Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH): AUA Guideline Amendment 2023

PURPOSE

The purpose of this American Urological Association (AUA) Guideline amendment is to provide a useful reference on the effective evidence-based management of male lower urinary tract symptoms secondary/attributed to BPH (LUTS/BPH).

MATERIALS AND METHODS

The Minnesota Evidence Review Team searched Ovid MEDLINE, the Cochrane Library, and the Agency for Healthcare Research and Quality (AHRQ) database to identify studies relevant to the management of BPH. The guideline was updated in 2023 to capture eligible literature published between September 2020 and October 2022. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions.

RESULTS

The BPH amendment resulted in changes to statements/supporting text on combination therapy, photoselective vaporization of the prostate (PVP), water vapor thermal therapy (WVTT), laser enucleation, and prostate artery embolization (PAE). A new statement on temporary implanted prostatic devices (TIPD) was added. In addition, statements on transurethral needle ablation (TUNA) and transurethral microwave thermotherapy (TUMT) were removed and information regarding these legacy technologies was added to the background section. References and the accompanying treatment algorithms were updated to align with the updated text.

CONCLUSION

This guideline seeks to improve clinicians' ability to evaluate and treat patients with BPH/LUTS based on currently available evidence. Future studies will be essential to further support these statements to improve patient care.

Improving Prostatic Preoperative Volume Estimation and Planning before Laser Enucleation

We aimed to validate a formula for improving the estimation of prostatic volume by abdominal ultrasound (AUS) prior to transurethral laser enucleation. A total of 293 patients treated for benign prostate hyperplasia (BPH) by laser enucleation from 2019−2022 were included. The preoperative AUS volume was adjusted by the formula 1.082 × Age + 0.523 × AUS − 53.845, which was based on specimens retrieved by suprapubic prostatectomy. The results were compared to the weight of the tissue removed by laser enucleation as determined by the intraclass correlation coefficient test (ICC). The potential impact of preoperative planning on operating time was calculated. The ICC between the adjusted volumes and the enucleated tissue weights was 0.86 (p < 0.001). The adjusted volume was more accurate than the AUS volume (weight-to-volume ratio of 0.84 vs. 0.7, p < 0.001) and even more precise for prostates weighing >80 g. The median operating time was 90 min. The adjusted volume estimation resulted in an overall shorter expected preoperative operating time by a median of 21 min (24%) and by a median of 40 min in prostates weighing >80 g. The adjustment formula accurately predicts prostate volume before laser enucleation procedures and may significantly improve preoperative planning, the matching of a surgeon’s level of expertise, and the management of patients’ expectations.

A Novel Modified Two-Lobe Holmium Prostate Enucleation Technique: Demirtaş-Erciyes Enucleation Prostatectomy

Objective

Endoscopic enucleation of the prostate has evolved and became popular for the surgical treatment of benign prostatic hyperplasia (BPH) during the last decade. Different surgical techniques have been described so far. We hereby described a new modified two-lobe technique for urologists who are inexperienced in endoscopic enucleation. We aimed here to present the data on a learning curve of this stepwise technique named Demirtaş-Erciyes Enucleation Prostatectomy (DEEP): reverse S-J incision technique and its postoperative outcomes.

Material and methods

The study included 102 patients who underwent holmium laser enucleation of the prostate (HoLEP) with the DEEP technique between October 2020 and December 2021. Demographic, preoperative, and postoperative variables were recorded. The operation was performed with a 150 W holmium laser system (Quanta System, Varese, Italy) with cutting and coagulation settings of 2J × 50 Hz with virtual basket mode and 2J × 12 Hz in bubble blast mode, respectively. Bladder irrigation was done for one day, and then, on the next day, the urethral catheter was removed. Postoperatively, uroflowmetry studies, continence status, and ejaculation status were recorded during follow-up. The data of all patients were divided into two groups (first 51 and final 51 patients). All variables were analyzed between two groups.

Results

The mean age of the patients was 68.48±8.74 years. The median Charlson Comorbidity Index (CCI) score was 3. The median International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF) values ​​were 26 (10-35) and 10 (0-25), respectively. Of the patients, 60.8% had Foley catheters due to urinary retention. The median anesthesia time, laser time, enucleation time, morcellation time, and enucleated tissue amount were 102.5 minutes, 17 minutes, 25 minutes, 20 minutes, and 50 g, respectively. Enucleation was performed in two stages in five patients due to bigger prostate volume or incomplete morcellation. The median catheter removal time was 48 hours. In six patients, the postoperative catheterization time was prolonged due to hematuria. The median increase in Qmax was 19.35 mL/second. The overall complication rate was 5.9%, which were all Clavien grade II. Enucleation time, laser time, and anesthesia time were significantly lower in the last 51 patients.

Conclusion

DEEP enucleation technique seems to provide effective and safe postoperative results for beginners in prostate enucleation.

[Multidisciplinary approach in urology. Laser technologies: faster, simpler, more efficient]

Laser technology has taken a place among the methods of treatment of various urological diseases. The new laser devices are being developed in addition to commonly used. Physicists of the russian NTO "IRE Polus" in collaboration with doctors from Sechenov University have developed a new generation laser device - thulium fiber laser. It has been actively used since 2017 for laser enucleation of prostate. Later the laser was used for treatment of bladder tumor, lithotripsy. The device has already managed to prove its efficacy in in-vitro experiments and clinical practice surpassing foreign analogues.

[Endoscopic enucleation of the prostate: a short term trend or a new treatment standard?]

Endoscopic enucleation of the prostate (EEP) techniques such as HoLEP (holmium laser enucleation of the prostate), ThuLEP (thulium laser enucleation of the prostate) and electroenucleation (mono- or bipolar) are highly effective and safe. They have been endorsed by the latest version of the European Association of Urology guidelines as an alternative to not only open adenomectomy but also transurethral resection of the prostate (EAU Guidelines on Treatment of Non-neurogenic Male LUTS 2018). Therefore, many urologists face the possibility of replacing the treatments of BPH. In this article, we analyze the history of EEP techniques, both their pros and cons and, what are they today - just a popular trend or a new standard procedure for the surgical treatment of BPH?

[Laser enucleation of the prostate (HOLEP and THULEP): a comparative effectiveness analysis in treating recurrent prostatic hyperplasia]

INTRODUCTION

The estimated recurrence rate of benign prostatic hyperplasia (BPH) after transurethral resection of the prostate is about 5 to 15%. Laser enucleation of the prostate results in a much lower recurrence rate (not exceeding 1-1.5%). At the same time, laser enucleation of the prostate is still not widely used for recurrent prostatic hyperplasia since it believed to be technically difficult in cases.

AIM

To describe the distinctive features of thulium and holmium laser enucleations of the prostate in the management of recurrent BPH and show that the technical difficulties are not an obstacle to the wide application of this technique.

MATERIALS AND METHODS

This was a retrospective study comprising 676 patients aged 54 to 87 years with clinically pronounced infravesical obstruction due to prostatic hyperplasia (IPSS>20, Qmax<10). All patients were divided into four groups. Groups 1 (n=489) and 3 (n=153) underwent holmium (HoLEP) and thulium (ThuLEP) laser enucleations of the prostate, respectively. Groups 2 (n=23) and 4 (n=11) included patients with BPH recurrence after HoLEP (group 2) and ThuLEP (group 4). All patients underwent diagnostic evaluation at baseline and at 6 months after surgery.

RESULTS

The mean ThuLEP operating time was shorter than that of HoLEP (p=0.02). The mean duration of repeat and primary ThuLEP and HoLEP did not differ statistically significantly (p>0.05). There was no difference in the length of hospitalization and catheterization between the four groups (p>0.05). At six months after surgery, a statistically significant improvement in I-PSS, Qmax, QoL, and RUV was observed in all groups compared with preoperative values (p>0.05)).

CONCLUSION

We found that the technical difficulties of the re-operation, such as the difficult separation of adenomatous tissue from the prostate capsule, the multinodular nature of the adenoma, increased tissue density are easy to overcome and do not confer a significant complexity. In turn, better completeness of resection, low complication and recurrence rates and the possibility of surgery, even in elderly patients with multiple comorbidities - these features allow us to conclude that laser enucleation of the prostate is not only an effective treatment for infravesical obstruction due to benign prostatic hyperplasia, but is also a method of choice in the treatment of patients with recurrent BPH.