Changes in diagnosis rate and treatment trends of benign prostatic hyperplasia in Korea: A nationwide population-based cohort study

Urethral Sparing versus Trans-Vesical Robot-Assisted Simple Prostatectomy: A Comparative Analysis of Perioperative, Postoperative Outcomes, and Ejaculation Preservation

PURPOSE

To compare the perioperative and postoperative outcomes between traditional trans-vesical robot-assisted simple prostatectomy (TV-RASP) and the newly introduced urethral-sparing (US) RASP.

MATERIALS AND METHODS

We retrospectively reviewed 42 patients who underwent TV-RASP (n=22) or US-RASP (n=20) performed by two experienced surgeons at two tertiary centers. Perioperative outcomes including operation time, estimated blood loss, length of hospital stay, and catheterization time were assessed. Postoperative outcomes were evaluated using the International Prostate Symptom Score (IPSS), quality of life (QoL), uroflowmetry parameters, Male Sexual Health Questionnaire-Ejaculation Dysfunction-Short Form (MSHQ-EjD-SF) scores, and maintenance of anterograde ejaculation.

RESULTS

This study analyzed 22 and 20 patients who underwent TV-RASP and US-RASP, respectively. Except for the TV-RASP group being older (70.0 years) than the US-RASP group (64.5 years) (p=0.028), no differences among other baseline characteristics existed. Perioperative outcomes indicated that hospital stay and catheterization time were significantly shorter in the US-RASP group than in the TV-RASP group (p<0.001). At postoperative month 1, the median IPSS and QoL scores were significantly better in the US-RASP group than in the TV-RASP group (p=0.001 and p=0.002, respectively). However, at months 6 and 12, no significant differences were noted in IPSS, QoL, maximum flow rate, and postvoid residual urine between the two groups. Sexually active patients in the US-RASP group maintained postoperative MSHQ-EjD functional and bother scores, whereas the TV-RASP group experienced a decline. Notably, 75.0% of patients in the US-RASP group preserved antegrade ejaculation, compared to only 20.0% in the TV-RASP group (p<0.001).

CONCLUSIONS

US-RASP is not inferior to TV-RASP in terms of functional outcomes. In addition, US-RASP yielded more rapid symptom improvements and preserved antegrade ejaculation than TV-RASP. However, larger prospective studies are required to confirm these findings and to further investigate the long-term efficacy and safety of US-RASP.

Revisiting the issue of "beach balls" in holmium laser enucleation of prostate: clinical and histological characterization

PURPOSE

To clinically and histologically characterize prostatic nodules resistant to morcellation ("beach balls," BBs).

PATIENTS AND METHODS

We reviewed a consecutive cohort of 559 holmium laser enucleation of the prostate (HoLEP) procedures performed between January 2020 and November 2023. The BBs group comprised 55 men (10%) and the control group comprised 504 men (90%). The clinical, intraoperative, outcome, and histologic data were statistically processed for the prediction of the presence of BBs and their influence on the perioperative course and outcome.

RESULTS

The BBs group in comparison to the controls was older (75 vs 73 years, respectively, p = 0.009) and had higher rates of chronic retention (51 vs 29%, p = 0.001), larger prostates on preoperative abdominal ultrasound (AUS) (140 vs 80 cc, p = 0.006E-16), longer operating time (120 vs 80 min, p = 0.001), higher weights of removed tissue (101 vs 60 gr, p = 0.008E-10), higher complication rates (5 vs 1%, p = 0.03), and longer hospitalization (p = 0.014). A multivariate analysis revealed that larger prostates on preoperative AUS and older age independently predicted the presence of BBs which would prolong operating time. ROC analyses revealed that a threshold of 103 cc on AUS predicted BBs with 94% sensitivity and 84% specificity. BBs were mostly characterized histologically by stromal component (p = 0.005).

CONCLUSIONS

BBs are expected in older patients and cases of chronic retention. Prostatic volume is the most reliable predictor of their presence. They contribute to prolonged operating time and increased risk of complications. The predominantly stromal composition of the BBs apparently confers their resistance to morcellation.

The epidemiology of male lower urinary tract symptoms associated with benign prostatic hyperplasia: Results of 20 years of Korean community care and surveys

PURPOSE

To investigate the prevalence of lower urinary tract symptoms/benign prostatic hyperplasia in a Korean population.

MATERIALS AND METHODS

The Korean Prostate & Voiding Health Association provided free prostate-related community health care and conducted surveys in all regions of Korea from 2001 to 2022 with the cooperation of local government public health centers. A total of 72,068 males older than 50 were surveyed and analyzed. History taking, International Prostate Symptom Score (IPSS), transrectal ultrasonography, prostate-specific antigen (PSA) testing, uroflowmetry, and urine volume testing were performed.

RESULTS

The mean prostate volumes in males in their 50s, 60s, 70s, and 80s or above were 24.7 g, 27.7 g, 31 g, and 33.7 g, respectively. The proportion of males with high PSA greater than 3 ng/mL was 3.8% among males in their 50s, 7.7% among males in their 60s, 13.1% among males in their 70s, and 17.9% among males 80 years of age or older. The mean IPSS total scores in males in their 50s, 60s, 70s, and 80s or above were 10.7, 12.7, 14.5, and 16, respectively. Severe symptoms were reported by 27.3% of males, whereas 51.7% reported moderate symptoms. The mean Qmax in males in their 50s, 60s, 70s, and 80s or above were 20 mL/s, 17.4 mL/s, 15.4 mL/s, and 13.8 mL/s, respectively.

CONCLUSIONS

In this population-based study, mean prostate volume, IPSS, PSA, and Qmax were 30.6±15.1 g, 14.8±8.2, 1.9±4.7 ng/mL, and 15.6±6.5 mL/s, respectively. Aging was significantly associated with increased prostate volume, PSA levels, and IPSS scores, and with decreased Qmax and urine volume.

Metabolic syndrome-related factors as possible targets for lower urinary tract symptoms in Korean males

INTRODUCTION

A positive association between benign prostate hyperplasia (BPH)/lower urinary tract symptoms (LUTS) and metabolic syndrome (MetS) was reported in several studies, but studies from Asia often showed conflicting results.

MATERIALS AND METHODS

Medical records were obtained from a health promotion center database between 2021 and 2022. Men without a history of treatment for LUTS were evaluated using the International Prostate Symptom Score (IPSS), Overactive Bladder Symptom Score (OABSS), transrectal ultrasonography.

RESULTS

Of 1345 individuals, 603 (44.8%) had MetS. Older age, higher IPSS values, higher prevalence rates of BPH and overactive bladder, higher triiodothyronine, and lower testosterone and sex-hormone binding globulin were observed in individuals with MetS than in individuals without MetS. The severity of LUTS significantly increased in the individuals with MetS (p = .002). In individuals with MetS, age, HbA1c, and cerebrovascular disease (CVD) were associated with IPSS. For OABSS, age, HbA1c, thyroid-stimulating hormone (TSH), coronary artery occlusive disease, and CVD were identified as predictors.

CONCLUSIONS

We confirmed the positive correlation between MetS and BPH/LUTS in Korean. Factors including TSH and atherosclerosis affected LUTS in individuals with MetS. These findings suggested a potential role of thyroid hormones and atherosclerosis in the etiology and treatment of BPH/LUTS in patients with MetS.

Evaluation of the efficiency of transurethral enucleation with bipolar energy according to prostate volume for patients with benign prostate hyperplasia

Background

This study evaluated the efficiency and safety of transurethral enucleation with bipolar energy (TUEB) using a spatula loop according to prostate volume.

Methods

We retrospectively evaluated 398 patients who underwent TUEB for benign prostatic hyperplasia at a single tertiary hospital between August 2018 and December 2022. The patients were divided into three groups according to estimated prostate volume (ePV): ≤40 mL (n = 67), 40-80 mL (n = 200), and ≥80 mL (n = 131). To compare the efficiency of TUEB, perioperative parameters including TUEB and enucleation efficiencies, were calculated as enucleated tissue weight per operation time and enucleated tissue weight per enucleation time, respectively. Preoperative and postoperative functional outcomes such as the International Prostate Symptom Score (IPSS), quality-of-life (QoL) score, maximum flow rate (Qmax), and post-void residual urine volume (PVR), were also compared.

Results

The IPSS total score, voiding sub-score, Qmax, and PVR improved after TUEB in all groups (all p < 0.05). The TUEB and enucleation efficiencies increased with increasing ePVs (all P < 0.001). When comparing the three prostate volume groups, there were no significant differences in functional outcomes within 12 months after TUEB (all-Bonferroni adjusted P > 0.017). A total of 57 patients experienced adverse events after TUEB, with no significant differences between the three groups (p = 0.507).

Conclusion

As prostate volume increases, the perioperative efficiency of TUEB is enhanced. Meanwhile, small prostates did not show significant differences in the improvement of functional outcomes and complications in comparison with larger prostates.

Optimal sequencing of the first- and second-line target therapies in metastatic renal cell carcinoma: based on nationally representative data analysis from the Korean National Health Insurance System

BACKGROUND

The authors intend to compare the effects of each targeted therapy (TT) in the treatment of patients with metastatic renal cell carcinoma (mRCC) using big data based on the Korean National Health Insurance System (NHIS) and determine the optimal treatment sequence.

METHODS

Data on the medical use of patients with kidney cancer were obtained from the NHIS database from January 1, 2002, to December 31, 2020. Patient variables included age, sex, income level, place of residence, prescribing department, and duration from diagnosis to the prescription date. The primary outcome was overall survival (OS) for each drug and sequencing. We performed propensity score matching (PSM) according to age, sex, and Charlson Comorbidity Index based on the primary TTs.

RESULTS

After 1:1 PSM, the sunitinib (SUN) (n = 1,214) and pazopanib (PAZ) (n = 1,214) groups showed a well-matched distribution across the entire cohort. In the primary treatment group, PAZ had lower OS than SUN (HR, 1.167; p = 0.0015). In the secondary treatment group, axitinib (AXI) had more favorable OS than cabozantinib (CAB) (HR, 0.735; p = 0.0118), and everolimus had more adverse outcomes than CAB (HR, 1.544; p < 0.0001). In the first to second TT sequencing, SUN-AXI had the highest OS; however, there was no statistically significant difference when compared with PAZ-AXI, which was the second highest (HR, 0.876; p = 0.3312). The 5-year survival rate was calculated in the following order: SUN-AXI (51.44%), PAZ-AXI (47.12%), SUN-CAB (43.59%), and PAZ-CAB (34.28%). When the four sequencing methods were compared, only SUN-AXI versus PAZ-CAB (p = 0.003) and PAZ-AXI versus PAZ-CAB (p = 0.017) were statistically significant.

CONCLUSIONS

In a population-based RWD analysis of Korean patients with mRCC, SUN-AXI sequencing was shown to be the most effective among the first to second TT sequencing methods in treatment, with a relative survival advantage over other sequencing combinations. To further support the results of this study, risk-stratified analysis is needed.

Comparison of three questionnaire forms used in the diagnosis of lower urinary tract symptoms: A prospective study

Purpose

Questionnaire forms (QFs) are used in the evaluation of all patients presenting with lower urinary tract symptoms (LUTSs). Our study aims to investigate the compatibility of the three QFs with each other and to investigate the relationship between education level and complete completion of these forms.

Materials and methods

A total of 224 patients between February 2018 and February 2019 were included. The patients were divided into 3 groups as primary, intermediate, and advanced according to their education level and the patients who gave incomplete answers to the questions were determined.

Results

The mean age of the patients was 61.0 ± 7.57(45-85), International Prostate Symptom Score (IPSS) value was 16.2 ± 8.3(1-35), the international incontinence form-male lower urinary tract symptoms (ICIQ-MLUTS) value was 16.5 ± 7.9(0-38), the visual prostate symptom score (VPSS) value was 9.9 ± 3.0(3-16). There was a significant correlation between the three QFs (P < 0.05). The correlation between IPSS and ICIQ-MLUTS was strong (r = 0.745). The incomplete response rate was 32.1% (n = 72) in ICIQ-MLUTS, 16.5% (n = 37) in VPSS, and 10.7% (n = 24) in IPSS (P < 0.05). The incomplete response rate was not affected by education. The rate of patients who could be questioned with ICIQ-MLUTS but not with the other two QFs varied between 12.9% and 85.2%, depending on the symptoms.

Conclusions

Each QF has its advantages and disadvantages. The strong correlation between IPSS and ICIQ-MLUTS found in our study indicates that these tools can be used interchangeably in daily clinical practice. ICIQ-MLUTS can evaluate symptoms that are not present in other QFs. In the evaluation of illiterate patients, VPSS should be used without any alternative.

Lifestyle habits to prevent the development of benign prostatic hyperplasia: Analysis of Japanese nationwide datasets

Objectives

Benign prostatic hyperplasia (BPH) refers to nonmalignant hyperplasia of prostate tissue, which causes lower urinary tract symptoms and has become a global public health concern in the aging population. The purpose of this study is to identify modifiable factors, which would prevent or delay BPH development.

Methods

The association between BPH marker drugs and climate-, socioeconomic-, health condition-, and lifestyle habits-related variables was investigated by analyzing nationwide datasets which were collected in 2018, aggregated by prefecture (administrative unit), and published by Japanese ministries. Uroselective α₁ receptor blockers and dutasteride were used as marker drugs referring to BPH prevalence. Correlation analysis, multiple linear regression analysis, and binomial logistic regression analysis were conducted with 47 Japanese prefectures as the unit.

Results

The variables which showed |r| > 0.5 by correlation analysis were exercise habits (r = -0.5696), smoking habits (r = 0.6116), and daily drinking (r = 0.6001) for uroselective α₁ receptor blockers, and antihypertensive medication (r = 0.5971), smoking habits (r = 0.6598), a small amount of drinking (r = -0.5292), and serum alanine aminotransferase (r = 0.6814) for dutasteride. Multiple linear regression equations were constructed by including these variables (R ²  = 0.5453 for uroselective α₁ receptor blockers and R ²  = 0.5673 for dutasteride). Binomial logistic regression analysis found a significant association between climate in the resident area and BPH development.

Conclusion

This ecological study, analyzing Japanese nationwide datasets, demonstrates that healthy lifestyle habits, especially avoidance of smoking, implementation of exercise in daily life, and a small amount of alcohol consumption, are important to prevent or delay BPH development. High blood pressure and high serum alanine aminotransferase are suggested as risk factors of BPH development.

Simplified Chinese version of the international prostate symptom score and the benign prostatic hyperplasia impact index: Cross-cultural adaptation, reliability, and validity for patients with benign prostatic hyperplasia

Background

Methods

Results

Conclusions

Robotic-assisted simple prostatectomy versus holmium laser enucleation of the prostate for large benign prostatic hyperplasia: a single-center preliminary study in Korea

Background

Holmium laser enucleation of the prostate (HoLEP) and robotic-assisted simple prostatectomy (RASP) are the two most important therapeutic modalities for large benign prostatic hyperplasia. However, there are currently no studies comparing these two treatments in a Korean setting. In this study, the authors seek to compare the safety and efficacy associated with these procedures.

Methods

The authors retrospectively analyzed 59 male patients who underwent HoLEP (n = 26) or RASP (n = 33) at single center. The following preoperative data were compared: age, the International Prostatic Symptom Score (IPSS), transrectal ultrasonography, uroflowmetry, and hemoglobin. Intraoperative data included operation time and specimen weight. Postoperative data included change in IPSS, uroflowmetry, and hemoglobin. Length of stay, catheterization time, and complications were also reviewed.

Results

No significant differences between the two groups were found in terms of age, total prostate, and transitional volume. Postoperatively, both groups showed similar improvement in the maximum flow rate, post-void residual urine, IPSS, and quality of life. Intraoperatively, there were no differences regarding operation time and resected prostate volume. Catheter removal time and length of stay were significantly shorter in the HoLEP group than the RASP group. In addition, postoperative hemoglobin changes were significantly lower in the HoLEP group. However, incontinence rates at 1 month and 2 months postoperative in the RASP group were lower than the HoLEP group.

Conclusions

Both HoLEP and RASP can produce excellent postoperative outcomes. However, catheter removal time, length of stay, and hemoglobin changes were more favorable in the HoLEP group. On the other hand, postoperative incontinence was more favorable in the RASP group. These factors must be heavily considered when deciding surgical the method for large benign prostatic hyperplasia.

Association between Predictors of Progression of Benign Prostatic Hyperplasia and Moderate to Severe Prostatitis-like Symptoms: A Propensity Score–Matched Analysis

Background

We investigated the association between moderate-to-severe prostatitis-like symptoms and the predictors of benign prostatic hyperplasia (BPH) progression.

Methods

Men who underwent health checkups were analyzed. We classified symptoms as “moderate to severe” if the pain score according to the National Institutes of Health-Chronic Prostatitis Symptoms Index was ≥8 and predictors of the progression of BPH were defined as having a prostate-specific antigen (PSA) ≥1.6 ng/mL, total prostate volume (TPV) ≥31 mL, international prostate symptom score (IPSS) ≥20, and maximal flow rate (Q_max) <10.6 mL/s. A total of 8368 patients formed the cohort for propensity score matching, including 445 men with moderate-to-severe prostatitis-like symptoms and 5390 men with no symptoms; ultimately, however, the propensity score of these groups matched at a 1:2 ratio.

Results

After propensity matching, the two groups were evenly distributed with respect to age, International Index of Erectile Function-5 score, metabolic syndrome, and testosterone. The percentage of participants with ≥1 predictor for the progression of BPH, a TPV of ≥31 cm³, PSA levels of ≥1.6 ng/mL, Q_max <10.6 mL/s, and IPSS ≥20 were all greater in men with moderate-to-severe prostatitis-like symptoms. There were significant differences in the percentage of participants with ≥1 predictor for the progression of BPH (30.6% vs. 58.0%; p < 0.001), Q_max <10.6 mL/s (3.9% vs. 7.0%, p = 0.023), and IPSS ≥20 (9.6% vs. 44.7%, p < 0.001).

Conclusion

Moderate-to-severe prostatitis-like symptoms are significantly and independently associated with predictors of BPH progression.

Korean Version of the Patient Perception of Study Medication Questionnaire: Translation and Linguistic Validation

Purpose

The patient perception of study medication (PPSM) questionnaire consists of 12 questions designed to quantify patient satisfaction with the efficacy of study treatment by focusing on specific changes that patients experience during the study period. This study aimed to develop a Korean version of the PPSM questionnaire.

Methods

The linguistic validation process consisted of obtaining permission for translation, forward translation, reconciliation, backward translation, cognitive debriefing, and proofreading. Two independent bilingual translators translated the original version of the questionnaire, and a panel discussed and combined the 2 versions. Another independent translator performed backward translation of the reconciled version, after which 15 patients underwent the cognitive debriefing.

Results

The 12 questions and 4 response scales of the PPSM questionnaire were forward translated into 2 Korean versions. The terms were adjusted to conceptually equivalent expressions in Korean. After backward translation, the panel made minor changes to the forward translations for brevity and better readability. No difficulties were experienced during cognitive debriefing by 15 patients, and all items were reported to be generally easy to understand.

Conclusions

The Korean version of the PPSM questionnaire has been successfully translated and validated. The questionnaire is appropriate for assessing symptom satisfaction in patients that undergo benign prostatic hyperplasia pharmacotherapy.