Open prostatectomy versus 180-W XPS GreenLight laser vaporization: Long-term functional outcome for prostatic adenomas > 80 g

Functional outcomes of GreenLight 180-W photoselective vaporization in patients with large (≥ 80 cc) prostates: an analysis of over 3000 men in the Global Greenlight Group (GGG) database

INTRODUCTION

GreenLight photoselective vaporization of the prostate (PVP) has gained widespread adoption as an option to traditional transurethral resection of the prostate. Prior reports expressed concern with the use of PVP in large prostates. The aim of this study was to investigate the adjusted outcomes of GreenLight PVP in men with large (≥ 80 cc) vs. small prostates (< 80 cc).

METHODS

Data were obtained from the Global Greenlight Group which pools data from 7 high volume centers. Men with established benign prostatic hyperplasia who underwent GreenLight PVP using the XPS-180 W system between 2011 and 2019 were eligible and assigned into two groups based on their prostate size (≥ 80 and < 80 cc). 11 functional and perioperative covariates were collected. Analyses were adjusted for patient age and presence of median lobe.

RESULTS

3426 men met the inclusion criteria. 34.6% (n = 1187) of patients had a large prostate size. Baseline age and prostate volume were significantly different between the groups. The magnitude of absolute improvement in unadjusted international prostate symptom score was significantly greater in the large (≥ 80 cc) prostate group at 12 months, with an absolute change of 19.17 points (95% CI 18.46-19.88; p < 0.01). There was also a significant drop in PVR at both 6- (p = 0.007) and 12 months (p = 0.005). There were no significant differences in transfusion (p = 0.42), hematuria (p = 0.80), or 30-day readmission rates (p = 0.28).

CONCLUSIONS

Greenlight PVP is a safe and effective alternative for patients with prostate sizes ≥ 80 cc, with durable outcomes relatively independent from prostate size.

Comparison of the efficacy and safety of transurethral laser versus open prostatectomy for patients with large-sized benign prostatic hyperplasia: A meta-analysis of comparative trials

PURPOSE

The selection of open prostatectomy (OP) over transurethral laser surgery is controversial for large volume prostates. Thus, we aim to compare the efficacy and safety of transurethral laser versus OP, and provide the latest evidence of clinical practice for large-sized benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

This meta-analysis used Review Manager V5.3 software and the systematic literature search of Cochrane Library, Embase, PubMed, and Web of Science datasets was performed for citations published from 2000 to 2020 that compared transurethral laser with OP for the treatment of large BPH. Variables of interest assessing the two techniques included clinical characteristics, and the perioperation-, effectiveness-, and complication-related outcomes.

RESULTS

The meta-analysis included twelve studies containing 1,514 patients, with 792 laser and 722 OP. The transurethral laser group was associated with shorter hospital stay and catheterization duration, and less hemoglobin decreased in the perioperative variables. There was no significant difference in the international prostate symptom score, post-void residual urine volume, maximum flow rate, and quality of life score. Transurethral laser group had a significantly lower incidence of blood transfusion than OP group (odds ratio, 0.10; 95% confidence interval, 0.05 to 0.19; p<0.001; I²=8%), and no statistical differences were found with respect to the other complications.

CONCLUSIONS

Both OP and transurethral laser prostatectomy are effective and safe treatments for large prostate adenomas. With these advantages of less blood loss and transfusion, and shorter catheterization time and hospital stay, laser may be a better choice for large BPH.

Transfusion rates after 800 Aquablation procedures using various haemostasis methods

OBJECTIVE

To determine if athermal methods are as effective in preventing blood transfusions as the use of cautery across various prostate volumes following prostate tissue resection for benign prostatic hyperplasia using Aquablation.

PATIENTS AND METHODS

The current commercial AQUABEAM robot that performs Aquablation therapy was first used in 2014. Since then numerous clinical studies have been conducted in various countries; Australia, Canada, Germany, India, Lebanon, Spain, New Zealand, United Kingdom, and the United States. All of the clinical trial data since 2014 were pooled with the early commercial procedures from France, Germany, and Spain to determine the effectiveness of haemostatic techniques in reducing the transfusion rate in patients after Aquablation.

RESULTS

In all, 801 patients were treated with Aquablation therapy from 2014 to early 2019. The mean (SD, range) prostate volume was 67 (33, 20-280) mL and 31 (3.9%) transfusions were reported. The largest contributing factor to transfusion risk was prostate size and method of traction. There was an increasing risk of transfusions in larger prostates when robust traction using a catheter-tensioning device (CTD) without cautery was used, ranging from 0.8% to 7.8% in prostates ranging from 20 to 280 mL. However, when standard traction (taping the catheter to the leg, gauze knot synched up to the meatus, or no traction at all) was used and where the surgeon performed bladder neck cautery only when necessary, the risk of transfusion was 1.4-2.5% in prostates ranging from 20 to 280 mL.

CONCLUSIONS

While the athermal subgroup with robust traction with a CTD had comparable transfusion rates for smaller prostates, the risk increased significantly as prostate volume increased. With standard traction methods and selective bladder neck cautery, the risk of transfusion was reduced to 1.9% across all prostate sizes.

Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue trial (WATER) vs WATER II: comparing Aquablation therapy for benign prostatic hyperplasia in 30-80 and 80-150 mL prostates

Objective

To compare the outcomes of Aquablation in 30–80 mL prostates with those in 80–150 mL prostates. Surgical options, especially with short learning curves, are limited when treating large prostates for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Aquablation (AquaBeam System, PROCEPT BioRobotics Inc., Redwood City, CA, USA) could solve this issue with global reproducibility, independent of prostate volume.

Patients and Methods

Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue (WATER [W‐I]; NCT02505919) is a prospective, double‐blind, multicentre, international clinical trial comparing Aquablation and transurethral resection of the prostate (TURP) for the treatment of LUTS/BPH in prostates between 30 and 80 mL. WATER II (W‐II; NCT03123250) is a prospective, multicentre, single‐arm international clinical trial of Aquablation in prostates between 80 and 150 mL. We compare baseline parameters and 12‐month outcomes in 116 W‐I and 101 W‐II study patients. Students’ t‐test or Wilcoxon tests were used for continuous variables and Fisher’s test for binary variables.

Results

The mean (SD) operative time was 33 (17) and 37 (13) min in W‐I and W‐II, respectively. Actual treatment time was 4 and 8 min in W‐I and W‐II, respectively. The mean change in the International Prostate Symptom Score was substantial averaging (at 12 months) 15.1 in W‐I and 17.1 in W‐II (P = 0.605). By 3 months, Clavien–Dindo grade ≥II events occurred in 19.8% of W‐I patients and 34.7% of W‐II patients (P = 0.468).

Conclusion

Aquablation clinically normalises outcomes between patients with 30–80 mL prostates and patients with 80–150 mL prostates treated for LUTS/BPH, with an expected increase in the risk of complications in larger prostates. Long‐term outcomes of procedure durability are needed.

Aquablation outcomes for the U.S. cohort of men with LUTS due to BPH in large prostates (80-150 cc)

Between September and December 2017, 82 men with moderate-to-severe lower urinary tract symptoms due to benign prostatic hyperplasia LUTS/BPH and prostate volume of 80-150 cc underwent Aquablation in a prospective multicenter clinical trial in the United States. Baseline patient and clinical demographics and standardized postoperative parameters were collected and tabulated in a central independently monitored database. Adverse events through 3 months were adjudicated by an independent clinical events committee. Mean pre-treatment prostate volume was 108 ± 21.1 cc. Mean operative time was 38.2 ± 14.4 min and mean Aquablation resection time was 7.7 ± 3.3 min. Additional electrocautery for hemostasis was not needed in any patient following Aquablation. The average length of stay following the procedure was 1.6 ± 1.0 days. Mean pre- and 3 months post-treatment IPSS scores were 23.7 ± 6.4 and 7.1 ± 5.1, -16.6, p < 0.01. Mean pre- and 3 months post-treatment Qmax were 9.2 ± 3.3 ml/s and 19.5 ± 13 ml/s, + 10.8 ml/s, p < 0.01. Mean pre- and 3 months post-treatment post-void residuals were 120.6 ± 119.1 cc and 50.6 ± 61.6 cc, -72.0 cc, p < 0.01. The observed Clavien-Dindo grade 2 or higher event rate at 3 months was 34.1%. Aquablation is a safe and effective treatment option for men with large prostates (80-150 cc) suffering from LUTS/BPH.

Pooled Aquablation Results for American Men with Lower Urinary Tract Symptoms due to Benign Prostatic Hyperplasia in Large Prostates (60-150 cc)

INTRODUCTION

To present short-term safety and efficacy data of men with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) treated with Aquablation.

METHODS

Men with LUTs secondary to BPH (60-150 cc) underwent Aquablation treatment from February 2016 to December 2017 across 17 investigational sites in the USA from two contemporary investigational device exemption (IDE) studies called WATER (NCT02505919) and WATER II (NCT03123250).

RESULTS

One hundred seven males with mean age of 67.3 ± 6.5 years were treated with Aquablation; mean prostate volume was 99.4 ± 24.1 cc. The pooled results show that large prostates have an average procedure time of less than 36 min and discharge on average 1.6 ± 1 days. The IPSS decreased by 16.7 ± 8.1 points at 3 months and Q_max increased by 11.2 ± 12.4 ml/s. The Clavien-Dindo (CD) grade 2 or higher event rate at 3 months was 29%. A non-hierarchical breakdown for CD events yielded 18% grade 2 and 19% grade 3 or higher.

CONCLUSION

Men with LUTS secondary to BPH (60-150 cc) in a pooled analysis were treated safely and effectively with Aquablation up to 3 months postoperatively.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers, NCT02505919 and NCT03123250.

FUNDING

PROCEPT BioRobotics.