Safety and Efficacy of Bipolar Versus Monopolar Transurethral Resection of the Prostate in Patients with Large Prostates or Severe Lower Urinary Tract Symptoms: Post Hoc Analysis of a European Multicenter Randomized Controlled Trial

Perioperative outcomes and trends of transurethral surgeries for benign prostatic hyperplasia in octogenarians: a comprehensive analysis using the NSQIP database (2011-2022)

INTRODUCTION

Advances in health care have resulted in an increasing octogenarian population in the United States. The prevalence of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) in this subgroup exceeds 70%. This study attempts to evaluate perioperative outcomes of different transurethral techniques in octogenarians and define their utilization trends from 2011 to 2022.

METHODS

We extracted data from the American College of Surgeons NSQIP for octogenarian patients who underwent prostatectomy for BPH. Procedures were categorized using CPT codes, and outcomes included postoperative complications, readmission, 30-day reoperation, and utilization trends from 2011 to 2022.

RESULTS

A total of 21,314 octogenarians were included. TURP was the most performed procedure (53.13-71.17%), followed by PVP and HoLEP. HoLEP utilization increased reaching up to 19% by year 2022. Higher American Society of Anesthesiologists (ASA) scores were observed more frequently in the TURP group. HoLEP consistently exhibits the longest operative times. Initially relatively higher transfusion rates for HoLEP decreased to 0% by 2022. Urinary tract infection rates did not significantly differ among the procedures most years.

RESULTS

TURP remained the most performed modality for BPH management in octogenarians amongst NSQIP-participating institutions. However, from 2011 to 2021, the utilization of HoLEP increased nearly by 2.5 folds, from 2.5 to 6.4%.

Comparative Outcomes of Monopolar and Bipolar Transurethral Resection of the Prostate: An Institutional Perspective

Objective This prospective comparative study aimed to highlight and compare two types of transurethral resection of the prostate (TURP), namely M-TURP (monopolar) and B-TURP (bipolar), in the endoscopic management of benign prostatic hyperplasia (BPH). Methods and materials This research was conducted between 2022 and 2023 at a tertiary care health center. Included in the investigation were 100 consenting study participants undergoing M-TURP and B-TURP at our center. All referred patients presenting with clinical, ultrasound, or uroflowmetry features of BPH and those with failed attempts at medical management were included in the study. Patients with carcinoma of the prostate were excluded from the study. Post-operatively, the endpoints for comparison included maximal urinary flow rate (Qmax), prostate volume, duration of hospital stay, duration of catheterization, drop in serum sodium concentration, and drop in hemoglobin levels. Descriptive statistics were computed to delineate the study sample. After the completion of data collection, data analysis was performed using SPSS for Windows, Version 16.0 (Released 2007; SPSS Inc., Chicago, IL, USA), and the correlations sought were achieved using the Chi-square test of significance. Results The peak incidence of BPH was seen in the sixth decade of life: the M-TURP group was 65.16 ± 7.07 years (mean ± standard deviation), while that in the B-TURP group was 62.32 ± 8.16 years (mean ± standard deviation). Nine percent of the study participants did not show any comorbidities. The most frequent symptom of BPH at presentation was a poor urinary stream (78%, n = 100), followed by nocturia (67%, n = 100). In our study, patients undergoing M-TURP had a mean serum prostate-specific antigen (PSA) level of 4.31 ± 1.03 ng/mL, while patients undergoing B-TURP had a mean serum PSA of 4.24 ± 0.99 ng/mL (p = 0.820; p > 0.05). The study found that patients undergoing M-TURP had a mean prostate size of 35.04 ± 3.57 cc, while those undergoing B-TURP had a mean prostate size of 35.72 ± 3.22 cc (p = 0.765). For the B-TURP group, the mean decrease in postoperative serum sodium concentration was 4.3 mEq/L, while for the M-TURP group, it was 6.4 mEq/L (p = 0.903). In the M-TURP group, there were three cases of transurethral resection (TUR) syndrome, while the B-TURP group had only one case. Conclusion BPH is a common problem affecting the quality of life of several male patients. Both M-TURP and B-TURP are comparable in their efficacy in treating BPH, with the exception of a higher incidence of hyponatremia and TUR syndrome in the M-TURP group.

Emerging Technologies for the Surgical Management of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Obstruction. A Systematic Review

CONTEXT

Surgical management of lower urinary tract symptoms (LUTS)/benign prostatic obstruction (BPO) aims at ablating prostate adenoma by resection, enucleation, or vaporisation. Apart from established ablation modes according to the European Association of Urology guidelines, various technologies have emerged as safe/effective alternatives but remain under investigation.

OBJECTIVE

To explore short-term benefits/harms of emerging technologies for surgical management of LUTS/BPO.

EVIDENCE ACQUISITION

A systematic literature search was conducted using MEDLINE, EMBASE, and CENTRAL via Ovid up to June 18, 2022. We included randomised controlled trials (RCTs) exploring aquablation, prostatic arterial embolisation (PAE), Rezum, prostatic urethral lift (PUL), and temporary implantable nitinol device (iTIND) versus sham/transurethral resection of the prostate (TURP).

EVIDENCE SYNTHESIS

We included ten RCTs (1108 men). Aquablation versus TURP: insignificant change in International Prostate Symptoms Score (IPSS; mean difference [MD] 0.0, 95% confidence interval [CI] -2.44 to 2.44), quality of life (QoL; MD 0.30, 95% CI -0.81 to 0.21), maximum urinary flow rate (Qmax; MD -0.30, 95% CI -3.71 to 3.11), retreatment (risk ratio [RR] 0.18, 95% CI 0.02-1.66), and urinary incontinence (UI; RR 0.71, 95% CI 0.26-1.95). PAE versus monopolar TURP (M-TURP): insignificant change in IPSS (MD 3.33, 95% CI -28.39 to 35.05), QoL (MD 0.12, 95% CI -0.30 to 0.54), International Index of Erectile Function (IIEF-5; MD 3.07, 95% CI -1.78 to 7.92), and UI (RR 0.15, 95% CI 0.01-2.86), and significant change in Qmax (MD -9.52, 95% CI -14.04 to -5.0), favouring M-TURP. PAE versus bipolar TURP: insignificant change in IPSS (MD -2.80, 95% CI -6.61 to 1.01), QoL (MD -0.69, 95% CI -1.46 to 0.08), Qmax (MD -3.51, 95% CI -8.08 to 1.06), UI (RR 0.14, 95% CI 0.01-2.51), and retreatment (RR 1.91, 95% CI 0.19-19.63). PUL versus TURP: insignificant change in QoL (MD 0.40, 95% CI -0.29 to 1.09), UI (RR 0.13, 95% CI 0.02-1.05), and retreatment (RR 0.48, 95% CI 0.12-1.86), and significant change in IPSS (MD 3.40, 95% CI 0.22-6.58), and IIEF-5 (MD 3.00, 95% CI 0.41-5.59) and Qmax (MD -9.60, 95% CI -13.44 to -5.76), favouring PUL and TURP, respectively. Rezum and iTIND have not been evaluated in RCTs against TURP to date.

CONCLUSIONS

Supporting evidence for clinical use of aquablation, PAE, PUL, Rezum, and iTIND is very limited. Benefits/harms should be investigated further in high-quality RCTs.

PATIENT SUMMARY

This review summarises the evidence for the clinical use of aquablation, prostatic arterial embolisation (PAE), prostatic urethral lift (PUL), Rezum, and temporary implantable nitinol device (iTIND) to manage lower urinary tract symptoms secondary to benign prostatic obstruction. The supporting evidence for the clinical usage of aquablation, PAE, PUL, Rezum, and iTIND is very limited. Benefits and harms should be investigated further in high-quality randomised controlled trials.

The activated complement pathway in the fibrous process of benign prostatic hyperplasia

BACKGROUND

To elucidate the changes in activated complement pathway in the fibrous process of benign prostatic hyperplasia (BPH), we analyzed the correlation between complement component expression and histological types of fibrosis using human BPH tissue.

METHODS

Fifty-six histological BPH patients who underwent prostate needle biopsy at our institution (mean age 68.6 ± 6.5 years), divided into two histological groups, fibromuscular and fibrous, were compared. Inflammatory cell infiltration in BPH tissue was evaluated by immunohistochemical staining using CD45, with complement expression analysis performed using C3, factor B, and C5b-9 antibody, and the occupancy ratio of the stained region was calculated. Further, correlation between the histological types of fibrous components in BPH tissue and lower urinary tract symptoms questionnaires was analyzed.

RESULTS

Twenty-seven (48.2%) and 29 (51.8%) cases were classified in the fibromuscular and fibrous groups, respectively. The proportion of CD45-positive cells in BPH tissue was significantly higher in the fibromuscular group. In complement component analysis, factor B did not significantly differ between groups, while C3 (fibromuscular group; 10.7 ± 8.2%, fibrous group; 16.4 ± 12.7%) and C5b-9 (fibromuscular group; 15.9 ± 6.2%, fibrous group; 17.6 ± 9.2%) were significantly higher in the fibrous group (p = 0.04, p = 0.04, respectively). International Prostate Symptom Score Q5 subscore, indicating slow stream, was significantly higher in the fibrous group (p = 0.04).

CONCLUSIONS

In fibrous BPH with abundant fibrosis, the late complement pathway in addition to alternative pathway was activated compared to fibromuscular BPH. These results suggested that the alternative and late complement pathways were involved in the histological fibrous process of BPH.

The role of irrigation fluid in transurethral resection of the prostate outcomes and surgeon performance

INTRODUCTION

Transurethral resection of the prostate (TURP) is the gold-standard for the treatment of benign prostate enlargement (BPE) associated with lower urinary tract symptoms (LUTS), after failure of conservative therapy. At present, only resection-rate (grams of prostate resected over time) is regarded as an efficiency parameter to evaluate the skill of the operator and to assess the outcome of the procedure.

MATERIALS AND METHODS

Five surgeons performed TURP using a Gyrus-type bipolar system in 123 patients with BPE/LUTS who came to our observation from June 2016 to December 2019. The amount of irrigation fluid used during the procedure was registered and correlated to the operating time, resection-rate, prostate adenoma weight, post-operative bladder irrigation time, intraoperative bleeding and days of catheterization.

RESULTS

We found an inverse correlation between the amount of irrigation fluid used during TURP and the resection-rate recorded for all operators, according to Spearman's Correlation (r = -0.78, p = 0.002); a direct correlation was also found between the amount of irrigation fluid and the adenoma weight. Finally, we also found a direct correlation with intraoperative bleeding and the duration and amount of bladder irrigation during and after TURP.

CONCLUSIONS

The amount of irrigation fluid used is proposed as a reliable parameter to estimate the efficiency of the endoscopic procedure as well to assess the skill of the operator and shortterm results. The observed data encourage the possibility of applying this new efficiency indicator to all endoscopic maneuvers.

Short-term efficacy and safety of second generation bipolar transurethral vaporization of the prostate (B-TUVP) for large benign prostate enlargement: Results from a retrospective feasibility study

Background

To investigate the efficacy and safety of a second-generation bipolar transurethral electro vaporization of the prostate (B-TUVP) with the new oval-shaped electrode for large benign prostatic enlargement (BPE) with prostate volume (PV) ≥100ml.

Materials and methods

100 patients who underwent second-generation B-TUVP with the oval-shaped electrode for male lower urinary tract symptom (LUTS) or urinary retention between July 2018 and July 2020 were enrolled in this study. The patients’ characteristics and treatment outcome were retrospectively compared between patients with PV <100ml and ≥100ml.

Results

17/41 (41.5%) cases of PV ≥100ml and 24/59 cases (40.7%) of PV <100ml were catheterised due to urinary retention. The duration of post-operative catheter placement and hospital-stay of PV ≥100ml (3.1±1.3 and 5.6±2.3 days) were not different from PV <100ml (2.7±1.2 and 5.0±2.4 days). In uncatheterised patients (N = 59), post-void residual urine volume (PVR) significantly decreased after surgery in both groups, however, maximum uroflow rate (Q_max) significantly increased after surgery only in PV <100ml but not in PV ≥100ml. Voiding symptoms and patients’ QoL derived from International Prostate Symptom Score (IPSS), IPSS-QoL (IPSS Quality of Life Index) and BPH Impact Index (BII) scores, significantly improved after B-TUVP in both groups. Catheter free status after final B-TUVP among patients with preoperative urinary retention was achieved in 18/24 (75.0%) and 14/17 (82.1%) cases in patient with <100ml and ≥100ml, respectively. There was no significant difference in post-operative Hb after B-TUVP, which was 97.0±5.4% of baseline for PV <100ml and 96.9±6.1% for PV ≥100ml and no TUR syndrome was observed.

Conclusions

This is the first study investigating short-term efficacy and safety of second-generation B-TUVP with the oval-shaped electrode on large BPE. B-TUVP appears to be effective and safe for treating moderate-to-severe lower urinary tract symptoms and urinary retention in patients with large BPE.

[Surgical and interventional management of benign prostatic obstruction: Guidelines from the Committee for Male Voiding Disorders of the French Urology Association]

OBJECTIVE

The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO).

METHODS

All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions.

RESULTS/GUIDELINES

Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm³, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm³. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm³. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm³ without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols.

CONCLUSION

Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.

Safety and Efficacy of Bipolar Transurethral Resection of the Prostate vs Monopolar Transurethral Resection of Prostate in the Treatment of Moderate-Large Volume Prostatic Hyperplasia: A Systematic Review and Meta-Analysis

Aims: To compare outcomes of monopolar vs bipolar transurethral resection of the prostate (TURP) in the management of exclusively moderate-large volume prostatic hyperplasia in terms of maximum flow rate as a surrogate for clinical efficacy, duration of catheterization, hospital stay, operative time, resection weight, transurethral resection (TUR) syndrome, acute urinary retention (AUR), clot retention, and blood transfusion. Methods: We conducted a search of electronic databases (PubMed, MEDLINE, EMBASE, CINAHL, and CENTRAL), identifying studies comparing the outcomes of monopolar and bipolar TURP in the management of large-volume prostatic hyperplasia. The Cochrane risk-of-bias tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa scale for observational studies were used to assess included studies. Random effects modeling was used to calculate pooled outcome data. Results: Three RCTs and four observational studies were identified, enrolling 496 patients. No difference was observed in the clinical efficacy between each procedure at 3 months postoperatively (p = 0.99), 6 months (p = 0.46), and 12 months (p = 0.29). The use of bipolar TURP was associated with significantly shorter inpatient stay (p = 0.01) and a shorter duration of catheterization (p = 0.05). Monopolar TURP was associated with an increased risk of TUR syndrome (p = 0.03). Operative time (p = 0.58), resection weight (p = 0.16), AUR (p = 0.96), clot retention (p = 0.79), and blood transfusion (p = 0.39) were similar in both groups. Conclusion: Our meta-analysis demonstrated that bipolar TURP in the treatment of moderate-large volume prostatic disease may be associated with a significantly lower rate of TUR syndrome and shortened length of hospital stay, with similar efficacy when compared with monopolar TURP. Further high-quality RCTs with adequate sample sizes are required to compare both monopolar and bipolar TURP to open prostatectomy or laser enucleation in the treatment of exclusively large-volume prostates with stricter definition of size.

[Anastomosis stenosis after radical prostatectomy and bladder neck stenosis after benign prostate hyperplasia treatment: reconstructive options]

Bladder neck stenosis (BNS) after simple prostatectomy and vesicourethral anastomosis stenosis (VUAS) after radical prostatectomy for prostate cancer are common sequelae. However, the two entities differ in their pathology, anatomy and their surgical results. VUAS has an incidence of 0.2-28%. Commonly, VUAS occurs within the first 2 years after surgery. Initial therapy should be performed endourologically: dilatation, (laser) incision or resection. After three unsuccessful treatment attempts, open reconstruction should be considered. Different surgical approaches (abdominal, perineal, abdominoperineal) have been described. All are associated with good success rates. However, they are accompanied by high rates of urinary incontinence. Incontinence can be treated safely by implantation of an artificial urinary sphincter. The incidence of BNS is around 5% for all types of surgery for benign prostate hyperplasia. It occurs within the first 2 years after surgery. Initial treatment should be performed endourologically. In case of recalcitrant BNS, open reconstruction is indicated. The YV-plasty is an established procedure, and the T‑plasty represents a modification. Success rates of both procedures are high. Robot-assisted reconstructive procedures have been described for both VUAS and BNS.

Bipolar versus monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction

BACKGROUND

Transurethral resection of the prostate (TURP) is a well-established surgical method for treatment of men with lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). This has traditionally been provided as monopolar TURP (MTURP), but morbidity associated with MTURP has led to the introduction of other surgical techniques. In bipolar TURP (BTURP), energy is confined between electrodes at the site of the resectoscope, allowing the use of physiological irrigation medium. There remains uncertainty regarding differences between these surgical methods in terms of patient outcomes.

OBJECTIVES

To compare the effects of bipolar and monopolar TURP.

SEARCH METHODS

A comprehensive systematic electronic literature search was carried out up to 19 March 2019 via CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, PubMed, and WHO ICTRP. Handsearching of abstract proceedings of major urological conferences and of reference lists of included trials, systematic reviews, and health technology assessment reports was undertaken to identify other potentially eligible studies. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared monopolar and bipolar TURP in men (> 18 years) for management of LUTS secondary to BPO.

DATA COLLECTION AND ANALYSIS

Two independent review authors screened the literature, extracted data, and assessed eligible RCTs for risk of bias. Statistical analyses were undertaken according to the statistical guidelines presented in the Cochrane Handbook for Systematic Reviews of Interventions. The quality of evidence (QoE) was rated according to the GRADE approach.

MAIN RESULTS

A total of 59 RCTs with 8924 participants were included. The mean age of included participants ranged from 59.0 to 74.1 years. Mean prostate volume ranged from 39 mL to 82.6 mL. Primary outcomes BTURP probably results in little to no difference in urological symptoms, as measured by the International Prostate Symptom Score (IPSS) at 12 months on a scale of 0 to 35, with higher scores reflecting worse symptoms (mean difference (MD) -0.24, 95% confidence interval (CI) -0.39 to -0.09; participants = 2531; RCTs = 16; I² = 0%; moderate certainty of evidence (CoE), downgraded for study limitations), compared to MTURP. BTURP probably results in little to no difference in bother, as measured by health-related quality of life (HRQoL) score at 12 months on a scale of 0 to 6, with higher scores reflecting greater bother (MD -0.12, 95% CI -0.25 to 0.02; participants = 2004; RCTs = 11; I² = 53%; moderate CoE, downgraded for study limitations), compared to MTURP. BTURP probably reduces transurethral resection (TUR) syndrome events slightly (risk ratio (RR) 0.17, 95% CI 0.09 to 0.30; participants = 6745; RCTs = 44; I² = 0%; moderate CoE, downgraded for study limitations), compared to MTURP. This corresponds to 20 fewer TUR syndrome events per 1000 participants (95% CI 22 fewer to 17 fewer). Secondary outcomes BTURP may carry a similar risk of urinary incontinence at 12 months (RR 0.20, 95% CI 0.01 to 4.06; participants = 751; RCTs = 4; I² = 0%; low CoE, downgraded for study limitations and imprecision), compared to MTURP. This corresponds to four fewer events of urinary incontinence per 1000 participants (95% CI five fewer to 16 more). BTURP probably slightly reduces blood transfusions (RR 0.42, 95% CI 0.30 to 0.59; participants = 5727; RCTs = 38; I² = 0%; moderate CoE, downgraded for study limitations), compared to MTURP. This corresponds to 28 fewer events of blood transfusion per 1000 participants (95% CI 34 fewer to 20 fewer). BTURP may result in similar rates of re-TURP (RR 1.02, 95% CI 0.44 to 2.40; participants = 652; RCTs = 6; I² = 0%; low CoE, downgraded for study limitations and imprecision). This corresponds to one more re-TURP per 1000 participants (95% CI 19 fewer to 48 more). Erectile function as measured by the International Index of Erectile Function score (IIEF-5) at 12 months on a scale from 5 to 25, with higher scores reflecting better erectile function, appears to be similar (MD 0.88, 95% CI -0.56 to 2.32; RCTs = 3; I² = 68%; moderate CoE, downgraded for study limitations) for the two approaches.

AUTHORS' CONCLUSIONS

BTURP and MTURP probably improve urological symptoms, both to a similar degree. BTURP probably reduces both TUR syndrome and postoperative blood transfusion slightly compared to MTURP. The impact of both procedures on erectile function is probably similar. The moderate certainty of evidence available for the primary outcomes of this review suggests that there is no need for further RCTs comparing BTURP and MTURP.

Bipolar endoscopic enucleation versus bipolar transurethral resection of the prostate: an ESUT systematic review and cumulative analysis

PURPOSE

To perform a cumulative analysis of the current evidence on the surgical and functional outcomes of bipolar endoscopic enucleation of the prostate (b-EEP) versus bipolar transurethral resection of the prostate (b-TURP).

METHODS

A systematic review of the literature was performed on PubMed, Ovid^®, and Scopus^® according to Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA Statement). The meta-analysis was conducted using the Review Manager 5.3 software. Parameters of interest were surgical and functional outcomes. Weighted mean difference, and odds ratio with 95% confidence interval were calculated for continuous and binary variables, respectively. Pooled estimates were calculated using the random-effect model.

RESULTS

Fourteen comparative studies were included. No statistically significant difference in terms of overall baseline characteristics was found. b-EEP had higher amount of resected tissue (p < 0.0001), shorter catheter time (p = 0.006), lower Hb drop (p = 0.03), and shorter length of stay (p < 0.0001). Equally, overall post-operative complications were lower (p = 0.01) as well as short (p = 0.04), and long-term complication rate (p = 0.04). There was higher re-intervention rate in the b-TURP group (p = 0.02) whereas b-EEP group had smaller residual prostate volume (p = 0.03), and lower post-operative PSA values (p < 0.00001). At long term, b-EEP presented lower IPSS (p = 0.04), higher Q_max (p = 0.002), and lower PVR (p < 0.00001).

CONCLUSIONS

b-EEP is an effective and safe surgical treatment for BPO. This procedure might offer several advantages over standard b-TURP, including the resection of a larger amount of tissue within the same operative time, shorter hospitalization, lower risk of complications, and lower re-intervention rate. This was submitted to PROSPERO registry: CRD42019126748.

Reduced bleeding with DRY CUT® transurethral resection of the prostate (TURP) compared to standard TURP

Objective: To compare bleeding and transfusion rate between patients who undergo standard transurethral resection of the prostate (TURP) and patients who undergo DRY CUT^® TURP.Materials and methods: A retrospective comparison was made of 626 patients who underwent a standard monopolar TURP during 2004-2007 at the Karolinska University Hospital Huddinge with 620 patients who underwent monopolar DRY CUT^® TURP during 2011-2014 at the same clinic. Transfusion rate, perioperative bleeding, prostate volume, resection weight, use of anticoagulation therapy, presence of prostate cancer, whether the operation was performed by a specialist doctor in urology or a resident and length of hospital stay were evaluated.Results: The median bleeding was 300 ml (IQR = 100-645 ml) in the group of patients who underwent standard TURP compared to 75 ml (IQR 30-268 ml) in the DRY CUT^® TURP group. The bleeding quotient for standard TURP was 2.3-times the perioperative bleeding for DRY CUT^® TURP. In a logistic regression model the patients who underwent standard TURP were more likely to undergo blood transfusion compared to DRY CUT^® TURP (OR = 3.18, 95% CI = 1.72-5.88). The results were not affected by adjustment for patient age, presence of prostate cancer, anticoagulation therapy or operation performed by a specialist in urology. However, the resection weight did influence the bleeding quotient.Conclusions: The shift from standard TURP to DRY CUT^® TURP has decreased the perioperative bleeding and need for blood transfusion at our hospital.

[Surgical treatment of BPO: Standard and innovations]

INTRODUCTION AND OBJECTIVE

Surgical management of benign prostatic hyperplasia has dramatically changed in the recent years towards higher proportion of endoscopic treatment and fewer perioperative complications. Nevertheless the question of urinary and sexual quality of life after surgical treatment remains partially unresolved with a high proportion of retrograde ejaculation after conventional surgical treatments. Therefore mini-invasive alternatives to conventional surgery have been proposed. The objective of this literature review was to provide an overview of the alternatives to monopolar TURP currently available in France.

MATERIAL AND METHOD

A non-systematic review of the scientific literature was conducted from the PubMed database to retrieve the most relevant scientific publications. A first research was cross-referenced with the results of literature reviews already published and enriched by the authors of this review. A synthesis is proposed for each alternative technique mentioning its level of clinical development, but also its potential advantages and disadvantages compared to conventional surgical techniques.

RESULTS

The quality of life of patients after surgical or interventional management has become the main priority of urologists since the risks of perioperative complication have been reduced by the use of laser or bipolar endoscopic techniques. Thanks to the development of minimally invasive alternatives that are better and better evaluated by randomized trials versus interventional simulation and conventional surgical treatment, more personalized care is possible. Patients' expectations and their individual risk factors can thus be placed at the center of the therapeutic decision and the preoperative information.

CONCLUSION

The surgical and interventional management of LUTS due to BPH has evolved to lower perioperative morbidity with the help of numerous technological developments. Mini-invasive alternatives to standard treatment have also been proposed in order to improve the quality of postoperative sexual life. These alternatives provide significant improvement in LUTS that remains lower than after conventional treatments. Somme of these alternative are also not fully supported by clinical trials, which should urge urologists to act with caution when proposing these alternatives in daily clinical practice.

Bladder Neck Contracture after Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia Treated with a Thermo-Expandable Metal Stent (Memokath® 045)

Bladder neck contracture following transurethral resection of the prostate is a rare but feared complication. Treatment is often challenging with significant recurrence rates. In this report, we present a complicated case treated with a simple procedure. A 75-year-old male developed urinary retention due to bladder neck contracture after transurethral resection of the prostate. He was initially treated with several transurethral incisions, but the obstruction recurred few months after each incision. At urethroscopy, the bladder neck was completely obstructed. Using both retrograde and antegrade endoscopy, it was possible to place a through-and-through guidewire, after which the length of the stricture could be measured. Subsequently, the stricture was slightly dilated, and a double-cone thermo-expandable metal stent (Memokath 045) could be placed. The correct position was monitored with antegrade and retrograde endoscopy, securing the proximal cone expanded above the stricture and the distal cone above the sphincter. The patient was discharged the same day with spontaneous voiding and minimal residual urine. Twenty-one months after stent placement, the patient still had no complaints of his urination. Thus, the double-cone thermo-expandable metal stent, Memokath 045, may be a durable option for treatment of complicated bladder neck contracture after TURP for benign prostatic hyperplasia.

Low-pressure monopolar electroresection of the prostate for glands sized > 70 vs. < 70 cc performed with continuous irrigation and suprapubic suction: perioperative and long-term outcome

Purpose

To evaluate long-term efficacy and safety of low-pressure transurethral resection of the prostate for prostates < 70 cc (group 1) vs. > 70 cc (group 2).

Patients and methods

In this study patients operated with monopolar TURP between 2009 and 2012 were evaluated retrospectively. During surgery a specially designed trocar (18 Fr) was placed suprapubically and connected to a suction pump to maintain stable low-pressure conditions. After sample size calculations, long-term follow-up was completed for 70 invited patients in each group up to 9/2015.

Results

Follow-up period was 57 vs. 56 months for group 1 and 2, respectively (p = 0.56). At baseline there was no significant difference in age, IPSS, peak flow, and post void residual (PVR). Mean prostate volume was 47 cc (15–65) vs. 100 cc (70–163). Mean operating time was 55.4 vs. 82.6 min (p = 0.00). Blood transfusion was necessary in 0.0 vs. 2.9% (p = 0.16), and 0.0 vs. 1.4% developed TUR syndrome (p = 0.32). At follow-up mean relative improvement in IPSS was 63 vs. 57% (p = 0.29), QoL 64 vs. 64% (p = 0.93), peak flow 139 vs. 130% (p = 0.85), and PVR 58 vs. 63% (p = 0.80). Long-term complications included recurring adenoma in 1.4 vs. 4.3% (p = 0.31), and stricture in 7.2 vs. 5.8% (p = 0.73). 1 patient in each group reported worsening incontinence symptoms.

Conclusions

In terms of safety and efficacy, the aforementioned modality of standardized monopolar TURP using suprapubic suction was non-inferior for prostates > 70 cc compared to the same procedure for prostates < 70 cc. This technique is a potential low-cost alternative for clinics that cannot afford modern laser approaches.

Study register number

DRKS00006527.

Transurethral Enucleation with Bipolar for Benign Prostatic Hyperplasia: 2-Year Outcomes and the Learning Curve of a Single Surgeon's Experience of 603 Consecutive Patients

BACKGROUND

To investigate perioperative outcomes, the learning curve, and 2-year follow-up after transurethral enucleation with bipolar (TUEB) for patients with benign prostatic hyperplasia (BPH).

METHODS

From December 2011 to October 2016, 603 consecutive patients underwent TUEB for BPH, performed by a single surgeon. Patients were preoperatively assessed by using the International Prostate Symptom Score (IPSS), quality-of-life score (QOLs), serum prostate-specific antigen (PSA), and uroflowmetry evaluation. Intra- and post-operative outcomes were also evaluated. Early and late complications were postoperatively recorded. Patients were evaluated at 3, 12, and 24 months of follow-up by using IPSS, QOLs, and uroflowmetry evaluations. TUEB efficiency was defined as prostatic specimen weight (grams) per operative time (minute) (g/min). Differences were compared by using Student's t-test for continuous values.

RESULTS

Mean age of patients was 69.6 ± 0.26 years, and estimated prostate volume was 54.7 ± 0.90 cc. Mean operative time was 57.5 ± 1.1 minutes, and mean prostatic specimen weight was 30.5 ± 0.68 g. Overall TUEB efficiency was 0.54 ± 0.01 g/min, and it improved markedly when the experience level exceeded 50 cases. Only three patients required hospital stay (0.49%). PSA level reduction before and after operation was 82.6% ± 0.70%. Significant improvement occurred in maximum flow rate (26.7 ± 1.3 mL/s, p < 0.0001), average flow rate (15.5 ± 0.45 mL/s, p < 0.0001), IPSS (3.8 ± 0.19, p < 0.0001), and QOLs (1.0 ± 0.06, p < 0.0001) at the 2-year follow-up compared with preoperative baseline values. No patients required transfusion after TUEB.

CONCLUSIONS

TUEB represents an effective and a safe surgical procedure. The relief from bladder outlet obstruction also proved to be durable after the 2-year follow-up.

Long-term Clinical Efficacy and Safety Profile of Transurethral Resection of Prostate Versus Plasmakinetic Resection of the Prostate for Benign Prostatic Hyperplasia

OBJECTIVE

To investigate the differences on clinical efficacy, complications, and safety profile between transurethral resection of the prostate (TURP) and bipolar plasmakinetic resection of the prostate (PKRP) for benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Six hundred ninety patients of BPH were recruited from May 2008 to May 2011 and divided into TURP group and PKRP group. The International Prostate Symptom Score (IPSS), quality of life score (QoL), postvoid residual urine (PVR), maximum flow rate (Q_max), complications, International Index of Erectile Function-5 (IIEF-5) questionnaire, and retrograde ejaculation were used for evaluation of clinical efficacy and safety and sexual function between the 2 groups.

RESULTS

The intraoperative irrigation volume, postoperative irrigation volume, postoperative irrigation time, decrease in sodium, intraoperative blood loss, and duration of catheterization of the PKRP group were significantly lower than those of the TURP group (P <.05). For comparison of complications, the incidence rates of massive hemorrhage, blood transfusion, capsular perforation, prolonged hematuria, micturition frequency, micturition urgency, and micturition pain of the PKRP group were significantly less than those of the TURP group (P <.05). During the 5-year follow-up, the PKRP group showed better effect on IPSS, QoL, PVR, and Q_max compared with the TURP group (P <.05), but there were no significant differences on IIEF-5 and retrograde ejaculation (P > .05).

CONCLUSION

PKRP is just as efficacious as TURP and is associated with a lower rate of certain morbidities. Its lower complications and better safety profile make PKRP an attractive alternative for treatment of BPH.

[Transurethral resection of the prostate]

Symptoms related to benign prostatic hyperplasia (BPH) are the most common reason why patients consult a urologist. Despite the rise of new minimally invasive technologies, transurethral resection of the prostate (TURP) remains the most commonly used procedure (at 84 %) to treat BPH patients in Germany. The continued popularity of this procedure can be explained by three main reasons: a robust, simple technique, an until now unsurpassed efficacy and-with regard to the risk-benefit ratio-a low morbidity. Following TURP, the mean Qmax is 19-20 ml/s and the mean IPSS is 6. BPH recurrence occurs in 2-7 % of patients within 8-22 years following TURP. Regarding clinical efficacy, meta-analyses now show relevant differences between monopolar and bipolar (B) TURP. However, B‑TURP seems to be favourable considering potential complications. Clot retention with an incidence of 1-5 % is the most common acute complication and urethral strictures with an incidence of 2-9 % are the most common long-term complications of TURP. TUR syndrome is nowadays a clinical rarity. However, many complications can be avoided by a proper resection technique. TURP is still the standard in surgical BPH therapy.

Secondary hemorrhage after bipolar transurethral resection and vaporization of prostate

Introduction:

We evaluated the factors associated with secondary hemorrhage after bipolar transurethral resection of prostate (TURP) and vaporization of prostate.

Materials and Methods:

The perioperative data of patients undergoing endoscopic surgery for benign prostatic hyperplasia (BPH) were prospectively collected. Procedures involved included bipolar TURP, bipolar vaporization of prostate, and hybrid bipolar TURP/vaporization of prostate. Secondary hemorrhage was defined as bleeding between 48 h and 30 days postsurgery requiring hospital attendance with or without admission. Risk factors for secondary hemorrhage were analyzed.

Results:

From 2010 to 2013, 316 patients underwent bipolar surgery for BPH. Bipolar TURP accounted for 48.1% of the procedures, bipolar vaporization accounted for 20.3% of the procedures, and the rest were hybrid TURP/vaporization of prostate. Among this cohort of patients, fifty patients had secondary hemorrhage with hospital attendance. Consumption of platelet aggregation inhibitors (PAIs) was found to be associated with secondary hemorrhage (P < 0.0005). Age, prostate volume, operation type, the use of 5-alpha reductase inhibitors, and being with a urethral catheter before operation were not found to be statistically significant risk factors for secondary hemorrhage.

Conclusions:

Secondary hemorrhage after bipolar surgery for BPH is a common event. Consumption of PAI is a risk factor for such complication.