GreenLight HPS™ 120-W laser vaporization vs transurethral resection of the prostate (<60 mL): a 2-year randomized double-blind prospective urodynamic investigation

Complications of GreenLight Laser vs Transurethral Resection of the Prostate for Treatment of Lower Urinary Tract Symptoms: Meta-analysis of Randomized Trials

OBJECTIVE

To compare perioperative outcomes and complications between GreenLight and transurethral resection of the prostate (TURP) for benign prostatic hyperplasia.

METHODS

A systematic review and random effects meta-analysis of randomized trials comparing GreenLight with TURP was completed. Primary outcomes included periprocedural milestones, 12 predefined complications, Clavien-Dindo class III-V complications, reoperations (all-cause), and a composite of reoperations and readmissions. Metaregression assessed the relationship between patient- and study-level factors with periprocedural outcomes and reoperation rates.

RESULTS

The review included 13 randomized trials with 1757 patients (839 GreenLight; 918 TURP). Procedure time was 10 minutes (95% CI: 5 to 15; P < .001) longer with GreenLight, while catheterization time (mean difference=-1.3days; 95% CI: -1.7 to -0.9; P<.001) and hospital stay (mean difference=-2.1days; 95% CI: -2.5 to -1.7; P<.001) were shorter. Bleeding-related complications, including clot retention (risk ratio [RR]=0.12; 95% CI: 0.05 to 0.32; P<.001) and transfusion (RR=0.26; 95% CI: 0.12 to 0.58; P = .001), as well as sexual dysfunction (RR=0.66; 95% CI: 0.45 to 0.98; P = .04), were less frequent with GreenLight. All other complications occurred at similar frequencies between groups. The risks of reoperation (RR: 1.17; 95% CI: 0.82 to 1.66; P = .38) and reoperation or readmission (RR: 1.05; 95% CI: 0.76 to 1.44; P = .79) did not differ.

CONCLUSION

GreenLight achieved shorter catheterization times and hospital stays with lower rates of sexual dysfunction and bleeding-related complications compared to TURP.

A systematic review and meta-analysis of efficacy and safety comparing greenlight laser vaporization with transurethral resection of the prostate for benign prostatic hyperplasia with prostate volume less than 80 ml

We conducted a meta-analysis to evaluate the efficacy and safety of photo selective vaporisation of the prostate (PVP) with the GreenLight Laser versus transurethral resection of the prostate (TURP) for the treatment of small-volume benign prostatic hyperplasia (BPH). As of July 2022, relevant literature in online databases such as Cochrane Library, PubMed, and Embase was searched, including studies published on or before that date, and there were 9 studies in total, including 5 RCTs and 4 non-RCTs. In total 1525 patients were included to compare the efficacy of PVP and TURP in treating BPH. The Cochrane Collaboration criteria were used to evaluate the risk of bias. The software was used for random effect meta-analysis with RevMan 5.3. Data extraction included: clinical baseline characteristics, perioperative parameters, complication rates, International Prostate Symptom Score (IPSS), prostate specific antigen (PSA), post-void residual urine (PVR), maximum flow rate (Qmax), and quality of life (QoL). The pooled analysis showed that PVP was associated with reduced blood loss, blood transfusion, clot retention, catheterization time, definitive catheter removal, and hospital stay, but was associated with longer operative time and more severe dysuria (all p < 0.05). The results of this meta-analysis show that PVP as a technique for the treatment of benign prostatic hyperplasia with a volume of less than 80 cc has similar efficacy to standard TURP in IPSS, PSA, PVR, Qmax and QoL, and is an effective alternative. It outperformed TURP in terms of blood transfusion, catheterization time and hospital stay, while TURP is superior to PVP in terms of operation time.

Impact of Surgery for Benign Prostatic Hyperplasia on Sexual Function: A Systematic Review and Meta-analysis of Erectile Function and Ejaculatory Function

CONTEXT

Several sexual side effects, including erectile, ejaculatory, and orgasmic dysfunction, were reported with the majority of surgical procedures for benign prostatic obstruction (BPO).

OBJECTIVE

To systematically review current evidence regarding the impact of benign prostatic hyperplasia (BPH) surgery on sexual function.

EVIDENCE ACQUISITION

A comprehensive bibliographic search on the MEDLINE, Cochrane Library, Embase, Web of Science, and Google Scholar databases was conducted in July 2021. The population, intervention, comparator, and outcome (PICO) model was used to define study eligibility. Studies were Included if they assessed patients with BPO and related lower urinary tract symptoms (P) undergoing BPH surgery (I) with or without a comparison between surgical treatments (C) evaluating the impact on sexual function (O). Retrospective and prospective primary studies were included. A pooled analysis was conducted on studies including the postoperative assessment of International Index of Erectile Function (IIEF)-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD; Function and/or Bother), or retrograde ejaculation (RE) rate (PROSPERO database ID: CRD42020177907).

EVIDENCE SYNTHESIS

A total of 151 studies investigating 20 531 patients were included. Forty-eight randomized controlled trials evaluating 5045 individuals were eligible for the meta-analysis. In most studies (122, 80.8%), only erectile and/or ejaculatory function was evaluated. A substantial number of articles (67, 44.4%) also used nonvalidated tools to evaluate erectile and/or ejaculatory function. The pooled analysis showed no statistically significant changes in IIEF-5 score compared with baseline for the transurethral resection of the prostate (TURP; weighted mean difference [WMD] 0.76 pts; 95% confidence interval [CI] -0.1, 1.62; p = 0.08), laser procedure (WMD 0.33 pts; 95% CI -0.1, 0.77; p = 0.13), and minimally invasive treatment (WMD -1.37 pts; 95% CI -3.19, 0.44; p = 0.14) groups. A statistically significantly higher rate of RE was found after TURP (risk ratio [RR] 13.31; 95% CI 8.37, 21.17; p < 0.00001), other electrosurgical procedures (RR 34.77; 95% CI 10.58, 127.82; p < 0.00001), and the entire laser group (RR 17.37; 95% CI 5.93, 50.81; p < 0.00001). No statistically significant increase in RE rate was described after most of the minimally invasive procedures (p > 0.05). The pooled analysis of MSHQ-EjD scores was possible only for prostatic urethral lift, showing no statistically significant difference between baseline and post-treatment MSHQ-EjD Function scores (WMD -0.80 pts; 95% CI -2.41, 0.81; p = 0.33), but postoperative MSHQ-EjD Bother scores were significantly higher (WMD 0.76 pts; 95% CI 0.22, 1.30; p = 0.006).

CONCLUSIONS

Erectile function appears to be unaffected by most surgical procedures for BPO. RE is a very common adverse event of BPH surgery, although emerging minimally invasive surgical procedures could be associated with a lower risk.

PATIENT SUMMARY

Benign prostatic hyperplasia surgery can have an impact on sexual function, mainly involving ejaculatory function.

Correlation between transurethral interventions and their influence on type and duration of postoperative urinary incontinence: results from a systematic review and meta-analysis of comparative studies

Objective To perform a systematic review to assess the incidence of transient (<6-month) and persistent (>6-month) stress (SUI), urge (UUI), and mixed urinary incontinence (MUI) after transurethral surgeries for benign prostatic hyperplasia (BPH). Materials and Methods A systematic literature search was performed using Embase, PubMed, and Web of Science. We included studies comparing monopolar(M)/bipolar(B) TURP vs ablation vs enucleation procedures. Incidence of incontinence was assessed using Cochran-Mantel-Haenszel Method and reported as odds ratio (OR), 95% confidence interval (CI), and p-values. Statistical significance was set at p <0.05 Evidence synthesis 28 studies were included. Incidence of transient SUI was 4.6%, 6.0%, 3.0%, 2.4% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent SUI was 1.1% after ablation, 1.7%, after enucleation and M-TURP, 1.0% after B-TURP. Incidence of transient UUI was 2.0%, 7.3%, 4.4%, 2.8% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent UUI was 2.2% after M-TURP. The incidence of transient MUI was 5.1%, 0.8%, 5.4%, 0.9% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent MUI was 3.1% after ablation, and 4.8% after M-TURP. Incidence of transient and persistent SUI and UUI did not differ after TURP vs enucleation. Incidence of transient (OR 3.32, 95% CI 0.41-26.65, p=0.26) and persistent SUI (OR 4.79, 95%CI 0.52-43.89,p=0.17) was not significantly higher after ablation. Incidence of transient UUI was not significantly higher after ablation (OR 2.62, 95%CI 0.04-166.01,p=0.65), whilst persistent UUI did not differ. Incidence of transient MUI was significantly higher after enucleation (OR 3.26, 95%CI 1.51-7.05,p=0.003). Incidence of transient and persistent MUI did not differ after TURP vs ablation. Conclusions Ablation, enucleation, and TURP have an impact on all forms of incontinence but this is transient in most cases with no difference between the groups, except for MUI which was higher after enucleation vs M-TURP.

Proctored Step by Step Training Program for GreenLight Laser Anatomic Photovaporization of the Prostate: A Single Surgeon's Experience

Objectives: To evaluate the feasibility and safety of a proctored step-by-step training program for GreenLight laser anatomic photovaporization (aPVP) of the prostate. Methods: Data from patients undergoing aPVP between January 2019 and December 2020 operated by a single surgeon following a dedicated step-by-step proctored program were prospectively collected. The procedure was divided into five modular steps of increasing complexity. Preoperative patients' data as well as total operative time, energy delivered on the prostate and postoperative data, were recorded. Then, we assessed how the overall amount of energy delivered and the operative times varied during the training program. Surgical steps were analyzed by cumulative summation. Univariable and multivariable regression models were built to assess the predictors of the amount of energy delivered on the prostate. Results: Sixty consecutive patients were included in the analysis. Median prostate volume was 56.5 mL. The training program was succesfully completed with no intraoperative or meaningful post-operative complications. The energy delivered reached the plateau after the 40th case. At multivariable analysis, increasing surgeon experience was associated with lower amounts of energy delivered as well as lower operative times. Conclusions: A step-by-step aPVP training program can be safely performed by surgeons with prior endoscopic experience if mentored by a skilled proctor. Considering the energy delivered as an efficacy surrogate metrics (given its potential impact on persistent postoperative LUTS), 40 cases are needed to reach a plateau for aPVP proficiency. Further studies are needed to assess the safety of our step-by-step training modular program in other clinical contexts.

Symptomatic Improvement of Lower Urinary Tract Symptoms of Benign Prostatic Hyperplasia: A Comparative Systematic Review and Meta-Analysis of 4 Different Minimally Invasive Therapies

PURPOSE

To review and compare the outcomes of prostatic artery embolization (PAE) with 3 other minimally invasive surgical treatments for benign prostatic hyperplasia, including photoselective vaporization (PVP), prostatic urethral lift (PUL), and water vapor thermal therapy (WV).

METHODS

A literature review was used to identify 35 publications, which included 2,653 patients (studies, patients): PVP (13, 949), PUL (9, 577), WV (3, 330), and PAE (10, 728). The international prostate symptom score (IPSS) and the international index of erectile function (IIEF-5) and quality of life (QOL) scores were recorded at baseline, 6 months, and 12 months. Meta-analyses, pooling the standardized mean difference between scores recorded before and after treatment, were conducted for each modality and time point to assess the magnitude of a therapy's effect to yield pooled effect sizes. A negative score indicates IPSS and QOL improvement. A positive score indicates IIEF-5 improvement.

RESULTS

At 6 and 12 months, the IPSS and QOL were most improved after PVP, followed by that after PAE, PUL, and, lastly, WV (measured only at 12 months). Between 6 and 12 months, the IPSS and QOL improved with PAE and worsened with PVP and PUL. Only PAE demonstrated statistical improvement in the IIEF-5, which improved from 6 to 12 months.

CONCLUSIONS

PVP and PAE resulted in the largest improvements in the IPSS and QOL. Only PAE resulted in improvement of the IIEF-5.

Erectile Function Following Surgery for Benign Prostatic Obstruction: A Systematic Review and Network Meta-analysis of Randomised Controlled Trials

CONTEXT

Benign prostatic obstruction (BPO) is associated with sexual dysfunction. Furthermore, numerous BPO interventions may themselves impact sexual function.

OBJECTIVE

To perform a systematic review with network meta-analysis to evaluate how BPO interventions affect erectile function.

EVIDENCE ACQUISITION

Three databases were searched for randomised controlled trials (RCTs) comparing surgical interventions for BPO. The primary outcome was postoperative International Index of Erectile Function-5 (IIEF-5) score at ten time points up to 72 mo. A random-effects Bayesian network meta-analysis with meta-regression was performed. In comparison to monopolar transurethral resection (mTURP), the mean difference (MD) with 95% credible interval (CrI) and rank probability (rank p) were calculated for interventions. The mean baseline score was studied in meta-regression. τ² values were used to quantify heterogeneity.

EVIDENCE SYNTHESIS

A total of 48 papers (33 RCTs, 5159 patients, 16 interventions) were included. Prostatic urethral lift (PUL) ranked highest at 1 mo (MD 3.88, 95% CrI -0.47 to 8.25; rank p = 0.742), 6 mo (MD 2.43, 95% CrI -0.72 to 5.62; rank p = 0.581), 12 mo (MD 2.94, 95% CrI -0.26 to 6.12, rank p = 0.782), and 24 mo (MD 3.63, 95% CrI 0.14 to 7.11; rank p = 0.948), at which point statistical significance was reached. At time points up to 60 mo, there were no statistically significant comparisons for other interventions. Analyses were not possible at 18, 48, or 72 mo. β did not reach statistical significance in meta-regression. τ² was highest at 1 mo (0.56) and 60 mo (0.55).

CONCLUSIONS

PUL ranked highly and resulted in erectile function improvement at 24 mo compared to mTURP, but direct evidence is lacking. We did not observe significant differences in erectile function following other interventions up to 60 mo. Owing to heterogeneity, our conclusions are weakest at 1 and 60 mo. Further RCTs comparing sexual function outcomes are recommended, such as PUL versus holmium laser or bipolar enucleation.

PATIENT SUMMARY

Different surgical treatments can be used to treat benign enlargement of the prostate causing urinary problems. We compared the effects of various treatments on erectile function at time points up to 5 years after surgery. Compared to surgical removal of some of the prostate gland (transurethral resection of the prostate, TURP), a technique called prostatic urethral lift resulted in better erectile function scores at 24 months. However, other treatments did not differ in their effect on erectile function.

GreenLight Laser™ Photovaporization versus Transurethral Resection of the Prostate: A Systematic Review and Meta-Analysis

GreenLight laser™ photovaporization of the prostate (GLL-PVP) has become a valid alternative to traditional transurethral resection of the prostate (TURP) in men requiring surgery for benign prostatic hyperplasia. We aimed to review systematically the safety and efficacy of studies comparing GLL PVP and TURP in the medium-term. A comprehensive literature search was performed. Twelve studies were identified for meta-analysis. Meta-analyses showed a longer postoperative catheterization time (risk ratio (RR): 1.12, 95% CI:1.09–1.14, p<0.00001) and length of stay (RR: 1.16, 95% CI:1.12–1.19, p<0.00001) in the TURP group; higher risk of transfusion in the TURP group (RR: 6.51, 95% CI: 2,90–14,64 p<0.00001); no difference in the risk of urinary tract infections (RR: 0.83, 95% CI: 0.58–1.18, p=0.30) and transient re-catheterization (RR: 1.11, 95% CI: 0.76–1.60, p=0.60). Regarding reoperation rate, no difference was found in term of postoperative urethral stricture (RR: 1.13, 95% CI: 0.73–1.75, p=0.59) and bladder neck contracture (RR: 0.66, 95% CI: 0.31–1.40, p=0.28). A significantly higher incidence in reoperation for persistent/regrowth adenoma was present in the GLLL-PVP (RR: 0.64, 95% CI: 0.41–0.99, p=0.05). Data at 2-year follow-up showed significant better post-voiding residual (PVR) (MD: -1.42, 95% CI: -2.01, -0.82, p<0.00001) and International Prostate Symptom Score (IPSS) (MD: -0.35, 95% CI: -0.50, -0.20, p<0.00001) after TURP. No difference was found in the mean PVR at 2 years after TURP, in the mean maximum flow rate (Qmax) (MD: 0.30, 95% CI: -0.02–0.61, p=0.06) and quality of life QoL score (MD: 0.05, 95% CI: -0.02–0.42, p=0.13). At 5-year follow-up, data showed better IPSS (MD: -1.70, 95% CI: -2.45,-0.95, p<0.00001), QoL scores (MD: -0.35, 95% CI: -0.69, -0.02, p=0.04) and Qmax (MD: 3.29, 95% CI: 0.19–6.38, p=0.04) after TURP. Data of PVR showed no significant difference (MD: -11.54, 95% CI: -29.55–6.46, p=0.21). In conclusion, our analysis shows that GLL-PVP is a safer and more efficacious procedure than standard TURP in the early and medium-term. However, in the long term period GLL-PVP showed a higher incidence of reoperation rate due to incomplete vaporization/regrowth of prostatic adenoma.

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

OBJECTIVE

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

METHODS

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

RESULTS/GUIDELINES

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

CONCLUSION

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

Influence of solifenacin on the improvement of storage symptoms in the early period after photoselective vaporization of the prostate

Purpose

We studied the effect of solifenacin on reducing storage symptoms after photoselective vaporization of the prostate (PVP).

Materials and Methods

This study included patients with persistent storage symptoms of urgency and frequency in a 3-day voiding diary, International Prostate Symptom Score (IPSS) storage subscore (IPSS-s) ≥5, overactive bladder symptom score (OABSS) ≥5, and OABSS for question 3 ≥4 at 5 days after urethral catheter removal. The patients were randomly assigned to receive once-daily solifenacin 5 mg or placebo for 4 weeks. Evaluation of the 3-day voiding diary, IPSS, and OABSS was performed at 2 and 4 weeks after treatment.

Results

At 2 and 4 weeks after treatment, the urgency and frequency in the 3-day voiding diary, IPSS, IPSS-s, and OABSS were decreased in the solifenacin group. Although the OABSS of the solifenacin group was not significantly different from that of the placebo group, the OABSS of the placebo group increased at 4 weeks compared with that at 2 weeks after treatment. The Benefit, Satisfaction, and Willingness to continue questionnaire showed no significant difference in patient satisfaction between the groups. Although the solifenacin group showed increased post-void residual volume compared with the placebo group, there was no statistically significant difference.

Conclusions

Storage symptoms measured using OABSS tended to decrease after medication with solifenacin in the early period after PVP. Therefore, we suggest that anticholinergics have a potential role in improving storage symptoms after PVP.

Comparison of photoselective green light laser vaporisation versus traditional transurethral resection for benign prostate hyperplasia: an updated systematic review and meta-analysis of randomised controlled trials and prospective studies

OBJECTIVE

To assess the efficacy and safety of green-light laser photoselective vaporisation of the prostate (PVP) compared with transurethral resection of the prostate (TURP) for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

DESIGN

Systematic review and meta-analysis, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement.

DATA SOURCES

PubMed, EMBASE, the Cochrane Library until October 2018.

ELIGIBILITY CRITERIA

Randomised controlled trials and prospective studies comparing the safety and efficacy of PVP versus TURP for LUTS manifesting through BPH.

DATA EXTRACTION AND SYNTHESIS

Perioperative parameters, complications rates and functional outcomes including treatment-related adverse events such as International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), postvoid residual (PVR), quality of life (QoL) and International Index of Erectile Function (IIEF).

RESULTS

22 publications consisting of 2665 patients were analysed. Pooled analysis revealed PVP is associated with reduced blood loss, transfusion, clot retention, TUR syndrome, capsular perforation, catheterisation time and hospitalisation, but also with a higher reintervention rate and longer intervention duration (all p<0.05). No significant difference in IPSS, Qmax, QoL, PVR or IIEF at 3, 24, 36 or 60 months was identified. There was a significant difference in QoL at 6 months (MD=-0.08; 95% CI -0.13 to -0.02; p=0.007), and IPSS (MD = -0.10; 95% CI -0.15 to -0.05; p<0.0001) and Qmax (MD=0.62; 95% CI 0.06 to 1.19; p=0.03) at 12 months, although these differences were not clinically relevant.

CONCLUSION

PVP is an effective alternative, holding additional safety benefits. PVP has equivalent long-term IPSS, Qmax, QoL, PVR, IIEF efficacy and fewer complications. The main drawbacks are dysuria and reintervention, although both can be managed with non-invasive techniques. The additional shortcoming is that PVP does not acquire histological tissue examination which removes an opportunity to identify prostate cancer.

GreenLight Laser for benign prostatic hyperplasia

PURPOSE OF REVIEW

GreenLight photoselective vaporization (GL-PV) is now established in the treatment of benign prostatic enlargement. The present review outlines the available technical armamentarium and summarizes the current best evidence on functional and safety outcomes. Moreover, future technical developments and refinements are presented.

RECENT FINDINGS

GL-PV has evolved to be the most commonly performed procedure, second to conventional transurethral resection of the prostate (TURP) for surgical management of benign prostatic obstruction (BPO). On the basis of the data published in the randomized controlled Goliath study, GL-PV with 180-W technology is noninferior in terms of functional outcomes compared with TURP considering short and intermediate follow-up with a complication-free rate of around 80% after 24 months.The ongoing push towards high-power lasers can be explained by their more effective tissue ablative effect, leading to shorter operating times. Comparative analysis between high-power and low-power laser systems demonstrated similar retreatment rates and most institutions are, therefore, now performing 180-W GL-PV.Performed as an outpatient procedure, GL-PV is cost-effective with a low hospital re-admission rate. Plasma kinetic vaporization of the prostate (PKVP) has recently emerged as a potential contender in the field; also GreenLight enucleation of the prostate (GreenLEP) might be even more effective than GL-PV.

SUMMARY

GL-PV appears to be a well tolerated surgical alternative for patients suffering from BPO. Long-term follow-up data from 120-W and 180-W laser systems are still pending. Potential competitors have recently been brought to the market and further trials and long-term data will show, whether GL-PV will stand the test of time. Regardless of technical specifications, surgeon's experience remains essential to achieve good functional and safety outcomes.

Optimal Monitoring of Prostate-Specific Antigen Detects Prostate Cancer at the Localized Stage after Photoselective Vaporization for Benign Prostatic Hyperplasia

Introduction

Photoselective vaporization of the prostate (PVP) does not provide prostate tissue for pathologic analysis. Here, we carried out early monitoring for prostate cancer by measuring prostate-specific antigen (PSA) levels and assessing clinicopathological features after PVP.

Materials and Methods

Patients (n = 800) who underwent PVP and were followed-up for more than 12 months were analyzed retrospectively. After PVP, PSA levels were measured at 3 and 12 months and each year thereafter. Prostate biopsies were performed when PSA levels increased continuously. We assessed the characteristics of patients diagnosed with prostate cancer.

Results

The mean follow-up period was 49 months. After PVP, 54 patients underwent biopsies, and 23 patients were diagnosed with prostate cancer. Overall, 10, 10, and 3 patients had clinical stage T1c, T2a, and T2b disease, respectively, and there were no cases of stage T2c disease or greater.

Conclusions

We found that it was possible to diagnose prostate cancer at a localized stage under our optimal PSA monitoring schedule before and after PVP.

Role of lasers in urology

Laser technology has long been a standard treatment for many diseases. In particular, laser treatment is considered the standard of care in various urological diseases. While originally primarily restricted to stone treatment, lasers have since evolved to play an important role even in the treatment of malignant diseases. In this review, we take a closer look at the history of lasers in urology and some implications for treatments today.

[Surgical treatment of BPO: Standard and innovations]

INTRODUCTION AND OBJECTIVE

Surgical management of benign prostatic hyperplasia has dramatically changed in the recent years towards higher proportion of endoscopic treatment and fewer perioperative complications. Nevertheless the question of urinary and sexual quality of life after surgical treatment remains partially unresolved with a high proportion of retrograde ejaculation after conventional surgical treatments. Therefore mini-invasive alternatives to conventional surgery have been proposed. The objective of this literature review was to provide an overview of the alternatives to monopolar TURP currently available in France.

MATERIAL AND METHOD

A non-systematic review of the scientific literature was conducted from the PubMed database to retrieve the most relevant scientific publications. A first research was cross-referenced with the results of literature reviews already published and enriched by the authors of this review. A synthesis is proposed for each alternative technique mentioning its level of clinical development, but also its potential advantages and disadvantages compared to conventional surgical techniques.

RESULTS

The quality of life of patients after surgical or interventional management has become the main priority of urologists since the risks of perioperative complication have been reduced by the use of laser or bipolar endoscopic techniques. Thanks to the development of minimally invasive alternatives that are better and better evaluated by randomized trials versus interventional simulation and conventional surgical treatment, more personalized care is possible. Patients' expectations and their individual risk factors can thus be placed at the center of the therapeutic decision and the preoperative information.

CONCLUSION

The surgical and interventional management of LUTS due to BPH has evolved to lower perioperative morbidity with the help of numerous technological developments. Mini-invasive alternatives to standard treatment have also been proposed in order to improve the quality of postoperative sexual life. These alternatives provide significant improvement in LUTS that remains lower than after conventional treatments. Somme of these alternative are also not fully supported by clinical trials, which should urge urologists to act with caution when proposing these alternatives in daily clinical practice.

A Review of Male Sexual Health and Dysfunction Following Surgical Treatment for Benign Prostatic Hyperplasia and Lower Urinary Tract Symptoms

PURPOSE OF REVIEW

Review how the various surgical treatments for benign prostatic hyperplasia and lower urinary tract symptoms impact on male sexual health and function.

RECENT FINDINGS

The interplay between benign prostatic hyperplasia and erectile function is complex, and the conditions seem linked. Most cavitating procedures to improve male voiding will degrade ejaculatory and possibly erectile function. Many of the newer minimally invasive therapies appear to preserve sexual function in the short term while sacrificing some of the voiding improvements realized with more complete removal of the prostate adenoma. Benign prostatic hyperplasia will affect the majority of men at some point in life, and surgical treatment remains an integral option for managing the associated urinary symptoms. These treatments are associated with variable rates of sexual side effects, including ejaculatory, erectile, and orgasmic dysfunction. As the impact of these treatment modalities on sexual dysfunction has become more widely acknowledged, there has been a rise in interest in modalities that minimize adverse sexual side effects. Recent studies have sought to further elucidate the relationship between surgical treatment of benign prostate hyperplasia and sexual outcomes, and a number of studies have demonstrated that treatment of benign prostate hyperplasia can actually result in improved sexual function for some patients. This work intends to review the proposed pathophysiology behind the sexual side effects resulting from the surgical treatment of benign prostate hyperplasia and review the literature regarding both established and emerging surgical techniques.

5-year long-term efficacy of 120-W GreenLight photoselective vaporization of the prostate for benign prostate hyperplasia

PURPOSE

To investigate 5-year long-term postoperative efficacy in benign prostate hyperplasia (BPH) following 120-W GreenLight high-performance system photoselective vaporization of the prostate (HPS-PVP).

METHODS

This was a retrospective study of surgical outcomes in 159 men who underwent HPS-PVP and were followed over 60 months postoperatively. Definitions of treatment success were established based on the following three variables: international prostate symptom scores (IPSS), maximum flow rates (Qmax), and quality of life scores QoL). Logistic regression analyses were performed to determine predictors of the postoperative success.

RESULTS

Postoperative IPSS/QoL, Qmax and post-voided residual urine volume were significantly improved after HPS-PVP. Postoperative Prostate specific antigen and prostate volume were also well reduced and sustained for 5 years. The postoperative success rate was assessed as 82.1%, 80.8% and 76.1% for each 1-, 3-, and 5-year. Thirty-eight (23.9%) patients had immediate postoperative complications, which were managed successfully with nonsurgical methods. None required transfusions, two (1.2%) patients required endoscopic reoperation for postoperative voiding difficulty due to bladder neck contracture or urethral stricture, and five (3.1%) required HPS-PVP reoperation. Presence of diabetes, voiding symptom subscore, QoL, maximal cystometric capacity, and bladder outlet obstructive index were valuable preoperative parameters for predicting postoperative success.

CONCLUSIONS

HPS-PVP is an effective, long-term treatment option for BPH, with sustained efficacy of 76.1% at 5-year follow up. Several preoperative parameters could help to predict the durable surgical improvements.

Recent research on the role of urodynamic study in the diagnosis and treatment of male lower urinary tract symptoms and urinary incontinence

Although evidence shows that urodynamic study may not improve outcomes, it can be used to evaluate men with lower urinary tract symptoms (LUTSs) which have not been adequately delineated and treated. In young men with LUTS not responding to treatment based on clinical examination, or elderly men with LUTS and incontinence, a complete urodynamic evaluation is mandatory to understand the pathophysiology underlying LUTS, such as bladder outlet obstruction (BOO), detrusor overactivity, and detrusor underactivity. Preoperative urodynamic study-proven BOO is a predictor of a successful surgical outcome. An urodynamic study should be performed when patients with LUTS are planning to undergo surgical treatment for benign prostatic obstruction.

Photoselective Vaporization of the Prostate Using 120 W High Performance System: A Prospective Evaluation of Results Over 2 Years

PURPOSE

This study evaluated the safety and efficacy of photoselective vaporization of prostate using the 120 W High Performance System for management of symptomatic benign prostatic hyperplasia (BPH).

METHODS

We prospectively obtained data from 229 patients between January 2009 and December 2012. We evaluated the serum prostate specific antigen level, International Prostate Symptom Score (IPSS), prostate volume; maximum urine flow rate (Q_max); and postvoid residual urine volume (PVR) in the patients at presentation and on follow-up at 1, 6, 12, and 24 months. The mean duration of the surgery, energy used, hospital stay, and intra- and postoperative complications were assessed.

RESULTS

The mean age of the patients was 71.2 ± 9.6 years, and the mean preoperative size of the prostate was 59.41 ± 28.1 mL. The mean duration of the surgery was 47.35 ± 16.14 min, and the mean energy use was 184.39 ± 101.3 kJ. The mean time to removal of the urinary catheter was 21.45 ± 11.06 h, while the mean duration of hospital stay was 24.82 ± 11.5 h. The IPSS declined and mean Q_max increased by over twofold within the first month. The PVR also declined significantly in all groups up to 6 months after the surgery and increased slightly thereafter. Urinary urgency and incontinence occurred in two patients, while four patients developed urinary strictures. Between 12 and 24 months after the surgery, four patients underwent repeat surgery.

CONCLUSIONS

Our findings show that photoselective vaporization is safe and effective for the management of BPH and resulted in few complications. It yielded improvements in all parameters that were sustained even up to 2 years after the surgery.

Benign Prostatic Obstruction Relief in Patients with Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Enlargement Undergoing Endoscopic Surgical Procedures or Therapy with Alpha-Blockers: A Review of Urodynamic Studies

Benign prostatic obstruction (BPO) contributes to the genesis of lower urinary tract symptoms as well as to pathologic remodeling of the lower and upper urinary tract in patients with benign prostate enlargement. Urodynamic studies demonstrate that both medical therapy with alpha-blockers (ABs) and endoscopic surgical procedures provide BPO relief. However, the magnitude of improvement is higher after surgery. Among ABs, silodosin is associated with the highest improvement of bladder outlet obstruction index (BOOI). A complex relationship exists between BOOI improvement and variations of both maximum urinary flow (Q _max) and detrusor pressure. When the reduction of BOOI is small, the improvement of Q _max is clinically irrelevant and the BOOI is mainly influenced by a decrease of detrusor pressure. In contrast, when the magnitude of BOOI reduction is robust, a meaningful improvement of both detrusor pressure and urinary flow is evident. When clustering ABs according to their receptor pharmacologic selectivity and urodynamic efficacy, three subgroups can be identified,with silodosin being the only member of a subgroup characterized by the highest levels of BOOI improvement and α-1A/α-1B receptor affinity ratio.

Bipolar, Monopolar, Photovaporization of the Prostate, or Holmium Laser Enucleation of the Prostate: How to Choose What's Best?

Endoscopic management of benign prostatic obstruction is based on resection, vaporization, or enucleation. Enucleation provides the best efficacy and long-term outcome. Lasers have advantages in patients at high risk of bleeding. Holmium enucleation is the best evaluated technique, but has a steep learning curve. Greenlight photovaporization is a safe alternative to transurethral resection of the prostate (TURP) in prostates of less than 100 mL, especially in patients at high risk of bleeding. Bipolar devices can be used for resection, vaporization, and enucleation and provides efficacy results similar to TURP in the short term with better safety.

[S2e guideline of the German urologists: Instrumental treatment of benign prostatic hyperplasia]

This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the instrumental treatment of the lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding open and transurethral procedures (TUR-P, bipolar TUR-P, TUI-P, HE-TUMT, TUNA, and the different Laser techniques). Recommendations are also given concerning intraprostatic stents and injection therapies. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.

A Systematic Review and Meta-Analysis of Functional Outcomes and Complications Following the Photoselective Vaporization of the Prostate and Monopolar Transurethral Resection of the Prostate

Purpose

To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing monopolar transurethral resection of the prostate (MTURP) and photoselective vaporization of the prostate (PVP) in order to provide the most up-to-date and reliable recommendations possible.

Materials and Methods

Relevant RCTs were identified from electronic databases for meta-analysis of the surgical outcomes and complications of MTURP and PVP. Meta-analytical comparisons were made using qualitative and quantitative syntheses. The outcome variables are presented as odds ratios with 95% confidence intervals (CIs).

Results

In total, 11 articles were included in this comparative analysis of PVP versus MTURP. Most of the recently published studies exhibited low risk in terms of quality assessment. MTURP was superior to PVP regarding operative time; however, with regard to catheterization and hospitalization time, the mean differences were -1.39 (95% CI=-1.83~-0.95, p<0.001) and -2.21 (95% CI=-2.73~-1.69, p<0.001), respectively, in favor of PVP. PVP was superior to MTURP with regard to transfusion rate and clot retention, but no statistically significant differences were found with regard to acute urinary retention and urinary tract infection. The long-term complications of bladder neck contracture and urethral stricture showed no statistically significant differences between PVP and MTURP. Long-term functional outcomes, including the International Prostate Symptom Score and maximum flow rate, likewise did not display statistically significant differences between PVP and MTURP.

Conclusions

Based on our findings, we believe that PVP should be considered as an alternative surgical procedure for treating male lower urinary tract symptoms secondary to benign prostatic hyperplasia.

Comparison of Patients Undergoing PVP Versus TURP for LUTS/BPH

Transurethral resection of the prostate (TURP) and photoselective vaporization of the prostate (PVP) are currently the two most commonly performed procedures for the treatment of benign prostatic hyperplasia (BPH). While each procedure has been shown to be efficacious, TURP or PVP may be preferred in certain clinical scenarios. A number of factors may influence the choice of which patients undergo PVP or TURP. This decision may take into account patient characteristics, such as age, co-morbidities, predominance of irritative symptoms, and/or ongoing anticoagulation. Additionally, balancing desired outcomes with possible risks is critical. Considerations should include possible effects on sexual function, rates of reoperation, cost, and need for tissue specimen in those at risk for prostate cancer. The primary objective of this article is to summarize the comparative research of PVP and TURP and the implications on differences between patients who undergo either procedure.

Different lasers in the treatment of benign prostatic hyperplasia: a network meta-analysis

All available surgical treatments for benign prostatic hyperplasia (BPH) have their individual advantages or disadvantages. However, the lack of head-to-head studies comparing different surgeries makes it unavailable to conduct direct analysis. To compare the efficacy and safety among different lasers and transurethral resection of prostate (TURP) for BPH, randomized controlled trials were searched in MEDLINE, EMBASE, Cochrane library, WHO International Clinical Trial Registration Platform, and Clinical Trial.gov by 2015.5; and the effectiveness-, perioperation- and complication-related outcomes were assessed by network meta-analysis. 36 studies involving 3831 patients were included. Holmium laser through resection and enucleation had the best efficacy in maximum flow rate. Thulium laser through vapo-resection was superior in improving international prostate symptom score and holmium laser through enucleation was the best for post-voiding residual volume improvement. Diode laser through vaporization was the rapidest in removing postoperative indwelling catheter, while TURP was the longest. TURP required the longest hospitalization and thulium laser through vapo-resection was relatively shorter. Holmium and thulium lasers seem to be relatively better in surgical efficacy and safety, so that these two lasers might be preferred in selection of optimal laser surgery. Actually, more large-scale and high quality head-to-head RCTs are suggested to validate the conclusions.

Evidence of the efficacy and safety of the thulium laser in the treatment of men with benign prostatic obstruction

In 2005, the high power thulium laser was introduced for the surgical treatment of benign prostatic obstruction. It has several properties that confer theoretical advantages over other lasers used for the same indication, such as technical versatility and a relatively small zone of thermal damage. Studies using the 70-150 W thulium laser systems demonstrate good efficacy of these procedures with low morbidity and few complications even in higher risk patients. Different techniques have been employed to treat the prostate with this technology, including enucleation, vapoenucleation, vaporization and resection. Comparative studies have been published comparing thulium laser prostatectomy to monopolar transurethral resection of prostate (TURP), bipolar TURP and holmium laser enucleation of prostate (HoLEP). In this review we discuss the current literature on the safety and efficacy of various thulium techniques for the treatment of benign prostatic hyperplasia and examine comparative studies.

Surgical Procedures for BPH/LUTS: Impact on Male Sexual Health

INTRODUCTION

Lower urinary tract symptoms (LUTS) because of benign prostatic hyperplasia (BPH) are a highly prevalent condition in men over 50 years old, and their incidence increases with age. The relationship between LUTS and erectile dysfunction (ED) has received increased attention recently because both diseases are highly prevalent, frequently co-associated in the same aging male group, and contribute significantly to the overall quality of life. In this review, we will examine the literature to assess the impact of surgical and minimally invasive treatments for LUTS/BPH on the male's sexual health.

METHODS

The impact of the various surgical and minimally invasive treatments for LUTS/BPH was reviewed to ascertain the impact on erectile and ejaculatory function.

RESULTS

Sexual side effects of treatment for LUTS/BPH are underappreciated by urologists but likely play a prominent role in patient decision making, creating a disparity between provider and patient. Almost all accepted therapies for LUTS (surgical or medical) can affect some aspect of sexual health, making it imperative that health-care professionals understand their patients' concerns and motivations in these two linked diseases. The incidence of newly diagnosed postoperative ED in patients treated with monopolar transurethral resection (TURP) is around 14%, with reported values in various studies ranging from 0-32.5%, 7.7%, 6.5%, 17%, to 14%. Importantly, there is no significant difference reported between bipolar and monopolar TURP on sexual function.

CONCLUSION

The risk of sexual side effects is an important one to consider in discussing the implications for any LUTS intervention as they play a prominent role in patient motivation, acceptance of bother and decision making concerning surgical intervention, thus creating a potential disparity between provider and patient. Becher EF and McVary KT. Surgical procedures for BPH/LUTS: Impact on male sexual health. Sex Med Rev 2014;2:47-55.

Postoperative Lower Urinary Tract Storage Symptoms: Does Prostate Enucleation Differ from Prostate Vaporization for Treatment of Symptomatic Benign Prostatic Hyperplasia?

PURPOSE

To assess the degree of postoperative storage symptoms after GreenLight™ laser photoselective vaporization of the prostate (PVP) and Holmium laser enucleation of the prostate (HoLEP) for management of benign prostatic hyperplasia (BPH) and its predictors.

METHODS

A retrospective review was performed for patients who underwent HoLEP or PVP for non catheter-dependent patients with BPH. Patients were followed up at 1, 3, 6, and 12 months and then annually by International Prostate Symptoms Score (IPSS), quality of life index, peak flow rate, residual urine volume, and prostate-specific antigen (PSA) level. Moderate or severe storage symptoms were defined as IPSS storage subscore ≥ 9.

RESULTS

Of 1673 laser procedures, a total of 1100 procedures met the inclusion criteria including 809 HoLEPs and 291 PVPs. The HoLEP group had significantly larger preoperative prostates and longer operative time. In the HoLEP group, postoperative IPSS was significantly better than in the PVP group at all follow-up points (P<0.05). Storage subscore was significantly higher after PVP and did not improve until 6 months postoperatively when it became comparable with that of the HoLEP group. The number of patients with IPSS-storage score ≥ 9 were significantly higher in the PVP group at 1 and 3 months follow-up (37.3% vs 15.1%, P<0.001) and (26.4% vs 17.5%, P=0.004), respectively. XPS-180W was associated with the lowest storage symptoms among the three GreenLight generations at all follow-up visits. In multivariate analysis, baseline IPSS-storage subscore ≥ 9, prolonged operative time >100 minutes, and lower percent of postoperative PSA level reduction significantly predicted less improvement of postoperative storage symptoms regardless of the laser procedure.

CONCLUSION

Storage urinary symptoms significantly improved more after HoLEP compared with PVP, irrespective of the generation of GreenLight laser used. Recovery from bothersome storage urinary symptoms after prostate vaporization is time dependent, and baseline degree of storage symptoms, prolonged operative time, and lower percent of postoperative PSA level reduction negatively predicts postoperative improvement of storage symptoms regardless of the laser procedure.

The Continuing Story of the Cost-Effectiveness of Photoselective Vaporization of the Prostate versus Transuretheral Resection of the Prostate for the Treatment of Symptomatic Benign Prostatic Obstruction

BACKGROUND

In 2008, a UK assessment of technologies for benign prostatic obstruction concluded negatively about photoselective vaporization of the prostate (PVP), and the 2010 National Institute for Health and Care Excellence guidance caused several UK institutions to abandon PVP.

OBJECTIVE

To reassess the costs and effects of PVP versus transurethral resection of the prostate (TURP) on the basis of most recent data.

METHODS

The same model was used as in 2008. Transition probabilities were estimated using a Bayesian approach updating the 2008 estimates with data from two meta-analyses and data from GOLIATH, the latest and largest trial comparing PVP with TURP. Utility estimates were from the 2008 assessment, and estimates of resource utilization and costs were updated. Effectiveness was measured in quality-adjusted life-years gained, and costs are in UK pounds. The balance between costs and effects was addressed by multivariate sensitivity analysis.

RESULTS

If the 2010 National Institute for Health and Care Excellence analysis would have updated the cost-effectiveness analysis with figures from its own meta-analysis, it would have estimated the change in quality-adjusted life-years at -0.01 (95% confidence interval [CI] -0.05 to 0.01) instead of at -0.11 (95% CI -0.31 to -0.01) as in the 2008 analysis. The GOLIATH estimate of -0.01 (95% CI -0.07 to 0.02) strengthens the conclusion of near equivalence. Estimates of additional costs vary from £491 (£21-£1286) in 2008 to £111 (-£315 to £595) for 2010 and to £109 (-£204 to £504) for GOLIATH. PVP becomes cost saving if more than 32% can be carried out as a day case in the United Kingdom.

CONCLUSIONS

The available evidence indicates that PVP can be a cost-effective alternative for TURP in a potentially broad group of patients.

Is absorption of irrigation fluid a problem in Thulium laser vaporization of the prostate? A prospective investigation using the expired breath ethanol test

BACKGROUND

Benign prostatic hyperplasia (BPH) is a prevalent entity in elderly men. If medical treatment fails, monopolar transurethral resection of the prostate (TUR-P) is still considered as the standard treatment. The proportion of high-risk patients with cardiac comorbidities increases and TUR-P goes along with a relevant perioperative risk. Especially large volume influx of irrigation fluid and transurethral resection syndrome (TUR syndrome) represent serious threats to these patients. Using isotonic saline as irrigation fluid like in transurethral laser vaporization (TUV-P), TUR syndrome can be prevented. However, no prospective trial has ever assessed occurrence or extent of irrigation fluid absorption in Thulium Laser TUV-P.

METHODS/DESIGN

This is a single-center prospective trial, investigating, if absorption of irrigation fluid occurs during Thulium Laser TUV-P by expired breath ethanol test. The expired breath ethanol technique is an established method of investigating intraoperative absorption of irrigation fluid: A tracer amount of ethanol is added to the irrigation fluid and the absorption of irrigation fluid can be calculated by measuring the expiratory ethanol concentrations of the patient with an alcohol breathalyzer. Fifty consecutive patients undergoing TUV-P at our tertiary referral center are included into the trial. Absorption volume of irrigation fluid during Thulium Laser TUV-P is defined as primary endpoint. Pre- to postoperative changes in bladder diaries, biochemical and hematological laboratory findings, duration of operation and standardized questionnaires are assessed as secondary outcome measures.

DISCUSSION

The aim of this study is to assess the safety of Thulium Laser TUV-P in regard to absorption of irrigation fluid.

The 80-W KTP GreenLight laser vaporization of the prostate versus transurethral resection of the prostate (TURP): adjusted analysis of 5-year results of a prospective non-randomized bi-center study

This study aims to compare long-term results of photoselective vaporization of the prostate (PVP) with an 80-W potassium titanyl phosphate (KTP) laser and monopolar transurethral resection of the prostate (TURP) in terms of efficacy, durability, and safety in an adjusted patient population. This prospective, non-randomized bi-center study included 120 (PVP) and 68 (TURP) patients in each arm. Patients were evaluated at 60 months of follow-up. Data from 30 (PVP) and 31 (TURP) patients were available for analysis. The primary outcome measurement was the International Prostate Symptom Score (IPSS) at 5 years. Secondary outcome measurements included voiding symptoms (quality of life (QoL) score), micturition parameters (maximal flow rate, Q max), post-void residual (PVR) volume, prostate-specific antigen (PSA) value, and reoperation rate. At study inclusion, voiding symptoms and micturition parameters were comparable between both groups. Age, prostate volume, and the proportion of patients with platelet aggregation inhibition or oral anticoagulation were significantly higher in the PVP group. No significant difference could be detected between patients available at 60 months and those lost to follow-up in terms of preoperative characteristics in either group. Sixty months postoperatively, the improvement of IPSS, QoL, Q max, and PVR volume showed no significant difference between both groups. PSA reduction was significantly higher after TURP. The reoperation rate due to urethral stricture (PVP, 13 %; TURP, none), bladder neck contracture (PVP, 3 %; TURP, none), and persisting or recurrent adenoma (PVP, 18 %; TURP, 3 %) was significantly higher after the 80-W PVP. Eighty-watt PVP leads to comparable functional outcomes to TURP. However, during a long-term follow-up, significantly more reoperations are necessary after PVP with the 80-W KTP laser, suggesting inferior tissue ablation capacity of the 80-W KTP laser.

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.

Comparison between complication rates of laser prostatectomy electrocautery transurethral resection of the prostate: A population-based study

INTRODUCTION

We compare the complication rates and length of stay (LOS) of laser transurethral resection of the prostate (L-TURP) versus electrocautery transurethral resection of the prostate (E-TURP) in a population-based cohort. L-TURP has shown enhanced intraoperative safety and equivalent efficacy relative to E-TURP in several high volume centres.

METHODS

Relying on the Florida Datafile as part of the Healthcare Cost and Utilization Project State Inpatient Databases (SID) between 2006 and 2008, we identified 8066 men with benign prostate hyperplasia who underwent L-TURP or E-TURP. Chi-square and Mann-Whitney tests were used to compare baseline characteristics. A multivariable linear regression model was used to analyze the effect of L-TURP versus E-TURP on complication rates and LOS.

RESULTS

Overall complication rates did not differ significantly for L-TURP compared to E-TURP in univariable (8.8 vs. 7.4%, p = 0.1) and multivariable analyses (odds ratio [OR]: 1.06, confidence interval [CI]: 0.85-1.32, p = 0.6). Individuals undergoing E-TURP were less likely to experience a LOS in excess of 1 day (46.2 vs. 59.7%, p < 0.001). A lower risk to experience a LOS in excess of 1 day was confirmed for patients undergoing L-TURP after a multivariable linear regression model (OR: 0.37, CI: 0.23-0.58, p < 0.001), but not for a LOS in excess of 2 days (OR: 0.96, CI: 0.83-1.10, p = 0.2).

CONCLUSIONS

Patient characteristics and perioperative safety were similar for L-TURP and E-TURP patients. However, LOS patterns demonstrated a modest benefit for L-TURP compared to E-TURP patients.

Vaporization of the prostate with 150-w thulium laser: complications with 6-month follow-up

Purpose: To analyze the efficacy and safety of vaporization of the prostate (VP) with the 150-W thulium:yttrium-aluminum-garnet (Tm:YAG) laser.

PATIENTS AND METHODS

In a prospective series of 55 patients with small- and medium-size prostates undergoing major outpatient surgery (MOS), the primary objectives were to analyze changes in maximum flow (Qmax) and International Prostate Symptom Score (IPSS) after 6 months. Immediate (<30 days) and late (>30 days) complications were subsequently recorded.

RESULTS

An increase in mean Qmax of 9.33 mL/s (95% confidence interval [CI] of the mean difference 6.73-11.93; P<0.001) was recorded, and mean IPSS was reduced by 16.88 points (95% CI 14.22-19.54; P<0.001). The immediate complications recorded were acute urinary retention (one patient), urinary tract infection without fever (two patients), and macroscopic hematuria (two patients). The only late complication observed was bladder neck sclerosis (one patient).

CONCLUSION

After 6 months, VP with 150-W Tm:YAG presents promising results in the clinical improvement of patients with small- and medium-size prostates. Its complication rate is low and it offers excellent hemostasis. The data from our study provide the basis for the design of clinical trials to compare this technique with other procedures.

Comparison of the risk of postoperative infection between transurethral vaporesection and transurethral resection of the prostate

BACKGROUND AND OBJECTIVE

We observed in our department at 3 months two episodes of bacteremia postoperatively to photoselective vaporization of the prostate (PVP). We decided to compare the frequency of postoperative urinary tract infections (POUTIs) in patients with preoperative bacterial colonization of urine between PVP and transurethral resection of the prostate (TURP).

MATERIALS AND METHODS

From January 2010 to December 2011, we studied patients who underwent PVP or TURP for benign prostatic obstruction in our department. Preoperative urine culture (UC) was carried out for all patients and we included those with preoperative bacterial colonization of the urinary tract. Patients were treated preoperatively with an appropriate antibiotic treatment and/or inductive prophylactic antibiotics. Patients were diagnosed with POUTI if they had clinical signs of infections (e.g., fever) and a positive UC during the month after surgery.

RESULTS

Patients were treated by PVP in 49 cases and TURP in 62 cases. A preoperative indwelling urinary catheter was inserted in 80% of the patients. During the postoperative period, eight episodes of fever were identified in the PVP group (16%), five (8%) in the TURP group (P = 0.18). We then studied the subgroup of patients with multiple bacteria strains present in the preoperative UC and identified significant differences. The risk of POUTI was significantly higher in patients treated by PVP than in those treated by TURP (P = 0.018).

CONCLUSIONS

We found significant differences between subgroups of patients with positive preoperative cultures (containing various bacterial strains). The risk of POUTI was significantly higher in patients treated by PVP.

Long-term outcomes of 80-watt KTP and 120-watt HPS GreenLight photoselective vaporization of the prostate

OBJECTIVE

Photoselective vaporization of the prostate (PVP) is becoming a surgical treatment alternative of transurethral resection of the prostate for male lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). We evaluated the outcome and postoperative complications of PVP performed by 80-W KTP and 120-W HPS GreenLight lasers (AMS®) over a 4-year period.

MATERIALS AND METHODS

This is a prospective monocentric study that included all patients who underwent PVP. They had routine follow-up at 1 month, 3 months, 6 months and every year until the fourth postoperative year. Listed data were maximum urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), post-void residual (PVR) volume, prostate-specific antigen (PSA) and prostate volume. We collected the postoperative complications.

RESULTS

From September 2005 to May 2008, 77 patients out of a 409 patients cohort underwent surgery and were followed during 4 years. At 4 years mean Qmax increase was 82.5%; mean IPSS, PVR volume, PSA and prostate volume decreases were 79.1, 69.8, 43.8 and 22.9%, respectively. The main side effects observed were storage LUTS. A urinary catheter was replaced after a first withdrawal failure in 10 patients (15.6%) after surgery.

CONCLUSIONS

PVP showed a sustainable efficacy and an appealing tolerance profile during a 4-year period in patients with LUTS secondary to BPO.

[Analysis of postoperative urgenturies after prostate photovaporization by the laser Greenlight ®]

Urgencies are classically described after prostate photovaporization (PVP). The objective of this study was to analyze the incidence of urgency in patients who underwent PVP using the International Prostate Symptom Score (IPSS) to defined urgencies.

METHOD

This is a single-center prospective cohort study assessing patients who underwent surgery between May 2005 and January 2011. The questions 2 and 4 of the IPSS and open questions were selected to evaluate urgency during the follow-up.

RESULTS

Two-hundred and four patients were operated during this period and 93 complete records were analyzed. Twenty-one percent of these patients had a clinical urgency after 1 month and 1,9% at 12 months (significant improvement, P<0.001) corresponding to scores greater than 4 for questions 2 and 4 of the IPSS. Answer scores to questions 2 and 4 improved significantly over 12 months (P<0.001). The clinical urgencies decreased significantly as well as answers to questions 2 and 4 of the IPSS.

CONCLUSION

Urgencies decreased significantly between 3 and 12 months of postoperative follow. Questions 2 and 4 of the IPSS score appeared to be a standardized definition of these urgencies.