Transurethral Resection of Prostate and Bleeding: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial to See the Efficacy of Short-Term Use of Finasteride and Dutasteride on Operative Blood Loss and Prostatic Microvessel Density

The relationship between prostatic microvessel density and different concentrations of oestrogen/androgen in Sprague-Dawley rats

BACKGROUND

Currently, there are relatively few studies on the effects of changes in oestrogen and androgen levels on prostatic microvessel density (MVD). This article aimed to study the changes in prostatic MVD in Sprague-Dawley (SD) rats after castration under the effect of oestrogen/androgen at different concentrations.

METHODS

Male SD rats aged 3-4 months were randomly divided into a control group, a castration group, and groups with different concentrations of oestrogen/androgen treatment after castration. Dihydrotestosterone (DHT) and oestradiol (E) were administered daily by subcutaneous injection for one month. All the rats were killed by cervical dislocation after one month, and the serum DHT and E concentrations of the rats in each group were measured by ELISA. Prostate tissue specimens were immunohistochemically stained with monoclonal antibodies against CD34 and factor VIII for MVD.

RESULTS

Compared with the control group, the MVD decreased significantly in the castration group (P < 0.05). When the exogenous E concentration was constant, in general, the MVD of rats in all the groups increased with increasing exogenous DHT concentration. Compared with the castration group, the MVD increased significantly in the E0.05 + DHT0.015 mg/kg, E0.05 + DHT0.05 mg/kg, E0.05 + DHT0.15 mg/kg, E0.05 + DHT0.5 mg/kg, and E0.05 + DHT1.5 mg/kg groups (P < 0.05). In addition, when the exogenous DHT concentration was constant, the MVD increased with increasing exogenous E concentration in all the groups. Among them, compared with the control and castration groups, the MVD increased significantly in the DHT0.15 + E0.015 mg/kg, DHT0.15 + E0.15 mg/kg, and DHT0.15 + E0.5 mg/kg groups (P < 0.05).

CONCLUSIONS

Androgens play an important role in the regulation of prostatic MVD in SD rats, and a decrease in DHT concentration can induce a decrease in prostatic MVD. In contrast, prostatic MVD can be increased with increasing DHT concentration. In addition, prostatic MVD can be increased gradually with increasing oestrogen concentration.

The impact of preoperative lower urinary tract symptoms medication on the functional performance of holmium laser enucleation of the prostate

Introduction

Medical treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) targets prostate size, to prevent disease progression, and prostate smooth muscle tone for rapid relieve of LUTS. Holmium laser enucleation of the prostate (HoLEP) is a size-independent method for surgical treatment of LUTS/BPO in medication-refractory patients and offers durable long-term results with reduced perioperative morbidity. As up to 50% of patients receive medical treatment for LUTS/BPO prior to surgery, we analyzed the impact of alpha-blockers and 5-alpha reductase inhibitors (5-ARI) on outcomes and perioperative morbidity in patients undergoing HoLEP for LUTS.

Material and methods

We retrospectively gathered data of 1,057 patients, who underwent HoLEP for LUTS/BPO from 2013–2018, and divided patients into group 1 (no medication), group 2 (α-blockers), and group 3 (5-ARI and α-blockers). Perioperative parameters, short-term functional outcomes and safety were assessed and statistical analysis was performed using SPSS V26.0 software.

Results

Even though preoperative LUTS profile was significantly different between groups, all patients improved significantly after HoLEP, irrespective of preoperative LUTS medication. Median improvement of IPSS was 9, 8 and 7 points, of Q_max was 10, 12 and 9.5 ml/s, with significant improvement of quality of life (QoL) and reduction of post-void residual volume (PVR) for groups 1–3, respectively, 30 days after surgery. With only 4.0% (42/1,057) of patients experiencing a Clavien-Dindo grade ≥II complication, there was no difference in prevalence of perioperative complications between groups (p = 0.943).

Conclusions

Although preoperative LUTS medication does not impair efficacy of HoLEP with acceptable perioperative morbidity, the time gap between medical therapy and surgical treatment may favor an earlier response.

Risk Factors of Emergency Room Visits for Bleeding Complications Following Transurethral Procedures in the Treatment of Benign Prostatic Hyperplasia: A Retrospective Cohort Study

Purpose

Transurethral procedures, including transurethral resection of the prostate (TURP) and laser prostatectomy, are often linked to emergency room (ER) visits for postoperative bleeding. Although some studies have been conducted, the risk factors associated with these ER visits are not completely understood. This retrospective cohort study identified potential risk factors associated with ER visits for postoperative bleeding.

Patients and Methods

Preoperative assessment data and operational and postoperational parameters recorded at Chang Gung Memorial Hospital, Taiwan between December 2015 and January 2017 for patients who underwent elective transurethral procedures were analyzed to identify potential risk factors. The primary endpoint was ER visits for gross hematuria within three months following operation, and the secondary endpoint was ER visits for blood clot-induced urinary retention (clot retention) within three months following operation.

Results

A total of 665 patients who underwent elective transurethral procedures were enrolled. The transurethral procedures included monopolar transurethral resection of the prostate (M-TURP), bipolar TURP (B-TURP), greenlight photoselective vaporization of the prostate (PVP), thulium laser enucleation of the prostate (ThuLEP) and thulium laser transurethral vaporesection of the prostate (ThuVARP). Regarding ER visits for clot retention within three months, multivariable logistic regression revealed significantly lower rates of clot retention in patients who received B-TURP than in those who underwent ThuVARP (AOR, 0.18; 95% confidence interval [CI], 0.04–0.82, p = 0.027). Moreover, significantly higher clot retention was observed in patients who underwent two or more rounds of manual irrigation (AOR, 9.51; 95% CI, 1.66–54.43, p = 0.011).

Conclusion

Multiple manual irrigations shortly after operation can be considered a novel predictor of postoperative clot retention-related ER visits. Among the transurethral procedures, ThuVARP was associated with a higher risk of clot retention-related ER visits than was B-TURP.

Surgical blood loss during holmium laser enucleation of the prostate (HoLEP) is not affected by short-term pretreatment with dutasteride: a double-blind placebo-controlled trial on prostate vascularity

Five α-reductase inhibitors (5ARIs) are able to reduce prostate volume and are a useful treatment for reducing perioperative bleeding during prostate surgery. Holmium laser enucleation of the prostate (HoLEP) is an effective surgical technique for the definitive cure of benign prostate enlargement.We investigated whether pretreatment with dutasteride before HoLEP could reduce intraoperative bleeding. A total of 402 patients were included in this double-blind placebo-controlled trial to receive daily 0.5 mg of dutasteride or placebo over 8 weeks before HoLEP. Vascular endothelial growth factor (VEGF) and microvascular density (MVD) were evaluated. Analysis was also stratified according to prostate volume (<70 mL vs ≥70 mL).Hemoglobin and hematocrit values before and after surgery were not statistically different between the two groups. MVD and VEGF index in smaller prostates were 23.35±1.96 and 4.06±0.76 in the treatment group and 19.04±0.96 and 2.55±0.55 in placebo (p<0.05); in patients with larger prostates MVD and VEGF were 26.83±2.812 and 8.54±1.18 in the treatment group and 20.76±0.79 and 3.21±0.54 in placebo (p<0.05).Vascularization of the prostate was affected by 5ARIs therapy. HoLEP is less burdened in perioperative bleeding and for this reason we did not find any difference in hemoglobin/hematocrit values pre- and post- surgery.

Complications after surgery for benign prostatic enlargement: a population-based cohort study in Ontario, Canada

OBJECTIVES

To examine the complication rates after benign prostatic enlargement (BPE) surgery and the effects of age, comorbidity and preoperative medical therapy.

DESIGN

A retrospective, population-based cohort study using linked administrative data.

SETTING

Ontario, Canada.

PARTICIPANTS

52 162 men≥66 years undergoing first BPE surgery between 1 January 2003 to 31 December 2014.

INTERVENTION

Medical therapy preoperatively and surgery for BPE.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was overall 30-day postoperative complication rates. Secondary outcomes included BPE-specific event rates (bleeding, infection, obstruction, trauma) and non-BPE specific event rates (cardiovascular, pulmonary, thromboembolic and renal). Multivariable analysis examined the association between preoperative medical therapy and postoperative complication rates.

RESULTS

The 30-day overall complication rate after BPE surgery was 2828 events/10 000 procedures and increased annually over the study period. Receipt of preoperative α-blocker monotherapy (relative rate (RR) 1.05; 95% CI 1.00 to 1.09; p=0.033) and antithrombotic medications (RR 1.27; 95% CI 1.22 to 1.31; p<0.0001) was associated with increased complication rates. Among the ≥80-year-old group, the rate of complications increased by 39% from 2003 to 2014 (RR 1.39; 95% CI 1.21 to 1.61; p<0.0001). The mean duration of medical and conservative management increased by a mean of 2.1 years between 2007 and 2014 (p<0.0001 for trend).

CONCLUSIONS

Thirty-day complication rates after BPE surgery have increased annually between 2003 and 2014. Preoperative medical therapy with alpha blockers or antithrombotics was independently associated with higher rates of complications. Over this time, the duration of conservative therapy also increased.

Factors Influencing Intraoperative Blood Loss in Patients Undergoing Holmium Laser Enucleation of the Prostate (HoLEP) for Benign Prostatic Hyperplasia: A Large Multicenter Analysis

OBJECTIVE

To assess blood loss during holmium laser enucleation of the prostate (HoLEP) and investigate the factors influencing it.

PATIENTS AND METHODS

Analysis of patients with benign prostatic hyperplasia (BPH) treated with HoLEP at 3 centers. Hemoglobin and hematocrit were measured before surgery and hospital discharge. All blood transfusions performed during and after HoLEP were recorded. Blood loss outcomes were analyzed regarding antithrombotic (antiplatelet/anticoagulant) therapies and drug treatments for BPH and other conditions.

RESULTS

The analysis included 963 patients with a mean age of 72 years. Mean (range) prostate size was 102 (40-316) g; 28% of patients were receiving antiplatelets and 11% anticoagulants. Mean (range) prostate-specific antigen was 6.0 (0.3-43.5) ng/dL. Mean (range) operation time was 77 (28-178) minutes. Bladder calculi were found in 54 (5.6%) patients; all of them were successfully treated with cystolitholapaxy. Forty-eight (5%) patients required blood transfusion during or immediately after the HoLEP procedure. Overall, mean (SD) hemoglobin decreased from 14.6 (1.5) g/dL to 12.3 (2.1) g/dL (P <.001), and mean (SD) hematocrit decreased from 44.3% (4.7) to 37.7% (6.5) (P <.001). Neither hemoglobin nor hematocrit decreases were significantly different between patients receiving and not receiving antithrombotic therapy or BPH therapy.

CONCLUSION

HoLEP is safe and has no remarkable impact on blood loss. Patients at high risk, such as those receiving antithrombotic therapy, had the same outcome than the rest regarding blood loss, although showed a higher transfusion rate. Operating time may influence hemoglobin decrease; therefore, it should be considered in patients with higher risk of bleeding.

The Utilization of Benign Prostatic Hyperplasia and Bladder-Related Medications After a Transurethral Prostatectomy

OBJECTIVE

To determine how often prostate- and bladder-specific medications for lower urinary tract symptoms are used following a transurethral prostatectomy (TURP).

METHODS

This study utilized several linked, routinely collected datasets from the province of Ontario, Canada to identify men older than 66 years who underwent their first TURP between April 2003 and March 2016. The primary outcome was the probability of using at least 30 days of either prostate-specific alpha blockers (AB), 5-alpha reductase inhibitors (5ARI), or anticholinergics/beta-3 agonists (AC/B3) after their TURP.

RESULTS

We identified 58,038 men (median age 75), with a median follow-up of 4.9 years. In the 6 months prior to their TURP, AB, 5ARIs or AC/B3 were used by 62%, 32%, and 6%, respectively. Following a 90-day washout period after TURP, these medications were used by 27%, 20%, and 15% of men, respectively. The cumulative probability of using these medications within the first 10 years after TURP was 38%, 28%, and 20%, respectively. Family physicians prescribed the majority of AB, while urologists prescribed the majority of the AC/B3. Among men on AC/B3 prior to TURP, 46% used them after TURP; in multivariate cox regression analysis age ≥75, diabetes, preoperative use of AC/B3, and no preoperative urinary retention predicted postoperative utilization of AC/B3 medications.

CONCLUSION

There is considerable use of AB and 5ARIs despite a lack of evidence for using these medications after a TURP. Given the well-characterized placebo response in BPH patients, this practice should be properly evaluated for clinical efficacy.