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

Robotic assisted simple prostatectomy mitigates perioperative morbidity compared to open simple prostatectomy - a single institution report

BACKGROUND

According to the guidelines of the European Association of Urology, open simple prostatectomy should be offered to men with a prostate size exceeding 80 mL suffering from moderate to severe LUTS in the absence of a transurethral enucleation technique. However, open simple prostatectomy is associated with complications such as bleeding, blood transfusions and increased length of stay compared to minimally invasive procedures. The aim of the study was to compare perioperative data from the first cases of robotic assisted simple prostatectomy (RASP) to that of patients subjected to open simple prostatectomy (OSP) at our department.

METHODS

The patients were identified by a search for the respective procedure codes. In the OSP group enucleation of the adenoma was performed through the prostatic capsule (Millin procedure), while access to the adenoma was gained through the bladder in the RASP group. Complications were scored according to the Clavien-Dindo classification system.

RESULTS

27 patients who underwent OSP were retrospectively identified and compared to the first 26 patients who were subjected to RASP. The groups were similar with respect to age, body mass index and ASA score. Operative time was significantly shorter in the OSP group compared to the RASP group. Bleeding volume, drop in postoperative hemoglobin and the number of blood transfusions were all significantly higher in the OSP group compared to the RASP group. Average length of stay was 5.5 (2-18) days in the OSP group compared to 1.6 (1-5) days in the RASP group (p < 0.001). The number of postoperative complications, Clavien-Dindo ≥ 2, were significantly higher in the OSP group (11) compared to the RASP group (none, p < 0.001).

CONCLUSIONS

The introduction of robotic assisted simple prostatectomy reduced perioperative morbidity at our department.

Efficacy and safety of transurethral thulium laser enucleation versus robot-assisted prostatectomy for large-volume benign prostatic hyperplasia: a systematic review and meta-analysis

To compare perioperative outcomes between Holmium laser enucleation of the prostate (HoLEP) and robotic-assisted simple pasta-ectomy (RASP)for large-volume benign prostatic hyperplasia(> 80 ml). In August 2023, we undertook a comprehensive search of major global databases including PubMed, Embase, and Google Scholar, focusing solely on articles written in English. Studies that were merely reviews or protocols without any specific published data were omitted. Furthermore, articles that comprised conference abstracts or content not pertinent to our subject of study were also disregarded. To calculate the inverse variances and 95% confidence intervals (CIs) for categorical variables' mean differences, we employed the Cochran-Mantel-Haenszel approach along with random-effects models. The findings were denoted in the form of odds ratios (ORs) and 95% CIs. A p-value less than 0.05 was deemed to indicate statistical significance. Our finalized meta-analysis incorporated six articles, including one randomized controlled trial (RCT) and five cohort studies. These studies accounted for a total of 1218 patients, 944 of whom underwent Holmium Laser Enucleation of the Prostate (HoLEP) and 274 who underwent Robotic-Assisted Simple Prostatectomy (RASP). The pooled analysis from these six papers demonstrated that compared to RASP, HoLEP had a shorter hospital stay, shorter catheterization duration, and a lower blood transfusion rate. Moreover, HoLEP patients exhibited a smaller reduction in postoperative hemoglobin levels. Statistically, there were no significant differences between the two procedures regarding operative time, postoperative PSA, the weight of prostate specimens, IPSS, Qmax, PVR, QoL, and postoperative complications. (HoLEP) and (RASP) are both effective and safe procedures for treating large-volume benign prostatic hyperplasia. HoLEP, with its benefits of shorter catheterization and hospitalization duration, lesser decline in postoperative hemoglobin, and reduced blood transfusion needs, stands as a preferred choice for treating extensive prostate enlargement. However, further validation through more high-quality clinical randomized trials is required.

Long-term outcomes of bipolar transurethral enucleation and resection of the prostate on patients with benign prostatic obstruction: a 10-year follow-up

OBJECTIVE

We aimed to explore the long-term outcomes of bipolar transurethral enucleation and resection of the prostate (B-TUERP) in patients with benign prostatic hyperplasia (BPH).

METHODS

A total of 1195 patients with BPH who underwent B-TUERP from July 2006 to June 2010 were enrolled in this retrospective study. Preoperative data, particularly urodynamic study (UDS) parameters, were collected by questionnaire and examination. Postoperative follow-up was performed at 3, 6, 12, 36, 60 and 120 months, respectively. Demographic, perioperative and functional data were analysed. International Prostate Symptom Score, quality of life and overactive bladder syndrome score (OABSS) were used to assess the functional scores. Predictors of postoperative urgency incontinence were identified by univariate analysis.

RESULTS

Long-term outcomes of functional score were significantly better than the preoperative values. All UDS variables, including maximum urinary flow rate, postvoid residual urine volume, compliance, maximum cystometric capacity (MCC), bladder outlet obstruction index, prostatic urethral pressure and detrusor pressure at maximum urinary flow rate, were all significantly improved. No one required reoperation due to recurrent BPH. The postoperative rate of transient urinary incontinence was 31.7%, while the long-term incontinence rate was 0%. Retrograde ejaculation occurred in 44.3% patients who remained sexually active after operation. Patients who had transient urge incontinence were older with preoperative higher OABSS, prostate-specific antigen (PSA) and detrusor overactivity rate and lower MCC.

CONCLUSION

B-TUERP is a safe, successful and highly effective treatment for BPH at 10-year follow-up. Increased age, OABSS, PSA level and detrusor overactivity rate are potential predictors for urge incontinence after B-TUERP.

Holmium Laser Enucleation of the Prostate vs Transvesical Single-port Robotic Simple Prostatectomy for Large Prostatic Glands

OBJECTIVE

To compare the perioperative outcomes of transvesical single-port robotic simple prostatectomy (SP-RASP) and holmium laser enucleation of the prostate (HoLEP).

MATERIALS AND METHODS

A retrospective review was performed of patients undergoing SP-RASP and HoLEP from 2019 to 2022 with preoperative prostatic volume (PPV) >80 cm3. Percent of prostate adenoma removed (%PAR) was estimated by specimen weight normalized by PPV. Univariate analysis was performed using chi-square, Fisher exact, and Wilcoxon rank-sum tests. A subgroup analysis with 1:1 matching for PPV was also performed.

RESULTS

A total of 50 SP-RASP and 90 HoLEP cases were analyzed. The median (interquartile range) PPV was 169 (128-244)cm3 for SP-RASP and 129 (100-150)cm3 for HoLEP, (P < .01). The median (interquartile range) %PAR was 57(44-68) for SP-RASP vs 51(42-62) for HoLEP (P = .10). Overall, 11(12%) HoLEP and 5(10%) SP-RASP patients experienced complications (P = .51). Same-day discharge occurred in 24(48%) SP-RASP vs 7(8%) HoLEP patients (P < .01). Median foley catheter duration was longer in SP-RASP (6 vs 1 day, P < .01) and trial of void was successful at first attempt in >94% (P = .68). Transient de novo incontinence was reported in 24(28%) HoLEP vs 2(5%) SP-RASP (P < .01). No differences in voiding parameters were observed at latest follow up. Subgroup postmatched analysis revealed analogous findings.

CONCLUSION

SP-RASP and HoLEP have similar favorable perioperative outcomes for management of large prostatic adenomas. SP-RASP may be considered in patients unwilling to accept the risk of transient incontinence and in those with unfavorable urethral access, large bladder stone burden, or diverticula.

Single Port Versus Multiport Robot-assisted Simple Prostatectomy: A Multi-institutional Study From the Single-port Advanced Research Consortium (SPARC)

OBJECTIVE

To compare robot-assisted simple prostatectomy intraoperative and postoperative.ßoutcomes between single-port (SP) and multiport (MP) robotic systems in a multi-institutional setting.

METHODS

We analyzed all-consecutive robot-assisted simple prostatectomy cases done in 5 centers from January 2017 to October 2022. Data were analyzed with descriptive statistics and compared with appropriate tests depending on the type of variable and distribution. Statistical significance was considered when P.ß<.05.

RESULTS

A total of 405 cases were analyzed:.ß249 and 156 were MP and SP, respectively. Operative times were similar between groups (P.ß=.ß.62). Estimated blood loss during surgery was significantly lower with the SP robot (P.ß<.001). Postoperatively, the SP approach required a significantly shorter hospital stay, less use of opioids, and a shorter duration of Foley catheter (P.ß<.001). There was no significant difference between the post-operative Clavien-Dindo ...3 complication rate (P.ß=.ß.30). The 30-day readmission rate of MP (10.8%) was significantly higher than for SP (0%) (P.ß<.001). De novo urge incontinence was more common in the MP group (P.ß=.ß.02).

CONCLUSION

The SP robotic approach to simple prostatectomy is advantageous when it comes to postoperative comfort for patients. Specifically, it requires a shorter hospital stay, less use of opioids, and a shorter Foley catheter duration.

18 F-FDG PET-Positive Large Pelvic Granuloma Mimicking Malignant Bladder Tumor

ABSTRACT

An 88-year-old man was admitted to our hospital with a recurrent lower urinary tract infection. He had a history of open prostatectomy for benign prostatic hyperplasia 15 years ago and smoking. A mass arising within a bladder diverticula was suspected on the left lateral wall of the bladder on ultrasonography. Although no mass was observed in the bladder lumen on the cystoscopy, abdominal CT detected a left-sided pelvic soft tissue mass. A hypermetabolic mass was detected on 18 F-FDG PET/CT performed because of suspicion of malignancy, and it was excised. Granuloma secondary to chronic vasitis was diagnosed histopathologically.

Outcomes of Robotic Simple Prostatectomy After Prior Failed Endoscopic Treatment of Benign Prostatic Hyperplasia

BACKGROUND

We compared outcomes of robotic simple prostatectomy (RASP) in patients with and without a history of prior prostate surgery for management of symptomatic benign prostatic hyperplasia.

METHODS

We retrospectively reviewed our multi-institutional database for all consecutive patients who underwent RASP between 05/2013 and 01/2021. Postoperatively, urinary function was assessed using the American Urological Association Symptom Score (AUASS) and Quality of Life (QOL) score.

RESULTS

Overall, 520 patients met inclusion criteria. Among the 87 (16.7%) patients who underwent prior prostate surgery, 49 (56.3%), 26 (29.9%), 8 (9.2%), 3 (3.4%) and 1 (1.1%) patients underwent transurethral resection of the prostate, photoselective vaporization of the prostate, transurethral microwave therapy, prostatic urethral lift or water vapor thermal therapy, respectively. There was no difference in mean prostate volume (p=0.40), estimated blood loss (p=0.32), robotic console time (p=0.86) or major 30-day postoperative (Clavien>2) complications (p=0.80) between both groups. With regards to urinary function, the mean improvement in preoperative and postoperative AUASS (p=0.31), QOL scores (p=0.11) and continence rates were similar between both groups.

CONCLUSION

For management of patients with BPH and LUTS, RASP is associated with an improvement in urinary function outcomes and a low risk of postoperative complications. Perioperative outcomes of RASP are similar in patients who underwent prior prostate surgery versus those that did not undergo prior prostate surgery.

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.

Clinical Study on the Application of Preserved Urethral Mucosa at the Prostatic Apex in Transurethral Plasmakinetic Resection of the Prostate

Objective

To explore the differences in the clinical efficacy, complications, and safety of transurethral plasmakinetic resection of the prostate (PKRP) by the conventional approach versus the approach preserving the urethral mucosa at the prostatic apex in the treatment of benign prostatic hyperplasia (BPH).

Methods

A total of 90 patients with PKRP admitted to the First Hospital of Qinhuangdao from December 2018 to March 2021 were selected and divided into a control group (conventional PKRP, n = 45) and an observation group (PKRP with preserved urethral mucosa at the prostatic apex, n = 45). The clinical efficacy, safety, and sexual function of the groups were evaluated using the patients’ International Prostate Symptom Score (IPSS), quality of life (QoL), prostate volume, maximum flow rate (Qmax), post-void residual (PVR), blood loss, surgical resection efficiency, and surgical complication data.

Results

The differences in the preoperative indicators, glandectomy quality, and glandectomy rate between the groups were not statistically significant (P > 0.05). However, in the observation group, the surgery time and blood loss were significantly lower compared with the control group, and the resection efficiency was significantly higher, with statistical significance (P < 0.05). In the follow-up, one month after surgery, the IPSS and QoL were lower in the observation group than in the control group, and the differences were statistically significant (P < 0.05); three months after surgery, the PVR, IPSS, QoL, and Qmax scores were similar between the groups, with no statistical significance (P > 0.05). In terms of surgical complications, the incidences of urinary incontinence and other complications after catheter extraction were significantly lower in the observation group than in the control group, and the differences between the groups were statistically significant (P < 0.05).

Conclusion

Compared with conventional PKRP, PKRP with preserved urethral mucosa at the prostatic apex can lead to immediate urinary continence after catheter extraction, reduce intraoperative blood loss, and shorten the surgery time, thus improving the surgical efficiency.

Standard Multi-Port versus Single-Port Robot‑Assisted Simple Prostatectomy: A Single Center Initial Experience

BACKGROUND

Robot-assisted simple prostatectomy (RASP) has emerged as a safe surgical treatment for patients with benign prostatic hyperplasia with large glands (>80 ml). Several studies reported on perioperative outcomes of RASP by the standard multiport (MP) da Vinci robotic system approach. Studies conducted on RASP utilizing the novel single-port da Vinci® SP robotic platform (Intuitive Surgical, Sunnyvale, CA) are scarce. We aimed to compare intraoperative and short-term postoperative outcomes between the da Vinci MP and SP robots for patients undergoing RASP in a referral center.

METHODS

In this retrospective study, we reviewed all patients who underwent RASP using MP or SP robot from September, 2016 to March, 2021. Intraoperative data, overall 30-day complications, complications by Clavien-Dindo classification and 90-day readmission and reoperation rates were assessed and compared between the two groups using appropriate statistical methods.

RESULTS

Seventy-five patients who underwent RASP were identified. Of these, 47 were in the MP group and 28 were in the SP. Compared to SP, mean operative time in MP group was 216.6 vs. 232.4 minutes (p=0.39), EBL was 195.7 vs. 227.1 ml (p=0.43) and length of stay was 2 vs. 2.5 days (p=0.45). There was a trend toward higher overall complication rate in SP group vs. MP (42.86% vs. 21.28%, p=0.09). There were no significant differences in the readmission (17.02% vs. 10.71%, p=0.52) and reoperation (2.1% vs. 7.14%, p=0.34) rates between MP vs. SP group.

CONCLUSION

SP-RASP is safe and shows equivalent perioperative outcomes when compared to the MP robotic system. A marginal increase of complication rate was recorded in the SP group; however, this did not demonstrate statistical significance.

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.

Safety and Efficacy of Laser Enucleation of the Prostate in Elderly Patients - A Narrative Review

Benign prostatic hyperplasia (BPH) is a common health condition in aging men resulting in lower urinary tract symptoms (LUTS) and low quality of life (QoL). We aimed to review studies on laser enucleation of the prostate (LEP) due to LUTS in elderly patients (>65 years) comparing different age groups, particularly considering functional outcomes, safety, and perioperative complications. A comprehensive search was conducted using the PubMed-MEDLINE, Web of Science, Wiley Online Library and Cochrane Library databases over the last 10 years until 7 October 2021 with the following search terms solely or in combination: “laser enucleation”, “prostate”, “laser prostatectomy”, “aging”, “elderly patients”, “older patients” and “age”. We identified 12 articles for inclusion in our analysis. Five studies focussed mainly on holmium laser enucleation of the prostate (HoLEP), one compared HoLEP to other laser prostatectomy procedures, two studies examined thulium laser enucleation of the prostate (ThuLEP), and two studies focused on GreenLight laser, one study focussed on potassium-titanyl-phosphate (KTP) laser, and another study compared laser prostatectomy to transurethral resection of the prostate (TURP). These studies showed that LEP improved IPSS, Qmax and QoL compared to baseline regardless of age; no significant difference was reported among age groups. Although ASA scores and anticoagulation/antiplatelet therapy rates are higher in elderly patients, studies revealed no significant difference in perioperative complication rates between age groups. Laser enucleation of the prostate is an effective and safe procedure in elderly patients, resulting in good functional outcomes, low morbidity, and few perioperative complications.

Robot assisted simple prostatectomy versus endoscopic enucleation of the prostate: A systematic review and meta-analysis of comparative trials

Robot assisted simple prostatectomy (RASP) and endoscopic enucleation of the prostate (EEP) are two minimally invasive alternatives to simple prostatectomy, which is considered the standard treatment in large prostate glands. It remains unclear which of the two is superior in terms of outcome and complications. To compare perioperative and functional outcomes of robot assisted simple prostatectomy (RASP) versus endoscopic enucleation of the prostate (EEP) systematic review and meta-analysis was conducted according to the recommendations of the Cochrane Collaboration and in line with the PRISMA criteria. The database search included clinicaltrials.gov, Medline (via PubMed), CINAHL and Web of Science and was using the PICO criteria. All comparative trials were considered. Risk of bias was assessed with the revised ROBINS-I tool. 760 studies were identified, four of which were eligible for qualitative and quantitative analysis, reporting on a total of 901 patients with follow-up up to 24 months. Hemoglobin drop (MD[CI]: 0.34 g/dl [0.09; 0.58]), the rate of blood transfusions (OR[CI]: 5.01 [1.60; 15.61]) catheterization time (MD[CI]: 3.26 d [1.30; 5.23]) and length of hospital stay (LoS) (MD[CI]: 1.94 d [1.11; 2.76]) were significantly lower in EEP. No significant differences were seen in operating time and enucleation weight. No significant differences were observed in the incidence of postoperative urinary retention, postoperative transient incontinence and complications graded according to the Clavien-Dindo Classification. Functional results were similar, with no significant differences in International Prostate Symptom Score and maximum urinary flow rate at follow-up. Conclusion: Both EEP and RASP offer excellent improvement of symptoms due to prostatic hyperplasia. EEP has lower blood loss, shorter catheterization time and LoS and should be the first choice if available. RASP remains an attractive alternative for extremely large glands, in concomitant diseases or whenever EEP is not available.

How many procedures are needed to achieve learning curve of Millin simple laparoscopic prostatectomy

BACKGROUND

Aim of our study was to evaluate learning curve of the Millin simple prostatectomy analysing three expert laparoscopic surgeons.

METHODS

Learning curve of 3 expert laparoscopic surgeons with excellent radical prostatectomy training was evaluated. Surgeon 1 had more than 20 years of experience, while other surgeons had 10 years of experience. The first 45 procedures of the surgeons were considered for analysis. The cumulative sum (CUSUM) technique, one of the methods developed to monitor the performance and quality of the industrial sector, was adopted to analyse learning curves. The variables included to evaluate learning curve of the surgeons were: operative time (OT), hospitalisation (HO) and complication rate.

RESULTS

Overall 135 patients were included in the analysis. Median age was 68 (64/74), median prostate volume was 83 (75/97), median Qmax 9 ml/s (6/11) and median IPSS 20 (18/22). Complications included: 9/135 (7%) transfusion, 4/135 (3%) Urinary retention, 3/135 (2%) fever, 1/35 (<1%) reintervention and 1/135 (<1%) conversion. Surgeon 1 presented a lower median operative time when compared to surgeon 2 and 3. No significant differences were recorded in terms of hospitalisation, blood loss and transfusion rate as well as postoperative outcomes. According to the CUSUM analysis the number of procedures needed to achieve a plateau in surgical time is 10/15 procedures (fig 1).

CONCLUSIONS

In conclusion, according to our results 15 procedures are needed to reach a plateau in surgical time for trained laparoscopic surgeons.

Laparoscopic simple prostatectomy vs bipolar plasma enucleation of the prostate in large benign prostatic hyperplasia: a two-center 3-year comparison

PURPOSE

To compare surgery outcomes and safety of button bipolar enucleation of the prostate vs laparoscopic simple prostatectomy in patients with large prostates (> 80 g) in a two-center cohort study.

METHODS

All patients with lower urinary tract symptoms due to benign prostatic enlargement (Prostate volume > 80 cc) undergoing button bipolar enucleation of the prostate (BTUEP) or laparoscopic simple prostatectomy (LSP) in two centers were enrolled. Data on clinical history, physical examination, urinary symptoms, uroflowmetry and prostate volume were collected at 0, 1, 3 6, 12, 24 and 36 months. Early and long-term complications were recorded.

RESULTS

Overall, 296 patients were enrolled. Out of them, 167/296 (56%) performed a LSP and 129/296 (44%) performed a BTUEP. In terms of efficacy both procedures showed durable results at three years with a reintervention rate of 8% in the LSP group and of 5% in the BTUEP group. In terms of safety, BTUEP and LSP presented similar safety profiles with a 9% of transfusion rate and no major complications.

CONCLUSION

LSP and BTUEP are safe and effective in treating large-volume adenomas with durable results at three years when performed in experienced centers.

Evaluation and treatment of urinary incontinence in the aging male

Risk of urinary incontinence (UI) increases with age and can have detrimental effects on patients and caregivers. UI should not be considered a normal part of aging and warrants a comprehensive evaluation. Treatment of UI in the aging male requires special consideration, particularly when it comes to comorbid conditions and potential side effects of intervention. The aim of this review is to discuss the evaluation of, risk factors for, and management of UI in the aging male.

Robotic-assisted simple prostatectomy versus open simple prostatectomy: a New York statewide analysis of early adoption and outcomes between 2009 and 2017

The factors driving early adoption of robotic-assisted simple prostatectomy (RASP) for large gland BPH have not yet been identified. This study aims to determine the patient, provider, and facility level differences and predictors in undergoing RASP versus OSP. This population-based cohort study used data from the all-payer New York State Statewide Planning and Research Cooperative System (SPARCS) database. Patient, provider, and facility characteristics for each cohort were analyzed, and a multivariate analysis was conducted to identify predictive factors associated with undergoing RASP versus OSP. From 2009 to 2017, 1881 OSP and 216 RASP cases were identified. RASP utilization increased from 2.6% of all cases in 2009 to 16.8% in 2017. Patient demographics were similar between both cohorts. Median length of stay was shorter for RASP patients (3 vs. 4 days, p < 0.001), and OSP was associated with a long length of stay (> 7 days) (p < 0.001). There were no significant differences in 30- and 90-day readmission rates or 1-year mortality. More OSP patients were discharged to continued care facilities than RASP patients (p = 0.049), and more RASP patients were discharged to home compared to OSP patients (p = 0.035). Positive predictors for undergoing RASP included teaching hospital status, medium and high hospital bed volume, high hospital operative volume, high surgeon volume, and surgeons that graduated within 15 years of surgery. As RASP shows favorable perioperative outcomes, the diffusion of robotic technology and newer graduates entering the workforce may augment the upward trend of RASP utilization.

Intermediate-term Urinary Function and Complication Outcomes After Robot-Assisted Simple Prostatectomy

OBJECTIVE

To assess the incidence of delayed complications after robot-assisted simple prostatectomy and evaluate postoperative lower urinary tract symptoms (LUTS) as a function of time with intermediate-term follow-up.

METHODS

We retrospectively reviewed 150 patients who underwent robot-assisted simple prostatectomy between May, 2013 and January, 2019. Indication for surgery was bothersome LUTS refractory to medical management and prostate volume ≥80 milliliters. The severity of LUTS was assessed using the International Prostate Symptom Score (IPSS) and quality of life (QOL) score. One-way analysis of variance test with post hoc Tukey's honest significant difference test was used to compare postoperative IPSS and QOL scores as a function of time; P <.05 was considered significant.

RESULTS

At a mean ± SD follow up of 31.3 ± 18.2 months, none of the patients developed a bladder neck contracture and none of the patients required reoperation for LUTS. Postoperatively, IPSS and QOL scores decreased with an increasing duration of follow up (P <.001). Mean IPSS and QOL scores improved between 2 weeks and 3 months postoperatively (P = .027 and P = .006, respectively). After 3 months postoperatively, mean IPPS and QOL scores stabilized and remained unchanged up to 36 months of follow-up (all P >.05).

CONCLUSION

Robotic simple prostatectomy is associated with a low incidence of delayed complications at a mean of 31.3 months postoperatively. After robotic simple prostatectomy, urinary function outcomes improve in the early postoperative period with maximal improvement occurring at 3 months. Excellent urinary function outcomes are durable up to at least 36 months postoperatively.

Robot-assisted simple prostatectomy versus open simple prostatectomy: a single-center comparison

Purpose

Open simple prostatectomy (OSP) is a standard surgical technique for patients with benign prostatic hyperplasia with prostate size larger than 80 ml. As a minimally invasive approach, robot-assisted simple prostatectomy (RASP) emerged as a feasible surgical alternative. Currently, there are no definite recommendations for the standard use of RASP. Therefore, we aimed at investigating various clinical outcomes comparing RASP with OSP.

Methods

In this retrospective single-center study, we evaluated clinical data from 103 RASP and 31 OSP patients. Both cohorts were compared regarding different clinical characteristics with and without propensity score matching. To detect independent predictive factors for clinical outcomes, multivariate logistic regression analysis was performed.

Results

Robot-assisted simple prostatectomy patients demonstrated a lower estimated blood loss and need for postoperative blood transfusions as well as less postoperative complications. OSP had a shorter operative time (125 min vs. 182 min) longer hospital stay (11 days vs. 9 days) and longer time to catheter removal (8 days vs. 6 days). In the multivariate analysis, RASP was identified as an independent predictor for longer operative time, lower estimated blood loss, shorter length of hospital stay, shorter time to catheter removal, less postoperative complications and blood transfusions.

Conclusion

Robot-assisted simple prostatectomy is a safe alternative to OSP with less perioperative and postoperative morbidity. Whether OSP (shorter operative time) or RASP (shorter length of hospital stay) has a more favorable economic impact depends on the particular conditions of different health care systems. Further prospective comparative research is warranted to define the value of RASP in the current surgical management of benign prostatic hyperplasia.

Holmium laser enucleation of the prostate for very large benign prostatic hyperplasia (≥ 200 cc)

PURPOSE

Patients presenting with prostate gland sizes greater than 200 cc pose a unique surgical challenge to both patients and surgeons. The objective of this study is to critically assess the efficacy and risks associated with performing holmium laser enucleation of the prostate (HoLEP) on glands ≥ 200 cc.

MATERIALS AND METHODS

Using a prospective maintained database, all consecutive benign prostatic hyperplasia (BPH) patients with gland size ≥ 200 cc who underwent HoLEP were included. We reported patient preoperative, intraoperative, postoperative outcomes and complications. Subgroup analysis of outcomes was stratified by gland sizes 200-299 cc and ≥ 300 cc. Univariate analysis using Kruskal-Wallis and Fisher exact test was performed to compare the two groups.

RESULTS

There were 88 patients with a mean preoperative gland size of 255.9 cc (200-770 cc). Mean operative (171 vs 182 min) and enucleation time (77 vs 83 min) were not different between the two subgroups (200-299 cc vs ≥ 300 cc). Enucleation efficiency was greater for glands ≥ 300 cc (2.6 cc/min vs 2.0 cc/min, p = 0.04). Morcellation time was longer in the ≥ 300 cc group (74.5 min vs 46.8 min, p = 0.021). Mean length of stay was 1.8 ± 1.2 days and catheter duration was 2.6 ± 2.7 days. 1 (1.1%) patient required retreatment of BPH at last follow-up. The main limitation of this study is the retrospective data analysis.

CONCLUSIONS

Holmium laser enucleation for prostate glands volume > 200 cc is feasible with minimal morbidity. These data further reinforce the size independence success of this procedure for BPH.

Value-based care for the treatment and evaluation of benign prostatic hyperplasia: an analysis of a metropolitan service area claims database

PURPOSE

With an aging population, cost containment and improved outcomes will be crucial for a sustainable healthcare ecosystem. Current data demonstrate great variation in payments for procedures and diagnostic workup of benign prostatic hyperplasia (BPH). To help determine the best financial value in BPH care, we sought to analyze the major drivers of total payments in BPH.

MATERIALS AND METHODS

Commercial and Medicare claims from the Truven Health Analytics Markestscan^® database for the Austin, Texas Metropolitan Service Area from 2012 to 2014 were queried for encounters with diagnosis and procedural codes related to BPH. Linear regression was utilized to assess factors related to BPH-related payments. Payments were then compared between surgical patients and patients managed with medication alone.

RESULTS

Major drivers of total payments in BPH care were operative, namely transurethral resection of prostate (TURP) [$2778, 95% CI ($2385-$3171), p < 0.001) and photoselective vaporization (PVP) ($3315, 95% CI ($2781-$3849) p < 0.001). Most office procedures were also associated with significantly higher payments, including cystoscopy [$708, 95% CI ($417-$999), p < 0.001], uroflometry [$446, 95% CI ($225-668), p < 0.001], urinalysis [$167, 95% CI ($32-$302), p = 0.02], postvoid residual (PVR) [$245, 95% CI ($83-$407), p < 0.001], and urodynamics [$1251, 95% CI ($405-2097), p < 0.001]. Patients who had surgery had lower payments for their medications compared to patients who had no surgery [$120 (IQR: $0, $550) vs. $532 (IQR: $231, $1852), respectively, p < 0.001].

CONCLUSION

Surgery and office-based procedures are associated with increased payments for BPH treatment. Although payments for surgery were more in total, surgical patients paid significantly less for BPH medications.

Comparison of the Transurethral Resection of the Prostate by Traditional Versus Preserved Urethral Mucosa of the Prostatic Apex

Background: Benign prostatic hyperplasia (BPH) is a common disease in elderly men. Transurethral resection of the prostate (TURP) is still the standard treatment for BPH. However, postoperative urinary incontinence (UI) is still one of the complications. Objective: This study aims to evaluate the clinical efficacy and safety of the TURP by traditional compared with preserved urethral mucosa of the prostatic apex (PUMPA). Materials and Methods: From July 2015 to June 2016, 80 patients with TURP were included and divided into the two groups: traditional nonpreserved urethral mucosa group (TURP group, n = 40) and the PUMPA group (PUMPA-TURP group, n = 40). This study identified the apex of the prostate and determined the cut position of mucosa. Then, we separated the preserved urethral mucosa, excised the hyperplastic prostate tissue, and trimmed the preserved urethral mucosa. Results: The rate of UI after PUMPA-TURP was significantly lower than that traditional TURP (0% vs 22.5%). The operative time was significantly shorter in the PUMPA-TURP group than traditional TURP group (50 ± 16.5 minutes vs 65 ± 18.5 minutes). The intraoperative bleeding loss was lower in the PUMPA-TURP group than traditional TURP group (280 ± 33 mL vs 190 ± 35 mL). International prostate symptom score, quality of life (QoL), and peak uroflowmetry data (Qmax) were similar between two groups. Conclusions: When compared with traditional TURP, PUMPA-TURP can reduce the occurrence of UI and intraoperative blood loss. Besides, PUMPA-TURP could shorten the operative time.

Laparoscopic simple prostatectomy: a large single-center prospective cohort study

BACKROUND

The aim of our study was to analyze outcomes and safety of laparoscopic simple prostatectomy (LSP) in a high-volume center.

METHODS

A consecutive series of men with lower urinary tract symptoms and large prostates (>80 cc) prospectively enrolled between November 2015 and December 2017 in one center. All patients underwent laparoscopic simple prostatectomy. Outcomes were evaluated considering the trifecta favorable outcome which was defined as a combination of the following items: 1) no perioperative complications; 2) postoperative IPSS <8; 3) postoperative Q<inf>max</inf> >15 mL/s. Complications were evaluated according to the modified Clavien classification system. Univariate and multivariate binary logistic regression was performed to identify predictors of a positive trifecta outcome.

RESULTS

Overall 272 patients were enrolled. At three months after surgery median IPSS total score was 4 (IQR: 3-7), median IPSS QoL was 1 (IQR:1-2), median prostate-specific antigen was 0.53 (IQR: 0.33-1.00) ng/ml and median Q<inf>max</inf> was 23 (IQR: 17-30) mL/s. All these parameters improved statistically when compared to baseline (P<0.001). The overall complication rate was 21% however most of the complications were low grade complications according to modified Clavien-Dindo classification (grade ≤2). Overall, 68% of the patients presented a positive trifecta outcome. On multivariate analysis only preoperative hemoglobin and hospital stay were confirmed predictors of positive trifecta outcome.

CONCLUSIONS

LSP represents a safe and effective procedure in the treatment of large adenomas. Although RCTs are needed before reaching definitive conclusions, LSP is a promising technique for patients with LUTS and large prostates.

Epidemiology and treatment modalities for the management of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is one of the most common conditions affecting men. BPH can lead to a number of symptoms for patients commonly referred to as lower urinary tract symptoms (LUTS). Over the last decade, increased modifiable risk factors, such as metabolic disease and obesity, have resulted in an increased incidence of BPH. This increasing incidence has brought about a multitude of treatment modalities in the last two decades. With so many treatment modalities available, physicians are tasked with selecting the optimal therapy for their patients. Current therapies can first be divided into medical or surgical intervention. Medical therapy for BPH includes 5-alpha-reductase inhibitors and alpha-blockers, or a combination of both. Surgical interventions include a conventional transurethral resection of the prostate (TURP), as well as newer modalities such as bipolar TURP, holmium laser enucleation of the prostate (HoLEP), Greenlight and thulium laser, and prostatic urethral lift (PUL). Emerging therapies in this field must also be further investigated for safety and efficacy. This narrative review attempts to consolidate current and emerging treatment options for BPH and highlights the need for additional investigation on optimizing treatment selection.

Initial experience with extraperitoneal robotic-assisted simple prostatectomy using the da Vinci SP surgical system

Robotic-assisted simple prostatectomy (RASP) has emerged as a safe and effective treatment option for symptomatic patients with lower urinary tract symptoms related to significant benign prostatic enlargement (BPE) above 80 g. The recent release of the da Vinci SP robotic system (Intuitive, Sunnyvale, CA, USA) continues to advance the minimally invasive nature of robotic surgical technology. We now report our institution's initial experience performing RASP using the da Vinci SP robotic system. An IRB-approved, retrospective chart review was performed of all patients undergoing robotic-assisted simple prostatectomy using the da Vinci SP surgical system in the treatment of benign prostatic enlargement by a single surgeon from March to June 2019. Pre-operative, intraoperative, and post-operative data were collected for descriptive analysis. A total of 10 men, mean age of 69 ± 4 years, with mean prostate volume of 104 ± 11 g underwent surgery. The robotic cannula and a single assistant port were utilized in all cases. No cases required conversion to a multi-port robotic platform or open approach, nor required the placement of additional assistant ports. No intraoperative or immediate post-operative complications were noted. Mean estimated blood loss was 141 ± 98 mL and operative time was 172 ± 19 min. Mean catheter time was 1.9 ± 1.8 days. One patient reported transient de novo stress urinary incontinence. Single-port RASP is a safe and effective intervention for BPE. The smaller surgical footprint from the device appears to make earlier catheter removal possible. Comparative evaluation with multi-port RASP and other modalities is warranted.