A 4-year follow-up of a randomized prospective study comparing transurethral electrovaporization of the prostate with neodymium: YAG laser therapy for treating benign prostatic hyperplasia

Impact of Surgery for Benign Prostatic Hyperplasia on Sexual Function: A Systematic Review and Meta-analysis of Erectile Function and Ejaculatory Function

CONTEXT

Several sexual side effects, including erectile, ejaculatory, and orgasmic dysfunction, were reported with the majority of surgical procedures for benign prostatic obstruction (BPO).

OBJECTIVE

To systematically review current evidence regarding the impact of benign prostatic hyperplasia (BPH) surgery on sexual function.

EVIDENCE ACQUISITION

A comprehensive bibliographic search on the MEDLINE, Cochrane Library, Embase, Web of Science, and Google Scholar databases was conducted in July 2021. The population, intervention, comparator, and outcome (PICO) model was used to define study eligibility. Studies were Included if they assessed patients with BPO and related lower urinary tract symptoms (P) undergoing BPH surgery (I) with or without a comparison between surgical treatments (C) evaluating the impact on sexual function (O). Retrospective and prospective primary studies were included. A pooled analysis was conducted on studies including the postoperative assessment of International Index of Erectile Function (IIEF)-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD; Function and/or Bother), or retrograde ejaculation (RE) rate (PROSPERO database ID: CRD42020177907).

EVIDENCE SYNTHESIS

A total of 151 studies investigating 20 531 patients were included. Forty-eight randomized controlled trials evaluating 5045 individuals were eligible for the meta-analysis. In most studies (122, 80.8%), only erectile and/or ejaculatory function was evaluated. A substantial number of articles (67, 44.4%) also used nonvalidated tools to evaluate erectile and/or ejaculatory function. The pooled analysis showed no statistically significant changes in IIEF-5 score compared with baseline for the transurethral resection of the prostate (TURP; weighted mean difference [WMD] 0.76 pts; 95% confidence interval [CI] -0.1, 1.62; p = 0.08), laser procedure (WMD 0.33 pts; 95% CI -0.1, 0.77; p = 0.13), and minimally invasive treatment (WMD -1.37 pts; 95% CI -3.19, 0.44; p = 0.14) groups. A statistically significantly higher rate of RE was found after TURP (risk ratio [RR] 13.31; 95% CI 8.37, 21.17; p < 0.00001), other electrosurgical procedures (RR 34.77; 95% CI 10.58, 127.82; p < 0.00001), and the entire laser group (RR 17.37; 95% CI 5.93, 50.81; p < 0.00001). No statistically significant increase in RE rate was described after most of the minimally invasive procedures (p > 0.05). The pooled analysis of MSHQ-EjD scores was possible only for prostatic urethral lift, showing no statistically significant difference between baseline and post-treatment MSHQ-EjD Function scores (WMD -0.80 pts; 95% CI -2.41, 0.81; p = 0.33), but postoperative MSHQ-EjD Bother scores were significantly higher (WMD 0.76 pts; 95% CI 0.22, 1.30; p = 0.006).

CONCLUSIONS

Erectile function appears to be unaffected by most surgical procedures for BPO. RE is a very common adverse event of BPH surgery, although emerging minimally invasive surgical procedures could be associated with a lower risk.

PATIENT SUMMARY

Benign prostatic hyperplasia surgery can have an impact on sexual function, mainly involving ejaculatory function.

Comparison of PKRP and TUVP in the treatment of high-risk BPH and analysis of postoperative influencing factors

Objective

This study aims to compare the efficacy of plasma kinetic loop resection of the prostate (PKRP) and transurethral vaporization of the prostate (TUVP) for the treatment of high-risk benign prostatic hyperplasia (BPH), and analyze the influence of the related factors on the operation of BPH.

Methods

A total of 108 high-risk BPH patients diagnosed in our hospital from March 2018 to September 2021 were selected and randomly divided into an observation group and a control group, with 54 cases in each group. The control group was treated with TUVP, and the observation group was treated with PKRP. The international prostate symptom score (IPSS), quality of life (QOL) index, maximum urine flow rate (Qmax), and residual urine volume (RU) were observed before and after treatment. The general information such as age, educational level, residence, and residence status of the patient, as well as clinical information such as surgical method, nocturia frequency, preoperative IPSS score, RU, medical history, and prostate texture, were also recorded. All patients were followed up for 1 month, and complications were recorded.

Results

The IPSS score, QOL score, and RU of patients in the two groups were lower after treatment than those before treatment, and the Qmax was higher than that before treatment (P < 0.05). The IPSS score, QOL score, and RU of the observation group were lower than those of the control group, and the Qmax was higher than that of the control group (P < 0.05). The incidence of postoperative complications in the observation group was lower than in the control group (P < 0.05). Univariate analysis showed that the patient's age, surgical method, nocturia frequency, preoperative IPSS score, RU, medical history, and prostatic texture all could affect the postoperative condition of patients with BPH (P < 0.05). Multivariate logistic analysis showed that the patient's age, surgical method, nocturia frequency, preoperative IPSS score, RU, and medical history were the independent influencing factors of the postoperative condition of patients with BPH (P < 0.05).

Conclusion

PKRP in the treatment of high-risk BPH patients can effectively reduce the IPSS score, QOL score, and RU and significantly increase Qmax, with fewer complications and a good prognosis. Patients’ postoperative recovery was related to their age, surgical method, nocturia frequency, preoperative IPSS score, RU, and medical history. Therefore, choosing PKRP to treat high-risk BPH patients can effectively improve the postoperative urethral functional recovery of patients and reduce the occurrence of complications.

A systematic review of the correlates and management of nonpremature ejaculatory dysfunction in heterosexual men

INTRODUCTION

A better understanding of ejaculatory disorders has led to an increasing interest in nonpremature ejaculatory dysfunction (non-PE EjD). Current reviews on the subject use a symptom-based classification to describe ejaculatory dysfunction even when it is a single case report. While these reviews provide important information on the disorder, a clearer picture of the prevalence of non-PE EjD in relation to the community and various pathophysiologic states is needed.

OBJECTIVES

The objective of this study was to provide a systematic review of studies of non-PE EjD excluding single case reports.

METHODS

A systematic review of Medline for terms including ejaculation, orgasm or hematospermia. Association with terms delay, pain or headache was made. The search was restricted to male gender and articles written in English. Abstracts were reviewed and those mainly concerned with premature ejaculation were excluded.

RESULTS

A total of 333 articles on non-PE EjD were identified. The condition was reported in community-based studies. In certain patient populations, non-PE EjD was commonly reported in association with antidepressant and antipsychotic treatments, in patients with chronic prostatitis/chronic pelvic pain syndrome, patients with lower urinary tract symptoms particularly in association with medical or surgical treatment, patients with retroperitoneal surgery and in patients with neurological diseases. Few articles were concerned with treatment options.

CONCLUSION

There is a significant prevalence of non-PE EjD in the community and in association with particular disease states or as a side effect of medical or surgical interventions. There is a need to direct efforts to prevent and treat these conditions.

Thulium laser vaporesection versus transurethral electrovaporization of the prostate in high-risk patients with benign prostatic hyperplasia

OBJECTIVE

The purpose of this study was to compare the safety and efficacy of the thulium laser vaporesection and transurethral electrovaporization of the prostate for the treatment of high-risk patients with benign prostatic hyperplasia.

BACKGROUND DATA

From September 2009 to March 2011, 98 consecutive patients with symptomatic bladder outlet obstruction caused by benign prostatic hyperplasia received either thulium laser vaporesection of the prostate (n=42) or transurethral electrovaporization of the prostate (n=56) at our institution.

MATERIALS AND METHODS

Functional follow-up included measurement of International Prostate Symptom Score, quality of life score, maximal urinary flow rate, and post-voiding residual urine volume. All complications were recorded.

RESULTS

Thulium laser vaporesection of the prostate was slightly superior to transurethral electrovaporization of the prostate in catheterization time (2.1±0.9 vs. 4.5±1.3 days, p<0.0001) and postoperative hospital stay (4.4±1.8 vs. 6.6±2.0 days, p<0.0001). Within the observation period, both groups had a significant improvement from baseline in subjective or objective success rates; however, no significant difference was found between the two groups. Peri- and postoperative complications were fewer in the thulium laser group.

CONCLUSIONS

Thulium laser vaporesection of the prostate is as effective as transurethral electrovaporization of the prostate in managing high-risk patients, with sufficient tissue ablation and acceptable hemostasis, and has the advantage of less morbidity and shorter catheter time and postoperative hospital stay.

Bloodless management of benign prostatic hyperplasia: medical and minimally invasive treatment options

Benign prostatic hyperplasia (BPH) is a medical condition affecting a wide range of the aging male population resulting in various degrees of lower urinary tract symptoms (LUTS). Today, a variety of medical therapies and minimally invasive BPH treatment modalities are available. Medical therapy includes α(1) blockers, 5()α reductase inhibitors and combination therapy. When these options fail, surgery is indicated. Transurethral resection of the prostate (TURP) is still considered the gold standard surgical treatment for BPH. Nevertheless, numerous minimally invasive treatment alternatives are available that are comparable in effectiveness to TURP, with significantly less morbidity. In this article, current treatment options for BPH are reviewed with respect to their indications, long-term safety and efficacy in relieving BPH related LUTS. The selection of the type of BPH treatment should be based on the physician's experience, patient's co-morbidities as well as the prostate size and clinical disease progression.

Transurethral Electrovapor Resection versus Standard Transurethral Resection Treatment for a Large Prostate: A 2-Year Follow-Up Study Conducted in Taiwan

INTRODUCTION

Those patients featuring a large prostate and undergoing transurethral resection typically face a longer duration of surgery, they have a higher degree of hemorrhage and a higher irrigant volume required for the procedure, and they tend to reflect a higher incidence of morbidity than is the case for a small prostate. We report on the relative safety and efficacy of transurethral electrovapor resection of the prostate (TUVRP) as compared with standard transurethral resection of the prostate (TURP) for Taiwanese patients having a prostate size >50 ml.

PATIENTS AND METHODS

Seventy-six symptomatic benign prostatic hyperplasia patients featuring a prostate size >50 ml were randomized and underwent either TUVRP using wedge loop or standard TURP. Perioperative parameters, treatment outcome, and adverse events associated with the surgical procedure are assessed herein.

RESULTS

Mean operation time, changes in hemoglobin levels, resected prostate weight, perioperative irrigant volume needed, and incidences of recatheterizations and readmissions, all differed significantly when the two surgical procedures were compared. The average expense differences for the two procedures were impressive (p < 0.0001). No postoperative intergroup sexual dysfunction differences were noted. Clinical improvements following either TUVRP or TURP were significant and sustained for at least a period of 2 years. Intergroup comparison of International Prostate Symptom Score, quality of life, peak flow rate, and postvoid residual volume revealed no significant differences at 2 years (p = 0.45, 0.48, 0.12, and 0.29, respectively). The need for postoperative medical retreatment and/or reoperation did not differ significantly between the two groups (p = 0.62 and p = 0.56, respectively, at 6 months and p = 0.47 and p = 0.48, respectively, at 2 years).

CONCLUSIONS

The TUVRP procedure offers advantages as regards a number of perioperative parameters when compared with the TURP procedure, and it seems that TUVRP might provide at least an equivalent treatment outcome as is the case for TURP.

Selecting therapy for maintaining sexual function in patients with benign prostatic hyperplasia

In the first of these mini-reviews the selection of therapy for the maintenance of sexual function in patients with BPH is outlined, along with an explanation of how altered regulation of neurotransmitters, especially noradrenaline, may underlie the syndrome of LUTS and sexual dysfunction. Other mini-reviews outline the current status of robotic surgery to treat renal and adrenal disorders, and its future applications, and the potential use of the nitric oxide/cGMP pathway as a potential target to treat BOO associated with benign prostatic enlargement. Finally, the capacity to be creative in academic departments is extolled as a core property of academicians, and its surfacing described as having the potential to revitalize individuals and departments.

Could the latest generation potassium titanyl phosphate lasers be the ones to make transurethral resection of the prostate an operation of historical interest only?

PURPOSE OF REVIEW

We have witnessed an explosion of interest in surgical alternatives to transurethral resection of the prostate over the past decade. These have predominantly involved the delivery of heat to the prostate to cause either coagulation or vaporization. The latest generation laser technique involves the delivery of the potassium titanyl phosphate wavelength at high powers to cause large volumes of prostatic vaporization. This short review assesses the limited present evidence base supporting its use and asks the question of whether it will relegate transurethral resection of the prostate to an operation of historical interest only.

RECENT FINDINGS

The 80 W delivery system clearly results in impressive tissue vaporization with minimal bleeding. There is a learning curve to the procedure with operative times varying between 30 and 120 min. The postoperative recovery appears rapid and generally uncomplicated with early catheter removals. The short-term results suggest equivalent efficacy to transurethral resection of the prostate with improved safety; the lack of phase III trials, however, means that the durability of the procedure cannot be assessed at this early stage.

SUMMARY

Like many of the surgical alternatives to transurethral resection of the prostate this procedure shows early promise and represents the latest evolutionary development in the laser prostatectomy story. Only randomized comparisons with transurethral resection will tell us if it is a worthy challenger or simply a young pretender to the throne.

Vaporization of the prostate

PURPOSE OF REVIEW

Transurethral resection of the prostate remains the treatment of choice for men with symptomatic benign prostatic enlargement. Concerns regarding the morbidity of this operation have led to the development of alternative surgical procedures. Vaporization of the prostate can be achieved using either laser energy or electrosurgery. The advantage of these approaches is that they allow tissue removal with reduced blood loss. Vaporization techniques have been around for almost a decade and more powerful lasers have recently become available. This has led to a minor resurgence in interest in laser vaporization. We reviewed articles on all forms of vaporization of the prostate published in the 12 months from August 2002.

RECENT FINDINGS

Electrovaporization of the prostate is an effective treatment for men who require surgery for benign prostatic enlargement. The results are well maintained at 5 years follow-up with low reoperation rates. Scanty data are available for the Gyrus (Gyrus Medical Ltd, Cardiff, Wales) bipolar electrovaporization system but preliminary results suggest there is no significant advantage over transurethral resection of the prostate. Early forms of laser vaporization of the prostate are not as effective as either transurethral resection of the prostate or transurethral electrovaporization of the prostate and have a higher retreatment rate. Newer, more powerful lasers have been recently introduced with encouraging initial results in small numbers of patients.

SUMMARY

Electrovaporization of the prostate is a safe, effective and durable alternative to transurethral resection. Early laser vaporization techniques have high retreatment rates, which limit their cost-effectiveness. Few data are yet available on high-powered lasers for bladder outflow obstruction. Whether any vaporization technique will stand the test of time is unclear.