HoLEP for acute and non-neurogenic chronic urinary retention: how effective is it?

Evaluation of new treatments for benign prostatic obstruction: ICI-RS 2023

AIMS

To address how invasive therapies for benign prostatic obstruction (BPO) have been evaluated, what their effect is on BPO, if they can prevent progression to BPO and how new therapies need to be evaluated before implementation into clinical practice.

METHODS

The think tank conducted a literature review and looked at the previous and current American Urological Association, European Association of Urology and the International Consultation on Urological Diseases guidelines to see what procedures have been used to treat BPO. They then assessed whether trials have been conducted before implementation of the procedures and whether they have been compared to a "gold" standard treatment. The use of urodynamics has also been addressed in the think tank in relation the clinical trials as well as terminology.

RESULTS

Guidelines vary in the use of terminology when it comes to BPO with some continuing to use the term benign prostatic hyperplasia (BPH). There are several procedures for example, TUNA, which have become obsolete although continues to be mentioned in the guidelines until recently. Majority of procedures have been introduced without comparing to "gold" standard treatment and without any long-term data. There continues to be many unknowns with regard to the success of some of the BPO procedures and why some of the adverse events develop.

CONCLUSION

There needs to be more robust long-term clinical trials conducted of new BPO therapies, with men who have both lower urinary tract symptoms and urinary retention, before introduction into clinical practice.

Can we predict whether a man with acute or chronic urinary retention will void after bladder outflow resistance reduction surgery? ICI-RS 2023

AIMS

To address the predictive factors of a successful voiding after bladder outflow resistance reduction surgery (BORRS) in men presenting with acute or chronic urinary retention (UR).

METHODS

A think tank (TT) of ICI-RS was gathered in 2023, Bristol, UK, to discuss several aspects of the problem, such as the pathophysiology of UR, the clinical and urodynamic evaluation of men with UR and whether it is possible to predict which men will be able to successfully void after treatment with contemporary surgical options.

RESULTS

The TT agreed that successful voiding after BORRS depends on several factors but that a strong recommendation cannot be made regarding preoperative evaluation and whether there are predictive factors of success because of the heterogeneity of patients and methodology in published trials. The diagnosis of obstruction in men with UR may be challenging when there is apparent reduced detrusor contraction during urodynamic studies. Even in the absence of bladder contractility there is documentation of such cases that have voided adequately after BORRS. Still, detrusor underactivity and inadequate relief of prostatic obstruction are the main causes of an unsuccessful voiding after BORRS. Conventional resection and enucleation methods remain the most successful surgeries in relieving UR in men, whereas the efficacy of minimally invasive surgical treatments needs to be assessed further.

CONCLUSION

Research is needed to understand the pathophysiology of UR and the predictors of successful voiding after different types of BORRS in men with UR.

Surgical outcomes of endoscopic enucleation of the prostate in community aging males with or without preoperative urinary retention

OBJECTIVES

This study aims to investigate the surgical outcomes of endoscopic enucleation of the prostate in older males with or without preoperative urinary retention (UR).

MATERIAL AND METHODS

We conducted a study on selected patients with symptomatic benign prostatic hyperplasia (BPH) who underwent either thulium:YAG laser (vela XL) prostate enucleation (ThuLEP) or bipolar plasma enucleation of the prostate (B-TUEP) at the geriatric urology department of our institution. The studied patients were categorized into two groups, namely the UR group and the non-UR group, on the basis of whether they experienced UR in the 1 month preceding their surgery. Their clinical outcomes following prostate endoscopic surgery were evaluated and analyzed.

RESULTS

Our results revealed comparable outcomes for operation time, length of hospital stay, percentage of tissue removed, re-catheterization rate, and urinary tract infection rate within the 1 month between the B-TUEP and ThuLEP surgery groups, regardless of UR history. However, the non-UR B-TUEP group experienced more blood loss relative to the non-UR ThuLEP group (P = .004). Notably, patients with UR exhibited significantly greater changes in IPSS total, IPSS voiding, and prostate-specific antigen values relative to those without UR.

CONCLUSIONS

Both ThuLEP and B-TUEP were effective in treating BPH-related bladder outlet obstruction. Our study identified more pronounced changes in IPSS total, IPSS voiding, and prostate-specific antigens within the UR group. Moreover, the rate of postoperative UR in this group was not higher than that observed in the non-UR group. Our study also revealed that the presumed benefits of laser surgery in reducing blood loss were less pronounced for patients with UR.

Optimizing hemostasis in HoLEP surgery: retrospective review of selective bipolar plasmakinetic technology guided by bladder irrigation fluid color

OBJECT

To evaluate the effectiveness of selective bipolar plasmakinetic technology based on bladder irrigation fluid color on hemostasis in HoLEP surgwery METHODS: A total of 209 patients who underwent HoLEP surgery from October 2021 to July 2023 were included and divided into Hemostasis Management Group and control group. the color of the irrigation fluid was categorized into 5 levels and the bipolar plasmakinetic technology was applied when the color came to level 4 or up. The following was analyzed: postoperative use of balloon compression, blood loss, irrigation time, length of hospital stay, and the number of a second operation.

RESULTS

Only 4 patients in Hemostasis Management Group required postoperative urinary catheter balloon compression, while there are 15 in the control group(p=0.03). The average irrigation time for patients in the HM Group with bipolar plasmakinetic hemostasis was 21.88±13.76 hours, compared to that in patients with catheter balloon compression(p=0.007).

CONCLUSION

Based on the bladder irrigation color chart, the selective application of bipolar plasmakinetic hemostasis led to a significant reduction in the number of patients requiring postoperative bladder catheter balloon compression. Secondly, the irrigation time of patients who underwent bipolar plasmakinetic hemostasis also decreased.

Factors predicting indistinct plane of surgical capsule in patients underwent HoLEP procedures

PURPOSE

To evaluate factors that effectively predict indistinct plane (IP) in patients who underwent holmium laser enucleation of the prostate (HoLEP).

METHODS

Data of 208 consecutive patients from our HoLEP database were reviewed and analyzed. IP was defined in 107 cases, as the plane could be identified only depending on endoscopic beak dissection rather than laser dissection in the initial stage of HoLEP, whereas the control group consisted of 101 cases. Variables including age, body mass index, prostatic volume (PV), intravesical prostatic protrusion, prostate-specific antigen, prostate-specific antigen density, bladder stones, urinary tract infection, microscopic hematuria, prior biopsy (PB), diabetes, hypertension, history of acute urinary retention, 5-alpha reductase inhibitor treatment, catheter dependency, residual urine, region, smoking, and alcohol consumption were compared between the two groups. The risk factors for predicting the presence of IP were determined using a multivariable binary logistic regression model using a forward selection approach with a focus on improvement in the area under the receiver operating characteristic curve (AUC).

RESULTS

The incidence of IP was 51.4% (107/208). PV (OR = 0.977, p < 0.001) and PB (OR = 0.297, p = 0.028) were identified as the independent predictors of capsule plane status. PV with a cutoff of 54 ml had the best predictive effectiveness for IP based on AUC (0.727; 95% CI 0.659-0.795). The specificity and sensitivity of this cutoff were 82.2% and 53.3%, respectively.

CONCLUSION

PV is the most reliable factor to predict IP during HoLEP procedures. There is a high possibility of IP in patients with a PV less than 54 ml.

Outcomes of Aquablation in Men With Acute and Chronic Urinary Retention

OBJECTIVE

To compare outcomes of Aquablation in men with acute and chronic urinary retention.

METHODS

We conducted a retrospective review of all men undergoing Aquablation resection of the prostate between May 2021 and August 2022. Men were classified as having acute urinary retention if they required either intermittent or indwelling catheter and chronic urinary retention if they had a postvoid residual >300 mL prior to surgery. We compared success rates and time to passage of trial without catheter as well as complication rates to those with no retention.

RESULTS

A total of 113 men underwent Aquablation including 28 with acute retention and 16 with chronic retention. Failure of initial void trial was significantly higher in patients with preoperative urinary retention (40%) and chronic retention with postvoid residual >300 mL (12.5%) compared to those with no retention (7.2%, P < .001). Among men with acute and chronic retention 98% were voiding spontaneously at a mean 5months follow-up. There was no difference in utilization of postoperative prostate medications, complications, International Prostate Symptom Score or uroflowmetry among men with acute, chronic, or no retention.

CONCLUSION

Aquablation is an effective method for treatment of men with urinary retention, with 98% achieving spontaneous voiding regardless of preoperative urodynamic findings. Men in acute retention prior to surgery were more likely to fail their initial void trial, which may support the recommendation for a delayed trial without catheter.

Mini-HoLEP (MILEP) vs HoLEP: a propensity score-matched analysis

BACKGROUND AND PURPOSE

Minimal invasiveness improves outcome in many surgical fields including urology. We aimed to assess intraoperative performance and clinical outcome of miniaturized holmium laser enucleation of prostate (MiLEP) (22FR).

METHODS

We ran a propensity score-matched analysis among all consecutive laser enucleations of prostate performed between 9/2022 and 2/2023. It resulted in two matched comparison groups: MiLEP 22 FR (n = 40) and holmium laser enucleation of prostate (HoLEP 26 Fr) (n = 40). Statistical analysis was performed.

RESULTS

MiLEP was associated with significantly less intraoperative irrigation (20.5 L vs 15 L, p = 0.002E-3), less decrease in body core temperature (0.6°C vs 0.1°C, p = 0.003E-5), and less need for meatal dilation (25% vs 78%, p = 0.01E-3). These parameters were identified as being independent in the multivariate analysis. There was a trend toward less and a shorter period of postoperative stress incontinence (SI) for the MiLEP group compared to the HoLEP group: 15% and 42% (p = 0.01) at 1 month, 8% and 14% (p = 0.07) at 2 months, and 0 and 0.3% (p = 1) at 3 months, respectively. There were no differences in prostatic enucleation effectiveness, operative time, hospital stay, complications, and improvement in the international prostate symptom score and quality of life score.

CONCLUSIONS

MiLEP is feasible and provides better maintenance of body core temperature, reduction in amount of fluid irrigation, and decrease in need for meatal dilation without affecting effectiveness in comparison with HoLEP. MiLEP may reduce early postoperative stress incontinence, thereby shortening the recovery period.

Imaging in urethral stricture disease: an educational review of current techniques with a focus on MRI

Urethral stricture disease refers to narrowing of the urethral lumen obstructing the flow of urine. Urethral strictures can significantly impact daily life due to incontinence, incomplete emptying, hesitancy, and increased risk of urinary tract infections. Imaging is central to the evaluation of suspected urethral stricture, as assessment of stricture length and severity is crucial for guidance of surgical management. The currently employed modalities include radiography, chiefly retrograde urethrography (RUG) and voiding cystourethrography (VCUG); magnetic resonance urethrography (MRU); and sonourethrography (SUG). MRU has become a recent focus of research as it provides high spatial resolution, multiplanar capacity, and soft tissue type differentiation for evaluation of periurethral compartments and concurrent soft tissue defects. The protocol for MRU has evolved over the years to now include dynamic micturition imaging and image reconstruction options. In this review, we discuss each of the imaging modalities used in the diagnosis and evaluation of urethral stricture and provide an overview of literature on MRU over the last decade, including suggested indications that have not yet been incorporated into current guidelines. We delineate scenarios where special diagnostic imaging beyond radiography is beneficial, providing examples from our practice and description of our techniques for each modality.

Incidence and risk factors for postoperative urinary incontinence after various prostate enucleation procedures: systemic review and meta-analysis of PubMed literature from 2000 to 2021

PURPOSE

To evaluate the risk of urinary incontinence (UI) after various prostate enucleation procedures (PEP).

METHODS

PubMed was searched from January 2000 to July 2021 for studies investigating UI after PEP. The articles were divided into 5 subgroups: holmium, thulium, greenlight laser, electrocautery, and simple prostatectomy. Meta-analysis was performed to examine rate of stress (SUI), urge (UUI) or unspecified UI at short (< 3 months), intermediate (3-6 months), and long-term (> 6 months). The impact of age, prostate size, surgery time, laser time, postoperative nadir PSA level and technical modifications on UI was analyzed.

RESULTS

Most (69.4%) of 49 articles included employed holmium laser. There was no significant difference in incidence of short-, intermediate-, and long-term UI, SUI and UUI between five sub-groups and within different technical modifications. Although not statistically significant, the incidence of UI was higher (15%) at short-term with green-light and simple prostatectomy (95% CI 9-23 and 1-84), and higher (4%) at intermediate-term with holmium laser (95% CI 2-8). SUI was more prevalent at short-term with holmium laser (4%; 95% CI 2-5%), and at intermediate term with simple prostatectomy (3%; 95% CI 1-14). UUI was higher in the thulium group (10%, 95% CI 7-16). Increased age, surgery time, laser time and prostate size up to 80 cc were associated with higher UI. There was no correlation between postoperative PSA and UI.

CONCLUSIONS

There is no significant difference in incidence of UI, SUI and UUI after various PEP. Patients age, prostate size, surgery and laser time are linearly associated with UI.