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Yilmaz M, Karaaslan M, Polat ME, Tonyali S, Aybal HÇ, Şirin ME, Toprak T, Tunç L, Gratzke C, Miernik A. Is day-case surgery feasible for laser endoscopic enucleation of the prostate? A systematic review. World J Urol 2023; 41:2949-2958. [PMID: 37689604 PMCID: PMC10632304 DOI: 10.1007/s00345-023-04594-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 08/23/2023] [Indexed: 09/11/2023] Open
Abstract
PURPOSE Laser endoscopic enucleation of the prostate (EEP) for benign prostatic obstruction has become increasingly prevalent worldwide. Considering the medical cost-savings and concomitantly fewer nosocomial infections, the feasibility of same-day postoperative discharge of patients who have undergone laser EEP in terms of its safety and effectiveness has become a subject matter of growing interest. We aimed to review those studies focussing on day-case surgery (DCS) in patients undergoing laser EEP. METHODS A systematic search was conducted using PubMed-MEDLINE and Web of Science databases until October 2022 with the following search terms: "same day discharge AND laser enucleation of the prostate", "day-case AND laser enucleation of the prostate", "same day surgery AND laser enucleation of the prostate" and "one day surgery AND laser enucleation of the prostate" by combining PICO (population, intervention, comparison, outcome) terms. We identified 15 eligible studies. RESULTS While 14 of the studies focussed on holmium laser EEP, one focused on thulium laser vapoenucleation of the prostate. We observed an improvement in functional parameters in all studies we reviewed, and DCS success and readmission rates ranged between 35.3-100% and 0-17.8%, respectively. The complication rates varied between 0 and 36.7%, most of the complicatons were Clavien-Dindo (CD) I and II. CD ≥ III complications did not significantly differ between same day discharge (SDD) and non-SDD groups in the studies. CONCLUSION Laser EEP is feasible and promising DCS treatment option delivering improved functional parameters compared to baseline values, and lower perioperative complication and readmission rates in certain patients.
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Affiliation(s)
- Mehmet Yilmaz
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
| | | | - Muhammed Emin Polat
- Department of Urology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Senol Tonyali
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Urology, Istanbul University Istanbul School of Medicine, Istanbul, Turkey
| | | | - Mehmet Emin Şirin
- Department of Urology, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Tuncay Toprak
- Department of Urology, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Lütfi Tunç
- Faculty of Medicine, Department of Urology, Gazi University, Ankara, Turkey
| | - Christian Gratzke
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Arkadiusz Miernik
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany.
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Ayoub CH, Haber R, Amine R, Mikati D, Mahfoud ZR, El Hajj A. Comparison of Postoperative Outcomes of Trans-urethral Resection of the Prostate, Laser Vaporization, and Laser Enucleation: A Double Propensity Score Matched Analysis. Urology 2023; 177:148-155. [PMID: 37182649 DOI: 10.1016/j.urology.2023.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To compare postoperative outcomes of 3 types of endourologic surgeries (trans-urethral resection of the prostate [TURP], laser vaporization [LVP], and laser enucleation [LEP]) for benign prostatic hypertrophy (BPH) treatment using the ACS-NSQIP database. METHODS The ACS-NSQIP database was queried for men who underwent TURP, PVP, and LEP for treatment of BPH from 2011 till 2019. Demographics, clinical, operative characteristics, and 30-day outcomes were compared. Univariate and multivariate regression models were constructed. Propensity score matching was then performed as a sensitivity analysis. RESULTS A total of 74,273 patients underwent endourologic surgeries for BPH, 65.4% had TURP, 28.6% PVP, and 5.9% LEP. Patients undergoing TURP were more likely to be older with higher ASA class, abnormal labs, and comorbidities (diabetic, congestive heart failure, and bleeding requiring transfusion) (P-value <.001). After adjusting for covariates and propensity score matching, LVP demonstrated shorter hospital stays, shorter operative times, less reoperation rates, decreased DVT/PE risk, with, however, higher odds of urinary tract infection and sepsis as compared to TURP (P-value<.028). Furthermore, LEP was found to have shorter hospital stays, longer operative times, and decreased odds of urinary tract infections and sepsis as compared to TURP (P-value<.006). CONCLUSION LVP and LEP showed better surgical outcomes and characteristics as compared to TURP. Further research is needed to account for longer duration of follow-up and patient-specific urologic outcomes, such as prostate size, urinary incontinence, erectile dysfunction, and retrograde ejaculation.
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Affiliation(s)
- Christian Habib Ayoub
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Rachelle Haber
- Department of Internal Medicine, Division of Endocrinology, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Reem Amine
- Department of Ophthalmology, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Diana Mikati
- Salim El-Hoss Bioethics & Professionalism Program, American University of Beirut Medical Center, Beirut, Lebanon.
| | | | - Albert El Hajj
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, Lebanon.
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Luu T, Gonzalez RR. Residency Surgical BPH Training Paradigms from MIST to HOLEP. Curr Urol Rep 2023; 24:261-269. [PMID: 36947390 DOI: 10.1007/s11934-023-01153-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE OF REVIEW Benign prostatic hyperplasia (BPH) is a common medical condition of older men that often requires medical or surgical therapy. Surgical options for BPH have grown exponentially over the last two decades. The numerous options and/or lack of access to them can make it challenging for new trainees to gain proficiency. We examine the literature for available BPH surgical simulators, learning curves, and training pathways. RECENT FINDINGS Each BPH surgical therapy has a learning curve which must be overcome. There is an abundance of TURP simulators which have shown face, content, and construct validity in the literature. Similarly, laser therapies have validated simulators. Newer technologies do have available simulators, but they have not been validated. There are strategies to improve learning and outcomes, such as having a structured training program. Simulators are available for BPH surgical procedures and some have been implemented in urology residencies. It is likely that such simulation may make urologists more facile on their learning curves for newer technologies. Further studies are needed. Future directions may include integration of simulator technology into training pathways that include surgical observation and proctorship.
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Affiliation(s)
- Thaiphi Luu
- Department of Urology, Scurlock Tower, Houston Methodist Hospital, Suite 2100, 6560 Fannin St, Houston, TX, 77030, USA.
| | - Ricardo R Gonzalez
- Department of Urology, Scurlock Tower, Houston Methodist Hospital, Suite 2100, 6560 Fannin St, Houston, TX, 77030, USA
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Grosso AA, Di Maida F, Nardoni S, Salvi M, Giudici S, Lambertini L, Cadenar A, Tellini R, Cocci A, Mari A, Minervini A, Tuccio A. Patterns and Predictors of Optimal Surgical and Functional Outcomes after Holmium Laser Enucleation of the Prostate (HoLEP): Introducing the Concept of "Trifecta". World J Mens Health 2023:41.e6. [PMID: 36593708 DOI: 10.5534/wjmh.220042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/23/2022] [Accepted: 06/07/2022] [Indexed: 01/03/2023] Open
Abstract
PURPOSE The present study sought to provide reproducible and patient-oriented metrics to assess the rate of "successful" outcomes (Trifecta) following holmium laser enucleation of the prostate (HoLEP). Clinical and surgical predictors of failure to achieve Trifecta were investigated. MATERIALS AND METHODS We queried our prospectively collected database of all patients treated with HoLEP between March 2017 and January 2021. Trifecta was defined as the contemporary presence of: (1) no postoperative complication within 3 months; (2) no urinary incontinence at 3-months follow-up; and (3) 3-month postoperative max flow-rate >15 mL/s. Cases were grouped according to Trifecta achievement. All surgical procedures were carried out by a single surgeon. Surgical experience was divided into two different eras according to the number of procedures conducted (surgical era). Multivariate logistic regression analysis was performed to assess predictors of Trifecta failure. RESULTS Overall 305 patients were included. Of these, 192 patients (63.0%) achieved Trifecta. Preoperative patient-related features were comparable between the two groups, except for a higher post-void residual (PVR) in non-Trifecta patients (median 180 vs. 130 mL, p=0.003). A significant proportion of Trifecta patients (88.5%) were treated in the second surgical era and in 126 (65.6%) cases an en-bloc enucleation was performed. Multivariate analysis confirmed PVR ≥250 mL, first surgical era and standard three-lobes enucleation technique as independent predictors of Trifecta failure. CONCLUSIONS In our experience the rate of "successful" HoLEP, defined according to our newly introduced Trifecta metric, was 63.0%. We demonstrated that surgical strategy together with rising experience and baseline PVR are key elements to forecast the outcomes.
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Affiliation(s)
- Antonio Andrea Grosso
- Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Fabrizio Di Maida
- Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Samuele Nardoni
- Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Matteo Salvi
- Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Sofia Giudici
- Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Luca Lambertini
- Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Anna Cadenar
- Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Riccardo Tellini
- Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Andrea Cocci
- Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Andrea Mari
- Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Andrea Minervini
- Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Agostino Tuccio
- Department of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy.
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Learning curve in aquablation: an international multicenter study. World J Urol 2022; 40:773-779. [PMID: 34988648 DOI: 10.1007/s00345-021-03898-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES To describe and analyze the learning curve (LC) of aquablation for the treatment of benign prostatic obstruction and determine the number of cases needed to achieve acceptable surgical safety, efficiency, and efficacy. METHODS A retrospective analysis of prospectively maintained aquablation databases from France, Lebanon, and Spain was conducted. The combined LC of three surgeons was defined by trifecta and pentafecta outcomes. Trifecta reflected efficiency and safety: operative time < 60 min, hemoglobin reduction ≤ 2 mg/dL, and no 90 day Clavien-Dindo grade ≥ 2 complications. Pentafecta reflected effectiveness: percent reduction in International Prostate Symptom Score (IPSS) and ejaculation preservation. The combined LC was plotted using a moving average with polynomial fitting. RESULTS The cohort included 175 consecutive patients. Median (IQR) prostate volume was 70 (50-91) cc, and baseline IPSS was 23 (18-27). The achievement of trifecta exceeded 50% after 4 cases, and 70% after 50 cases. Pentafecta achievement exceeded 50% after 38 cases. Logistic regression showed significant improvement in hemoglobin reduction and ejaculation preservation. Grade ≥ 2 complication was not affected by experience, and neither was 3 month %IPSS reduction as 94% of patients showed ≥ 50% symptoms' improvement. CONCLUSION Aquablation is associated with a quick learning curve for the defined trifecta and pentafecta outcomes. It provided effective LUTS relief and low complication rates independent of surgeon experience. Hemoglobin drop and ejaculatory function preservation were the two factors influenced by the surgeons' LC. Training to reduce operative time, standardization of hemostasis techniques, and early assistance to improve veru-protection zone planning are keys to quicker learning.
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Kim TH, Song PH. Anatomical endoscopic enucleation of bladder outlet obstruction. Yeungnam Univ J Med 2021; 39:12-17. [PMID: 34749443 PMCID: PMC8895962 DOI: 10.12701/yujm.2021.01522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/18/2021] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Tae Hyo Kim
- Department of Urology, College of Medicine, Dong-A University, Busan, Korea
| | - Phil Hyun Song
- Department of Urology, Yeungnam University College of Medicine, Daegu, Korea
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7
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Ferrari G, Rabito S, Gatti L, Ntep NN, Vitelli FD, Marchioni M, Rocco BM, Micali S, Ferrari R, Cindolo L. Green Light laser enucleation of the prostate with early apical release is safe and effective: single center experience and revision of the literature. Minerva Urol Nephrol 2021; 74:467-474. [PMID: 33781016 DOI: 10.23736/s2724-6051.21.04145-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Green Light laser enucleation of the prostate (GreenLEP) is an endoscopic treatment to treat bladder outlet obstruction in men with large prostate (>100 cc). Herein, we describe our GreenLEP series and describe its safety and efficacy. METHODS Between February 2014 and April 2019, 120 patients from a single center underwent en-bloc GreenLEP with early apical release. All procedures were performed with the AMS XPS laser generator (set: 120 W for vaporization and 20 W for coagulation). Morcellation was carried out with the Wolf Piranha morcellator. Data concerning the pre-, intra- and postoperative outcomes were prospectively collected. The follow-up data at 6, 12 months and at the last control were collected. RESULTS The median age was 66.0 (IQR: 61.0-71.0) years; 37.5% of the patients were under antiplatelet/anticoagulant therapy, 15.0% had indwelling catheter history. The median prostate volume and the baseline PSA value were 98.5ml (IQR 83.0-130.0) and 4.2ng/ml (IQR: 3.2-6.8), respectively. The median operative and lasing time were 65.0 (IQR: 51.0-83.5) and 6.0 (IQR: 6.0-10.0) minutes, respectively. In the post-operative period 1 patient was transfused. The median follow-up was 18.0 (IQR: 12.0-39.5) months. All patients had significant improvement in terms of improvement of uroflowmetry [median from 9ml/sec (IQR 7.8, 11.0) to 20.0 (IQR 18.0, 22.0), p <0.001] and symptoms control [IPSS median score from 26.0ml/sec (IQR 22.0, 28.0) to 7.0 (IQR 6.0, 8.0), p <0.001]) over time. After 12 months 1 patient complained of stress incontinence (1 pad/day) and 1 of "de novo" wet urgency. CONCLUSIONS En-bloc GreenLEP with early apical release is a safe and effective procedure even for large volume prostates. It allows us to limit the use of laser energy and shorten the operating times with stable and satisfactory long-term outcomes.
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Affiliation(s)
- Giovanni Ferrari
- Department of Urology, CURE Group, Hesperia Hospital, Modena, Italy
| | - Salvatore Rabito
- Department of Urology, CURE Group, Hesperia Hospital, Modena, Italy - .,Department of Urology, Nuovo Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Lorenzo Gatti
- Department of Urology, CURE Group, Hesperia Hospital, Modena, Italy
| | - Nicolas N Ntep
- Department of Urology, CURE Group, Hesperia Hospital, Modena, Italy
| | | | - Michele Marchioni
- Urology Unit, Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University of Chieti, Chieti, Italy
| | - Bernardo M Rocco
- Department of Urology, Nuovo Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Salvatore Micali
- Department of Urology, Nuovo Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Riccardo Ferrari
- Department of Urology, Nuovo Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Luca Cindolo
- Department of Urology, CURE Group, Hesperia Hospital, Modena, Italy.,Department of Urology, Villa Stuart Private Hospital, Rome, Italy
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Gasmi A, Khene ZE, Guérin S, Bensalah K, Peyronnet B, Mathieu R, Roupret M, Rijo E, Pradère B, Misrai V. Propensity-score analysis comparing perioperative and functional outcomes between XPS 180 W-photovaporization and GreenLight laser enucleation of the prostate: reasons to discard vaporization and move to enucleation. World J Urol 2021; 39:2269-2276. [PMID: 33590278 DOI: 10.1007/s00345-021-03590-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/06/2021] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To compare the perioperative and functional outcomes between 180_W XPS GreenLight photoselective vaporization (PVP) and 532-nm GreenLight laser enucleation of the prostate (GreenLEP) in the surgical management of benign prostatic obstruction (BPO). METHODS Retrospective review of a prospectively maintained international database of patients managed with GreenLight laser surgery (PVP or GreenLEP) was performed. To adjust for potential baseline confounders, propensity-score matching (PSM) was applied at a ratio of 1:1 to compare the perioperative and functional outcomes between the groups. RESULTS A total of 2,420 patients were included. 1,491 (61.6%) underwent PVP and 929 (38.4%) underwent GreenLEP. Before PSM analysis, patients in the vaporization group were older (p < 0.001), had a lower PSA and prostate volume at baseline (p < 0.001). Using estimated propensity scores, 78 patients in the PVP group were matched 1:1 to the patients in the GreenLEP group. The incidence of overall postoperative complications was comparable between the two groups (19 vs. 16%, p = 0.06). However, after PSM, PVP was found to be associated with a higher rate of overall complications (33 vs. 11%, p = 0.001). At 3 months and at last follow-up the I-PSS, Qmax and PSA had similarly decreased in the two groups with a greater improvement in the GreenLEP group (all p < 0.05). CONCLUSIONS PVP and GreenLEP are two efficient and safe techniques for treating BPO. However, PVP was associated with longer operative time and higher risk of reoperation on a midterm follow-up compared to GreenLEP.
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Affiliation(s)
- Anis Gasmi
- Department of Urology, Rennes University Hospital, Rennes, France
| | | | - Sonia Guérin
- Department of Urology, Rennes University Hospital, Rennes, France
| | - Karim Bensalah
- Department of Urology, Rennes University Hospital, Rennes, France
| | - Benoit Peyronnet
- Department of Urology, Rennes University Hospital, Rennes, France
| | - Romain Mathieu
- Department of Urology, Rennes University Hospital, Rennes, France
| | - Morgan Roupret
- Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France
| | - Enrique Rijo
- Department of Urology, Hospital Quiron Barcelona, Barcelona, Spain
| | - Benjamin Pradère
- Department of Urology, Rennes University Hospital, Rennes, France
| | - Vincent Misrai
- Department of Urology, Clinique Pasteur, 45 Avenue de Lombez, 31300, Toulouse, France.
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9
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Lebdai S, Chevrot A, Doizi S, Pradère B, Barry Delongchamps N, Baumert H, Benchikh A, Della Negra E, Fourmarier M, Gas J, Misraï V, Rouscoff Y, Theveniaud PE, Vincendeau S, Wilisch J, Descazeaud A, Robert G. [Surgical and interventional management of benign prostatic obstruction: Guidelines from the Committee for Male Voiding Disorders of the French Urology Association]. Prog Urol 2021; 31:249-265. [PMID: 33478868 DOI: 10.1016/j.purol.2020.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/24/2020] [Accepted: 12/04/2020] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- S Lebdai
- Service d'urologie, CHU d'Angers, Angers, France.
| | - A Chevrot
- Service d'urologie, CHU de Nîmes, Nîmes, France
| | - S Doizi
- Service d'urologie, hôpital européen Georges-Pompidou, Paris, France
| | - B Pradère
- Service d'urologie, CHU de Tours, Tours, France
| | | | - H Baumert
- Service d'urologie, hôpital Ambroise-Paré, Paris, France
| | - A Benchikh
- Service d'urologie, Clinique les Martinets, Versailles, France
| | - E Della Negra
- Service d'urologie, hôpital des Côtes d'Armor, Saint-Brieuc, France
| | - M Fourmarier
- Service d'urologie, hôpital Aix-en-Provence, Aix-en-Provence, France
| | - J Gas
- Service d'urologie, CHU de Toulouse, Toulouse, France
| | - V Misraï
- Service d'urologie, clinique Pasteur, Toulouse, France
| | - Y Rouscoff
- Service d'urologie, polyclinique Saint-Georges, Nice, France
| | - P E Theveniaud
- Service d'urologie, CHR de Metz Thionville, Metz, France
| | - S Vincendeau
- Service d'urologie, CHU de Rennes, Rennes, France
| | - J Wilisch
- Service d'urologie, hôpital privé Natecia, Lyon, France
| | - A Descazeaud
- Service d'urologie, CHU de Limoges, Limoges, France
| | - G Robert
- Service d'urologie, CHU de Bordeaux, Bordeaux, France
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10
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Systematic review of the endoscopic enucleation of the prostate learning curve. World J Urol 2020; 39:2427-2438. [PMID: 32940737 DOI: 10.1007/s00345-020-03451-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 09/07/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION It has been shown that endoscopic enucleation of the prostate (EEP) allows for similar efficacy and safety, no matter what energy and type of instruments we use, but the length of learning may differ greatly. The aim of this systematic review is to verify if there is any significant difference between EEP methods in learning. EVIDENCE ACQUISITION We performed a systematic literature search in three databases and included only the articles containing their own data on the EEP learning curve assessment during the last 10 years. The primary endpoint was to determine the necessary experience needed to achieve a plateau. The secondary endpoints were to review methods used to evaluate a learning curve. EVIDENCE SYNTHESIS The final sample included 17 articles, containing a total of 4615 EEPs performed by 76 surgeons, the most common method was HoLEP (9/17). The majority of articles studying HoLEP report a learning curve of experience level achievement in roughly 30-40 (min 20; max 60) cases. The studies of GreenLight laser showed high heterogeneity in the results with minimum of 20 cases and maximum of 150-200 cases. TUEB required roughly 40-50 cases to reach the plateau. CONCLUSION Although EEP is considered challenging, it shows a steep learning curve with a plateau after 30-50 cases. Proper criteria are critical for accurate assessment of the learning curve. The Trifecta and Pentafecta criteria are currently the most appropriate method to evaluate EEP learning.
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Rijo E, Misrai V. En bloc GreenLight laser enucleation of the prostate (GreenLEP): An in-depth look at the anatomical endoscopic enucleation of the prostate using a 532-nm lithium triborate laser. Andrologia 2020; 52:e13729. [PMID: 32662906 DOI: 10.1111/and.13729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 12/12/2022] Open
Abstract
GreenLight laser enucleation of the prostate (GreenLEP) is an alternative endoscopic enucleation of the prostate (EEP) technique for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). GreenLEP is an 'en bloc' EEP technique to remove the transitional zone tissue in one piece. The procedure is a combination of laser enucleation and blunt gentle mechanical dissection using the tip of the resectoscope. The advantage of mechanical dissection is that it allows for better visualisation of the capsule and in some cases makes the dissection a little faster. This procedure is performed with a 532-nm lithium triborate laser (GreenLight™ XPS 180 W generator, AMS), a 2090 side-firing fibre and a Piranha™ morcellator (Richard Wolf GmbH). We offer a review of the evolution of the technique including the most important technical aspects, complications, advantages/disadvantages, tips and tricks and a visual step by step guide to perform the GreenLEP technique. GreenLEP is one of the latest energy sources reported in the armamentarium of EEP techniques for the treatment of BPO. GreenLEP has previously demonstrated its feasibility, safety and similar short- to mid-term functional outcomes compared to surgical gold standards in the literature.
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Affiliation(s)
- Enrique Rijo
- Department of Urology, Hospital Quiron Barcelona, Barcelona, Spain
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12
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Dornbier R, Pahouja G, Branch J, McVary KT. The New American Urological Association Benign Prostatic Hyperplasia Clinical Guidelines: 2019 Update. Curr Urol Rep 2020; 21:32. [PMID: 32607874 DOI: 10.1007/s11934-020-00985-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Ryan Dornbier
- Center for Male Health, Department of Urology, Stritch School of Medicine, Loyola University Medical Center, 2160 S. First Ave., Maywood, IL, 60153, USA.
| | - Gaurav Pahouja
- Center for Male Health, Department of Urology, Stritch School of Medicine, Loyola University Medical Center, 2160 S. First Ave., Maywood, IL, 60153, USA
| | - Jeffrey Branch
- Center for Male Health, Department of Urology, Stritch School of Medicine, Loyola University Medical Center, 2160 S. First Ave., Maywood, IL, 60153, USA
| | - Kevin T McVary
- Center for Male Health, Department of Urology, Stritch School of Medicine, Loyola University Medical Center, 2160 S. First Ave., Maywood, IL, 60153, USA
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13
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Wroclawski ML, Teles SB, Carneiro A. Anatomical endoscopic enucleation of the prostate: The next gold standard? No! (or not yet!). Andrologia 2020; 52:e13707. [PMID: 32559344 DOI: 10.1111/and.13707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/15/2020] [Indexed: 12/13/2022] Open
Abstract
Most cases of lower urinary tract symptoms due to benign prostatic hyperplasia are initially managed through medical therapy. In cases that surgery is indicated, the anatomical endoscopic enucleation of the prostate (aEEP), first described in 1983, allegedly presents the same safety profile as the best endoscopic non-enucleating procedures and the same long-term functional outcomes as simple prostatectomy. Thus, why aEEP has not yet been consolidated as the gold-standard BPH surgical treatment? The main reasons are as follows: (a) Multiple energy sources and techniques; (b) High costs; (c) Steep learning curve; (d) Rare in-residency training; (e) Reimbursement issues; (f) Outcomes and (g) Complications. We do believe aEEP is an important advance and a "practice-changing" procedure that will play an important role in the BPH surgical options arsenal, especially for larger prostates. However, there is a need to start an in-residency training program, with a mentor guidance, and, over time, the cost will likely be reduced due to greater competition between companies and greater support from health insurers. Considering these points, in the future, EEP may be considered the gold-standard treatment for BPH… but not yet.
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Affiliation(s)
- Marcelo Langer Wroclawski
- Hospital Israelita Albert Einstein, São Paulo, Brazil.,BP - a Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | | | - Arie Carneiro
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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14
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Tuccio A, Sessa F, Campi R, Grosso AA, Viola L, Muto G, Scoffone C, Cracco CM, Gómez-Sancha F, Misrai V, Muto G, Mari A, Di Maida F, Tellini R, Figueiredo F, Carini M, Oriti R, Amparore D, Fiori C, Porpiglia F, Minervini A. En-bloc endoscopic enucleation of the prostate: a systematic review of the literature. MINERVA UROL NEFROL 2020; 72:292-312. [PMID: 32026670 DOI: 10.23736/s0393-2249.20.03706-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Transurethral resection of the prostate (TURP) remains the gold standard for treatment of benign prostatic hyperplasia (BPH). Yet, the introduction of lasers for the treatment of LUTS due to BPO has dramatically changed the surgical landscape of benign prostatic obstruction (BPO) treatment. Recently, "en-bloc" techniques have shown to prove advantageous in terms of better visualization, more prompt identification of the surgical capsule and the correct plane to dissect. Herein we provide a comprehensive overview of available series of en-bloc enucleation of the prostate, focusing on surgical techniques, perioperative and functional outcomes. EVIDENCE ACQUISITION A systematic review of the literature was performed according to PRISMA recommendations and was conducted on surgical techniques and perioperative outcomes of minimally invasive en-bloc surgery for prostate adenoma detachment. EVIDENCE SYNTHESIS Overall, 16 studies with 2750 patients between 2003 and 2019 were included. Specific technical nuances have been described to maximize perioperative outcomes of en-bloc prostatic enucleation, including early apical release, horse-shape incisions, inverted U-shape tractions and low power. Overall, regardless of the energy employed, en-bloc prostatic enucleation achieved favorable outcomes including low risk of major complications and quality of life improvement. However, a great heterogeneity of study design, patients' inclusion criteria, prostate volume and en-bloc surgical strategy was found. CONCLUSIONS En-bloc endoscopic enucleation of the prostate has been shown to be technically feasible and safe, with potential technical advantages over the classic three-lobe technique. Larger comparative studies are needed to evaluate the ultimate impact of the en-bloc approach on postoperative outcomes, in light of the surgeon's learning curve.
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Affiliation(s)
- Agostino Tuccio
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy -
| | - Francesco Sessa
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Riccardo Campi
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Antonio A Grosso
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Lorenzo Viola
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Gianluca Muto
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | | | | | | | - Vincent Misrai
- Department of Urology, Clinique Pasteur, Toulouse, France
| | - Giovanni Muto
- Department of Urology, Humanitas Gradenigo University, Turin, Italy
| | - Andrea Mari
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Fabrizio Di Maida
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Riccardo Tellini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Marco Carini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Rino Oriti
- Department of Urology, Ulivella e Glicini Clinic, Florence, Italy
| | - Daniele Amparore
- Department of Urology, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
| | - Cristian Fiori
- Department of Urology, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
| | - Francesco Porpiglia
- Department of Urology, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
| | - Andrea Minervini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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15
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Misrai V, Rijo E, Zorn KC, Barry-Delongchamps N, Descazeaud A. Reply to Francesco Montorsi, Paolo Capogrosso, Andrea Salonia's Letter to the Editor re: Vincent Misrai, Enrique Rijo, Kevin C. Zorn, Nicolas Barry-Delongchamps, Aurélien Descazeaud. Waterjet Ablation Therapy for Treating Benign Prostatic Obstruction in Patients with Small- to Medium-size Glands: 12-month Results of the First French Aquablation Clinical Registry. Eur Urol 2019;76:667-75. Surgery for Benign Prostatic Enlargement: Water Keeps Flowing Under the Bridge but Are Things Changing?: Aquablation: One Small Step for Benign Prostatic Hyperplasia, One Giant Leap for Surgical Standardization. Eur Urol 2019; 77:e19-e20. [PMID: 31563502 DOI: 10.1016/j.eururo.2019.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 09/10/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Vincent Misrai
- Department of Urology, Clinique Pasteur, Toulouse, France.
| | - Enrique Rijo
- Department of Urology, Hospital Quirón Salud, Barcelona, Spain
| | - Kevin C Zorn
- Brunswick Science and Technology, Montreal, Canada
| | | | - Aurélien Descazeaud
- Department of Urology, Dupuytren Hospital, University of Limoges, Limoges, France
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