Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention

Comparative analysis of the safety and efficacy of 1470-nm diode laser enucleation of the prostate and plasmakinetic resection of prostate in the treatment of large volume benign prostatic hyperplasia (>80 ml)

OBJECTIVE

To compare the efficacy and safety of 1470-nm diode laser enucleation of the prostate (DiLEP) with that of plasmakinetic resection of the prostate (PKRP) in treating patients with large benign prostatic hyperplasia (BPH > 80ml).

METHODS

The clinical data from 211 cases of BPH (>80 ml) were collected for analysis. The patients were divided into two groups: the PKRP group (n = 118) and the DiLEP group (n = 93), based on the surgical method used.

RESULT

The DiLEP group demonstrated significantly lower surgical time (p < 0.001), intraoperative bleeding (p < 0.001), bladder flushing time (p = 0.003), indwelling catheter time (p < 0.005), and length of hospital stay (p = 0.018) compared to the PKRP group. However, the quality of the prostatectomy was significantly higher in the DiLEP group (p = 0.005). The Qmax for the DiLEP group was significantly higher than that of the PKRP group (p < 0.05). Compared to the PKRP group, the incidence of urinary incontinence in the DiLEP group increased significantly 4 weeks post-surgery (p = 0.026), although the need for blood transfusion during surgery was significantly reduced (p = 0.037).

CONCLUSION

Both DiLEP and PKRP are safe and effective methods for treating large-volume BPH. However, DiLEP offers advantages such as more thorough glandular resection, shorter surgical time, reduced bleeding, quicker recovery, and fewer complications.

Future aspects of plant derived bioactive metabolites as therapeutics to combat benign prostatic hyperplasia

ETHNOPHARMACOLOGICAL RELEVANCE

Benign prostatic hyperplasia (BPH), characterized by prostate enlargement due to cell proliferation, is a common urinary disorder in men over 50, manifesting as lower urinary tract symptoms (LUTS). Currently, several therapeutic options are accessible for treating BPH, including medication therapy, surgery and watchful waiting. Conventional drugs such as finasteride and dutasteride are used as 5α-reductase inhibitors for the treatment of BPH. However long-term use of these drugs is restricted due to their unpleasant side effects. Despite the range of available medical therapies, the effective treatment against BPH is still inadequate. Certain therapeutic plants and their phytochemicals have the aforementioned goals and work by regulating this enzyme.

AIM OF THE STUDY

This review aims to provide a comprehensive insight to advancements in diagnosis of BPH, modern treatment methods and the significance of ethnobotanically relevant medicinal plants as alternative therapeutics for managing BPH.

MATERIAL AND METHODS

A thorough and systematic literature search was performed using electronic databases and search engines such as PubMed, Web of Science, NCBI and SciFinder till October 2023. Specific keywords such as "benign prostatic hyperplasia", "medicinal plants", "phytochemicals", "pharmacology", "synergy", "ethnobotany", "5-alpha reductase", "alpha blocker" and "toxicology". By include these keywords, a thorough investigation of pertinent papers was assured, and important data about the many facets of BPH could be retrieved.

RESULTS

After conducting the above investigation, 104 herbal remedies were found to inhibit Phosphodiesterase-5 (PDE-5) inhibition, alpha-blockers, or 5α -reductase inhibition effects which are supported by in vitro, in vivo and clinical trial studies evidence. Of these, 89 plants have ethnobotanical significance as alpha-blockers, alpha-reductase inhibition, or PDE-5 inhibition, and the other fifteen plants were chosen based on their ability to reduce BPH risk factors. Several phytocompounds, including, rutaecarpine, vaccarin, rutin, kaempferol, β-sitosterol, quercetin, dicaffeoylquinic acid, rutaevin, and phytosterol-F have been reported to be useful for the management of BPH. The use of combination therapy offers a strong approach to treating long-term conditions compare to single plant extract drugs. Furthermore, several botanical combinations such as lycopene and curcumin, pumpkin seed oil and saw palmetto oil, combinations of extracts from Funtumia africana (Benth.) Stapf and Abutilon mauritianum (Jacq.) Medik., and Hypselodelphys poggeana (K.Schum.) Milne-Redh. and Spermacoce radiata (DC.) Sieber ex Hiern are also supported through in vitro and in vivo studies for managing BPH through recuperation in patients with chronic long-term illnesses, as measured by the International Prostate Symptom Score.

CONCLUSION

The review proposes and endorses careful utilization of conventional medications that may be investigated further to discover possible PDE-5, 5 alpha-reductase, an alpha-blocker inhibitor for managing BPH. Even though most conventional formulations, such as 5 alpha-reductase, are readily available, systemic assessment of the effectiveness and mechanism of action of the herbal constituents is still necessary to identify novel chemical moieties that can be further developed for maximum efficacy. However, there exist abundant botanicals and medicinal plants across several regions of Africa, Asia, and the Americas, which can be further studied and developed for utilization as a potential phytotherapeutic for the management of BPH.

Application of root cause analysis and TEAMSTEPPS post intravesical gas explosion during transurethral resection of the prostate: a rare case report

BACKGROUND

An intravesical gas explosion is a rare complication of transurethral resection of the prostate (TURP). It was first reported in English literature in 1926, and up to 2022 were only forty-one cases. Injury from an intravesical gas explosion, in the most severe cases appearing as extraperitoneal or intraperitoneal bladder rupture needed emergent repair surgery.

CASE PRESENTATION

We present a case of a 75-year-old man who suffered an intravesical gas explosion during TURP. The patient underwent an emergent exploratory laparotomy for bladder repair and was transferred to the intensive care unit for further observation and treatment. Under the medical team's care for up to sixty days, the patient recovered smoothly without clinical sequelae.

CONCLUSIONS

This case report presents an example of a rare complication of intravesical gas explosion during TURP, utilizing root cause analysis (RCA) to comprehend causal relationships and team strategies and tools to improve performance and patient safety (TeamSTEPPS) method delivers four teamwork skills that can be utilized during surgery and five recommendations to avoid gas explosions during TURP to prevent the recurrence of medical errors. In modern healthcare systems, promoting patient safety is crucial. Once complications appear, RCA and TeamSTEPPS are helpful means to support the healthcare team reflect and improve as a team.

Adherence to Antimicrobial Prophylaxis Guidelines in Endourologic Procedures: Frequency and Related Outcomes

Background: Surgical antimicrobial prophylaxis (SAP), when used appropriately based on evidence-based guidelines, can reduce the rate of infectious complications following endourologic procedures without compromising patient outcomes. Objectives: To investigate the appropriateness of the current SAP used in endourologic surgeries based on international guidelines and report their associated outcomes (urinary tract infection [UTI] and blood stream infection [BSI]). Design: Prospective cross-sectional study. Methodology: The medical records of patients undergoing endourologic procedures were reviewed to assess healthcare providers' adherence to international guideline recommendations. Assessed parameters included indication, duration, choice, and dose of the antibiotics used in endourologic procedures in two medical centers in Amman/Jordan. Furthermore, patients were asked to conduct laboratory urine tests to determine the rate of infectious complications within one month post-procedure. Results: Three hundred and sixty-one patients were recruited for the study. The adherence rates to guidelines regarding indication, choice, and dose of pre-operative antibiotics were 90.3%, 2.8%, and 77.8%, respectively. The duration was concordant with guidelines in only 3.4% of participants. A total of 41.8% of patients completed follow-up. Among those, 4.6% developed bacterial UTIs, and 0.7% developed BSI. Conclusion: Adherence to SAP guidelines in endourologic procedures was far from optimal. Primary deviations in the implementation of guidelines' recommendations were pinpointed. These results are crucial for planning interventions that optimize SAP utilization.

Prostate Artery Embolization (PAE) with Small Beads for the Treatment of Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH) is the most frequent cause of Lower Urinary Tract Symptoms (LUTSs) in elderly populations. Minimally invasive treatments of BPH are safe and effective and are gaining popularity among both professionals and patients. Prostate Artery Embolization (PAE) has proven to be effective in Trans-Urethral Resection of the Prostate (TURP) in terms of prostate volume reduction and LUTS relief. PAE entails the selective catheterization of the prostatic artery and later embolization of distal vessels with beads of various calibers. Universal consensus regarding the ideal particle size is yet to be defined. We retrospectively evaluated 24 consecutive patients (median age: 75 years; range: 59-86 years) treated with PAE at our institution from October 2015 to November 2022. Particles of different sizes were employed; 12 patients were treated with 40-120 µm particles, 5 with 100 µm, 5 with 100-300 µm and 2 with 250 µm. Technical success, defined as selective prostate artery catheterization and controlled release of embolizing beads, was achieved in all patients. Removal vs. retention of the urinary catheter at the first post-procedural urological visit was the main clinical objective. No major peri-procedural complications were recorded, with 56% of patients successfully removing the urinary catheter.

Suprapubic Transvesical Adenoma Resection of the Prostate (STAR-P): A Novel Technique for Surgical Treatment of Benign Prostatic Hyperplasia

BACKGROUND AND OBJECTIVE

Several minimally invasive treatments have been developed to treat benign prostatic obstruction (BPO) via a transurethral approach, with a non-negligible risk of complications such as urethral stricture and external sphincter damage. Our aim was to present the Gozzi surgical technique for suprapubic transvesical adenoma resection of the prostate (STAR-P) for BPO and to assess its safety, feasibility, and outcomes.

METHODS

We conducted a retrospective analysis of 44 consecutive patients who underwent STAR-P for BPO. All the procedures were performed in a single private hospital by one surgeon from 2020 to 2022. An innovative resectoscope designed by the surgeon was subsequently produced by Tontarra Medizintechnik (Wurmlingen, Germany) with a 42.06 Fr external sheath that allows the use of loops of three different sizes. The instrument is inserted into the bladder via suprapubic access, which ensures greater freedom of movement without compromising the external sphincter. Clinical data were retrospectively collected. Preoperative and intraoperative variables, postoperative complications, and functional outcomes of the STAR-P procedure were assessed. A descriptive statistical analysis was performed.

KEY FINDINGS AND LIMITATIONS

No intraoperative complications were observed. Two patients (4.5%) experienced urinary urgency symptoms after catheter removal that resolved within 90 d. Median times were 105 min for surgery overall and 65 min for resection. All patients showed an improvement in voiding quality.

CONCLUSIONS AND CLINICAL IMPLICATIONS

STAR-P is a safe, feasible, and cost-effective procedure that spares the bulbomembranous and penile urethra and the external urethral sphincter, and should be discussed with patients as a possible option for treatment of BPO.

PATIENT SUMMARY

We describe a new, safe, and feasible technique for surgical treatment of urinary obstruction caused by a large prostate. Keyhole surgery is performed through the lower abdomen, which means that the urethra below the prostate is not damaged. Only a small scar of 2-3 cm in the lower abdomen is evident at the end of the healing process.

Persistent Lower Urinary Tract Symptoms After BPH Surgery

PURPOSE OF REVIEW

Lower urinary tract symptoms (LUTS) after surgical management for BPH pose a significant clinical challenge for urologists. Despite high success rates in relieving LUTS, there is a subset of patients who experience persistent symptoms after intervention. In this review article, we describe the management of patients with new or persistent LUTS after endoscopic bladder outlet surgery.

RECENT FINDINGS

Previously, the goal for BPH management was to remove as much adenomatous tissue as possible. While potentially effective, this may lead to unwanted side effects. There has been a recent paradigm shift for new minimally invasive surgical therapies (MIST) that strategically treat adenomatous tissue, adding potential complexity in managing patients with new or residual symptoms in the postoperative setting. There is a paucity of literature to guide optimal workup and care of patients with persistent LUTS after surgical management. We characterize patients into distinct groups, defined by types of symptoms, irritative versus obstructive, and timing of the symptomatology, short term versus long term. By embracing this patient-centered approach with shared decision management, clinicians can optimize outcomes efficiently improving their patients' quality of life.

Machine learning algorithm predicts urethral stricture following transurethral prostate resection

PURPOSE

To predict the post transurethral prostate resection(TURP) urethral stricture probability by applying different machine learning algorithms using the data obtained from preoperative blood parameters.

METHODS

A retrospective analysis of data from patients who underwent bipolar-TURP encompassing patient characteristics, preoperative routine blood test outcomes, and post-surgery uroflowmetry were used to develop and educate machine learning models. Various metrics, such as F1 score, model accuracy, negative predictive value, positive predictive value, sensitivity, specificity, Youden Index, ROC AUC value, and confidence interval for each model, were used to assess the predictive performance of machine learning models for urethral stricture development.

RESULTS

A total of 109 patients' data (55 patients without urethral stricture and 54 patients with urethral stricture) were included in the study after implementing strict inclusion and exclusion criteria. The preoperative Platelet Distribution Width, Mean Platelet Volume, Plateletcrit, Activated Partial Thromboplastin Time, and Prothrombin Time values were statistically meaningful between the two cohorts. After applying the data to the machine learning systems, the accuracy prediction scores for the diverse algorithms were as follows: decision trees (0.82), logistic regression (0.82), random forests (0.91), support vector machines (0.86), K-nearest neighbors (0.82), and naïve Bayes (0.77).

CONCLUSION

Our machine learning models' accuracy in predicting the post-TURP urethral stricture probability has demonstrated significant success. Exploring prospective studies that integrate supplementary variables has the potential to enhance the precision and accuracy of machine learning models, consequently progressing their ability to predict post-TURP urethral stricture risk.

Risk Factors for Bladder Neck Contracture following Transurethral Resection of the Prostate in Patients with Benign Prostatic Enlargement

INTRODUCTION

Benign prostatic enlargement (BPE) and lower urinary tract symptoms present challenges in aging men, often addressed through transurethral resection of the prostate (TURP). Despite technological advancements, bladder neck contracture (BNC) remains a concern. This study explores predictors, including comorbidities, influencing BNC after TURP.

METHODS

A retrospective cohort study at Changhua Christian Hospital analyzed 2041 BPE patients undergoing bipolar TURP. Preoperative urinary catheterization and resection speed were categorized. Patient data included demographics, comorbidities, operative details, and outcomes. Statistical analyses utilized χ2, Kruskal-Wallis tests, and Cox regression models.

RESULTS

Within 3 years, 306 (15%) patients developed BNC. Univariate Cox regression identified chronic heart failure (p = 0.033), chronic obstructive pulmonary disease (COPD; p = 0.002), preoperative urinary catheterization (p < 0.001), and low resection speed (p = 0.045) as significant BNC risk factors. Notably, COPD (p = 0.011) and preoperative urinary catheterization (p < 0.001) emerged as independent risk factors for BNC development in multivariate Cox regression analysis.

CONCLUSIONS

Preoperative urinary catheterization and COPD were significant predictors of BNC post-TURP, while resection speed showed no significant influence. These findings offer clinicians insights for risk assessment, enhancing patient outcomes, and optimizing resources post-TURP.

Aquablation versus HoLEP in patients with benign prostatic hyperplasia: a comparative prospective non-randomized study

PURPOSE

The question of best surgical treatment for lower urinary tract symptoms (LUTS) due to benign prostate hyperplasia (BPH) remains controversial. We compared the outcomes of aquablation and holmium laser enucleation of the prostate ("HoLEP") in a prospective cohort.

METHODS

Patients with BPH underwent aquablation or HoLEP according to their preference between June 2020 and April 2022. Prostate volume ("PV"), laboratory results, postvoid residual volume, uroflowmetry, IPSS, ICIQ-SF, MSHQ-EjD, EES and IIEF were evaluated preoperatively and at three, six and 12 months postoperatively. We also analyzed perioperative characteristics and complications via the Clavien Dindo ("CD") classification.

RESULTS

We included 40 patients, 16 of whom underwent aquablation and 24 HoLEP. Mean age was 67 years (SD 7.4). Baseline characteristics were balanced across groups, except the HoLEP patients' larger PV. IPSS fell from 20.3 (SD 7.1) at baseline to 6.3 (SD 4.2) at 12 months (p < 0.001) without differences between aquablation and HoLEP. HoLEP was associated with shorter operation time (59.5 (SD 18.6) vs. 87.2 (SD 14.8) minutes, p < 0.001) and led to better PV reduction over all timepoints. At three months, aquablation's results were better regarding ejaculatory (p = 0.02, MSHQ-EjD) and continence function (p < 0.001, ICIQ-SF). Beyond three months, erectile, ejaculatory, continence function and LUTS reduction did not differ significantly between aquablation and HoLEP. CD ≥ grade 3b complications were noted in six patients in aquablation group while only one in HoLEP group (p =  < 0.01).

CONCLUSIONS

While aquablation revealed temporary benefits regarding ejaculation and continence at three months, HoLEP was superior concerning operation time, the safety profile and volumetric results.

Efficacy of a Novel Prophylactic Scheme of Fosfomycin Trometamol in Patients Undergoing Endoscopic Surgery for Benign Prostatic Hyperplasia: Findings from a Prospective Monocentric Single-Arm Study

This study aimed to assess the efficacy of a novel prophylactic scheme of fosfomycin trometamol in patients undergoing elective HoLEP (holmium laser enucleation of the prostate) or TURP (transurethral resection of the prostate) procedures for treating benign prostatic hyperplasia. Patients affected by benign prostatic hyperplasia and undergoing elective HoLEP or TURP procedures during the period February 2022-June 2023 were prospectively enrolled. Two 3 g oral fosfomycin trometamol doses 12 h apart were administered at 8.00 p.m. on day -1 (i.e., the day before HoLEP or TURP procedure) and at 8.00 a.m. on day 0 (i.e., the day of the surgical procedure). The following outcomes were assessed: prevalence of fever occurring in the first 48 h after surgical procedure; prevalence of urological complications occurring after the surgical procedure; prevalence of proven urinary tract infections (UTIs) and/or bloodstream infections (BSIs) at 14 days post-procedure; and prevalence of emergency department admission for UTI-related sepsis at 14 days post-procedure. Univariate analysis comparing patients with and without proven UTI, BSI, or emergency department admission at 14 days post-procedure was carried out. Overall, 96 patients (median age 70 years) undergoing HoLEP (82.3%) or TURP (17.7%) were prospectively included. Median (IQR) time of surgical procedure after the morning fosfomycin dose was 226.5 min (range 88.5-393.75 min). Fever in the post-surgical 48 h occurred in 3/96 patients (3.1%). Prevalence of proven UTI at 14 days was as low as 1.0% (1/96), whereas no patient had proven BSI or UTI-related sepsis requiring emergency department admission at 14 days. Our findings support the contention that a prophylactic scheme based on two doses of fosfomycin trometamol 12 h apart before surgical intervention may represent a valuable strategy for preventing infectious complications in urologic patients undergoing HoLEP or TURP. Larger definitive confirmatory studies are warranted.

Short time (10 min) Catheter Traction Following TURP: IS it helpful with less morbidity?

INTRODUCTION

Transurethral Resection of Prostate (TURP) is the most common treatment for Benign Prostatic Hyperplasia (BPH). Blood loss during and after transurethral resection of the prostate (TURP) is a potential cause of morbidity and clot retention. Usual practise is to apply traction in every case of TURP to reduce early postoperative hematuria and clot retention. There are very few studies in the literature and they have mainly concentrated on the effect of traction on reducing blood loss but there is scanty data regarding the morbidity associated with the use of traction. Various authors have described their method of traction application. So, in this study, we will compare the result of short term (10 min) traction with standard (4-6 h) traction.

MATERIALS AND METHODS

It is a prospective comparative study with 50 participants, conducted at the department of Urology of a tertiary care hospital in eastern India after taking ethical clearance and consent from the patient. The patients attending urology O.P.D. with LUTS and diagnosed as BPH and planned for elective TURP and who had prolonged traction after TURP were excluded. Study period was one and the half year.

RESULTS

Post operatively 25 patients were managed with catheter traction while 25 patients were managed with short term traction of 10 min. Pain which is assessed by visual analog scale (VAS) at 2 and 4 h post operatively is statistically significant with p value of <0.05 and cut off of 65 g prostate volume is drawn below which the successful outcome of short term traction is feasible without any complications.

CONCLUSION

If hemostatsis is done properly then short term traction is preferable, safe and had fewer complications for prostate volume <65 g in comparison to standard traction TURP comparing the overall factors. Although, VAS score at 2 and 4 h post operatively shows patient experienced less pain even in prostate volume >65 g.

Evaluation of Current Surgical BPH Interventions for Young and Elderly Men

PURPOSE OF REVIEW

Benign prostatic hyperplasia affects the quality of life of a significant number of men, especially as they age. There are continuous innovations in the surgical management of benign prostatic hyperplasia, but many of these innovations are studied in the core population of men 50-70 years of age. This review focuses on the outliers of men aged 18-50 and 70 and older.

RECENT FINDINGS

Older populations have more comorbidities, higher rates of antithrombotic medications, and advanced symptoms. Properly selected older men can safely have significant objective and subjective improvement in their symptoms. The literature was scarce when evaluating younger men; however, ejaculatory preserving techniques are promising providing improvement in symptoms and preserving ejaculation. This review demonstrates that in properly selected elderly patients, improvements in quality of life while also providing safe surgical interventions can be achieved. Ejaculatory preservation techniques demonstrate promising results, but further studies are required to elucidate true outcomes.

Are adverse events during surgery for benign prostatic hyperplasia device related? A review of the MAUDE database

PURPOSE

The Manufacturer and User Facility Device Experience database contains anonymous, voluntary medical device reports. A review of device-related adverse events associated with Benign Prostatic Hyperplasia surgeries was completed. The objective was to evaluate the occurrence and contributing factors to clinically significant complications in a cohort of patients electing to undergo surgical intervention for Benign Prostatic Hyperplasia.

METHODS

The Manufacturer and User Facility Device Experience database was queried for "Aquablation, Greenlight Laser, Holmium Laser, Morcellator, Water Vapor Thermal Therapy, Loop Resection, and Prostatic Urethral Lift" from 2018 through 2021. A complication classification system (Level I-IV) based on the Clavien-Dindo system was used to categorize events. These events were then correlated with procedural technology malfunctions and classified as "device related" and "non-device related." Chi squared analysis was performed to identify associations between procedural technology and complication classification distribution.

RESULTS

A total of 873 adverse events were identified. The adverse events were classified into level I (minimal harm) versus levels II-IV (clinically significant). Aquablation (p < 0.017) and Water Vapor Thermal Therapy (p < 0.012) were associated with a higher proportion of reports with Level II-IV complications compared with other procedure types. Level II-IV complications were not associated with a reported device related malfunction.

CONCLUSIONS

Aquablation and water vapor thermal therapy demonstrated noteworthy clinically significant complications which were not driven by device-related malfunctions.

Outcomes of Ventral Onlay Buccal Mucosal Graft Urethroplasty in Bulbomembranous Urethral Strictures Post-transurethral Resection of the Prostate

OBJECTIVE

To evaluate the outcomes of ventral onlay buccal mucosal graft urethroplasty (VOBMGU) in bulbomembranous urethral strictures after transurethral resection of the prostate.

METHODS

After approval of the institutional ethical committee, we retrospectively examined the database of patients diagnosed with post-TURP urethral stricture (PTS) and treated by VOBMGU from January 2020 to January 2022. The patients were evaluated by retrograde urethrogram and voiding cystourethrogram. Follow-up evaluation included assessment of lower urinary tract symptoms, physical examination, uroflowmetry (Q-max and International Prostate Symptom Score) 3, 6, and 12months of follow-up.

RESULTS

A total of 30 patients underwent VOBMGU for bulbomembranous PTS were included. The median age of the patients was 63.5 (11.25). The median stricture length was 3.5 (1.5) cm. During follow-up, the mean Q-max significantly increased to 21.1 ± 5.5 mL/s (P < .0001), 20.1 ± 5.4 mL/s (P < .001), and 19.1 ± 5.3 mL/s (P < .003) at 3, 6, and 12months, respectively. IPSS significantly decreased to 8.93 ± 6.37 at the 12-month follow-up mark (P < .0001). Three patients developed stricture recurrence and two patients developed postoperative urinary incontinence.

CONCLUSION

VOBMGU in cases of bulbomembranous urethral PTS offered excellent functional outcomes with low stricture recurrence and minimal risk of incontinence. Further prospective studies are warranted to confirm the results.

Rezŭm water vaporization therapy versus transurethral resection of the prostate in the management of refractory urine retention: matched pair comparative multicenter experience

PURPOSE

To compare the efficacy of Rezūm with a matched cohort of patients undergoing transurethral resection of the prostate (TURP) for catheter-dependent urine retention secondary to benign prostate hyperplasia (BPH).

METHODS

A retrospective review was performed for consecutive catheter-dependent patients who underwent Rezūm for BPH. Patients were matched and compared with a similar cohort undergoing TURP, using non-inferiority analysis on propensity score-matched patient pairs. Patients were followed up at 1, 3, 6 and 12 months by international prostate symptoms score (IPSS), quality of life (QoL) index, peak flow rate (Qmax) and postvoid residual urine (PVR).

RESULTS

Eighty-one patients undergoing Rezūm were compared with equal number of matched patients who undergoing TURP. Patients undergoing Rezūm experienced significantly shorter operation time (25.5 ± 8.7 vs. 103.4 ± 12.6 min; p < 0.001), lower intraoperative bleeding (2.4% vs. 20.7%, p < 0.001), shorter hospital stay (1.2 ± 0.9 vs. 2.4 ± 1.3 d, p < 0.001) and longer catheter time (12.6 ± 6.0 vs. 2.3 ± 1.2 d, p < 0.001), with no need for transfusion. Successful postoperative voiding was comparable between both arms (90.2% vs. 92.7%, p = 0.78), respectively. Despite patients undergoing TURP had significantly better voiding outcomes after 1 and 3 months, both groups were comparable after six and 12 months in terms of mean IPSS (11.1 ± 6.4 vs. 10.8 ± 3.4, p = 0.71), QoL indices (2.4 ± 1.6 vs. 2.1 ± 2.3, p = 0.33) and Qmax (22.0 ± 7.7 v. 19.8 ± 6.9 ml/sec, p = 0.06).

CONCLUSION

This study supports the safety and efficacy of Rezūm in the management of catheter-dependent patients secondary to BPH, with comparable functional outcomes to TURP. Until a randomized clinical comparison is available, long-term data are crucially recommended to compare the recurrence and reoperation rates.

Temporary implantable nitinol device for benign prostatic hyperplasia-related lower urinary tract symptoms: over 48-month results

BACKGROUND

This study (MT02) reports >48-month (50-79 months) results of a prospective, single-arm, multicenter study (NCT02145208) of temporary implantable nitinol device (iTind®) in men with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS).

METHODS

Men with symptomatic BPH (International Prostate Symptom Score [IPSS] ≥10, Maximum flow rate [Qmax] <12 mL/s, and prostate volume <75 mL) from 9 centers were enrolled from December 2014 to December 2016. Total 50/81 (62%) patients at 3/9 sites (Italy, Switzerland, and Belgium), pursued the study beyond 36 months following iTind® device, per study protocol. Due to COVID-19, follow-up was amended. Each patient was assessed once during 50-79 months postoperatively for IPSS and IPSS-quality of life (IPSS-QoL), change in medication, need for surgical re-treatment and adverse events telephonically.

RESULTS

Post 36 month-follow-up, 5 patients were lost to follow-up and 2 patients died unrelated to iTind® device placement. Two patients (36-48 months follow-up) required surgical re-treatments (1 transurethral resection of prostate, 1 Thulium laser enucleation of prostate). >48 months results were available for 41 patients wherein iTind® device treatment showed significant improvement in symptoms (IPSS: -45.3%, P<0.0001 and IPSS-QoL: -45.1%, P<0.0001) from baseline to 79 months post-procedure; mean±SD of 11.26±7.67 and 2.10±1.41 points, respectively. No complications were recorded between 36 up to 79 months; no patient required additional medication.

CONCLUSIONS

iTind® device provided significant and durable symptom reduction and improved IPSS-QoL for >48 months post treatment. No late postoperative complications were reported beyond 36 months of follow-up. Surgical re-treatment rate for >36 months was 4%.

Perioperative and functional outcomes of salvage versus primary Holmium laser enucleation of the prostate: Evidence-based on controlled studies

To evaluate the perioperative and functional outcomes of holmium laser enucleation of the prostate (HoLEP) among patients with and without prior transurethral prostate surgery. we performed a systematic search of the Cochrane Library, PubMed, Embase, Web of Science and Scopus databases for articles evaluating the effectiveness of salvage HoLEP (S-HoLEP) versus primary HoLEP (P-HoLEP) until January 2023. Nine studies involving 6044 patients were included for both quantitative and qualitative analysis. Compared with P-HoLEP, S-HoLEP used more energy (weighted mean difference = 14.27 KJ; 95% CI = 4.75-23.79; P = 0.003) and had an increased incidence of postoperative clot retention (odds ratio = 2.12; 95% CI = 1.25-3.59; P = 0.005) and urethral stricture (OR = 1.99; 95% CI = 1.04-3.8; P = 0.04). However, the International Prostate Symptom Score at the sixth month of follow-up was significantly lower for S-HoLEP than for P-HoLEP (WMD = -0.80; 95% CI = -1.38 to -0.22; P = 0.007). There was no significant difference between S-HoLEP and P-HoLEP in terms of operative time, enucleation time, enucleation efficiency, morcellation time, resected weight, catheterisation time, hospital stay duration, quality of life, maximum urinary flow rate, postvoid residual and intraoperative and postoperative overall complications. compared with P-HoLEP, S-HoLEP is still a feasible and effective method for treating residual benign prostatic hyperplasia, with only a slight increase in the probability of energy utilisation, clot retention and urethral stricture. Despite these minor discrepancies, the overall beneficial effects of the two modalities on symptom resolution is noteworthy.

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.

Short- and long-term risks of photoselective laser vaporization of the prostate: a population-based comparison with transurethral resection of the prostate

BACKGROUND

Transurethral resection of the prostate (TURP) is the standard surgical treatment for benign prostate enlargement (BPE). Photoselective vaporization of the prostate (PVP) is an alternative, but there is limited real-life evidence of PVP risks.

OBJECTIVE

To compare short- and long-term risks of PVP to those of TURP in the treatment of BPE.

MATERIALS AND METHODS

Consecutive patients who underwent elective PVP or TURP between 2006 and 2018 in 20 hospitals in Finland were retrospectively studied using a combination of national registries (n = 27,408; mean age 71 years). Short-term risks were postoperative mortality, major adverse cardiovascular events (MACE), and reoperations for bleeding. Long-term risks were reoperations for BPE or any urethral operations within 12 years. Differences between treatment groups were balanced by inverse probability of treatment weighting. Risks were analyzed using the Kaplan-Meier method and Cox regression.

RESULTS

There were no differences in postoperative mortality or MACE between the study groups. Reoperations for bleeding were less frequent after PVP (0.9%, HR: 0.72, p = 0.042). Bleeding was more likely in patients with atrial fibrillation (number needed to treat [NNT] for PVP vs TURP: 61). Cumulative incidence for reoperation was higher after PVP (23.5%) than after TURP in long-term follow-up (17.8%; HR: 1.20, p < 0.0001, NNT: -31.7).

CONCLUSIONS

PVP is associated with lower postoperative bleeding risk but higher long-term reoperation risk than TURP. Patients with high bleeding risk and a low likelihood of needing reoperation appear most suitable for laser vaporization.KEY MESSAGEPVP is associated with lower postoperative bleeding risk but higher long-term reoperation risk than TURP. PVP appears an attractive treatment option, especially for patients with high bleeding risk and a low likelihood of needing a reoperation.

The effect of tranexamic acid on perioperative blood loss in transurethral resection of the prostate: A double-blind, randomized controlled trial

BACKGROUND

Bleeding and bleeding-related complications remain common after bipolar transurethral resection of the prostate (TURP) for benign prostatic hyperplasia. This may possibly lead to prolonged postoperative irrigation, catheterization, and hospital stay. The objective of this trial was to evaluate the effect of high-dose tranexamic acid (TXA) on perioperative blood loss in patients treated with bipolar TURP for prostate sizes between 30 and 80 g.

METHODS

We conducted a single-center, prospective, double-blind, randomized controlled trial. Eighty patients were screened for inclusion between March 2020 and January 2023. After exclusion, 65 patients were randomized in two comparable groups. The TXA group (31 patients) received a TXA intravenous loading dose of 10 mg/kg over 30 min before induction, followed by a maintenance dose of 5 mg/kg/h over 12 h. The placebo group (34 patients) received an equal dose of saline infusion. We measured age, weight, preoperative prostate size, anticoagulant use, 5-alpha reductase inhibitor use, preoperative urinary tract infection, American Society of Anesthesiologists score, difference in pre- and 24 h postoperative hemoglobin and hematocrit levels, operative time, resected adenoma weight, duration of postoperative irrigation, total amount of postoperative irrigation fluid, indwelling catheter time, duration of hospital stay, blood transfusion rate, and 4-week complication rate.

RESULTS

Baseline characteristics in both groups were comparable. Postoperative hemoglobin decrease in TXA versus placebo group was 1 versus 1.6 mg/dL, respectively (p = 0.04). In addition, the amount of postoperative irrigation fluid (10.7 vs. 18.5 L), irrigation time (24.3 vs. 37.9 h), catheterization time (40.8 vs. 53.7 h), and hospital stay (46.9 vs. 59.2 h) were statistically significant in favor of TXA use. No blood transfusions were carried out. Four-week complication rate was comparable between the two groups.

CONCLUSIONS

Perioperative high-dose TXA seems beneficial in reducing hemoglobin loss, postoperative irrigation, catheterization time, and hospital stay in bipolar TURP for prostate sizes between 30 and 80 g, without increased risk of TXA-related thromboembolic events.

Virtual screening approach for the discovery of selective 5α-reductase type II inhibitors for benign prostatic hyperplasia treatment

Background: 5α-Reductase type II (5αR2) inhibition is a promising strategy for benign prostatic hyperplasia treatment. A computational approach including virtual screening, ligand-based 3D pharmacophore modeling, 2D quantitative structure-activity relationship and molecular docking simulations were adopted to develop novel inhibitors. Results: Hits were first filtered via the validated pharmacophore and 2D quantitative structure-activity relationship models. Docking on the recently determined cocrystallized structure of 5αR2 showed three promising hits. Visual inspection results were compared with finasteride ligand and dihydrotestosterone as reference, to explain the role of binding to Glu57 and Tyr91 for 5αR2 selective inhibition. Conclusion: Alignment between Hit 2 and finasteride in the binding pocket showed similar binding modes. The biological activity prediction showed antitumor and androgen targeting activity of the new hits.

Transurethral columnar balloon dilation of the prostate combined with holmium laser incision for bladder neck contracture in day-surgery mode

The study aimed to investigate the clinical effect of transurethral columnar balloon dilation of the prostate combined with holmium laser in the treatment of bladder neck contracture (BNC). This retrospective study included 41 patients with BNC, who had been treated with transurethral columnar balloon dilation and holmium laser in our hospital from June 2020 to June 2022. Admission, operation, and discharge of all the patients were completed in 24 h. The patients' satisfaction, postoperative complications, and chronic pain after operation were followed up. Clinical parameters, such as International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), quality of life (QoL), and post-void residual volume (PVR) in pre-operation, 1 month and 6 months after operation were recorded. All patients underwent the operations successfully. Six patients experienced urge incontinence and one patient experienced recurrence of BNC after 12 months. At 1 month and 6 months after the operation, IPSS, QoL, PVR, and Qmax of the patients were significantly better than those before the operation (P < 0.05). Transurethral columnar balloon dilation of the prostate combined with holmium laser can effectively treat BNC with simple performance and satisfactory clinical effects. It is a minimally invasive treatment that can be conducted by simple day surgery.

Pathogen species are the risk factors for postoperative infection of patients with transurethral resection of the prostate: a retrospective study

This study aimed to analyze the infection risk factors for transurethral resection of the prostate (TURP) and establish predictive models to help make personalized treatment plans. Our study was designed one-center and retrospectively enrolled 1169 benign prostatic hyperplasia (BPH) patients. Risk factors were explored for postoperative infection. A TURP-postoperative infection (TURP-PI) model with infection prediction values was created. The improved-TURP-PI (I-TURP-PI) model, including extra new factors (pathogens species), was also built to see whether it could optimize the prediction abilities. At last, we developed a nomogram for better clinical application. Operation time, preoperative indwelling urinary catheter (PIUC), and positive preoperative urine culture were independent risk factors (all P < 0.05). Interestingly, pathogens species in pre-surgery urine (PEnterococcus faecium = 0.014, PPseudomonas aeruginosa = 0.086) were also independent risk factors. Patients with positive Enterococcus faecium (37.50%) were most likely to have postoperative infection. We built two models with AUCTURP-PI = 0.709 (95% CI 0.656-0.763) and AUCI-TURP-PI = 0.705 (95% CI 0.650-0.760). The nomogram could help improve the prediction ability. To our knowledge, our study is the first to use pathogen species in urine before surgery as risk factors for infection prediction after TURP. TURP-PI and I-TURP-PI models have essential roles in predicting patients' postoperative infections and in better postoperative antibiotic decision-making.

Reoperation after surgical treatment for benign prostatic hyperplasia: a systematic review

Context

Surgical treatment is important for male lower urinary tract symptom (LUTS) management, but there are few reviews of the risks of reoperation.

Objective

To systematically evaluate the current evidence regarding the reoperation rates of surgical treatment for LUTS in accordance with current recommendations and guidelines.

Evidence acquisition

Eligible studies published up to July 2023, were searched for in the PubMed® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), and Web of Science™ (Clarivate™, Philadelphia, PA, USA) databases. STATA® (StataCorp LP, College Station, TX, USA) software was used to conduct the meta-analysis. Random-effects models were used to calculate the pooled incidences (PIs) of reoperation and the 95% confidence intervals (CIs).

Evidence synthesis

A total of 119 studies with 130,106 patients were included. The reoperation rate of transurethral resection of the prostate (TURP) at 1, 2, 3, and 5 years was 4.0%, 5.0%, 6.0%, and 7.7%, respectively. The reoperation rate of plasma kinetic loop resection of the prostate (PKRP) at 1, 2, 3, and 5 years was 3.5%, 3.6%, 5.7%, and 6.6%, respectively. The reoperation rate of holmium laser enucleation of the prostate (HoLEP) at 1, 2, 3, and 5 years was 2.4%, 3.3%, 5.4%, and 6.6%, respectively. The reoperation rate of photoselective vaporization of the prostate (PVP) at 1, 2, 3, and 5 years was 3.3%, 4.1%, 6.7%, and 7.1%, respectively. The reoperation rate of surgery with AquaBeam® at 1, 2, 3, and 5 years was 2.6%, 3.1%, 3.0%, and 4.1%, respectively. The reoperation rate of prostatic artery embolization (PAE) at 1, 2, 3, and 5 years was 12.2%, 20.0%, 26.4%, and 23.8%, respectively. The reoperation rate of transurethral microwave thermotherapy (TUMT) at 1, 2, 3, and 5 years was 9.9%, 19.9%, 23.3%, and 31.2%, respectively. The reoperation rate of transurethral incision of the prostate (TUIP) at 5 years was 13.4%. The reoperation rate of open prostatectomy (OP) at 1 and 5 years was 1.3% and 4.4%, respectively. The reoperation rate of thulium laser enucleation of the prostate (ThuLEP) at 1, 2, and 5 years was 3.7%, 7.7%, and 8.4%, respectively.

Conclusion

Our results summarized the reoperation rates of 10 surgical procedures over follow-up durations of 1, 2, 3, and 5 years, which could provide reference for urologists and LUTS patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023445780.

Transurethral resection of the prostate (TURP) versus transperineal laser ablation (TPLA) due to benign prostatic hyperplasia (BPH): prospective and comparative study

AIM

We aimed to compare the first-year results of Transurethral resection of the prostate (TURP), the gold standard method, and Transperineal laser ablation (TPLA) techniques.

MATERIAL AND METHODS

This study was designed as a prospective, randomized, controlled, and single-center and was conducted between November 2021 and February 2023. TURP candidates were included in the study. Demographic data and perioperative data were recorded. Preoperative and first-year International Prostate Symptom Score (IPSS), International Erectile Function Index (IIEF-5), Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD), QoL, peak urinary flow rate (Qmax), prostate volume (PV) and postvoid residual (PVR) data were recorded.

RESULTS

Fifty patients were included in the study and were assigned to equal numbers of groups. TPLA group had a higher ASA score (p = 0.03). There was improvement in IPSS, Qmax, and PVR parameters compared to baseline values in both groups at 1 year (p < 0.01). The improvement in Qmax was better in the TURP group (p < 0.01). IIEF-5 score was similar between groups (p = 0.83 and p = 0.12, respectively). The MSHQ scores in the first year did not change according to their baseline values in the TPLA group (p = 0.54 and p = 0.34, respectively).

CONCLUSION

According to the first-year results of TPLA, the symptomatic improvement effect without sacrificing ejaculatory functions is comparable to TURP. We think that this method will can be an alternative, especially for patients who want to avoid ejaculatory dysfunction, who have a high risk of anesthesia, and whose anticoagulant/antiplatelet therapy cannot be discontinued.

A scoping review of office-based prostatic stents: past, present, and future of true minimally invasive treatment of benign prostatic hyperplasia

PURPOSE

To conduct a scoping review of the existing literature and recent developments on prostatic stents for the treatment of benign prostatic hyperplasia (BPH).

METHODS

A comprehensive search was performed on Embase, MEDLINE, and Web of Science to identify English literature on prostatic stents for the treatment of BPH. Additional studies and upcoming devices were identified through grey literature search and expert consultation. Study characteristics and stent information were extracted and tabulated narratively.

RESULTS

Of the 1171 search results, 64 studies were included in this review. iTiND was the prostatic stent with the most long-term evidence. iTiND is a safe and effective minimally invasive treatment for BPH that preserves sexual function. Adverse events are mild and transitory. Emerging stents (e.g. Zenflow, Butterfly, Urocross, and Exime) had 7/64 eligible studies, where no studies had long-term follow-up. These newer stents show promising results for quality of life and BPH symptom management; however, long-term monitoring and head-to-head comparisons are needed.

CONCLUSION

Over the last 50 years, prostatic stents have evolved and demonstrated improved clinical efficacy. iTiND provides a safe and effective outpatient treatment of LUTS secondary to BPH preserving erectile and ejaculatory function. Emerging prostatic stents are a promising, effective, and safe intervention in well-selected patients interested in its benefits.

Combination of 180-W GreenLight XPS laser and bipolar transurethral resection of prostate for the treatment of large prostates beyond 100 ml: a novel hybrid technique

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate the safety and efficacy of the 180-W GreenLight laser (GL) XPS™ plus bipolar transurethral resection of the prostate (TURP) for the treatment of a prostate volume (PV) beyond 100 ml.

STUDY DESIGN/MATERIALS AND METHODS

From January 2014 to December 2022, 79 patients with PV > 100 ml who underwent GL-XPS plus bipolar TURP were enrolled. The median follow-up time was 13.7 months. The International Prostate Symptom Score (IPSS), PV, uroflow study, post-void residual (PVR) volume, and prostate-specific antigen (PSA) before and after the operation were recorded. Subgroup analysis was performed to compare the outcomes between the patients with follow-up times of < 36 months and > 36 months.

RESULTS

Statistically significant improvements in all the postoperative parameters were observed in both < 36 months and > 36 months groups. There was no blood transfusion or transurethral resection (TUR) syndrome in this series. Most of all, a second TURP was unnecessary during the follow-up. Only one (1.3%) Clavien-Dindo grade 3b complication was noted.

CONCLUSIONS

The hybrid technique of 180-W XPS™ GreenLight laser plus bipolar TURP can be safely and efficiently performed on patients with a prostate volume of > 100 ml.

Treatment Algorithm for Management of Benign Prostatic Obstruction: An Overview of Current Techniques

The management of benign prostatic obstruction (BPO) should involve a treatment algorithm that takes into account prostate size, and patient's symptoms and preference with the aim of helping with urinary symptoms and enhance quality of life. The diagnostic assessment for men with lower urinary tract symptoms (LUTS) should be comprehensive to help choose the best management strategy. Strategies from lifestyle modifications to medical treatment with alpha blockers and/or 5-alpha-reductase inhibitors to surgical procedures can all be used in the management algorithm. Surgical management ranges from transurethral resection of prostate (TURP) to minimally invasive surgical therapies (MIST) including laser therapies such as Holmium laser enucleation (HoLEP) and photoselective vaporisation (PVP), aquablation, Rezūm system, prostate artery embolisation (PAE), prostatic urethral lift (PUL), temporary implantable nitinol device (iTind) and Optilume BPH catheter system. BPO is a common urological condition that has a significant impact on quality of life and economic burden globally and is likely to become increasingly prevalent with an ageing population. Selecting the most appropriate treatment modality will depend on the individual patient preferences, availability of resources, cost, anatomical factors and the goals of treatment.

Treating overactive bladder symptoms after transurethral prostatic surgery for benign prostatic hyperplasia - Which medication to choose?

Objectives

Overactive bladder (OAB) symptoms are often encountered in patients after transurethral resection of the prostate (TUR-P) or transurethral incision of the prostate (TUI-P) for benign prostatic obstruction (BPO). Either antimuscarinics or β-3 agonist has been found effective in relieving OAB symptoms. However, urologists usually do not prescribe such medication immediately after TUR-P or TUI-P to avoid an increase in postvoid residual and risk of urinary tract infection. If OAB medication can be used and adverse events (AEs) can be reduced to minimum, patients' quality of life after bladder outlet obstruction surgery could be improved. This study compared the safety and efficacy between solifenacin and mirabegron in men undergoing TUR-P or TUI-P.

Materials and Methods

This prospective, randomized trial compared the safety and efficacy of OAB medication on the reduction in Urgency Severity Score (USS), OAB Symptoms Score (OABSS), International Prostate Symptom Score, and urgency urinary incontinence episodes in men with BPO undergoing surgical intervention. All patients could void smoothly after catheter removal and were randomly received daily solifenacin 5 mg, mirabegron 50 mg, or no interventions for 4 weeks. At 2 and 4 weeks postoperatively, participants' OAB symptoms and AEs were evaluated.

Results

A total of 57 men were enrolled in this study with a mean age of 70.8 ± 6.1 years. At 2 weeks postoperatively, USS (1.56 ± 1.72 vs. 2.39 ± 1.72 vs. 2.26 ± 1.73, P < 0.011) and OABSS (5.33 ± 3.65 vs. 7.67 ± 4.19 vs. 8.58 ± 4.31, P < 0.000) were significantly reduced in patients taking solifenacin, mirabegron, or control, respectively. Two patients in the solifenacin group developed urinary retention. However, the changes of variables at 4 weeks postoperatively were insignificant among the three groups.

Conclusion

Solifenacin and mirabegron are two different drug classes both equally effective in treating immediate OAB symptoms after TUR-P or TUI-P. However, OAB symptoms could be relieved at 4 weeks without any medication. Considering AEs, β-3 agonist has a more favorable safety profile than antimuscarinics.

Outcome of transurethral resection of the prostate (TURP) using 5% dextrose water as irrigant

Background

TURP remains the gold standard for simple prostatectomy presently. Different fluids have been used for irrigation while performing monopolar TURP. The choice of irrigation fluid depends on a lot of factors.

Aim

We sought to find out if the outcome of monopolar TURP using 5% dextrose water in our setting compares with findings in other studies using different fluids as irrigation fluid in monopolar TURP.

Materials and Methods

This was a prospective study of 220 patients who had monopolar TURP using 5% dextrose water as irrigation fluid from 2015 to 2020.

Results

The study was completed by 220 patients. The mean age was 66.25 yrs. The mean weight of prostate was 53.2 g, and mean resected weight was 30.10 g using a mean irrigation volume of 45.35 liters, 5% dextrose water over a mean resection time of 66.08 mins. The mean changes in International Prostate Symptom Score/quality of life score (IPSS/QOLS) were statistically significant. Early complications recorded were postoperative hematuria with clot retention (1.4%), urinary tract infection (UTI) (13.2%), and secondary hemorrhage (10%). TURP syndrome was not recorded. Late complications seen within 2 years follow-up were transient urinary incontinence (6.4%), urethral stricture (4.1%), and bladder neck contracture (2.3%). There was no repeat TURP for residual adenoma within this period.

Conclusion

TURP using 5% dextrose water has comparable outcomes to other irrigation fluids for monopolar TURP. It is a good alternative to any other irrigation fluid.

Ocular abscess: An extremely rare complication of transurethral resection of the prostate

Ocular abscess following transurethral resection of the prostate is an rare complication. We report the case of a male who developed an ocular abscess with purulent melting of the eye after undergoing TURP for benign prostatic hyperplasia. The patient successfully underwent the TURP procedure. However, he developed a right epididymitis and subsequently an ocular abscess on the same side. Treatment involved dual antibiotic therapy for the epididymitis, followed by incision of the ocular abscess and intravenous antibiotics. Multidrug-resistant Escherichia coli was identified in both ocular and postoperative urine cultures. This case highlights the rarity and potential serious complications following TURP.

Does previous transurethral resection of the prostate negatively influence subsequent robotic-assisted radical prostatectomy in men diagnosed with prostate cancer? A systematic review and meta-analysis

It is not uncommon to incidentally discover prostate cancer during the transurethral resection of the prostate (TURP) for the treatment of benign prostatic hyperplasia and necessitate a subsequent robotic-assisted radical prostatectomy (RARP). The study aims to evaluate whether TURP have negative influence on subsequent RARP. Through a literature search using MEDLINE, EMBASE and the Cochrane Library, 10 studies with 683 patients who underwent RARP after previous TURP and 4039 patients who underwent RARP only were identified for the purposes of the meta-analysis. Compared to standard RARP, RARP after TURP was related to longer operative time (WMD: 29.1 min, 95% CI: 13.3-44.8, P < 0.001), more blood loss (WMD: 49.3 ml, 95% CI: 8.8-89.7, P = 0.02), longer time to catheter removal (WMD: 0.93 days, 95% CI: 0.41-1.44, P < 0.001), higher rates of overall (RR: 1.45, 95% CI: 1.08-1.95, P = 0.01) and major complications (RR: 3.67, 95% Cl: 1.63-8.24, P = 0.002), frequently demand for bladder neck reconstruction (RR: 5.46, 95% CI: 3.15-9.47, P < 0.001) and lower succeed in nerve sparing (RR: 0.73, 95% CI: 0.62-0.87, P < 0.001). In terms of quality of life, there are worse recovery of urinary continence (RR of incontinence rate: RR: 1.24, 95% CI: 1.02-1.52, P = 0.03) and potency (RR: 0.8, 95% CI: 0.73-0.89, P < 0.001) at 1 year in RARP with previous TURP. In addition, the RARP with previous TURP had greater percentage positive margins (RR: 1.24, 95% CI: 1.02-1.52, P = 0.03), while there is no difference in length of stay and biochemical recurrence rate at 1 year. RARP is feasible but challenging after TURP. It significantly increases the difficulty of operation and compromises surgical, functional and oncological outcomes. It is important for urologists and patients to be aware of the negative impact of TURP on subsequent RARP and establish treatment strategies to lessen the adverse effects.

Comparison of holmium laser enucleation and transurethral resection of prostate in benign prostatic hyperplasia: a systematic review and meta-analysis

Transurethral resection of the prostate (TURP) is the gold-standard classical method for the treatment of benign prostatic hyperplasia (BPH). In minimally invasive surgery, holmium laser enucleation of the prostate (HoLEP) is considered an alternative option. In this systematic review and meta-analysis, we aimed to comprehensively evaluate the advantages and disadvantages of TURP and HoLEP the treating BPH. We comprehensively searched PubMed, Cochrane Library, EMBASE, and Web of Science databases for all randomized controlled trials published before 1 December 2022 comparing HoLEP and TURP. The study protocol is registered on INPLASY (DOI: 10.37766/inplasy2023.5.0065). Compared with TURP, HoLEP required longer operation time but shorter catheter duration, hospital stay, and bladder irrigation time, as well as less postoperative irrigation. With HoLEP, maximum urinary flow rate at 12 and 24 months after surgery; post-void residual volume at 1, 6, and 12 months; and International Prostate Symptom Score at 12 months after surgery were superior to those with TURP. HoLEP was associated with significantly lower risk of hyponatremia, blood transfusion, and urethral stricture but greater risk of postoperative dysuria. Compared with TURP, HoLEP had better curative efficacy at 6, 12, and 24 months after operation and lower incidence of adverse events in patients with BPH.

Durable benefit after treatment of obstructive benign prostatic hyperplasia with a novel drug-device combination product: 2-year outcomes from the EVEREST-I study

PURPOSE

To evaluate the safety and efficacy of the Optilume BPH Catheter System for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

METHODS

This open-label, single-arm study enrolled eighty subjects with LUTS secondary to BPH who were treated with the Optilume BPH Catheter System. Symptoms were recorded utilizing the International Prostate Symptom Score (IPSS) and Benign Prostatic Hyperplasia Impact Index (BPH-II). Functional improvement was measured utilizing peak urinary flow rate (Qmax) and post-void residual urine volume (PVR). Adverse events were systematically captured and reported at each follow-up visit.

RESULTS

Subjects treated with the Optilume BPH Catheter System experienced a significant improvement in LUTS from baseline through 2 years of follow-up, as measured by IPSS (22.3 vs 8.2, p < 0.001) and BPH-II (6.9 vs 2.3, p < 0.001). Functional improvement was also significant, with Qmax improving from an average of 10.9 mL/s at baseline to 17.2 mL/s at the 2-year follow-up and PVR improving from 63.1 to 45.0 mL. Treatment-related adverse events were typically minor, with none occurring between 1- and 2-year post-treatment.

CONCLUSIONS

The Optilume BPH Catheter System is a unique minimally invasive surgical therapy that combines mechanical and pharmaceutical aspects for the treatment of BPH. The functional and symptomatic improvements seen after treatment are significant and have been sustained through 2 years in this early feasibility study.

REGISTRATION

NCT03423979, registered February 6, 2018.

Comparison of Postoperative Outcomes of Trans-urethral Resection of the Prostate, Laser Vaporization, and Laser Enucleation: A Double Propensity Score Matched Analysis

OBJECTIVE

To compare postoperative outcomes of 3 types of endourologic surgeries (trans-urethral resection of the prostate [TURP], laser vaporization [LVP], and laser enucleation [LEP]) for benign prostatic hypertrophy (BPH) treatment using the ACS-NSQIP database.

METHODS

The ACS-NSQIP database was queried for men who underwent TURP, PVP, and LEP for treatment of BPH from 2011 till 2019. Demographics, clinical, operative characteristics, and 30-day outcomes were compared. Univariate and multivariate regression models were constructed. Propensity score matching was then performed as a sensitivity analysis.

RESULTS

A total of 74,273 patients underwent endourologic surgeries for BPH, 65.4% had TURP, 28.6% PVP, and 5.9% LEP. Patients undergoing TURP were more likely to be older with higher ASA class, abnormal labs, and comorbidities (diabetic, congestive heart failure, and bleeding requiring transfusion) (P-value <.001). After adjusting for covariates and propensity score matching, LVP demonstrated shorter hospital stays, shorter operative times, less reoperation rates, decreased DVT/PE risk, with, however, higher odds of urinary tract infection and sepsis as compared to TURP (P-value<.028). Furthermore, LEP was found to have shorter hospital stays, longer operative times, and decreased odds of urinary tract infections and sepsis as compared to TURP (P-value<.006).

CONCLUSION

LVP and LEP showed better surgical outcomes and characteristics as compared to TURP. Further research is needed to account for longer duration of follow-up and patient-specific urologic outcomes, such as prostate size, urinary incontinence, erectile dysfunction, and retrograde ejaculation.

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.

Can the Sandwich Method Be an Alternative Treatment Choice for BPH Patients With Large Prostates?

OBJECTIVE

To compare the efficacy and safety of the sandwich method with GreenLight photoselective vaporization (GLPVP) and bipolar transurethral resection (B-TURP) with those of the enucleation method in patients with BPH and a prostate volume ≥ 80 g.

METHODS

Patients with BPH who underwent either the sandwich method with GLPVP and B-TURP or the enucleation method between 2014 and 2021 were included in the analysis. The primary outcome was the comparison of uroflowmetry results between the 2 groups. Safety analysis of the complication rates was also compared.

RESULTS

The cohort included 55 patients in the sandwich group and 41 patients in the enucleation group. In the efficacy analysis, both groups showed comparable uroflowmetry results, except for a higher postoperative average flow rate in the enucleation group. Regarding perioperative parameters, the sandwich method required a longer operating time, and the enucleation group had a higher incidence of manual Foley irrigation. Both groups demonstrated similar postoperative complications.

CONCLUSION

The sandwich method exhibited comparable efficacy and safety to the enucleation method in patients with BPH with a prostate volume ≥ 80 g. Thus, for surgeons who are familiar with GLPVP and B-TURP, the sandwich method may be an alternative surgical approach for BPH patients with large prostates.

Frailty as a risk marker of adverse lower urinary symptom outcomes in patients with benign prostatic hyperplasia undergoing transurethral resection of prostate

Purpose

Lower urinary symptoms (LUTS) may persist in a proportion of patients with benign prostatic hyperplasia (BPH) following transurethral resection of prostate (TURP), which is a major cause of reduced quality-of-life. We aimed to investigate the effect of frailty on LUTS in patients with BPH treated with TURP.

Methods

We longitudinally evaluated LUTS and health-related quality-of-life (HRQOL) in patients with BPH treated with TURP from February 2019 and January 2022 using International Prostate Symptom Score (IPSS) and Short Form-8 (SF-8), respectively. Patients were divided into frail and non-frail groups according to the Fried phenotype (FP). The primary purpose was comparing the outcomes of LUTS and HRQOL between two groups. Secondary purposes were investigating the frailty as a preoperative predictor of postoperative adverse LUTS outcomes following TURP using logistic regression analysis. A 1:2 propensity score matching (PSM) was performed to reduce the effects of selection bias and potential confounders.

Results

Of the 567 patients enrolled, 495 (87.3%) patients were non-frail (FP = 0-2), and the remaining 72 (12.7%) patients were classified into the frail group. There were no significant differences in body mass index (BMI), urine white blood cell (UWBC), creatinine, prostate-specific antigen (PSA) and prostate volume in both groups at baseline (all p > 0.05). However, patients with frailty were older, higher comorbidity rates, lower peak flow rates and lower HRQOL. In the frail group, although LUTS and HRQOL at 6 months following TURP improved significantly compared to those at baseline, it did not show a significant improvement compared with the non-frail group (both p < 0.001). Moreover, multivariable logistic regression analysis demonstrated that preoperative frailty was significantly associated with poor LUTS improvement in both the entire cohort and PSM subset (both p < 0.05), whereas age and comorbidities were not after PSM analysis.

Conclusion

In patients with frail or non-frail, TURP for BPH provides overall good results. However, frail individuals are at higher risk of postoperative adverse LUTS outcomes. Frailty has the potential to be a strong objective tool for risk stratification and should be considered during the perioperative evaluation.

Thulium laser vaporesection of prostates with volume exceeding 100 cm3 as an alternative to HoLEP and ThuLEP

The aim of this study is to evaluate the outcomes of thulium laser vaporesection of prostates with volume exceeding 100 cm³. In the present prospective study, patients with infra-vesical urinary obstruction due to a prostate with volume exceeding 100 cm³ underwent endoscopic vaporesection using thulium laser. In this procedure, prostate chips were resected without morcellation. The technical aspects of surgery, admission time, post-operative catheter time and post-operative complications were analyzed. Flowmetry was performed combined with prostatic ultrasound in the follow-up. Between March 2010 and November 2018, 156 cases with benign prostatic hyperplasia (BPH; volume >100 cm³) were treated. The mean patient age was 67.8 years (48.4-86.6 years), and the mean prostatic volume was 137 cm³ (100-436 cm³). The mean length of hospitalization was 1.48 days (1-8 days), and the mean post-operative catheter time was 5.1 (1-17). Three cases (1.9%) required readmission due to hematuria. The mean follow-up time was 31.2 months (standard deviation = 27.7). Urethral stricture was observed in 14 cases (9%), with bulbar urethra being the most frequent finding. Urinary tract infection was observed in 11 cases (7.1%), and urinary incontinence was observed in 5 cases. The mean peak urinary flow at 12 and 24 months was 26.9 ± 12.5 and 23.9 ± 11.7 ml/s, respectively, and the mean urinary flow during the final follow-up at 41 months was 21.6 ml/s. Thulium laser vaporesection is a valid alternative to open prostatectomy, HoLEP and ThuLEP in patients with large BPH. Urinary flow remained elevated throughout the follow-up.

The effect of intraurethral heparin on inflammation and spongiofibrosis in a rat model of experimentally induced urethral trauma

AIM

To determine the effect of heparin administered during the early post urethral trauma period on inflammation and spongiofibrosis in rats.

MATERIALS AND METHODS

The study included 24 male rats that were randomized into 3 groups of 8 each. The urethra was traumatized using a 24-G needle sheath in all rats. Group 1 (control group) received intraurethral saline 0.9% injected b.i.d. for 27 days, group 2 received intraurethral Na-heparin (liquemine-Roche) 1500 IU kg^-1 injected b.i.d. for 27 days, and group 3 received intraurethral Na-heparin 1500 IU kg^-1 injected b.i.d and saline 0.9% s.i.d. for 27 days. On day 28 the rats' penises were degloved and penectomy was performed. Inflammation, spongiofibrosis, and congestion in the urethra were investigated in each group.

RESULTS

A statistically significant difference was found between the three groups (control, heparin, and heparin + saline) in the histopathological status of spongiofibrosis, inflammation, and congestion, respectively (P = 0.0001, P = 0.002, P = 0.0001). Severe spongiofibrosis was observed in six (75%) of the rats in group 1 (control group), whereas severe spongiofibrosis was not observed in group 2 (heparin) or group 3 (heparin + saline).

CONCLUSION

We observed that intraurethral Na-heparin 1500 IU kg^-1 injectioned during the early posturethral trauma period in rats significantly decreased inflammation, spongiofibrosis, and congestion.

Conservative interventions for managing urinary incontinence after prostate surgery

BACKGROUND

Men may need to undergo prostate surgery to treat prostate cancer or benign prostatic hyperplasia. After these surgeries, men may experience urinary incontinence (UI). Conservative treatments such as pelvic floor muscle training (PFMT), electrical stimulation and lifestyle changes can be undertaken to help manage the symptoms of UI.

OBJECTIVES

To assess the effects of conservative interventions for managing urinary incontinence after prostate surgery.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearched journals and conference proceedings (searched 22 April 2022). We also searched the reference lists of relevant articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of adult men (aged 18 or over) with UI following prostate surgery for treating prostate cancer or LUTS/BPO. We excluded cross-over and cluster-RCTs. We investigated the following key comparisons: PFMT plus biofeedback versus no treatment; sham treatment or verbal/written instructions; combinations of conservative treatments versus no treatment, sham treatment or verbal/written instructions; and electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions.

DATA COLLECTION AND ANALYSIS

We extracted data using a pre-piloted form and assessed risk of bias using the Cochrane risk of bias tool. We used the GRADE approach to assess the certainty of outcomes and comparisons included in the summary of findings tables. We used an adapted version of GRADE to assess certainty in results where there was no single effect measurement available.

MAIN RESULTS

We identified 25 studies including a total of 3079 participants. Twenty-three studies assessed men who had previously undergone radical prostatectomy or radical retropubic prostatectomy, while only one study assessed men who had undergone transurethral resection of the prostate. One study did not report on previous surgery. Most studies were at high risk of bias for at least one domain. The certainty of evidence assessed using GRADE was mixed. PFMT plus biofeedback versus no treatment, sham treatment or verbal/written instructions Four studies reported on this comparison. PFMT plus biofeedback may result in greater subjective cure of incontinence from 6 to 12 months (1 study; n = 102; low-certainty evidence). However, men undertaking PFMT and biofeedback may be less likely to be objectively cured at from 6 to 12 months (2 studies; n = 269; low-certainty evidence). It is uncertain whether undertaking PFMT and biofeedback has an effect on surface or skin-related adverse events (1 study; n = 205; very low-certainty evidence) or muscle-related adverse events (1 study; n = 205; very low-certainty evidence). Condition-specific quality of life, participant adherence to the intervention and general quality of life were not reported by any study for this comparison. Combinations of conservative treatments versus no treatment, sham treatment or verbal/written instructions Eleven studies assessed this comparison. Combinations of conservative treatments may lead to little difference in the number of men being subjectively cured or improved of incontinence between 6 and 12 months (RR 0.97, 95% CI 0.79 to 1.19; 2 studies; n = 788; low-certainty evidence; in absolute terms: no treatment or sham arm: 307 per 1000 and intervention arm: 297 per 1000). Combinations of conservative treatments probably lead to little difference in condition-specific quality of life (MD -0.28, 95% CI -0.86 to 0.29; 2 studies; n = 788; moderate-certainty evidence) and probably little difference in general quality of life between 6 and 12 months (MD -0.01, 95% CI -0.04 to 0.02; 2 studies; n = 742; moderate-certainty evidence). There is little difference between combinations of conservative treatments and control in terms of objective cure or improvement of incontinence between 6 and 12 months (MD 0.18, 95% CI -0.24 to 0.60; 2 studies; n = 565; high-certainty evidence). However, it is uncertain whether participant adherence to the intervention between 6 and 12 months is increased for those undertaking combinations of conservative treatments (RR 2.08, 95% CI 0.78 to 5.56; 2 studies; n = 763; very low-certainty evidence; in absolute terms: no intervention or sham arm: 172 per 1000 and intervention arm: 358 per 1000). There is probably no difference between combinations and control in terms of the number of men experiencing surface or skin-related adverse events (2 studies; n = 853; moderate-certainty evidence), but it is uncertain whether combinations of treatments lead to more men experiencing muscle-related adverse events (RR 2.92, 95% CI 0.31 to 27.41; 2 studies; n = 136; very low-certainty evidence; in absolute terms: 0 per 1000 for both arms). Electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions We did not identify any studies for this comparison that reported on our key outcomes of interest.

AUTHORS' CONCLUSIONS

Despite a total of 25 trials, the value of conservative interventions for urinary incontinence following prostate surgery alone, or in combination, remains uncertain. Existing trials are typically small with methodological flaws. These issues are compounded by a lack of standardisation of the PFMT technique and marked variations in protocol concerning combinations of conservative treatments. Adverse events following conservative treatment are often poorly documented and incompletely described. Hence, there is a need for large, high-quality, adequately powered, randomised control trials with robust methodology to address this subject.

How Would You Manage This Patient With Benign Prostatic Hyperplasia? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) are common in older patients assigned male sex at birth, regardless of gender identity, and treatment of these symptoms is therefore common in primary care practice. In 2021, the American Urological Association published guidelines for management of BPH. They recommend using a standardized scoring system such as the International Prostate Symptom Score to help establish a diagnosis and to monitor the efficacy of interventions, α-blockers as the first-choice pharmacotherapy option, and 5α-reductase inhibitors for patients with prostate size estimated to be at least 30 cc. Tadalafil is another option regardless of erectile dysfunction. Combination therapies with α-blockers and 5α-reductase inhibitors, anticholinergic agents, or β₃-agonists are effective options. A surgical referral is warranted if the BPH results in chronic kidney disease, refractory urinary retention, or recurrent urinary tract infections; if there is concern for bladder or prostate cancer; or if symptoms do not respond to medical therapy. In this article, a general internal medicine physician and a urologist discuss the treatment options and how they would apply their recommendations to a patient who wishes to learn more about his options.

Management of urethral strictures and stenosis caused by the endo-urological treatment of benign prostatic hyperplasia-a single-center experience

Objective

Urethral stricture disease after endo-urological treatment of benign prostatic hyperplasia (BPH) is a sparsely described complication. We describe management of five categories of these strictures in this retrospective observational case series.

Methods

One hundred and twenty-one patients presenting with symptoms of bladder outflow obstruction after endo-urological intervention for BPH from February 2016 to March 2019 were evaluated. Among them, 76 were eligible for this study and underwent reconstructive surgery. Preoperative and postoperative assessments were done with symptom scores, uroflowmetry, ultrasound for post-void residue, and urethrogram. Any intervention during follow-up was classed as a failure. The recurrence and 95% confidence interval for recurrence percentage were calculated.

Results

The following five categories of patients were identified: Bulbo-membranous (33 [43.4%]), navicular fossa (21 [27.6%]), penile/peno-bulbar (8 [10.5%]), bladder neck stenosis (6 [7.9%]), and multiple locations (8 [10.5%]). The average age was 69 years (range: 60-84 years). Overall average symptom score, flow rate, and post-void residue changed from 21 to 7, 6 mL/s to 19 mL/s, and 210 mL to 20 mL, respectively. The average follow-up was 34 months (range: 12-58 months). Overall recurrence and complication rates were 10.5% and 9.2%, respectively. The recurrence in each category was seen in 3, 1, 2, 1, and 1 patient, respectively. Overall 95% confidence interval for recurrence percentage was 4.66-19.69.

Conclusion

Urethral stricture disease is a major long-term complication of endo-urological treatment of BPH. The bulbo-membranous strictures need continence preserving approach. Navicular fossa strictures require minimally invasive and cosmetic consideration. Peno-bulbar strictures require judicious use of grafts and flaps. Bladder neck stenosis in this cohort could be treated with endoscopic measures. Multiple locations need treatment based on their sites in single-stage as far as possible.

Perioperative, functional, and oncologic outcomes in patients undergoing robot-assisted radical prostatectomy previous transurethral resection of prostate: a systematic review and meta-analysis of comparative trials

The influence of robot-assisted radical prostatectomy (RARP) on patients who have previously undergone transurethral resection of the prostate (TURP) versus TURP-naive patients is still debatable. The present study aimed to compare perioperative, functional, and oncologic outcomes of RARP between TURP and Non-TURP groups. We systematically searched the databases such as Science, PubMed, Embase, Web of Science, and the Cochrane Library database to identify relevant studies published in English up to August 2022. Review Manager was used to compare various parameters. The study was registered with PROSPERO (CRD42022378126). Eight comparative trials with a total of 4186 participants were conducted. The TURP group had a longer operative time (WMD 22.22 min, 95% CI 8.48, 35.95; p = 0.002), a longer catheterization time (WMD 1.32 day, 95% CI 0.37, 2.26; p = 0.006), a higher estimated blood loss (WMD 23.86 mL, 95% CI 2.81, 44.90; p = 0.03), and higher bladder neck reconstruction rate (OR 8.02, 95% CI 3.07, 20.93; p < 0.0001). Moreover, the positive surgical margin (PSM) was higher in the TURP group (OR 1.49, 95% CI 1.12, 1.98 p = 0.007). However, there was no difference between the two groups regarding the length of hospital stay, transfusion rates, nerve-sparing status, complication rates, long-term continence, potency rates and biochemical recurrence (BCR). Performing RARP on patients who have previously undergone TURP is a safe procedure. Furthermore, the current findings demonstrated that the TURP group had comparable oncologic and long-term functional outcomes to the Non-TURP group.

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.

Ejaculatory Preserving Holmium Laser Enucleation of the Median Lobe: Preserving Sexual Function While Improving Urinary Outcomes

OBJECTIVE

To evaluate perioperative outcomes related to sexual and urinary function in patients who underwent a holmium laser enucleation of the prostate (HoLEP) with selective laser enucleation of the median lobe.

MATERIALS AND METHODS

We retrospectively reviewed the first 450 HoLEP cases by a single surgeon from April 2019 to March 2022. Fifty-five patients with intravesical-prostatic protrusion or high bladder neck without obstructing lateral lobes underwent selective enucleation of the median lobe of the prostate. Patients were asked to comment on whether they had retrograde ejaculation during their follow-up appointment. Urinary function was assessed using the American Urological Association Symptom Score and subjective evaluation of urinary incontinence.

RESULTS

Median age of the cohort was 65 years (range: 44-91). Compared to preoperative, there was significant improvement in mean postoperative American Urological Association Symptom Score (22.5 vs 6.9, P < .001), mean postoperative quality of life scores (4 vs 1.2, P < .001), and mean postoperative post void residual volumes (244.1 vs 69.3 cc, P < .001). No patients reported stress urinary incontinence. Of the 55 patients who underwent selective enucleation of the median lobe, 40 were sexually active. Of those men, 35 reported normal ejaculation, 3 had retrograde ejaculation that was unchanged from pre-op, and 2 had new ejaculatory dysfunction.

CONCLUSION

In this case series of selective laser enucleation of the median lobe, urinary function significantly improved in short-term follow-up with preservation of ejaculation in approximately 90% of men.

The role of Rezum in the management of refractory urinary retention due to benign prostate hyperplasia: A literature review

Background

Benign prostatic hyperplasia is the most common cause of urinary retention in men (BPH). The gold standard surgical treatment is transurethral resection of the prostate (TURP). However, due to the morbidity and mortality associated with TURP, more minimally invasive treatments, such as vaporizing the prostate with the Rezum system, have been introduced. We investigated the efficacy of Rezum in the treatment of refractory urinary retention due to BPH in this review.

Methodology and materials

To conduct this review, the Cochrane methodology for systematic reviews was used. All studies that used Rezum to treat catheter-dependent patients with enlarged prostates were included. The literature search showed 111 studies, 84 of which were excluded due to non-relevance based on titles and 18 due to lack of relevance based on abstract review. Full manuscripts were reviewed in nine studies, three of which were excluded because they did not meet the inclusion criteria.

Results

This review included 301 patients in total. The rate of a successful trial of voiding post Rezum therapy was 85%. The complication rated between 3.8 and 4.3% all of which were mild and self-limited. As there was no major complication of Rezum (clavien dindo >2), the procedure-related morbidity is negligible.

Conclusion

In this review, Rezum was found to be an efficacious and safe alternative in the treatment of refractory retention with mild complications and minimal morbidity.

Short- and intermediate-term outcome of robot-assisted inverted YV-plasty for recurrent bladder neck stenosis - a single centre study

OBJECTIVES

To report the technique and preliminary results for extraperitoneal robot-assisted laparoscopic YV-plasty (RAYV) for refractory bladder neck stenosis (BNS) and vesicourethral anastomosis stenosis (VUAS).

MATERIALS AND METHODS

Included were patients with recurrent BNS and VUAS who underwent RAYV at our institution. Primary outcome was short- and intermediate-term functional results measured with urinary peak flow (Qmax), post-void residual urine (PVR) as well as quality of life assessment with the international prostate symptom score (IPSS) and short form health survey (SF-8). Short- and intermediate-term follow-up periods were defined as 1 to 6 months and 6 to 24 months, respectively. Secondary, all patients were reviewed for etiology as well as perioperative data. Treatment success was defined by absence of further treatment and/or need for intermittent or permanent catheterization.

RESULTS

Between March 2016 and October 2020 a total of 30 patients with a median age of 70.8 (64 - 77) years underwent RAYV with a median follow-up of 27 months. Median operative time (skin-skin) was 131 (112 - 145) minutes. The transurethral indwelling catheter was removed after 10 (5 - 16) days. There were no intraoperative complications but two postoperative major complications Clavien-Dindo IIIa and IV, respectively. Short- and intermediate-term results revealed significant improvement of IPS symptom score from 17 (11-24) points to 11 (6-13) points and 6 (3-9) points, respectively. Further thePVR decreased from 90 (5-302) mL to 0 (0-30) mL and 0 (0-90) mL, respectively, and Qmax increased from 7.4 mL/s to 13 (8-16) mL/s and 17 (12-4) mL/s, respectively. Improvement of SF-8 did not reach significance. A total of 5/30 (16.7%) patients had a treatment failure after 24 months whereof 2 had a re-stricture.

CONCLUSION

RAVY-Plasty for recurrent bladder neck stenosis is a safe and effective procedure with good functional short- and median-term outcome.