Bipolar plasma enucleation of the prostate vs open prostatectomy in large benign prostatic hyperplasia cases - a medium term, prospective, randomized comparison

Transurethral bipolar enucleation using a TUEB loop for large benign prostatic hyperplasia: a retrospective cohort study

PURPOSE

We aimed to assess the efficacy and safety of transurethral enucleation with bipolar system (TUEB) regardless of the prostate size using a specially developed TUEB loop.

METHODS

A total of 251 patients who underwent TUEB were categorized into two groups depending on the prostate volume (PV): small-PV (≤ 80 mL) group, 133 patients; large-PV (> 80 mL) group, 118 patients. Comparisons of background information and treatment outcomes were performed between the groups.

RESULTS

Operation (113.5 vs 166.4 min), enucleation (49.4 vs 68.1 min), and morcellation (11.4 vs 26.4 min) times were longer and hemoglobin decreased significantly (0.84 vs 1.30 g/dL) in the large PV group. However, the enucleation efficiency (enucleated weight per enucleation time; 0.71 vs 0.97 g/min) and prostate-specific antigen reduction rate (24.6% vs 16.1%) were significantly better in the large-PV group, with similar enucleation rates (enucleated weight per transitional zone volume; 82% vs 81%). The International Prostate Symptom Score, uroflowmetry maximum flow rate, and post-void residual urine in both groups improved at 3, 6, and 12 months compared with baseline. No patient underwent blood transfusion. There were no differences in the frequency of postoperative clot retention, urethral stricture, or stress incontinence at 3, 6, and 12 months.

CONCLUSION

TUEB using a TUEB loop resulted in high levels of satisfaction regarding the enucleation efficiency, efficacy, and safety for BPH surgery regardless of the prostate size. TUEB should be considered one of the best treatment options for large BPH that is uncontrollable with medication.

Monopolar Transurethral Enucleoresection of Prostate: Feasibility of Modified Nesbit's Enucleoresection with Apical Release

Background: Transurethral resection of the prostate (TURP) has been the standard surgical treatment for Benign Hyperplasia of the Prostate (BPH) for decades. Our objective was to evaluate the outcome of our new technique: Monopolar Transurethral Enucleoresection of the Prostate (TUERP) with apical release (bring it all to centre). Methods: A prospective study of all cases undergoing TUERP at a tertiary centre from January 2020 to October 2022 was performed. Patient demographics, intraoperative variables and postoperative results along with follow-up data were collected. Data of all the cases who had completed a one-year follow-up post-surgery were included and analysed. Results: A total of 240 patients with complete data including a one-year follow-up were included. Mean prostatic volume was 55.3 ± 11.6 gm, and 28 (11.67%) cases were >100 gm. The mean operative time was 31.7 ± 7.6, and mean haemoglobin drop at 24 h was 0.73 ± 1.21 gm/dL. The overall complication rate was 16.67%, with only two (0.83%) Clavien-Dindo III complications (haematuria and clots needing evacuation) and the other complications being Clavien-Dindo I/II complications. Sustained improvement at 1 year of follow-up was noted: Qmax: 25.2 ± 5.6 mL/s, IPSS: 4.7 ± 2.5 and PVR: 22.5 ± 9.6 mL. Conclusions: Monopolar TUERP with a modified Nesbit's enucleoresection with apical release can be considered a promising technique, which needs further studies to be validated with appropriate comparisons.

Transurethral versus open enucleation of the prostate in Sweden - a retrospective comparative cohort study

OBJECTIVE

To investigate if treatment with transurethral enucleation of the prostate (TUEP) during the learning curve is as efficient and safe in the short term as transvesical open prostate enucleation (OPE), in patients with benign prostatic obstruction (BPO) > 80 ml in a population in Sweden.  Methods: 54 patients with ultrasound verified BPO > 80 ml and indication for surgery underwent TUEP or OPE between 2013 and 2019. Peri- and postoperative outcome variables regarding voiding efficiency and morbidity from 20 OPE at Skåne University Hospital (SUS) and from the first 34 TUEP performed at SUS and Ystad Hospital were retrospectively assembled. Follow-up data from the first 6 postoperative months were collected by chart review.

RESULTS

Intraoperative bleeding during TUEP was less than in OPE (225 ml vs. 1,000 ml). TUEP took longer surgery time than OPE (210 vs. 150 min.). Within 30 days postoperatively, bleeding occurred less often after TUEP (23% vs. 40%), requiring one fourth of the blood transfusions given after OPE. After TUEP, patients had shorter hospitalisation (3 days vs. 7 days) and catheterisation time (3 days vs. 12 days). During the 6-month follow-up period, incontinence and UTI defined as symtomatic significant bacteriuria (urinary culture) were observed as main complications after TUEP and OPE. Functional outcome data availability (International Prostate Symptom Score [IPSS] questionnaire, uroflowmetry, residual urine) were limited.

CONCLUSIONS

Treatment with TUEP during the learning curve led to less bleeding, shorter hospitalisation- and catheterisation time than treatment with OPE. However, surgery time was shorter with OPE. There were no major differences between the groups concerning mid-term functional outcomes, with the reservation of an inconsistent follow-up.

A randomized trial of holmium laser vs thulium laser vs bipolar enucleation of large prostate glands

OBJECTIVE

To compare the outcome and morbidity of bipolar transurethral enucleation of the prostate (B-TUEP) and thulium laser enucleation of the prostate (ThuLEP) with those of holmium laser enucleation of the prostate (HoLEP) in the treatment of large symptomatic benign prostatic obstruction (BPO) through a non-inferiority randomized controlled trial (NCT03916536).

PATIENTS AND METHODS

A total of 155 patients were recruited from a single centre between February 2019 and August 2020. All had BPO, with a prostate volume ≥80 ml. Patients were randomly assigned to HoLEP, ThuLEP or B-TUEP using computer-generated random tables in a 1:1:1 ratio. Participants, investigators and surgeons were blinded to group assignment until the date of the operation. Thereafter, the patients were followed up at 1, 3, 6 and 12 months. The primary outcome was maximum urinary flow rate (Qmax ) at 6 months. Secondary outcomes included assessment of other functional urinary variables, peri-operative records, and adverse events.

RESULTS

There were 138 and 120 patients available for analysis at 6 and 12 months. There was no significant difference in Qmax between the groups at 6 and 12 months (P = 0.4 and P = 0.7, respectively), and no significant difference regarding International Prostate Symptom Score (IPSS), quality of life (QoL) or postvoid residual urine volume (PVR). The median (interquartile range) prostate-specific antigen (PSA) reductions (ng/ml) were similar in the three groups at last follow-up point (4.7 [2.2-7.1]; 5.6 [2.3-9.5] and 5 [3.4-10] after HoLEP, ThuLEP and B-TUEP, respectively). Differences in enucleation time, enucleation efficiencies and auxiliary manoeuvres were statistically insignificant (P = 0.1, 0.8 and 0.07, respectively). At 1 year, patients with prostate volumes >120 ml showed significant IPSS improvement in favour of HoLEP and ThuLEP (P = 0.01). Low- and high-grade adverse effects were recorded in 31 and five cases, respectively, with no statistically significant difference between the groups.

CONCLUSIONS

We conclude that ThuLEP and B-TUEP are as safe and effective as HoLEP for the treatment of large-sized BPO. Significant PSA reductions indicate that there was effective adenoma enucleation with all three approaches. The study provides objective evidence that endoscopic enucleation of the prostate is a technique rather than energy dependent procedure.

Summary Paper on the 2023 European Association of Urology Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms

CONTEXT

Lower urinary tract symptoms (LUTS) are common, often bothersome, and have multifactorial aetiology.

OBJECTIVE

To present a summary of the 2023 version of the European Association of Urology guidelines on the management of male LUTS.

EVIDENCE ACQUISITION

A structured literature search from 1966 to 2021 selected the articles with the highest certainty evidence. The Delphi technique consensus approach was used to develop the recommendations.

EVIDENCE SYNTHESIS

The assessment of men with LUTS should be practical. A careful medical history and physical examination are essential. Validated symptom scores, urine test, uroflowmetry, and postvoid urine residual, as well as frequency-volume charts for patients with nocturia or predominately storage symptoms should be used. Prostate-specific antigen should be ordered if a diagnosis of prostate cancer changes the treatment plan. Urodynamics should be performed for selected patients. Men with mild symptoms are candidates for watchful waiting. Behavioural modification should be offered to men with LUTS prior to, or concurrent with, treatment. The choice of medical treatment depends on the assessment findings, predominant type of symptoms, ability of the treatment to change the findings, and the expectations to be met in terms of the speed of onset, efficacy, side effects, and disease progression. Surgery is reserved for men with absolute indications, and for patients who fail or prefer not to receive medical therapy. Surgical management has been divided into five sections: resection, enucleation, vaporisation, and alternative ablative and nonablative techniques. The choice of surgical technique depends on patient's characteristics, expectations, and preferences; surgeon's expertise; and availability of modalities.

CONCLUSIONS

The guidelines provide an evidence-based approach for the management of male LUTS.

PATIENT SUMMARY

A clinical assessment should identify the cause(s) of symptoms and define the clinical profile and patient's expectations. The treatment should aim to ameliorate symptoms and reduce the risk of complications.

Comparison of Holmium Laser Enucleation of the Prostate with Bipolar Plasmakinetic Enucleation of the Prostate: A Randomized, Prospective Controlled Trial at Midterm Follow-Up

Objective: To compare the clinical efficacy and safety of holmium laser enucleation of the prostate (HoLEP) with bipolar plasmakinetic enucleation of the prostate (BPEP) in the surgical management of obstructive benign prostatic hyperplasia (BPH) at midterm (minimum 3 years) follow-up. Patients and Methods: Between June 2016 and January 2018, 181 patients who had bothersome lower urinary tract symptoms or refractory retention of urine due to obstructive BPH (prostate 32-128 g) were randomized to undergo either HoLEP or BPEP using the en bloc technique. Patient's age, associated comorbidities, baseline International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), postvoid residual (PVR) urine, and quality of life (QoL) scores were comparable in both groups. From each group, 86 patients who completed regular follow-up for 36 months were analyzed. Results: The mean preoperative prostate volume was comparable in both groups (HoLEP group 61.09 ± 28.25 and BPEP group 62.66 ± 27.37 g). The HoLEP group showed a significantly better enucleation time (27.87 ± 13.18 minutes vs 38.37 ± 14.55 minutes), operative time (30.91 ± 14.82 minutes vs 41.63 ± 16.19 minutes), and enucleation efficiency (1.69 ± 0.28 vs 1.28 ± 0.06 g/min), with a lesser drop in hemoglobin (0.46 ± 0.23 vs 0.87 ± 0.26 g/dL). Bladder irrigation time, catheterization time, hospital stay, and sodium drop were comparable in both groups. One patient in the BPEP group needed clot evacuation. Both groups showed a significant reduction in IPSS, improvement in Qmax, reduction in PVR, and improved QoL scores at 3 months, which was maintained till 36 months. At the 3-year follow-up, two patients in each group needed reintervention for bladder neck contracture. Conclusions: HoLEP and BPEP provide comparable safety and efficacy in the treatment of bladder outlet obstruction due to BPH at the immediate and midterm (3-5 years) follow-up. HoLEP has an advantage of being faster with lesser perioperative morbidity.

Influence of transurethral enucleation with bipolar of the prostate on erectile function: Prospective analysis of 51 patients at 12-month follow-up

Background

Transurethral enucleation with bipolar (TUEB) is a safe and effective surgery for benign prostatic obstruction (BPO). However, few data exist concerning the influence of TUEB on erectile function (EF) in patients with BPO.

Objective

To evaluate the influence of TUEB on EF in patients with BPO at 3- and 12-month follow-up.

Material and methods

We prospectively enrolled 51 patients who underwent TUEB from June 2016 to April 2020. We evaluated maximum urinary flow rate (Qmax), postvoid residual urine (PVR), International Prostate Symptom Score (IPSS), quality of life (QoL), and International Index of Erectile Function-5 (IIEF-5) preoperatively and at 3- and 12-month follow-up. We classified the patients according to their preoperative IIEF-5 score into group 1 (IIEF-5 ≥10; n = 24) and group 2 (IIEF-5 <10; n = 27), and for further evaluation of EF, into subgroups a: severe (IIEF-5 5–7), b: moderate (8–11), c: mild to moderate (12–16), d: mild (17–21), and e: no erectile dysfunction (22–25). Data are displayed as median or median (interquartile range).

Results

The study comprised 51 patients with a median age of 75 (70.5–79.5) years. Median prostate and transition zone volumes were 69.5 (46.5–78.8) mL and 30.5 (19–43) mL, respectively. Urinary function improved significantly when comparing respective preoperative, 3-month, and 12-month follow-up values: Qmax (7.6, 12.9, 15.2 mL/s), PVR (50, 0, 0 mL), IPSS (20.5, 9, 6), and QoL (5, 2, 2), respectively. There was no significant change in IIEF-5 score across the three time points: 9, 7, 8. The IIEF-5 score slightly but significantly increased between the preoperative and 12-month follow-up values in group 2 (5, 5, 6) and subgroup a (5, 5, 5).

Conclusion

TUEB was effective and safe surgery for patients with BPO and showed no significant influence on EF at 12-month follow-up after TUEB in patients with BPO.

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

BACKGROUND

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Immediate Transurethral Plasma Kinetic Enucleation of the Prostate Gland for Treatment of Benign Prostatic Hyperplasia-Associated Massive Hemorrhage: A Single-Center Experience

Purpose: Benign prostatic hyperplasia-associated massive hemorrhage is a urological emergency. We evaluated the outcome from immediate transurethral plasma kinetic enucleation of the prostate gland (i-TUPKEP) for BHM treatment.

Methods: We retrospectively analyzed the records of 49 patients with acute BMH who underwent i-TUPKEP between January 2014 and November 2018 at our institution. The hemostatic effect, International Prostate Symptom Score (IPSS), and quality of life (QoL) score were evaluated preoperatively as well as 3, 6, and 12 months postoperatively. Postoperative follow-up also included measurement of the peak flow rate (Qmax) and post-void residual urine volume (PVR). Clinical characteristics, weight of resected tissue, duration of bladder irrigation, duration of hospital stay, complications, as well as the time required for enucleation and resection, were recorded.

Results: BMH causes were attributed to transurethral surgery (17/49, 34.7%), violent catheterization (13/49, 26.5%), cystoscopy (10/49, 20.4%), and urethral dilatation (9/49, 18.4%). Bleeding was from different sites of prostate-gland tissues during i-TURKEP. i-TUPKEP-controlled BMH effectively induced immediate, notable, and lasting improvements in the IPSS and QoL score. Qmax was close to normal, and the PVR was within the physiological range, postoperatively. Long-term complications were not observed.

Conclusion: Our preliminary data suggest that i-TUPKEP is a feasible method for controlling BHM and relieving BPH symptoms.

Holmium laser enucleation versus bipolar transurethral enucleation for treating benign prostatic hyperplasia, which one is better?

OBJECTIVE

This study aims to evaluate the overall efficacy and safety between holmium laser enucleation of the prostate (HoLEP) and bipolar transurethral enucleation of the prostate (B-TUEP) for the treatment of benign prostatic hyperplasia (BPH).

METHOD

We systematically searched electronic databases (PubMed, Scopus, Web of Science, and Cochrane Library) to identify eligible comparative studies as of July 2021. The parameters including perioperative results, complications, and functional outcomes were evaluated. RevMan version 5.4 was used for the analysis.

RESULTS

A total of 10 studies involving 1725 patients were included. HoLEP had lower operative time (p = .03), shorter catheterization time (p = .007), lower bladder irrigation time (p = .01), and higher enucleation weight (p = .01) compared with B-TUEP. However, there were no significant differences between the techniques regarding the length of stay (LOS), hemoglobin drop, transfusion rates, and complications. Furthermore, no significant differences were also observed in postoperative functional outcomes at 1, 3, 6, 12, or 24 months.

CONCLUSIONS

HoLEP has more advantages in perioperative parameters compared with B-TUEP, but no significant differences are found regarding functional outcomes and complications. Large-scale studies with long-term follow-up are required to compare the outcomes of these two techniques.

Predictors of Storage Symptom Improvement After Plasma Kinetic Enucleation of the Prostate

OBJECTIVE

To investigate which preoperative findings portend poor improvement in storage symptoms in patients undergoing plasma kinetic enucleation of prostate (PKEP).

METHODS

A single surgeon series of patients who had undergone PKEP with minimum 1 year follow up were evaluated. Patients were grouped into those with less than 33% improvement in storage symptoms (LIS) according to the international prostate symptom score (IPSS) and those with greater than 33% improvement in storage symptoms (GIS). Pre and postoperative factors were evaluated, along with IPSS, storage symptoms percentage (the total from frequency, urgency and nocturia divided by the total IPSS), bother index, and post void residual (PVR) at 6 weeks, 4 months, and yearly.

RESULTS

Two hundred sixty-eight patients had a minimum 1 year of follow up and had completed the IPSS. IPSS and bother index improved significantly from preoperatively to all time points post operatively in both groups, but the difference was greater in the GIS group. Patients in the GIS group had significantly larger prostates, more prostatic ingrowth, higher preoperative PVR, and a higher overall IPSS compared to the LIS group. Those in the LIS group had a higher incidence of prior prostate surgery, and a higher BMI. However, storage symptom percentages were equal between the GIS and LIS groups at all time points.

CONCLUSION

Greater prostatic ingrowth, larger prostate volume, higher preoperative PVR volume, and a higher overall IPSS was associated with greater improvement in storage symptoms. Prior prostate surgery and higher BMI portend less improvement in storage symptoms.

Anatomical endoscopic enucleation of bladder outlet obstruction

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

Bipolar Transurethral Enucleation of the Prostate: Is it a size-independent endoscopic treatment option for symptomatic benign prostatic hyperplasia?

Background

Bipolar Transurethral Enucleation of the Prostate (B-TUEP) is recommended as a first-choice treatment for benign prostatic obstruction in prostates >80 ml. Differently, B-TUEP is only considered as an alternative option after TURP for smaller prostates (30–80 ml). The aim of our study is to assess the relation between prostate size and surgical outcomes after B-TUEP.

Methods

We performed a retrospective analysis of data collected from 172 patients submitted to B-TUEP. Patients were segregated according to tertiles of prostate volume (PV) (≤60 ml, 61–110 ml, >110 ml). For each group we evaluated enucleation efficacy (enucleated weight/enucleation time), complication rates, urinary and sexual function parameters. Functional and sexual parameters were compared between groups at baseline, 1 and 3 months follow up. Descriptive statistics and linear and logistic regression models tested the association between PV and postoperative complications/outcomes.

Results

Operative time and weight of enucleated adenomas increased along with prostate volumes (all p≤0.01). Enucleation efficacy was higher in men with PV >110 ml compared to other groups (p≤0.001). Length of hospital stay, catheterization time and rates of postoperative complications, such as transfusion and clot evacuation rates and bladder neck/urethral strictures, were comparable between groups. Urinary symptoms improved at 1-and 3-months in each group as compared to baseline evaluation (all p<0.01) but they did not differ according to PV. In each group maximum urinary flow and post-void residual volume significantly improved at 3 months compared to baseline (all p≤0.01), without differences according to PV. Sexual symptoms were similar between groups at each follow up assessment. At multivariable linear and logistic regression analysis, prostate volume was not associated with postoperative functional outcomes and complications. Conversely, patient’s comorbid status and antiplatelet/anticoagulation use were independently associated with postoperative complications.

Conclusion

According to our findings, B-TUEP should be considered a “size independent procedure” as it can provide symptom relief in men with prostates of all sizes with the same efficacy and safety profile.

Enucleation vs. Resection: A Matched-pair Analysis of TURP, HoLEP and Bipolar TUEP in Medium-sized Prostates

OBJECTIVE

To evaluate efficacy and safety of holmium laser enucleation of the prostate (HoLEP), bipolar enucleation of the prostate (bTUEP) and transurethral resection of the prostate (TURP) in medium-sized prostates (50cc).

METHODS

We present a retrospective analysis of 2230 patients treated for lower urinary tract symptoms. We analysed perioperative parameters, short-term clinical outcomes and adverse events in matched-pair cohorts.

RESULTS

Both HoLEP and bTUEP were superior in terms of efficacy compared to TURP (surgery time: 51min and 50min vs. 60min; P < 0.001; tissue retrieval percentage: 71.4% and 70% vs. 50%; P < 0.001) and showed stronger improvement of LUTS (change IPSS: -15 and -14 vs. -10; P = 0.008). Furthermore, urodynamic parameters (Qmax: +15 ml/s and +19 ml/s vs. +12 ml/s; P < 0.001; PVR: -100 ml and -95 ml vs. - 80ml; P < 0.008) were significantly more improved after enucleation than after TURP. All techniques showed an equally low complication rate (6.9% and 6.9% vs. 10.3%; P = 0.743). No relevant difference of clinical outcomes was identified between HoLEP and bTUEP.

CONCLUSION

Both resection and enucleation are efficient and safe procedures in patients with medium-sized prostates (50cc), but irrespective of the technical approach, transurethral enucleation is superior to TURP in terms of perioperative and functional outcomes.

MODERN METHODS OF ENDOSCOPIC ENUCLEATION OF BENIGN PROSTATIC HYPERPLASIA AND PROSPECTS FOR THEIR MODIFICATION

The disadvantage of bipolar and holmium enucleation in transurethral surgery of benign prostatic hyperplasia (BPH) is the frequent postoperative urination disorders. To increase the effectiveness of surgical treatment, a modification of the surgical technique is necessary.Objective: to compare the perioperative results of endosurgical treatment of large sized BPH using transurethral bipolar (TUEB), laser (HoLEP) and modified laser prostate enucleation (HoLEP-M) methods. Patients and methods: A randomized prospective study was conducted according to the results of surgical treatment of 1104 patients with BPH with a volume of 80 to 350 cm3, divided by methods of endoscopic enucleation of the prostate. A mod-ification of the HoLEP technique was to optimize access to the surgical site with the designation of new anatomical landmarks.Results: Comparison of surgical methods showed their equivalence in the volume of removed tissue, the low frequency of hemorrhagic and infectious complications, the dynamics of urological indicators in the delayed period. TUEB has the least parameters for the time of surgical intervention (98.2 ± 2.24 min.), the vol-ume of blood loss (65.5 ± 1.83 ml), the terms of postoperative catheterization of the bladder (2.0 ± 0.32 days), and the days of hospitalization (3.2 ± 0.40 days). The safety of laser methods is higher than TUEB, during which 3.1% of closed perforations of the prostatic capsule and bladder were observed (versus 0.8-1.5% with laser methods). Modification of the HoLEP technique allows reducing the frequency of late dysuric disorders by 2-3 times, urinary incontinence by 3.4-4 times, cicatricial complications by 1.7-2 times.Conclusion: Bipolar and laser methods of transurethral enucleation of the prostate of large sizes are comparable by criteria of complete removal of prostatic tissue, effectiveness and tolerability in patients with thrombohemorrhagic risk. In terms of the frequency of intraoperative injuries, the safety of laser methods is higher due to the reduced penetrating ability of laser energy. Modification of surgical access to the prostate preserves the prostatic urethra as much as possible and is a promising measure for the prevention of late obstructive and functional complications of transurethral interventions.

Superselective prostatic artery embolization in the treatment of large benign prostatic hyperplasia

PURPOSE

To evaluate the use of prostatic artery embolization (PAE) as a treatment option for patients with symptomatic benign prostatic hyperplasia (BPH) with prostate volumes of 80 cc and more.

MATERIALS AND METHODS

The study included 75 patients with high anesthesia-related risks for conventional surgery (TURP). All patients were surveyed for symptom burden, using IPSS and quality of life score. The prostate volume was determined by transrectal ultrasonography (TRUS). At baseline, prostate-specific antigen (PSA) level was obtained in all patients. Urodynamics was evaluated using uroflowmetry. Clinical outcomes were assessed at follow-up 1, 3, 6, 12, and 24 months after PAE.

RESULTS

The prostate volume decreased significantly at months 1 and 3 post-treatment; the prostate continued shrinking until month 12, and the size was then stabilized. At month 24, prostate volume decreased by 40.82%, from 134.0 ± 8.3 mL at baseline to 79.3 ± 6.6 mL. Postvoid residual (PVR) urine volume was significantly decreased from 55.9 ± 5.3 mL to 22.0 ± 1.8 mL 1 month after PAE (p < 0.001). Qmax increased from 9.2 ± 0.3 mL/s to 15.7 ± 0.4 mL/s. IPSS score following PAE decreased from 28.2 ± 0.7 to 9.7 ± 0.8 (p < 0.001). QoL improvement was observed from 4.8 ± 0.2 at baseline to 1.8 ± 0.2 at month 24 (p < 0.001). Decreased activity and density of adenomatous tissue resulted in decreased total PSA levels: from 5.9 ± 1.1 ng/mL to 2.6 ± 0.2 ng/mL (p < 0.001). TURP became feasible in 35 patients due to reduction of prostate volumes below 80 mL after PAE.

CONCLUSIONS

PAE was effective in relieving LUTS and reducing prostate size, and may be considered as a preoperative approach for patients with large prostate.

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

OBJECTIVE

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

METHODS

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

RESULTS/GUIDELINES

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

CONCLUSION

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

Holmium laser enucleation of prostate versus minimally invasive simple prostatectomy for large volume (≥120 mL) prostate glands: a prospective multicenter randomized study

BACKGROUND

The aim of this study was to compare the perioperative and functional results between laparoscopic and robot-assisted simple prostatectomy (LSP and RASP) and Holmium laser enucleation of prostate (HoLEP) in prostate volumes ≥120 mL. The primary endpoint was to investigate and compare minimally invasive techniques in the management of large prostate gland volume, and the secondary endpoint was to evaluate the frequency and type of postoperative complications according to Clavien Dindo Classification.

METHODS

This multicenter study was conducted on male patients with LUTS associated with BPO candidates for surgical treatment. The surgery approach choice in relation to the prostatic volume ≥120 mL was HoLEP or minimally-invasive simple prostatectomy (LSP or RASP). All patients were prospectively randomized into three groups, according to a simple computed randomization: HoLEP, LSP and RASP groups. During the follow-up, all patients underwent postoperative control at 1, 3, 6, 12 and 24 months from the surgical procedure.

RESULTS

One hundred ten male patients were randomized in three homogeneous groups: 36 in LSP, 32 in RASP and 42 in HoLEP group. During the follow-up (mean 26.15 months), despite the significant improvement compared to baseline results, no significant differences were shown, between the groups in terms of functional and perioperative outcomes. The only statistically significant data was reported for catheterization time, that resulted longer in the LSP group than RASP and HoLEP groups (P=0.002). Furthermore, MISP resulted in longer hospitalization, and lower rate of patients with new-onset irritative symptoms.

CONCLUSIONS

This prospective randomized study is the first to compare extraperitoneal LSP, RASP and HoLEP in the treatment of LUTS secondary to benign prostatic hyperplasia for prostate volumes ≥120 mL. Our findings confirm the safety and efficacy of MISP, demonstrating its equivalence in functional outcomes and perioperative morbidity in comparison to HoLEP.

Laparoscopic simple prostatectomy vs bipolar plasma enucleation of the prostate in large benign prostatic hyperplasia: a two-center 3-year comparison

PURPOSE

To compare surgery outcomes and safety of button bipolar enucleation of the prostate vs laparoscopic simple prostatectomy in patients with large prostates (> 80 g) in a two-center cohort study.

METHODS

All patients with lower urinary tract symptoms due to benign prostatic enlargement (Prostate volume > 80 cc) undergoing button bipolar enucleation of the prostate (BTUEP) or laparoscopic simple prostatectomy (LSP) in two centers were enrolled. Data on clinical history, physical examination, urinary symptoms, uroflowmetry and prostate volume were collected at 0, 1, 3 6, 12, 24 and 36 months. Early and long-term complications were recorded.

RESULTS

Overall, 296 patients were enrolled. Out of them, 167/296 (56%) performed a LSP and 129/296 (44%) performed a BTUEP. In terms of efficacy both procedures showed durable results at three years with a reintervention rate of 8% in the LSP group and of 5% in the BTUEP group. In terms of safety, BTUEP and LSP presented similar safety profiles with a 9% of transfusion rate and no major complications.

CONCLUSION

LSP and BTUEP are safe and effective in treating large-volume adenomas with durable results at three years when performed in experienced centers.

Medication Discontinuation Following Transurethral Prostatectomy: an Unrecognized Effectiveness Measure?

PURPOSE OF REVIEW

Freedom from medication is a common goal for patients undergoing surgical treatment of benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS). Knowing medication discontinuation rates following various forms of transurethral prostatectomy may aid patient counseling and assessing the comparative effectiveness of different approaches. This review examined discontinuation rates of BPH/LUTS medications following transurethral prostatectomy.

RECENT FINDINGS

Rates of BPH/LUTS medication use after transurethral resection of the prostate varied from 15% to 55%, and discontinuation rates were 54-95% across medications and follow-up periods. For laser prostatectomy, approximately 18% of patients continued medications postoperatively and discontinuation rates ranged from 53% to 75%. Minimal data on holmium laser enucleation existed. For reference, medication discontinuation rates after transurethral needle ablation or microwave therapy were only 15-28%. No recommendations or best practices inform the use of medical therapy following BPH surgery. Rates of BPH/LUTS medication use following transurethral prostatectomy are considerable.

[TUEB (TRANSURETHRAL ENUCLEATION WITH BIPOLAR) COMBINED WITH CYSTOTOMY OF THE GIANT PROSTATIC HYPERTROPHY: A CASE REPORT]

A 75-year-old man with urinary retention was referred to our hospital. Pelvic magnetic resonance imaging showed that his prostate was remarkably enlarged, with an estimated prostate weight of 509 g. He underwent TUEB (transurethral enucleation with bipolar) combined with cystotomy. The surgical specimen weighed 349 g. He did well postoperatively, and his urinary function was improved at 3 months after the operation. Although transurethral methods are effective for resection of adenoma and control of bleeding, effective performance of the procedure with a resectoscope and resection of an adenoma in cases of giant prostatic hypertrophy need to be considered on a case-by-case basis.

Endoscopic enucleation for prostate larger than 60 mL: comparison between holmium laser enucleation and plasmakinetic enucleation

PURPOSE

To compare perioperative and functional outcomes of two different energy sources, holmium laser and bipolar current for endoscopic enucleation of prostate larger than 60 mL.

METHODS

A prospective, monocentric, comparative, non-randomized study was conducted including all patients treated for prostate larger than 60 mL, measured by transrectal ultrasound. Patients were assigned to each group based on the surgeons' practice. Perioperative data were collected (preoperative characteristics, operating, catheterization and hospitalization times, hemoglobin loss, complications) and functional outcomes (IPSS, IPSS Quality of Life (QoL), PSA) at 3 months and 1 year.

RESULTS

100 patients were included in each group from October 2015 to March 2018. No differences between HoLEP and plasma groups were observed at baseline, except for mean IPSS score, IPSS QoL score and preoperative PVR that were significantly higher in the HoLEP group. Operating time (142.1 vs 122.4 min; p = 0.01), catheterization time (59.6 vs 44.4 h; p = 0.01) and hospitalization time (2.5 vs 1.8 days; p = 0.02) were significantly shorter in the plasma group. Complication and transfusion rate were no significantly different between HoLEP and plasma. No significant differences were observed concerning functional outcomes at 3 months and 1 year. The urinary incontinence rate was higher 21.1% vs 6.4% (p < 0.01) at 3 months in HoLEP group, but no difference was observed at 1 year.

CONCLUSION

Holmium and plasma are both safe and effective for endoscopic treatment for prostate larger than 60 mL. Operating, catheterization and hospitalization times were significantly shorter in the plasma group. The complication rate and functional outcomes were not significantly different.

Prostate artery embolization for the treatment of urinary retention caused by large (>80 ​mL) benign prostatic hyperplasia: Results of 21 patients

Objective

A large prostate size (>80 ​mL) of benign prostatic hyperplasia (BPH) is technically challenging to treat surgically. This study aimed to investigate the safety and efficacy of super-selective prostatic artery embolization (PAE) for the treatment of urinary retention caused by large BPH.

Methods

A total of 21 patients with urinary retention, indwelling urinary catheter, or suprapubic cystostomy as a consequence of giant BPH (prostate volume [PV] ​> ​80 ​mL) who sought treatment between January 2013 and December 2017 were enrolled. A microcatheter (1.9-2.7 Fr) and a "two-step embolization" combining 50-μm and 100-μm polyvinyl alcohol embolization particles were used in all patients. International Prostate Symptom Score (IPSS), quality of life (QoL), PV, and prostate-specific antigen (PSA) were evaluated at 3, 6, and 12 months post-PAE. Clinical success was defined as removal of urinary catheter or suprapubic cystostomy and ability to void spontaneously.

Results

The clinical success rate was 95.2% (20/21). Compared with pre-procedural values, IPSS, QoL, PV, and PSA showed statistically significant differences at 3, 6, and 12 months post-PAE (P ​< ​0.05). There were no serious complications after PAE.

Conclusions

PAE was safe and effective for the treatment of urinary retention caused by large BPH in patients without surgical treatment options.

How to optimise urinary continence in anatomical endoscopic enucleation of the prostate?

The traditional transurethral resection of the prostate (TURP) is considered as gold-standard surgical treatment to relieve symptoms resulting from bladder outlet obstruction by prostate enlargement. However, with the advances of novel laser technologies and more experienced surgeon conquering the steep learning curve, anatomical endoscopic enucleation of prostate (AEEP) has become a more popular alternative surgical technique. Although AEEP has compatible functional outcome, less blood loss, shorter catheterisation duration and hospital stay, the risk of post-operative urinary incontinence (UI) is often an issue of concern. In this review, we focus on discussion about risk factors related to increased incidence of UI, some surgical tips to avoid damaging external urinary sphincter and treatment strategies to facilitate recovery of urinary continence after surgery.

The Feasibility and Efficacy of Ultrasound-Guided C2 Nerve Root Coblation for Cervicogenic Headache

OBJECTIVE

The cervicogenic headache is a syndrome caused by dysfunction of the upper cervical spine and its component bony, disc, and/or soft tissue elements. The C2 nerve root may play a pivotal role in cervicogenic headache. In this retrospective study, we evaluated the feasibility and efficacy of ultrasound-guided C2 nerve root coblation in managing 26 patients with cervicogenic headache.

DESIGN AND SETTING

The data were collected retrospectively by reviewing the patient's medical records and pain questionnaires.

SUBJECTS AND METHODS

A total of 109 patients with cervicogenic headache sustained for at least six months were identified. Of those patients, 26 had a visual analog scale score ≥6 and subsequently underwent an ultrasound-guided C2 nerve root coblation.

RESULTS

All 26 patients had >50% pain relief one day after coblation. Twenty-three of the 26 patients (92.31%) had a decrease in their pain score of 50% or more at 24-week follow-up. The mean pain score was 7.38 ± 1.13 before coblation and 1.85 ± 0.83 one day after coblation (Bonferroni-adjusted P < 0.001). At 12 and 24 weeks after coblation, the mean pain scores were 2.96 ± 0.96 (P < 0.001) and 3.08 ± 1.38 (P < 0.008), respectively.

CONCLUSIONS

C2 nerve coblation may provide the majority of patients with a pain relief period as long as 24 weeks. And ultrasound guidance is an efficient method with which to perform coblation.

Transurethral endoscopic enucleation of the prostate using a diode laser versus bipolar plasmakinetic for benign prostatic obstruction: a meta-analysis

To evaluate the clinical efficacy and safety of diode laser enucleation of the prostate (DiLEP) versus bipolar plasma kinetic enucleation of the prostate (PKEP) in the management of benign prostatic hyperplasia (BPH). A systematic literature search was undertaken using PubMed, Embase, Web of Science, Cochrane Library, and CKNI databases to identify eligible studies published before April 2019. The quality of evidence and methodology was assessed. Primary outcomes were clinical and demographic characteristics and postoperative efficacy including maximum flow rate (Qmax), postvoid residual (PVR), quality of life (QoL), and International Prostate Symptom Score (IPSS); secondary outcomes were intraoperative variables and major complications. Meta-analyses of extracted data were performed with the RevMan version 5.2. The overall effects were determined by the Z-test, and a p value less than 0.05 was considered with significant difference. A fixed- or random-effect model was chosen to fit the pooled heterogeneity (determined by Chi-squared test and I²). As qualified trials were few, subgroup analyses were not performed. Four randomized controlled trials (RCTs) involving 451 patients were enrolled in our meta-analysis. In the included trials, all the diode (wavelength at 980 nm and 1470 nm) lasers applied output at continuous wave mode; the energy settings ranged from 120 to 160 W for enucleation and 30 to 60 W for coagulation. DiLEP provided less perioperative hemoglobin decrease (MD = - 3.22; 95% CI (- 5.15, - 1.29); p = 0.001; I² = 65%), less postoperative catheterization time (MD = - 17.82; 95% CI (- 32.74, - 2.90); p = 0.02; I² = 96%), less postoperative irrigation time (MD = - 7.15; 95% CI (- 13.67, - 0.62); p = 0.03; I² = 98%), and lower incidence of urinary irritative symptoms (OR = 0.31; 95% CI (0.14, 0.67); p = 0.003; I² = 0%) compared with PKEP. During the 1, 3, 6, and 12-month postoperative follow-up, no statistically significant difference was found in Qmax, IPSS, QoL, and PVR between the procedures. As regards other perioperative and postoperative parameters and major complications, we found no significant difference. Both DiLEP and PKEP are safe and efficient methods for the treatment of BPH. However, DiLEP showed less perioperative hemoglobin decrease, less postoperative catheterization time, less postoperative irrigation time, and lower rates of postoperative irritative symptoms compared with the PKEP group.

Ergonomics and musculoskeletal symptoms in surgeons performing endoscopic procedures for benign prostatic hyperplasia

BACKGROUND AND PURPOSE

Benign prostatic hyperplasia (BPH) is the most common urologic disorder affecting older men, necessitating medical or surgical intervention. Limited data exists regarding the effect these surgeries have on the endourologist's musculoskeletal system following the surgery because of the required difficult posture, prolonged procedures, repetitive movements, and the settings of an adjustable visual display terminal workstation. The aim of our study was to survey the prevalence and possible causes of musculoskeletal disorders among endourologists performing transurethral resection of the prostate (TURP) or laser prostatectomy using either holmium laser enucleation or thulium laser enucleation.

MATERIALS AND METHODS

An email inviting all members of the Endourological Society to participate in the survey was sent. The questionnaire included different demographic and practice characteristics, with concern regarding performing either TURP or laser prostatectomy and the incidence and type of musculoskeletal incidents following these surgeries. All responses were collected by a commercially available internet based survey host (www.surveymonkey.com) over a period of 6 weeks.

RESULTS

Of the 121 complete responses, 84 (69%) of endourologists complained of a musculoskeletal disorder following TURP or laser prostatectomy. The most frequent complaint was for neck (64%), followed by back (57%), shoulder (48%), hand (40%), and elbow (18%). The average prostate volume turned out to be the most compelling predictor for musculoskeletal disorder occurrence with an average prostate volume of 76 g operated on by the complaining group compared with 59 g in the noncomplaining group. Those with more severe symptoms were linked to a mean prostate size of 80 g (60-146) and constantly complained of shoulder, neck, or back trouble compared with the less-severely complaining group.

CONCLUSIONS

A high prevalence of musculoskeletal complaints among urologists performing endourologic prostatectomy was confirmed and was found to be proportionally related to the size of the prostate. The integration of an ergonomic specialist inside the operation room to watch and correct the surgeon's position during endourologic procedures may reduce the endourologist's exposure to these occupational hazards.

Bipolar endoscopic enucleation versus bipolar transurethral resection of the prostate: an ESUT systematic review and cumulative analysis

PURPOSE

To perform a cumulative analysis of the current evidence on the surgical and functional outcomes of bipolar endoscopic enucleation of the prostate (b-EEP) versus bipolar transurethral resection of the prostate (b-TURP).

METHODS

A systematic review of the literature was performed on PubMed, Ovid^®, and Scopus^® according to Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA Statement). The meta-analysis was conducted using the Review Manager 5.3 software. Parameters of interest were surgical and functional outcomes. Weighted mean difference, and odds ratio with 95% confidence interval were calculated for continuous and binary variables, respectively. Pooled estimates were calculated using the random-effect model.

RESULTS

Fourteen comparative studies were included. No statistically significant difference in terms of overall baseline characteristics was found. b-EEP had higher amount of resected tissue (p < 0.0001), shorter catheter time (p = 0.006), lower Hb drop (p = 0.03), and shorter length of stay (p < 0.0001). Equally, overall post-operative complications were lower (p = 0.01) as well as short (p = 0.04), and long-term complication rate (p = 0.04). There was higher re-intervention rate in the b-TURP group (p = 0.02) whereas b-EEP group had smaller residual prostate volume (p = 0.03), and lower post-operative PSA values (p < 0.00001). At long term, b-EEP presented lower IPSS (p = 0.04), higher Q_max (p = 0.002), and lower PVR (p < 0.00001).

CONCLUSIONS

b-EEP is an effective and safe surgical treatment for BPO. This procedure might offer several advantages over standard b-TURP, including the resection of a larger amount of tissue within the same operative time, shorter hospitalization, lower risk of complications, and lower re-intervention rate. This was submitted to PROSPERO registry: CRD42019126748.

Monopolar enucleation versus transurethral resection of the prostate for small- and medium-sized (< 80 cc) benign prostate hyperplasia: a prospective analysis

AIM

To assess efficacy and safety of monopolar enucleation of the prostate (MEP) and to compare it with the current treatment standard for medium-sized prostates, < 80 cc, transurethral resection of the prostate (TURP).

METHODS

A prospective analysis patients undergoing a surgical procedure for their diagnosis of BPH (benign prostatic hyperplasia) (IPSS > 20, Q_max < 10; prostate volume < 80 cc) was performed. IPSS, Q_max were assessed preoperatively, at 6 and 12 months postoperatively. The complications were classified according to the modified Clavien-Dindo grading system.

RESULTS

A total of 134 patients were included in the study: 70 underwent MEP and 64 - TURP for BPH (mean prostate volumes were comparable with p = 0.163). The mean surgery time was 44 min in the TURP group and 48.2 min in the MEP group, (p = 0.026). Catheterization time for MEP was 1.7 and 3.2 days for TURP (p < 0.001). Hospital stay for MEP was 3.2 days vs. 4.8 days for TURP (p < 0.001). Both techniques shown comparable efficiency in benign prostatic obstruction relief with IPSS drop in MEP from 23.1 to 5.9 and in TURP group from 22.8 to 7.3, whereas Q_max increased from 8.2 to 20.5 after MEP and from 8.3 and 19.9 after TURP. Urinary incontinence rate after catheter removal in TURP group was 9.0% and 7.8% in MEP group, at 1 year follow-up, it was 1.4% and 3.1% in MEP and TURP, respectively (p = 0.466).

CONCLUSIONS

Our experience demonstrated that MEP is an effective and safe BPH treatment option combining the efficacy of endoscopic enucleation techniques and accessibility of conventional TURP.

Clinical Comparison of Holmium Laser Enucleation of the Prostate and Bipolar Transurethral Enucleation of the Prostate in Patients Under Either Anticoagulation or Antiplatelet Therapy

BACKGROUND

A significant number of patients who require surgery for benign prostatic hyperplasia are under either anticoagulation (AC) or antiplatelet (AP) therapy.

OBJECTIVE

To assess the efficacy and morbidity of holmium laser enucleation of the prostate (HoLEP) and bipolar transurethral enucleation of the prostate (B-TUEP) in patients who required AC/AP therapy.

DESIGN, SETTING, AND PARTICIPANTS

This study included 296 (67.6%) and 142 (32.4%) patients who underwent HoLEP and B-TUEP, respectively. The AC/AP group included patients whose AP therapy was not interrupted pre-, peri-, and/or postoperatively, and patients who underwent perioperative AC therapy bridging with low-molecular-weight heparin.

INTERVENTION

HoLEP and B-TUEP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We tested the hypothesis that AC/AP therapy had a limited impact on the efficacy of HoLEP and B-TUEP. To adjust for potential baseline confounders, propensity-score matching was performed. Clinical characteristics were compared among groups using the Kruskal-Wallis or chi-square test. Logistic regression analyses tested the association between clinical variables and the odds of Clavien-Dindo ≥2 complications after surgery.

RESULTS AND LIMITATIONS

Overall, 28 (9.5%) and 46 (15.5%) patients in the HoLEP group and 15 (10.5%) and 24 (16.9%) men in the B-TUEP group had AC and AP therapy, respectively (p=0.9). HoLEP patients under either AC or AP therapy deserved longer catheter maintenance and a longer hospital stay (HS) than those without AC/AP therapy (all p≤0.01). Operative time, rates of postoperative complications, and 2-mo International Prostate Symptoms Score (IPSS) were similar between patients with and without AC/CP. Among B-TUEP patients, HS was longer (p=0.03) and the rate of complications was higher (p<0.001) in patients under AC or AP therapy. Postoperative haemoglobin drop and 2-mo IPSS were similar among groups and surgical techniques. Limitations are the retrospective nature of the study, and the lack of long-term complications and functional outcomes.

CONCLUSIONS

HoLEP and B-TUEP can safely be performed in patients deserving continuous AP/AC therapy with only a slight increase in HS and catheterisation time.

PATIENT SUMMARY

We assessed the safety and efficacy of holmium laser enucleation of the prostate (HoLEP) and bipolar transurethral enucleation of the prostate (B-TUEP) in men under chronic anticoagulation/antiplatelet therapy. Both HoLEP and B-TUEP could safely be performed as minimally invasive treatment options in this subset of patients at a high risk of bleeding from benign prostatic hyperplasia surgery.

Comparison of bipolar plasmakinetic transurethral enucleation and resection of prostate gland in patients receiving anticoagulants and/or platelet aggregation inhibitors

BACKGROUND

The aim of this study was to evaluate the safety and efficacy of bipolar plasmakinetic enucleation of the prostate (BPEP) and bipolar plasmakinetic transurethral resection of prostate (B-TURP) for patients on oral anticoagulants (OA) and/or platelet aggregation inhibitors (PAI) with benign prostatic obstruction (BPO) and having a gland size of >60 g.

METHODS

Patient database of our hospital for the period of May 2012 to September 2017 was retrospectively reviewed for BPH patients with a gland size of >60 g who either underwent BPEP or B-TURP and were on OA and/or PAI. Patient demographic, perioperative, and follow-up data were analyzed.

RESULTS

There were no significant differences between the two surgical groups preoperatively. The mean operative time was lower in the BPEP group however, no statistical difference was found between them (P=0.77). There was significant difference in the mean resected tissue weight (52.11±17.92 vs. 77.19±17.78 g, P value ≤0.001), irrigation time and total hospital stay in favor of BPEP group. The blood loss observed in the B-TURP group and BPEP group was 2.57±0.36 and 1.45±0.44 g/dL, respectively, which was statistically significant (P<0.033). Eight and three patients of B-TURP and BPEP groups needed blood transfusion respectively. All patients were followed up for 12 months postoperatively. Both groups resulted in a significant improvement from baseline in terms of IPSS, QoL, Q-max, and PVRU volume values. No significant difference was found between them, however.

CONCLUSIONS

Both procedures are safe and effective options in patients who are on OA and/or PAI but BPEP is better in terms of low clot retention rate, less irrigation time and decreased hospital stay.

1470 nm Diode Laser Enucleation vs Plasmakinetic Resection of the Prostate for Benign Prostatic Hyperplasia: A Randomized Study

Objective: The purpose of the current work was to comparatively assess 1470 nm diode laser enucleation of the prostate (DiLEP) and plasmakinetic resection of the prostate (PKRP) for treating benign prostatic hyperplasia (BPH).

Patients and Methods: From January 2016 to March 2017, 157 individuals with bladder outflow obstruction caused by BPH were randomized to DiLEP and PKRP groups, for prospective analysis. Of these, 152 cases were evaluated before operation and at 3, 6, and 12 months postsurgery. Patient baseline properties, presurgery data, and postsurgical outcomes were comparatively assessed, as well as complications.

Results: There were no significant preoperative differences between surgical groups. DiLEP-treated cases showed remarkable reduced operative time, postsurgical bladder irrigation time, catheterization duration, and hospital stay compared with the PKRP group (P < 0.001). Hemoglobin amount decrease was markedly less pronounced after DiLEP (P = 0.004). However, no patients needed blood transfusion in either group. The decrease in sodium level showed no marked differences between the DiLEP and PKRP groups (P = 0.380). In addition, complications were comparable and no significant differences in both groups. At 3, 6, and 12 months, International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and postvoid residual (PVR) were similar in both groups (P > 0.05).

Conclusions: DiLEP and PKRP are similar in efficacy and safety for relieving obstruction and low urinary tract symptoms. Compared with PKRP, DiLEP has decreased risk of hemorrhage, operative time, bladder irrigation time, catheterization duration, and hospital stay. However, IPSS, QoL, Qmax, and PVR were similar for both procedures within 12 postoperative months.

Transurethral Enucleation With Bipolar Energy (TUEB):AINU Technique and Short-term Outcomes

OBJECTIVE

To present our transurethral enucleation with bipolar energy (TUEB) technique, wherein the enucleated adenoma is resected while keeping it attached near the verumontanum avoiding the need of a morcellator, and to evaluate the safety and short-term outcomes of our technique of TUEB for the treatment of symptomatic benign prostatic hypertrophy (BPH).

METHODS

This was a retrospective evaluation of prospectively maintained database of patients with symptomatic BPH who underwent TUEB from January 2016 to September 2017. Patients with a minimum follow-up period of 6 months were included in the study. All patients were assessed using the international prostate symptom score (IPSS), uroflometry (Q-max), and transrectal ultrasonography (TRUS) of the prostate. TUEB was indicated for patients with total prostate volumes >60 g on TRUS. Postoperative outcome measures, including urinary incontinence, Q-max, and IPSS, were recorded at each follow-up visit.

RESULTS

A total of 103 patients underwent TUEB. The mean patient age was 64 ± 7 years, and the median operative time was 54 minutes (interquartile range [IQR]: 44-66). The median resected prostate weight was 39 g (IQR: 28-54 g), corresponding to approximately 87% of the assessed transitional zone volume. The mean postoperative hemoglobin drop of 1.08 ± 0.28 g/dL was clinically insignificant. There was significant improvement in the IPSS and Q-max postoperatively, when compared to baseline parameters (P < .05).

CONCLUSION

Our TUEB technique is safe and effective in treating symptomatic BPH with acceptable complications and favorable short-term outcomes. TUEB allows near-complete enucleation of a prostate adenoma, followed by resection, thus avoiding the need for a morcellator.

Dual-centre randomized-controlled trial comparing transurethral endoscopic enucleation of the prostate using diode laser vs. bipolar plasmakinetic for the treatment of LUTS secondary of benign prostate obstruction: 1-year follow-up results

PURPOSE

Bipolar endoscopic enucleation of the prostate (BEEP) was recommended by the 2016 EAU guidelines as the first choice of surgical treatment in men with a substantially enlarged prostate and moderate-to-severe lower urinary tract symptoms. The main aim of this study was to compare a modified diode laser enucleation of the prostate (DiLEP) to BEEP.

METHODS

A total of 114 patients with prostate (20-160 mL) were randomized 1:1 into either DiLEP or BEEP in a dual-centre, non-inferiority-design randomized-controlled trial. The primary outcomes included Q_max and IPSS at 12 months. Non-inferiority was evaluated by comparing the two-sided 95% CI for the mean differences of Q_max and IPSS. Secondary endpoints included other perioperative parameters, postoperative micturition variables, and complication rate.

RESULTS

A total of 111 patients (97%) had completed the intent-to-treat analysis, The results showed that DiLEP was comparable to BEEP regarding Q_max (28.0 ± 7.0 vs. 28.1 ± 7.2 mL/s) and IPSS (3.0 ± 2.2 vs. 2.9 ± 2.6) at 12 months, the non-inferiority was met for both Q_max and IPSS. There were also no significant difference between two groups regarding tissue removal rate (71.8 vs. 73.8%), hemoglobin decrease (0.33 ± 0.66 vs. 0.36 ± 0.75 g/dL), sodium decrease (1.0 ± 2.7 vs. 0.3 ± 2.9 mmol/L), and Clavien III complications (5.3 vs. 1.8%) at 12 months.

CONCLUSIONS

This DiLEP is an anatomical endoscopic enucleation technique for the treatment of benign prostatic hyperplasia, it is non-inferior to BEEP regarding Q_max and IPSS at 12 months postoperatively.

MRI features after prostatic artery embolization for the treatment of medium- and large-volume benign hyperplasia

PURPOSE

To assess magnetic resonance imaging (MRI) features after prostatic artery embolization (PAE) for the treatment of medium- and large-volume benign prostatic hyperplasia and to correlate prostate volume with clinical indexes.

METHODS

We retrospectively evaluated 28 patients who underwent PAE. MRI examinations of the prostate were performed to evaluate signal intensity changes and the characteristics of infarcted areas. Prostate volume and the apparent diffusion coefficient (ADC) were measured at an average of 10 days post-PAE and at 1, 3, 6, and 12 months post-PAE. Some clinical indexes were evaluated before and 12 months after PAE. The paired t test, ANOVA, and multiple linear correlation analyses were performed by using the statistical software, SPSS.

RESULTS

All patients experienced prostatic infarction. The prostate volume decreased continuously (p < 0.05). The ADC values before and after 1, 3, 6, or 12 months of embolization (b = 1000 and 2000 s/mm²) were statistically significantly different. The ADC values (b = 3000 s/mm²) were also statistically significantly different before and at each interval time after embolization (p < 0.05). Prostate volume changes correlated significantly with patient age and post-void residual urine volume (p < 0.05).

CONCLUSIONS

MRI can be used for assessing changes in signal intensity and ADC values of infarction as well as the volume of the prostate after PAE. After PAE, ultrahigh b value diffusion-weighted imaging (DWI) can show early infarction better than lower b value DWI.

Benign prostatic hyperplasia surgical scoring (BPHSS): an novel scoring system for the perioperative outcomes of holmium laser enucleation of the prostate

To develop a standardized scoring system, the BPH surgical scoring (BPHSS) system, to quantify the ability to predict the perioperative outcomes resulting from an enlarged prostate. There are two parts included in this study: the retrospective observational study (875 patients treated with holmium laser enucleation of the prostate, HoLEP) and the prospective observational study (111 patient underwent HoLEP). All the outcome data included the following: the basic patient preoperative characteristics, operation time (OT), pre- and post- surgery hemoglobin decrease, Na⁺ variation, hospital stay duration, duration of bladder irrigation, catheterization time, and hospitalization time. The BPHSS, consisting of prostatic volume (PV), prostate-specific antigen (PSA), bladder stones, intravesical prostatic protrusion (IPP), and metabolic syndrome (MetS), was observed regarding the perioperative outcomes. In the retrospective study, patients in high BPHSS group (6-8 points) showed significant increase in the OT (74.61, 95%CI = 16.98-327.84, P < 0.001), hemochrome reduction (416.50, 95%CI = 35.48-4889.88, P < 0.001), hospital stay (1.80, 95%CI = 1.35-2.41, P < 0.001), and bladder irrigation duration (4.04, 95%CI = 1.35-12.10, P = 0.013) compared with the low BPHSS group (0-2 points). In the prospective study, there also existed significant differences between the three scoring grades (P < 0.01) in OT, hemochrome decrease, and the hospital stay. The BPHSS is suitable to predict the perioperative outcomes in patients undergoing HoLEP. It may help urologist to prepare more before surgery to treat the enlarged prostates. Further studies are needed to validate this scoring system in BPH patients in multiple centers.

Bipolar transurethral enucleation and resection of the prostate: Whether it is ready to supersede TURP?

Objective

According to the EAU Guidelines, transurethral resection of the prostate (TURP) has so far still been considered as the gold standard for surgical treatment for patients with obstructing clinical benign prostate hyperplasia (BPH). However, its relatively high rate of complications and postoperative recurrence necessitates further modification and innovation on the surgery technique. We reported the patient outcomes with our technique.

Methods

We retrospectively analyzed 52 patients with obstructing clinical BPH who underwent bipolar transurethral enucleation and resection of the prostate (B-TUERP) between March 2015 and September 2015. Pre- and perioperative parameters were obtained from medical charts. Postoperative follow-ups were administrated at 1, 3, 6, 12 and 24 month(s) after surgery, respectively.

Results

All the operations were performed successfully with a mean operative time of 43.1 min and an average tissue removal rate of 74.7%. Q_max was significantly improved immediately after surgery, followed by a continuous improvement throughout the follow-ups. Following a steep decrease in mean prostate specific antigen (PSA) and post void residual (PVR) observed within the first half year after surgery, the serum PSA was then maintained at a constant level of 0.61 ng/mL. Temporary urinary retention was found in four cases (7.7%). Stress urinary incontinence occurred in five patients (9.6%), with the condition resolved in 1–2 weeks without extra treatment. Urethral strictures and bladder neck contractures, as the most commonly observed long-term complications, developed in four patients (7.7%). No recurrence was found during 2 years of follow-ups. An improvement in International Index of Erectile Function (IIEF-5) scores was witnessed in 17 patients preoperatively with normal sexual function during the first 6 months after surgery, and sustained throughout the 24-month period.

Conclusions

Enucleation reflects an improvement on surgical technique in many ways with a need for surgical equipment that can be broadly accessible in clinical practice. Currently, bipolar resection is a commonly employed procedure in clinical settings, and its similarity shared with bipolar enucleation technique warrants a quick learning of B-TUERP by urologists. Based on these findings, we believe that the substitution of TURP by TUERP as the gold standard for prostate endoscopic procedure can be expected in the future.

Bipolar Plasmakinetic Enucleoresection of the Prostate: Our Experience with 245 Patients for 3 Years of Follow-Up

OBJECTIVE

The aim of this study was to evaluate the safety, feasibility, and effectiveness of bipolar transurethral plasmakinetic enucleation of the prostate (PKEP).

PATIENTS AND METHODS

Between January 2010 and October 2013, 245 patients with lower urinary tract symptoms due to benign prostatic hyperplasia underwent transurethral enucleation of prostate using bipolar plasma vaporization energy. Patients were evaluated preoperatively by full detailed history, routine preoperative investigation digital rectal examination, serum prostate-specific antigen, abdominal and transrectal ultrasonography, and maximum flow rates (Q_max).

RESULTS

Patients' ages ranged from 50 to 81 (65.5 ± 6) years with transrectal ultrasound-measured prostate volume of 97.1 ± 36.7 mL resulting in an operating time of 76.9 ± 27.9 minutes, and postoperative irrigation and catheterization times were 3.5 ± 3.2 and 12.7 ± 6.1 hours, respectively. No significant complication occurred intra- or postoperatively. Q_max increased from 7.1 ± 3.2 mL/second preoperative to 18.4 ± 4.2 mL/second (p < 0.001). The International Prostate Symptom Score decreased from 25 ± 6 to 7.9 ± 2.4 (p < 0.01).

CONCLUSION

This study confirmed that PKEP is a safe, easy to learn, and durable technique suitable for any prostate sizes.

A prospective, randomized trial comparing thulium vapoenucleation with holmium laser enucleation of the prostate for the treatment of symptomatic benign prostatic obstruction: perioperative safety and efficacy

INTRODUCTION AND OBJECTIVES

To compare the perioperative outcomes of thulium vapoenucleation of the prostate (ThuVEP) with holmium laser enucleation of the prostate (HoLEP) for patients with symptomatic benign prostatic obstruction (BPO).

METHODS

Forty-eight and 46 patients were prospectively randomized to ThuVEP and HoLEP. All patients were assessed preoperatively and 4-week postoperatively. The complications were noted and classified according to the modified Clavien classification system. Patient data were expressed as median (interquartile range) or numbers (%).

RESULTS

Median age at surgery was 73 (67-76) years and median prostate volume was 80 (46.75-100) cc and not different between the groups (p = 0.207). The median operative time was 60 (41-79) minutes without significant differences between both groups (p = 0.275). There were no significant differences between the groups regarding catheterization time [2 (2-2) days, p = 0.966] and postoperative stay [2 (2-3) days, p = 0.80]). Clavien 1 (13.8%), Clavien 2 (3.2%), Clavien 3a (2.1%), and Clavien 3b (4.3%) complications occurred without significant differences between the groups. However, the occurrence of acute postoperative urinary retention was higher after HoLEP compared to ThuVEP (15.2 vs. 2.1%, p ≤ 0.022). At 1-month follow-up, peak urinary flow rates (10.7 vs. 22 ml/s), post-void residual volumes (100 vs. 20 ml), International Prostate Symptom Score (20 vs. 10) and Quality of Life (4 vs. 3) had improved significantly (p ≤ 0.005) without significant differences between the groups.

CONCLUSIONS

ThuVEP and HoLEP are safe and effective procedures for the treatment of symptomatic BPO. Both procedures give equivalent and satisfactory immediate micturition improvement with low perioperative morbidity.