Role of Holmium laser enucleation of the prostate to increase cancer detection rate in patients with gray-zone PSA level

Relationships between holmium laser enucleation of the prostate and prostate cancer

Holmium laser enucleation of the prostate (HoLEP) is a size-independent surgical option for treating benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) with excellent, durable functional outcomes. The prevalence of LUTS secondary to BPH and prostate cancer both increase with age, although the two diseases develop independently. Urologists often face a diagnostic dilemma, as men with LUTS secondary to BPH might also present with an elevated PSA and, therefore, need a diagnostic work-up to exclude prostate cancer. Nevertheless, ~15% of men with a negative elevated PSA work-up will undergo HoLEP and will be diagnosed with incidental prostate cancer at the time of HoLEP. Indeed, prostate cancer is often found in men undergoing HoLEP, and this situation can be challenging to manage. Variables associated with the detection of incidental prostate cancer, strategies to reduce incidental prostate cancer, as well as the natural history and management of this condition have been extensively studied, but further work in this area is still needed.

Functional Results after First- and Second-Generation Temporary Implantable Nitinol Device (TIND) for BPH: A Narrative Review of the Literature

Purpose of review

In the last decades, new promising technologies for the treatment of BPH-related lower urinary tract symptoms (LUTS) have been widely experienced in clinical practice, with the aim of offering fewer complications but similar functional outcomes compared with the gold standard transurethral resection of the prostate (TURP). Among these so-called minimally invasive approaches, transurethral implantation of first- and second-generation temporary implantable nitinol device (TIND and iTIND, respectively) (Medi-Tate; Medi-Tate Ltd., Or Akiva, Israel) has been included by the European Association of Urology (EAU) Guidelines as one of the available alternative treatments to TURP. In the present paper, we conducted a systematic review of the current literature on TIND and iTIND implantation focusing on functional outcomes. Medline, Embase, and Cochrane databases were queried for relevant Literature in May 2021.

Recent findings

Data regarding the use of temporary implantable nitinol device for BPH are still very limited, with only seven studies currently available in Literature. All the studies report that both TIND and iTIND procedures are safe, effective, and well tolerated. Moreover, such treatments seem to not affect patient’s sexual and ejaculatory functions.

Summary

Current clinical evidence suggests that temporary implantation of first- and second-generation temporary implantable nitinol devices are valid options for the minimally invasive surgical treatment of BPH-related LUTS. Further studies are required in order to confirm the functional results, especially over a long-term follow up.

Night shift workers refer higher urinary symptoms with an impairment quality of life: a single cohort study

BACKGROUND

The aim of the present study is to assess the impact of night shift work (NSW) on urinary symptoms.

METHODS

Between March 2018 to October 2018, we evaluated a group of National Health care system workers. Urinary symptoms and quality of life were measured by Overactive Bladder Questionnaire Short Form (OABq-sf). Clinical variables (i.e. age, smoking status, medical history) were collected and analyzed according to be NS workers (NSWs) from subjects working at least one time from 8 pm to 8 am or from traditional workers (TWs). Univariate and multivariate analysis was performed to identify predictive variables of worse OAB outcomes (OABq-sf>30, OABq-SB≥12, OABq HRQL≥18).

RESULTS

A total of 136 participants (68 males and 68 females) were included in the study. On OABq-sf, total score, symptoms bother (OABq-SB) and health related quality of life (OABq-HRQL) domains were significantly (P<0.05) higher in NSWs group, respectively: 31 (IQR 26-35) vs. 19 (IQR 19-20); 11 (IQR 10-13) vs. 6 (IQR 6-7); 19 (IQR 16-22) vs. 13 (13-14). Finally, seven NSWs (10.6%) referred nocturia respect to only one (1%) TWs, (P=0.02). On multivariate analysis NSW was an independent predictor of OABq-sf>30 units (OR:30; CI: 9-111, P=0.001), OABq-SB ≥12 units (OR:16, CI: 6-43, P=0.001) and OABq HRQL≥18 units (OR:20, CI: 6-70, P=0.001).

CONCLUSIONS

Night shift workers presented worst OAB Score and poor QL when compared to similar traditional workers. Long-term data on NSWs patients are also needed to further clarify this relationship.

Laparoscopic simple prostatectomy: complications and functional results after five years of follow-up

BACKGROUND

The aim of this study was to investigate complications and functional results in a cohort of patients who underwent extraperitoneoscopic transcapsular laparoscopic simple prostatectomy (LSP) for large prostate adenomas with a minimum follow-up of 5 years.

METHODS

We retrospectively reviewed data obtained from our prospectively maintained database of patients treated with LSP at our institution between January 2004 and June 2012, with at least 5 years of reported follow-up data. Demographics, perioperative results, early and late complications, and functional results were evaluated. The various impacts of the independent variables on the development of complications was evaluated performing logistic regression models. Follow-up was planned at 1, 3, 6 and 12 months, then yearly up to a minimum of 5 years.

RESULTS

One-hundred patients were included in our analysis. Median follow-up was 135 (IQR 24) months (11 years and 3 months). Grade III complications were recorded in 2 cases. Five cases of late postoperative complications were recorded. Logistic regression models showed a statistically significant correlation between the adenoma volume and the risk of developing early postoperative complications (OR 1.014). International Prostate Symptom Score (I-PSS), I-PSS quality of life (QoL) index, and maximum urine flow (Qmax) significantly improved when comparing preoperative and postoperative results. No significant differences were recorded in the I-PSS and I-PSS QoL index during follow-up. A low but significant worsening in Qmax was observed starting the 48th month after surgery.

CONCLUSIONS

The present findings confirm that LSP carries a low rate of early and late complications, and it offers good functional outcomes at 5 years.

Can preoperative multiparametric MRI avoid unnecessary prostate biopsies before holmium laser enucleation of the prostate? Preliminary results of a multicentric cohort of patients

BACKGROUND

Holmium laser enucleation of the prostate (HoLEP) is a surgical technique that allows to safely and effectively treat bladder outlet obstruction due to benign prostate enlargement and retrieve an adequate surgical specimen. We investigated the role of multiparametric magnetic resonance imaging of the prostate (mpMRI) as a tool to exclude incidental prostate cancer (iPCa) and to compare mpMRI alone with a contextual transrectal ultrasound guided biopsy (TRUS-GB).

METHODS

Retrospective multicentric evaluation of 244 patients underwent to HoLEP with a suspicion of prostate cancer (PCa) due to raised PSA and/or abnormal digital rectal examination (DRE) and a negative mpMRI (PI-RADS score <3), was performed. Of these, 118 patients had only a negative mpMRI (MRI group) while 126 had a negative mpMRI and a contextual preoperative negative TRUS-GB (MRI + TRUS-GB group). Comparison between the two groups, univariate and multivariate analysis were conducted in order to identify any predictive factors of iPCa.

RESULTS

Median age, PSA, prostate volume and PSA density were 64.0 years (IQR: 58.0-69.0), 6.10 ng/mL (IQR: 4.76-9.65), 86.0 cc (IQR: 65.0-115.0), 50.0 cc (IQR: 37.5-80.0) and 0.08 ng/mL/cc (IQR: 0.06-0.10), respectively. In surgical specimen, iPCa was detected in 21 cases (8.8%). No statistically differences between MRI and MRI + TRUS-GB group were found in terms of iPCa (7.6% and 8.5%, respectively), pathological T stage and ISUP Grade Group. A contextual TRUS-GB added to mpMRI did not correlate to iPCa either at uni- and multivariate analysis while a significant correlation of a PSA density >0.15 ng/mL/cc was found only at univariate analysis.

CONCLUSIONS

Including a mpMRI in clinical evaluation of patients eligible to HoLEP with a preoperative PCa suspicion leads to low the rates of iPCa and might avoid unnecessary TRUS-GB.

Intraprostatic injections for lower urinary tract symptoms/benign prostatic enlargement treatment

INTRODUCTION

Endoscopic surgical treatment represents the gold standard in patients with lower urinary tract symptoms (LUTS) when medical treatment fails. In the past years there has been a growing interest in intraprostatic injections which represent a minimally invasive alternative for those patients not suitable for surgery. Aim of our study is to systematically review all the available data on intraprostatic injections for the treatment of LUTS patients with benign prostatic enlargement (BPE).

EVIDENCE ACQUISITION

A systematic review of the literature using the Medline, Scopus and Web of Science databases for relevant articles published until June 2018 was performed using both the Medical Subjects Heading and free test protocols. The MeSH search was conducted by combining the following terms: "Intraprostatic Injections," "Botulinum Toxin A," "Onabotulinum," "Ethanol," "Lower Urinary tract Symptoms," "Benign prostatic enlargement," "Benign Prostatic Hyperplasia," "NX1207," "PRX302." Each article's title and abstract were reviewed for their appropriateness and their relevance with regards to the relationship to intraprostatic injections.

EVIDENCE SYNTHESIS

Intraprostatic injections for the treatment of LUTS/BPE patients may be performed using different products as: ethanol, onabotulinum toxin A, NX1207 and PRX 302. Ethanol, the first agent for intraprostatic use, showed promising results in prospective trials, however, the rare but serious adverse events associated with extraprostatic diffusion of ethanol stopped its use. Many studies on onabotulinum toxin A (BotoxR) have been performed, however, two large randomized clinical trials showed no differences in terms of symptoms improvements and flow improvements when compared to placebo. Two new promising drugs NX 1207 and PRX 302 have been developped in the past years. NX 1207 showed lack of efficacy in the two large European phase III RCT. PRX 302 showed promising results in phase I and II studies, however, definitive results from a large phase III randomized controlled trial (RCT) are awaited before drawing any definitive conclusions.

CONCLUSIONS

Intraprostatic injections are still to be considered investigational for the minimally invasive management of LUTS/BPE patients. Emerging data suggest a possible role of new agents in the near future when definitive data of ongoing RCTs will be available.