Transurethral resection of prostate with plasmakinetic energy: 100 months results of a prospective randomized trial

Reoperation after surgical treatment for benign prostatic hyperplasia: a systematic review

Context

Surgical treatment is important for male lower urinary tract symptom (LUTS) management, but there are few reviews of the risks of reoperation.

Objective

To systematically evaluate the current evidence regarding the reoperation rates of surgical treatment for LUTS in accordance with current recommendations and guidelines.

Evidence acquisition

Eligible studies published up to July 2023, were searched for in the PubMed® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), and Web of Science™ (Clarivate™, Philadelphia, PA, USA) databases. STATA® (StataCorp LP, College Station, TX, USA) software was used to conduct the meta-analysis. Random-effects models were used to calculate the pooled incidences (PIs) of reoperation and the 95% confidence intervals (CIs).

Evidence synthesis

A total of 119 studies with 130,106 patients were included. The reoperation rate of transurethral resection of the prostate (TURP) at 1, 2, 3, and 5 years was 4.0%, 5.0%, 6.0%, and 7.7%, respectively. The reoperation rate of plasma kinetic loop resection of the prostate (PKRP) at 1, 2, 3, and 5 years was 3.5%, 3.6%, 5.7%, and 6.6%, respectively. The reoperation rate of holmium laser enucleation of the prostate (HoLEP) at 1, 2, 3, and 5 years was 2.4%, 3.3%, 5.4%, and 6.6%, respectively. The reoperation rate of photoselective vaporization of the prostate (PVP) at 1, 2, 3, and 5 years was 3.3%, 4.1%, 6.7%, and 7.1%, respectively. The reoperation rate of surgery with AquaBeam® at 1, 2, 3, and 5 years was 2.6%, 3.1%, 3.0%, and 4.1%, respectively. The reoperation rate of prostatic artery embolization (PAE) at 1, 2, 3, and 5 years was 12.2%, 20.0%, 26.4%, and 23.8%, respectively. The reoperation rate of transurethral microwave thermotherapy (TUMT) at 1, 2, 3, and 5 years was 9.9%, 19.9%, 23.3%, and 31.2%, respectively. The reoperation rate of transurethral incision of the prostate (TUIP) at 5 years was 13.4%. The reoperation rate of open prostatectomy (OP) at 1 and 5 years was 1.3% and 4.4%, respectively. The reoperation rate of thulium laser enucleation of the prostate (ThuLEP) at 1, 2, and 5 years was 3.7%, 7.7%, and 8.4%, respectively.

Conclusion

Our results summarized the reoperation rates of 10 surgical procedures over follow-up durations of 1, 2, 3, and 5 years, which could provide reference for urologists and LUTS patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023445780.

Greenlight laser (XPS-180watt) prostatectomy for treatment of benign prostate obstruction, Pursuit of durability

Objectives

To report 5-year outcomes, need and predictors of retreatment post greenlight laser photoselective vaporization (GL.PVP) and vapo-enucleation (GL.PVEP), as long-term data on safety and efficacy of GL.PVP and GL.PVEP and on the prostate using XPSTM system are still pending.

Patients and methods

Primary outcome was the need for retreatment (medical treatment and reintervention) for recurrent BOO. Time-to-event (retreatment) analysis, perioperative events, change in the urinary outcome measures at different follow-up visits, early and late complications and PSA kinetics were reported.

Results

Between September 2014 and April 2017, 248 patients underwent GL/XPS procedures. GL.PVP and GL.PVEP were carried out for 157 (63.3%) and 91 (36.7%) patients with mean prostate sizes of 60 ± 18 and 100 ± 22 cc, respectively. After a mean duration of 62 ± 9-month follow-up, overall retreatment rate (medical and interventional) was 23% (57 patients). It was comparable between both GL.PVP and GL.PVEP cases: 38 (24.2%) and 19 (20.9%) patients, P = 0.5, respectively. Significantly more surgical reintervention rate was reported after GL.PVP compared to GL.PVEP (P = 0.03). In retreatment group, more intraoperative bleeding (P = 0.02), early postoperative hematuria (P = 0.03), higher median preoperative PSA (P = 0.02) and less postoperative one-year percent PSA reduction (P = 0.02) were detected. Lower postoperative one-year percent PSA reduction independently predicts retreatment with a cut-off point of 64.2% (58.2% sensitivity, 73.4% specificity, AUC 0.647, 95% CI 0.52-0.76).Median (range in months) time to event was 20 (1-60) for all cases and 13.5 (1-42) and 30 (18-60), P = 0.7, for GL.PVP and GL.PVEP groups, respectively.

Conclusion

Greenlight laser XPS is an effective, durable and versatile tool in treating benign prostatic obstruction. Durability of the outcome is predictable with more postoperative PSA reduction.

Bipolar Plasma Enucleation of the Prostate: 5 Years Outcomes

Background: Aim of our study is to assess outcomes and safety of button bipola transurethral enucleation of the prostate (B-TUEP) in patients with lower urinary tract symptoms (LUTS) caused by benign prostatic enlargement (BPE) in a single-center cohort study. Materials and Methods: All patients with LUTS caused by BPE undergoing button B-TUEP between May 2012 and December 2013 were prospectively enrolled in our study. Data on clinical history, physical examination, urinary symptoms, erectile function, uroflowmetry, and prostate volume were collected at 0, 1, 3, 6, 12, 24, 36, 48, and 60 months. Early and long-term complications were recorded. Results: Overall 50 patients were enrolled at baseline. Nine patients were excluded during the 5 years. All patients completed the procedure without severe complications. In terms of outcomes, improvement in International Prostate Symptom Score (IPSS) were sustained for all 5 years and mean difference from baseline at 5 years was 17 points. As well, improvements in Q_max (maximum urinary flow rate) were sustained for all 5 years and mean improvement at 5 years was 16 mL/second. Erectile function was slightly improved after surgery and maintained for the following 5 years. Conclusions: Our single-center study suggests that B-TUEP may have excellent outcomes at 5 years with no recurrence. Further multicentre studies should confirm our results.

Bipolar versus monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction

BACKGROUND

Transurethral resection of the prostate (TURP) is a well-established surgical method for treatment of men with lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). This has traditionally been provided as monopolar TURP (MTURP), but morbidity associated with MTURP has led to the introduction of other surgical techniques. In bipolar TURP (BTURP), energy is confined between electrodes at the site of the resectoscope, allowing the use of physiological irrigation medium. There remains uncertainty regarding differences between these surgical methods in terms of patient outcomes.

OBJECTIVES

To compare the effects of bipolar and monopolar TURP.

SEARCH METHODS

A comprehensive systematic electronic literature search was carried out up to 19 March 2019 via CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, PubMed, and WHO ICTRP. Handsearching of abstract proceedings of major urological conferences and of reference lists of included trials, systematic reviews, and health technology assessment reports was undertaken to identify other potentially eligible studies. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared monopolar and bipolar TURP in men (> 18 years) for management of LUTS secondary to BPO.

DATA COLLECTION AND ANALYSIS

Two independent review authors screened the literature, extracted data, and assessed eligible RCTs for risk of bias. Statistical analyses were undertaken according to the statistical guidelines presented in the Cochrane Handbook for Systematic Reviews of Interventions. The quality of evidence (QoE) was rated according to the GRADE approach.

MAIN RESULTS

A total of 59 RCTs with 8924 participants were included. The mean age of included participants ranged from 59.0 to 74.1 years. Mean prostate volume ranged from 39 mL to 82.6 mL. Primary outcomes BTURP probably results in little to no difference in urological symptoms, as measured by the International Prostate Symptom Score (IPSS) at 12 months on a scale of 0 to 35, with higher scores reflecting worse symptoms (mean difference (MD) -0.24, 95% confidence interval (CI) -0.39 to -0.09; participants = 2531; RCTs = 16; I² = 0%; moderate certainty of evidence (CoE), downgraded for study limitations), compared to MTURP. BTURP probably results in little to no difference in bother, as measured by health-related quality of life (HRQoL) score at 12 months on a scale of 0 to 6, with higher scores reflecting greater bother (MD -0.12, 95% CI -0.25 to 0.02; participants = 2004; RCTs = 11; I² = 53%; moderate CoE, downgraded for study limitations), compared to MTURP. BTURP probably reduces transurethral resection (TUR) syndrome events slightly (risk ratio (RR) 0.17, 95% CI 0.09 to 0.30; participants = 6745; RCTs = 44; I² = 0%; moderate CoE, downgraded for study limitations), compared to MTURP. This corresponds to 20 fewer TUR syndrome events per 1000 participants (95% CI 22 fewer to 17 fewer). Secondary outcomes BTURP may carry a similar risk of urinary incontinence at 12 months (RR 0.20, 95% CI 0.01 to 4.06; participants = 751; RCTs = 4; I² = 0%; low CoE, downgraded for study limitations and imprecision), compared to MTURP. This corresponds to four fewer events of urinary incontinence per 1000 participants (95% CI five fewer to 16 more). BTURP probably slightly reduces blood transfusions (RR 0.42, 95% CI 0.30 to 0.59; participants = 5727; RCTs = 38; I² = 0%; moderate CoE, downgraded for study limitations), compared to MTURP. This corresponds to 28 fewer events of blood transfusion per 1000 participants (95% CI 34 fewer to 20 fewer). BTURP may result in similar rates of re-TURP (RR 1.02, 95% CI 0.44 to 2.40; participants = 652; RCTs = 6; I² = 0%; low CoE, downgraded for study limitations and imprecision). This corresponds to one more re-TURP per 1000 participants (95% CI 19 fewer to 48 more). Erectile function as measured by the International Index of Erectile Function score (IIEF-5) at 12 months on a scale from 5 to 25, with higher scores reflecting better erectile function, appears to be similar (MD 0.88, 95% CI -0.56 to 2.32; RCTs = 3; I² = 68%; moderate CoE, downgraded for study limitations) for the two approaches.

AUTHORS' CONCLUSIONS

BTURP and MTURP probably improve urological symptoms, both to a similar degree. BTURP probably reduces both TUR syndrome and postoperative blood transfusion slightly compared to MTURP. The impact of both procedures on erectile function is probably similar. The moderate certainty of evidence available for the primary outcomes of this review suggests that there is no need for further RCTs comparing BTURP and MTURP.

A Preliminary, Multicenter, Prospective and Real World Study on the Hemostasis, Coagulation, and Safety of Hemocoagulase Bothrops Atrox in Patients Undergoing Transurethral Bipolar Plasmakinetic Prostatectomy

Objective: To evaluate the hemostasis and coagulation effect of Hemocoagulase Bothrops Atrox in benign prostatic hyperplasia (BPH) patients undergoing transurethral bipolar plasmakinetic prostatectomy (TUPKP).

Methods: This study adopted a multicenter, prospective, and real world design. BPH patients undergoing TUPKP were divided into two groups according to whether they adopted Hemocoagulase Bothrops Atrox (group B) or not (group A) during perioperative period. The electronic clinical data on every included subject, including the international prostate symptom score (IPSS) and the quality of life scale (QoL), maximum urinary flow rate (Qmax), complete blood count, coagulation screening test and adverse events, were measured and compared between the two groups.

Results: Finally, 695 patients, 443 in group A and 252 in group B were included. Baseline characteristics showed no significant difference between two groups. In group A, compared with baseline, IPSS decreased 15.66 (95% CI = −16.45 to −14.87), QoL decreased 3.08 (95% CI = −3.30 to −2.87), prothrombin time prolonged 1.02 s (95% CI = 0.56 to 1.48), while white blood cells, neutrophils, lymphocytes, and hemoglobin also significantly changed; white blood cells, neutrophils and platelets increased, while lymphocytes decreased by 0.14×109/L (95% CI = −0.21 to −0.08) before discharge. In group B, compared with baseline, IPSS decreased 16.12 (95% CI = −17.02 to −15.21), QoL decreased 3.32 (95% CI = −3.56 to −3.07), and white blood cells, neutrophils, lymphocytes, and hemoglobin were also significantly changed, along with white blood cells and lymphocytes that tested before discharge (p < 0.01); however, prothrombin time was not significant prolonged (MD= 0.48, 95% CI = −0.05 to 1.01). When compared with group A and group B, the average hospitalization time in group A was longer than group B (p < 0.01), transfusion risk was similar in the two groups (OR = 1.582, 95% CI = 0.552 to 4.538). Parameters had no substantial difference between the two subgroups whether prostate volume was more than 80 mL or not.

Conclusion: Our study indicated that Hemocoagulase Bothrops Atrox can shorten the prothrombin time, hospitalization time and is probably safe among BPH patients undergoing TUPKP, exhibiting fine hemostasis and coagulation efficacy, and would not be influenced by prostate volume.

Pure Bipolar Plasma Vaporization of the Prostate: Results from a Prospective 3D Ultrasound Volumetry Study with Clinical Outcome After 3 Years

INTRODUCTION AND OBJECTIVES

Bipolar plasma vaporization (BPV) has been shown to be a low-morbidity alternative to conventional transurethral resection of the prostate (TURP). Improved functional short-term outcome and a postoperative prostate volume reduction comparable to TURP have been reported. However, comprehensive mid- or long-term results following BPV are still lacking.

METHODS

A consecutive series of men who underwent pure BPV in a tertiary care academic center was prospectively investigated. Clinical parameters [International Prostate Symptom Score with Quality-of-Life domain, peak urinary flow rate (Qmax), postvoid residual volume, and prostate-specific antigen] as well as prostate volume (assessed by planimetric volumetry following transrectal 3D-ultrasound) were recorded preoperatively and regularly after BPV (after catheter removal, 6 weeks, 6 months, 1 year, and 3 years). Statistical analysis was performed using the Wilcoxon signed-rank test. All p-values ≤0.05 were considered significant.

RESULTS

Seventy-five men were included in this prospective investigation. Their median (interquartile range) prostate volume was 41.0 mL (30.6-57.4 mL). In the first year after BPV, the prostate volume continuously decreased over time and the relative volume reduction was 52.2% after 12 months. Subsequently, the volume reduction remained stable with 50.7% after 3 years. All investigated outcome parameters improved significantly after the procedure and remained so after 3 years. Reoperations due to persistent or regrown adenoma were not necessary. Six (8.0%) and five patients (6.6%) developed a de novo urethral stricture or bladder neck contracture, respectively.

CONCLUSIONS

Three years after pure BPV of the prostate, a durable prostate volume reduction in combination with a stable improvement of functional outcome parameters was detectable in our prospective study. The low morbidity of the procedure and the possibility to perform BPV under ongoing platelet aggregation inhibition confirms its role as minimally invasive alternative to conventional TURP.

Transurethral procedures in the treatment of benign prostatic hyperplasia: A systematic review and meta-analysis of effectiveness and complications

BACKGROUND

With the progress of surgical techniques and instruments, various minimally invasive surgical therapies were developed to treat benign prostatic hyperplasisa (BPH). However, the efficacy and safety of different transurethral procedures for the treatment of BPH are still undefined.

METHOD

A systematic search was performed for all randomized controlled trials (RCTs), which compared the transurethral procedures for BPH from 1995 to 2016. The clinical baseline characteristics, International Prostate Symptom Score (IPSS), quality of life (QoL), postvoid residual (PVR), maximum flow rate (Qmax), short-term and long-term complications were analyzed using RevMan and ADDIS software.

RESULT

Eighty-eight randomly controlled trials and fifteen procedures were included in the network meta-analysis. HoLEP greatly inproved PVR. TmLRP had the best efficacy in improving QoL score. Diode laser vaporization of prostate was superior in improving IPSS and Qmax. Diode laser through vaporization required the shortest time in catheterization, while Nd:YAG was the longest procedure. For the hospitalization time, TUR was the longest and HoLEP was the shortest. TmLRP was related to the lowest postoperative hemoglobin decrease. TmLEP had the least rates of occurrence of hematuria, reoperation and erectile dysfunction. HoLEP was the best choice to reduce the incidence of recatheterization, urinary retention, urinary tract infection, stress urinary incontinence and retrograde ejaculation. The complications such as blood transfusion, urethral stricture, bladder neck contracture were relatively rare in the patients who underwent diode laser vaporization of prostate.

CONCLUSION

Compared with other transurethral procedures, thulium, holmium and diode lasers were associated with better efficacy and fewer complications.

[THE 10-YEAR OUTCOMES OF PVP (PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE) FOR TREATING BPH (BENIGN PROSTATIC HYPERPLASIA)]

(Purpose) Photoselective vaporization of the prostate (PVP) was introduced in Japan about 10 years ago, and there has been few studies regarding long-term outcomes so far. Herein we report our 10-year follow up result of PVP. (Patients and methods) From January 2006 to June 2006, 31 patients with benign prostatic hyperplasia (BPH) underwent PVP and 20 patients were evaluable in 10 years after PVP. Patients were evaluated preoperatively, at 6 months and at 10 years after surgery by International Prostate Symptom Score (IPSS) and Quality of life score (QOL score). The surgery used 80 watt potassium-titanyl-phosphate laser that was an old model. (Results) The mean IPSS preoperatively, at 6 months and at 10 years was 21.1, 5.5 and 9.4, respectively. The mean QOL score preoperatively, at 6 months and at 10 years was 5.3, 2.2 and 2.5, respectively. Both IPSS and QOL score were significantly improved at 6 months and at 10 years compared with preoperatively. However, among 20 patients re-operation for residual adenoma was required in 4 patients (20%) during the follow-up period. (Conclusion) PVP is an effective method for BPH treatment, allowing sustained long-term improvement of the voiding function.

Bipolar transurethral enucleation and resection of the prostate versus bipolar resection of the prostate for prostates larger than 60gr: A retrospective study at a single academic tertiary care center

OBJECTIVE

To evaluate the efficacy and safety of bipolar transurethral enucleation and resection of the prostate (B-TUERP) versus bipolar transurethral resection of the prostate (B-TURP) in the treatment of prostates larger than 60g.

MATERIAL AND METHODS

Clinical data for 270 BPH patients who underwent B-TUERP and 204 patients who underwent B-TURP for BPH from May 2007 to May 2013 at our center were retrospectively analyzed. Outcome measures included operative time, decreased hemoglobin level, total prostate specific antigen (TPSA), International Prostate Symptom Score (IPSS), maximal urinary flow rate (Qmax), quality of life (QoL) score, post void residual urine volume (RUV), bladder irrigation duration, hospital stay, and the weight of resected prostatic tissue. Other measures included perioperative complications including transurethral resection syndrome (TURS), hyponatremia, blood transfusion, bleeding requiring surgery, postoperative acute urinary retention, urine incontinence and urinary sepsis. Patients in both groups were followed for two years.

RESULTS

Compared with the B-TURP group, the B-TUERP group had shorter operative time, postoperative bladder irrigation duration and hospital stay, a greater amount of resected prostatic tissue, less postoperative hemoglobin decrease, better postoperative IPSS and Qmax, as well as lower incidences of hyponatremia, urinary sepsis, blood transfusion requirement, urine incontinence and reoperation (P<0.05 for all).

CONCLUSIONS

B-TUERP is superior to B-TURP in the management of large volume BPH in terms of efficacy and safety, but this finding needs to be validated in further prospective, randomized, controlled studies.

Transurethral enucleation of prostate with button electrode plasmakinetic vaporization for the treatment of Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is a common disease in aged men. In this study, we investigated the efficacy and safety of transurethral enucleation of prostate with button electrode plasmakinetic vaporization for the treatment of BPH. 60 patients diagnosed with BPH who were treated in our hospital from August to December, 2014 by enucleation with button electrode were retrospectively reviewed, and operation time, urinary catheter indwelling time, continuous bladder irrigation time, operation related complications, maximum urinary flow rate (Q_max), post-void residual urine volume (PVR), International Prostate Symptom Score (IPSS), quality of life assessment (QOL), perioperative hemoglobin and electrolytes were recorded. All the operations were completed successfully. The operation time and urinary catheter indwelling time were 45.3 ± 16.2 min and 1.72 ± 0.32 d, respectively. During the follow-up, urethral stricture (n = 1), and urinary incontinence (n = 2) were found with recovery after 1-month training. Postoperative PVR at 1, 3 and 6 months significantly decreased compared with preoperative ones (P < 0.05). IPSS, Q_max, QOL at 1, 3 and 6 months improved significantly (P < 0.05). There was no significant difference in serum hemoglobin, sodium and potassium before and after the operation. Thus, the study proved that enucleation of prostate with button electrode was efficient and safe, which was worth being recommended.

Long-term follow-up data more than 5 years after surgical management of benign prostate obstruction: who stands the test of time?

PURPOSE OF REVIEW

Surgical techniques are an integral part of the urologist's armamentarium for the treatment of benign prostatic obstruction. Currently, several techniques are available. The purpose of the current review is to analyse the long-term outcomes of currently available techniques.

RECENT FINDINGS

Open prostatectomy shows a low long-term reoperation rate. Available evidence suggests that bipolar transurethral resection of the prostate (TURP) is an attractive alternative to monopolar TURP as both techniques lead to a long-lasting and comparable efficacy. For patients with a larger prostate volume, bipolar enucleation of the prostate appears as safe and effective alternative to open prostatectomy. Holmium laser enucleation of the prostate appears as a durable alternative to TURP and open prostatectomy with comparable long-term results. For photoselective vaporization of the prostate, differently powered models are available. Currently, only long-term data with lower powered 80 W laser are available, reporting reoperation rates higher than those reported from other surgical techniques. On the thulium laser, currently only one study reported 5-year results and despite encouraging results further confirmation seems necessary.

SUMMARY

Various surgical methods have proven to be safe and effective for the treatment of benign prostate obstruction and stand the test of time. The choice of the technique depends on prostate size, risk factors of the patient as well as expertise of the surgeon.

Transurethral plasmakinetic resection of the prostate is a reliable minimal invasive technique for benign prostate hyperplasia: a meta-analysis of randomized controlled trials

To evaluate the efficacy and safety of plasmakinetic resection of the prostate (PKRP) versus transurethral resection of the prostate (TURP) for the treatment of patients with benign prostate hyperplasia (BPH), a meta-analysis of randomized controlled trials was carried out. We searched PubMed, Embase, Web of Science and the Cochrane Library. The pooled estimates of maximum flow rate, International Prostate Symptom Score, operation time, catheterization time, irrigated volume, hospital stay, transurethral resection syndrome, transfusion, clot retention, urinary retention and urinary stricture were assessed. There was no notable difference in International Prostate Symptom Score between TURP and PKRP groups during the 1-month, 3 months, 6 months and 12 months follow-up period, while the pooled Q max at 1-month favored PKRP group. PKRP group was related to a lower risk rate of transurethral resection syndrome, transfusion and clot retention, and the catheterization time and operation time were also shorter than that of TURP. The irrigated volume, length of hospital stay, urinary retention and urinary stricture rate were similar between groups. In conclusion, our study suggests that the PKRP is a reliable minimal invasive technique and may anticipatorily prove to be an alternative electrosurgical procedure for the treatment of BPH.

Prospective Randomized Comparison of Monopolar TURP, Bipolar TURP and Photoselective Vaporization of the Prostate in Patients with Benign Prostatic Obstruction: 36 Months Outcome

OBJECTIVES

To assess durability of efficacy of monopolar transurethral resection of the prostate (TURP), bipolar TURP, and photoselective vaporization of the prostate (PVP) using 120W Green light laser at 36 months follow up.

METHOD

The 186 patients who presented with benign prostatic obstruction and planned for surgery were randomized into three groups: Group A - monopolar TURP; group B - bipolar TURP; and group C - PVP. International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5) score, quality of life (QoL) score, maximum flow rate (Qmax), prostate volume and postvoid residual urine (PVRU) were analyzed up to 36 months follow up.

RESULTS

The improvement observed in the mean IPSS, QoL score, Qmax, prostate volume and PVRU at 12-month was sustained till 36 months follow up. However, the mean IIEF-5 score did not show improvement in any group. Few complications noted in second and third year of follow up compared to first year follow up. The results of subgroups analysis did not reveal any significant finding, different from group analysis, for efficacy parameters.

CONCLUSION

Monopolar TURP, Bipolar TURP and PVP provides durable and comparable efficacy at 36 months follow up in patients with prostate size <80 mL.

Bipolar plasma vaporization using plasma-cutting and plasma-loop electrodes versus cold-knife transurethral incision for the treatment of posterior urethral stricture: a prospective, randomized study

OBJECTIVE

Evaluate the efficiency and safety of bipolar plasma vaporization using plasma-cutting and plasma-loop electrodes for the treatment of posterior urethral stricture. Compare the outcomes following bipolar plasma vaporization with conventional cold-knife urethrotomy.

METHODS

A randomized trial was performed to compare patient outcomes from the bipolar and cold-knife groups. All patients were assessed at 6 and 12 months postoperatively via urethrography and uroflowmetry. At the end of the first postoperative year, ureteroscopy was performed to evaluate the efficacy of the procedure. The mean follow-up time was 13.9 months (range: 12 to 21 months). If re-stenosis was not identified by both urethrography and ureteroscopy, the procedure was considered "successful".

RESULTS

Fifty-three male patients with posterior urethral strictures were selected and randomly divided into two groups: bipolar group (n=27) or cold-knife group (n=26). Patients in the bipolar group experienced a shorter operative time compared to the cold-knife group (23.45±7.64 hours vs 33.45±5.45 hours, respectively). The 12-month postoperative Qmax was faster in the bipolar group than in the cold-knife group (15.54±2.78 ml/sec vs 18.25±2.12 ml/sec, respectively). In the bipolar group, the recurrence-free rate was 81.5% at a mean follow-up time of 13.9 months. In the cold-knife group, the recurrence-free rate was 53.8%.

CONCLUSIONS

The application of bipolar plasma-cutting and plasma-loop electrodes for the management of urethral stricture disease is a safe and reliable method that minimizes the morbidity of urethral stricture resection. The advantages include a lower recurrence rate and shorter operative time compared to the cold-knife technique.

Post-Transurethral Resection of the Prostate Inflation of Pressure-Controlled Endorectal Balloon-Impact on Postoperative Bleeding: A Preliminary Experimental Pilot Study

OBJECTIVE

To evaluate the impact of rectal balloon (RB) inflation on post-transurethral resection of the prostate (TURP) bleeding in patients with symptomatic benign prostatic hyperplasia.

METHODS

After institutional review board approval, patients who were eligible for TURP were randomized into two equal groups, depending on whether they received postoperative endorectal balloon (RB) (GII) or not (GI). The tip of three-way Foley catheter was fixed to a balloon by a blaster strip to prepare air-tight RB. Postoperatively, the RB was inflated for 15 minutes by a pressure-controlled sphygmomanometer. Perioperative data were compared between both groups, including hemoglobin (Hb) deficit 24-hour postoperatively and at time of discharge. Functional outcomes, anorectal complaints, and adverse events were assessed perioperatively and after 1 and 3 months.

RESULTS

Fifty patients were enrolled, including 13 (26%) patients who presented with indwelling urethral catheters. Baseline data and mean resected tissue weight were comparable between both groups, including preoperative Hb (p = 0.17). Immediate postoperative Hb deficit was, comparable between GI and GII patients (0.58 ± 0.18 vs 0.60 ± 0.2, p = 0.56) before RB inflation, respectively. However, compared to GI patients, mean Hb deficit significantly decreased in GII patients 24-hour postoperatively (0.2 ± 0.2 vs 0.7 ± 0.3 g, p = 0.002) and at time of discharge (0.8 ± 0.2 vs 1.3 ± 0.4 g, p = 0.003). GII patients needed significantly less postoperative irrigation (2.1 ± 1.6 vs 8.3 ± 1.8 L, p < 0.001), shorter catheterization time (2.3 ± 0.8 vs 3.8 ± 1.3 days, p < 0.001), and shorter hospital stay (2.6 ± 0.5 vs 4.3 ± 1.0 days, p < 0.001). Both groups were comparable in all functional outcomes at the most recent follow-up. Blood transfusion was needed in only one patient (4%) in GI. No patient needed recystoscopy for hematuria or clot retention in either group, while there were no anorectal complaints reported by GII patients.

CONCLUSIONS

Post-TURP endorectal balloon inflation seems to be simple, safe, and an efficient procedure to reduce postoperative bleeding and irrigation volume. It is significantly associated with shorter catheterization time and hospital stay.

Five-Year Follow-Up Study of Transurethral Plasmakinetic Resection of the Prostate for Benign Prostatic Hyperplasia

PURPOSE

To explore the long-term clinical efficacy and safety of transurethral plasmakinetic resection of the prostate (PKRP) for benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

A total of 550 patients with BPH who had undergone PKRP from October 2006 to September 2009 were enrolled in this study. All patients were evaluated at baseline and follow-up (3, 12, 24, 36, 48, 60 months postoperatively) by peak flow rate (Qmax), postvoid residual (PVR), quality of life (QoL), International Prostate Symptom Score (IPSS), and Overactive Bladder Symptom Score (OABSS). Operative details and postoperative complications regarded as safety outcomes were documented.

RESULTS

A total of 467 patients completed the 5-year follow-up. The mean duration of surgery was 36.43 minutes, mean catheterization time was 48.81 hours, mean hospital stay was 4.21 days. At 60 months postoperatively, the mean Qmax increased from 6.94 mL/s at baseline to 19.28 mL/s, the mean PVR decreased from 126.33 mL to 10.45 mL, the mean IPSS score decreased from 15.79 to 7.51, the mean QoL score decreased from 4.36 to 1.91, and the mean OABSS score decreased from 6.39 to 3.65 (P < 0.001), respectively. In perioperative complications, the blood transfusion rate was 2.7%, urinary tract infection rate was 3.6%; no transurethral resection syndrome (TUR syndrome) occurred. In late complications, urethral stricture rate was 5.4%, recurrent bladder outlet obstruction rate was 2.1%, and the reoperation rate was 4.5%.

CONCLUSIONS

PKRP is based on conventional monopolar transurethral resection of the prostate (TURP) and uses a bipolar plasmakinetic system. Our results indicate that the long-term clinical efficacy and safety of PKRP for BPH are remarkable. In particular, the incidence of urethral stricture, recurrent bladder outlet obstruction, and reoperation is low. We suggest that PKRP is a reliable minimally invasive technique that may be the preferred procedure for the treatment of patients with BPH.

Plasmakinetic vaporization versus plasmakinetic resection to treat benign prostatic hyperplasia: A prospective randomized trial with 1 year follow-up

INTRODUCTION

We evaluate the efficacy and outcomes of plasma-kinetic vaporization (PKVP) and plasmakinetic resection (PKR) to treat benign prostatic hyperplasia (BPH).

METHODS

A total of 183 patients with BPH underwent plasma-kinetic prostatic surgery between 2008 and 2012 at Kars State Hospital and Kafkas University Faculty of Medicine, Turkey. After clinical and preoperative evaluation, the patients were randomized to PKRP or PKVP groups sequentially by using computer-generated numbers. Group 1 included 96 patients treated with PKR. Group 2 included 87 patients treated with PKVP. Patients in both groups were compared in terms of hemoglobin drop, operation time, catheter duration, reobstruction, incontinence and recatheterization.

RESULTS

When we compared the maximum flow rates (Qmax values) at the 12th month, there was no statistical difference between 2 groups. Group 1 had a mean Qmax value of 17.92 ± 3.819 and Group 2 had a 18.15 ± 3.832 value (p > 0.05). There was a statistical difference between the groups in terms of hemoglobin drop, catheter duration and operation time. The mean catheter duration in Group 1 was 3.74 ± 1.049 days, and in Group 2 it was 2.64 ± 0.849 days (p < 0.05). Operation time was statistically longer in Group 2 (PKVP) and hemoglobin drop was statistically higher in Group 1 (PKR).

CONCLUSION

PKVP for BPH is safe and effective. When compared with PKRP, it provides a significantly shorter catheter duration and less bleeding due to hemostasis control with similar IPSS and Qmax improvements after 1 year.

A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update

CONTEXT

A number of transurethral ablative techniques based on the use of innovative medical devices have been introduced in the recent past for the surgical treatment of benign prostatic obstruction (BPO).

OBJECTIVE

To conduct a systematic review of the literature and a meta-analysis of available randomized controlled trials (RCTs), and to evaluate the efficacy and safety of transurethral ablative procedures for BPO.

EVIDENCE ACQUISITION

A systematic literature search was performed for all RCTs comparing any transurethral surgical technique for BPO to another between 1992 and 2013. Efficacy was evaluated after a minimum follow-up of 1 yr based on International Prostate Symptom Score, maximum flow rate, and postvoid residual volume. Efficacy at midterm follow-up, prostate volume, perioperative data, and short-term and long-term complications were also assessed. Data were analyzed using RevMan software.

EVIDENCE SYNTHESIS

A total of 69 RCTs (8517 enrolled patients) were included. No significant difference was found in terms of short-term efficacy between bipolar transurethral resection of the prostate (B-TURP) and monopolar transurethral resection of the prostate (M-TURP). However, B-TURP was associated with a lower rate of perioperative complications. Better short-term efficacy outcomes, fewer immediate complications, and a shorter hospital stay were found after holmium laser enucleation of the prostate (HoLEP) compared with M-TURP. Compared with M-TURP, GreenLight photoselective vaporization of the prostate (PVP) was associated with a shorter hospital stay and fewer complications but no different short-term efficacy outcomes.

CONCLUSIONS

This meta-analysis shows that HoLEP is associated with more favorable outcomes than M-TURP in published RCTs. B-TURP and PVP have resulted in better perioperative outcomes without significant differences regarding efficacy parameters after short-term follow-up compared with M-TURP. Further studies are needed to provide long-term comparative data and head-to head comparisons of emerging techniques.

PATIENT SUMMARY

Bipolar transurethral resection of the prostate, photovaporization of the prostate, and holmium laser enucleation of the prostate have shown efficacy outcomes comparable with conventional techniques yet reduce the complication rate. The respective role of these new options in the surgical armamentarium needs to be refined to propose tailored surgical treatment for benign prostatic obstruction relief.

Comparative outcomes of plasmakinetic versus monopolar transurethral resection of benign prostatic hyperplasia: 7 years' results

OBJECTIVE

We compared results from the standard monopolar or the bipolar plasmakinetic method for the transurethral resection of the prostate (TURP) due to benign prostatic hyperplasia (BPH) at 4 and 7 years after surgery (medium to long term).

MATERIAL AND METHODS

A retrospective analysis was performed on the complete data from 124 patients who were alive and had 7 years of regular follow-up. Of those 124 patients with BPH, 65 (52%) underwent monopolar TURP (M-TURP) and 59 (48%) underwent plasmakinetic TURP (P-TURP). During the follow-up period, the International Prostate Symptom Score (IPSS), the maximal flow rate (Qmax) measured using uroflowmetry and the prostate specific antigen (PSA) values were recorded. Patients in whom alpha blockers were administered due to the growth of postoperative adenoma and who had been operated on due to urethral stricture, bladder neck contracture or a growing adenoma were also noted and recorded.

RESULTS

There was no statistically significant difference between M-TURP and P-TURP groups in any pre-operative or post-operative follow-up parameter at 4 or 7 years post-surgery. Specifically, PSA, IPSS and Qmax values; urethrotomies performed; alpha-blocker use; and the frequency of re-operations were statistically insignificant (p>0.05).

CONCLUSION

Our study demonstrated that when medium-to long-term results are compared, P-TURP and M-TURP appear to result in similar IPSS scores, Qmax values, complication rates and retreatment rates. Larger prospective studies are required to corroborate these results.

Early outcomes of thulium laser versus transurethral resection of the prostate for managing benign prostatic hyperplasia: a systematic review and meta-analysis of comparative studies

PURPOSE

To assess the efficacy and safety of thulium laser resection of the prostate (TmLRP) vs transurethral resection of the prostate (TURP) for treating patients with benign prostatic hyperplasia (BPH).

METHODS

A systematic search of the electronic databases, including Medline, Scopus, China National Knowledge Infrastructure, and the Cochrane Library was performed up to May 1, 2013. The pooled outcomes of interest assessing the two techniques included demographic and clinical baseline characteristics, perioperative variables, complications, and postoperative efficacy including maximum flow rate (Qmax), postvoid residual (PVR), quality of life (QoL) and International Prostate Symptom Score (IPSS).

RESULTS

Nine trials assessing TmLRP vs. TURP were considered suitable for meta-analysis including three randomized controlled trials (RCTs), two prospective, and four retrospective studies. Compared with TURP, although TmLRP needed a longer operative time (weighted mean difference [WMD]: 9.00 min; 95% confidence interval [CI], 2.53-15.47; P=0.006), patients having TmLRP might benefit from significantly less serum sodium decreased (-3.58 mmol/L; 95% CI, -4.04 to -3.12; P<0.001), less serum hemoglobin decreased (WMD: -0.94 mmol/L; 95% CI, -1.44 to -0.44; P<0.001), shorter time of catheterization (WMD: -2.07 days; 95% CI, -2.66 to -1.49; P<0.001), shorter length of hospital stay (WMD: -1.87 days; 95% CI, -2.41 to -1.33; P<0.001), and fewer total complications (odds ratio [OR]: 0.29; 95% CI, 0.20-0.41; P<0.001). During the 1, 3, 6, and 12 months of postoperative follow-up, the procedures did not demonstrate a significant difference in Qmax, IPSS, PVR, and QoL.

CONCLUSIONS

Our data suggest that as a promising minimally invasive technique, TmLRP appears to be a safe, feasible, and efficient alternative to TURP for treating patients with BPH with reliable perioperative safety, fewer complications, and comparable efficacy in relation to Qmax, PVR, QoL, and IPSS. Because of the inherent limitations of the included studies, further large sample prospective, multicentric, long-term follow-up studies and RCTs should be undertaken to confirm our findings.