was comparable between the two groups (19 vs. 16%, p = 0.06). However, after PSM, PVP was found to be associated with a higher rate of overall complications (33 vs. 11%, p = 0.001). At 3 months and at last follow-up the I-PSS, Qmax and PSA had similarly decreased in the two groups with a greater improvement in the GreenLEP group (all p < 0.05).

CONCLUSIONS

PVP and GreenLEP are two efficient and safe techniques for treating BPO. However, PVP was associated with longer operative time and higher risk of reoperation on a midterm follow-up compared to GreenLEP.

[Surgical and interventional management of benign prostatic obstruction: Guidelines from the Committee for Male Voiding Disorders of the French Urology Association]

OBJECTIVE

The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO).

METHODS

All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions.

RESULTS/GUIDELINES

Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm³, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm³. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm³. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm³ without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols.

CONCLUSION

Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.

Photoselective sharp enucleation of the prostate with a front-firing 532-nm laser: an innovative surgical technique for benign prostatic hyperplasia-a single-center study of 475 cases

PURPOSE

To describe the novel technique of photoselective sharp enucleation of the prostate (PSEP) with a front-firing 532-nm laser and evaluate its efficacy and safety.

METHODS

A seven-step standardized surgical procedure was established, and PSEP was performed in an en bloc or lobulate manner according to the size of the middle lobe of the prostate. The following clinical data of 583 patients who underwent PSEP in our center from November 2016 to May 2018 were retrospectively reviewed: maximum flow rate (Q_max), International Prostate Symptom Score (IPSS), quality of life score (Q_ols), post-void residual volume (PVR), prostate volume, operation time, serum prostate-specific antigen (PSA) concentration, and complications at 1, 6, and 12 months postoperatively.

RESULTS

Of the 583 patients, 475 had complete clinical information and were included in the study. The median operation time was 39 min. There were significant improvements in the Q_max, IPSS, Q_ols, PVR and PSA concentration at each follow-up time point postoperatively. Postoperative hemorrhage occurred in 22 patients (4.6%), urinary retention in 29 (6.1%), urinary tract infection in 55 (11.6%), bladder neck contracture in 8 (1.7%), urethral strictures in 11 (2.3%), and stress urinary incontinence in 9 (1.9%).

CONCLUSIONS

PSEP is effective and safe for the treatment of benign prostatic hyperplasia. The innovative technique integrates the excellent hemostatic property of the 532-nm laser and the high efficiency of enucleation. It decreases the occurrence of postoperative incontinence associated with "blunt" enucleation of 532-nm laser and eliminates the lack of tissue samples problem associated with photoselective vaporization of the prostate.

Transurethral laser versus open simple prostatectomy for large volume prostates: a systematic review and meta-analysis of randomized controlled trials

The benefit of transurethral laser prostatectomy over open simple prostatectomy (OSP) is controversial in aged symptomatic benign prostatic hyperplasia (BPH) patients with large volume prostates, and the aim of this study is to compare the safety and efficiency of these two methods. Meta-analysis was applied using the Review Manager V5.3 software and the retrieved randomized controlled clinical trials (RCTs) comparing transurethral laser prostatectomy with OSP were analyzed for the treatment of large volume prostates from 2000 to 2019 in PubMed, Web of Science, Cochrane, and EMBASE datasets. Five RCTs assessing transurethral laser prostatectomy versus OSP were considered suitable for this meta-analysis, which included a total of 448 patients, with 232 patients undergoing laser and 216 patients undergoing OSP. Compared with OSP, although transurethral laser prostatectomy required a longer operative time (weighted mean difference (WMD) 27.49 mins; 95% confidence interval (CI) 16.54-38.44; P < 0.00001) and obtained a less resected prostate weight (WMD - 11.72 g; 95% CI - 21.75 to - 1.70; P = 0.02), patients undergoing laser prostatectomy benefited from significantly less hemoglobin decline (- 0.97 g/dL; 95% CI - 1.31 to - 0.64; P < 0.00001), shorter time of catheterization (WMD - 3.67 days; 95% CI - 5.60 to - 1.75; P = 0.0002), shorter length of hospital stay (WMD - 4.75 days; 95% CI - 6.57 to - 2.93; P < 0.00001), and less blood transfusion (odds ratio 0.10; 95% CI 0.03 to 0.35; P = 0.0003). During postoperative follow-up, no significant difference was observed between the two groups in IPSS, QoL, Q_max, and PVR. Both transurethral laser prostatectomy and OSP are safe and effective for large prostates that require prostate resection. Taking into account of less blood loss, shorter catheterization time and hospital stay, and less blood transfusion, transurethral laser prostatectomy may be a better treatment for patients with large prostates.

Reasons to overthrow TURP: bring on Aquablation

PURPOSE

In this review, we will discuss the state of the literature regarding Aquablation, its limitations, and opportunities for its application in the treatment of benign prostatic enlargement (BPE).

METHODS

A comprehensive review of original research on Aquablation was conducted. Articles related to transurethral resection of the prostate, holmium laser enucleation of the prostate, greenlight photoselective vaporization of the prostate, and simple prostatectomy were reviewed for discussion.

RESULTS

For small-medium prostates (30-80 mL), Aquablation's main advantages include better ejaculatory function and similar functional outcomes compared to TURP. For large prostates (80-150 mL), Aquablation demonstrates shorter operative time and superior ejaculatory function when compared to simple prostatectomy, HoLEP, and Greenlight PVP. In addition, Aquablation displays shorter hospital stays than simple prostatectomy. The integration of software programming and semi-automatic technology increases the reproducibility of the procedure and helps standardize overall outcomes, while also accelerating the learning curve. Its ability to preserve antegrade ejaculation makes Aquablation a very compelling option for sexually active patients. However cost and postoperative bleeding risks remain a concern.

CONCLUSION

The current evidence suggests that Aquablation is a safe and effective alternative for BPE for small to large prostates. Further prospective clinical trials, with comparisons to other BPE modalities, and data from longer follow-up periods are still required.

En bloc GreenLight laser enucleation of the prostate (GreenLEP): An in-depth look at the anatomical endoscopic enucleation of the prostate using a 532-nm lithium triborate laser

GreenLight laser enucleation of the prostate (GreenLEP) is an alternative endoscopic enucleation of the prostate (EEP) technique for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). GreenLEP is an 'en bloc' EEP technique to remove the transitional zone tissue in one piece. The procedure is a combination of laser enucleation and blunt gentle mechanical dissection using the tip of the resectoscope. The advantage of mechanical dissection is that it allows for better visualisation of the capsule and in some cases makes the dissection a little faster. This procedure is performed with a 532-nm lithium triborate laser (GreenLight™ XPS 180 W generator, AMS), a 2090 side-firing fibre and a Piranha™ morcellator (Richard Wolf GmbH). We offer a review of the evolution of the technique including the most important technical aspects, complications, advantages/disadvantages, tips and tricks and a visual step by step guide to perform the GreenLEP technique. GreenLEP is one of the latest energy sources reported in the armamentarium of EEP techniques for the treatment of BPO. GreenLEP has previously demonstrated its feasibility, safety and similar short- to mid-term functional outcomes compared to surgical gold standards in the literature.

The New American Urological Association Benign Prostatic Hyperplasia Clinical Guidelines: 2019 Update

PURPOSE OF REVIEW

The goal of this paper was to analyze the efficacy of the current modalities available to surgically treat lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH).

RECENT FINDINGS

There have been significant surgical advancements for the treatment of BPH, including an increasing development and utilization of minimally invasive surgical techniques (MISTs). These procedures have varying outcomes that are critical to understand. In addition, MISTs have important adverse effects, though have minimized effects on sexual function when compared to more invasive surgical techniques. It is important for all urologists to be familiar with the surgical techniques available to treat BPH and the updated American Urological Association (AUA) Guidelines. Further studies evaluating efficacy, safety, and sexual functioning will help guide care in the future and evolve practice.

GreenLight Laser photoselective vapo-enucleation of the prostate with front-firing emission versus plasmakinetic resection of the prostate for benign prostate hyperplasia

Background

Although the conventional, monopolar transurethral resection of the prostate (TURP) has proven to be an effective and relatively safe treatment for patients with benign prostatic hyperplasia (BPH), many new endoscopic technologies have been introduced to treat BPH. With the development of laser, there are several alternative transurethral procedures embracing laser therapies. Herein, this study sought to explore the efficacy, safety and follow-up of GreenLight laser photoselective vapo-enucleation of the prostate (PVEP) with front-firing emission compared with plasmakinetic resection of the prostate (PKRP) used to surgically manage BPH.

Methods

Data from patients who underwent either GreenLight laser PVEP or PKRP were retrospectively collected from March 2013 to May 2018. Perioperative data from both groups were compared.

Results

Totally, 43 and 45 patients were included in the PVEP and PKRP groups, respectively. No significant difference was observed in excision efficiency ratio (resected prostate weight/operation time) between the two groups (P=0.372). The efficiency ratio of the first 20 PVEP procedures (0.36±0.09 g/min) was significantly lower than that of the second 23 PVEP procedures (0.45±0.18 g/min) (P=0.042). The PVEP group experienced a shorter duration of catheterization, postoperative hospital stay and irrigation time than the PKRP group (P<0.001, P=0.001 and P<0.001, respectively). There was no statistically significant difference between the two groups (P=0.937) in terms of overall postoperative complications. Three months after surgery, the international prostate symptoms (IPSS) score, quality of life (QOL) score, postvoid residual (PVR) volume and maximum urinary flow rate (Q_max) were decreased in both groups (P<0.001 for all) and were comparable between both groups (P=0.635, 0.662, 0.671 and 0.924, respectively).

Conclusions

GreenLight laser PVEP with front-firing emission was safe and effective modality in treating patients with BPH with short-term follow-up. PVEP was associated with shorter catheterization and postoperative hospital stay time compared with PKRP.

Standardization of 532 nm Laser Terminology for Surgery in Benign Prostatic Hyperplasia: A Systematic Review

Introduction: The use of GreenLight™ laser technology to remove the prostatic transitional zone transurethrally has grown considerably in recent years. This increased utilization has resulted in an increase in the number of terms that are used to describe various laser techniques. Variable terminology complicates literature analysis and publication, which can cause confusion when performing reviews and comparisons of the techniques in the available literature. It has therefore become necessary to simplify and standardize terminology used to describe transurethral prostate debulking procedures using the 532 nm laser to simplify communication on these techniques. Materials and Methods: We conducted a search on September 17, 2019, in the following databases: Ovid MEDLINE^®, Ovid EMBASE, and PubMed. Results: Of the 1115 unique records found in our database search, a total of 27 articles were selected for inclusion. Of the 16 search terms used, we found that 4 terms could be used to describe the fundamental technique associated with each search term. These terms include "vaporization," "vaporesection," "vapoenucleation," and "enucleation." Conclusions: Standardizing terminology leads to an efficient consolidation of terms based on the above outcomes. This will streamline the literature search process for future publications and facilitate comparison of varying techniques.

En bloc greenlight laser enucleation of prostate (GreenLEP): about the first hundred cases

PURPOSE

To report the functional outcomes, perioperative morbidity and surgical learning curve key points using "en bloc" greenlight enucleation of prostate (EB-GreenLEP) for patients with refractory lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH).

METHODS

Between December, 2015 and May, 2018, all consecutive patients with refractory LUTS due to BPH in our institution were included and underwent EB-GreenLEP by a single surgeon. Perioperative data, complications and functional outcomes at 1-, 6- and 12-month follow-ups were collected and retrospectively analyzed.

RESULTS

One hundred patients were included whose median age was 69 years. The median prostate volume (PV) was 84 mL and median enucleated PV was 45.5 mL. Mean irrigation, catheterization and hospitalization times were 1.3, 1.4 and 1.6 days, respectively. Average follow-up was 9.3 months. A single high-grade Clavien-Dindo complication occurred. No urinary retention was reported. Two conversions to conventional resection of the prostate were noted. Three patients had postoperative urinary incontinence at 6 months, only one at 1 year (1%). At 1, 6 and 12 months, there was a significant improvement in IPSS score, QoL and Q_max. Enucleation and energy efficiency ratios were shorter after the 30th procedure. We demonstrated a linear correlation between enucleation time and PV (r = 0.53, p < 0.0001).

CONCLUSION

Our study shows that the mid-term functional results of EB-GreenLEP are comparable to other laser sources for the endoscopic enucleation of the prostate but with a shorter learning curve. We showed that, with (a) low rates of complications and a short hospital stay, EB-GreenLEP can manage medium-size glands (60-90 mL).

Aquablation among novice users in Canada: A WATER II subpopulation analysis

INTRODUCTION

Surgical management options for lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) associated with prostates of small to moderate volume (<80 cc) are numerous; however, for men with enlarged prostates (>80 cc), many of these options are neither safe nor effective. Recently, Aquablation (PROCEPT BioRobotics, Inc., U.S.), a precise ultrasound-guided, robotically executed prostatic ablative procedure, has become available with U.S. Food and Drug Administration approval. Herein, we present three-month safety and efficacy data from the cohort of Canadian men included in the WATER II trial.

METHODS

WATER II is a prospective clinical trial of the Aquablation system for the treatment of BPH in men with prostate volumes between 80 and 150 cc. Only patients from Canada were included for this analysis. At baseline, subjects completed International Prostate Symptom Score (IPSS), as well as several validated questionnaires, uroflowmetry and post-void residual volume measurements, and underwent standard laboratory blood assessment. These were repeated at one and three months post-Aquablation.

RESULTS

A total of 19 subjects who met inclusion and exclusion criteria were enrolled at three Canadian academic sites. Mean pre-, one-month, and three-month post-treatment IPSS scores were 21.2±5.5, 9.9±6.9 (p<0.0001), and 5.0±4.5 (p<0.0001), respectively. Mean pre-, one-month, and three-month post-treatment maximum urinary flow rates (Qmax) were 6.6±3.1 ml/s, 19.5±6.1 ml/s (p<0.0001), and 23.1±9.2 ml/s (p<0.0001), respectively. The Clavien-Dindo grade 2 or higher event rate at three months was 31.6% (six events).

CONCLUSIONS

In this short-term, three-month analysis of Canadian men, Aquablation appears to provide a strong surgical alternative in patients with LUTS/BPH due to larger prostate volumes, with impressive functional outcomes, relatively short operative time and length of hospital stay, and acceptable complication and low transfusion rates.

Comparison of Robot-Assisted Versus Open Simple Prostatectomy for Benign Prostatic Hyperplasia

PURPOSE OF REVIEW

Recent advancements in minimally invasive approaches for prostate surgery have provided numerous options for surgical management of benign prostatic hyperplasia (BPH). In the setting of a large prostate, an open simple prostatectomy was previously considered the gold standard surgical treatment. However, the recently updated American Urological Association (AUA) guidelines on surgical management of BPH now consider both open and minimally invasive approaches to simple prostatectomy viable alternatives for treating large glands, depending on expertise with the techniques. The purpose of our review is to discuss the minimally invasive robot-assisted approach and compare it to the classic open approach to simple prostatectomy.

RECENT FINDINGS

Despite longer operative times, the robotic approach is associated with shorter hospital stay and lower morbidity profile. The morbidity of an open approach remains significant. Blood transfusions are 3-4 times as likely compared to a robotic approach and major complications are twice as likely. Consistent with previous literature, our review shows functional outcome improvements like flow rate and symptom score to be comparable between the robotic and open approach. The amount of adenoma resected and PSA decline is also similar among robotic and open cases. Robot-assisted simple prostatectomy is a safe and effective procedure for BPH secondary to a large prostate gland. Appropriately, it is no longer deemed "investigational" by the latest AUA guidelines on BPH and recommended as an alternative to the open approach.