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

Benign prostate hyperplasia over 150cm3: Should we perform an endoscopic enucleation of the prostate or robotic-assisted simple prostatectomy?

INTRODUCTION

Benign prostatic hyperplasia (BPH) is a prevalent condition in ageing men, often resulting in significant lower urinary tract symptoms (LUTS) that impact quality of life. For patients with huge prostate volumes (>150mL), surgical management presents challenges. Traditionally, open simple prostatectomy (OSP) was the gold standard; however, minimally invasive approaches such as robotic-assisted simple prostatectomy (RASP) and endoscopic enucleation of the prostate (EEP), especially holmium laser enucleation of the prostate (HoLEP), offer similar or superior outcomes with reduced morbidity.

METHODS

This review analyzed studies comparing the perioperative, functional, and complication outcomes of RASP and HoLEP in treating very large prostates (>150mL). A comprehensive literature search was performed to evaluate evidence on surgical efficacy, complication rates, and recovery profiles.

RESULTS

Both RASP and HoLEP demonstrated excellent perioperative outcomes, with HoLEP providing reduced operative time and hospital stays. HoLEP also showed lower blood loss and a reduced need for transfusions, while RASP offered advantages in terms of precision and surgeon control, especially for anatomically complex cases. Functional outcomes, including improvement in urinary flow and symptom scores, were comparable between the two techniques. However, complications such as transient incontinence were more commonly reported with HoLEP.

CONCLUSION

Both RASP and HoLEP are effective and safe for the management of very large prostates. HoLEP offers significant advantages in perioperative recovery and reduced morbidity, whereas RASP provides excellent outcomes in complex cases requiring precise dissection. The choice between these techniques should be guided by patient-specific factors and surgical expertise. Future studies should focus on long-term functional outcomes to refine surgical recommendations further.

Open simple prostatectomy in the last three decades: results of a meta-analysis

PURPOSE

Open simple prostatectomy (OSP) has been a cornerstone in treating large prostate volumes (> 80 ml) in benign prostatic hyperplasia (BPH). With evolving minimally invasive procedures like minimally invasive simple prostatectomy (MISP) and laser enucleation, the role of OSP needs contemporary evaluation. This way, we assessed the efficacy and safety of OSP to understand its current standing in the treatment of BPH, especially in comparison with newer surgical modalities.

METHODS

A comprehensive search of MEDLINE, Cochrane and EMBASE was conducted to include randomized controlled trials (RCTs) comparing OSP with other treatments for BPH from 1993 to 2023. A total of 10 RCTs were included in the meta-analysis. Data on various outcomes including IPSS, Qmax, PVR, quality of life, perioperative factors, and postoperative complications were analysed.

RESULTS

Our meta-analysis, covering 557 patients, confirms OSP's significant improvement in voiding symptoms and objective voiding metrics. However, it also reveals a higher incidence of postoperative complications, such as bleeding and transfusion requirements. The study found moderate to high heterogeneity in perioperative outcomes, indicating variations in surgical techniques and postoperative care. OSP remains a reliable option with an easily accessible and effective approach for managing large prostates, despite advancements in minimally invasive surgeries.

CONCLUSION

OSP continues to be a relevant surgical option for BPH in large prostates, offering significant symptom relief. However, the associated higher morbidity warrants careful patient selection and highlights the need for continued research into optimizing surgical techniques and improving outcomes.

Laparoscopic prostatectomy with complete urethral reconstruction for sexual active BPH patients

OBJECTIVE

To describe our technique of transvesical laparoscopic simple prostatectomy (LSP) plus complete urethral reconstruction(CUR).

MATERIAL AND METHODS

From May 2019 to May 2021, 28 BPH patients with prostate volumes > 80 ml and the requirement to preserve the ejaculatory function (EF) received LSP plus CUR. Baseline demographics, pathology data, perioperative and postoperative complications, and functional outcomes were assessed. Data were analyzed with the Wilcoxon test.

RESULTS

The median prostate volume was 106 ml. All patients successfully underwent LSP with no intraoperative complications or conversions to open surgery. The median operative time was 146 min. A total of five Clavien-Dindo Grade1-2 postoperative complications were noted, including infection, prolonged urine leakage and cardiac arrhythmia. No patient reported postoperative urgent or stress urinary incontinence. Functional outcomes at one-year follow-up demonstrated significant improvement from baseline with median IPSS and Qmax (p both < 0.001). Compared with baseline, no significant difference was observed in IIEF and MSHQ-EjD-SF at 6 and 12 months postoperatively.

CONCLUSIONS

Our data support transperitoneal-transvesical LSP plus CUR as a safe and effective surgical technique for treating BPH with large prostate adenoma, regardless of the volume of the median lobe, especially for patients requiring to preserve antegrade ejaculation.

Prostatic Leiomyoma: An Uncommon Diagnosis Found in Clinically Suspected Cases of Severe Benign Prostatic Hyperplasia Without Elevated Serum Total Prostate-Specific Antigen Levels

Leiomyomas of the prostate are uncommon benign tumors. We report the case of a 67-year-old man who underwent an emergent, open prostatectomy for symptomatic relief of clinically severe benign prostatic hyperplasia (BPH). Ultrasound showed a severe prostatic enlargement with urinary tract obstruction. Gross pathology findings showed a 134-g prostate gland containing a 2.5-cm-long, well-circumscribed lesion. Histological findings showed a bland, smooth muscle neoplasm with positive staining for smooth muscle markers. No necrosis, nuclear atypia, or mitoses are identified. In such cases, gross and microscopic examination of adequately sampled lesions is necessary to assure a conclusive diagnosis and to exclude overt stromal malignancies, such as leiomyosarcoma.

An Outcomes Comparison Between Holmium Laser Enucleation of the Prostate, Open Simple Prostatectomy, and Robotic Simple Prostatectomy for Large Gland Benign Prostatic Hypertrophy

OBJECTIVE

To compare perioperative outcomes between Holmium laser enucleation of the prostate (HoLEP), open simple prostatectomy (OSP), and robotic simple prostatectomy (RSP) for large prostates (> 80 cc).

MATERIALS AND METHODS

A retrospective study of 340 patients who underwent HoLEP (n = 209), OSP (n = 66), or RSP (n = 65) at a large academic medical center between January 2013 - September 2021 was performed. Length of stay (LOS), operative time, catheter duration, estimated blood loss (EBL), blood transfusion, and 30-day ED visits and readmissions were compared between the three groups. Univariate analyses consisted of ANOVA with Tukey's corrections and Chi-square tests. Linear and multivariate logistic regression was also performed. All tests were two-sided and a p-value <0.05 was pre-determined to be statistically significant. Analyses were performed with SAS v9.4.

RESULTS

HoLEP was found to have the shortest: operative time (1.4 vs 2.7 vs 3.8h), LOS (0.65 vs 4.2 vs 2.6d), and catheter duration (0.38 vs 9.9 vs 11.2d) compared to OSP and RSP, respectively (all P <.0001). HoLEP also had the lowest EBL (66 vs 795 vs 326 mL, P <.0001). HoLEP and RSP had a lower risk of blood transfusion compared to OSP (P <.0001). These associations remained significant on multivariable analyses.

CONCLUSION

HoLEP is a minimally invasive treatment option for large prostates that was found to have shorter operative time, LOS, and catheter duration as well as lower EBL compared to OSP and RSP.

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.

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.

Same-Day Discharge Following Holmium Laser Enucleation in Patients Assessed to Have Large Gland Prostates (≥175 cc)

Background: Holmium laser enucleation of the prostate (HoLEP) is a highly effective and durable minimally invasive surgery for benign prostatic hyperplasia. Historically, alternative treatments for large glands (≥175 cc) are associated with prolonged length of stay (LOS) and postoperative catheterization. However, advances in laser technology combined with surgical technique optimization have early evidence supporting same-day discharge. We look to examine contemporary same-day discharge outcomes for large glands. Materials and Methods: With Institutional Review Board (IRB) approval we queried our electronic medical record and retrospective clinical registry to examine perioperative outcomes of large gland (≥175 cc) prostates that underwent HoLEP with consideration for same-day discharge. Results: From December 10, 2019 to September 29, 2020 we identified 55 patients with a preoperative prostate size ≥175 cc (39 CT, 12 MRI, 4 transrectal ultrasound), of which 45 were scheduled for same-day discharge and 10 for admission. Mean preoperative prostate size was 229.9 cc (range 175-535 cc) and 36 (65.5%) were in urinary retention. Mean preoperative prostate-specific antigen (PSA) was 8.58 ng/mL, American Urological Association Symptom Score (AUASS) 22.3, and Qmax 8.8 mL/second. At 3 months postoperative follow-up mean AUASS was 6.7, PSA 0.87 ng/mL and Qmax 20.4 mL/second. All comer same-day discharge rate was 70% (38/55). Of patients planned for same-day discharge 38/45 (84%) were effective. Average LOS for all patients was 11.8 hours with catheterization of 21.2 hours. When compared with 2010 published large gland outcomes, our current LOS represents a 220% reduction. Looking specifically at patients planned for same-day discharge, average LOS and catheter duration was 8.8 and 17.0 hours, whereas LOS and catheter duration for patients planned for admission was 25.7 and 39.4 hours, respectively. Conclusions: We report the first outcomes of preoperatively planned same-day discharge for HoLEP in large glands (≥175 cc). A combination of technologic advances and optimization of technique have allowed for a safe adoption of same-day discharge, providing additional advantages over alternative large gland treatments.