Transurethral surgical anatomy of the arterial bleeder in the enucleated capsular plane of enlarged prostates during holmium laser enucleation of the prostate

Optimizing hemostasis in HoLEP surgery: retrospective review of selective bipolar plasmakinetic technology guided by bladder irrigation fluid color

OBJECT

To evaluate the effectiveness of selective bipolar plasmakinetic technology based on bladder irrigation fluid color on hemostasis in HoLEP surgwery METHODS: A total of 209 patients who underwent HoLEP surgery from October 2021 to July 2023 were included and divided into Hemostasis Management Group and control group. the color of the irrigation fluid was categorized into 5 levels and the bipolar plasmakinetic technology was applied when the color came to level 4 or up. The following was analyzed: postoperative use of balloon compression, blood loss, irrigation time, length of hospital stay, and the number of a second operation.

RESULTS

Only 4 patients in Hemostasis Management Group required postoperative urinary catheter balloon compression, while there are 15 in the control group(p=0.03). The average irrigation time for patients in the HM Group with bipolar plasmakinetic hemostasis was 21.88±13.76 hours, compared to that in patients with catheter balloon compression(p=0.007).

CONCLUSION

Based on the bladder irrigation color chart, the selective application of bipolar plasmakinetic hemostasis led to a significant reduction in the number of patients requiring postoperative bladder catheter balloon compression. Secondly, the irrigation time of patients who underwent bipolar plasmakinetic hemostasis also decreased.

Evaluation of early apical release with bipolar Collins knife versus Thulium-Yag laser enucleation of large-sized prostate. A randomized study

Introduction and objectives

Anatomical endoscopic enucleation of the prostate (AEEP) provides durable management for patients with lower urinary tract symptoms (LUTS) secondary to large-sized prostate over other surgical modalities. We aimed to assess the early outcomes of Collins knife-assisted bipolar enucleation (BipolEP) versus Thulium-Yag enucleation (ThuLEP) in a group of patients with LUTS secondary to a prostate larger than 80 grams.

Methods

We included patients with benign prostatic hyperplasia (BPH) having a prostate volume > 80 grams, international prostate symptom score (IPSS) >7, urine flow (Q-max) <15, and post-void residual (PVR)>150 ml. We excluded those with a history of previous prostatic surgery, stone, or neurogenic bladder. Bipolar enucleation with early apical release was performed using Collins knife at an 80/100-watt setting (Lamidey Noury), while ThuLEP was conducted using 550- micron fiber and 40/15-watt energy (Lisa Laser). Patients were evaluated before then 2 weeks and 3, 6,12 months postoperatively for changes in IPSS, Q- max, PVR, and the incidence of stress incontinence.

Result

One hundred and twenty patients were equally randomized with a mean prostate size of 104 ± 25 gram. The mean IPSS score was 25 ± 6, Qmax 7.6 ± 1.3 mL/S, and PVR 225 ± 39. There was no significant difference regarding enucleation time, morcellation time, and enucleated tissue volume. Irrigation volume and post-operative hemoglobin drop were significantly lower in the bipolar group (p = 0.008, p = 0.0002), respectively. At the third-month follow-up, IPSS, Q-max, and PVR were comparable across both groups, with stress incontinence at 3.3% in the bipolar group versus 1.6% in the thulium group, showing an insignificant difference (p = 0.5)."

Conclusion

Both BipolEP and ThuLEP, with early apical release, provide a safe and effective management of large-size prostate resulting in significant decrease in post-operative stress incontinence incidence during early follow-up. Intraoperative irrigation saline volume, and post-operative hemoglobin drop favored the bipolar group.

Comparison of the efficacy and safety of robotic-assisted simple prostatectomy and laser enucleation of prostate for large benign prostatic hyperplasia

Laser enucleation of the prostate (LEP) and robotic-assisted simple prostatectomy (RASP) are two main treatment methods for large benign prostatic hyperplasia (BPH), but the superiority between these two methods in treating large BPH is currently unclear. This study aims to conduct a meta-analysis to compare the efficacy and the safety of LEP and RASP in treating large BPH. We systematically searched the PubMed, Embase, and Cochrane Library databases for studies that compared safety and efficacy outcomes of both LEP and RASP. Review Manager 5.3 was used for the meta-analysis. Six studies with a total of 1235 patients were included in the analysis. Resected adenoma weight was similar in LEP than RASP group. Operative time [mean difference (MD) - 67.96; 95% confidence interval [CI] - 131.66 to - 4.25; p = 0.04], catheterization time (MD -6.31; 95% CI - 9.44 to - 3.18; p < 0.0001), and length of stay (MD - 2.44; 95% CI - 3.55 to - 1.34; p < 0.0001) were lower in LEP. The International Prostate Symptom Score, maximum urinary flow rate, prostate-specific antigen, and post-void residual urine volume were also comparable between two groups. Furthermore, LEP demonstrated lesser hemoglobin decrease (MD - 0.50; 95% CI - 0.96 to - 0.05; p = 0.03), lower blood transfusion rate [odd ratio (OR) 0.23, 95% CI 0.08-0.66; p = 0.006], and lower rate of Clavien-Dindo Grade ≥ 3 complications (OR 0.435, 95% CI 0.189-0.998; p = 0.049). Finally, there was no significant difference in overall complications between two groups. Current evidence shows that LEP offers favorable perioperative outcomes compared with RASP. However, there was no conclusive evidence that LEP was advantaged in terms of efficacy outcomes.

V.I.P. Score: A Comprehensive Grading System to Predict Difficulty of HoLEP Procedure for Small-to-Moderate Sized Prostate (<120 ml)

OBJECTIVES

To develop a comprehensive scoring system in addition to the conventionally used prostatic volume (PV), for predicting the difficulty of holmium laser enucleation of the prostate (HoLEP) that may arise with small-to-moderate sized prostate.

METHODS

We retrospectively reviewed 151 consecutive patients who underwent HoLEP and had a PV less than 120 ml. Based on previous literature, a difficult procedure was defined as a prolonged operative time (OT>90 min) in 88 cases, while the control group (OT≤90 min) consisted of 63 patients. The clinical data, including age, body mass index, PV, intravesical prostatic protrusion (IPP), prostate specific antigen (PSA), prostate specific antigen density, urinary tract infection, microscopic hematuria, prior biopsy, diabetes mellitus, hypertension, history of acute urinary retention, catheter dependency and use of antiplatelet / anticoagulation drugs or 5-alpha reductase inhibitor were compared between the two groups.

RESULTS

Univariate analysis revealed significant differences between the two groups. Multivariate analysis identified three main independent predictors for difficulty, including volume (V) (60-90 ml OR=9.812, P<0.001) (≥90 ml OR=18.173, P=0.01), IPP (I) (OR=3.157, P=0.018), and PSA (P) (≥4 ng/ml OR=16.738, P<0.001). Therefore, a V.I.P. score was developed based on the regression model and ranged from 0 to 7 points. The area under the curve showed preferable predictive ability of the V.I.P. score compared to PV (0.906 versus 0.869).

CONCLUSIONS

We developed a V.I.P. score that can accurately predict the difficulty of the HoLEP procedure for PV less than 120 ml in order to optimize clinical outcomes.

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.

Bipolar plasmakinetic transurethral enucleation and resection versus bipolar plasmakinetic transurethral resection for surgically treating large (≥60 g) prostates: a propensity score-matched analysis with a 3-year follow-up

BACKGROUND

There are extremely limited published studies comparing bipolar plasmakinetic transurethral resection of prostate (BP-TURP), bipolar plasmakinetic transurethral enucleation and resection of prostate (BP-TUERP) for enlarged prostates. Our purpose was to evaluate the safety and efficiency of BP-TUERP and BP-TURP for large (≥60 g) prostates with a 3-year follow-up.

METHODS

We retrospectively identified 229 patients according to inclusion criteria between 2014 and 2016. After applying propensity score matching method, preoperative results and three-year follow-up outcomes in International Prostate Symptom Score (IPSS), urinary peek flow rate (Q<inf>max</inf>), postvoid residual urine (PVRU) volume and quality of life (QoL) score were compared.

RESULTS

Finally, within the well-balanced matched cohort, the BP-TUERP was significantly associated with longer mean operating time (OT) (P=0.039), shorter mean catheter time (CT) (P=0.001) and lower mean hemoglobin decrease (P=0.002) with more prostatic tissue removed (P=0.001) than the BP-TURP, but the median hospital stay lengths and the short- and long-term complication rates were similar between the two series. The patients in the BP-TUERP group had better long-term outcomes in IPSS, Q<inf>max</inf> and PVRU volume than these in the BP-TURP group, but not in QoL score.

CONCLUSIONS

For patients with large (≥60 g) prostates, BP-TUERP and BP-TURP are safe options, but the former is a more effective choice in long-term follow-up outcomes. BP-TUERP is related to reduced CT and hemoglobin decrease with more removal of prostatic tissue at the expense of longer OT than BP-TURP.

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.

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.

Monopolar Transurethral Enucleo-Resection of the Prostate Versus Holmium Laser Enucleation of the Prostate: A Canadian Novel Experience

OBJECTIVE

To study the functional outcome of patients undergoing transurethral enucleation and resection of the prostate (TUERP) vs patients undergoing holmium laser enucleation of the prostate (HoLEP) in men with bladder outlet obstruction.

MATERIALS AND METHODS

We retrospectively analyzed our prospectively collected database of two groups of patients. Twenty-four patients underwent TUERP (group 1), and 27 underwent HoLEP (group 2). Preoperative characteristics, intervention parameters, postoperative functional outcomes, uroflowmetry, and complications were collected.

RESULTS

Mean prostate size in groups 1 and 2 were 87.2 and 93.5 cc, respectively. The mean duration of surgery was 110 minutes in group 1 and 136 minutes in group 2. In group 1, prostate-specific antigen (PSA) dropped from 4.4 to 1.2 ng/cc after 12 months. International Prostate Symptom Score (IPSS) was 3.75 at 12 months with a preoperative value of 20.9. With respect to maximum urinary flow rate (Q_max), it increased to 21.8 mL/s from a preoperative value of 6.4 mL/s. In group 2, the PSA dropped from 7.6 to 1.3 ng/cc. IPSS dropped from 22.3 to 3.8, Q_max increased from 7.7 to 22.5 mL/s. Hemoglobin, complications, and all studied parameters were not statistically significant between both groups.

CONCLUSION

In this study, TUERP was safe and efficacious in benign prostatic hyperplasia patients with large glands. Modifications can be implemented on the standard transurethral resection of the prostate technique to treat patients with prostate sizes >70 cc.

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.

A Focused Review on the Effects of Preoperative 5α-Reductase Inhibitors Treatment in Patients Undergoing Holmium Laser Enucleation of the Prostate: What Do We Know So Far?

INTRODUCTION

The effects of medical therapy with finasteride or dutasteride during transurethral enucleation of prostate and tissue morcellation are not well defined. In theory, the risk of prostatic fibrosis versus the potential benefit of reduced intraoperative bleeding has been addressed as potential competing factors. The aim of this review was to provide evidence whether 5α-reductase inhibitors (5-ARIs) put the surgeon at a disadvantage or impact on patient outcomes.

MATERIALS AND METHODS

We performed a literature search of PubMed, Scopus, and Web of Science databases. All articles in English language related to the topic were reviewed to provide data on the influence of preoperative 5-ARIs in holmium laser enucleation of prostate (HoLEP).

RESULTS

Parameters of surgical efficiency such as enucleation time and efficiency, morcellation time, operating time, prostate tissue volume resected, energy, and saline usage were evaluated in the included studies. The review failed to show any definite impact of preoperative 5-ARI use on the mentioned parameters. One study, assessing the surgical difficulty using retrospective video recording analysis, showed that use of dutasteride increases the difficulty of enucleation step, which did not translate in statistical difference of surgical efficiency in an experienced level of surgeons.

CONCLUSIONS

Overall, 5-ARIs do not seem to affect HoLEP. However, the quality of evidence is still quite poor in comparison with other surgical techniques. Further well-designed studies are required before making any definite recommendations on the use of 5-ARIs in patients undergoing HoLEP.

Monopolar Transurethral Enucleation of Prostatic Adenoma: Preliminary Report

OBJECTIVE

To describe preliminary results of our monopolar transurethral enucleation of prostatic adenoma (mTUEPA).

MATERIALS AND METHODS

A consecutive series of male patients treated with mTUEPA, a retrograde enucleation of the prostatic adenoma performed by means of a standard monopolar resectoscope, were prospectively enrolled. Symptoms, uroflowmetry parameters, and post-voiding residual were assessed at baseline and at 1, 6, and 12 months postoperatively. Prostate volume was evaluated at baseline by means of transrectal ultrasound. Antiplatelet and anticoagulant drugs were stopped at least 1 week before the operation.

RESULTS

Forty-seven patients were enrolled. Mean preoperative prostate volume was 64.9 ± 28.5 g. When assessed at baseline, the mean total International Prostatic Symptoms Score was 15.2 ± 3.9, peak flow rate (Qmax) was 8.4 ± 2.9 mL/s and the post-voiding residual was 103.2 ± 90.6 mL. Four weeks after surgery, patients reported a mean International Prostatic Symptoms Score of 5.3 ± 3. This lower urinary tract symptoms relief was further maintained at 6 and 12 months after surgery. A significant postoperative improvement in uroflowmetry parameters was described, being the 6 and 12 months mean Qmax of 23.4 ± 10.6 mL/s and 18.8 ± 9.2 mL/s, respectively (P < .001). Overall, 14 postoperative complications were reported by 13 of 47 (27.6%) patients: most of them were minor complications (Clavien-Dindo Grade I-II), whereas 1 patient reported capsule perforation during surgery, requiring interruption of the procedure and its further completion (Clavien-Dindo IIIb).

CONCLUSION

mTUEPA is a safe and effective technique, merging the principles of laser enucleation and the advantages of mechanical enucleation with standard monopolar transurethral resection of the prostate equipment.