Long-term results of open transvesical prostatectomy from a contemporary series of patients

Benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is a histopathologic definition associated with enlargement of the prostate gland that causes obstruction of the lower urinary tract and manifests clinically with characteristic symptoms that are what bring patients for consultation. Urinary tract symptoms are common, especially in an increasingly aging population. Diagnosis and the decision on when and how to treat depend on the patient's quality of life and objective clinical parameters. An individualized, risk-based approach is necessary to guide conservative, pharmacologic, or surgical treatment.

Initial experience with thulium fiber laser for prostate enucleation: Analysis of the intraoperative and short-term outcomes in a prospective, multicenter cohort

INTRODUCTION

Holmium laser enucleation of the prostate has rapidly become the gold standard for the surgical treatment of benign prostate hyperplasia, although thulium fiber laser (TFL) has also been postulated as an effective and safe alternative for prostate enucleation. The aim of this study is to describe our initial experience with the TFL for endoscopic enucleation of the prostate.

MATERIAL AND METHODS

All patients proposed to TFL prostate enucleation were included in the analysis, regardless their prostate volume, catheter status and severity of symptoms, in 3 centers. Preoperative characteristics, intraoperative times and functional 3-months follow-up variables were collected, along with complications.

RESULTS

Fifty-six patients were available, with a mean age of 68.7 years. Enucleation and morcellation efficiencies were 2.04 and 7.47 g/min, respectively. Median hospital stay was one day. Comparable functional data, pre and 3-month post-surgery was: mean prostate volume 88.9 vs 21.3 g, maximum urinary flow 13.2 vs 27.3 ml/s, post-void residual volume 149 vs 7.8 ml, prostatic specific antigen level 11.2 vs 1 ng/ml, and International Prostate Symptom Score 20.75 vs 3.96. Fourteen out of 56 (25%) patients presented with complications grade ≤2, according to the Clavien-Dindo classification.

DISCUSSION

With wider evidence for other urological indications, very recent evidence about the suitability of TFL for prostate enucleation has arisen, since the first case described in 2021. Our results seem to back up these previous successful experiences as long as we obtained good intraoperative and short term follow-up functional results. However, there is still a need of longer follow-up data.

CONCLUSIONS

TFL represents a novel technology for prostate enucleation, with a good intraoperative and short follow-up functional results, and a safety profile similar to the observed for those techniques that have been wider used for this indication. Further studies with longer follow-up periods and comparative with these other techniques are necessary.

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.

Extraperitoneal Laparoscopic Simple Prostatectomy for large prostatic adenomas: A single-centre experience on 14 patients with significant lower urinary tract symptoms

INTRODUCTION AND OBJECTIVES

There are various approaches available for surgical management of large prostatic adenomas - open, laparoscopic as well as laser enucleation - but there are no available clear cut consensus or guidelines. We present our experience in Extraperitoneal Laparoscopic Simple Prostatectomy on 14 patients with large prostatic adenoma (>100 g).

MATERIALS AND METHODS

This is a retrospective analysis on 14 patients with large prostatic adenoma who underwent extraperitoneal laparoscopic prostatectomy (LSP) over a period of 2 years (2021-2023). All selected patients underwent extraperitoneal LSP. The case records were retrospectively reviewed and data were collected regarding age, clinical presentation, prostate size, median surgical time, intra-operative and post-operative events, pre-operative and post-operative assessment of IPSS score, Uroflowmetry and PVR values and duration of hospital stay.

RESULTS

A total of 14 patients underwent LSP. The median age was 64.2 years and the median prostatic size was 123.25 g. Median operative time was 150 min. None of the patients required blood transfusion; mean Post-operative day (POD) for drain removal was 2.5 days. The mean duration of hospital stay was 3.5 days. Only one patient had urinary leak and vesico-cutaneous fistula which was managed conservatively by prolonged catheterisation. At 3 months follow-up, there was significant improvement in IPSS Score (mean 7.8 vs 21.3 pre-operatively), uroflow values (mean Qmax of 27.3 vs 6.8 pre-operatively) and PVR (mean 30.5 vs 350 ml pre-operatively).

CONCLUSION

Laparoscopic Simple Prostatectomy is a safe and feasible approach for large prostatic adenomas with lesser morbidity and complications and satisfactory outcome.

Single-port robot-assisted simple prostatectomy: techniques and outcomes

PURPOSE

To describe the surgical techniques and to analyse the outcomes of single-port robot-assisted simple prostatectomy (SP RASP) procedure for the surgical treatment of benign prostatic hyperplasia (BPH).

METHODS

Three databases (PubMed®, Web of Science™, and Scopus®) were queried to identify studies reporting on the technical aspects and outcomes of SP RASP. Different combinations of keywords were used, according to a free-text protocol, to identify retrospective and prospective studies, both comparative and non-comparative, systematic reviews (SR) and meta-analysis (MA) describing surgical techniques for SP RASP and the associated surgical and functional outcomes.

RESULTS

The transvesical approach represents the most common approach for SP RASP. A decrease in terms of estimated blood loss was observed when SP RASP was compared to open simple prostatectomy (OSP) and multi-port (MP) RASP. Furthermore, this technique allowed for a shorter length of hospital stay (LoS) and a lower post-operative complication rate, compared to OSP. Post-operative subjective and objective functional outcomes are satisfying and comparable to OSP and MP RASP.

CONCLUSION

SP RASP represents a safe and feasible approach for the surgical management of BPH. It provides comparable surgical and functional outcomes to MP RASP, enabling for minimal invasiveness, enhanced recovery, and potential for improving patient care.

Comparison of the efficacy and safety of robotic-assisted simple prostatectomy and laser enucleation of prostate for large benign prostatic hyperplasia

Laser enucleation of the prostate (LEP) and robotic-assisted simple prostatectomy (RASP) are two main treatment methods for large benign prostatic hyperplasia (BPH), but the superiority between these two methods in treating large BPH is currently unclear. This study aims to conduct a meta-analysis to compare the efficacy and the safety of LEP and RASP in treating large BPH. We systematically searched the PubMed, Embase, and Cochrane Library databases for studies that compared safety and efficacy outcomes of both LEP and RASP. Review Manager 5.3 was used for the meta-analysis. Six studies with a total of 1235 patients were included in the analysis. Resected adenoma weight was similar in LEP than RASP group. Operative time [mean difference (MD) - 67.96; 95% confidence interval [CI] - 131.66 to - 4.25; p = 0.04], catheterization time (MD -6.31; 95% CI - 9.44 to - 3.18; p < 0.0001), and length of stay (MD - 2.44; 95% CI - 3.55 to - 1.34; p < 0.0001) were lower in LEP. The International Prostate Symptom Score, maximum urinary flow rate, prostate-specific antigen, and post-void residual urine volume were also comparable between two groups. Furthermore, LEP demonstrated lesser hemoglobin decrease (MD - 0.50; 95% CI - 0.96 to - 0.05; p = 0.03), lower blood transfusion rate [odd ratio (OR) 0.23, 95% CI 0.08-0.66; p = 0.006], and lower rate of Clavien-Dindo Grade ≥ 3 complications (OR 0.435, 95% CI 0.189-0.998; p = 0.049). Finally, there was no significant difference in overall complications between two groups. Current evidence shows that LEP offers favorable perioperative outcomes compared with RASP. However, there was no conclusive evidence that LEP was advantaged in terms of efficacy outcomes.

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.

Outcomes of robotic modified Freyer's prostatectomy in an Australian patient cohort

Introduction

The study aims to demonstrate the feasibility, safety and efficacy of robotic simple prostatectomy (RSP) using the modified Freyer's approach in an Australian patient cohort. Although RSP is performed in several Australian centres, there is a paucity of published Australian data.

Methods

We reviewed prospectively collected perioperative and outcomes data for patients who underwent a robotic modified Freyer's prostatectomy (RMFP) from June 2019 to March 2022. Statistics were completed using SPSS statistics v27.0 and reported as mean and range with a p value of <0.05 considered statistically significant.

Results

There were 27 patients who underwent RMFP over the study period with a mean age of 67 years and prostate volume of 159.74 cc (100-275). The mean console time was 168 min (122-211), blood loss of 233 ml (50-600) and average length of hospital stay of 3.8 days (3-8). The preoperative versus postoperative outcome means were as follows: serum prostate-specific antigen was 9.69 versus 1.2 ng/mL, IPPS score was 17.1 versus 1.25, quality of life (QOL) score 3.4 versus 0.4, postvoid residual volume: 223.6 versus 55.9 ml, Q-max 7.86 versus 29.6 ml/s. These were all statistically significant (p < 0.001). The mean weight of resected tissue was 74 g (43-206) with 25 patients having benign histopathology and two being diagnosed with prostate cancer (Gleason 3 + 3 = 6 and 3 + 4 = 7). No patients returned to theatre or required a blood transfusion.

Conclusions

Data from our patient cohort demonstrate the feasibility, safety and efficacy of RMFP for benign prostatic hyperplasia in an Australian patient cohort. Our outcomes compare favourably with published studies on RSP.

[Surgical treatment options of lower urinary tract symptoms due to benign prostatic obstruction : The German S2e guideline 2023-part 3]

BACKGROUND

Lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) are one of the most common diagnoses in clinical practice. Bothersome LUTS impact considerably quality of life of men and may cause severe complications without treatment. According to the diagnostic assessment every patient should be treated with an adequate therapy. Management comprises a conservative approach, medication, novel minimally invasive options, and surgical procedures with the aim to remove the obstructing adenoma. The German guideline panel has updated the German guidelines on diagnostic evaluation and management of LUTS due to BPO.

OBJECTIVES

Evidence-based recommendations of surgical treatment options of LUTS due to BPO are evaluated.

MATERIALS AND METHODS

Chapters 11.1.1 and 11.2 of the updated German S2e guideline on the management of LUTS due to BPO are summarized as a review article.

RESULTS

A treatment algorithm based on current evidence has been proposed. It is considered to provide guidance for the selection of the best procedure according to the needs of the patient. Anatomic features of the prostate, the patients' morbidity, and the preservation of ejaculatory function are taken into account for the choice of the best procedures. These surgical options can be divided into techniques with direct, delayed or no removal of the adenoma, procedures with suprapubic access, and embolizing approaches.

CONCLUSIONS

The updated German S2e guideline on the management of LUTS due to BPO provides evidence-based recommendations for the selection of the best procedure according to the needs of the individual patient.

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.

Open prostatectomy for benign prostatic hyperplasia: A critical analysis of patient presentation and surgical outcomes in a contemporary series

Background

Open prostatectomy (OP) is still a valid treatment option for benign prostatic hyperplasia (BPH), but it needs to be constantly reevaluated in the context of minimally invasive treatments (MITs).

Aim

Our purpose is to present contemporary data on patient presentation and surgical outcomes of OP with which other OP series and MITs can be compared.

Methods

A retrospective study of all OP was carried out in our institution from January 2011 to December 2020. All patients had a thorough preoperative workup and optimization of comorbidities before surgery. Data were collected in a predesigned pro forma and analyzed.

Results

The mean age of the 148 patients studied was 66.2 (±7.9) yrs. The mean duration of symptoms before surgery was 32.2 (±33.7) mos. The mean preoperative prostate volume was 118.0 (±67.1) cm3. There was a 54.4% comorbidity rate with diabetes mellitus (DM) topping the list (16.0%). An incidental prostate cancer rate of 6.1% was found. The overall complication rate was 45.3%. Perioperative hemorrhage requiring blood transfusion (BT) was the most common complication (26.1%). There was no significant difference in age, duration of surgery, and prostrate volume between subjects with and without BT (P > 0.05). Wound infection was significantly associated with diabetes (P = 0.043, OR = 3.507, 95% CI = 1.042-11.805). The reoperation rate was 1.4%, and mortality rate was 0.7%. The International Prostate Symptom Score (IPSS), quality-of-life (QOL) score, and post-void residual urine (PVR) volume were significantly improved (P < 0.001).

Conclusion

OP was found to be a safe and effective procedure for the relief of bladder outlet obstruction (BOO) secondary to BPH. However, it was associated with high morbidity and low reoperation rate.

Single-port transvesical versus open simple prostatectomy: a perioperative comparative study

OBJECTIVE

To compare the initial perioperative outcomes of single-port transvesical simple prostatectomy (SP RASP) patients to those of open simple prostatectomy (OSP).

PATIENTS AND METHODS

Perioperative data from 42 consecutive patients with BPH who underwent SP RASP were prospectively reviewed. Similarly, data from forty-three consecutive patients who underwent the standard OSP, were retrospectively collected. Through direct suprapubic bladder access, prostatic enucleation was performed using the prostatic capsule as a landmark. Then a complete vesicourethral mucosal advancement flap was accomplished. OSP was performed according to the standard approach. Demographics, Intra- and perioperative data were analyzed and assessed with a descriptive analysis.

RESULTS AND LIMITATIONS

Baseline characteristics were comparable between the two groups, except for the preoperative median post-void residual volume, which was higher in the OSP group (p = 0.004). The SP RASP group had less intraoperative estimated blood loss (p < 0.001), no need for continuous bladder irrigation (p < 0.001), and less in-hospital opioid use (p < 0.001). Patients in the SP RASP group were discharged on postoperative day zero, compared to a median of 2 days for OSP (p < 0.001). The median Foley catheter duration was 7 days for SP RASP, compared to a median of 10 days for OSP (p < 0.001). SP RASP group had fewer postoperative complications, however, this did not reach statistical significance.

CONCLUSION

SP RASP is an alternative approach in treating surgical BPH. It may offer patients less morbidity in comparison to OSP.

Initial Experience of Robot-Assisted Simple Prostatectomy with Hugo Robot-Assisted Surgery System: Step-by-Step Description of Two Different Techniques

Introduction: There are only a few clinical data on nononcologic procedures performed with the new Hugo™ robot-assisted surgery (RAS) system. Robot-assisted simple prostatectomy (RASP) is a minimally invasive treatment option for benign prostatic hyperplasia, and it demonstrated equal early functional and better perioperative outcomes as compared with open simple prostatectomy. In this article, we reported the first large series of RASP performed with Hugo RAS system. Methods: This Supplementary Video S1 is a step-by-step description of two different techniques for RASP. We analyzed the data of 20 consecutive patients who underwent RASP at OLV Hospital (Belgium) between February 2022 and March 2023. Patients baseline characteristics, perioperative and pathologic, and 1-month postoperative outcomes were reported, using the median (interquartile range [IQR]) and frequencies, as appropriate. Results: Median age (IQR) and preoperative prostate specific antigen (PSA) were 72 (67-76) years, and 7.7 (5.0-13.4) ng/mL, respectively. A total of 11 patients experienced an episode of preoperative acute urinary retention, and 8 men had an indwelling bladder catheter at the time of the surgery. No intraoperative complication occurred, and there was no need for conversion to open surgery. Median operative and console time were 165 (121-180) and 125 (101-148) minutes. On the first postoperative day the urethral catheter was removed in 80% of the patients. Median length of stay was 3 (3-4) days. Three patients had minor postoperative complications. On final pathology report, median prostate volume was 120 (101-154) g. On postoperative uroflowmetry, median Qmax and postvoid residual were 16 (13-26) mL/s and 15 (0-34) mL, respectively. Conclusions: This series represents the first report of surgical outcomes of RASP executed with Hugo RAS system. Awaiting study with longer follow-up, our study suggests that Hugo RAS has multiple applications, and it can ensure optimal outcomes in nononcologic procedures.

Initial Postoperative Prostate Specific Antigen and PSA Velocity Are Important Indicators of Underlying Malignancy After Simple Prostatectomy

Background: There is a paucity of guidelines for prostate-specific antigen (PSA) monitoring after simple prostatectomy (SP) despite these patients remaining at risk for prostate cancer (PCa). Our objective was to determine if PSA kinetics can be a potential indicator of PCa after SP. Methods: A retrospective review was performed of all simple prostatectomies at our institution from 2014 to 2022. All patients who met criteria were included in the study. Relevant clinical variables were collected preoperatively, including PSA value, prostate size, and voiding symptoms. Surgical and urinary function outcomes were analyzed. Results: A total of 92 patients were divided into two groups based on malignancy status. Sixty-eight patients did not have PCa, while 24 patients had known PCa before surgery (14) or were diagnosed as having incidental PCa from the pathological specimen (10). Patients with benign prostates had an initial postoperative PSA value of 0.76 ng/mL compared with 1.68 ng/mL for those with cancer (p < 0.01). PSA velocity for the first 24 months after surgery was 0.042 ± 1.61 ng/(mL·year) for the benign cohort compared with 1.29 ± 1.02 ng/(mL·year) for the malignant cohort (p = 0.01). Voiding improvements were noted by objective (postvoid residual and flow rate) and subjective (American Urological Association symptom score and quality of life score) measures in both groups. Conclusions: PSA interpretation and monitoring after SP have not been well established. Our study indicates that initial postoperative PSA value and PSA velocity are important indicators of underlying malignancy in patients after SP. Further efforts are needed to establish threshold values and formal guidelines.

Treating LUTS in Men with Benign Prostatic Obstruction: A Review Article

Benign prostatic obstruction (BPO) is a prevalent condition that affects men, primarily toward their old age. The condition is often accompanied by lower urinary tract symptoms (LUTS), which can significantly impair a patient's quality of life and lead to other medical complications. Accurate diagnosis of BPO is essential for effective management of complications secondary to BPO, and treatment plans should be tailored patients, and occasionally according to surgeon experience. As such, this literature review aims to analyze the current available data on male LUTS secondary to BPO by providing a comprehensive overview of relevant studies, as well as the surgical and medical management guidelines from the Canadian Urological Association (CUA), American Urological Association (AUA), and European Association of Urology (EAU). By synthesizing the existing literature, this review purports to summarize the current body of knowledge surrounding BPO and male LUTS, and support healthcare providers in making informed decisions about the management of male LUTS secondary to BPO, ultimately improving patient outcomes and quality of life.

Summary Paper on the 2023 European Association of Urology Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms

CONTEXT

Lower urinary tract symptoms (LUTS) are common, often bothersome, and have multifactorial aetiology.

OBJECTIVE

To present a summary of the 2023 version of the European Association of Urology guidelines on the management of male LUTS.

EVIDENCE ACQUISITION

A structured literature search from 1966 to 2021 selected the articles with the highest certainty evidence. The Delphi technique consensus approach was used to develop the recommendations.

EVIDENCE SYNTHESIS

The assessment of men with LUTS should be practical. A careful medical history and physical examination are essential. Validated symptom scores, urine test, uroflowmetry, and postvoid urine residual, as well as frequency-volume charts for patients with nocturia or predominately storage symptoms should be used. Prostate-specific antigen should be ordered if a diagnosis of prostate cancer changes the treatment plan. Urodynamics should be performed for selected patients. Men with mild symptoms are candidates for watchful waiting. Behavioural modification should be offered to men with LUTS prior to, or concurrent with, treatment. The choice of medical treatment depends on the assessment findings, predominant type of symptoms, ability of the treatment to change the findings, and the expectations to be met in terms of the speed of onset, efficacy, side effects, and disease progression. Surgery is reserved for men with absolute indications, and for patients who fail or prefer not to receive medical therapy. Surgical management has been divided into five sections: resection, enucleation, vaporisation, and alternative ablative and nonablative techniques. The choice of surgical technique depends on patient's characteristics, expectations, and preferences; surgeon's expertise; and availability of modalities.

CONCLUSIONS

The guidelines provide an evidence-based approach for the management of male LUTS.

PATIENT SUMMARY

A clinical assessment should identify the cause(s) of symptoms and define the clinical profile and patient's expectations. The treatment should aim to ameliorate symptoms and reduce the risk of complications.

Six novel minimally invasive therapies for benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptoms in men. When drug treatment is ineffective or conventional surgery is not suitable, novel minimally invasive therapies can be considered. These include prostatic urethral lift, prostatic artery embolisation, water vapor thermal therapy, Aquablation-image guided robotic waterjet ablation, temporary implantable nitinol device and prostatic stents. These novel therapies can be performed in outpatient setting under local anesthesia, with shorter operative and recovery times, and better protection of ejaculatory function and erectile function. General conditions of the patient and advantages and disadvantages of the each of these therapies should be fully considered to make individualized plans.

Robot-assisted simple prostatectomy for treatment of large prostatic adenomas: surgical technique and outcomes from a high-volume robotic centre

PURPOSE

Aim of the present study is to describe our robot-assisted simple prostatectomy technique and to report 6-month surgical and clinical outcomes.

METHODS

Eighty men were consecutively submitted to robot-assisted simple prostatectomy in our institution from October 2019 to October 2020. All procedures were performed by the same surgical team. Diagnostic preoperative assessment was based on history, symptoms evaluation by International Prostate Symptom Score, digital rectal examination, flowmetry with post-void residual volume measurement by abdominal ultrasound, prostatic volume estimation by MRI, PSA dosage. Under combined general and subarachnoid anesthesia, surgery was performed via a transperitoneal approach using a Da Vinci Si system in the four-arm configuration. Operative time, blood loss, hospital stay, catheterization time, intraoperative and postoperative complications were assessed. Clinical postoperative 6 months of evaluation was based on physical examination, flowmetry with post-void residual volume measurement, PSA dosage, and International Prostate Symptom Score.

RESULTS

Mean operative time was 105.29 min, mean hospital staying 5.4 days. Blood loss was low in all cases and only 2 patients received transfusion. Catheterization time was 7 days. According to the Clavien-Dindo classification, only minor (grade I and grade II) intraoperative and postoperative complications were observed. At 6-month postoperative assessment, a statistically significant increase of urinary flow indexes and bladder capacity was recorded, as a significant reduction of urinary residual volume. No patient experienced stress urinary incontinence and the mean postoperative IPSS score was significantly reduced to 4.3. Two patients were diagnosed with incidental prostatic cancer at the histopathological examination.

CONCLUSIONS

Data collected in our experience on a large cohort confirm efficacy and safety of Robot-Assisted Simple Prostatectomy. This procedure allows both short operative time and hospital staying, with low incidence of perioperative complications. This surgical technique can therefore be considered a valid alternative to other procedures for the surgical treatment of large volume prostates. Randomized prospective and comparative studies are warranted in the future to assess if different RASP techniques provide similar surgical and functional outcomes.

Laparoscopic simple prostatectomy versus robot-assisted simple prostatectomy for large benign prostatic hyperplasia: a systematic review and meta-analysis of comparative trials

Laparoscopic simple prostatectomy (LSP) and robot-assisted simple prostatectomy (RASP) are important approaches for large benign prostatic hyperplasia (BPH), though it is still unclear which is superior. This study aimed to perform a pooled analysis to compare the safety and efficacy profiles of LSP and RASP. We systematically searched the databases of Science, PubMed, Embase, Web of Science, and Cochrane Library database for randomized controlled trials (RCTs) and non-RCTs, comparing LSP to RASP. The principal outcomes included perioperative, functional and complications variables. The results are presented as odds ratio (OR) or weighted mean difference (WMD) with 95% confidence intervals (CI) of dichotomous and continuous variables. Five comparative trials involving 1928 patients were included. RASP demonstrated a shorter length of hospital stay compared to LSP (WMD 1.20 days, 95% CI 0.09, 2.32; p = 0.03). However, there was no difference between the two groups regarding operative time, estimated blood loss, catheterization time and complications. Moreover, RASP had a higher maximum flow rate (Q_max) (WMD - 2.15 mL/s, 95% CI - 3.75, - 0.55; p = 0.0009) and comparable international prostate symptom score (IPSS) and sexual health inventory (SHIM) in men with LSP. The results of this study demonstrated that RASP offered comparable efficacy and safety to LSP, while maintaining a superior perioperative and functional profile. However, treatment selection should also be based on the availability and experience of the operator.

Standard Multi-Port versus Single-Port Robot‑Assisted Simple Prostatectomy: A Single Center Initial Experience

BACKGROUND

Robot-assisted simple prostatectomy (RASP) has emerged as a safe surgical treatment for patients with benign prostatic hyperplasia with large glands (>80 ml). Several studies reported on perioperative outcomes of RASP by the standard multiport (MP) da Vinci robotic system approach. Studies conducted on RASP utilizing the novel single-port da Vinci® SP robotic platform (Intuitive Surgical, Sunnyvale, CA) are scarce. We aimed to compare intraoperative and short-term postoperative outcomes between the da Vinci MP and SP robots for patients undergoing RASP in a referral center.

METHODS

In this retrospective study, we reviewed all patients who underwent RASP using MP or SP robot from September, 2016 to March, 2021. Intraoperative data, overall 30-day complications, complications by Clavien-Dindo classification and 90-day readmission and reoperation rates were assessed and compared between the two groups using appropriate statistical methods.

RESULTS

Seventy-five patients who underwent RASP were identified. Of these, 47 were in the MP group and 28 were in the SP. Compared to SP, mean operative time in MP group was 216.6 vs. 232.4 minutes (p=0.39), EBL was 195.7 vs. 227.1 ml (p=0.43) and length of stay was 2 vs. 2.5 days (p=0.45). There was a trend toward higher overall complication rate in SP group vs. MP (42.86% vs. 21.28%, p=0.09). There were no significant differences in the readmission (17.02% vs. 10.71%, p=0.52) and reoperation (2.1% vs. 7.14%, p=0.34) rates between MP vs. SP group.

CONCLUSION

SP-RASP is safe and shows equivalent perioperative outcomes when compared to the MP robotic system. A marginal increase of complication rate was recorded in the SP group; however, this did not demonstrate statistical significance.

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.

Thulium laser enucleation of prostate versus laparoscopic trans-vesical simple prostatectomy in the treatment of large benign prostatic hyperplasia: head-to-head comparison

Objectives:

To compare thulium laser enucleation of prostate (ThuLEP) versus laparoscopic trans-vesical simple prostatectomy (LSP) in the treatment of benign prostatic hyperplasia (BPH).

Materials and Methods:

Data of patients who underwent surgery for “large” BPH (>80mL) at three Institutions were collected and analyzed. Two institutions performed ThuLEP only; the third institution performed LSP only. Preoperative (indwelling catheter status, prostate volume (PVol), hemoglobin (Hb), Q_max, post-voiding residual volume (PVR), IPSS, QoL, IIEF-5) and perioperative data (operative time, enucleated adenoma, catheterization time, length of stay, Hb-drop, complications) were compared. Functional (Q_max, PVR, %ΔQ_max) and patient-reported outcomes (IPSS, QoL, IIEF-5, %ΔIPSS, %ΔQoL) were compared at last follow-up.

Results:

80 and 115 patients underwent LSP and ThuLEP, respectively. At baseline, median PVol was 130 versus 120mL, p <0.001; Q_max 9.6 vs. 7.1mL/s, p=0.005; IPSS 21 versus 25, p <0.001. Groups were comparable in terms of intraoperative complications (1 during LSP vs. 3 during ThuLEP) and transfusions (1 per group). Differences in terms of operative time (156 vs. 92 minutes, p <0.001), Hb-drop (-2.5 vs. −0.9g/dL, p <0.001), catheterization time (5 vs. 2 days, p <0.001) and postoperative complications (13.8% vs. 0, p <0.001) favored ThuLEP. At median follow-up of 40 months after LSP versus 30 after ThuLEP (p <0.001), Q_max improved by 226% vs. 205% (p=0.5), IPSS decreased by 88% versus 85% (p=0.9), QoL decreased by 80% with IIEF-5 remaining almost unmodified for both the approaches.

Conclusions:

Our analysis showed that LSP and ThuLEP are comparable in relieving from BPO and improving the patient-reported outcomes. Invasiveness of LSP is more significant.

Malament stitch and increased risk of bladder neck stenosis: any association following open prostatectomy in Enugu Southeast Nigeria

Background

Malament stitch is one of the effective techniques employed to minimize bleeding in simple open prostatectomy but concerns about possibility of increased risk of bladder neck stenosis has limited its routine use.

Aim

We studied patients who had open prostatectomy with Malament stitch to determine the incidence of bladder neck stenosis amongst them.

Material and methods

This was a prospective study of 72patients who had simple open prostatectomy in which malament stitch was applied from 2010 to 2020. A proforma was designed to collect data. Pretreatment variables were transrectal ultrasound (TRUS) volume of prostate, pretreatment IPSS value, postvoidal residual urine volume before surgery, weight of enucleated prostate adenoma, time to removal of Malament stitch. Outcome measures were done with post treatment IPSS and PVR at 6 weeks, 3 months and 6 months. Cystoscopy was done at 3 months or 6 months for patients with rising outcome measures to determine presence of bladder neck stenosis.

Results

The mean age of patients in this study was 68.3 years (SD = 7.1, range 52–82). The mean of the pretreatment score for IPSS was 30.7 (SD = 3.9, range 18–34) and 5.9 (SD = 0.2) for QOLS. The mean weight of prostate estimated with ultrasound was 169.5 g and mean weight of enucleated adenoma of the prostate was 132.5 g. The mean time of removal of Malament stitch was 23.1 h. Only 3 (4.2%) patients required cystoscopy because of increasing IPSS and PVR at 3 months postprostatectomy. 2 (2.8%) patients out of 72patients were confirmed to have bladder neck stenosis at cystoscopy.

Conclusion

Malament stitch did not lead to significant incidence of bladder neck stenosis in this study.

A Retrospective Operative and Early Outcome Comparison of Suprapubic Transvesical Prostatectomy and Transurethral resection of the Prostate

Background

BPH is the major cause of bladder outlet obstruction over the age of 40 years. Multiple surgical management options have been described of which STVP and TURP are the oldest and widely available procedures. The objective of this study is to describe and compare the intraoperative and early outcome situations of STVP and TURP.

Methods

This is a hospital-based retrospective descriptive study that compares intraoperative and early outcomes of STVP and TURP in Menilik II Hospital from January 2017 to December 2019. The study samples were 72 STVP and 72 TURP patients.

Results

The mean duration of surgery in the STVP group was 97.8 minutes which is significantly longer than TURP group (66.15 minutes). Duration of post-op catheterization and hospital stay are significantly longer in STVP than TURP.

Conclusion

The duration of surgery, length of hospital stays and post op catheterization are longer in STVP. There was no significant difference in intra-op and early complications from STVP and TURP.

Surgical management of benign prostate hyperplasia in Nigeria: open prostatectomy versus transurethral resection of the prostate

Introduction

transvesical (open) prostatectomy (OP), an invasive surgical procedure, is a common form of treatment offered to patients with benign prostatic enlargement in emerging economies. Recently, there has been an increase in the use of electrosurgical means in treating benign prostate hyperplasia in our environment, especially transurethral resection of the prostate (TURP). This study compares the perioperative, short-term outcomes and complications of open prostatectomy and TURP.

Methods

the records of men who had prostatectomies (OP and TURP) from Jan 2016 to Dec 2019 for prostate gland less than 80g were reviewed. The patients´ age, size of the prostate gland, duration of surgery (mins), blood transfusion, clot retention, length of catheterisation (days), hospital stay (days), postoperative infection, postoperative incontinence, reoperation, bladder neck stenosis and urethral stricture were analysed.

Results

fifty-nine patients were studied. Twenty-nine patients had OP, while 30 had TURP. Mean age for OP was 63.8 (SD 7.2) years, while for TURP is 68.5 (SD 8.0) years (p=0.019). The mean for length of catheterisation for OP vs TURP was 9.1 (SD 3.7) vs 3.3 (SD 1.03) days (p=0.001), mean hospital stay was 9.6 (SD 4.1) and 4.7 (SD 2.2) days (p=0.001) for OP and TURP while duration of surgery (mins) for OP and TURP was 106.7 (SD 15.2) vs 53.8 (SD 14.0) minutes (p=0.001). The blood transfusion rate was 13.8% and postoperative incontinence 13.8% in OP, while in the TURP group, the reoperation rate was 3.3% and urethral stricture at a rate of 3.3%. Overall complications showed no statistical difference (p=0.462) between the two groups.

Conclusion

the patients who underwent TURP had shorter hospital stay, shorter duration of surgery and catheterisation, and less frequently required blood transfusion compared to those who had open prostatectomy. However, reoperation rate was higher compared to open prostatectomy. The overall complication was fewer with TURP, but this is not statistically significant; hence both forms of surgical therapy remain relevant in a poor resource setting.

Bipolar transurethral enucleation of the prostate combined with open cystolithotomy in the treatment of large and giant prostate with bladder stones: Case series

The surgical management of large or giant prostate still has challenges to urologists, especially if combined with bladder stones, and the traditional techniques by open prostatectomy and cystolithotomy have significant morbidity rates. The endoscopic procedure might not be feasible to treat both conditions in a single procedure, despite advances in surgical techniques and instrumentation, we present a one-session procedure by a combined endoscopic and open approach for treating benign prostatic hyperplasia (BPH) larger than 100 g combined with bladder stones in the elderly patient with other comorbidities. Between May 2017 and January 2020, bipolar transurethral plasma kinetic enucleation of the prostate (TUEP) followed by open cystolithotomy was performed to six patients at our institution, three of them combined with a big bladder stone(s). All the patients have other chronic chest and heart diseases; we retrospectively collected the data. All the patients diagnosed as BPH of big size or giant prostate over 100 g, with bladder stone, and all the patients treated with the same procedure. We founded that the combination methods showed a significant effect in terms of surgery time, patient outcomes and recovery, hospital discharge. The mean age of patients was 78.16 ± 4.2 (73-84) years, and the mean prostate-specific antigen (PSA) value was 16.27 ± 10.01 (8.32-32.17) ng/mL. The mean size of the prostate measured by MRI/US was 266.16 ± 89.1 (169-405) mL. The mean total operation time was 70.5 ± 10.9 (60-90) min, while the mean enucleation time was 28.38 ± 6.61 (23-40) min. The mean intraoperative blood loss was 193.33 ± 19.66 (170-220) mL. The mean resected prostate weight was 217.166 ± 94.67 (117-365) g. The mean post-operative hospital stay was 2.6 ± 0.81 (2-4) days. One patient was readmitted 2 months later due to urinary tract infection, and one patient complains of urine incontinence who spontaneously subsided in 4 months after surgery, other that no severe postoperative complications observed, a significant reduction of serum PSA and IPSS recorded at 3 months, postoperatively. Although simple open prostatectomy remains the reference standard for the treatment. Of excessively large or giant prostatic hyperplasia, the combination procedure not only facilitates the management of selected cases of hyperplasia but further imparts significant benefits to patients and surgeons alike. This treatment plan is safe, time-consuming, and could revolutionize future treatment approaches to giant prostate.

Greenlight laser photoselective vaporization vs open simple prostatectomy: long-term functional outcomes after treatment of large volume prostates (> 80 cc)

PURPOSE

To compare long-term outcomes between photoselective vaporization (PVP) and Open simple prostatectomy (OSP) for prostates > 80 cc.

METHODS

Men operated either by PVP or OSP for BPH > 80 cc were included in two expert centres. Functional and uroflowmetric outcomes were assessed pre- and postoperatively. Data were collected prospectively in the PVP group and retrospectively in the OSP group and compared at long-term follow-up. Complications and re-intervention rates were used as main outcomes.

RESULTS

332 men underwent surgery: 132 PVP were performed in a fist expert-centre and 200 OSP were performed in a second one with a median follow-up of 54 and 48 months, respectively. Mean Prostate volume was similar between OSP and PVP group (119 vs 116 cc). Major complications were more common in the OSP group (12.5 vs 1.5%, p < 0.001). At long-term follow-up, Qmax was higher and PVR was lower (p < 0.05) in the OSP group. IPSS score was similar between groups (p = 0.45) but the Qol was better in the OSP group (0.9 vs. 1.6; p < 0.05). There were more re-interventions in the PVP group compared to OSP (15.2 vs. 0%, p < 0.005).

CONCLUSION

PVP is a good alternative for prostates > 80 cc particularly for fragile patients as it is associated with a lower complication rate. At long-term follow-up, IPSS was similar between groups, but Qol was better in the OSP group. Patients treated by PVP should be informed that they could require reoperation in 15% of the cases.

Factores de riesgo y estrategias de prevención para el desarrollo de estrechez uretral de origen iatrogénico: Papel del urólogo

La estrechez uretral constituye una patología con morbilidad importante en el sexo masculino. Se evidencia en la actualidad un cambio en la frecuencia de las etiologías, con la disminución de causas inflamatorias y una transición hacia la iatrogenia como la más común. Mediante la búsqueda del estado del arte en cuanto a los procedimientos diagnósticos y terapéuticos conocidos como factores asociados a la estrechez uretral iatrogénica, se realizó una revisión narrativa de la literatura con el fin de describir y generar estrategias para su prevención. De los procedimientos terapéuticos que originan la estrechez uretral como complicación, el sondaje vesical es la mayor causa (hasta 34,3%), seguido de la prostatectomía radical (29,9%). Una buena técnica de sondaje vesical orientada desde el adecuado entrenamiento del personal disminuye de forma considerable su incidencia. Por otra parte, la adecuada selección de tratamientos y aspectos técnicos en pacientes que requieren el manejo de patologías obstructivas del tracto urinario como la hiperplasia prostática y litiasis u oncológicas como el cáncer de próstata, son unas de las recomendaciones para la prevención de ese trastorno. El entendimiento de los factores de riesgo y la adherencia a las estrategias de prevención descritas buscan disminuir la incidencia de la estrechez uretral de origen iatrogénico.

[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.

Open simple prostatectomy and robotic simple prostatectomy for large benign prostatic hyperplasia: Comparison of safety and efficacy

Background

To compare the safety and efficacy of open simple prostatectomy (OSP) and robotic simple prostatectomy (RSP) for the treatment of large benign prostatic hyperplasia (BPH).

Materials and methods

We retrospectively reviewed the medical records of 52 patients who underwent OSP (n = 23) and RSP (n = 29) between January 2005 and March 2019 at a single institution. The preoperative status of the patients, complications related to surgery, and the functional outcomes of the surgery were analyzed.

Results

There were no significant differences in the preoperative total prostate volume, transitional volume, prostate-specific antigen value, and age between the two groups. Postoperative improvements in the International Prostate Symptom Score, maximum urinary flow rate, and postvoid residual were significant and similar for both groups. There were no significant differences between the two groups regarding surgery duration and resected prostate volume. The majority of patients in both groups had the urethral Foley catheter removed within the planned 10 day postoperative period, with the exception of two patients in the OSP group who had prolonged indwelling Foley catheter placement because of persistent hematuria. Postoperative hematocrit changes were significantly lower in the RSP group (RSP: 7.8 ± 4.1%, OSP: 14.2 ± 4.9%, P < 0.001). Seven patients (30.4%) who underwent OSP and two patients (6.9%) who underwent RSP were transfused because of significant intraoperative bleeding. Two patients from the RSP group who received transfusion comprised the first two cases that underwent RSP treatment. During the follow-up period, two patients (one patient in the OSP group and one patient in the RSP group) underwent transurethral incision of the bladder neck for bladder neck contracture.

Conclusion

Both OSP and RSP can produce excellent outcomes after surgery. However, complications of bleeding are significantly less prevalent in RSP, suggesting that RSP can replace conventional OSP.

Robotic assisted laparoscopic radical prostatectomy following open trans-vesical adenomectomy: A single centre experience and review of the literature

Introduction:

Robotic assisted laparoscopic radical prostatectomy (RALRP) following endoscopic resection of the prostate is known to be feasible with good outcomes. However, the literature evidence is limited on the feasibility and outcomes of RALRP following open prostatic surgery. In this study, our aim was to report our experience with RALRP in patients who had undergone trans-vesical adenomectomy of the prostate in the past.

Patients and methods:

We reviewed our prospectively maintained database of men treated with RALRP at our institution to identify patients with previous history of open suprapubic trans-vesical adenomectomy, between 2016 and 2020. Data were collected on demographic information, interventions, oncological outcomes and follow-up.

Results:

Out of 362 patients, four individuals were identified that had previous open suprapubic trans-vesical adenomectomy. The mean age was 71 years with a mean pre-operative prostate specific antigen (PSA) of 11.35 ng/ml, and an average of 10 years after their trans-vesical adenomectomy. The mean console time was 119 min with an average estimated blood loss of 137.5 ml and 75% underwent lymphadenectomy. Post-operatively, all patients were discharged after 1 day with their urinary catheters removed at 7 days post-op. For one of the patients, a urine leak was identified, and his pelvic drain was removed at 5 days instead of 1 day as for the other three patients. No other complications were noted within 30 days. The average prostate weight was 54.7 g with all specimens being T3a R0. At 6 weeks follow-up, PSA was undetectable, three patients reported full continence and 1 was using two pads/day.

Conclusion:

RALRP following previous open trans-vesical prostatectomy is feasible and safe with excellent oncological outcomes. They are, however, more challenging and cumbersome with increased console time.

Holmium laser enucleation of prostate versus minimally invasive simple prostatectomy for large volume (≥120 mL) prostate glands: a prospective multicenter randomized study

BACKGROUND

The aim of this study was to compare the perioperative and functional results between laparoscopic and robot-assisted simple prostatectomy (LSP and RASP) and Holmium laser enucleation of prostate (HoLEP) in prostate volumes ≥120 mL. The primary endpoint was to investigate and compare minimally invasive techniques in the management of large prostate gland volume, and the secondary endpoint was to evaluate the frequency and type of postoperative complications according to Clavien Dindo Classification.

METHODS

This multicenter study was conducted on male patients with LUTS associated with BPO candidates for surgical treatment. The surgery approach choice in relation to the prostatic volume ≥120 mL was HoLEP or minimally-invasive simple prostatectomy (LSP or RASP). All patients were prospectively randomized into three groups, according to a simple computed randomization: HoLEP, LSP and RASP groups. During the follow-up, all patients underwent postoperative control at 1, 3, 6, 12 and 24 months from the surgical procedure.

RESULTS

One hundred ten male patients were randomized in three homogeneous groups: 36 in LSP, 32 in RASP and 42 in HoLEP group. During the follow-up (mean 26.15 months), despite the significant improvement compared to baseline results, no significant differences were shown, between the groups in terms of functional and perioperative outcomes. The only statistically significant data was reported for catheterization time, that resulted longer in the LSP group than RASP and HoLEP groups (P=0.002). Furthermore, MISP resulted in longer hospitalization, and lower rate of patients with new-onset irritative symptoms.

CONCLUSIONS

This prospective randomized study is the first to compare extraperitoneal LSP, RASP and HoLEP in the treatment of LUTS secondary to benign prostatic hyperplasia for prostate volumes ≥120 mL. Our findings confirm the safety and efficacy of MISP, demonstrating its equivalence in functional outcomes and perioperative morbidity in comparison to HoLEP.

Laparoscopic simple prostatectomy vs bipolar plasma enucleation of the prostate in large benign prostatic hyperplasia: a two-center 3-year comparison

PURPOSE

To compare surgery outcomes and safety of button bipolar enucleation of the prostate vs laparoscopic simple prostatectomy in patients with large prostates (> 80 g) in a two-center cohort study.

METHODS

All patients with lower urinary tract symptoms due to benign prostatic enlargement (Prostate volume > 80 cc) undergoing button bipolar enucleation of the prostate (BTUEP) or laparoscopic simple prostatectomy (LSP) in two centers were enrolled. Data on clinical history, physical examination, urinary symptoms, uroflowmetry and prostate volume were collected at 0, 1, 3 6, 12, 24 and 36 months. Early and long-term complications were recorded.

RESULTS

Overall, 296 patients were enrolled. Out of them, 167/296 (56%) performed a LSP and 129/296 (44%) performed a BTUEP. In terms of efficacy both procedures showed durable results at three years with a reintervention rate of 8% in the LSP group and of 5% in the BTUEP group. In terms of safety, BTUEP and LSP presented similar safety profiles with a 9% of transfusion rate and no major complications.

CONCLUSION

LSP and BTUEP are safe and effective in treating large-volume adenomas with durable results at three years when performed in experienced centers.

Efficacy, safety, and perioperative outcomes of holmium laser enucleation of the prostate-a comparison of patients with lower urinary tract symptoms and urinary retention

Holmium laser enucleation of the prostate (HoLEP) is a valid treatment option to relieve bladder outlet obstruction in patients with large prostate volumes (PV). Its efficacy, tolerability, and safety are comparable to the ones of other laser treatments of the prostate and resection techniques. However, safety and efficacy of HoLEP have not been compared between patients with and without preoperative urinary retention. We included 350 patients (mean age 71.2 years) who had undergone HoLEP due to lower urinary tract symptoms (LUTS) or urinary retention caused by prostatic hyperplasia. We evaluated the differences in peri- and postoperative outcomes and complications between patients with and patients without preoperative urinary retention. The mean PV was 115 cm³. PV was > 100 cm³ in 61.9% and < 100 cm³ in 38.1% of the patients. Perioperative complications occurred in 23 patients (6.6%), 15 of which (4.3%) required operative revision. We found no significant differences in terms of complication rates between patients with PV > 100 cm³ and patients with PV < 100 cm³. Mean catheterization-duration was 3.3 days. Preoperatively, 140 patients (40%) had a suprapubic or transurethral indwelling catheter; they did not differ from patients without preoperative catheter regarding postoperative catheter removal success rate, early postoperative complications, and functional outcomes. Prostate cancer was diagnosed in 43 patients (12.3%). Median postoperative PSA-decline was 6.1 ug/l (89.8% drop). HoLEP is a safe and effective treatment for patients with LUTS or urinary retention and large PV. PV > 100 cm³ was not associated with higher complication rates or successful catheter-removal. Furthermore, functional outcomes were independent of preoperative catheterization.

Transurethral laser versus open simple prostatectomy for large volume prostates: a systematic review and meta-analysis of randomized controlled trials

The benefit of transurethral laser prostatectomy over open simple prostatectomy (OSP) is controversial in aged symptomatic benign prostatic hyperplasia (BPH) patients with large volume prostates, and the aim of this study is to compare the safety and efficiency of these two methods. Meta-analysis was applied using the Review Manager V5.3 software and the retrieved randomized controlled clinical trials (RCTs) comparing transurethral laser prostatectomy with OSP were analyzed for the treatment of large volume prostates from 2000 to 2019 in PubMed, Web of Science, Cochrane, and EMBASE datasets. Five RCTs assessing transurethral laser prostatectomy versus OSP were considered suitable for this meta-analysis, which included a total of 448 patients, with 232 patients undergoing laser and 216 patients undergoing OSP. Compared with OSP, although transurethral laser prostatectomy required a longer operative time (weighted mean difference (WMD) 27.49 mins; 95% confidence interval (CI) 16.54-38.44; P < 0.00001) and obtained a less resected prostate weight (WMD - 11.72 g; 95% CI - 21.75 to - 1.70; P = 0.02), patients undergoing laser prostatectomy benefited from significantly less hemoglobin decline (- 0.97 g/dL; 95% CI - 1.31 to - 0.64; P < 0.00001), shorter time of catheterization (WMD - 3.67 days; 95% CI - 5.60 to - 1.75; P = 0.0002), shorter length of hospital stay (WMD - 4.75 days; 95% CI - 6.57 to - 2.93; P < 0.00001), and less blood transfusion (odds ratio 0.10; 95% CI 0.03 to 0.35; P = 0.0003). During postoperative follow-up, no significant difference was observed between the two groups in IPSS, QoL, Q_max, and PVR. Both transurethral laser prostatectomy and OSP are safe and effective for large prostates that require prostate resection. Taking into account of less blood loss, shorter catheterization time and hospital stay, and less blood transfusion, transurethral laser prostatectomy may be a better treatment for patients with large prostates.

Intermediate-term Urinary Function and Complication Outcomes After Robot-Assisted Simple Prostatectomy

OBJECTIVE

To assess the incidence of delayed complications after robot-assisted simple prostatectomy and evaluate postoperative lower urinary tract symptoms (LUTS) as a function of time with intermediate-term follow-up.

METHODS

We retrospectively reviewed 150 patients who underwent robot-assisted simple prostatectomy between May, 2013 and January, 2019. Indication for surgery was bothersome LUTS refractory to medical management and prostate volume ≥80 milliliters. The severity of LUTS was assessed using the International Prostate Symptom Score (IPSS) and quality of life (QOL) score. One-way analysis of variance test with post hoc Tukey's honest significant difference test was used to compare postoperative IPSS and QOL scores as a function of time; P <.05 was considered significant.

RESULTS

At a mean ± SD follow up of 31.3 ± 18.2 months, none of the patients developed a bladder neck contracture and none of the patients required reoperation for LUTS. Postoperatively, IPSS and QOL scores decreased with an increasing duration of follow up (P <.001). Mean IPSS and QOL scores improved between 2 weeks and 3 months postoperatively (P = .027 and P = .006, respectively). After 3 months postoperatively, mean IPPS and QOL scores stabilized and remained unchanged up to 36 months of follow-up (all P >.05).

CONCLUSION

Robotic simple prostatectomy is associated with a low incidence of delayed complications at a mean of 31.3 months postoperatively. After robotic simple prostatectomy, urinary function outcomes improve in the early postoperative period with maximal improvement occurring at 3 months. Excellent urinary function outcomes are durable up to at least 36 months postoperatively.

Robot-assisted simple prostatectomy versus open simple prostatectomy: a single-center comparison

Purpose

Open simple prostatectomy (OSP) is a standard surgical technique for patients with benign prostatic hyperplasia with prostate size larger than 80 ml. As a minimally invasive approach, robot-assisted simple prostatectomy (RASP) emerged as a feasible surgical alternative. Currently, there are no definite recommendations for the standard use of RASP. Therefore, we aimed at investigating various clinical outcomes comparing RASP with OSP.

Methods

In this retrospective single-center study, we evaluated clinical data from 103 RASP and 31 OSP patients. Both cohorts were compared regarding different clinical characteristics with and without propensity score matching. To detect independent predictive factors for clinical outcomes, multivariate logistic regression analysis was performed.

Results

Robot-assisted simple prostatectomy patients demonstrated a lower estimated blood loss and need for postoperative blood transfusions as well as less postoperative complications. OSP had a shorter operative time (125 min vs. 182 min) longer hospital stay (11 days vs. 9 days) and longer time to catheter removal (8 days vs. 6 days). In the multivariate analysis, RASP was identified as an independent predictor for longer operative time, lower estimated blood loss, shorter length of hospital stay, shorter time to catheter removal, less postoperative complications and blood transfusions.

Conclusion

Robot-assisted simple prostatectomy is a safe alternative to OSP with less perioperative and postoperative morbidity. Whether OSP (shorter operative time) or RASP (shorter length of hospital stay) has a more favorable economic impact depends on the particular conditions of different health care systems. Further prospective comparative research is warranted to define the value of RASP in the current surgical management of benign prostatic hyperplasia.

Assessment of posterior urethra in benign prostatic hyperplasia and after its surgery

Introduction:

Surgical management of benign prostatic hyperplasia (BPH) primarily consists of transurethral resection of the prostate (TURP). Due to BPH and after surgical intervention, anatomic variations in the posterior urethra are expected. Due to the paucity of information regarding posterior urethral anatomic variations in these conditions and its aftermath, this study was undertaken to evaluate the anatomic variations in the posterior urethra after TURP.

Materials and Methods:

This prospective observational study was conducted over 2 years at the Department of Surgery and Radiodiagnosis, University College of Medical Sciences, Delhi. All consenting patients undergoing TURP for BPH were included in the study. We assessed the posterior urethral changes in BPH before and 3 months after the procedure. Diagnostic modalities used were urethrocystoscopy, micturating cystourethrogram, and retrograde urethrogram. Furthermore, the prostate volume and postvoid residual volume of urine were compared before and after its surgery using ultrasonography. Urodynamic studies were used to calculate total voided volume (TVV), peak flow rate (PFR), voiding time (VT), and hesitancy.

Results:

Mean age of the patients was 68.12 ± 7.83 years. Lengthening in posterior urethra was seen in BPH patients with a mean of 4.24 ± 1.012 cm. Postprocedure, there was a mean reduction of 2.6 ± 1.225 cm in length of the posterior urethra (P < 0.0001). Prostatic urethral angle was increased in patients suffering from BPH, and it decreased after undergoing surgical management (P < 0.679). All patients enrolled in our study had prostatic lobes enlargement, and after surgery, this enlargement was reduced in most of the patients with 21 having no prostatic enlargement, and in four patients, bilateral lateral lobe was not completely reduced (P = 1.000). Stricture in prostatic urethra was observed in 2 out of 25 (8%) patients operated for BPH. Evaluation of various parameters of urodynamic studies revealed the net improvement in the TVV of 157.746 ± 120.999 ml, as before the procedure, this value was 176.715 ± 72.272 ml, and after surgery, it was 334.46 ± 78.588 ml (P < 0.001). VT taken by patients before surgery was 57.377 ± 16.858 s, and postprocedure, this value was 33.31 ± 8.807 s. This net reduction of 24.069 ± 14.88 s was statistically significant (P < 0.0001). PFR before the procedure was 6.177 ± 3.5067, and postprocedure, this value was 26.43 ± 7.112 ml/s with a net improvement of 20.253 ± 9.226 ml/s (P < 0.0001). Hesitancy in BPH patients before the procedure was 23.908 ± 15.521 s. Postprocedure, hesitancy decreased to a value of 6.79 ± 4.435 s with a net reduction of mean 17.115 ± 15.817 s (P < 0.002).

Conclusion:

By our findings, we conclude that BPH is associated with anatomic variations in posterior urethra such as lengthening of the length of the posterior urethra and increased posterior urethral elevation, which is measured by an increase in posterior urethral angle (PUA). Whereas post-TURP, there is a shortening of posterior urethra, decrease in PUA, decrease in prostatic volume, postvoid residual urine volume, and improvement in uroflowmetric parameters.

A review of surgery and new technology procedures for the management of benign prostatic obstruction

Level of evidence: Not applicable for this review article.

Evolution of Bloodless Surgery: A Case for Bloodless Suprapubic Prostatectomy

Allogeneic blood transfusion is commonly prescribed to patients undergoing suprapubic prostatectomy for benign prostatic hyperplasia as a treatment option to replace blood loss. Historically, suprapubic prostatectomy has been perceived as an extremely high hemorrhagic surgery, and this has led to the association of suprapubic prostatectomy with a high rate of allogeneic blood transfusion. However, the outcome of suprapubic prostatectomy has significantly improved over the years and has become less hemorrhagic in many hands - creating the opportunity to consistently avoid allogeneic blood transfusion. On the other hand, the efficacy of blood transfusion has come under more stringent scrutiny as many clinical studies have reported inconsistent effects of blood transfusion on patient outcome. In contemporary practice, a more conservative/bloodless approach in the perioperative management of anemia in surgical patients is strongly being advocated with convincing evidence that many surgical patients can be routinely and safely managed without allogeneic blood transfusion. There is no large-scale discussion on bloodless surgery in urology in the contemporary literature, especially in the area of suprapubic prostatectomy that has been historically associated with a high rate of blood transfusion. This review article will discuss the evolution of bloodless surgery including the ongoing controversies surrounding blood transfusion in general, and then the relatively small but ongoing penetration of bloodless surgical approach in the field of suprapubic prostatectomy. Furthermore, the authors' approach to bloodless suprapubic prostatectomy will be highlighted, and in doing so, it can be emphasized that suprapubic prostatectomy is no more as hemorrhagic as was historically perceived, but rather a routine bloodless suprapubic prostatectomy is now possible in many hands.

The clinical application of combination suprapubic prostatectomy with transurethral resection of the prostate (TURP) in patients with large volume benign prostatic hyperplasia (BPH)

Objective:

To investigate the safety and efficacy of the combination of suprapubic prostatectomy with transurethral resection of the prostate (TURP) for the treatment of large volume benign prostatic hyperplasia (BPH).

Methods:

We retrospectively analyzed the clinical data of two methods of treatment with 60 cases of a large volume BPH (>100 g) from January 2011 to 2017; the methods were suprapubic prostatectomy and suprapubic prostatectomy combination with TURP, in which the single open group comprised 30 cases, treated using the former method, and the combined open group comprised the other 30 cases, treated using the latter method. In the combined open group, the residual prostate gland was removed by TURP. We compared both the groups of patients using age, prostate volume, international prostate symptom score (IPSS), prostate-specific antigen (PSA), maximum flow rate, residual urine, operation time, hospitalization time, postoperative washing time, blood transfusion rate, and decreased amount of intraoperative hemoglobin in operation, and compared the preoperative and postoperative IPSS, maximum flow rate, and residual urine volume.

Results:

There was no significant difference between the two groups in age, prostate volume, IPSS, PSA, maximum flow rate, residual urine, and other clinical data ( P > 0.05); the single group operation time, postoperative bladder irrigation time, hospitalization time, blood transfusion rate, and decreased amount of intraoperative hemoglobin were significantly greater in the single open group than in the combined open group, and statistically significant differences were observed between both the groups ( P < 0.05). Postoperative voiding function improved significantly compared with the preoperative, and a statistically significant difference was observed ( P < 0.05).

Conclusion:

The combination of suprapubic prostatectomy with TURP is an effective and a safe surgical method for the treatment of patients with large volume BPH. It is certainly worthy of clinical application.

Aquablation among novice users in Canada: A WATER II subpopulation analysis

INTRODUCTION

Surgical management options for lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) associated with prostates of small to moderate volume (<80 cc) are numerous; however, for men with enlarged prostates (>80 cc), many of these options are neither safe nor effective. Recently, Aquablation (PROCEPT BioRobotics, Inc., U.S.), a precise ultrasound-guided, robotically executed prostatic ablative procedure, has become available with U.S. Food and Drug Administration approval. Herein, we present three-month safety and efficacy data from the cohort of Canadian men included in the WATER II trial.

METHODS

WATER II is a prospective clinical trial of the Aquablation system for the treatment of BPH in men with prostate volumes between 80 and 150 cc. Only patients from Canada were included for this analysis. At baseline, subjects completed International Prostate Symptom Score (IPSS), as well as several validated questionnaires, uroflowmetry and post-void residual volume measurements, and underwent standard laboratory blood assessment. These were repeated at one and three months post-Aquablation.

RESULTS

A total of 19 subjects who met inclusion and exclusion criteria were enrolled at three Canadian academic sites. Mean pre-, one-month, and three-month post-treatment IPSS scores were 21.2±5.5, 9.9±6.9 (p<0.0001), and 5.0±4.5 (p<0.0001), respectively. Mean pre-, one-month, and three-month post-treatment maximum urinary flow rates (Qmax) were 6.6±3.1 ml/s, 19.5±6.1 ml/s (p<0.0001), and 23.1±9.2 ml/s (p<0.0001), respectively. The Clavien-Dindo grade 2 or higher event rate at three months was 31.6% (six events).

CONCLUSIONS

In this short-term, three-month analysis of Canadian men, Aquablation appears to provide a strong surgical alternative in patients with LUTS/BPH due to larger prostate volumes, with impressive functional outcomes, relatively short operative time and length of hospital stay, and acceptable complication and low transfusion rates.

A new surgical technique: transvesical resection of prostate - case series

OBJECTIVE

To protect the urethra from instrumentation related urethra injures and stricture, we developed a new surgical technique which can be defined as transvesical resection of prostate without using urethra.

MATERIALS AND METHODS

Our study included 12 consecutive bladder outlet obstruction patients treated with transvesical prostate resection in our clinic between March 2016 and May 2016. Detailed anamnesis, results of physical examination, digital rectal examination, routine lab tests, international prostate symptoms score, transrectal ultrasound, measurement of prostate-specific antigen levels and uroflowmetry was performed in all patients prior to surgery.

RESULTS

Hospitalization period following surgery was 1 day. Foley catheter and suprapubic cystostomy catheters were removed in a median period of 3.6 days and 1 day. Median mass of resected adenomas was measured as 21.8 gr. Median maximum flow rate was measured as 6mL/s. Median postvoid residual urine volume was 70.6 cc and median international prostate symptoms score and quality of life scores were 9 and 1.4, respectively.

CONCLUSION

In this study, we would like to show the possible practicality of transvesical resection of prostate technique in this patient group. However, we think that this technique is very useful in special patient groups such as patients with bladder stones, priapism and penile prosthesis.