Comparison of Long-term Effect and Complications Between Holmium Laser Enucleation and Transurethral Resection of Prostate: Nations-Wide Health Insurance Study

Evaluation of new treatments for benign prostatic obstruction: ICI-RS 2023

AIMS

To address how invasive therapies for benign prostatic obstruction (BPO) have been evaluated, what their effect is on BPO, if they can prevent progression to BPO and how new therapies need to be evaluated before implementation into clinical practice.

METHODS

The think tank conducted a literature review and looked at the previous and current American Urological Association, European Association of Urology and the International Consultation on Urological Diseases guidelines to see what procedures have been used to treat BPO. They then assessed whether trials have been conducted before implementation of the procedures and whether they have been compared to a "gold" standard treatment. The use of urodynamics has also been addressed in the think tank in relation the clinical trials as well as terminology.

RESULTS

Guidelines vary in the use of terminology when it comes to BPO with some continuing to use the term benign prostatic hyperplasia (BPH). There are several procedures for example, TUNA, which have become obsolete although continues to be mentioned in the guidelines until recently. Majority of procedures have been introduced without comparing to "gold" standard treatment and without any long-term data. There continues to be many unknowns with regard to the success of some of the BPO procedures and why some of the adverse events develop.

CONCLUSION

There needs to be more robust long-term clinical trials conducted of new BPO therapies, with men who have both lower urinary tract symptoms and urinary retention, before introduction into clinical practice.

Can we predict whether a man with acute or chronic urinary retention will void after bladder outflow resistance reduction surgery? ICI-RS 2023

AIMS

To address the predictive factors of a successful voiding after bladder outflow resistance reduction surgery (BORRS) in men presenting with acute or chronic urinary retention (UR).

METHODS

A think tank (TT) of ICI-RS was gathered in 2023, Bristol, UK, to discuss several aspects of the problem, such as the pathophysiology of UR, the clinical and urodynamic evaluation of men with UR and whether it is possible to predict which men will be able to successfully void after treatment with contemporary surgical options.

RESULTS

The TT agreed that successful voiding after BORRS depends on several factors but that a strong recommendation cannot be made regarding preoperative evaluation and whether there are predictive factors of success because of the heterogeneity of patients and methodology in published trials. The diagnosis of obstruction in men with UR may be challenging when there is apparent reduced detrusor contraction during urodynamic studies. Even in the absence of bladder contractility there is documentation of such cases that have voided adequately after BORRS. Still, detrusor underactivity and inadequate relief of prostatic obstruction are the main causes of an unsuccessful voiding after BORRS. Conventional resection and enucleation methods remain the most successful surgeries in relieving UR in men, whereas the efficacy of minimally invasive surgical treatments needs to be assessed further.

CONCLUSION

Research is needed to understand the pathophysiology of UR and the predictors of successful voiding after different types of BORRS in men with UR.

Persistent Lower Urinary Tract Symptoms After BPH Surgery

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Comparison of EEP and TURP long-term outcomes: systematic review and meta-analysis

OBJECTIVE

To compare long-term reoperation rate and functional outcomes between EEP (endoscopic enucleation of the prostate) and TURP (transurethral resection of the prostate).

EVIDENCE ACQUISITION

A systematic literature review of Medline, Scopus, and Web of Science was conducted with primary outcome assessed being reoperation rate and secondary outcomes after a long term (> 3 years) being functional outcomes or related values (prostate volume, PSA level, etc.).

EVIDENCE SYNTHESIS

Five studies were found with long-term follow-up 4-7 years. EEP reoperation rate ranged from 0 to 1.27%, while from 1.7 to 17.6% for TURP. Meta-analysis showed significantly lower OR for EEP, 0.27 (95% CI 0.24-0.31), with notable homogeneity of the results, I2 = 0%. Long-term Qmax and IPSS were significantly better for EEP. Qmax pooled mean difference was 1.79 (95% CI 1.72-1.86) ml/s with a high concordance among the studies, I2 = 0%. IPSS mean difference -1.24 (95% CI - 1.28 to - 1.2) points, I2 = 57% but QoL did not differ, with mean difference being 0.01 (95% CI - 0.02 to 0.04), I2 = 0%. IIEF-5 score was also significantly better for EEP, mean difference 1.08 (95% CI 1.03-1.13), but heterogeneity was high, I2 = 70%. PSA level and prostate volume were only reported in one study and favored EEP slightly yet statistically significant.

CONCLUSION

EEP had a significantly lower reoperation rate and better functional outcomes (Qmax and IPSS) at long term compared with TURP. It may also be beneficial in terms of IIEF-5, PVR, and PSA level.

Predictive factors for postoperative medication therapy for overactive bladder symptoms after holmium laser enucleation of prostate

OBJECTIVE

To preoperative factors that could predict the persisting storage symptoms after Holmium laser enucleation of the prostate (HoLEP).

METHODS

Medical records of 257 patients who underwent HoLEP between December 2014 and January 2021 were reviewed. Participants with a follow-up period exceeding 6 months were included. Preoperative data, including International Prostate Symptom Score (IPSS), uroflowmetry, prostate size, and prostate-specific antigen, were collected. All participants underwent a preoperative urodynamic study. The correlation between perioperative variables and postoperative medication therapy (antimuscarinics or beta-3 agonists) was assessed.

RESULTS

Out of 257 participants in the study, 46 (18.6%) were allocated to the medication group, of which 25 (54.3%) initiated medication therapy postoperatively. The medication group showed worse postoperative IPSS storage symptom score and quality of life score compared to the medication-free group (p = 0.048 and p = 0.002, respectively), but no significant differences were observed in complications or operative variables. In the de-novo medication group, patients had lower preoperative Qmax , larger prostate volume, and smaller maximum cystometric capacity (MCC) compared to the persisting medication group (p = 0.020, p = 0.009, and p = 0.008, respectively). Overactive bladder (OAB) history, terminal detrusor overactivity (DO), and IPSS urgency item were identified as possible predictive factors for post-HoLEP medication use.

CONCLUSIONS

Preoperative factors such as OAB history, terminal DO, and IPSS urgency item may predict the need for post-HoLEP medication therapy. Further follow-up studies are warranted to understand the characteristics of the de-novo medication group due to the significant discomfort it can cause to patients.

Osteitis pubis following holmium laser enucleation of the prostate

Osteitis pubis is a rare, inflammatory condition involving the pubic symphysis. While osteitis pubis has been reported following many urological procedures, including those addressing bladder outlet obstruction such as transurethral resection of the prostate, it has never been reported after holmium laser enucleation of the prostate (HoLEP). Here, we detail the clinical course of a patient found to have osteitis pubis following HoLEP. This patient presented several weeks after surgery with non-specific, persistent symptoms of groin pain and difficulty ambulating, alerting our clinicians to consider osteitis pubis which was confirmed on MRI of the pelvis. While the majority of osteitis pubis cases are managed with locally invasive techniques, our patient's symptoms were successfully managed conservatively with Foley catheter placement, oral antibiotics and close follow-up. At 9 months postoperative, the patient has reported complete resolution of symptoms and continues to be followed closely.

Adequate Mentorship Program for Holmium Laser Enucleation of the Prostate (HoLEP) Leads to Satisfactory Short-Term Outcomes in the Early Learning Curve of Young Urologists: First-Year Outcomes of a Newly Established Mentorship Training in Mexico

Introduction Benign prostatic hyperplasia (BPH) is one of the most common causes of lower urinary tract symptoms in men. Holmium Laser Enucleation of the Prostate (HoLEP) has been recommended by international guidelines as an alternative to transurethral resection of the prostate (TURP). HoLEP's learning curve and the lack of adequate mentorship remains an obstacle for the worldwide adoption of this technique. Objective To report the first-year learning curve of a newly established mentorship program in young urologists without any previous HoLEP experience. Methods We report a cohort of patients with BPH, with prostate size ≥70 grams, treated with HoLEP, analyzed for perioperative data and complications, and short-term postoperative complications and functional outcomes, at three and six months after surgery. Results A total of 47 patients were managed with HoLEP. Mean total operative time was 149.8 ± 42.9 minutes. We experienced five (10.6%) intraoperative complications, including one intravesical resection of the prostate with bipolar energy, three conversions to TURP and one conversion to open prostatectomy. We experienced four postoperative complications, all of them Clavien-Dindo ≤2. Median International Prostate Symptom Score (IPSS) decrease at six months was -17 points from baseline. Mean post-void residual volume and prostate-specific antigen significantly decreased by the third postoperative month. Multiple linear regression showed that prostate size is directly related to increased surgical time during the early learning curve. Discussion Our experience adequately reflects the importance of HoLEP mentorship in young urologists seeking training in this technique. Both surgeons had perioperative and postoperative outcomes deemed satisfactory based on previously published learning curves. Conclusions HoLEP is a technically difficult procedure, however, adequate mentorship leads to satisfying short-term outcomes since the early stages of the learning curve in young urologists with no previous training on this technique.

Observation of complications assessed by Clavien-Dindo classification in different endoscopic procedures of benign prostatic hyperplasia: An observational study

The Clavien-Dindo classification (CDC) was widely used in the assessment of surgical complications, but some inconsistencies always existed in urological literature. This study was aimed to report complications of the transurethral resection of the prostate (TURP), plasmakinetic resection of the prostate (PKRP), and holmium laser enucleation of the prostate (HoLEP) by using a more detailed way under the framework of CDC. A total of 623 eligible cases underwent endoscopic procedures from January 2018 and December 2020 were divided into the TURP group (212 cases), the PKRP group (208 cases), and the HoLEP group (203 cases) according to the surgical type. Patients' surgical complications assessed by the CDC were compared among the 3 groups. The operation time, intraoperative irrigation volume, postoperative irrigation time and volume, decrease in hemoglobin and sodium, postoperative catheterization time, visual analogue scale, hospital stay of the PKEP group and the HoLEP group were significantly less than those of the TURP group, and the decrease in hemoglobin and visual analogue scale in the HoLEP group were significantly lower than those in the PKEP group (all P < .05). The electrolyte disturbance, urinary tract irritation, and patients with grade II of CDC in the PKRP group were significantly lower than those in the TURP group; The electrolyte disturbance, lower abdominal pain, urinary tract irritation, intraoperative hemorrhage, secondary hemorrhage, clot retention, patients with grade I, II, III of CDC in the HoLEP group were significantly lower than those in the TURP group, and the urinary tract irritation, grade I, II of CDC in the HoLEP group was significantly lower than that in the PKRP group (all P < .05). The CDC should be recommended because of the enhanced insight into surgical complications, and the HoLEP should be given a priority for Benign prostatic hyperplasia (BPH) surgical treatment in terms of the merits in surgical characteristics and complications.

Comparison of Emergency Room Visits and Rehospitalization for Bleeding Complications following Transurethral Procedures for the Treatment of Benign Prostatic Hyperplasia: A Population-Based Retrospective Cohort Study

Background: The postoperative bleeding complications associated with laser surgery of the prostate and transurethral resection of the prostate (TURP) were compared. Methods: We used the Taiwan National Health Insurance Research Database to conduct an observational population-based cohort study. All eligible patients who received transurethral procedures between January 2015 and September 2018 were enrolled. Patients who received laser surgery or TURP were matched at a ratio of 1:1 by using propensity score matching, and the association of these procedures with bleeding events was evaluated. Results: A total of 3302 patients who underwent elective transurethral procedures were included. The multivariable Cox regression analysis revealed that diode laser enucleation of the prostate (DiLEP) resulted in significantly higher emergency room risks within 90 days after surgery due to clot retention than the Monopolar transurethral resection of the prostate (M-TURP) (Hazard Ratio: 1.52; 95% Confidence Interval [CI], 1.06–2.16, p = 0.022). Moreover, GreenLight photovaporization of the prostate (PVP) (0.61; 95% CI, 0.38–1.00 p = 0.050) and thulium laser vaporesection of the prostate (ThuVARP) (0.67; 95% CI, 0.47–0.95, p = 0.024) resulted in significantly fewer rehospitalization due to clot retention than did M-TURP. No significant increase in blood clots were observed in patients using comedications and those with different demographic characteristics and comorbidities. Conclusions: Among the investigated six transurethral procedures for Benign prostatic hyperplasia, PVP and ThuVARP were safer than M-TURP because bleeding events and clot retention were less likely to occur, even in patients receiving anticoagulant or antiplatelet therapy. However, DiLEP and holmium laser enucleation of the prostate (HoLEP) did not result in fewer bleeding events than M-TURP.

Predictive factors for alpha blocker use after transurethral prostatectomy: Can preoperative urodynamic outcome predict alpha blocker medication after surgery?

Objective

To analyze the diagnostic value of conducting urodynamic study (UDS) and show predictors for alpha blocker use 12 months after transurethral prostatectomy.

Materials and methods

Our study includes 406 participants that had a transurethral prostatectomy at our hospital between 2010 and 2019. All participants took alpha blockers for more than a month. We collected the participants’ preoperative international prostatic symptom score (IPSS), uroflowmetry, transrectal ultrasound, and serum prostatic antigen (PSA) level. A total of 254 patients conducted UDS. After surgery, participants visited our hospital at 1,3,6, and 12 months.

Results

133 patients (32.6%) took alpha blockers continuously for 12 months after surgery. They reported poor preoperative IPSS scores and uroflowmetry outcomes. They also had high postoperative PVR (40.68±24.56 vs 29.34±25.11, p<0.001) and total IPSS score (10.35±7.96 vs 8.43±6.74, p = 0.018) compared to the group which discontinued alpha blockers. A multivariate analysis (Table 2) found that conducting preoperative UDS (Odds ratio (OR) 6.067, p<0.001) Age>75 (OR 2.463, p<0.001), a history of taking 5-alpha reductase inhibitors (5-ARI) before surgery (OR 2.186 [95% CI 1.334–3.583], p = 0.002), IPSS item straining (OR 1.224, p = 0.003), duration of taking alpha blockers [OR 1.009, p = 0.020), and Qmax (OR 0.926, p = 0.018), PVR (OR 1.002, p = 0.022) were confirmed as a strong predictors of persistent alpha blocker use.

Conclusion

Conducting preoperative UDS, Age>75, history of taking 5-ARI before surgery, IPSS item straining, duration of alpha blocker medication, Qmax, and PVR are possible determinant factors of alpha blocker use after surgery. By comparing UDS outcomes, detrusor underactivity can be a strong predictor of persisting alpha blocker therapy 12 months after surgery.