The impact of surgical duration on complications after transurethral resection of the prostate: an analysis of NSQIP data

Intraprostatic Injection of Tranexamic Acid Decrease Blood Loss During Monopolar Transurethral Resection of the Prostate: A Randomized Controlled Clinical Trial

OBJECTIVE

To assess the role of intraprostatic injection of tranexamic acid (TXA) in reducing blood loss during transurethral resection of the prostate (TURP).

METHODS

We conducted a randomized, controlled, double-blind trial involving 60 patients with benign prostatic hyperplasia aged 50-85years, undergoing monopolar TURP. Patients' prostatic weights ranged from 50 to 80 g. They were divided equally into two groups: group I received an intraprostatic injection of 1 g of TXA (Cyklokapron) dissolved in 50 mL of 0.9 % saline at multiple sites, while group II (control) received a 60 mL saline injection. Comprehensive clinical assessments and standard laboratory tests, including screenings for TXA hypersensitivity, were performed for all patients.

RESULTS

Group I exhibited significantly lower intraoperative blood loss and hemoglobin concentration in irrigation fluid immediately postsurgery and at the 6-hour postoperative mark compared to group II (P < .05). Coagulation parameters-activated partial thromboplastin time, prothrombin time, fibrinogen level, and thrombin clotting time-showed no significant differences between the groups preoperatively or at 6 and 24 hours postoperatively. No thromboembolic events or other complications were reported in either group.

CONCLUSION

The intraprostatic injection of TXA during monopolar TURP is safe, with minimal adverse effects, and effectively reduces blood loss.

REGISTRATION

The study was registered on ClinicalTrials.gov No (ID: NCT05913466).

Incidence and management of BPH surgery-related urethral stricture: results from a large U.S. database

INTRODUCTION AND OBJECTIVES

Urethral stricture (US) is a well-known complication after surgical treatment of benign prostatic hyperplasia (BPH). This study aimed to evaluate the contemporary incidence of the US after different types of BPH surgery, to identify associated risk factors and to assess its management.

METHODS

A retrospective analysis was conducted using the PearlDiver™ Mariner database, containing de-identified patient records compiled between 2011 and 2022. Specific International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify population characteristics and outcomes. All the most employed surgical procedures for BPH treatment were considered. Multivariable logistic regression was employed to evaluate factors associated with diagnosis of post-operative US.

RESULTS

Among 274,808 patients who underwent BPH surgery, 10,918 developed post-operative US (3.97%) within 12 months. Higher incidence of US was observed following TURP (4.48%), Transurethral Incision of the Prostate (TUIP) (3.67%), Photoselective Vaporization of the Prostate (PVP) (3.92%), HoLEP/ThuLEP (3.85%), and open Simple Prostatectomy (SP) (3.21%). Lower incidence rates were observed after laparoscopic\robot-assisted SP (1.76%), Aquablation (1.59%), Prostatic Urethral Lift (PUL) (1.07%), Rezum (1.05%), and Prostatic Artery Embolization (PAE) (0.65%). Multivariable analysis showed that patients undergoing PUL, Rezum, Aquablation, PAE, and PVP were associated with a reduced likelihood of developing US compared to TURP. US required surgical treatment in 18.95% of patients, with direct visual internal urethrotomy (DVIU) and urethroplasty performed in 14.55% and 4.50% of cases, respectively. Urethral dilatation (UD) in an outpatient setting was the primary management in most cases (76.7%).

CONCLUSIONS

The present analysis from a contemporary large dataset suggests that the incidence of US after BPH surgery is relatively low (<5%) and varies among procedures. Around 94% of US cases following BPH surgery are managed using minimally invasive treatment approaches such as UD and DVIU.

Five historical innovations that have shaped modern urological surgery

Throughout history, many innovations have contributed to the development of modern urological surgery, improving patient outcomes and expanding the range of treatment options available to patients. This article explores five key historical innovations that have shaped modern urological surgery: External shockwave lithotripsy, transurethral resection of prostate, cystoscope, perioperative prostate-specific antigen and robotic surgery. The selection of innovations for inclusion in this article was meticulously determined through expert consensus and an extensive literature review. We will review the development, impact and significance of each innovation, highlighting their contributions to the field of urological surgery and their ongoing relevance in contemporary and perioperative practice.

Rezŭm water vaporization therapy versus transurethral resection of the prostate in the management of refractory urine retention: matched pair comparative multicenter experience

PURPOSE

To compare the efficacy of Rezūm with a matched cohort of patients undergoing transurethral resection of the prostate (TURP) for catheter-dependent urine retention secondary to benign prostate hyperplasia (BPH).

METHODS

A retrospective review was performed for consecutive catheter-dependent patients who underwent Rezūm for BPH. Patients were matched and compared with a similar cohort undergoing TURP, using non-inferiority analysis on propensity score-matched patient pairs. Patients were followed up at 1, 3, 6 and 12 months by international prostate symptoms score (IPSS), quality of life (QoL) index, peak flow rate (Qmax) and postvoid residual urine (PVR).

RESULTS

Eighty-one patients undergoing Rezūm were compared with equal number of matched patients who undergoing TURP. Patients undergoing Rezūm experienced significantly shorter operation time (25.5 ± 8.7 vs. 103.4 ± 12.6 min; p < 0.001), lower intraoperative bleeding (2.4% vs. 20.7%, p < 0.001), shorter hospital stay (1.2 ± 0.9 vs. 2.4 ± 1.3 d, p < 0.001) and longer catheter time (12.6 ± 6.0 vs. 2.3 ± 1.2 d, p < 0.001), with no need for transfusion. Successful postoperative voiding was comparable between both arms (90.2% vs. 92.7%, p = 0.78), respectively. Despite patients undergoing TURP had significantly better voiding outcomes after 1 and 3 months, both groups were comparable after six and 12 months in terms of mean IPSS (11.1 ± 6.4 vs. 10.8 ± 3.4, p = 0.71), QoL indices (2.4 ± 1.6 vs. 2.1 ± 2.3, p = 0.33) and Qmax (22.0 ± 7.7 v. 19.8 ± 6.9 ml/sec, p = 0.06).

CONCLUSION

This study supports the safety and efficacy of Rezūm in the management of catheter-dependent patients secondary to BPH, with comparable functional outcomes to TURP. Until a randomized clinical comparison is available, long-term data are crucially recommended to compare the recurrence and reoperation rates.

Pathogen species are the risk factors for postoperative infection of patients with transurethral resection of the prostate: a retrospective study

This study aimed to analyze the infection risk factors for transurethral resection of the prostate (TURP) and establish predictive models to help make personalized treatment plans. Our study was designed one-center and retrospectively enrolled 1169 benign prostatic hyperplasia (BPH) patients. Risk factors were explored for postoperative infection. A TURP-postoperative infection (TURP-PI) model with infection prediction values was created. The improved-TURP-PI (I-TURP-PI) model, including extra new factors (pathogens species), was also built to see whether it could optimize the prediction abilities. At last, we developed a nomogram for better clinical application. Operation time, preoperative indwelling urinary catheter (PIUC), and positive preoperative urine culture were independent risk factors (all P < 0.05). Interestingly, pathogens species in pre-surgery urine (PEnterococcus faecium = 0.014, PPseudomonas aeruginosa = 0.086) were also independent risk factors. Patients with positive Enterococcus faecium (37.50%) were most likely to have postoperative infection. We built two models with AUCTURP-PI = 0.709 (95% CI 0.656-0.763) and AUCI-TURP-PI = 0.705 (95% CI 0.650-0.760). The nomogram could help improve the prediction ability. To our knowledge, our study is the first to use pathogen species in urine before surgery as risk factors for infection prediction after TURP. TURP-PI and I-TURP-PI models have essential roles in predicting patients' postoperative infections and in better postoperative antibiotic decision-making.

Serum copeptin as a predictor of risk of hyponatremia after transurethral prostatectomy

Background: Transurethral resection of the prostate gland (TURP) frequently leads to the de-velopment of dilutional serum sodium decrease. Copeptin has been established as a surrogate marker of vasopressin and is measured for clinical assessment of various sodium and water dis-turbances. This study aims to assess the utility of serum concentration of copeptin and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) for prediction of post-TURP al-terations of serum sodium concentration.Methods: Forty-three patients with benign prostatic hyperplasia undergoing TURP were enrolled. Serum sodium and copeptin were measured before the procedure, then 12 hours after its com-pletion. NT-proBNP was assessed at baseline. The total amount of fluids and sodium adminis-tered intravenously and used to flush the bladder during TURP was calculated in each patient. Receiver operator characteristic (ROC) curve analysis was used to determine value of copeptin and NT-proBNP for prediction of serum sodium decrease after TURPResults: In forward stepwise multiple regression analysis of serum copeptin before surgery and the duration of TURP explained the significant portion of the sodium concentration variation 12 hours from the start of the surgery. ROC curve analysis showed that serum copeptin before sur-gery predicted development of hyponatremia 12 hours after TURP (area under the curve, 0.775; 95% confidence interval, 0.62–0.89; p < 0.001) with a cut-off point of >78.6 pg/mL with 77% sensitivity and 64.7% specificity. Serum NT-proBNP before surgery did not predict hypo-natremia 12 hours after TURP.Conclusion: Serum copeptin before TURP surgery, but not NT-proBNP, may be a clinically use-ful marker of the risk of serum sodium decrease after TURP.

Correlation of Postoperative Outcomes According to the Amount of Prostatic Tissue Removed in Patients Undergoing Transurethral Resection of the Prostate

OBJECTIVE

The present study assesses the effect of the proportion of tissue resected during transurethral resections of the prostate (TUR-P) on lower urinary tract symptoms (LUTS) and other parameters in patients with a benign prostatic obstruction (BPO).

MATERIALS AND METHODS

Forty-three patients who underwent TUR-P between 2018 and 2021 were assessed prospectively. The patients were divided into two groups according to the percentage of tissue removed (group 1 <30%, group 2 >30% resection). Age, prostate volume, amount of resected tissue, operative time, length of hospital stay, duration of catheterization, International Prostate Symptom Score (IPSS), quality of life score (QoL), maximum urinary flow rate (Qmax), and serum prostate-specific antigen (PSA) (ng/dl) at preoperative and postoperative three months were recorded.

RESULTS

The percentage of tissue removed was 22.2% vs. 48.4% (p = 0.001), IPSS reduction was 77.7% vs. 83.3% (p = 0.048), QoL improvement was 77.2% vs. 84.8% (p = 0.133), Qmax increase was 171.3% vs. 193.5% (p = 0.032), and serum PSA decrease was 56.4% vs. 69.2% (p = 0.049) in groups 1 and 2, respectively. In addition, the operative time was 38.5 vs. 53.6 min (p = 0.001), the length of hospital stay was 2.0 vs. 2.4 days (p = 0.001), and the duration of catheterization average was 4.1 vs. 4.9 days (p = 0.002).

CONCLUSION

Resections of at least 30% of prostatic tissue can provide a significant improvement in the symptoms and parameters related to benign prostatic obstruction, while resections of less than 30% of prostatic tissue can effectively reduce urinary symptoms and improve the quality of life in older adult patients with comorbidities who require shorter operating times.

The Efficacy and Safety of HoLEP for Benign Prostatic Hyperplasia With Large Volume: A Systematic Review and Meta-Analysis

This meta-analysis was to evaluate the efficacy and safety of holmium laser enucleation of prostate (HoLEP) in the treatment of benign prostatic hyperplasia (BPH) with large volume. PubMed, Embase, and Cochrane Library databases (until March 2022) were used to search related randomized controlled trials. A total of 11 studies including 1,258 patients were involved. HoLEP could significantly decrease the length of hospital stay and accelerate recovery. In subanalysis, HoLEP had better perioperative outcomes than bipolar transurethral resection of the prostate (B-TURP) and bipolar transurethral enucleation of the prostate (BPEP). The improvement in operative time and enucleation time was better in thulium laser enucleation of the prostate (ThuLEP) than HoLEP. In the follow-up period, the HoLEP decreased post-void residual urine (PVR) in short-term intervals and improved patients’ maximum flow rate (Qmax) and prostate-specific antigen (PSA) in mid- and long-term intervals. In subanalysis, HoLEP presented significant improvements in Qmax, PSA, and quality of life (QoL) than B-TURP, and HoLEP could also improve Qmax than ThuLEP after 6 months of surgery. The HoLEP reduced the risk of postoperative bleeding compared with other surgeries in safety. In our study, we confirmed the advantages of HoLEP in treating BPH when the prostate size was larger than 80 mL, which indicated that HoLEP could be the best choice for treatment of large volume of prostate.

Evaluating Factors That Influence Healthcare Resource Utilization in Transurethral Resection of Prostate

INTRODUCTION

Transurethral resection of prostate (TURP) remains the gold standard for treatment of benign prostatic hyperplasia (BPH) but is associated with complications. The association of healthcare resource utilization (HRU) and TURP has been poorly studied. We seek to evaluate HRU in patients undergoing TURP and identify factors contributing to outcomes.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was reviewed from 2012-2018 for TURP by CPT code. HRU was defined as discharge to continued care, unplanned readmission within 30 days, or prolonged length of stay (>75th percentile). We included preoperative variables, including age, BMI, diabetes, and ASA class. OD was broken into deciles by minutes. Preoperative characteristics and outcomes were compared against OD. Predictors of HRU were found using a stepwise multivariate logistic regression.

RESULTS

38,749 patients were included. Variables significantly associated with OD (values are 3 shortest and 3 longest deciles, respectively): any HRU (35.9%, 32.4%, 31.4% and 32.4%, 33.7%, 37.6%), and prolonged length of stay (31.3%, 27.6%, 26.5% and 28.0%, 30.4%, 34.1%). Findings in the first decile seemed to be an outlier, shown in Figure 1. Complications associated with OD are shown in Figure 2. On multivariable analysis, patients with OD > 58 minutes were more likely to have increased HRU, OR 1.22, 1.33, 1.54, 1.78 for deciles 58-66, 67-78, 78-99 and >100, respectively, p<0.005. Preoperative variables associated with HRU on multivariable analysis include age 71-80 and >80, COPD, dyspnea, hypertension, diabetes, not functionally independent, ASA class III and IV-V, and dirty/infected wound class, p<0.005.

CONCLUSIONS

OD is an independent predictor of HRU in patients undergoing TURP and is more modifiable than other preoperative variables associated with increased HRU. Patients in the longest decile were more likely to have complications and increased HRU. Further study is needed to evaluate causation.

Monopolar transurethral resection of the prostate using water as the irrigation fluid: Our initial experience

Background

Monopolar transurethral resection of the prostate (M-TURP) has been the gold standard of surgical intervention in patients with benign prostatic hyperplasia with the indication for surgery. This can be achieved using varieties of irrigation fluids.

Objectives

To document our experience with M-TURP using water as irrigation fluid in 123 consecutive patients.

Materials and Methods

A retrospective study of all patients who had M-TURP with water as irrigation fluid was performed between January 2017 and July 2019. Information retrieved from theatre records and case notes includes patient's socio-demographic data, indications for surgery, intra-operative findings, the volume of resected chips and irrigation fluid used, post-operative complications and patient's satisfaction with the outcome of the procedure. These data were analysed using SPSS version 23.

Results

Data from 123 patients were analysed and presented. The age range was 44-96 years with a mean of 69 years. Prostate volume ranges from 13.9 to 276.00 mls with a mean of 95.69 mls while resected prostate volume ranges from 2.0 to 158.0 mls with a mean of 56.68 mls. Volume of the sterile water used as irrigation fluid ranged from 5.0 L to 174.0 L with a mean of 68.7 L. Mean reduction in International Prostate Symptoms Score, improvement in Q-max and reduction in post-void residual urine were 22.1, 16.9 and 141.6 mls, respectively. Transfusion rate was 6.5% while the duration of admission ranges from 1 to 6 days, with a mean of 2.5 days. The overall complication rate was 26.0%. Ninety-six percent were satisfied with the outcome.

Conclusion

M-TURP using water as irrigation fluid is safe and is as good as using the more rather expensive glycine or normal saline in bipolar TURP.

Neuraxial vs General Anesthesia: 30-Day Mortality Outcomes Following Transurethral Resection of Prostate

OBJECTIVE

To examine the occurrence of 30-day mortality, and other procedure related morbidities in cohorts of patient receiving neuraxial anesthesia (NAX) or general anesthesia (GA) in the setting of transurethral resection of the prostate (TURP). Historically, NAX has been recommended for patients undergoing TURP permitting monitoring of consciousness and early diagnosis of absorption-related hyponatremia. We aim to analyze a broader comparison of mortality and other associated morbidities regarding the form of anesthesia utilized.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was accessed and queried from January 2010 to December 2016 for TURP. 28,486 TURP cases were identified and further stratified by the type anesthesia administration, NAX 7,261 and GA 21,225. Chi-square analyses and Kaplan-Meier tests were performed for univariate comparisons. Using propensity score, data were optimally (1:1) matched to account for potential confounding variables. Outcomes were then compared for NAX vs. GA with a primary endpoint of 30-day mortality, followed by secondary endpoint of adverse outcomes reported per NSQIP.

RESULTS

Prior to matching, 30-day mortality was found to be 0.4% in the NAX cohort and 0.7% GA. 12,180 patients equally matched between the 2 groups. NAX was found to be superior to GA in terms of 30-day survival benefit (OR 0.55, 95% CI 0.33 -0.92, P <0.05), sepsis (OR 0.60, 95% CI 0.50 -0.73, P <0.001), and return to operating room (OR 0.76, 95% CI 0.60 -0.98, P <0.05) when comparing matched cohorts. NAX was associated with lower incidence of overall adverse clinical outcomes 12.4% vs 13.7% (P = 0.036).

CONCLUSION

NAX was found to have statistically relevant advantage for 30-day postoperative outcomes when compared to GA for TURP based on NSQIP database reporting.

Pharmacological and interventional treatment of benign prostatic obstruction: An evidence‐based comparative review

Introduction

The recommended treatment for bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) after the failure of behavioral therapy and fluid modification includes pharmacological, minimally invasive interventional, and surgical approaches. Each option has different risk and benefit profiles, and the urologist must be aware of the unique characteristics of each option in order to be able to accurately counsel the patients based on their individual values and preferences. We provide a comparative review of the commonest pharmacological and most widely performed interventional/surgical treatments for BPO, discussing the evidence for the treatment characteristics that are most useful for the practicing urologist.

Methods

A search of the PubMed database was performed for articles reporting on the following treatments for LUTS due to BPO: α‐blockers, 5α‐reductase inhibitors, phosphpdiesterase‐5 inhibitors, prostatic urethral lift (Urolift), convective radiofrequency water vapor thermal therapy (Rezum), Temporary implantable Nitinol Device (iTIND), prostate artery embolization (PAE), transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), Aquablation, and anatomical endoscopic enucleation of the prostate (AEEP). We performed a narrative review focussing on the following outcomes: efficacy, safety, durability, duration of catheterization, length of stay, re‐treatment rate, efficacy in special situations (enlarged median lobe, prostate size, urinary retention, and anticoagulant use), and sexual adverse events.

Results

AEEP offers the greatest long‐term improvement in maximum flow rate, IPSS, and prostate volume reduction, with lowest re‐treatment rate, followed by PVP, TURP, and Aquablation. Urolift, Rezum, and PAE have similar efficacy for prostate volume up to 80cc, and all are more effective than the pharmacological treatment. Urolift offers the lowest rate of sexual dysfunction, followed by Rezum, and both can be performed as a day case under local anesthesia.

Conclusion

Several treatment options exist to treat voiding LUTS due to BPO. Newer minimally invasive treatments reduce the hospital stay and postoperative complications, whereas AEEP provides the greatest long‐term symptom improvement at the expense of higher morbidity and sexual dysfunction. Men should be counseled regarding all suitable treatment options as some may favor reduced efficacy in association with reduced side effects.

The iTind Temporarily Implanted Nitinol Device for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Multicenter, Randomized, Controlled Trial

OBJECTIVE

To report the results of a multicenter, randomized, controlled trial with a temporarily implanted nitinol device (iTind; Medi-Tate Ltd, Hadera, Israel) compared to sham for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia.

MATERIALS AND METHODS

Men 50 years or older were randomized 2:1 between iTind and sham procedure arms. A self-expanding, temporary nitinol device was placed for 5-7 days and an 18F Foley catheter was inserted and removed for the iTind and sham group, respectively. Patients were assessed at baseline, 1.5, 3, and 12 months postoperatively using the IPSS, peak urinary flow rate, residual urine, quality of life, and the International Index of Erectile Function. Unblinding occurred at 3 months.

RESULTS

A total of 175 men (mean age 61.1 ± 6.5) participated (118 iTind vs 57 sham). A total of 78.6% of patients in the iTind arm showed a reduction of ≥3 points in IPSS, vs 60% of patients in the control arm at 3 months. At 12 months, the iTind group reported a 9.25 decrease in IPSS (P< .0001), a 3.52ml/s increase in peak urinary flow rate (P < .0001) and a 1.9-point reduction in quality of life (P < .0001). Adverse events were typically mild and transient, most Clavien-Dindo grade I or II, in 38.1% of patients in the iTind arm and 17.5% in the control arm. No de novo ejaculatory or erectile dysfunction occurred.

CONCLUSION

Treatment with the second-generation iTind provided rapid and sustained improvement in lower urinary tract symptoms for the study period while preserving sexual function.

Review of Sexual Preservation After Novel Benign Prostatic Hyperplasia Surgical Treatment Modalities From Food and Drug Administration Clinical Trials

INTRODUCTION

Traditional benign prostatic hyperplasia treatment options, such as transurethral resection of the prostate and laser, have focused on addressing urinary symptoms for men; however, these options are associated with a high risk of sexual dysfunction.

OBJECTIVE

The objective of this study was to assess newer technologies (Aquablation therapy, UroLift, and Rezum) for the treatment of benign prostatic hyperplasia and the impact of preserving sexual function compared with transurethral resection of the prostate.

METHODS

A comprehensive review of Food and Drug Administration randomized studies from each of the technologies was carried out. A comparison of 3-year outcomes for International Index of Erectile Function-5 and Male Sexual Health Questionnaire Ejaculatory Function domain short form was analyzed.

RESULTS

Aquablation and prostatic urethral lift were the only therapies to show permanent sexual function preservation in both Male Sexual Health Questionnaire Ejaculatory Function domain short form (ejaculatory function) and International Index of Erectile Function-5 (erectile function) at 3 years after treatment.

CONCLUSION

For prostates less than 80 cc, Aquablation and prostatic urethral lift were able to demonstrate permanent sexual function preservation in both Male Sexual Health Questionnaire Ejaculatory Function domain short form (ejaculatory function) and International Index of Erectile Function-5 (erectile function) at 3 years after treatment. Bhojani N, Yafi FA, Misrai V, et al. Review of Sexual Preservation After Novel Benign Prostatic Hyperplasia Surgical Treatment Modalities From Food and Drug Administration Clinical Trials. Sex Med Rev 2021;9:169-173.

Transfusion rates after 800 Aquablation procedures using various haemostasis methods

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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