Different lasers in the treatment of benign prostatic hyperplasia: a network meta-analysis

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.

Minimally Invasive Treatment in Benign Prostatic Hyperplasia (BPH)

Review efficacy and safety of minimally-invasive treatments for Low Urinary Tract Symptoms (LUTS) in patients affected by Benign Prostate Hyperplasia (BPH). We performed a systematic review of the literature from 1993 to 2022 leveraging original research articles, reviews, and case-studies published in peer-reviewed journals and stored in public repositories. Prostate artery embolization (PAE), transurethral needle ablation (TUNA), transurethral microwave thermotherapy (TUMT), high intensity focused ultrasound (HIFU), laser treatments and Cryoablation are valid and safe alternatives to the gold standard (surgery) in the treatment of LUTS in patients affected by BPH, with fewer undesired effects being reported.

Holmium laser enucleation of the prostate: a 3-year single-center experience of 173 cases

Background

Holmium laser enucleation of the prostate (Holep) is a safe, effective, and prostate size-independent procedure for benign prostatic hyperplasia treatment (BPH). Holep has demonstrated comparable long-term outcomes with historical BPH mainstay treatments, namely open prostatectomy or transurethral resection of the prostate, as well as straightforward evidence of its low morbidity. In this study, we aimed to report our 3-year Holep experience based on 173 patients.

Methods

We conducted a retrospective descriptive single center study utilizing medical charts of 173 patients who underwent Holep between 2017 and 2020. Peri and postoperative measures included prostate volume, peak urinary flow rate (Qmax), prostate specific antigen, catheterization time, hospital stay, and complications.

Results

The mean age and mean prostate weight at baseline were 71.3 ± 7.8 years and 64.2 g (17 and 380 g), respectively. Holep was associated with a short catheterization time and hospital stay (2.7 and 3 days, respectively). Qmax significantly improved after Holep (8.1 vs 20.4 ml/s, p < 0.05), and results sustained at 06 months postoperatively. Perioperative and postoperative complications were mainly represented by hematuria (29%). However, more than half of these patients were taking anticoagulation drug therapy at the time of surgery. Complications mostly occurred during the early years following Holep’s introduction and tended to decrease with time and experience.

Conclusion

Holep remains a safe and effective procedure for BPH treatment, with durable long-term results even in clinical settings where the procedure is new. The rate of complications, which is associated with the learning curve, improves with time and experience.

The effectiveness and safety of three surgical procedures for the treatment for benign prostatic hyperplasia: A network meta-analysis

Objective

To evaluate the effectiveness and safety of transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP) and thulium laser enucleation of the prostate (ThuLEP) in the treatment of benign prostatic hyperplasia using a network Meta-analysis.

Methods

Randomized controlled trials of TURP, HoLEP and ThuLEP for benign prostatic hyperplasia were collected by computerized searches of databases including CNKI, WANFANG, VIP, PubMed, The Cochrane Library, the Web of Science and Embase, with a search time frame of build to January 2022. The literature was screened and data was extracted by two investigators separately, while the risk of bias of the included studies was evaluated before systematic evaluation and network meta-analysis using ADDIS 1.16.8 software and RevMan 5.3 software.

Results

A total of 27 RCTs with a total of 3335 patients were involved. The results of the network meta-analysis showed that ThuLEP was better than the remaining two procedures in terms of enhancing patients' subjective perception and improving objective indicators, and the incidence of adverse events such as postoperative urethral stricture and urinary incontinence was lower compared with that of conventional TURP in both short- and long-term postoperative follow-ups.

Conclusion

As ThuLEP is effective, safe, and featured with few postoperative complications, it can be the preferred surgical procedure for prostate enlargement. Nevertheless, because of the limited number of studies included, more-sample, multicenter, double-blind clinical randomized controlled trials are required in the future to further verify the findings of the present study.

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.

A prospective randomized controlled trial comparing the effect and safety of Piranha and VersaCut morcellation devices in transurethral holmium laser enucleation of the prostate

PURPOSE

Holmium laser enucleation of the prostate (HoLEP) is reported to be widely used in the surgical treatment of benign prostatic hyperplasia (BPH), which consists of two procedures: enucleation and morcellation. This study is to examine the efficiency and safety of two different morcellator systems within a cohort of men undergoing HoLEP for BPH.

METHODS

A total of 210 consecutive patients undergoing HoLEP and morcellation procedures were enrolled. Individuals were randomly divided into 2 separated groups: the first group (105 patients) was performed with a nephroscope using a mechanical Versacut morcellator and the second (105 patients) was performed with the new morcellation system, nephroscopes and Piranha morcellator. Perioperative characteristics were studied and analyzed.

RESULTS

The morcellation time and the morcellation rate was similar when the prostate volume (PV) ≤ 60 mL while the morcellation time was significantly shorter and the morcellation rate was higher in the Piranha group with PV > 60 mL. No significant difference was observed according to the bladder irrigation time, indwelling catheter time, and discharge time.

CONCLUSION

Piranha morcellator presents a higher efficiency for the prostate over 60 mL.

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.

Multicentric comparative analysis of Retzius versus Retzius sparing robotic assisted simple prostatectomy in the management of large prostate glands

AIM

Robot-assisted simple prostatectomy (RASP) is a minimally invasive alternative to open simple prostatectomy in the management of patients with large prostate glands suffering from moderate-to-severe lower urinary tract symptoms (LUTS). Our study aimed to evaluate two transvesical robotic approaches in order to compare functional outcomes and postoperative complications.

MATERIALS AND METHODS

Clinical data from 111 consecutive patients from three tertiary robotic centers were retrospectively collected. Patients were divided into two groups depending on the surgical approach: 58 Retzius sparing and 53 Retzius approach RASP. We evaluated peri-operative outcomes (operating time, blood loss, transfusion rate, length of hospital stay), as well as intra-operative and early complications using a Clavien Dindo scale. Fisher's exact test, chi-square test and Mann-Whitney U test were applied for statistical analyses. A p-value <0.05 was considered statistically significant.

RESULTS

Neither subgroup differed significantly in age (p = 0.104), Charlson comorbidity index (p = 0.088) or prostate volume (p = 0.507), total IPSS score (0.763) and Q_max (p = 0.651). Total complication rates were lower for the Retzius approach subgroup (19 vs 11.9%) without reaching statistical significance in multivariate analysis (HR = 1.21, 95% CI = 0.17 - 8.44, p = 0.84). No significant differences based on IPSS total score and Q_max could be observed between the two subgroups during follow-up.

CONCLUSIONS

Both RASP approaches provide similar results in terms of functional outcomes and present a good safety profile in the management of large prostatic adenomas. Larger trials are needed in order to establish the indications for each robotic technique.

Laser procedures in the treatment of BPH: a bibliometric study

PURPOSE

To perform a bibliometric analysis of lased-based BPH treatment publications and to obtain an understanding of the publication trends over time.

MATERIALS AND METHODS

The Medline database was searched for articles in English language regarding laser-based BPH therapy up to 2018. Matching articles were assigned to at least one of the following categories: Ho:YAG, Tm:YAG, green light, diode, Nd:YAG laser and review articles. The laser categories were analysed using bibliometric procedures regarding citation rate, authors, country of origin and journal of publication. Moreover, the articles on laser BPH therapy included in the EAU, AUA and JUA guidelines were analysed to evaluate the most influential articles.

RESULTS

In total, 982 articles were included: 317 articles were assigned to green light, 283 to Ho:YAG, 101 to Tm:YAG, 74 to Nd:YAG and 39 to diode lasers. The publication rate for Nd:YAG laser has declined, but continues to grow for Ho:YAG and Tm:YAG lasers. We found a positive correlation between number of authors and year of publication (R = 0.3, p < 0.001*). Articles on Ho:YAG lasers are cited the most (mean 23.0 ± 37.1). Asia has contributed the most articles. Mostly, countries with high health and research and development (R&D) expenditures influenced the guidelines regarding laser-based approaches. Yet, after adjustment of all search results to GDP, health and R&D expenditure, India and China were the most prolific countries.

CONCLUSION

Laser-based approaches for BPH treatment are increasing but have not been implemented worldwide. Asia's contribution should be acknowledged. An inflationary trend regarding the number of authors per article is confirmed.

Economic Evaluation of 1470 nm Diode Laser Enucleation vs Bipolar Transurethral Resection of the Prostate

Purpose: Large meta-analyses demonstrate the noninferiority of laser enucleation to transurethral resection of the prostate (TURP) with regard to long-term efficacy and reoperation rate. Although the 1470 nm diode laser enucleation of the prostate (DiLEP) is superior in hemostasis and surgical visibility, its complexity and associated longer operative time limit its widespread usage. The objective of this study was to generate long-term cost estimates for bipolar TURP and DiLEP, taking into account perioperative and adverse event costs. Materials and Methods: This is a retrospective review of patients who underwent DiLEP (n = 114; November 2016 to February 2020) or TURP (n = 194; January 2016 to December 2018). A decision analysis model was constructed to compare costs of the primary procedure and subsequent complications taking into account disposable costs, operating room time, length of stay, reoperation rates, and readmissions. Costs were estimated from internal data, published literature and Medicare procedure costs. Markov modeling was used to create cost projections up to 10 years. Results: DiLEP was associated with shorter length of stay and fewer total complications, but longer operative times and greater initial costs. Cost were recuperated at 8 years postoperatively. At 10 years postoperatively, DiLEP represented approximately $664 cost savings per patient over TURP. Conclusions: DiLEP is a cost-effective alternative to TURP for the treatment of benign prostatic hyperplasia in the properly selected patient. DiLEP has greater initial costs due to longer operative times. Costs are recuperated by 10 years postoperatively due to higher rate of same-day discharges, and lower complication and reoperation rates, incurring a $664 cost savings per patient treated by DiLEP relative to TURP.

Endoscopic enucleation vs endoscopic vaporization procedures for benign prostatic hyperplasia: how should we choose: A protocol for systematic review and meta-analysis

OBJECTIVE

To assess the safety and efficacy of different endoscopic procedures of the prostate techniques, by comparing endoscopic enucleation (EEP) and endoscopic vaporization procedures (EVP) of the prostate; and laser enucleation procedures (L-EEP) vs laser vaporization procedures (L-EVP) surgeries for benign prostatic hyperplasia.

METHODS

A systematic literature review was performed in December 2019 using PubMed, Embase and the Cochrane Library to identify relevant studies. Two analyses were carried out: (1) EEP vs EVP; and (2) L-EEP vs L-EVP. Efficacy and safety were evaluated using perioperative data, functional outcomes, including maximum urinary flow rate (Qmax), quality of life (QoL), international prostate symptom score (IPSS), postvoiding residual urine volume (PRV), and rate of complications. Meta-analyses were conducted using RevMan5.3.

RESULTS

Sixteen studies (4907 patients) evaluated EEP vs EVP, and 12 of them (4392 patients) evaluated L-EEP vs L-EVP. EEP showed improved functional outcomes compared with EVP. EEP was always presented a better Qmax at various follow-up times. EEP also associated with a reduced PRV and IPSS at 12 months postsurgery, an increased Qmax, and reduced IPSS and QoL score at both 24 and 36 months postsurgery. In addition, EEP was associated with less total energy utilized and retreatment for residual adenoma, but a longer catheterization time. Among other outcomes, there was no significant difference. L-EEP favors total energy used, retreatment for residual adenoma, and functional outcomes. L-EEP was associated with reduced PRV at 1, 6, and 12 months postsurgery, a greater Qmax at 6 and 12 months postsurgery, a lower IPSS at 12 months postsurgery, and higher Qmax and lower IPSS and QoL scores at 24 and 36 months postsurgery. However, there was no difference at 3 months postsurgery. No significant differences were observed for other perioperative data and complications.

CONCLUSIONS

Both EEP and EVP displayed sufficient efficacy and safety for treating benign prostatic hyperplasia. EEP and L-EEP were favored in perioperative data, rate of complications, and functional outcomes. However, the clinical significance of those statistical differences was unclear. Hence, higher-quality randomized controlled trials may be needed to provide a clear algorithm.

The International Continence Society (ICS) report on the terminology for male lower urinary tract surgery

INTRODUCTION

In the development of terminology of the lower urinary tract (LUT), due to its increasing complexity, the terminology for male LUT surgery needs to be updated using a male-specific approach and via a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardization Committee of the International Continence Society in a Working Group with recognized experts in the field, assisted by many external referees. Appropriate core clinical categories and a subclassification were developed to give a numeric coding to each definition. An extensive process of 14 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus).

RESULTS

A Terminology Report for male LUT and pelvic floor surgery, encompassing 149 separate definitions/descriptors, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in male LUT surgery. Figures have not been included to avoid any preference or bias towards a specific procedure.

CONCLUSIONS

A consensus-based Terminology Report for male LUT surgery has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Thulium laser transurethral vaporesection versus transurethral resection of the prostate for benign prostatic obstruction: the UNBLOCS RCT

BACKGROUND

Transurethral resection of the prostate (TURP) is the standard operation for benign prostatic obstruction (BPO). Thulium laser transurethral vaporesection of the prostate (ThuVARP) vaporises and resects the prostate using a technique similar to TURP. The small amount of existing literature suggests that there may be potential advantages of ThuVARP over TURP.

OBJECTIVE

To determine whether or not the outcomes from ThuVARP are equivalent to the outcomes from TURP in men with BPO treated in the NHS.

DESIGN

A multicentre, pragmatic, randomised controlled parallel-group trial, with an embedded qualitative study and economic evaluation.

SETTING

Seven UK centres - four university teaching hospitals and three district general hospitals.

PARTICIPANTS

Men aged ≥ 18 years who were suitable to undergo TURP, presenting with bothersome lower urinary tract symptoms (LUTS) or urinary retention secondary to BPO.

INTERVENTIONS

Patients were randomised 1 : 1 to receive TURP or ThuVARP and remained blinded.

MAIN OUTCOME MEASURES

Two co-primary outcomes - patient-reported International Prostate Symptom Score (IPSS) and clinical measure of maximum urine flow rate (Qmax) at 12 months post surgery.

RESULTS

In total, 410 men were randomised, 205 to each arm. The two procedures were equivalent in terms of IPSS [adjusted mean difference 0.28 points higher for ThuVARP (favouring TURP), 95% confidence interval (CI) -0.92 to 1.49 points]. The two procedures were not equivalent in terms of Qmax (adjusted mean difference 3.12 ml/second in favour of TURP, 95% CI 0.45 to 5.79 ml/second), with TURP deemed superior. Surgical outcomes, such as complications and blood transfusion rates, and hospital stay were similar for both procedures. Patient-reported urinary and sexual symptoms were also similar between the arms. Qualitative interviews indicated similar patient experiences with both procedures. However, 25% of participants in the ThuVARP arm did not undergo their randomised allocation, compared with 2% of participants in the TURP arm. Prostate cancer was also detected less frequently from routine histology after ThuVARP (65% lower odds of detection) in an exploratory analysis. The adjusted mean differences between the arms were similar for secondary care NHS costs (£9 higher for ThuVARP, 95% CI -£359 to £376) and quality-adjusted life-years (0.01 favouring TURP, 95% CI -0.04 to 0.01).

LIMITATIONS

Complications were recorded in prespecified categories; those not prespecified were excluded owing to variable reporting. Preoperative Qmax and IPSS data could not be collected for participants with indwelling catheters, making adjustment for baseline status difficult.

CONCLUSIONS

TURP was superior to ThuVARP in terms of Qmax, although both operations resulted in a Qmax considered clinically successful. ThuVARP also potentially resulted in lower detection rates of prostate cancer as a result of the smaller volume of tissue available for histology. Length of hospital stay after ThuVARP, anticipated to be a key benefit, was equal to that after TURP in this trial. Overall, both ThuVARP and TURP were effective procedures for BPO, with minor benefits in favour of TURP. Therefore, the results suggest that it may be appropriate that new treatment alternatives continue to be compared with TURP.

FUTURE WORK

Longer-term follow-up to assess reoperation rates over time, and research into the comparative effectiveness of ThuVARP and TURP in large prostates.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN00788389.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 41. See the NIHR Journals Library website for further project information.

The diagnostic value of prostate cancer between holmium laser enucleation of the prostate and transurethral resection of the prostate for benign prostatic hyperplasia: A retrospective comparative study

BACKGROUND

To compare the diagnostic value of prostate cancer (PCa) between holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TURP).

METHODS

We retrospectively analyzed the clinical data of 2909 patients who underwent surgery for benign prostatic hyperplasia (BPH) from January 2008 to June 2018. A total of 1362 patients received HoLEP, and 1547 patients received TURP. The baseline patient characteristics were collected. We then compared the perioperative outcomes of these patients who diagnosed with incidentally diagnosed prostatic carcinoma (IDPC) or PCa after BPH surgeries.

RESULTS

The total detection rate of PCa in HoLEP group was higher than that in TURP group (85/6.24% vs. 61/3.94%, p = 0.005). Specifically, 55(4.6%) patients were diagnosed with IDPC in HoLEP group with prostate-specific antigen (PSA) less than 4 ng/ml, and 37(2.7%) patients in TURP group (p = 0.014). For the patients with PSA between 4 and 10 ng/ml, 15(13.9%) patients were diagnosed with PCa after HoLEP, and 6(5.0%) patients after TURP (p = 0.023). But the detection rate of PCa was not significantly different between the two groups when PSA was over 10 ng/ml. On the other hand, 57 in 1215 patients with no prostate biopsy preoperatively were diagnosed with PCa after HoLEP, while 42 in 1370 patients after TURP (4.7% vs. 3.1%, p = 0.040), respectively. Twenty-six patients received once biopsy and diagnosed with PCa in HoLEP group, while 15 patients in TURP group (18.4% vs. 8.9%, p = 0.018), respectively. However, no significant difference was observed for patients who received twice prostate biopsy in the two groups.

CONCLUSIONS

The present study showed that HoLEP can provide a higher total detection rate of PCa when compared with TURP. Besides, this superiority was especially embodied in patients with PSA less than 10 ng/ml.

A pilot study of the shapes of ablation lesions in the canine prostate by laser, radiofrequency and microwave and their clinical significance

To explore the shape characteristics of ablation lesions created via laser ablation (LA), radiofrequency ablation (RFA) and microwave ablation (MWA) in canine prostates and the clinical significance of these characteristics, six adult male beagles were randomly assigned to the LA, RFA, and MWA groups. These ablations were performed with common parameters applied in clinical practice (LA, 3 W/1200 J; RFA and MWA, 30 W/120 s). One ablation lesion was created in each lobe of the prostate via the ablation technique, resulting in a total of twelve ablation lesions. Transrectal ultrasound (TRUS) was used as guidance during puncture and to monitor changes in the ablation lesions. Finally, the ablation efficacy was assessed using transrectal contrast-enhanced ultrasonography (CEUS), and the transverse diameter (TRD), anteroposterior diameter (APD) and longitudinal diameter (LD) of each ablation lesion were measured. The volume (V) and the ratio (R) value were calculated. R reflects the shape characteristic of the ablation lesion (the R value close to 1.0 indicates a more spherical shape). The R values of the ablation lesions were 0.89 ± 0.02, 0.72 ± 0.01, and 0.65 ± 0.03 for RFA, MWA and LA, respectively, and they were significantly different (P = 0.027). The volumes of the ablation lesions were 2.17 ± 0.10 ml, 1.51 ± 0.20 ml, and 0.79 ± 0.07 ml for MWA, LA and RFA, respectively, and they were also significantly different (P = 0.001). The three abovementioned thermal ablation techniques with common parameters in clinical practice can be used for ablation in the prostate. The shapes and volumes of the ablation lesions of the three techniques were varied: The RFA-created lesions had the lowest volumes and were more spherical in shape, demonstrating that RFA could be used for the treatment of relatively small lesions or tumours adjacent to vital organs. The MWA lesions had the largest size with a spherical shape, which could be advantageous for the ablation of tumours with relatively large sizes. The sizes of the ablation lesions created via LA were between those of RFA and MWA but presented more oval in shape, suggesting that this method is highly appropriate for the ablation of benign prostatic hyperplasia (BPH).

Detection of blackbody radiation during fiber guided laser-tissue vaporization

Laser-tissue vaporization through a fiber catheter is evolving into a major category of surgical operations to remove diseased tissue. Currently, during a surgery, the surgeon still relies on personal experience to optimize surgical techniques. Monitoring tissue temperature during laser-tissue vaporization would provide important feedback to the surgeon; however, simple and low-cost temperature sensing technology, which can be seamlessly integrated with a fiber catheter, is not available. We propose to monitor tissue temperature during laser-tissue vaporization by detecting blackbody radiation (BBR) between 1.6 µm-1.8 µm, a relatively transparent window for both water and silica fiber. We could detect BBR after passing through a 2-meter silica fiber down to ∼70°C using lock-in detection. We further proved the feasibility of the technology through ex vivo tissue studies. We found that the BBR can be correlated to different tissue vaporization levels. The results suggest that this simple and low-cost technology could be used to provide objective feedback for surgeons to maximize laser-tissue vaporization efficiency and ensure the best clinical outcomes.

Pyuria and Post-Operation Urinary Tract Infection after Diode Laser Vaporesection of the Prostate

Background: Monopolar transurethral resection of prostate (m-TURP) remains the gold standard for benign prostate obstruction (BPO). Recently developed laser surgical technique provides fewer peri-operative complications with equivalent outcomes. Diode laser vaporesection (DiLRP) offers better hemostasis, shorter catheterization duration, and shorter hospital stay, however, deep thermal penetration might cause prolonged prostatic urethra inflammation and subsequent complications. We conducted a retrospective study to compare the pyuria duration and post-operative urinary tract infection sequelae (POUTIs) between DiLRP and m-TURP. Methods: From July 2011 to September 2015, we retrieved medical records for patients with lower urinary tract symptoms resulting from prostate obstruction who underwent m-TURP and DiLRP. Demographic characteristics were recorded from a computerized database. The duration of pyuria after operation was compared by Kaplan-Meier analysis and risk factors were evaluated by Cox regression analysis. Results: One hundred twelve patients underwent DiLRP and 81 underwent m-TURP performed by the same surgeon during the same period. The mean age of the patients was 72 ± 7.3 years in the DiLRP group and 70 ± 7.6 years in the m-TURP group (p = 0.069). There was a higher percentage of anticoagulant used in the DiLRP group than in the m-TURP group (18.5% vs. 7.4%, p = 0.028). Operation time was longer but post-operative normal saline irrigation interval was shorter in DiLRP compared with m-TURP, respectively (62.8 ± 20.6 vs. 47.4 ± 22.1 minutes, p < 0.001; 2.1 ± 0.3 vs. 2.5 ± 0.9 days, p < 0.001). The post-operative infections were statistically significantly higher in the DiLRP group, including epididymitis (10.2% vs. 1.2%, p = 0.013) and POUTIs-related hospitalization (8.3% vs. 1.2%, p=0.031).The DiLRP resulted in longer pyuria period (16 vs. 12 weeks, p = 0.0014), with factors including operative method by DiLRP (hazard ratio [HR]: 1.828, p = 0.003) and age (HR: 0.665, p = 0.040). Conclusions: According to our study, DiLRP associated with more POUTIs is possibly caused by a longer pyuria period. Further larger prospective studies are necessary for the evaluation of the association between post-operative pyuria and POUTIs.

A phytosterol-enriched saw palmetto supercritical CO2 extract ameliorates testosterone-induced benign prostatic hyperplasia by regulating the inflammatory and apoptotic proteins in a rat model

BACKGROUND

Benign prostatic hyperplasia (BPH) is a pathological condition affecting older men. BPH complications often lead to deterioration in the quality of life. Serenoa repens (Saw Palmetto) is used for treating lower urinary tract infections in traditional medicine.

METHODS

This study was performed to compare the efficacy of β-sitosterol enriched saw palmetto oil (VISPO) and conventional saw palmetto oil (SPO) extracted using supercritical fluid extraction, in alleviating the BPH complications using testosterone-induced BPH model rats. The animals received testosterone (5 mg/kg s.c.) with or without SPO and VISPO (200 and 400 mg/kg b.w.) or Finasteride (1 mg/kg b.w.) p.o. for 28 days. At the end of the experiment, overnight fasted animals were euthanized, blood samples collected for serum analysis of testosterone. Prostate tissue histomorphology was examined by hematoxylin and eosin (H&E) staining. Western blot analysis was performed using prostate tissue homogenates.

RESULTS

VISPO exhibited superior efficacy compared to SPO as evident from the significant decrease in prostate weight to body weight ratio, serum testosterone level and increase in growth inhibition of prostate tissue compared to BPH group (p < 0.001). Histological examination of prostate tissue samples showed that VISPO treatment was comparatively better than SPO in improving the hyperplastic patterns. Further, VISPO significantly regulated the expression of inflammatory and apoptotic marker proteins in BPH rats.

CONCLUSION

Our data provide experimental evidence that β-sitosterol enriched saw palmetto oil could be higher efficacious in treating the BPH complications compared to the conventional saw palmetto oil preparations.

Epidemiology and treatment modalities for the management of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is one of the most common conditions affecting men. BPH can lead to a number of symptoms for patients commonly referred to as lower urinary tract symptoms (LUTS). Over the last decade, increased modifiable risk factors, such as metabolic disease and obesity, have resulted in an increased incidence of BPH. This increasing incidence has brought about a multitude of treatment modalities in the last two decades. With so many treatment modalities available, physicians are tasked with selecting the optimal therapy for their patients. Current therapies can first be divided into medical or surgical intervention. Medical therapy for BPH includes 5-alpha-reductase inhibitors and alpha-blockers, or a combination of both. Surgical interventions include a conventional transurethral resection of the prostate (TURP), as well as newer modalities such as bipolar TURP, holmium laser enucleation of the prostate (HoLEP), Greenlight and thulium laser, and prostatic urethral lift (PUL). Emerging therapies in this field must also be further investigated for safety and efficacy. This narrative review attempts to consolidate current and emerging treatment options for BPH and highlights the need for additional investigation on optimizing treatment selection.

Heat injured stromal cells-derived exosomal EGFR enhances prostatic wound healing after thulium laser resection through EMT and NF-κB signaling

BACKGROUND

This study investigated shallow heat injury to prostate stromal fibroblasts and epithelial cells and their interaction to regulate the wound healing and the underlying molecular events.

METHODS

Prostate stromal fibroblasts and epithelial cells were cultured individually or cocultured and subjected to shallow heat injury for assessments of cell proliferation, migration, apoptosis, cell cycle distribution, and gene expression. The supernatant of heat-injured WPMY-1 cells was collected for exosome extraction and assessments. Furthermore, beagle dogs received thulium laser resection of the prostate (TmLRP) and randomly divided into Gefitinib, GW4869, and control treatment for the histological analysis, tissue re-epithelialization, and epidermal growth factor receptor (EGFR) expression on the prostatic wound surface. Immunofluorescence was to evaluate p63-positive basal progenitor cell trans-differentiation and macrophage polarization and ELISA was to detect cytokine levels in beagles' urine.

RESULTS

Shallow heat injury caused these cells to enter a stressed state and enhanced their crosstalk. The prostate stromal fibroblasts produced and secreted more exosomal-EGFR and other cytokines and chemokines after shallow heat injury, resulting in increased proliferation and migration of prostate epithelial cells during wound healing. The wound healing of the canine prostatic urethra following the TmLRP procedure was slower in the Gefitinib and GW4869 treatment group than in the control group of animals. Immunofluorescence and ELISA showed that reduced EGFR expression interrupted macrophage polarization but increased the inflammatory response.

CONCLUSIONS

Shallow heat injury was able to promote the interaction of prostate stromal cells with prostate epithelial cells to enhance wound healing. Stromal-derived exosomal-EGFR plays a crucial role in the balance of the macrophage polarization and prostatic wound healing.

M1 macrophage mediated increased reactive oxygen species (ROS) influence wound healing via the MAPK signaling in vitro and in vivo

Thulium laser resection of the prostate (TmLRP), a major treatment for benign prostatic hyperplasia (BPH), has several postoperative complications that affect the patients' quality of life. The aim of this study was to investigate the effect of the M1 macrophage-secreted reactive oxygen species (ROS) on prostatic wound healing, and the role of MAPK signaling in this process. A co-culture model in vitro was established using macrophages and prostate epithelial or stromal cells. Cell proliferation, migration, apoptosis, MAPK pathway-related gene expression levels were evaluated by standard assays. In addition, an in vivo model of prostatectomy was established in beagles by subjecting them to TmLRP, and were either treated with N-acetyl-L-cysteine (NAC) and or placebo. Wound healing and re-epithelialization were analyzed histopathologically in both groups, in addition to macrophage polarization, oxidative stress levels and MAPK pathway-related proteins expressions. Intracellular ROS levels were significantly increased in the prostate epithelial and stromal cells following co-culture with M1-like macrophages and H₂O₂ exposure via MAPK activation, which affected their proliferation, migration and apoptosis, and delayed the wound healing process. The cellular functions and wound healing capacity of the prostate cells were restored by blocking or clearing the macrophage-secreted ROS. In the beagle model, increased ROS levels impaired cellular functions, and appropriate removing ROS accelerated the wound healing process.

Outcome of thulium laser enucleation of prostate surgery in high-risk patients with benign prostatic hyperplasia

Background

Benign prostatic hyperplasia (BPH) is one of the most common diseases in aging men and a significant cause of burden worldwide. Here, we report our experience of Thulium LASER enucleation of the prostate (ThuLEP) in high-risk patients with BPH.

Methods

This was a prospective study conducted between July 2011 and June 2016. The study participants were patients with a confirmed diagnosis of BPH, who required surgery, and were clinically eligible for ThuLEP.

Results

A total of 109 patients were included in the study. Of the total 109 patients, 82 patients had American Society of Anesthesiologists (ASA) Grade 3 and 27 had ASA Grade 4. The most common comorbidity was ischemic heart diseases (72.5%), followed by hypertension (57.8%) and diabetes mellitus (48.6%). During the procedure, a total of 11 (10.1%) patients had a fall in blood pressure requiring noradrenaline or mephentine and seven (6.4%) patients had early left ventricular failure. Sixteen (14.8%) patients had arrhythmias (benign) and seven (6.4%) patients with arrhythmias required antiarrhythmic drugs. The overall duration of surgery ranged from 55 to 70 min, laser time ranged from 25 to 35 min, hospital stay ranged from 30 to 36 h, and the mean catheter time was around 24 h. Overall, the change in hemoglobin ranged from 0.5 to 0.8 g/dL.

Conclusion

Results show that ThuLEP could be a better option in high-risk patients with BPH.

Fabrication of Chlorophyll-Incorporated Nanogels for Potential Applications in Photothermal Cancer Therapy

Nanogels have been widely used in biomedical applications, such as carriers for hyperthermia cancer treatment, drug delivery, and imaging. Owing to the enhanced permeability and retention effect, nanogels have shown a great potential in cancer therapy. In this study, sodium copper chlorophyllin (SCC), a low cytotoxicity and biodegradable photothermal agent, was copolymerized with a nanogel of N-[3-(dimethylamino)propyl]methacrylamide. The nanogels could produce heat under exposure to a green laser with a 532 nm wavelength. The positively charged nature of the nanogels enhanced the endocytosis of the nanogels. The cell mortality was greatly enhanced with the treatment of the SCC-containing nanogels and green light illumination. Our results suggest the potential of SCC-containing nanogels in photothermal cancer therapy.

Thulium (Tm:YAG) laser vaporesection of prostate and bipolar transurethral resection of prostate in patients with benign prostate hyperplasia: a systematic review and meta-analysis

Thulium laser vaporesection (ThuVARP) and bipolar transurethral resection of the prostate (B-TURP) are novel surgeries for benign prostate hyperplasia (BPH). This paper is a systematic review and analysis of literatures comparing efficacy indicators, operative parameters, as well as safety indicators between ThuVARP and B-TURP for the treatment of BPH. A systematic search of electronic databases, including PubMed, the Cochrane Library, Web of Science, Embase, and China National Knowledge Internet (CNKI), was carried out up to December 1, 2015 (updated on March 1, 2016). The captivating outcomes included basic clinical characteristics, perioperative parameters, local complications, and efficacy indicators which included International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and postvoid residual (PVR). After assessing the quality of methodology and extracting data, a meta-analysis was carried out by using STATA 12.0 software. Five studies involving 500 patients met the standard. The outcomes of this analysis were as follows: (a) efficacy indicators: there were no significant differences in IPSS, QoL, PVR, and Qmax between the two groups (all P > 0.05); (b) perioperative indicators: ThuVARP had longer operative time [standardized mean difference (SMD) = 0.843; 95% confidence interval (CI) - 0.391, 1.296; P < 0.001] but less serum hemoglobin decreased (SMD = - 0.561; 95% CI - 0.796, - 0.327; P < 0.001), shorter hospital stay (SMD = - 1.558; 95% CI - 2.709, - 0.407; P < 0.01), and catheterization time (SMD = - 1.274; 95% CI - 2.158, - 0.390; P < 0.01). Additionally, no significant difference was found in estimated resected weight (P > 0.05); (c) safety indicators: no significant difference was found in local complication rates (all P > 0.05) between ThuVARP and B-TURP. In our analysis, there exists no statistical difference between ThuVARP and B-TURP group in efficacy. However, in spite of requiring longer surgical time, ThuVARP was better in terms of less blood loss as well as shorter hospitalization and catheterization time.

Optimal biopsy strategy for prostate cancer detection by performing a Bayesian network meta-analysis of randomized controlled trials

Objective: With the increasing recognition of the over-diagnosis and over-treatment of prostate cancer (PCa), the choice of a better prostate biopsy strategy had confused both the patients and clinical surgeons. Hence, this network meta-analysis was conducted to clarify this question. Methods: In the current network meta-analysis, twenty eligible randomized controlled trials (RCTs) with 4,571 participants were comprehensively identified through Pubmed, Embase and Web of Science databases up to July 2017. The pooled odds ratio (OR) with 95% credible interval (CrI) was calculated by Markov chain Monte Carlo methods. A Bayesian network meta-analysis was conducted by using R-3.4.0 software with the help of package "gemtc" version 0.8.2. Results: Six different PCa biopsy strategies and four clinical outcomes were ultimately analyzed in this study. Although, the efficacy of different PCa biopsy strategies by ORs with corresponding 95% CrIs had not yet reached statistical differences, the cumulative rank probability indicated that overall PCa detection rate from best to worst was FUS-GB plus TRUS-GB, FUS-GB, CEUS, MRI-GB, TRUS-GB and TPUS-GB. In terms of clinically significant PCa detection, CEUS, FUS-GB or FUS-GB plus TRUS-GB had a higher, whereas TRUS-GB or TPUS-GB had a relatively lower significant detection rate. Meanwhile, TPUS-GB or TRUS-GB had a higher insignificant PCa detection rate. As for TRUS-guided biopsy, the general trend was that the more biopsy cores, the higher overall PCa detection rate. As for targeted biopsy, it could yield a comparable or even a better effect with fewer cores, compared with traditional random biopsy. Conclusion: Taken together, in a comprehensive consideration of four clinical outcomes, our outcomes shed light on that FUS-GB or FUS-GB plus TRUS-GB showed their superiority, compared with other puncture methods in the detection of PCa. Moreover, TPUS or TRUS-GB was more easily associated with the over-diagnosis and over-treatment of PCa. In addition, targeted biopsy was obviously more effective than traditional random biopsy. The subsequent RCTs with larger sample sizes were required to validate our findings.

Transurethral vaporesection of prostate: diode laser or thulium laser?

This study compared the safety and effectiveness of the diode laser and thulium laser during prostate transurethral vaporesection for treating benign prostate hyperplasia (BPH). We retrospectively analyzed 205 patients with BPH who underwent a diode laser or thulium laser technique for prostate transurethral vaporesection from June 2016 to June 2017 and who were followed up for 3 months. Baseline characteristics of the patients, perioperative data, postoperative outcomes, and complications were compared. We also assessed the International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Q_max), average flow rate (AFR), and postvoid residual volume (PVR) at 1 and 3 months postoperatively to evaluate the functional improvement of each group. There were no significant differences between the diode laser and thulium laser groups related to age, prostate volume, operative time, postoperative hospital stays, hospitalization costs, or perioperative data. The catheterization time was 3.5 ± 0.8 days for the diode laser group and 4.7 ± 1.8 days for the thulium laser group (p < 0.05). Each group had dramatic improvements in IPSS, QoL, Q_max, AFR, and PVR compared with the preoperative values (p < 0.05), although there were no significant differences between the two groups. Use of both diode laser and thulium laser contributes to safe, effective transurethral vaporesection in patients with symptomatic BPH. Diode laser, however, is better than thulium laser for prostate transurethral vaporesection because of its shorter catheterization time. The choice of surgical approach is more important than the choice of laser types during clinical decision making for transurethral laser prostatectomy.

Benign prostatic hyperplasia surgical scoring (BPHSS): an novel scoring system for the perioperative outcomes of holmium laser enucleation of the prostate

To develop a standardized scoring system, the BPH surgical scoring (BPHSS) system, to quantify the ability to predict the perioperative outcomes resulting from an enlarged prostate. There are two parts included in this study: the retrospective observational study (875 patients treated with holmium laser enucleation of the prostate, HoLEP) and the prospective observational study (111 patient underwent HoLEP). All the outcome data included the following: the basic patient preoperative characteristics, operation time (OT), pre- and post- surgery hemoglobin decrease, Na⁺ variation, hospital stay duration, duration of bladder irrigation, catheterization time, and hospitalization time. The BPHSS, consisting of prostatic volume (PV), prostate-specific antigen (PSA), bladder stones, intravesical prostatic protrusion (IPP), and metabolic syndrome (MetS), was observed regarding the perioperative outcomes. In the retrospective study, patients in high BPHSS group (6-8 points) showed significant increase in the OT (74.61, 95%CI = 16.98-327.84, P < 0.001), hemochrome reduction (416.50, 95%CI = 35.48-4889.88, P < 0.001), hospital stay (1.80, 95%CI = 1.35-2.41, P < 0.001), and bladder irrigation duration (4.04, 95%CI = 1.35-12.10, P = 0.013) compared with the low BPHSS group (0-2 points). In the prospective study, there also existed significant differences between the three scoring grades (P < 0.01) in OT, hemochrome decrease, and the hospital stay. The BPHSS is suitable to predict the perioperative outcomes in patients undergoing HoLEP. It may help urologist to prepare more before surgery to treat the enlarged prostates. Further studies are needed to validate this scoring system in BPH patients in multiple centers.

Clinical implications of underactive bladder

Underactive bladder (UAB) is a common urologic condition but a complex disease that causes troublesome lower urinary tract symptoms. Currently, management of UAB remains unsatisfactory. Also, many urological diseases can be combined with UAB. In these combined cases, the treatment results may be affected by UAB component. This review focuses on the clinical implications of UAB in patients with common urologic conditions, including bladder outlet obstruction, overactive bladder syndrome and stress urinary incontinence.

A novel vaporization-enucleation technique for benign prostate hyperplasia using 120-W HPS GreenLight™ laser: Seoul technique II in comparison with vaporization and previously reported modified vaporization-resection technique

PURPOSE

We developed a novel vaporization-enucleation technique (Seoul II), which consists of vaporization-enucleation of the prostate using 120-W HPS GreenLight laser, and enucleated prostate resection using bipolar devices for tissue removal. We compared the outcomes of the Seoul II with vaporization and a previously reported modified vaporization-resection technique (Seoul I).

METHODS

Among patients with benign prostate hyperplasia who underwent transurethral surgery using GreenLight laser at our institute, 347 patients with prostate volume ≥ 40 ml were included. The impact of surgical techniques on efficacy and postoperative functional outcomes was compared.

RESULTS

No difference was found in baseline characteristics, although the prostate volume was marginally greater in Seoul II (p = 0.051). Prostate volume reduction per operation time (p < 0.001) and lasing time (p = 0.016) were greater in Seoul II. At postoperative 12 months, the International Prostate Symptom Score (I-PSS) was lower (p = 0.011), and the decrement in I-PSS was greater in Seoul II (p = 0.001) than other techniques. In multivariate analysis, postoperative 12-month I-PSS for Seoul II was significantly superior to vaporization (p < 0.001), although it was similar to Seoul I. The maintenance of immediate postoperative I-PSS decrement, until postoperative 12 months was superior in Seoul II compared with vaporization (p = 0.014) and Seoul I (p = 0.048).

CONCLUSIONS

Seoul II showed improved efficacy and voiding functional maintenance over postoperative 12 months in patients with prostate volume ≥ 40 ml compared with vaporization and Seoul I. This technique could be easily accepted by clinicians who are familiar with GreenLight lasers and add flexibility to surgery without additional equipment.

Predictors of Improvement in Storage Symptoms at Three Years After 120W GreenLight High Performance System Laser Treatment for Benign Prostate Hyperplasia

PURPOSE

This study was conducted to investigate the indicators of recovery in storage symptoms after GreenLight High Performance System photoselective vaporization of the prostate (HPS-PVP) in men with benign prostate hyperplasia.

METHODS

A total of 155 men with a baseline subtotal storage symptom score of international prostate symptom score (sIPSS) greater than or equal to six, who underwent HPS-PVP and were followed up on for as much as 3 years, were included in this retrospective study. Surgical outcomes were evaluated at 1, 3, 6, 12, 24, and 36 months after surgery. Improvement of storage symptoms was defined as a reduction greater than or equal to 30% of sIPSS after surgery compared to the baseline.

RESULTS

The mean age was 67.5 ± 7.8 years and the preoperative median prostate-specific antigen, mean total prostate volume, and sIPSS were 1.95 (0.97-5.27) ng/mL, 52.1 ± 32.5 mL, and 9.6 ± 2.6, respectively. The mean improvement rate of sIPSS after 3 years was 34.4%. Age was only associated with an improvement of sIPSS in the multivariate analysis (odds ratio = 0.889, p = 0.008). The mean improvement rates of sIPSS according to age group (<65 vs ≥65) were 44.7% and 26.0%, respectively.

CONCLUSIONS

Age can serve as an independent predictor of storage symptom improvement for as much as 3 years. Therefore, we suggest that older patients who are being considered candidates for surgical treatment should be further evaluated.

Transperineal Laser Ablation for Percutaneous Treatment of Benign Prostatic Hyperplasia: A Feasibility Study

PURPOSE

To assess the feasibility and safety of transperineal laser ablation (TPLA) for treating benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Institutional review board approval was obtained for this prospective non-randomized trial. Eightteen patients (age 71.7 ± 9.4 years) with urinary symptoms secondary to BPH underwent TPLA under local anesthesia. Under US guidance, up to four 21G applicators were inserted in the prostatic tissue. Each treatment was performed with diode laser operating at 1064 nm changing the illumination time according to prostate size. Primary endpoints were technical success and safety of TPLA. Secondary endpoints included operation time, ablation time, energy deployed, hospitalization time, catheterization time, and change in International Prostate Symptom Score (IPSS), Quality of Life (QoL), peak urinary flow rate (Q _max), post-void residual (PVR), and prostatic volume at 3 months. χ ² and Fisher exact tests were used.

RESULTS

All procedures were technically successful. No complications occurred. Mean operation time was 43.3 ± 8.7 min, mean ablation time 15.9 ± 3.9 min, mean energy deployed 10,522 ± 3290.5 J, mean hospital stay 1.5 ± 0.4 days, and mean catheterization time 17.3 ± 10.0 days. At 3 months, IPSS improved from 21.9 to 10.7 (P < 0.001), QoL from 4.7 ± 0.6 to 2.1 ± 1.2 (P < 0.001), Q _max from 7.6 to 13.3 mL/s (P = 0.001), PVR from 199.9 ± 147.3 to 81.5 ± 97.8 (P < 0.001), and mean prostate volume from 69.8 to 54.8 mL (P < 0.001).

CONCLUSIONS

TPLA is feasible and safe in the treatment of BPH, providing significant clinical results at 3 months.

LEVEL OF EVIDENCE

Case series, Level IV.

A randomised controlled trial to determine the clinical and cost effectiveness of thulium laser transurethral vaporesection of the prostate (ThuVARP) versus transurethral resection of the prostate (TURP) in the National Health Service (NHS) - the UNBLOCS trial: a study protocol for a randomised controlled trial

BACKGROUND

Transurethral resection of the prostate (TURP) has been the standard operation for benign prostatic obstruction (BPO) for 40 years, with approximately 25,000 procedures performed annually, and has remained largely unchanged. It is generally a successful operation, but has well-documented risks for the patient. Thulium laser transurethral vaporesection of the prostate (ThuVARP) vaporises and resects the prostate using a surgical technique similar to TURP. The small amount of study data currently available suggests that ThuVARP may have certain advantages over TURP, including reduced blood loss and shorter hospital stay, earlier return to normal activities, and shorter duration of catheterisation.

DESIGN

A multicentre, pragmatic, randomised, controlled, parallel-group trial of ThuVARP versus standard TURP in men with BPO. Four hundred and ten men suitable for prostate surgery were randomised to receive either ThuVARP or TURP at four university teaching hospitals, and three district general hospitals. The key aim of the trial is to determine whether ThuVARP is equivalent to TURP judged on both the patient-reported International Prostate Symptom Score (IPSS) and the maximum urine flow rate (Qmax) at 12 months post-surgery.

DISCUSSION

The general population has an increased life expectancy. As men get older their prostates enlarge, potentially causing BPO, which often requires surgery. Therefore, as the population ages, more prostate operations are needed to relieve obstruction. There is hence sustained interest in the condition and increasing need to find safer techniques than TURP. Various laser techniques have become available but none are widely used in the NHS because of lengthy training required for surgeons or inferior performance on clinical outcomes. Promising initial evidence from one RCT shows that ThuVARP has equivalent clinical effectiveness when compared to TURP, as well as other potential advantages. As ThuVARP uses a technique similar to that used in TURP, the learning curve is short, potentially making it also very quickly generalisable. This randomised study is designed to provide the high-quality evidence, in an NHS setting, with a range of patient-reported, clinical and cost-effectiveness outcomes, which will underpin and inform future NICE guidance.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN00788389 . Registered on 20 September 2013.