Comparison Between Minimally Invasive Simple Prostatectomy and Open Simple Prostatectomy for Large Prostates: A Systematic Review and Meta-Analysis of Comparative Trials

Robotic assisted simple prostatectomy mitigates perioperative morbidity compared to open simple prostatectomy - a single institution report

BACKGROUND

According to the guidelines of the European Association of Urology, open simple prostatectomy should be offered to men with a prostate size exceeding 80 mL suffering from moderate to severe LUTS in the absence of a transurethral enucleation technique. However, open simple prostatectomy is associated with complications such as bleeding, blood transfusions and increased length of stay compared to minimally invasive procedures. The aim of the study was to compare perioperative data from the first cases of robotic assisted simple prostatectomy (RASP) to that of patients subjected to open simple prostatectomy (OSP) at our department.

METHODS

The patients were identified by a search for the respective procedure codes. In the OSP group enucleation of the adenoma was performed through the prostatic capsule (Millin procedure), while access to the adenoma was gained through the bladder in the RASP group. Complications were scored according to the Clavien-Dindo classification system.

RESULTS

27 patients who underwent OSP were retrospectively identified and compared to the first 26 patients who were subjected to RASP. The groups were similar with respect to age, body mass index and ASA score. Operative time was significantly shorter in the OSP group compared to the RASP group. Bleeding volume, drop in postoperative hemoglobin and the number of blood transfusions were all significantly higher in the OSP group compared to the RASP group. Average length of stay was 5.5 (2-18) days in the OSP group compared to 1.6 (1-5) days in the RASP group (p < 0.001). The number of postoperative complications, Clavien-Dindo ≥ 2, were significantly higher in the OSP group (11) compared to the RASP group (none, p < 0.001).

CONCLUSIONS

The introduction of robotic assisted simple prostatectomy reduced perioperative morbidity at our department.

Prostate volume on computed tomography correlates well with magnetic resonance imaging measurements and is reproducible across rater training levels

BACKGROUND

Data are lacking for the accuracy of computed tomography (CT) in measuring prostate size, which can streamline care and prevent invasive procedures. We evaluate agreement and intra/inter-observer variability in prostate sizing between CT and magnetic resonance imaging (MRI) planimetry for a wide range of gland sizes.

METHODS

We retrospectively reviewed 700 patients who underwent MRI fusion biopsy at a single institution and identified 89 patients that had a CT within 2 years of the MRI. Six reviewers from different training levels were categorized as student, resident, or attending and each measured prostate size on CT by the prolate ellipse method. Bland-Altman analysis determined the degree of agreement between CT and MRI. Inter- and intra-observer reliability was calculated for CT.

RESULTS

Mean CT volume was higher than MRI volume in the < 60 g group (51.5 g vs. 44.5 g, p = 0.004), but not in the ≥ 60 g group (101 g vs. 100 g, p = 0.458). The bias for overestimation of prostate volume by CT was 4.1 g across prostate volumes, but the proportional agreement between modalities improved with size. The Pearson correlation coefficient between CT/MRI and inter/intra-rater reliability for CT increased in the ≥ 60 g vs. the < 60 g group for all training levels.

CONCLUSIONS

Our data show that there is greater clinical utility for prostate size estimation by CT than previously established, particularly for larger glands where accurate size estimation may influence therapeutic decisions. In larger glands, prostate size estimation by CT is also reproducible across various training levels.

Urethral Sparing versus Trans-Vesical Robot-Assisted Simple Prostatectomy: A Comparative Analysis of Perioperative, Postoperative Outcomes, and Ejaculation Preservation

PURPOSE

To compare the perioperative and postoperative outcomes between traditional trans-vesical robot-assisted simple prostatectomy (TV-RASP) and the newly introduced urethral-sparing (US) RASP.

MATERIALS AND METHODS

We retrospectively reviewed 42 patients who underwent TV-RASP (n=22) or US-RASP (n=20) performed by two experienced surgeons at two tertiary centers. Perioperative outcomes including operation time, estimated blood loss, length of hospital stay, and catheterization time were assessed. Postoperative outcomes were evaluated using the International Prostate Symptom Score (IPSS), quality of life (QoL), uroflowmetry parameters, Male Sexual Health Questionnaire-Ejaculation Dysfunction-Short Form (MSHQ-EjD-SF) scores, and maintenance of anterograde ejaculation.

RESULTS

This study analyzed 22 and 20 patients who underwent TV-RASP and US-RASP, respectively. Except for the TV-RASP group being older (70.0 years) than the US-RASP group (64.5 years) (p=0.028), no differences among other baseline characteristics existed. Perioperative outcomes indicated that hospital stay and catheterization time were significantly shorter in the US-RASP group than in the TV-RASP group (p<0.001). At postoperative month 1, the median IPSS and QoL scores were significantly better in the US-RASP group than in the TV-RASP group (p=0.001 and p=0.002, respectively). However, at months 6 and 12, no significant differences were noted in IPSS, QoL, maximum flow rate, and postvoid residual urine between the two groups. Sexually active patients in the US-RASP group maintained postoperative MSHQ-EjD functional and bother scores, whereas the TV-RASP group experienced a decline. Notably, 75.0% of patients in the US-RASP group preserved antegrade ejaculation, compared to only 20.0% in the TV-RASP group (p<0.001).

CONCLUSIONS

US-RASP is not inferior to TV-RASP in terms of functional outcomes. In addition, US-RASP yielded more rapid symptom improvements and preserved antegrade ejaculation than TV-RASP. However, larger prospective studies are required to confirm these findings and to further investigate the long-term efficacy and safety of US-RASP.

Safety and complications of continuation of aspirin therapy in patients undergoing robot-assisted laparoscopic simple prostatectomy

To evaluate the safety and feasibility of continued perioperative aspirin at the time of robotic assisted simple prostatectomy (RASP). We performed a retrospective review of our IRB approved institutional database of patients who underwent RASP between 2013 and 2022. Comparative groups included patients taking aspirin in the perioperative period and those not taking aspirin pre-operatively. The primary outcome was any post-operative bleeding related complication using the modified Clavien-Dindo classification. Secondary outcomes included the identification of risk factors for increased blood loss in the entire study population, operative time, and blood transfusion requirement. 143 patients underwent RASP of which 55 (38.5%) patients continued perioperative aspirin therapy and 88 (61.5%) patients did not. Baseline demographics were similar between groups. Patients taking perioperative aspirin had a higher rate of hypertension (74.5% vs 58.0%, p = 0.04) and other cardiovascular disease (30.9% vs 11.4%, p = 0.007). Postoperative complications were similar between the groups (Clavien-Dindo ≥ 3; p = 0.43). Median blood loss (150 cc vs 150 cc, p = 0.38), percentage drop in hemoglobin (13.4 vs 13.2, p = 0.94) and blood transfusion rate (3.6 vs 1.1, p = 0.56) were also similar between groups. The median blood loss was 150 ml for the whole study population. On regression analysis, neither aspirin nor any other variable was associated with increased blood loss (> 150 ml). Aspirin can be safely continued perioperatively in patients undergoing RASP without any risk of bleeding related complications, blood loss, or increased transfusion rate.

Quality of life after robotic versus conventional minimally invasive cancer surgery: a systematic review and meta-analysis

Optimizing postoperative quality of life (QoL) is an essential aspect of surgical oncology. Minimally invasive surgery (MIS) decreases surgical morbidity and improves QoL outcomes. This meta-analysis aimed to compare post-operative QoL after oncologic resections using different MIS modalities. The PubMed, Embase, Scopus, and CENTRAL databases were searched for articles that compared post-operative QoL in patients undergoing video-assisted thoracoscopic (VATS) or laparoscopic surgery (LS) versus robotic surgery (RS) for malignancy. Quality assessment was performed using the ROBINS-I and Cochrane Risk of Bias 2 (RoB-2) tools. Meta-analysis was performed using an inverse-variance random effects model. 27 studies met the inclusion criteria, including 5 randomized controlled trials (RCTs). 15 studies had a low risk of bias, while 11 had a moderate risk of bias and 1 had serious risk of bias. 8330 patients (RS: 5090, LS/VATS: 3240) from across 25 studies were included in the meta-analysis. Global QoL was significantly better after robotic surgery in the pooled analysis overall (SMD: - 0.28 [95% CI: - 0.49, - 0.08]), as well as in the prostatectomy and gastrectomy subgroups. GRADE certainty of evidence was low. Analysis of EPIC-26 subdomains also suggested greater sexual function after robotic versus laparoscopic prostatectomy. Robotic and conventional MIS approaches produce similar postoperative QoL after oncologic surgery for various tumor types, although advantages may emerge in some patient populations. Our results may assist surgeons in counseling patients who are undergoing oncologic surgery.

[Surgical treatment options of lower urinary tract symptoms due to benign prostatic obstruction : The German S2e guideline 2023-part 3]

BACKGROUND

Lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) are one of the most common diagnoses in clinical practice. Bothersome LUTS impact considerably quality of life of men and may cause severe complications without treatment. According to the diagnostic assessment every patient should be treated with an adequate therapy. Management comprises a conservative approach, medication, novel minimally invasive options, and surgical procedures with the aim to remove the obstructing adenoma. The German guideline panel has updated the German guidelines on diagnostic evaluation and management of LUTS due to BPO.

OBJECTIVES

Evidence-based recommendations of surgical treatment options of LUTS due to BPO are evaluated.

MATERIALS AND METHODS

Chapters 11.1.1 and 11.2 of the updated German S2e guideline on the management of LUTS due to BPO are summarized as a review article.

RESULTS

A treatment algorithm based on current evidence has been proposed. It is considered to provide guidance for the selection of the best procedure according to the needs of the patient. Anatomic features of the prostate, the patients' morbidity, and the preservation of ejaculatory function are taken into account for the choice of the best procedures. These surgical options can be divided into techniques with direct, delayed or no removal of the adenoma, procedures with suprapubic access, and embolizing approaches.

CONCLUSIONS

The updated German S2e guideline on the management of LUTS due to BPO provides evidence-based recommendations for the selection of the best procedure according to the needs of the individual patient.

Treatment Algorithm for Management of Benign Prostatic Obstruction: An Overview of Current Techniques

The management of benign prostatic obstruction (BPO) should involve a treatment algorithm that takes into account prostate size, and patient's symptoms and preference with the aim of helping with urinary symptoms and enhance quality of life. The diagnostic assessment for men with lower urinary tract symptoms (LUTS) should be comprehensive to help choose the best management strategy. Strategies from lifestyle modifications to medical treatment with alpha blockers and/or 5-alpha-reductase inhibitors to surgical procedures can all be used in the management algorithm. Surgical management ranges from transurethral resection of prostate (TURP) to minimally invasive surgical therapies (MIST) including laser therapies such as Holmium laser enucleation (HoLEP) and photoselective vaporisation (PVP), aquablation, Rezūm system, prostate artery embolisation (PAE), prostatic urethral lift (PUL), temporary implantable nitinol device (iTind) and Optilume BPH catheter system. BPO is a common urological condition that has a significant impact on quality of life and economic burden globally and is likely to become increasingly prevalent with an ageing population. Selecting the most appropriate treatment modality will depend on the individual patient preferences, availability of resources, cost, anatomical factors and the goals of treatment.

Robotic assisted simple prostatectomy versus other treatment modalities for large benign prostatic hyperplasia: a systematic review and meta-analysis of over 6500 cases

BACKGROUND

Current guidelines recommend simple prostatectomy or endoscopic enucleation of the prostate (EEP) as treatment of choice for bladder prostatic obstruction (BPO) caused by large prostate glands. We aimed to provide a wide-ranging analysis of the currently available evidence, comparing safety and effectiveness of robot-assisted simple prostatectomy (RASP) versus open simple prostatectomy (OSP), laparoscopic simple prostatectomy (LSP), and laser EEP.

METHODS

A systematic search was performed across MEDLINE, EMBASE, and Web of Science databases for retrospective and prospective studies comparing RASP to OSP or LSP or laser EEP (HoLEP/ThuLEP). Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) recommendations were followed to design the search strategies, selection criteria, and evidence report. A meta-analysis evaluated perioperative safety and effectiveness outcomes. The weighted mean difference and risk ratio were used to compare continuous and dichotomous variables, respectively. Quality was assessed using the Newcastle-Ottawa scale and the Cochrane Collaboration's tool for RCT article assessing risk of bias.

RESULTS

15 studies, including 6659 patients, were selected for meta-analysis: 13 observational studies, 1 non-randomized prospective study, and 1 randomized controlled trial. RASP was associated with statistically significant longer operative time (OT) and lower postoperative complication rate, length of stay (LOS), estimated blood loss (EBL), and transfusion rate (TR) compared to OSP. LSP showed longer LOS and lower postoperative SHIM score, with no difference in OT, EBL, and complications. Compared to laser EEP, RASP presented longer LOS and catheterization time and higher TR. ThuLEP presented shorter OT than RASP. No difference were found in functional outcomes between groups both subjectively (IPSS, QoL) and objectively (Qmax, PVR).

CONCLUSION

RASP has become a size-independent treatment for the management of BPO caused by a large prostate gland. It can duplicate the functional outcomes of OSP while offering a better safety profile. When compared to LSP, the latter still stands as a valid lower-cost option, but it requires solid laparoscopic skill sets and therefore it is unlikely to spread on larger scale. When compared to laser EEP, RASP offers a shorter learning curve, but it still suffers from longer catheterization time and LOS.

Outcomes of Robotic Simple Prostatectomy After Prior Failed Endoscopic Treatment of Benign Prostatic Hyperplasia

BACKGROUND

We compared outcomes of robotic simple prostatectomy (RASP) in patients with and without a history of prior prostate surgery for management of symptomatic benign prostatic hyperplasia.

METHODS

We retrospectively reviewed our multi-institutional database for all consecutive patients who underwent RASP between 05/2013 and 01/2021. Postoperatively, urinary function was assessed using the American Urological Association Symptom Score (AUASS) and Quality of Life (QOL) score.

RESULTS

Overall, 520 patients met inclusion criteria. Among the 87 (16.7%) patients who underwent prior prostate surgery, 49 (56.3%), 26 (29.9%), 8 (9.2%), 3 (3.4%) and 1 (1.1%) patients underwent transurethral resection of the prostate, photoselective vaporization of the prostate, transurethral microwave therapy, prostatic urethral lift or water vapor thermal therapy, respectively. There was no difference in mean prostate volume (p=0.40), estimated blood loss (p=0.32), robotic console time (p=0.86) or major 30-day postoperative (Clavien>2) complications (p=0.80) between both groups. With regards to urinary function, the mean improvement in preoperative and postoperative AUASS (p=0.31), QOL scores (p=0.11) and continence rates were similar between both groups.

CONCLUSION

For management of patients with BPH and LUTS, RASP is associated with an improvement in urinary function outcomes and a low risk of postoperative complications. Perioperative outcomes of RASP are similar in patients who underwent prior prostate surgery versus those that did not undergo prior prostate surgery.

Comparison of Cost and Perioperative Outcomes Among Patients Undergoing Simple Prostatectomy and Laser Enucleation of the Prostate

Introduction: Simple prostatectomy (SP) and laser enucleation of the prostate (LEP) are treatments for symptomatic benign prostatic hyperplasia (BPH) in men with large glands (e.g., >80 g). The decision between the two operations is often dependent on surgeon preference/experience and equipment availability. As the use of minimally invasive techniques, such as robotic-assisted simple prostatectomy, has increased for the treatment of large gland BPH, studies comparing the outcomes and cost of these modalities in a contemporary cohort are lacking. Methods: All-payer data from Healthcare Cost and Utilization Project State Databases from Florida, New York, California, and Maryland from 2016 to 2018 were used to identify adults who underwent SP or LEP for BPH. Patient demographics, facility characteristics, revisit rates, and cost of the index hospitalization were examined. Multivariable logistic and gamma generalized linear regression models were utilized to compare predictors of the operation performed, 30-day revisits, and index hospitalization cost among the two operations. Results: Of the 2032 patients in the cohort, 1067 (46.4%) underwent LEP and 965 (41.9%) underwent SP. On multivariable logistic regression analysis, SP patients were younger, had higher comorbidity scores, and were more likely to be uninsured compared with LEP patients. Thirty-day revisit rates among the operations were equivalent (odds ratio 0.89, 95% confidence interval 0.63-1.27, p = 0.05). The mean adjusted cost of the index hospital stay for LEP was significantly greater than that of SP ($7291 vs $6442, p = 0.04). However, our sub-group analysis examining high-volume centers revealed no significant differences in cost ($6184 vs $5353, p = 0.1). Conclusions: Across the four states examined, SP and LEP were performed with comparable volume and had similar rates of 30-day revisits. The SP was less expensive than LEP overall; however, among high-volume facilities, the cost of both operations was reduced, such that they were equivalent.

Laparoscopic simple prostatectomy versus robot-assisted simple prostatectomy for large benign prostatic hyperplasia: a systematic review and meta-analysis of comparative trials

Laparoscopic simple prostatectomy (LSP) and robot-assisted simple prostatectomy (RASP) are important approaches for large benign prostatic hyperplasia (BPH), though it is still unclear which is superior. This study aimed to perform a pooled analysis to compare the safety and efficacy profiles of LSP and RASP. We systematically searched the databases of Science, PubMed, Embase, Web of Science, and Cochrane Library database for randomized controlled trials (RCTs) and non-RCTs, comparing LSP to RASP. The principal outcomes included perioperative, functional and complications variables. The results are presented as odds ratio (OR) or weighted mean difference (WMD) with 95% confidence intervals (CI) of dichotomous and continuous variables. Five comparative trials involving 1928 patients were included. RASP demonstrated a shorter length of hospital stay compared to LSP (WMD 1.20 days, 95% CI 0.09, 2.32; p = 0.03). However, there was no difference between the two groups regarding operative time, estimated blood loss, catheterization time and complications. Moreover, RASP had a higher maximum flow rate (Q_max) (WMD - 2.15 mL/s, 95% CI - 3.75, - 0.55; p = 0.0009) and comparable international prostate symptom score (IPSS) and sexual health inventory (SHIM) in men with LSP. The results of this study demonstrated that RASP offered comparable efficacy and safety to LSP, while maintaining a superior perioperative and functional profile. However, treatment selection should also be based on the availability and experience of the operator.

Evaluating Surgical Outcomes of Robot Assisted Simple Prostatectomy in the Retreatment Setting

OBJECTIVE

To report perioperative and postoperative outcomes in men who undergo salvage RASP (sRASP) following some other endoscopic outlet procedure for benign prostate enlargement (BPE) compared to those undergoing RASP for primary treatment (pRASP).

METHODS

A prospectively maintained database consisting of all RASP surgeries (December 2014 - October 2019) performed at our institution by three different urologists was used. Patients who had received an endoscopic procedure for BPE prior to their RASP (sRASP) were compared to those who had not had a prior outlet procedure (pRASP).

RESULTS

In total, 310 men underwent RASP during the study period. Of those, 30 (9.7%) had undergone an endoscopic procedure prior to surgery. There were no significant differences in age, race, ASA, BMI, prostate volume, PSA or rates of preoperative retention (p>0.05 for all). Men who were treatment-naive had significantly higher preoperative International Prostate Symptom Scores (IPSS) than men who had a prior procedure (18.3 ±7.7 vs. 13.6 ±6.2, p=0.008). However, there were no significant differences in functional or quality of life outcomes between the two groups (p>0.05 for all). There were no significant differences in perioperative or post-operative outcomes between the two groups. Furthermore, rates of post-operative complications and incontinence were similar between groups (11% vs. 10%, p=0.9 and 2% vs. 0%, p=1 respectively).

CONCLUSION

Performing a RASP after prior endoscopic procedure for BPE was found to be safe and effective. Success and complication rates were similar to patients with no prior procedures.

Minimally invasive simple prostatectomy: Robotic-assisted versus laparoscopy. A comparative study

PURPOSE

Robotic-assisted simple prostatectomy (RASP) is a novel surgical procedure for the management of obstructive symptoms caused by enlarged prostate glands. Before the introduction of minimally invasive techniques, the standard approach was the open simple prostatectomy (OSP). The aim of our study was to compare intraoperative and perioperative outcomes of robotic (RASP) and laparoscopic (LSP) simple prostatectomy.

METHODS

We retrospectively analyzed data from patients who underwent minimally invasive simple prostatectomy at the Urological Department of Portogruaro Hospital, Portogruaro, and at the Urological Department of "San Bassiano" Hospital, in Bassano del Grappa, from March 2015 to December 2020. Data collected from medical records included age, body mass index, prostate volume, operative time, preoperative International Prostatic Symptoms Score (IPSS), postoperative IPSS, time with drainage, blood transfusion, intraoperative complications, perioperative complications and length of hospital stay.

RESULTS

Robotic-assisted (n = 25) and laparoscopic simple prostatectomy (n = 25) were performed with a transvesical approach. No significant differences were observed regarding baseline characteristics, body mass index, prostate volume and IPSS. Operative time was lower in the laparoscopic group (122 min vs 139 min) (p = 0.024), while hospital stay was lower in the robotic group (4 days vs 6 days) (p = 0.047).

CONCLUSIONS

Robotic-assisted simple prostatectomy is a safe technique with results comparable to laparoscopic simple prostatectomy, encompassing the advantage of a shorter hospitalization. Considering the costs and the limited availability of robotic-assisted simple prostatectomy, laparoscopic simple prostatectomy is a valid and safe alternative for experienced surgeons.

Comparison on the Efficacy and Safety of Different Surgical Treatments for Benign Prostatic Hyperplasia With Volume >60 mL: A Systematic Review and Bayesian Network Meta-Analysis of Randomized Controlled Trials

The objective of this study was to compare the efficacy and safety of 10 different surgical treatments for benign prostatic hyperplasia (BPH) with volume >60 mL. A systematic literature review and network meta-analysis of randomized controlled trials (RCTs) within a Bayesian framework was performed. A total of 52 parallel-group RCTs included, reporting on 6,947 participants, comparing open prostatectomy (OP), monopolar/bipolar transurethral resection of prostate (monopolar/ bipolar TURP), thulium, holmium and diode laser enucleation of prostate (LEP), bipolar enucleation of prostate, potassium titanyl phosphate laser vaporization of prostate (KTP LVP), bipolar vaporization of prostate (bipolar VP), and laparoscopic simple prostatectomy (laparoscope SP). Compared with OP, laparoscope SP identified better maximal flow rate (Qmax; mean differences [MDs] = 2.89 mL/s) at the 24th month, but bipolar VP demonstrated worse Qmax (MD = −3.20 mL/s) and International Prostate Symptom Score (IPSS; MD = 2.60) at the 12th month. Holmium LEP (MD = 1.37) demonstrated better International Index of Erectile Function–5 at the 12th month compared with OP. However, compared with OP, KTP LVP demonstrated worse postvoid residual volume (PVR) at the sixth (MD = 10.42 mL) and 12th month (MD = 5.89 mL) and monopolar TURP (MD = 6.9 mL) demonstrated worse PVR at the 12th month. Eight new surgical methods for BPH with volume >60 mL appeared to be superior in safety compared with OP and monopolar TURP due to fewer complications. Bipolar VP and KTP LVP maybe not suitable for prostates more than 60 mL due to short- and middle-term worse Qmax, IPSS, and PVR than OP.

Comparison of the Efficacy and Safety of Minimally Invasive Simple Prostatectomy and Endoscopic Enucleation of Prostate for Large Benign Prostatic Hyperplasia

Background: Minimally invasive simple prostatectomy (MISP) and endoscopic enucleation of the prostate (EEP) are the two most commonly used methods for large benign prostatic hyperplasia (BPH), but it remains unclear which of the two is superior. This study aims to perform a pooled analysis to compare efficacy and safety profiles between MISP and EEP.

Methods: We conducted a comprehensive search of PubMed, Embase, Web of Science, and ClinicalTrials.gov databases to identify eligible studies comparing MISP with EEP. Parameters including efficacy and safety outcomes were compared using Stata 14.0 version.

Results: Eight comparative trials with 1,504 patients were included. Compared to MISP, EEP demonstrated shorter operative time (mean difference [MD] 46.37, 95% confidence interval [CI] 19.92 to 72.82, p = 0.0006), lesser hemoglobin decrease (standardized MD [SMD] 0.59, 95% CI 0.23 to 0.95, p = 0.001), lower catheterization time (SMD 4.13, 95% CI 2.16 to 6.10, p < 0.001), and shorter length of stay (SMD 2.38, 95% CI 1.40 to 3.36, p < 0.001). However, overall complications and blood transfusions did not differ between the two groups. Moreover, EEP had better postvoid residual volume (PVR) at 6-month (MD 14.39, 95% CI 11.06 to 17.72, p < 0.001) and comparable 3- and 6-month International Prostate Symptom Score, 3- and 6-month maximum flow rate, 3-month PVR, and 3-month quality of life compared with MISP.

Conclusion: Both MISP and EEP are effective and safe surgical procedures for the treatment of large BPH. EEP appears to have a superior perioperative profile compared to MISP. This should be interpreted with caution due to the significant heterogeneity between studies. Hence, treatment selection should be based on the surgeon's experience and availability.

The place of robotic-assisted laparoscopy for BPO surgical management in 2021

PURPOSE OF REVIEW

Robot-assisted laparoscopic simple prostatectomy (RASP) is being used increasingly for the surgical treatment of benign prostatic obstruction (BPO). Our purpose is to review the main outcomes of RASP for the management of BPO.

RECENT FINDINGS

A computerised bibliographic search of Medline was performed for articles that included detailed results of RASP, published over the past 2 years. Although RASP seems to be associated with better perioperative and functional outcomes, this procedure remains expensive when compared to open or endoscopic surgery. However, considering the enhanced safety of RASP compared to open simple prostatectomy and its favourable learning-curve when compared to endoscopic laser enucleation, RASP seems to be a good and effective option in centres with extended robotic expertise. Single-port robotic surgery appeared to be safe and effective in two preliminary studies. Other studies reported interesting and improved results for the preservation of ejaculatory function.

SUMMARY

Many RASP techniques have been developed, with the common goal of improving the quality of life of patients. Although the cost of RASP is higher than open surgery, the perioperative benefits of the robotic approach make RASP a favourable option in centres with extended robotic expertise.

Robotic-Assisted vs. Open Simple Prostatectomy for Large Prostates: A Meta-Analysis

Purpose: To compare the efficacy and safety of robotic-assisted simple prostatectomy and open simple prostatectomy for large benign prostatic hyperplasia. Methods: We systematically searched the Cochrane Library, PubMed, Embase, and Science databases for studies published through December 2020. Controlled trials on RASP and OSP for large prostates were included. The meta-analysis was conducted with the Review Manager 5.4 software. Results: A total of seven studies with 3,777 patients were included in the analysis. There were no significant differences in IPSS (WMD, 0.72; 95%CI: -0.31, 1.76; P = 0.17), QoL (WMD, 0.00; 95%CI: -0.39, 0.39; P > 0.99), Qmax (WMD, 1.88; 95% CI: -1.15, 4.91; P = 0.22), or PVR (WMD, -10.48; 95%CI: -25.13, 4.17; P = 0.16) among patients undergoing RASP and OSP. However, compared with patients who underwent OSP, patients who underwent RASP had a shorter LOS (WMD, -2.83; 95%CI: -3.68, -1.98; P < 0.001), less EBL (WMD, -304.68; 95% CI: -432.91, -176.44; P < 0.001), a shorter CT (WMD, -2.61; 95%CI: -3.94, -1.29; P < 0.001), and fewer overall complications (OR, 0.30; 95% CI: 0.16, 0.57; P < 0.001). Nevertheless, RASP was associated with a longer OT (WMD, 59.69, 95% CI: 49.40, 69.98; P < 0.001). Conclusion: The results of the current study demonstrated that RASP provided similar efficacy to those of OSP in the treatment of large prostate, while maintaining better security. Our findings indicate that RASP is a feasible and effective alternative to OSP.

[Surgical and interventional management of benign prostatic obstruction: Guidelines from the Committee for Male Voiding Disorders of the French Urology Association]

OBJECTIVE

The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO).

METHODS

All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions.

RESULTS/GUIDELINES

Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm³, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm³. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm³. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm³ without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols.

CONCLUSION

Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.

Holmium Laser Enucleation, Laparoscopic Simple Prostatectomy, or Open Prostatectomy: The Role of the Prostate Volume in terms of Operation Time

INTRODUCTION

To compare the prostate removal speeds of 3 enucleation techniques and to evaluate how the operating times change depending on the prostate volume.

METHODS

Medical records of patients with 80-g or larger prostates who underwent holmium laser enucleation of the prostate (HoLEP), laparoscopic simple prostatectomy (LSP), or open prostatectomy (OP) due to medical treatment-resistant benign prostatic hyperplasia (BPH) were reviewed retrospectively. Patients were classified into 3 groups according to the surgical procedure. Age, BMI, prostate weights, total operation times, prostate removal speeds, hospitalization and catheterization days, complications, and improvements on functional outcomes in the 3rd month of follow-up were compared between groups. In addition, the association between prostate weight and total operation time was analyzed for each group.

RESULTS

HoLEP, LSP, and OP groups consisted of 60, 61, and 37 patients, respectively. While HoLEP was similar to OP in terms of prostate removal speed and total operation time, LSP was statistically slower and required more operation time than HoLEP and OP. There was a relationship between prostate weight and total operation time only in HoLEP.

CONCLUSION

LSP, one of the enucleation techniques in the treatment of large prostates, was slower and required more operation time than HoLEP and OP in terms of total operation time and prostate removal speed. HoLEP seems going to be the fastest candidate for the rapid removal of large prostates in the future.

Perioperative outcomes and cost of robotic vs open simple prostatectomy in the modern robotic era: results from the National Inpatient Sample

OBJECTIVES

To perform a comparative analysis of perioperative outcomes and hospitalisation cost between open (OSP) and robot-assisted simple prostatectomy (RASP) for treatment of benign prostatic hyperplasia (BPH) using the National Inpatient Sample (NIS) in the contemporary robotic era.

MATERIALS AND METHODS

The NIS was queried for cases of OSP and RASP for the treatment of BPH between 2013 and 2016. Perioperative complications, unadjusted hospital cost and length of stay (LOS) were compared between RASP and OSP. Smoothed linear regression curves comparing hospitalisation cost by increasing LOS was stratified by surgical approach to identify point of cost equivalency between RASP and OSP. Multivariable linear regression analysis was used to construct a hospitalisation cost model to examine the contribution of the robotic approach and LOS to hospitalisation cost.

RESULTS

The total analytical cohort included 2551 OSP and 704 RASP procedures. Patients undergoing RASP were younger, at a median (interquartile range [IQR]) age of 68 (63-73) vs 71 (65-77) years, and with less comorbidity (76.8% vs 86.5%, P < 0.01). RASP was associated with fewer total complications (11.1% vs 29.2%, P < 0.01) and a greater likelihood of routine discharge to home rather than another facility (88.9% vs 76.7%, P < 0.01). While LOS was shorter with RASP (median [IQR], 2 [1-3] vs 4 [3-6] days, P < 0.01), total unadjusted hospitalisation cost (in United States dollars) was greater (median [IQR], $10 855 [$7965-$15 675] vs $13 467 [$10 572-$17 722], P < 0.01). Presence of any complication increased both LOS and hospitalisation cost (P < 0.01). Linear regression modelling determined the point of cost equivalence between RASP staying a median of 2 days was an OSP case staying between 5 and 6 days. On multivariable regression analysis, the robotic approach contributed an additional $6175 (P < 0.01) to the cost model, whereas each additional day of hospitalisation contributed $1687 (P < 0.01), suggesting LOS would need to be 3-4 days shorter with RASP to offset surgical costs of the robot.

CONCLUSIONS

While RASP appears to have significantly better perioperative complication rates with shorter LOS and likely discharge to home, total hospitalisation cost remained greater, likely related to upfront operative costs. While this retrospective study is limited by selection bias for patients undergoing RASP, the benefits of improved convalescence, discharge to home, and lower rate of perioperative complications appear to justify performance of RASP in an experienced pelvic robotic centre despite relatively greater hospitalisation cost if referral to an experienced holmium laser enucleation of the prostate centre is not feasible.

The New American Urological Association Benign Prostatic Hyperplasia Clinical Guidelines: 2019 Update

PURPOSE OF REVIEW

The goal of this paper was to analyze the efficacy of the current modalities available to surgically treat lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH).

RECENT FINDINGS

There have been significant surgical advancements for the treatment of BPH, including an increasing development and utilization of minimally invasive surgical techniques (MISTs). These procedures have varying outcomes that are critical to understand. In addition, MISTs have important adverse effects, though have minimized effects on sexual function when compared to more invasive surgical techniques. It is important for all urologists to be familiar with the surgical techniques available to treat BPH and the updated American Urological Association (AUA) Guidelines. Further studies evaluating efficacy, safety, and sexual functioning will help guide care in the future and evolve practice.

Robotic-Assisted Simple Prostatectomy: A Systematic Review

Contemporary minimally invasive surgical (MIS) treatment options of patients with male Lower Urinary Tract Symptoms (LUTS) in men with prostate glands >80 mL include Holmium Laser Enucleation Prostate (HoLEP), Thulium laser VapoEnucleation Prostate (ThuVEP), and Laparoscopic (LSP) or Robotic-Assisted Simple Prostatectomy (RASP). Implementing new laser technologies is costly, and the steep learning curve of these laser techniques limit their wide range use. This promoted the use of LSP and RASP in centers with readily established laparoscopy or robotic surgery programs. The aim of this study is to review case and comparative series of RASP. We systematically reviewed published data from 2008 to 2020 on RASP and have identified 26 non-comparative and 9 comparative case series. RASP has longer operation time but less time spent in hospital and less blood loss. The outcomes of improvements in symptom score, post-voiding residual urine (PVR), postoperative PSA decline, complications, and cost are similar when compared to open and laser enucleation techniques. These outcomes position RASP as a viable MIS treatment option for patients with male LUTS needing surgical treatment for enlarged prostates. Nevertheless, prospective, randomized controlled trials (RCTs) with multicenter and large sample size are needed to confirm the findings of this systematic review.

Modified simple prostatectomy: an approach to address large volume BPH and associated prostate cancers

Simple prostatectomy is an option for management of patients with enlarged prostates and obstructive symptoms. However, the guidelines still do not state a gold-standard treatment for men with BPH and some of these patients with BPH are also known to harbor prostate cancer. This issue can be a challenge because, in the traditional simple prostatectomy, the prostate capsule is often left in place, and that is usually the area of the prostate cancers. With the robotic approach, our goal is to analyze the outcomes of modified simple prostatectomy (MSP) by the elimination of the entire prostate tissue. Thirty-four patients underwent MSP for BPH diagnosis. We evaluated the pre- and postoperative clinical characteristics as well as pathological data. MSP was performed using the DaVinci Xi robot; the entire prostate was removed. We performed a full nerve sparing bilaterally with an intrafascial plane dissection, minimal apical dissection, seminal vesicles sparing, and full vesicourethral anastomosis. The pre- and postoperative AUA scores were compared on paired T test. The mean operative time and blood loss were 126 min and 160.5 ml, respectively. The final pathology report described 17 patients (50%) with BPH and 17 (50%) with BPH and prostate adenocarcinoma. After surgery, 97% had an AUA score improvement. Regarding the patients with a prostate cancer diagnosis, 97% had PSA lower than 0.01 ng/ml. Modified simple prostatectomy is an acceptable treatment option for men with BPH. The procedure allows for significant symptom relief and removal of chronic catheters. Our modified approach was able to eliminate the entire prostate, which was significant because 50% of these patients had prostate cancer on the final pathology.