Enucleation, Vaporization, and Resection: How To Choose the Best Surgical Treatment Option for a Patient with Male Lower Urinary Tract Symptoms

A systematic review and meta-analysis of efficacy and safety comparing greenlight laser vaporization with transurethral resection of the prostate for benign prostatic hyperplasia with prostate volume less than 80 ml

We conducted a meta-analysis to evaluate the efficacy and safety of photo selective vaporisation of the prostate (PVP) with the GreenLight Laser versus transurethral resection of the prostate (TURP) for the treatment of small-volume benign prostatic hyperplasia (BPH). As of July 2022, relevant literature in online databases such as Cochrane Library, PubMed, and Embase was searched, including studies published on or before that date, and there were 9 studies in total, including 5 RCTs and 4 non-RCTs. In total 1525 patients were included to compare the efficacy of PVP and TURP in treating BPH. The Cochrane Collaboration criteria were used to evaluate the risk of bias. The software was used for random effect meta-analysis with RevMan 5.3. Data extraction included: clinical baseline characteristics, perioperative parameters, complication rates, International Prostate Symptom Score (IPSS), prostate specific antigen (PSA), post-void residual urine (PVR), maximum flow rate (Qmax), and quality of life (QoL). The pooled analysis showed that PVP was associated with reduced blood loss, blood transfusion, clot retention, catheterization time, definitive catheter removal, and hospital stay, but was associated with longer operative time and more severe dysuria (all p < 0.05). The results of this meta-analysis show that PVP as a technique for the treatment of benign prostatic hyperplasia with a volume of less than 80 cc has similar efficacy to standard TURP in IPSS, PSA, PVR, Qmax and QoL, and is an effective alternative. It outperformed TURP in terms of blood transfusion, catheterization time and hospital stay, while TURP is superior to PVP in terms of operation time.

Reaching a Tipping Point: A Qualitative Exploration of Quality of Life and Treatment Decision-Making in People Living With Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is a common condition amongst older men and is associated with lower urinary tract symptoms and erectile dysfunction; these symptoms can be burdensome and negatively affect quality of life. Various surgical and pharmaceutical treatment options exist but there is a paucity of qualitative research exploring men's decision-making when seeking BPH treatment. This study qualitatively explored men's experience of living with BPH and seeking treatment for BPH. Twenty men (aged 52-75) were recruited from outpatient urology clinics at a hospital trust in Southern England. Data were collected using semi-structured interviews (via video or telephone call) and were audio-recorded; transcripts were analysed using thematic analysis. Four themes were generated: 'Impacts are about more than just physical symptoms', 'The path towards treatment', 'The process of information gathering' and 'Navigating hopes, fears and uncertainty'. Results indicate most men appear to seek treatment for BPH following a gradual, and sometimes lengthy, period of deterioration in symptoms; for some men, however, treatment seeking follows an acute episode of sudden or severe symptoms. The decision to proceed with surgical or minimally invasive treatment options appears to be dependent on men reaching a tipping point; they no longer perceive their symptoms as tolerable and feel their ability to cope with symptoms is reduced. Men each bring their own set of concerns and preferences about side effects and risk-benefit profiles of different treatments. Clinicians need to be sensitive to these individual differences and incorporate them into shared decision-making for choosing between treatment options for BPH.

[Endoscopic enucleation of the prostate]

The spectrum of surgical procedures for the minimally invasive treatment of benign prostatic hyperplasia (BPH) has significantly increased over the last two decades. The simple suprapubic prostatectomy (subtotal prostatectomy, SP) has largely lost relevance in current practice. On the other hand, transurethral resection of the prostate (TURP) has been further standardized and potentially made safer by the introduction of the bipolar technique and low-pressure systems.Transurethral (endoscopic) enucleation techniques (endoscopic enucleation of the prostate, EEP) are increasingly competing with the current gold standard TURP and are replacing SP for treatment of larger adenomas. This approach is especially related to the rapid development of laser technology, which has sustainably changed the face of modern BPH treatment in a similar way to stone therapy. This has been incorporated in the clinical patient management, clinical studies and standardization of numerous surgical techniques that are systematically described in this article. Additionally, efforts have also been made to use other energy sources, such as bipolar current in EEP. With respect to scientific objectivity, high-quality clinical trials are regularly published which further strengthen the position of EEP.

Outcome of Photoselective Vaporization of the Prostate with the GreenLight-XPS 180 Watt System Compared to Transurethral Resection of the Prostate

The aim of this paper was to compare the perioperative and postoperative results of photoselective vaporization of the prostate with the GreenLight-XPS 180 Watt System (PVP) and transurethral resection of the prostate (TURP). This retrospective study included 140 men who underwent PVP and 114 men who underwent TURP for symptomatic benign prostate enlargement (BPE) between June 2010 and February 2015. The primary outcome measures were the patient reported outcome, operative results, International Prostate Symptom Score-Quality of Life (IPSS-QoL), complication rates, catheterization time, and length of hospital stay. The median follow-up times were 27 months (range 14-44) for the PVP group and 36 months (range 25-47) for the TURP group. The patient characteristics were well balanced in both groups with a median age of 71 years (PVP group) vs. 70 years (TURP group) and a comparable prostate volume (median 50 mL in the PVP group vs. 45 mL in the TURP group). The IPSS-QoL was significantly higher in the PVP group than in the TURP group (median 22 + 4; range 16-27 + 3-5 vs. median 19 + 3; range 15-23 + 3-4; p = 0.02). Men undergoing PVP were more likely to be on anticoagulants (PVP group n = 23; 16% vs. TURP group n = 2; 2%, p < 0.001). The median operation time (OT; min) for both procedures was comparable with 68 min (PVP group; range 53-91) vs. 67 min (TURP group; range 46-85). The rate of severe intraoperative bleeding was significantly lower in the PVP group than in the TURP group (n = 7; 5% vs. n = 16; 14%; p = 0.01). The postoperative catheterization time and length of hospital stay was significantly lower in the PVP group (median 1-2 days; range 1-4) vs. the TURP group (median 2-4 days; range 2-5; both p < 0.001). Complication rates (Clavien-Dindo classification ≥III) based on the follow-up data showed no statistically significant difference between the PVP group and the TURP group (n = 6; 4% vs. n = 6; 5%; p = 0.28). The IPSS on follow-up showed an equivalent reduction in symptoms for both treatment modalities (IPSS-QoL of 5 + 1; range 2-11 + 0-2 for both). There were no differences concerning urge (PVP group n = 3; 2% vs. TURP group n = 3; 3%; p = 0.90) and men were similarly satisfied with the postoperative outcome (PVP group 92% vs. TURP group 87%; p = 0.43). The PVP group was associated with a shorter hospitalization time and showed a reduced risk of bleeding, despite patients remaining on anticoagulants, without increasing the overall operative time. There was no difference in the patient reported outcome for both procedures.