Preoperative pelvic floor muscle exercise for early continence after holmium laser enucleation of the prostate: a randomized controlled study

Real world propensity score matched analysis evaluating the influence of en-bloc vs. non en-bloc techniques, energy and instrumentation on enucleation outcomes for large and very large prostates

PURPOSE

The primary aim of the study was to evaluate if en-bloc vs. non en-bloc made a difference to intra-, peri- and post-operative surgical outcomes of anatomical endoscopic enucleation (AEEP) in large (> 80 cc) and very large prostates (> 200 cc). The secondary aim was to determine the influence of energy and instruments used.

METHODS

Data of patients with > 80 cc prostate who underwent surgery between 2019 and 2022 were obtained from 16 surgeons across 13 centres in 9 countries. Propensity score matching (PSM) was used to reduce confounding. Logistic regression was performed to evaluate factors associated with postoperative urinary incontinence (UI).

RESULTS

2512 patients were included with 991 patients undergoing en-bloc and 1521 patients undergoing non-en-bloc. PSM resulted in 481 patients in both groups. Total operation time was longer in the en-bloc group (p < 0.001), enucleation time was longer in the non en-bloc group (p < 0.001) but morcellation times were similar (p = 0.054). Overall, 30 day complication rate was higher in the non en-bloc group (16.4% vs. 11.4%; p = 0.032). Rate of late complications (> 30 days) was similar (2.3% vs. 2.5%; p > 0.99). There were no differences in rates of UI between the two groups. Multivariate analysis revealed that age, Qmax, pre-operative, post-void residual urine (PVRU) and total operative time were predictors of UI.

CONCLUSIONS

In experienced hands, AEEP in large prostates by the en-bloc technique yields a lower rate of complication and a slightly shorter operative time compared to the non en-bloc approach. However, it does not have an effect on rates of post-operative UI.

Novel online comprehensive pelvic floor therapy program following prostatectomy

Background

Although pelvic floor muscle training (PFMT) is widely shown to improve post-prostatectomy incontinence (PPI), numerous barriers impede access to formal PFMT and include the limited availability of specialized therapists and financial or scheduling barriers. To address these barriers, we developed a novel online program delivering comprehensive long-term PFMT, pelvic floor education (PFE), and dietary/behavioral modification education. This study is a prospective interim analysis of online PFMT/PFE (oPFMT/PFE), with focus on feasibility, satisfaction, and continence outcomes.

Methods

Patients anticipating robotic-assisted laparoscopic prostatectomy (RALP) were recruited (6/2021-9/2022) for oPFMT/PFE. oPFMT/PFE comprises a 12-month program of 3 phases, including multiple exercises with varied contraction types and duration, and comprehensive dietary and behavioral technique education. Incontinence and quality of life (QOL) outcomes are assessed at 3 weeks, 3, 6, and 12 months following RALP using validated International Consultation on Incontinence Questionnaire Male Lower Urinary Tract Symptoms (ICIQ-MLUTS) and Incontinence Impact Questionnaire (IIQ-7) questionnaires and additional items assessing satisfaction, improvement, and daily pad use. Primary study outcomes included ICIQ-MLUTS stress urinary incontinence (SUI) domain score (SDS) and SUI cure [ICIQ SUI domain score (SDS) =0]. Interim 6-month analysis was performed using mixed effects linear regression and mixed effects Poisson regression.

Results

Analysis included 21 men (64±6 years). At 6-month follow-up, men undergoing oPFMT/PFE showed significant improvement in SDS compared to the 3-week time point [mean ± standard error (SE) =1.05±0.24 vs. 0.45±0.17, P=0.011], but still experienced higher scores than at baseline (P=0.017). Six-month patient-reported improvement averaged 7.42±0.74 (10-point Likert scale). All (100%) of 19 respondents (2 missing data) found the program easy to use, educational, and would recommend it to others, with 89% expressing satisfaction with the program. During patient interview at 6-month follow-up, no men reported inability to access the program online or any adverse events. Finally, IIQ-7 score improved significantly from the 3-week timepoint (4.47±1.10) at both time points (3-month 1.14±0.44, P<0.001 and 6-month 1.10±0.37, P<0.001), and neither 3- nor 6-month scores differed from baseline (P=0.808 and P=0.444, respectively).

Conclusions

Our novel oPFMT/PFE yields significant improvements to validated urinary incontinence (UI) and QOL measures, providing a valuable and accessible treatment option for PPI.

Is Holmium Laser Enucleation of the Prostate Truly Size-Independent? A Critical Evaluation at the Extreme Ends of the Spectrum

OBJECTIVE

To assess the outcomes of holmium laser enucleation of the prostate (HoLEP) at the extremes of the size spectrum, comparing whether the results are consistent for very large and small prostates.

METHODS

A retrospective review of 402 patient charts was conducted to compare the outcomes of HoLEP in patients with prostate size ≤40 g (group 1), 41-200 g (group 2), and >200 g (group 3). Various preoperative, perioperative, and postoperative variables were collected.

RESULTS

HoLEP showed comparable voiding outcomes among all 3 groups, although patients with small prostates had a higher International Prostate Symptom Score during follow-up (P = .022). We noted a higher rate of perioperative blood transfusion in patients with very large prostates (P = .019) and a higher rate of transient acute urinary retention (AUR) in group 1 when compared to group 3 (P = .048). Patients with smaller prostates had a higher rate of bladder neck stenosis and urethral strictures, but the differences were not found to be statistically significant. The incidence of other complications, length of hospital stay, and catheterization duration did not differ significantly among the groups.

CONCLUSION

HoLEP has consistent and safe outcomes across a wide range of prostate sizes. Although, the risk of blood transfusion is higher in patients with very large prostates and the risk of transient AUR is greater in patients with small glands, the overall efficacy and safety of HoLEP are not significantly influenced by prostate size.

Non-pharmacological and nonsurgical interventions in male urinary incontinence: A scoping review

AIMS

To describe and synthesize non-pharmacological and nonsurgical interventions for male urinary incontinence from the existing literature.

METHODS

A scoping review was conducted following the methodology suggested by Arksey and O'Malley: (1) identification of the research questions; (2) identification of relevant studies using a three-step search recommended by JBI: an initial search within PubMed and CINAHL, a comprehensive literature search within PubMed, CINAHL, EMBASE, PsycINFO, Cochrane Library, and literature search of references lists; (3) study selection; (4) data extraction and charting; (5) collation, summarization, and reporting of the results. The PRISMA-ScR Checklist was used to report.

RESULTS

A total of 4602 studies were identified, of which 87 studies were included. Approximately 78% were randomized controlled trials. More than 88% of the participants were men with prostate cancer. Exercising pelvic floor muscles 30 times per day for 12 weeks was the most frequently reported. Parameters of electrical stimulation were typically set up to 50 Hz and 300 μs for frequency and width of pulse, respectively, and lasted for 15 min. Pure pelvic floor muscle training, Pilates, Yoga, whole body vibration, diaphragm/abdominal muscle training, micturition interruption exercise, acupuncture, and auriculotherapy showed positive effects on reducing urinary incontinence.

CONCLUSION

The findings suggested implementing pelvic floor muscle training alone before or after surgery can both prompt the recovery of continence in men after prostate cancer surgery. The decision to use biofeedback or electrical stimulation to enhance the therapeutic effect of pelvic floor muscle training should be approached with caution. More rigorous designed studies are needed to validate the effectiveness of Traditional Chinese Medicine techniques and diverse novel methods.

RELEVANCE TO CLINICAL PRACTICE

Physicians and nurses need to be up to date on the latest evidence-based non-pharmacological and nonsurgical interventions in male urinary incontinence and select appropriate interventions based on available medical resources and patient preferences.

Surgical prehabilitation in older and frail individuals: a scoping review

Background:

Older individuals who are scheduled for elective procedures often have co-morbidities at baseline and may be classified as frail. Both older age and frailty are associated with poor fitness and preoperative deconditioning, which can be predictors of postoperative complications. Prehabilitation aims to improve preoperative health in order to reduce complications and expedite postoperative recovery. To date, the effect of prehabilitation on improving outcomes in older and frail individuals is unclear, and the evidence in support of multi-modal treatments is evolving.

Methods:

In this scoping review, searches of PubMed and Cochrane Library between August 2012 and August 2022 were performed to identify studies investigating the efficacy of prehabilitation prior to surgical procedures.

Results:

A total of 36 articles were included in the review. Most of these examined the efficacy of unimodal (n=21) prehabilitation interventions, most commonly exercise therapy. Multimodal prehabilitation programs (n=15) included a variety of intervention components (e.g., exercise training, nutrition, psychological intervention or geriatric consultation). The most commonly studied populations were patients with gastrointestinal cancer (mostly colorectal cancer). Exercise therapy and multimodal interventions are likely to be of greatest impact on postoperative functional decline in patients awaiting total knee or hip arthroplasty, and cancer-related resection surgery (e.g., due to colorectal, gastric or lung cancer) in older and frail patients.

Conclusions:

Presurgical prehabilitation showed the potential to diminish postoperative outcomes in older and frail patients prior to surgery. However, adequately powered, randomized controlled, assessor blinded intervention trials demonstrating overall benefit of prehabilitation are needed.

Aims

This scoping review aims to summarize the current literature on the efficacy of prehabilitation in older and frail individuals who are undergoing surgical procedures in order to support clinical protocols and inform future research.

Physiotherapy as an Effective Method to Support the Treatment of Male Urinary Incontinence: A Systematic Review

Urinary incontinence (UI) is a serious health issue that affects both women and men. The risk of UI increases in men with age and after treatment for prostate cancer and affects up to 32% of men. Furthermore, UI may affect up to 69% of men after prostatectomy. Considering such a high incidence, it is critical to search for effective methods to mitigate this issue. Hence, the present review aims to provide an overview of physiotherapeutic methods and evaluate their effectiveness in treating UI in men. This systematic review was performed using articles included in PubMed, Embase, WoS, and PEDro databases. A total of 6965 relevant articles were found. However, after a risk of bias assessment, 39 studies met the inclusion criteria and were included in the review. The research showed that the available physiotherapeutic methods for treating men with UI, including those after prostatectomy, involve pelvic floor muscle training (PFMT) alone or in combination with biofeedback (BF) and/or electrostimulation (ES), vibrations, and traditional activity. In conclusion, PFMT is the gold standard of UI therapy, but it may be complemented by other techniques to provide a personalized treatment plan for patients. The effectiveness of the physiotherapeutic methods varies from study to study, and large methodological differences make it difficult to accurately compare individual results and draw unequivocal conclusions.

[Quality of life and outcome after holmium laser enucleation of the prostate (HoLEP)]

BACKGROUND

Holmium Laser Enucleation of the Prostate (HoLEP) was established 20 years ago as an alternative to Transurethral Resection of the Prostate (TUR-P) based on improved morbidity in patients with benign prostate syndrome (BPS). HoLEP can be applied independently to almost all sizes of prostate glands and is recommended in national and international guidelines. Although the HoLEP procedure has a good reputation, many patients still prefer conservative treatment due to fears of side-effects such as pain and urinary incontinence. The aim of this study was to identify patients' feelings, fears and perception of their HoLEP treatment based on Patient-reported Outcome Measures (PROMs) via questionnaires.

MATERIAL UND METHODS

During the time period from June to December 2020, 152 consecutive patients were treated by HoLEP due to BPS and were interviewed based on questionnaires right after their surgical treatment and 3 months later concerning their satisfaction as well as micturition and continence. Based on a written informed consent, 112 patients were included in the study, and a complete 3-month follow-up was available for 88 patients.

RESULTS

The mean volume of enucleated prostate tissue was 62.1 [g] and the mean prostate volume estimated pre-operatively (trans-rectal ultrasound) was 83.1 [cm3]. Overall patient-reported satisfaction with the hospital stay including surgical treatment was 94.6%; after 3 months it was 91.8%. Concerning micturition, 76.5% of the patients reported satisfaction after surgery and 80.4% were satisfied after 3 months. Urinary incontinence was reported in 8.3% initially and in 9.1% after 3 months. Positive answers to questions concerning the quality of life index [L] were obtained in 62.1% initially and their number increased to 85.7% after 3 months. The share of negative answers decreased from 11.7% after surgery to 3.4% within the 3-month follow-up.

DISCUSSION

HoLEP is a well-established treatment of BPS with lower side-effects compared with TUR-P according to the literature. To address doubts and misgivings, it is important to perform surveys on subjective patient satisfaction after the surgical procedure and over time. The high patient satisfaction could help future patients and the urologists treating them to establish the indication for HoLEP treatment earlier in order to avoid severe LUTS or catheterization.

European Association of Urology Guidelines on Male Urinary Incontinence

CONTEXT

Urinary incontinence (UI) is a common condition in elderly men causing a severe worsening of quality of life, and a significant cost for both patients and health systems.

OBJECTIVE

To report a practical, evidence-based, guideline on definitions, pathophysiology, diagnostic workup, and treatment options for men with different forms of UI.

EVIDENCE ACQUISITION

A comprehensive literature search, limited to studies representing high levels of evidence and published in the English language, was performed. Databases searched included Medline, EMBASE, and the Cochrane Libraries. A level of evidence and a grade of recommendation were assigned.

EVIDENCE SYNTHESIS

UI can be classified into stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence. A detailed description of the pathophysiology and diagnostic workup has been reported. Simple clinical interventions, behavioural and physical modifications, and pharmacological treatments comprise the initial management for all kinds of UI. Surgery for SUI includes bulking agents, male sling, and compression devices. Surgery for UUI includes bladder wall injection of botulinum toxin A, sacral nerve stimulation, and cystoplasty/urinary diversion.

CONCLUSIONS

This 2022 European Association of Urology guideline summary provides updated information on definition, pathophysiology, diagnosis, and treatment of male UI.

PATIENT SUMMARY

Male urinary incontinence comprises a broad subject area, much of which has been covered for the first time in the literature in a single manuscript. The European Association of Urology Non-neurogenic Male Lower Urinary Tract Symptoms Guideline Panel has released this new guidance, with the aim to provide updated information for urologists to be able to follow diagnostic and therapeutic indications for optimising patient care.

State of the art on stress incontinence management after benign prostatic obstruction surgery

PURPOSE OF REVIEW

Stress urinary incontinence (SUI) is mostly seen after prostate surgery (radical prostatectomy or benign prostatic obstruction [BPO] relief). As new surgical techniques (laser, endoscopic enucleation) have been dramatically expanded in the past decade, a focus on postoperative SUI is necessary to provide the best management in this iatrogenic situation.

RECENT FINDINGS

Surgery is the main option for curative management of SUI after BPO as no oral medication is recommended. Preoperative work-up is mandatory to assess concomitant bladder dysfunction. All available surgical options (peri-urethral injections, periurethral balloons, various male slings, and artificial urinary sphincter) have been studied, but the level of evidence is very low. In this setting, SUI after BPO management is widely inspired from post-PR SUI management, mainly based on clinical experience.

SUMMARY

The available literature regarding persistent SUI after BPO relief is very scarce and further studies are warranted in this specific population.

Efficacy and safety of holmium laser enucleation of the prostate for elderly patients: surgical outcomes and King's Health Questionnaire

Background

Holmium laser enucleation of the prostate (HoLEP) has been a widely utilized minimally invasive surgical procedure for benign prostate hyperplasia. The current study aimed to compare surgical outcomes and King’s Health Questionnaire (KHQ) assessment scores following HoLEP between younger men and those aged ≥75 years.

Methods

This prospective single-center study compared perioperative complications, postoperative urinary conditions, and KHQ scores (nine categories) between men aged ≥75 years (group A) and men aged <75 years (group B) before and 1, 3, and 6 months after surgery.

Results

A total of 100 patients were included for analysis (group A, n=38 and group B, n=62). No differences in patient backgrounds, perioperative complications, such as perioperative decrease in hemoglobin, postoperative fever, postoperative indwelling catheterization duration, or postoperative hospitalization duration, and KHQ were observed between both groups. Both groups showed significantly better International Prostate Symptom Scores, quality of life, maximum urinary flow rate, and postvoid residual volume 1, 3, and 6 months after HoLEP compared to their respective preoperative levels (P<0.01). Regarding KHQ categories, both groups showed significantly better general health perceptions, impact on life, emotions, and sleep/energy 1 month after HoLEP; role limitations, physical limitations, and social limitations 3 months after HoLEP; and personal relationships and incontinence severity measures 6 months after HoLEP compared to their respective preoperative levels (P<0.05).

Conclusions

HoLEP could be safe and effective even for men aged ≥75 years, comparing complications, urinary condition, and KHQ scores.

Development and validation of a nomogram for predicting early stress urinary incontinence following endoscopic enucleation of the prostate

PURPOSE

To develop and validate a predictive nomogram for early stress urinary incontinence (SUI) after endoscopic enucleation of the prostate (EEP) in patients with benign prostatic hyperplasia (BPH).

METHODS

The records of 458 patients who underwent plasmakinetic- or diode-based EEP at our center from March 2016 to December 2019 were reviewed. Among these, 326 and 132 cases were randomly assigned to the training and validation set, respectively. A predictive nomogram was constructed based on multivariate logistic regression analysis. Receiver operating characteristic (ROC) analysis and calibration curves were employed to evaluate its performance.

RESULTS

65 years ≤ age < 70 years, 75 years ≤ age, 25 kg/m² ≤ BMI < 30 kg/m², 30 kg/m² ≤ BMI, 5 years ≤ LUTS duration, and 75 ml ≤ prostate volume were finally selected as independent predictors of early SUI into the multivariate logistics regression model. It was visualized as a concise nomogram with satisfactory discrimination and accuracy in both training and validation sets.

CONCLUSIONS

A concise nomogram was developed and validated as a useful clinical tool for predicting early SUI post-EEP.

Anteroposterior dissection three-lobe technique: an effective surgical method for inexperienced surgeons performing holmium laser enucleation of the prostate

PURPOSE

To evaluate the effectiveness of anteroposterior dissection three-lobe technique for surgeons with no prior experience of holmium laser enucleation of the prostate (HoLEP) METHODS: In this retrospective single-center study, we compared perioperative complications and postoperative urinary conditions between an experienced surgeon and surgeons with no prior experience of HoLEP. Forty patients were operated by one experienced surgeon (group A), and another 40 patients were operated by four inexperienced surgeons (group B) under the guidance of the instructor. The enucleation procedure was performed by anteroposterior dissection three-lobe technique.

RESULTS

Patient characteristics were comparable in the two groups in age, body mass index, and preoperative prostate volume. The enucleation efficiency rate [0.96 vs 0.56 g/min (P < 0.001)] was significantly different between groups A and B. However, there were no significant differences in enucleate prostate weight, hemoglobin decrease, or postoperative catheter-indwelling period between the two groups. There were no significant differences with respect to postoperative urinary incontinence rate at 1 month [43 vs 50% (P = 0.65)], 3 months [13 vs 20% (P = 0.55)], and 6 months [0 vs 3% (P = 1.00)] between the two groups. Both groups showed a significant improvement in the maximum flow rate and postvoid residual volume after HoLEP compared with baseline levels (P < 0.01).

CONCLUSION

Anteroposterior dissection HoLEP three-lobe technique was found to be a safe and effective enucleation method for surgeons with no prior experience of HoLEP under the guidance of the instructor.

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.