Nonspecific genitourinary pain improves after prostatectomy using holmium laser enucleation of prostate in patients with benign prostatic hyperplasia: a prospective study

Pre-therapeutical assessment of lower urinary tract symptoms in adult men: Systematic review and clinical practice guidelines

INTRODUCTION

The aim was to propose initial and pre-therapeutical assessment of lower urinary tract symptoms in adult men through a systematic review and clinical practice guidelines.

METHODS

These guidelines were based on a systematic review performed between January 2011 and November 2021 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. The protocol was registered in the International Prospective Register of Systematic Reviews database (CRD42022336418). The recommendations and the methodology of elaboration were prospectively validated by the French Health Authority (Haute Autorité de santé [HAS]).

RESULTS

In total, 1662 publications were screened for eligibility and 311 met the inclusion criteria, 167 studies were retained among them 17 guidelines from French, European or International institutions. Perform on initial evaluation: identification of cardiovascular risk factors, metabolic syndrome, current medication, urinary and sexual symptoms (by structured interview or validated self-questionnaires), physical examination (lumbar fossa, pelvis, prostate, genitalia), urinalysis (dipstick or microscopy), abdominal ultrasound of the urinary tract (kidneys, bladder, prostate), post-void residual urine measurement (by ultrasound or automated measurement; under physiological conditions). Micturition flowmetry is recommended (except for general practitioners). Update and complete initial assessment before medication, interventional or surgical treatment if too old or incomplete. Perform a preoperative assessment (bleeding risk, infectious risk, geriatric risk). Urodynamic assessment, endorectal ultrasound and cystoscopy should not be systematically performed (only if additional information is needed). Perform urodynamics and urethrocystoscopy in case of failed interventional or surgical treatment. Following the initial workup, it is recommended to refer the patient to a urologist in case of: macroscopic hematuria, recurrent urinary tract infection or persistent perineal and/or suprapubic pain, persistent microscopic hematuria or leukocyturia in absence of urinary tract infection, predominant storage-phase symptoms, abnormal examination of the genitals or suspected prostate cancer, urinary retention, urinary tract stones, ureterohydronephrosis or morphological abnormalities of the prostate or the urinary tract.

CONCLUSION

These guidelines aimed to define the recommended investigation for LUTS in adult men at diagnosis, before medical treatment and before surgical and interventional treatments, in order to better personalize management and avoid unnecessary and/or invasive examinations.

Advancing Holmium Laser Enucleation of the Prostate Outcomes Reporting: An Assessment of Patient-Reported Outcomes in the Literature

Holmium laser enucleation of the prostate (HoLEP) is a size-independent option for benign prostatic hyperplasia surgical management. Since lower urinary tract symptoms (LUTS) are a quality-of-life issue, studies should prioritize patient-reported outcomes (PROs). This HoLEP review assesses PROs inclusion in the top 20 cited HoLEP studies and defines their limitations. PROs were categorized by domain: LUTS, incontinence, sexual function, pain, hematuria, and patient satisfaction. On review, no top-cited study included all PRO domains. The nuanced patient experience after HoLEP could be better defined via standardized utilization of validated PROs, while also improving comparability between HoLEP studies.

Risk Factors for Transurethral Coagulation for Hemostasis During Holmium Laser Enucleation of the Prostate

PURPOSE

We aimed to identify risk factors for transurethral coagulation (TUC) using bipolar electrocautery for hemostasis during holmium laser enucleation of the prostate (HoLEP) surgery for benign prostatic hyperplasia (BPH).

METHODS

We analyzed the clinical outcomes of HoLEP surgery performed by a single surgeon between January 2010 and April 2020 at the Seoul National University Hospital. Patient characteristics and perioperative parameters were used to identify the risk factors for TUC. The TUC group was defined as a case of conversion to hemostasis using electrocautery during the hemostasis step after enucleation.

RESULTS

Of 1,563 patients, 357 underwent TUC (TUC group; 22.8%) as an adjuvant (n=299, 19.1%) or salvage (n=58, 3.7%) therapy. Patients in the TUC group were older (mean±standard deviation, 70.6±7.3 years vs. 69.3±7.0 years; P=0.002), had more 5-alpha reductase inhibitor (5-ARI) use (35.6% vs. 25.9%, P<0.001), higher serum prostate-specific antigen (PSA) (5.4 ±4.8 ng/mL vs. 3.8 ±4.5 ng/mL, P <0.001), larger total prostate volume (TPV) (89.5 ±44.7 mL vs. 66.0 ±32.6 mL, P<0.001), and larger transitional zone volume (TZV) (57.3±34.9 mL vs. 37.7±24.2 mL, P<0.001) than those who did not undergo TUC (non-TUC group). In univariate logistic regression analysis, age, 5-ARI use, PSA, TPV, and TZV correlated with TUC, whereas in multivariate logistic regression analysis, only TZV was associated with TUC. The odds ratios (ORs) of TUC were analyzed per TZV quartile. Compared to TZV<22.3 mL, the OR was 2.42 in 34.1 mL≤TZV<53.5 mL (95% confidence interval [CI], 1.58-3.72; P<0.001), 5.17 in ≥53.5 mL (95% CI, 3.44-7.77; P<0.001).

CONCLUSION

The risk of TUC during HoLEP surgery increases in patients with TZV >35 mL. Therefore, TUC may be potentially necessary in patients with a large transition zone volume in patients with BPH.

Shedding light on polypragmasy of pain after transurethral prostate surgery procedures: a systematic review and meta-analysis

PURPOSE AND OBJECTIVE

To evaluate and compare the incidences of post-operative pelvic pain (PPP) in patients undergoing ablation, enucleation and conventional transurethral resection of the prostate (TURP).

METHODS

A systematic review and meta-analysis was conducted according to the PRISMA guidelines. Using MEDLINE via PubMed and Cochrane CENTRAL, randomised control trials (RCTs) and observational studies reporting PPP rates post-ablation, enucleation or TURP were identified. The risk of biases (RoB) in RCTs and observation studies were assessed using the Cochrane RoB1.0 tool and the Newcastle-Ottawa Scale, respectively.

RESULTS

62 studies were included for qualitative analysis, while 51 of them reported number of patients with PPP post-intervention. Three observational studies and 13 RCTs compared the rates of PPP in patients undergoing ablation, enucleation or TURP. The most reported types of PPP are dysuria, abdominal pain and irritative symptoms. The pooled incidence of PPP at 1-month follow-up in patients undergoing ablation, enucleation and TURP were 0.15 (95% CI 0.10-0.22), 0.09 (95% CI 0.04-0.19 and 0.10 (95% CI 0.06-0.15), respectively. PPP is no longer prevalent at 3-months and onwards post-operatively. Ablation is associated with a higher risk of PPP than enucleation (RR 2.19, 95% CI 1.04-4.62) and TURP (RR 2.40, 95% CI 1.03-5.62) in observational studies but not RCTs; and there were no significant differences in the rates of PPP upon comparison of other modalities.

CONCLUSION

PPP is common after transurethral benign prostatic hyperplasia surgery. Patients undergoing ablation had a higher rate of post-intervention PPP than those undergoing enucleation and TURP in observational studies.