Anatomical endoscopic enucleation of the prostate: The next gold standard? Yes!

Evaluation of new treatments for benign prostatic obstruction: ICI-RS 2023

AIMS

To address how invasive therapies for benign prostatic obstruction (BPO) have been evaluated, what their effect is on BPO, if they can prevent progression to BPO and how new therapies need to be evaluated before implementation into clinical practice.

METHODS

The think tank conducted a literature review and looked at the previous and current American Urological Association, European Association of Urology and the International Consultation on Urological Diseases guidelines to see what procedures have been used to treat BPO. They then assessed whether trials have been conducted before implementation of the procedures and whether they have been compared to a "gold" standard treatment. The use of urodynamics has also been addressed in the think tank in relation the clinical trials as well as terminology.

RESULTS

Guidelines vary in the use of terminology when it comes to BPO with some continuing to use the term benign prostatic hyperplasia (BPH). There are several procedures for example, TUNA, which have become obsolete although continues to be mentioned in the guidelines until recently. Majority of procedures have been introduced without comparing to "gold" standard treatment and without any long-term data. There continues to be many unknowns with regard to the success of some of the BPO procedures and why some of the adverse events develop.

CONCLUSION

There needs to be more robust long-term clinical trials conducted of new BPO therapies, with men who have both lower urinary tract symptoms and urinary retention, before introduction into clinical practice.

Bicentric retrospective study comparing the postoperative outcomes of patients treated surgically for bladder stones with or without concomitant surgery for BPH

PURPOSE

To compare the postoperative outcomes of male patients who underwent bladder stone (BS) removal, with or without concomitant benign prostatic hyperplasia (BPH) surgery.

PATIENTS AND METHODS

All men aged > 50 years who underwent BS removal at two French university hospitals between 2009 and 2018 were retrospectively reviewed. Four binary outcome criteria were identified during the follow-up: early postoperative complications, stone recurrence, subsequent surgery for BS or BPH, and late surgical complications. A composite score ranging from 0 to 4 was calculated by combining the four criteria.

RESULTS

A median follow-up period of 42 months was observed in 179 patients. Of these, 107 patients were in the "concomitant surgical treatment" (CST) group and 72 in the bladder "stone removal alone" (SRA) group. The CST group presented higher baseline post-void residual volume (105 vs. 30 ml, p = 0.005). Patients who underwent CST had a significantly lower rate of BS recurrence (12% vs. 39%; p = 0,001) and underwent fewer subsequent surgeries (14% vs. 44%; p < 0.001). There was no significant difference in the early (51% vs. 35%, p = 0,168) and late (26% vs. 17%, p = 0,229) complications rates between the two groups. A better composite score was observed in the CST than in the SRA, but the difference was not significant (3.07 vs. 2.72, p = 0.078).

CONCLUSION

As CST increases morbidity and decreases the risk of reoperation, each situation should be considered, taking into account patient choice and comorbidities.

Evaluating the Impact of Benign Prostatic Hyperplasia Surgical Treatments on Sexual Health

Benign prostatic hyperplasia (BPH), a prevalent condition in older men, is often managed through various surgical interventions. This narrative review aims to explore the impact of these surgical treatments on sexual function, a critical aspect of patient quality of life often overlooked in BPH management. The methodology encompassed a thorough review of contemporary surgical techniques for BPH, including prostate resection, enucleation, vaporization, and minimally invasive therapies such as UroLift, Rezum, and Aquablation. Additionally, the focus was on patient-centered outcomes, with a special emphasis on sexual health following surgery. Findings reveal that, while surgical interventions effectively alleviate BPH symptoms, they often have significant repercussions in sexual function, including erectile and ejaculatory dysfunction. However, emerging techniques demonstrate potential in preserving sexual function, underscoring the need for patient-centric treatment approaches. The study highlights the complex interplay between BPH surgery and sexual health, with minimally invasive treatments showing promise in balancing symptom relief and sexual function preservation. In conclusion, the study advocates for an integrated, interdisciplinary approach to BPH treatment, emphasizing the importance of considering sexual health in therapeutic decision-making. This narrative review suggests a paradigm shift towards minimally invasive techniques could optimize patient outcomes, marrying symptom relief with quality-of-life considerations. The need for further research in this domain is evident, particularly in understanding long-term sexual health outcomes following different surgical interventions for BPH.

From Consensus to Validation: A Multicenter Study for Design and Development of a Holmium Laser Enucleation of the Prostate Hydrogel Simulation Platform

Background: Holmium laser enucleation of the prostate (HoLEP) has emerged as a new gold standard for treatment of benign prostatic hyperplasia; however, its steep learning curve hinders generalization of this technique. Therefore, there is a need for a benchtop HoLEP simulator to reduce this learning curve and provide training. We have developed a nonbiohazardous HoLEP simulator using modern education theory and validated it in a multicenter study. Materials and Methods: Six experts established key components for a HoLEP simulator through a Delphi consensus over three rounds including 250 questions. After consensus, a digital design was created and approved by experts, then used to fabricate a physical prototype using three-dimensional printing and hydrogel molding. After a process of iterative prototype testing, experts completed a survey assessing the simulator with a 5-point Likert scale for final approval. The approved model was validated with 56 expert and novice participants at seven institutions using subjective and objective performance metrics. Results: Consensus was reached on 85 of 250 questions, and experts found the physical model to adequately replicate 82.5% of required features. Objective metrics were statistically significant (p < 0.0001) when comparing experts and novices for enucleation time (37.4 ± 8.2 vs 16.7 ± 6.8 minutes), adenoma weight (79.6 ± 20.4 vs 36.2 ± 9.9 g), and complications (6 vs 22), respectively. Conclusion: We have effectively completed a multicenter study to develop and validate a nonbiohazardous benchtop simulator for HoLEP through modern education theory. A training curriculum including this simulator is currently under development.

Comparison of EEP and TURP long-term outcomes: systematic review and meta-analysis

OBJECTIVE

To compare long-term reoperation rate and functional outcomes between EEP (endoscopic enucleation of the prostate) and TURP (transurethral resection of the prostate).

EVIDENCE ACQUISITION

A systematic literature review of Medline, Scopus, and Web of Science was conducted with primary outcome assessed being reoperation rate and secondary outcomes after a long term (> 3 years) being functional outcomes or related values (prostate volume, PSA level, etc.).

EVIDENCE SYNTHESIS

Five studies were found with long-term follow-up 4-7 years. EEP reoperation rate ranged from 0 to 1.27%, while from 1.7 to 17.6% for TURP. Meta-analysis showed significantly lower OR for EEP, 0.27 (95% CI 0.24-0.31), with notable homogeneity of the results, I2 = 0%. Long-term Qmax and IPSS were significantly better for EEP. Qmax pooled mean difference was 1.79 (95% CI 1.72-1.86) ml/s with a high concordance among the studies, I2 = 0%. IPSS mean difference -1.24 (95% CI - 1.28 to - 1.2) points, I2 = 57% but QoL did not differ, with mean difference being 0.01 (95% CI - 0.02 to 0.04), I2 = 0%. IIEF-5 score was also significantly better for EEP, mean difference 1.08 (95% CI 1.03-1.13), but heterogeneity was high, I2 = 70%. PSA level and prostate volume were only reported in one study and favored EEP slightly yet statistically significant.

CONCLUSION

EEP had a significantly lower reoperation rate and better functional outcomes (Qmax and IPSS) at long term compared with TURP. It may also be beneficial in terms of IIEF-5, PVR, and PSA level.

Results from a global multicenter registry of 6193 patients to refine endoscopic anatomical enucleation of the prostate (REAP) by evaluating trends and outcomes and nuances of prostate enucleation in a real-world setting

PURPOSE

To collect a multicentric, global database to assess current preferences and outcomes for endoscopic enucleation of the prostate (EEP).

METHODS

Endourologists experienced in EEP from across the globe were invited to participate in the creation of this retrospective registry. Surgical procedures were performed between January 2020 and August 2022.

INCLUSION CRITERIA

lower urinary tract symptoms not responding to or worsening despite medical therapy and absolute indication for surgery.

EXCLUSION CRITERIA

prostate cancer, concomitant lower urinary tract surgery, previous prostate/urethral surgery, pelvic radiotherapy.

RESULTS

Ten centers from 7 countries, involving 13 surgeons enrolled 6193 patients. Median age was 68 [62-74] years. 2326 (37.8%) patients had large prostates (> 80 cc). The most popular energy modality was the Holmium laser. The most common technique used for enucleation was the 2-lobe (48.8%). 86.2% of the procedures were performed under spinal anesthesia. Median operation time was 67 [50-95] minutes. Median postoperative catheter time was 2 [1, 3] days. Urinary tract infections were the most reported complications (4.7%) followed by acute urinary retention (4.1%). Post-operative bleeding needing additional intervention was reported in 0.9% of cases. 3 and 12-month follow-up visits showed improvement in symptoms and micturition parameters. Only 8 patients (1.4%) required redo surgery for residual adenoma. Stress urinary incontinence was reported in 53.9% of patients and after 3 months was found to persist in 16.2% of the cohort.

CONCLUSION

Our database contributes real-world data to support EEP as a truly well-established global, safe minimally invasive intervention and provides insights for further research.

Bipolar Needlescopic Enucleation Versus Bipolar Vapoenucleation of the prostate: A prospective single Centre Randomized Study

BACKGROUND

Endoscopic enucleation of the prostate (EEP) is a safe and effective interventional option for the management of variable-sized adenomas.

PURPOSE

To point out the safety and efficacy of needlescopic enucleation of the prostate (BNEP) in comparison with vapoenucleation of the prostate (BVEP).

MATERIALS AND METHODS

This is a prospective randomized trial. In all, 214 patients with variable size adenoma were randomly assigned (1:1) to either: the BNEP group (108 patients underwent Bipolar-EEP (BEEP) using a needle electrode, or a vapoenucleation one (BVEP) group (106 patients underwent BEEP using vaporization electrodes). Intra & intergroup objective and subjective outcomes were compared at different time points for 1 year. Also, all other procedure's related events and mishaps were registered and compared.

RESULTS

The median (interquartile range (IQR)) operative time, resected tissue weight, postoperative irrigation time, and Hb drop were: 60 (50-88) Vs 80 (60 - 98) minutes, 67 (56 - 86) Vs 46 (40- 61) grams, 10 (8 - 12) Vs 12 (10 -18) hours, and 1 (0.6 - 1.3) Vs 1.2 (0.88 - 1.9) g/dl, for BNEP and BVEP groups, respectively, (P<0.05). Both subjective and objective parameters were analogously improved in the two groups (P> 0.5). However, the post-operative irritative symptoms and urinary infections were lower in BNEP group (P<0.05).

CONCLUSIONS

Our results revealed that although both BNEP and BVEP are effective and safe in the management of benign prostatic obstruction, BNEP is superior in terms of less operative time, intra-operative blood loss, irrigation time, irritative symptoms and urinary infections.

Contemporary surgical management of benign prostatic obstruction: does there remain a place in the toolbox for TURP?

Level of evidence: 5

Anatomical endoscopic enucleation of bladder outlet obstruction

Anatomical endoscopic enucleation of the prostate (AEEP) differs from other endoscopic modalities for bladder outlet obstruction (BOO) because it extracts the whole benign prostatic hyperplasia component. AEEP has been launched for almost 40 years as a first-line treatment method for BOO regardless of prostate size according to several guidelines. However, it remains underperformed worldwide. In this review article, we elaborate on the advantages and disadvantages of AEEP compared to other surgical modalities for BOO to investigate its efficacy and safety as a gold standard surgical management option for males with BOO.

A call for HoLEP: AEEP for mega-prostates (≥ 200 cc)

PURPOSE

To evaluate the efficiency and efficacy of HoLEP, and methods of tissue retrieval, in patients with prostate volume (PV) ≥ 200 cc (Group 1) and to compare these to patients with PV 80-199 cc (Group 2).

METHODS

A database of all cases performed under the care of two surgeons at a tertiary HoLEP centre was reviewed.

RESULTS

157 patients with PV ≥ 200 cc were compared to 157 of the most recent consecutive cases with PV 80-199 cc. Median (IQR) enucleation efficiency was greater in Group 1 [2.8 g/min (2.2-3.5)] than Group 2 [2.1 g/min (1.6-2.5), p < 0.001]. Morcellation efficiency did not differ significantly. Cystotomy was required for tissue retrieval in Group 1 only (5.7%). Decrease in serum haemoglobin (Hb) was greater in Group 1 (19 g/l (30-8) vs 12 (18-3.5), p < 0.001) with a transfusion rate of 4.5% vs 1.3%, respectively (p = 0.104). Length of stay was longer in Group 1 than Group 2 (1 day (1-2) vs 1 (1-1), p < 0.001). There were no significant differences between groups in: time to and success of first trial without catheter, pre- and post-operative IPSS, Qmax and PVR, and 3 month catheter-free and urinary incontinence rates.

CONCLUSION

HoLEP outcomes are largely PV-independent even when PV is ≥ 200 cc, although length of stay and reduction in Hb are greater in this group. Alternatives to pure morcellation, such as cystotomy and resection of nodules, are more likely to be necessary with PV ≥ 200 cc.

The constant search for the greater good: evolving from TURP to anatomic enucleation of the prostate is a safe bet

PURPOSE

In a troubling moment in history with an ongoing world pandemic and the impending economic crises, there is today a plethora of commercially available options for the minimally invasive treatment of BPH. New industry-driven evaluation criteria of these treatments, the logical marketing hype, a short follow-up for many of them, make challenging to interpret the role they will finally adopt in the armamentarium to treat BPH.

METHOD

The author comments on recently published literature based in own experience and insight.

RESULTS AND CONCLUSIONS

In this situation, choosing to evolve from TURP to the next step of endoscopic treatment, the size-independent anatomic endoscopic enucleation of the prostate is a safe bet. It is now exceedingly feasible when the paradigm of AEEP has changed, due to better learning opportunities and technological and surgical technique modifications that have refined this procedure significantly since its inception.