Incidence of Surgical Reintervention for Benign Prostatic Hyperplasia Following Prostatic Urethral Lift, Transurethral Resection of the Prostate, and Photoselective Vaporization of the Prostate: A TriNetX Analysis

Background

Prostatic urethral lift, or UroLift, has gained popularity as a treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). Surgical reintervention rates are a reliable indicator for treatment durability.

Objective

The objective of this study was to utilize TriNetX, a third-party database, to investigate the incidence of surgical reintervention following UroLift, transurethral resection of the prostate (TURP), and photoselective vaporization of the prostate (PVP) procedures for BPH from 2015 to 2018.

Design setting and participants

Male patients aged 18-100 yr diagnosed with BPH were identified in the TriNetX Diamond Network database between January 2015 and December 2018. Cohorts of individuals undergoing their first UroLift procedure were built using Current Procedural Terminology and International Classification of Diseases 10th Revision codes. TURP and PVP cohorts were built as comparison groups. The cohorts were then queried for subsequent BPH-related procedures.

Outcome measurements and statistical analysis

Reprocedure rates were assessed and descriptive statistics were used.

Results and limitations

The mean age at first-time UroLift was 70.1 ± 9.4 yr (n = 14 343). Cumulative reprocedure rates collected after first-time UroLift included 1 yr after UroLift (5.1%, n = 14 343) and 4 yr after UroLift (16.1%, n = 710), with an average annual increase of +3.6% per year following 1 yr after the procedure. Comparatively, TURP (n = 22 071) and PVP (n = 14 110) had 4-yr reprocedure rates of 7.5% and 7.8%, respectively, during the same timeframe. Limitations include a lack of clinical data and loss of follow-up data outside the Diamond Network.

Conclusions

The reprocedure rate of UroLift at 4 yr is double the rate of TURP and PVP. In appropriately selected patients, UroLift might be a suitable option for those who desire symptomatic relief from BPH with minimal erectile and ejaculatory side effects. However, the risk of secondary surgical intervention should be considered when considering BPH treatments.

Patient summary

We compared the reintervention rates of prostatic urethral lift (PUL), transurethral resection of the prostate (TURP), and photoselective vaporization of the prostate (PVP) using the TriNetX database, and have found that the highest reintervention rates were for PUL of 16% at 4 yr of follow-up, compared with about 8% for those who had TURP and PVP. Interestingly, the most common reintervention was the same operation at 1 yr. This has important implications when counseling patients about the durability of these various outlet procedures for BPH.

Effect of 10 Minutes of Prewarming and Prewarmed Intravenous Fluid Administration on the Core Temperature of Patients Undergoing Transurethral Surgery under General Anesthesia

Background: Patients undergoing transurethral urologic procedures using bladder irrigation are at increased risk of perioperative hypothermia. Thirty minutes of prewarming prevents perioperative hypothermia. However, its routine application is impractical. We evaluated the effect of 10 minutes of prewarming combined with the intraoperative administration of warmed intravenous fluid on patients' core temperature. Methods: Fifty patients undergoing transurethral bladder or prostate resection under general anesthesia were included in this study and were randomly allocated to either the control group or the prewarming group. Patients in the prewarming group were warmed for 10 minutes before anesthesia induction with a forced-air warming device and received warmed intravenous fluid during operations. The patients in control group did not receive preoperative forced-air warming and were administered room-temperature fluid. Participants' core body temperature was measured on arrival at the preoperative holding area (T0), on entering the operating room, immediately after anesthesia induction, and in 10-minute intervals from then on until the end of the operation (Tend), on entering PACU, and in 10-minute intervals during the postanesthesia care unit stay. The groups' incidence of intraoperative hypothermia, change in core temperature (T0 - Tend), and postoperative thermal comfort were compared. Results: The incidence of hypothermia was 64% and 29% in the control group and prewarming group, respectively (P = 0.015). Change in core temperature was 0.93 ± 0.3 °C and 0.55 ± 0.4 °C in the control group and prewarming group, respectively (P = 0.0001). Thermal comfort was better in the prewarming group (P = 0.004). Conclusions: Ten minutes of prewarming combined with warmed intravenous fluid significantly decreased the incidence of intraoperative hypothermia and resulted in better thermal comfort in patients undergoing transurethral urologic surgery under general anesthesia.

Wound healing process in beagles after vaporization of the prostate with a novel 200W 450-nm laser

In comparison to other commercially used lasers, the coagulation layer of the novel 450-nm laser is thinner, and this coagulation layer's thickness is a key factor influencing wound healing. In this study, we investigated whether the novel 200W 450-nm laser system (BR6800, Blueray Medical Ltd., Shaanxi, China) is superior to classic transurethral resection of the prostate (TURP) for wound healing in beagles. Twenty-two 6-to 8-year-old male beagles were treated with TURP or blue laser vaporization of the prostate (BLVP). Prostate wounds were observed via cystoscopy at 3 h and at 1, 2, 3, and 5 weeks post-operation (two beagles per group). Additionally, two elderly beagles without surgery served as normal controls. After cystoscopy examination, prostate samples were collected and fixed for hematoxylin and eosin (H&E) and immunofluorescence staining to observe wound healing progression under microscopy. The urethras of prostates under cystoscopy in BLVP groups were healed three weeks after surgery, while in the TURP group, they were healed five weeks after surgery. H&E staining confirmed that the coagulation necrosis layer in the TURP group was thicker than that in the BLVP group and it took longer to remove coagulation necrosis after surgery. Macrophage polarity transformation was also earlier in the BLVP group. The new 200W 450-nm laser was superior to TURP for wound healing. The thinner coagulation layer of the 450-nm laser was the primary reason for this process.

Risk Factors of Salvage Procedure for Refractory Morcellation During Holmium Laser Enucleation of the Prostate

PURPOSE

We aimed to identify the risk factors for salvage procedure (SP) required for refractory adenomatous tissue resistant to morcellation during holmium laser enucleation of the prostate (HoLEP).

METHODS

Patients who underwent HoLEP between January 2010 and April 2020 at Seoul National University Hospital were analyzed. SPs were defined as cases of conversion to resection of the prostatic tissue using an electrosurgical loop after morcellation or secondary morcellation a few days after surgery or conversion to open cystotomy.

RESULTS

Among a total of 2,427 patients, 260 were identified as having SP (SP group) (transurethral resection-nodule [n = 250, 96.1%], secondary morcellation a few days after surgery [n = 9, 3.5%], and conversion to open cystotomy [n = 1, 0.4%]). Patients in the SP group were older and had higher 5-α reductase inhibitors use, higher prostate-specific antigen, larger total prostate volume, and larger transition zone volume (TZV) than those in the non-SP group. In the multivariable logistic regression analysis, only age and TZV were associated with SP. Compared to 40s and 50s, the odds ratios (ORs) were 3.84 in 60s (95% confidence interval [CI] 1.37-10.78, P = 0.011), 4.53 in 70s (95% CI, 1.62-12.62, P = 0.004), and 6.59 in 80s or older (95% CI, 2.23-19.46, P = 0.001). The ORs of the SP were analyzed per TZV quartile. Compared to TZV ≤ 20.3 mL, the OR was 3.75 in 32.0 mL < TZV ≤ 50.4 mL (95% CI, 2.00-7.04, P < 0.001) and 8.25 in 50.4 mL < TZV (95% CI, 4.06-16.77, P < 0.001).

CONCLUSION

The risk of refractory morcellation increased in patients aged > 60 years or those with TZV > 32 mL. In order to more efficiently remove these resistant adenomas, it is necessary to develop more efficient morcellators in the future.

[Effect of equal temperature bladder irrigation in patients with transurethral resection of prostate: A meta-analysis]

OBJECTIVE

To evaluate the effect of equal temperature bladder irrigation on bladder spasm, postoperative bleeding, vital signs and discomfort of chills in patients of transurethral resection of prostate using meta-analysis.

METHODS

Several electronic databases included Cochrane Library, PubMed, Embase, China National Knowledge Infrastructure (CNKI), Wanfang, VIP, China Biology Medicine (CBM) were searched systematically for published randomized controlled trial about equal temperature bladder irrigation in patients with transurethral resection of prostate before November 20, 2019. Two reviewers selected independently the literature in the light of the inclusion and exclusion criteria, assessed the risk of bias by quality assessment and extracted data which were consisted of clinical efficacy indexes, such as incidence of bladder spasm, severity of bladder spasm, incidence of tube plugging, amount of bladder flushing fluid, time of bladder flushing, heart rate, systolic pressure, diastolic pressure, and incidence of chills. Data were pooled using fixed-effects model or random-effects model, and the summary effect measure was calculated by risk ratio (RR) or mean difference (MD) and 95% confidence interval (95%CI). Meta-analysis was performed by Review Manager 5.3 Software.

RESULTS

In the study, 13 randomized controlled trails met the requirement with a total of 2 033 patients of transurethral resection of prostate were included, of whom 1 015 were carried out with equal temperature bladder irrigation and 1 018 with room temperature bladder irrigation. The results of meta-analysis showed that incidence of bladder spasm [RR=0.51, 95%CI (0.45, 0.57), P < 0.001], severity of bladder spasm [MD=-1.61, 95%CI (-2.00, -1.23), P < 0.001], incidence of urinary blockage [RR=0.29, 95%CI (0.19, 0.44), P < 0.001], dosage of bladder irrigation [MD=-6.75, 95%CI (-7.33, -6.17), P < 0.001], time of bladder rinse [MD=-7.60, 95%CI (-11.91, -3.29), P < 0.001], heart rate [MD=-13.68, 95%CI (-15.19, -12.17), P < 0.001], systolic pressure [MD=-29.26, 95%CI (-31.92, -26.59), P < 0.001], diastolic pressure [MD=-29.36, 95%CI (-31.75, -26.98), P < 0.001], incidence of chills and discomfort [MD=0.37, 95%CI (0.31, 0.44), P < 0.001] in equal temperature group of the patients with transurethral resection of prostate had significantly statistical difference compared with room temperature group.

CONCLUSION

Based on current available evidence, equal temperature bladder irrigation reduced the incidence of bladder spasm and urinary blockage, relieved bladder spasm, reduced dosage and time of bladder irrigation, and hardly affected normal vital signs and increased the patient' s comfort.

Anterior fibromuscular stroma-preserved endoscopic enucleation of the prostate: a precision anatomical approach

BACKGROUND

Benign prostate obstruction (BOO) is becoming increasingly important in this aging society. Some urge/stress urinary incontinence (UUI/SUI) still occurs after endoscopic enucleation of the prostate (EEP). It remains unclear how post-EEP incontinence can be avoided. Currently, early apical release to ameliorate the traction of the external sphincter is the best technique for incontinence prevention.

OBJECTIVE

To describe our surgical technique of anterior fibromuscular stroma (AFS)-preserved EEP for BOO.

DESIGN, SETTING, AND PARTICIPANTS

The medical records of 60 consecutive patients who underwent AFS-preserved EEP for BOO in our center from September 2019 to December 2019 were retrospectively reviewed.

SURGICAL PROCEDURE

AFS-preserved EEP starts at the 12 o'clock position of the urethra, and the junction between the AFS and transitional zone (T-zone) was identified. The AFS and T-zone were separated first to protect the AFS in the initial operative procedure. Then, following the usual enucleation procedure, AFS-preserved EEP could be achieved.

MEASUREMENTS

Postoperative prostate-specific antigen (PSA), testosterone, urethral stricture, and voiding status, such as incontinence, uroflow, and postvoiding residual urine were assessed.

RESULTS AND LIMITATIONS

The data show that AFS-preserved EEP could achieve similar surgical outcomes as other early apical release approaches.

CONCLUSIONS

The preserved AFS provides a nice landmark at the 12 o'clock position during EEP.

Intraoperative accidental hypothermia as a probable cause of malignant ventricular arrhythmias in an elderly patient undergoing transurethral resection of prostate: A case report

Background

Intraoperative hypothermia is a common but severe condition that is defined as a core body temperature below 36 °C. Accidental hypothermia can produce coagulopathy, immunosuppression and peripheral hypoperfusion that can ultimately lead to life-threatening ventricular arrhythmias and vital organ injury, and it is significantly associated with perioperative complications and mortality.

Case description

We report the case of an 82-year-old man who presented with persistent ventricular tachycardia intraoperatively due to accidental hypothermia. The patient was diagnosed with benign prostatic hypertrophy and scheduled for transurethral resection of the prostate. Laboratory tests showed moderate anemia, and echocardiography indicated mild tricuspid and mitral regurgitation. The patient received general anesthesia with endotracheal intubation. Four hours after the start of surgery, the patient developed sudden ventricular tachycardia with severe hypotension. Arterial blood gas sampling indicated that there was no disturbance of electrolytes, acid-base balance or excessive bleeding. The rectal temperature was measured immediately, and the core temperature was 32 °C. The patient received antiarrhythmic therapy and rewarming measures. No additional ventricular arrhythmias appeared after the core temperature rose to 35 °C and the blood pressure returned to normal. The patient was transferred to the intensive care unit after surgery for further observation and was moved to the general ward the next day. He was discharged 4 days later without significant organ damage.

Conclusions

Intraoperative hypothermia may increase ventricular arrhythmia risk, especially in elderly patients. Surgeons and anesthesiologists should pay more attention to preventing and reversing accidental hypothermia, necessitating aggressive efforts to maintain normothermia during surgery.

Efficacy of botulinum toxin-A injection versus oral anticholinergic medications following transurethral resection of the prostate to manage bladder outlet obstruction with overactive bladder: a prospective randomized clinical trial study

BACKGROUND

To compare the effect of botulinum toxin-A (BoNT-A) injection versus oral anticholinergic agents following transurethral resection of the prostate (TURP) in patients with benign prostatic hyperplasia (BPH) and Overactive Bladder.

MATERIALS AND METHODS

In this randomized clinical trial from February 2021 till May 2022 data of patients with obstructive urinary symptoms and urgency incontinence were analyzed. The intervention group consisted of 35 patients who were injected with 300 units of BoNT-A (Dysport^®) into the detrusor muscles at the same time as TURP. 38 participants in the control group were treated with solifenacin 5 mg (Urinacin^®) daily after TURP.

RESULTS

In the evaluation of 73 included patients (mean age: 67.54±6.3), IPSS score change (first month, P=0.777; 6^th month, P=0.761) and storage irritative symptoms change score (first month, P=0.995; 6^th month, P=0.962) were decreased and Qmax was increased (first month, P=0.195; 6^th month, P=0.174) similarly in 2 groups. Lower number of patients experienced urgency incontinence during follow up time in intervention group, significantly (first month, 18 versus 5, P=0.002; 6^th month, 20 versus 6, P=0.002). PVR was also decreased more in first month and 6^th month follow up in patients of intervention group (1^th month, P=0.012; 6^th month, P=0.033).

CONCLUSION

Anticholinergic agents or intradetrusor BoNT-A injection would improve the storage symptoms in patients with BPH and detrusor overactivity following TURP. In contrast to IPSS score, storage irritative score and Qmax, which improve similarly in both groups, the PVR and urgency incontinence episodes will improve more in patients receive intradetrusor BoNT-A injection.

Effect of Diabetes Mellitus on Symptomatic Improvement After Surgery for Benign Prostatic Hyperplasia in Patients With Lower Urinary Tract Symptom and its Relations With Prostatic Urethral Angulation

PURPOSE

To compare improvement of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia in diabetic versus nondiabetic patients after transurethral resection of the prostate (TURP) or holmium laser enucleation of the prostate (HoLEP).

METHODS

The medical records of 437 patients who underwent TURP or HoLEP at a tertiary referral center from January 2006 to January 2022 were retrospectively analyzed. Among them, 71 patients had type 2 diabetes. Patients in the diabetic mellitus (DM) and non-DM groups were matched 1:1 according to age, baseline International Prostate Symptom Score (IPSS), and ultrasound measured prostate volume. Changes in LUTS were assessed at 3 months after surgery using IPSS and evaluated by categorizing patients according to prostatic urethral angulation (PUA; <50° vs. ≥50°). Medication-free survival after surgery was also investigated.

RESULTS

No significant differences were noted between the DM and non-DM groups in baseline characteristics except for comorbidities (i.e., hypertension, cerebrovascular disease, and ischemic heart disease, P=0.021, P=0.002, and P=0.017, respectively) and postvoid residual urine volume (115±98 mL vs. 76±105 mL, P=0.028). Non-DM patients showed significant symptomatic improvement regardless of PUA, while DM patients demonstrated improvement in obstructive symptoms only in those with large PUA (≥51°). Among patients with small PUA, DM patients had worse medication-free survival after surgery compared to controls (P=0.044) and DM was an independent predictor of medication reuse (hazard ratio, 1.422; 95% confidence interval, 1.285-2.373; P=0.038).

CONCLUSION

DM patients experienced symptomatic improvement after surgery only in those with large PUA. Among patients with small PUA, DM patients were more likely to reuse medication after surgery.

Necrosis zone depth after bipolar plasma vaporization and resection in the human prostate

Objectives

To compare the depth of thermal necrosis after use of bipolar resection and vaporization technique comparing intra-individually bipolar loop and bipolar button electrodes.

Methods

Transurethral resection and vaporization of the prostate was performed in 55 male patients (260 specimens in total). In a standardized procedure, a bipolar resection loop was used for resection, and a bipolar button electrode was used for vaporization. Both electrodes were applied in each patient, either in the left or in the right lateral lobe. The depth of necrotic zones in the resected or vaporized tissue of each patient was measured in a standardized way by light microscopy.

Results

The mean depth with standard deviation of thermal injury caused by the loop electrode was 0.0495±0.0274 mm. The vaporization electrode caused a mean thermal depth with standard deviation of 0.0477±0.0276 mm. The mean difference of necrosis zone depths between the two types of electrodes (PlasmaButton-resection loop) was -0.0018 mm (p=0.691).

Conclusion

For the first time, we present directly measured values of the absolute necrosis zone depth after application of plasma in the transurethral treatment of benign prostatic hyperplasia. The measured values were lower than in all other transurethral procedures. Standardized procedures of measurement and evaluation allow a statistically significant statement that the low necrosis depth in bipolar procedures is independent of the applied electrodes.

Management of urethral strictures and stenosis caused by the endo-urological treatment of benign prostatic hyperplasia-a single-center experience

Objective

Urethral stricture disease after endo-urological treatment of benign prostatic hyperplasia (BPH) is a sparsely described complication. We describe management of five categories of these strictures in this retrospective observational case series.

Methods

One hundred and twenty-one patients presenting with symptoms of bladder outflow obstruction after endo-urological intervention for BPH from February 2016 to March 2019 were evaluated. Among them, 76 were eligible for this study and underwent reconstructive surgery. Preoperative and postoperative assessments were done with symptom scores, uroflowmetry, ultrasound for post-void residue, and urethrogram. Any intervention during follow-up was classed as a failure. The recurrence and 95% confidence interval for recurrence percentage were calculated.

Results

The following five categories of patients were identified: Bulbo-membranous (33 [43.4%]), navicular fossa (21 [27.6%]), penile/peno-bulbar (8 [10.5%]), bladder neck stenosis (6 [7.9%]), and multiple locations (8 [10.5%]). The average age was 69 years (range: 60-84 years). Overall average symptom score, flow rate, and post-void residue changed from 21 to 7, 6 mL/s to 19 mL/s, and 210 mL to 20 mL, respectively. The average follow-up was 34 months (range: 12-58 months). Overall recurrence and complication rates were 10.5% and 9.2%, respectively. The recurrence in each category was seen in 3, 1, 2, 1, and 1 patient, respectively. Overall 95% confidence interval for recurrence percentage was 4.66-19.69.

Conclusion

Urethral stricture disease is a major long-term complication of endo-urological treatment of BPH. The bulbo-membranous strictures need continence preserving approach. Navicular fossa strictures require minimally invasive and cosmetic consideration. Peno-bulbar strictures require judicious use of grafts and flaps. Bladder neck stenosis in this cohort could be treated with endoscopic measures. Multiple locations need treatment based on their sites in single-stage as far as possible.

Patient Blood Management in Transurethral Resection Surgery: Overview and Strategy Analysis from a French Tertiary Hospital

INTRODUCTION

Since Patient blood management (PBM) suggests a bundle of measures aiming to reduce perioperative blood transfusion because preoperative anemia and blood transfusion are associated with poor postoperative outcomes. There is a lack of data on the effect of PBM in patients undergoing transurethral resection of prostate (TURP) or bladder tumor (TURBT). We aimed to assess the bleeding risk in TURP and TURBT procedures and the effect of preoperative anemia on postoperative morbimortality.

METHODS

A single-center retrospective observational cohort study was conducted in a tertiary hospital in Marseille, France. All patients undergoing TURP or TURBT were included in 2020 and divided into two groups: preoperative anemia (n = 19) and no preoperative anemia (n = 59). We recorded demographic characteristics, preoperative hemoglobin concentration, iron deficiency markers, preoperative initiation of a treatment for anemia, perioperative bleeding, and postoperative outcomes up to 30 days including blood transfusion, hospital readmission, reintervention, infection, and mortality.

RESULTS

Baseline characteristics were comparable between groups. No patient had iron deficiency markers and no prescription of iron was initiated before surgery. No major bleeding was reported during surgery. Postoperative anemia was found in 21 patients, including 16 (76%) in the preoperative anemia group and 5 (24%) in the non-preoperative anemia group. One patient of each group received a blood transfusion after surgery. No significant differences in 30-day outcomes were reported.

CONCLUSION

Our study suggests that TURP and TURBT are not associated with a high-risk of postoperative bleeding. In such procedures, adherence PBM strategies do not seem beneficial. Since recent guidelines recommend restricting preoperative testing, our results may help to improve preoperative risk stratification.

Effect of urinary retention on the surgical outcome of holmium laser enucleation of the benign prostatic hyperplasia

PURPOSE

To evaluate the effect of urinary retention (UR) on holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms.

MATERIALS AND METHODS

A retrospective analysis of a prospective cohort of patients who underwent HoLEP between January 2010 and December 2016 was performed. The perioperative factors, including the International Prostate Symptom Score, Overactive Bladder Symptom Score, prostate-specific antigen, urodynamic study results, uroflowmetry results, transrectal ultrasound prostate volume, operative time, morcellation time, enucleation weight, and complications, were evaluated. Postoperative evaluation was performed at 2, 3, and 6 months.

RESULTS

Overall, 903 patients were identified. The mean age and follow-up were 68.3 years and 6 months, respectively. Among the patients, 135 (15.0%) patients had a history of acute UR (AUR), and 36 patients (4.0%) had chronic UR (CUR). The mean detrusor pressures at maximum flow were 64.4, 74.3, and 77.7 cmH₂O (p<0.001). The mean maximum flow rates (Qmax) were 7.6, 6.6, and 4.8 mL/s (p<0.001). Additionally, the mean bladder outlet obstruction indices were 49.5, 61.1, and 69.4 (p<0.001). The postoperative Qmax improved in all three groups. The mean postvoid residual volumes (PVRs) were 55, 75, and 333 mL preoperatively; 20, 29, and 66 mL at 2 weeks; 16, 23, and 45 mL at 3 months; and 15, 22, and 52 mL at 6 months (p<0.001).

CONCLUSIONS

Voiding symptoms, PVR, and Qmax of BPH patients with preoperative AUR and CUR significantly improved after Ho-LEP, similar to those without preoperative UR.

Risk factors for the postoperative bladder neck contracture in patients with small-volume prostatic hyperplasia

OBJECTIVE

This study was to explore the risk factors for postoperative bladder neck contracture (BNC) after transurethral operation of prostate in patients with small-volume prostatic obstruction.

METHODS

Clinicopathologic data at our center from February 2016 to January 2020 were retrospectively collected and analyzed. Clinicopathological characteristics between patients with and without BNC were compared. Multivariate logistic regression was used to determine the risk factors for postoperative BNC.

RESULTS

There were a total of 39 patients (8.53%) with postoperative BNC. Multivariate logistic regression analysis demonstrated that preoperative bladder neck diameter (BND), intravesical prostatic protrusion (IPP), surgical methods (transurethral resection of prostate (TURP)/anatomical endoscopic enucleation of the prostate (AEEP)), and postoperative urinary tract infection (UTI) were independent risk factors for postoperative BNC in patients with small-volume prostatic obstruction (P < 0.05). The incidence of postoperative BNC in patients undergoing AEEP was significantly decreased compared with those undergoing TURP. The optimal cut-off value of preoperative IPP was 6.10 mm while the optimal cut-off value of preoperative BND was 2.52 cm.

CONCLUSIONS

Larger preoperative bladder neck and higher preoperative IPP lead to decreased incidence of postoperative BNC in patients with small-volume prostatic obstruction. Active management of postoperative UTI could effectively prevent the occurrence of postoperative BNC. Compared with TURP, complete AEEP would contribute to reduce BNC in patients with small-volume prostatic obstruction.

Comparison of bipolar radiofrequency thermotherapy and transurethral prostate resection in treatment of benign prostate hyperplasia

OBJECTIVES

Lower urinary tract symptoms due to benign prostatic hyperplasia in men increase with aging. Risks related to anesthesia and surgery have led a search for alternative treatments. Bipolar radiofrequency (RF) thermotherapy is one of the methods adopted in patients with high surgical risks. The aim of this study is to compare the effect of bipolar RF thermotherapy and transurethral resection of the prostate (TURP) methods on voiding symptoms and on post-operative complication rates especially in patients carrying high surgical risks.

METHODS

Pre-operative, post-operative 1st and 6th month International Prostate Symptom Score (IPSS), Qmax, quality of life, prostate volumes, and postoperative complications of the patients underwent TURP and RF for benign prostatic hyperplasia (BPH) were compared.

RESULTS

In the RF group, the pre-operative median IPSS was 30, prostate volume 41.5 cc, post-void residual (PVR) 80 ml, and Qmax is 5.85 ml/s.; In the TURP group, these were 29, 40 cc, 85 ml, and 5.3 ml/sec, respectively. In the Bipolar RF group, post-operative 1st- and 6th-month median values were IPSS 18, 21; prostate volume 40, 40; PVR 40, 35; Qmax 10.9, 9.15 and in the TURP group IPSS 9, 8; prostate volume 20, 20; PVR 30, 10; Qmax 17.25, 19.1, respectively.

CONCLUSION

Bipolar RF thermotherapy is an applicable treatment method for BPH patients with high surgical risks.

Clinical benefits of retrograde bladder filling method prior to catheter removal after TURP for BPH: A prospective randomized trial

PURPOSE

To evaluate possible benefits and clinical feasibility of retrograde bladder filling method prior to intra-vesical catheter removal after transurethral prostatectomy (TURP) for benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Male patients undergoing TURP for BPH from January 2019 to October 2019 were randomized in a 1:1 ratio into either retrograde filling (RF) or spontaneous voiding (SV) methods at a single institution to determine safety and efficacy of RF (NCT04309032), with surgeons blinded to allocation. Perioperative outcomes including postoperative complications were compared between two groups. Clinician/patients' satisfaction level which was evaluated with postoperative questionnaires were also compared.

RESULTS

A total of 56 patients were randomized into two groups and 56 were included in final analysis (28 men in RF group, 26 in SV group). No significant differences in baseline characteristics including age, prostate volume, or perioperative uroflowmetry were observed. However, RF significantly facilitated time to void (67.0±63.2 vs. 144.0±78.7 min; p<0.001) and time to discharge (168.4±57.2 vs. 218.9±106.9 min; p=0.046). Immediate postoperative complications were comparable in both methods with no significant difference. Overall patient and medical staff satisfaction showed tolerable and similar response by either procedure.

CONCLUSIONS

RF method for intra-vesical catheter removal is a safe and satisfactory method that can facilitate early voiding detection and shorten the time to discharge. Further trials are required to further validate our results.

Comparative Analysis of Proteomes and Phosphoproteomes in Patients with Prostate Cancer Using Different Surgical Conditions

Purpose

To establish the standard of procedure in preparing benign and cancerous prostate tissues and evaluate the quality of proteomics and phosphoproteomics during transurethral resection of the prostate (TUR-P) with different surgical conditions.

Materials and Methods

TUR-P tissue samples from three patients, two diagnosed with prostate cancer and one with benign prostatic hyperplasia, were each analyzed under three different conditions, based on differences in energy values, tissue locations, and surgical techniques. Global- and phosphorylated proteomic profiles of prostate tissues were analyzed by liquid chromatography-tandem mass spectrometry.

Results

A total of 6,019 global proteins and 4,280 phosphorylated peptides were identified in the nine tissues. The quantitative distributions of proteins and phosphorylation in tissues from the same patient were not affected by changes in the surgical conditions, but indirect relative comparisons differed among patients. Phosphorylation levels, especially of proteins involved in the androgen receptor pathway, important in prostate cancer, were preserved in each patient.

Conclusions

Proteomic profiles of prostate tissue collected by TUR-P were not significantly affected by energy levels, tissue location, or surgical technique. In addition, since protein denaturation of samples through TUR-P is rarely confirmed in this study, we think that it will be an important guide for tissue samples in castration resistant prostate cancer patients, where it is difficult to obtain tissue. This result is the first report about proteomic and phosphoproteomic results with TUR-P samples in prostate cancer and will be theoretical basis in protein analysis research with prostate cancer tissues.

[Impact of simulation-based training in endourology: A systematic review of the literature]

INTRODUCTION

The impact of simulation on the acquisition of surgical skills as well as their transfer to the operating room is still debated. The objective was to assess these two specific points, focusing on the field of endourology.

METHODS

A systematic review of the literature, following the PRIMA statement, was performed using Medline database through September 2021 without time limit. Studies focusing on the impact of simulators on the acquisition of surgical technical skills as well as their transfer to the operating room in the field of endourology were included. The endourological procedures were: cystoscopy, ureteroscopy, percutaneous nephrolithotomy, endoscopic treatment of benign prostatic hyperplasia, endoscopic bladder resection.

RESULTS

Among the 11,442 publications identified, fifty-two studies were included in the analysis. The majority reported an improvement in procedure time of the requested tasks and dexterity of participants, regardless of the type of simulator and procedure. The level of evidence of included studies was often low. Few studies evaluated the transfer of acquired skills from the simulator to the operating room.

CONCLUSION

This review showed the positive impact of simulation on the acquisition of technical skills in endourology. However, in order to include proficiency-based progression in the curriculum of trainees, some parameters such as the choice of reference simulators, choice of tasks, and method of validation of acquired skills must be validated in a consensual manner to offer a quality training.

Crowned dens syndrome as a rare cause of anterior neck pain after transurethral resection of the prostate: a case report

We describe the case of a 79-year-old man who presented with progressive aggravation of severe axial neck pain and fever 3 days after transurethral resection of the prostate (TURP), despite maintaining neutral neck posture during surgery. Laboratory examination revealed markedly elevated C-reactive protein levels and erythrocyte sedimentation rates. Computed tomography revealed crown-like calcifications surrounding the odontoid process. We diagnosed crowned dens syndrome (CDS) as the cause of acute-onset neck pain after TURP. The patient was treated with nonsteroidal anti-inflammatory drugs for 5 days, and his symptoms resolved completely. CDS is a rare disease characterized by calcific deposits around the odontoid process with acute onset of severe neck pain and restricted motion. Evidence of inflammation on serological testing and fever are typical of CDS. However, the prevalence and pathophysiology of CDS remain unclear. We hypothesized that systemic inflammation after prostate surgery may have induced a local inflammatory response involving calcification around the odontoid process.

The Effect of Transurethral Resection of the Prostate on Erectile and Ejaculatory Functions in Patients with Benign Prostatic Hyperplasia

Introduction

The aim of this study was to investigate the effect of TURP on erectile function (EF) and ejaculatory function (EJF).

Methods

A total of 91 patients who underwent TURP were retrospectively assessed. Patients were divided into two groups based on International Index of Erectile Function (IIEF-5): group A included 41 patients with normal EF, and group B included 50 patients with erectile dysfunction (ED). All patients were evaluated for EF and EJF at baseline, 1, 3, and 6 months after TURP by using IIEF-5, Ejaculatory Domain-Male Sexual-Health Inventory (Ej-MSHQ).

Results

In group A, there were no significant statistical differences in mean IIEF-5 at baseline and after TURP 22.88 ± 0.81 versus 22.63 ± 2.63 (p = 0.065). However, in group B, there was significant improvement in IIEF-5 after TURP all over the follow-up time points in comparison to the baseline (p = <0.001). The loss of EJF was significant among patients in group A. There was significant improvement of IPSS and Qmax in group A after surgery compared to group B.

Conclusion

The results confirmed that TURP has no significant negative influence on EF, and patients with preexisting ED were improved after TURP. On the contrary, the loss of EJF was significant.

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.

Comparison of the efficacy and safety of transurethral laser versus open prostatectomy for patients with large-sized benign prostatic hyperplasia: A meta-analysis of comparative trials

PURPOSE

The selection of open prostatectomy (OP) over transurethral laser surgery is controversial for large volume prostates. Thus, we aim to compare the efficacy and safety of transurethral laser versus OP, and provide the latest evidence of clinical practice for large-sized benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

This meta-analysis used Review Manager V5.3 software and the systematic literature search of Cochrane Library, Embase, PubMed, and Web of Science datasets was performed for citations published from 2000 to 2020 that compared transurethral laser with OP for the treatment of large BPH. Variables of interest assessing the two techniques included clinical characteristics, and the perioperation-, effectiveness-, and complication-related outcomes.

RESULTS

The meta-analysis included twelve studies containing 1,514 patients, with 792 laser and 722 OP. The transurethral laser group was associated with shorter hospital stay and catheterization duration, and less hemoglobin decreased in the perioperative variables. There was no significant difference in the international prostate symptom score, post-void residual urine volume, maximum flow rate, and quality of life score. Transurethral laser group had a significantly lower incidence of blood transfusion than OP group (odds ratio, 0.10; 95% confidence interval, 0.05 to 0.19; p<0.001; I²=8%), and no statistical differences were found with respect to the other complications.

CONCLUSIONS

Both OP and transurethral laser prostatectomy are effective and safe treatments for large prostate adenomas. With these advantages of less blood loss and transfusion, and shorter catheterization time and hospital stay, laser may be a better choice for large BPH.

Cerebrovascular accident after transurethral resection of the prostate: A rare complication

INTRODUCTION

Benign prostatic hyperplasia is considered a worldwide disease among males in middle age. Transurethral resection of the prostate (TURP) is a wide used intervention for this condition. A few reports mentioned cerebrovascular accidents after TURP.

PRESENTATION OF CASE

A 65-year-old male presented with recurrent urinary retention in the past two years. Clinical examination showed a full urinary bladder with abdominal discomfort. Abdominal ultrasound revealed an enlarged prostate (90 ml) with approximately 500 ml of urine. After that, we performed transurethral resection of the prostate (TURP). The surgery was uneventful. After three days of discharge, he presented with a loss of vision in the left eye and left lower limb pain. Computed tomography of the brain showed right occipital lobe infarction. Ultrasound of the left lower limb revealed deep venous thrombosis. Echocardiography showed a patent foramen ovale. As a result, he had deep venous thrombosis with patent foramen ovale that led to infarction. We started with anticoagulants for two weeks. Later, he reclaimed his vision completely.

CLINICAL DISCUSSION

Cerebral vascular accidents are a rare complication of transurethral resection of the prostate. Early recognition and diagnosis of this condition will lead to good results. Searching for cardiac anomalies is the first step to reaching the diagnosis.

CONCLUSION

Urologists should suspect cardiac anomalies in patients who underwent TURP surgery and develop cerebrovascular accidents. Collaboration with other specialties is considered basic to help with this complication.

Modified bladder outlet obstruction index for powerful efficacy prediction of transurethral resection of prostate with benign prostatic hyperplasia

Background

The correlation between modified bladder outlet obstruction index (MBOOI) and surgical efficacy still remains unknown. The purpose of the study was to investigate the clinical value of the MBOOI and its use in predicting surgical efficacy in men receiving transurethral resection of the prostate (TURP).

Methods

A total of 403 patients with benign prostate hyperplasia (BPH) were included in this study. The International Prostate Symptom Score (IPSS), quality of life (QoL) index, transrectal ultrasonography, and pressure flow study were conducted for all patients. The bladder outlet obstruction index (BOOI) (P_detQ_max–2Q_max) and MBOOI (P_ves–2Q_max) were calculated. All patients underwent TURP, and surgical efficacy was accessed by the improvements in IPSS, QoL, and Q_max 6 months after surgery. The association between surgical efficacy and baseline factors was statistically analyzed.

Results

A comparison of effective and ineffective groups based on the overall efficacy showed that significant differences were observed in PSA, P_ves, P_detQ_max, P_abd, BOOI, MBOOI, TZV, TZI, IPSS-t, IPSS-v, IPSS-s, Q_max, and PVR at baseline (p < 0.05). Binary logistic regression analysis suggested that MBOOI was the only baseline parameter correlated with the improvements in IPSS, QoL, Q_max, and the overall efficacy. Additionally, the ROC analysis further verified that MBOOI was more optimal than BOOI, TZV and TZI in predicting the surgical efficacy.

Conclusion

Although both MBOOI and BOOI can predict the clinical symptoms and surgical efficacy of BPH patients to a certain extent, however, compared to BOOI, MBOOI may be a more useful factor that can be used to predict the surgical efficacy of TURP.

Trial registration retrospectively registered.

Unusual case of infectious endocarditis in a patient subjected to transurethral resection of the prostate (TURP) without cardiovascular risk factors

OBJECTIVE

Transurethral resection of the prostate (TURP) is the gold standard for the treatment of obstructive prostatic hyperplasia. A bacteremia leading to infectious endocarditis (IE) can be the result of urological procedures. IE post TURP is rare.

METHODS

We report an unusual case of an infectious endocarditis complicating TURP for benign prostatic hyperplasiain absence of known previous cardiovascular risk factors or conditions.

RESULTS AND CONCLUSIONS

The patient developed intermittent episodes of fever lasting more than two months starting 3 weeks from hospital discharge, and he was never referred to the hospital by his general practitioner, until he was evaluated by his Surgeon, admitted to the Emergency Department and diagnosed with infectious endocarditis, later dying for cardiac arrest before getting a cardiac valve replacement. This report aims to be a reminder of how invasive procedures can trigger secondary distant complications that should be taken into account while assessing a post-operative patient.

A Retrospective Operative and Early Outcome Comparison of Suprapubic Transvesical Prostatectomy and Transurethral resection of the Prostate

Background

BPH is the major cause of bladder outlet obstruction over the age of 40 years. Multiple surgical management options have been described of which STVP and TURP are the oldest and widely available procedures. The objective of this study is to describe and compare the intraoperative and early outcome situations of STVP and TURP.

Methods

This is a hospital-based retrospective descriptive study that compares intraoperative and early outcomes of STVP and TURP in Menilik II Hospital from January 2017 to December 2019. The study samples were 72 STVP and 72 TURP patients.

Results

The mean duration of surgery in the STVP group was 97.8 minutes which is significantly longer than TURP group (66.15 minutes). Duration of post-op catheterization and hospital stay are significantly longer in STVP than TURP.

Conclusion

The duration of surgery, length of hospital stays and post op catheterization are longer in STVP. There was no significant difference in intra-op and early complications from STVP and TURP.

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.

Rapidly recurrent prostatic obstruction due to granulomatosis with polyangiitis

Granulomatosis with polyangiitis (GPA) is a rare cause of prostatitis. Our case illustrates a case of granulomatous prostatitis secondary to unrecognised GPA requiring multiple surgical interventions. The patient presented with lower urinary tract symptoms. They underwent two endoscopic prostatic resections for recurrent urinary obstruction due to granulomatous prostatitis before a diagnosis of GPA was made. The rarity of this pathology, challenges in making a diagnosis and the systemic nature of this disease are emphasised.

Loss of vision after transurethral resection of prostate: A case report

The overall complication rate of Transurethral resection of prostate (TURP) is about 11.1%. Amongst all complications, ocular complications are one of the rarest. In this paper, we present a case of vision loss due to paradoxical embolism as a rare complication following TURP. Ocular complications are very rare in urological surgeries but can happen due to paradoxical embolism following patent foramen ovale. Therefore, we recommend the early diagnosis and treatment of PFO prior to this type of surgery.

Comparison between thulium laser vapoenucleation and plasmakinetic resection of the prostate in men aged 75 years and older in a real-life setting: a propensity score analysis

BACKGROUND

Urologists may hesitate to offer transurethral resection of the prostate (TURP) because of increased morbidity in elderly patients.

AIMS

We aimed to compare data on postoperative outcomes of elderly men undergoing bipolar transurethral resection of the prostate (B-TURP) as compared to thulium laser vapoenucleation of the prostate (ThuVEP).

METHODS

We retrospectively reviewed data of all patients aged ≥ 75 years who underwent benign prostatic hyperplasia surgery. Differences between interventions were estimated using propensity scores (PS) to adjust for different patients characteristics.

RESULTS

Between 2017 and 2020, 275 men were included in the analysis. Propensity score retrieved 65 patients in each group. Median age was 78 (4) years in B-TURP group and 78 (6) in ThuVEP group. Median prostate volume was 63 (35) ml and 54 (24) ml in B-TURP group and ThuVEP group, respectively. Only American Society of Anesthesiologists score was significantly higher in ThuVEP group (p = 0.006). Median operation time, catheterization time, and hospital stay were similar in both groups (55 min, 2 and 3 days). Overall, 84.6% of men had no complications, with no significant differences between the groups (p = 0.234). Only one patient in B-TURP group experienced a Clavien grade IIIb complication. By 1 year, there were a statistically significant differences in International Prostate Symptom Score (p = 0.000) in favor of B-TURP group and in maximal urine flow rate (p = 0.000) in favor of ThuVEP group.

DISCUSSION AND CONCLUSIONS

Both procedures showed excellent functional improvements one year after surgery with a low rate of major complications in men aged ≥ 75 years with small-to-medium sized prostates.

Bladder neck stenosis after transurethral prostate surgery: a systematic review and meta-analysis

PURPOSE

Bladder neck stenosis (BNS) is a long-term complication of surgical procedures for benign prostatic hyperplasia (BPH). We performed a systematic literature review and a meta-analysis of the incidence of BNS after transurethral procedures for BPH.

METHODS

We performed a systemic literature review using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. We accepted only randomized trials comparing transurethral resection of the prostate (TURP) vs. other transurethral surgery for BPH that were grouped in Ablation vs. Enucleation modalities. The incidences of BNS were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and expressed as Risk Ratios, 95% Confidence Intervals, and p values. Study heterogeneity was assessed utilizing the I² value.

RESULTS

72 studies were identified for meta-analysis, 46 comparing TURP vs. Ablation and 26 TURP vs. Enucleation. The pooled incidence of BNS was 1.3% after TURP, 0.66% after enucleation and 1.2% after Ablation. The incidence of BNS was higher after TURP than after Enucleation but the difference was not statistically significant (RR 1.75 95% CI 0.81-3.79, p = 0.16). There was no significant heterogeneity among the studies (I² 0%, Chi² 4.11, p = 0.90). The incidence of BNS was higher after TURP than after Ablation, but the difference was not statistically significant (RR 1.31, 95% CI 0.82-2.11, p = 0.26) with no significant heterogeneity (I² 0%, Chi² 21.1, p = 0.51).

CONCLUSION

Our study showed no difference in the rate of BNS incidence among randomized trials comparing TURP vs. Ablation vs. Enucleation and can be used as a reference to counsel patients undergoing BPH surgery.

Comparison of Efficacy of Different Surgical Techniques for Benign Prostatic Obstruction

Purpose

We compared success rates of 3 surgical techniques (holmium laser enucleation of the prostate [HoLEP], transurethral resection of the prostate [TURP], and photoselective laser vaporization prostatectomy [PVP]) for treatment of benign prostatic obstruction (BPO). We aimed to identify preoperative clinical variables and urodynamic parameters that predict surgical success.

Methods

A total of 483 patients who underwent surgical treatment for BPO at Samsung Medical Center between 2006 and 2017 were retrospectively analyzed; of these 361, 81, and 41 patients underwent HoLEP, TURP, and PVP, respectively. Prostate-specific antigen, prostate volume, urodynamic parameters, and International Prostate Symptom Score (IPSS)/quality of life (QoL) index were evaluated preoperatively; uroflowmetry, postvoid residual urine, and IPSS/QoL index were measured 6 months postoperatively. Surgical success was defined based on IPSS, maximum flow rate, and QoL index and predictive factors were identified using multiple logistic regression analyses.

Results

Success rates of HoLEP, TURP, and PVP were 67.6%, 65.4%, and 34.1%, respectively, and the HoLEP and TURP groups were not significantly different. Regression analysis revealed prostate volume ≥50 mL and bladder outlet obstruction index (BOOI) ≥40 to be independent factors predicting HoLEP success. Only high preoperative QoL could predict the success of TURP, whereas other urodynamic parameters remained unrelated.

Conclusions

Patients treated with HoLEP and TURP displayed equivalent efficacies, but PVP was relatively less efficient than both. Preoperative variables of prostate volume ≥50 mL and BOOI ≥40 were independent predictive factors for the success of HoLEP but not of TURP.

Analysis of risk factors of bladder neck contracture following transurethral surgery of prostate

BACKGROUNDS

The aim of the present study was to investigate the perioperative parameters associated with bladder neck contracture (BNC) after transurethral surgery of the prostate and to compare the incidence of BNC after transurethral resection of the prostate (TURP) or Thulium vaporesection (resection group) versus Thulium vapoenucleation or enucleation of the prostate (enucleation group).

METHODS

Between March 2008 and March 2020, 2363 patients received TURP and 1656 patients received transurethral surgery of the prostate with Thulium laser (ThuP) at Mackay Memorial Hospital. A total of 62 patients developed BNC. These BNC patients were age-and operation-matched to 124 randomly sampled TURP/ThuP controls without BNC. A 1:1 propensity score matching model was used to evaluate the difference in incidence of BNC.

RESULTS

Our study demonstrated that a greater proportion of BNC patients had history of cerebrovascular accidents (11/62 vs. 7/124, p = 0.009), coronary artery disease (14/48 vs. 16/108, p = 0.03), chronic kidney disease (14/62 vs. 11/124, p = 0.01), and two or more comorbidities (29/62 vs. 27/124, p = 0.001) compared with NBNC patients. Multivariate analysis showed that smaller prostate volume (OR 0.96 (0.94-0.99), p = 0.008) and recatherization (OR 5.6 (1.02-30.6), p = 0.047) were significantly associated with BNC. A ROC curve predicted that a prostate volume < 42.9 cm³ was associated with a notably higher rate of BNC. The propensity score matching model reported there was no difference in incidence between resection and enucleation groups.

CONCLUSION

This study demonstrated that incidence of BNC was the same in different surgical techniques and that low prostate volume, recatherization and ≥ 2 comorbidities were positively correlated with the development of BNC after TURP or ThuP.

The state of TURP through a historical lens

In 1926 Maximilian Stern introduced a new instrument to treat obstructions at the vesical orifice and baptized it resectoscope. With reference to astonishing historical statements about the new instrument and surgical technique made by the pioneers and their critics we will value why transurethral resection of the prostate (TURP) remains the gold standard for most men suffering from lower urinary tract symptoms (LUTS) due to benign prostatic enlargement. TURP is currently challenged by recently introduced new instruments and techniques claiming advantages over TURP. However, TURP offers an excellent balance between high efficacy in symptom relieve and low morbidity along with low costs and favorable long term outcome compared to other treatment options. We will outline these arguments demonstrating that even after a century has elapsed, since its introduction into the urologists armamentarium, TURP continues to stand the passage of time.

[Effect of total prostate volume and transitional zone volume on the curative effect of transurethral resection of prostate in benign prostatic hyperplasia]

Objective: To compare the clinical effect of different total prostate volume (TPV) and different transitional zone volume (TZV) on benign prostatic hyperplasia (BPH) treated with transurethral resection of prostate(TURP). Methods: Clinical data of 210 patients with BPH admitted to Guizhou provincial people's hospital from June 2016 to August 2018 were retrospectively collected and analyzed. All patients underwent transrectal ultrasonography, and they were divided into three groups according to TPV: 70 patients in group A:TPV<40mL, 98 patients in group B: 40 ml≤TPV<80 ml, and 42 patients in group C:TPV≥80 ml. Meanwhile, three groups were divided according to TZV: 88 patients in group a: TZV<20ml, 67 patients in group b: 20 ml≤TZV<40 ml, and 55 patients in group c:TZV≥40 ml. All of the patients with TURP were followed up for 6 months after surgery, and the data of international prostate symptom score (IPSS), storage symptoms IPSS (IPSS-S), voiding symptoms IPSS (IPSS-V), Quality of Life (QoL) index, and maximum urinary flow rate (Qmax) were collected before and after surgery. Finally, the effect of TPV and TZV on TURP was analyzed respectively by analysis of variance. Results: There were no statistically significant differences in preoperative IPSS, IPSS-V, IPSS-S, QoL and Qmax among the three groups of patients grouped by TPV (P>0.05), but the age of patients in group C(73.5±6.5) was significantly higher than that in group A (69.3±7.6) and group B (70.9±7.3) (P=0.015). Postoperative IPSS, IPSS-V, IPSS-S, QoL and Qmax of patients in groups A, B and C also showed no significant difference (P>0.05). There were no statistically significant differences in preoperative IPSS, IPSS-V, IPSS-S, QoL, and Qmax among the three groups of patients grouped according to TZV (P>0.05), while the age of patients in group a (69.2±7.6) was significantly lower than that of patients in group b (72.1±7.2) and group c (72.5±6.7) (P=0.017). There were statistically significant differences in IPSS (P=0.010), IPSS-V (P=0.037), IPSS-S (P=0.022), QoL (P=0.038) and Qmax (P=0.037) among the groups a, b, and c after surgery. Moreover, IPSS, IPSS-V, IPSS-S and QoL were negatively correlated with TZV, while Qmax was positively correlated with TZV. Postoperative IPSS, IPSS-V, IPSS-S, QoL and Qmax were significantly different from those before surgery in groups A, B, C and groups a, b, c (P<0.001). Conclusion: TPV and TZV may not be significantly correlated with BPH symptoms, but may be correlated with age. TURP is an effective treatment for patients with different TPV and TZV. There is no significant statistical difference in the surgical efficacy among patients with different TPV, but patients with larger TZV tended to have better outcome. TZV may be better than TPV in predicting the postoperative efficacy.

A randomized controlled trial comparing high and medium power settings for holmium laser enucleation of prostate

PURPOSE

To report the results of a randomized controlled trial comparing outcomes between medium power (MP) and high power (HP) laser settings for HoLEPs.

METHODS

The primary objective was to compare the enucleation efficiency (EE) of HP- HoLEP (80-100 W) with MP-HoLEP (50 - 60 W). The secondary objectives were to compare treatment efficacy and safety between both groups. To show a 25% difference in EE, a sample size of 45 individuals per treatment arm was required (alpha = 0.05; Beta = 0.80). Patients demographic and perioperative factors were analyzed, including EE, hemoglobin drop, duration of catheterization, and length of hospital stay. The surgical outcome was evaluated with AUA symptom score, maximum flow rate, postvoid residual urine, and complications to assess differences between MP and HP HoLEP at baseline, 3 months, 1, and 5 years. Quantitative outcomes were compared with independent sample t tests (2-tailed) and qualitative outcomes were compared with chi-square tests.

RESULTS

Preoperative data with the exception of indication for surgery were comparable in both treatment arms. There was no statistically significant difference in enucleation efficiency between the HP-HoLEP and MP-HoLEP laser setting (0.97 ± 0.47 vs. 0.85 ± 0.47 gm/min, p = 0.209). MP laser settings did not increase perioperative or postoperative complications and resulted in durable outcome comparable with HP laser settings at 5-year follow-up.

CONCLUSIONS

MP-HoLEP is safe and efficient and does not compromise the outcome for HoLEPs when compared with HP-HoLEP.

Detrusor underactivity influences the efficacy of TURP in patients with BPO

PURPOSE

To investigate the effect of detrusor underactivity on the efficacy of TURP in patients with benign prostate obstruction.

METHODS

A retrospective study of 350 patients with benign prostate obstruction who underwent TURP was carried out. Different degrees of bladder outlet obstruction were grouped by the bladder outlet obstruction index. ROC curves were used to calculate the optimal cut-off point for the bladder contractility index used to divide the DU patients into mild DU and severe DU patients. The effect of DU on the efficacy of TURP in benign prostate obstruction patients was studied by comparing the subjective and objective parameters preoperatively and 3 months postoperatively between severe DU, mild DU and non-DU benign prostate obstruction patients in two obstruction groups (20 ≤ BOOI < 40 and BOOI ≥ 40).

RESULTS

According to the ROC curve, the optimal cut-off point for the bladder contractility index was 82; thus, 69 patients were considered mild DU patients (82 ≤ BCI < 100), 67 patients were considered severe DU patients (BCI < 82), and 214 patients were considered non-DU patients (BCI ≥ 100). Both the postoperative subjective and objective parameters of the non-DU, mild DU and severe DU patients significantly improved in two obstruction groups. However, in the 20 ≤ BOOI < 40 group, the successful improvement rates for the IPSS, IPSS-S, IPSS-V, QoL and fQmax in the severe DU patients were only 38.2%, 38.2%, 44.1%, 41.2% and 38.2%, respectively.

CONCLUSION

Patients with varying degrees of benign prostate obstruction can benefit from TURP, but for patients with severe DU in the 20 ≤ BOOI < 40 group, TURP should be considered only after deliberation.

Efficacy of holmium laser enucleation in patients with a small (less than 30 mL) prostate volume

Purpose

To evaluate the efficacy of holmium laser enucleation of the prostate (HoLEP) in patients with a small prostate volume (≤30 mL).

Materials and Methods

We retrospectively evaluated 1,135 patients who underwent HoLEP at two institutions between July 2007 and March 2020. Patients who were not evaluated for the International Prostate Symptom Score (IPSS) before or after HoLEP were excluded. We divided patients into two groups according to estimated prostate volume (ePV): ≤30 (n=198) and >30 mL (n=539). The patient characteristics, IPSS, peak urinary flow rate (Qmax), postvoid residual urine volume (PVR), and other data were compared before and after surgery in each group and between the two groups. Multivariate analysis was performed to identify the factors associated with the efficacy of HoLEP in the group with ePV ≤30 mL.

Results

A total of 737 patients were included in this retrospective study. ePV (23.4 mL vs. 50 mL; p<0.001) and PVR differed significantly between the two groups. The IPSS, IPSS-quality of life, PVR, and Qmax significantly improved after HoLEP in both groups. Improvements in the IPSS, IPSS-quality of life, Qmax, and PVR were greater in the >30 mL group (p<0.001), whereas operation time and morcellation time were significantly shorter in the ≤30 mL group. In the multivariate analysis, age <70 years was independently associated with improvement by HoLEP.

Conclusions

HoLEP is an effective treatment for patients with a small prostate, even though the extent of improvement after HoLEP was greater in those with a larger prostate.

Intrasphincteric anastomotic urethroplasty allows preservation of continence in men with bulbomembranous urethral strictures following benign prostatic hyperplasia surgery

PURPOSE

Injury to the external sphincter during urethroplasty at or near the membranous urethra can result in incontinence in men whose internal sphincter mechanism has been compromised by previous benign prostatic hyperplasia (BPH) surgery. We present outcomes of a novel reconstructive procedure, incorporating a recent anatomic discovery revealing a connective tissue sheath between the external sphincter and membranous urethra, which provides a surgical plane allowing for intrasphincteric bulbo-prostatic urethroplasty (ISBPA) with continence preservation.

METHODS

Stricture at or near the membranous urethra after transurethral resection (TURP) or open simple prostatectomy (OSP) was reconstructed with ISBPA. The bulbomembranous junction is approached dorsally with a bulbar artery sparing approach and the external sphincter muscle is carefully reflected, exposing the wall of the membranous urethra. Gentle blunt dissection along this connective tissue plane allows separating the muscle away up to the prostatic apex, where healthy urethra is found for anastomosis.

RESULTS

From January 2010 to August 2019, 40 men (18 after TURP and 22 after OSP) underwent ISBPA at a single institution. Mean age was 67 years (54-82). Mean stricture length was 2.6 cm (1-6) with obliterative stricture identified in 10 (25%). At a mean follow-up of 53 months (10-122), 36 men (90%) are free of stricture recurrence and 34 (85%) were completely dry or using one security pad.

CONCLUSION

This novel intrasphincteric urethroplasty technique for stricture following BPH surgery is feasible and safe, allowing successful reconstruction with continence preservation in most patients. A larger series and reproduction in other centers is needed.

Pitfalls of FDG-PET in the prostate for the surgical oncologist

A 78-year-old man was referred for investigation of prostate cancer following incidental uptake on 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET). Despite normal PSA and benign digital rectal exam, he was referred for consideration of trans-perineal biopsy to exclude prostate cancer. It was only on review of imaging that it became clearly apparent that the 18F-FDG uptake was due to urinary tracer pooling in a trans-urethral resection cavity. Surgeons, oncologists and nuclear medicine physicians should be aware of this common pitfall in interpretation of 18F-FDG-PET in the prostate.

Holmium laser enucleation of the prostate for very large benign prostatic hyperplasia (≥ 200 cc)

PURPOSE

Patients presenting with prostate gland sizes greater than 200 cc pose a unique surgical challenge to both patients and surgeons. The objective of this study is to critically assess the efficacy and risks associated with performing holmium laser enucleation of the prostate (HoLEP) on glands ≥ 200 cc.

MATERIALS AND METHODS

Using a prospective maintained database, all consecutive benign prostatic hyperplasia (BPH) patients with gland size ≥ 200 cc who underwent HoLEP were included. We reported patient preoperative, intraoperative, postoperative outcomes and complications. Subgroup analysis of outcomes was stratified by gland sizes 200-299 cc and ≥ 300 cc. Univariate analysis using Kruskal-Wallis and Fisher exact test was performed to compare the two groups.

RESULTS

There were 88 patients with a mean preoperative gland size of 255.9 cc (200-770 cc). Mean operative (171 vs 182 min) and enucleation time (77 vs 83 min) were not different between the two subgroups (200-299 cc vs ≥ 300 cc). Enucleation efficiency was greater for glands ≥ 300 cc (2.6 cc/min vs 2.0 cc/min, p = 0.04). Morcellation time was longer in the ≥ 300 cc group (74.5 min vs 46.8 min, p = 0.021). Mean length of stay was 1.8 ± 1.2 days and catheter duration was 2.6 ± 2.7 days. 1 (1.1%) patient required retreatment of BPH at last follow-up. The main limitation of this study is the retrospective data analysis.

CONCLUSIONS

Holmium laser enucleation for prostate glands volume > 200 cc is feasible with minimal morbidity. These data further reinforce the size independence success of this procedure for BPH.

Is Holmium Laser Enucleation of the Prostate a Good Surgical Alternative in Benign Prostatic Hyperplasia Management? A Review Article

Several therapeutic approaches such as holmium laser enucleation of the prostate (HoLEP) have been introduced to relieve bladder outlet obstruction caused by benign prostatic hyperplasia (BPH). Compared with other techniques including the transurethral resection of the prostate (TURP) and simple open prostatectomy, HoLEP results in a shorter hospital stay and catheterization time and fewer blood loss and transfusions. HoLEP is a size-independent treatment option for BPH with average gland size from 36 g to 170 g. HoLEP is a safe procedure in patients receiving an anticoagulant and has no significant influence on the hemoglobin level. Also, HoLEP is an easy and safe technique in patients with a prior history of prostate surgery and a need for retreatment because of adenoma regrowth. The postoperative erectile dysfunction rate of patients treated with HoLEP is similar to TURP or open prostatectomy and about 77% of these patients experience loss of ejaculation. Patients with transitional zone volume less than 30 mL may suffer from persistent stress urinary incontinence following HoLEP so other surgical techniques like bipolar TURP are a good choice for these patients. In young patients, considering HoLEP with high prostate-specific antigen density and a negative standard template prostate biopsy, multiparametric MRI needs to be considered to exclude prostate cancer.

[Effect of transition zone index on the outcome after transurethral resection of prostate]

Objective: To investgate the effect of properative transitional zone index (TZI) on the outcome of transurethral resection of prostate (TURP). Methods: A retrospective analysis was performed on 206 patients with TURP who were admitted to our hospital from January 2016 to September 2018. All patients underwent transrectal ultrasound (TRUS) to determine the total prostate volume (TPV) and the transition zone volume (TZV). Patients were divided into two groups according to TZI (TZV/TPV) (group A: TZI<0.5, group B: TZI≥0.5). We collected data 6-months after surgery including international prostate symptom score (IPSS), quality of life score (QOL), maximum flow rate (Qmax), and postvoiding residue (PVR) to compare the difference of the postoperative outcome of two groups, while the IPSS was subdivided into voiding (IPSS-v) and storage(IPSS-s) symptoms, and the changes of IPSS, IPSS-v, IPSS-s, QOL, Qmax and PVR before and after surgery were analyzed. The treatment efficacy was determined as the changes of IPSS (post/preoperative IPSS: %IPSS), QOL (preoperative QOL-postoperative QOL: ΔQOL) and Qmax(preoperative Qmax-postoperative Qmax: ΔQmax). Pearson linear correlation analysis was employed to estimate the correlation of TZI and %IPSS, ΔQOL and ΔQmax, respectively. Results: A total of 126 patients were in Group A, and 80 patients were in group B. 1. The preoperative clinical data of the two groups were compared. There were no significant differences regarding age, IPSS, IPSS-v, IPSS-s, QOL, Qmax, and PVR between two groups (all P>0.05). However, the TPV of patients in group B (74.57±29.25) ml was significantly larger than that in group A (46.25±24.56) ml, P<0.001. While the postoperative follow-up outcomes of the two groups were compared, we found that IPSS-s (P=0.079), QOL (P=0.710), and PVR (P=0.651) were not statistically different between the two groups, but the postoperative IPSS, IPSS-v, and Qmax (8.50±5.75 vs 6.38±4.36, 4.03±3.75 vs 2.63±2.5, and (16.54±4.43) ml/s vs (18.94±4.84) ml/s, all P<0.05) were significantly different between the two groups. 2. Postoperative IPSS, IPSS-v, IPSS-s, QOL, Qmax and PVR were significantly different from those before surgery in two groups, respectively. 3. Pearson linear correlation analysis showed a significant positive correlation between TZI and ΔQmax (r=0.32, P<0.01), a weaker negative correlation between TZI and %IPSS (r=-0.22, P<0.01), and no correlation between TZI and ΔQOL (r=0.08, P=0.238). Conclusion: There may be a correlation between the outcome of TURP and TZI, and the outcome of TURP may be better in patients with TZI ≥ 0.5.

Enterococcal prosthetic valve endocarditis secondary to transurethral prostatic resection

Prosthetic valve endocarditis (PVE) is a catastrophic complication of cardiac valve replacement, associated with high mortality rates. Staphylococci (both Staphylococcus aureus and coagulase-negative Staphylococcui) are the most common cause of PVE. Diagnosis may often be difficult because of its complications and extracardiac manifestations. Positive blood and valve cultures are one of the most important diagnostic criteria for IE. Transesophageal echography should be performed without delay in all patients suspected to have PVE. As for treatment, according to the guidelines sensitive antimicrobials should be administered for 6 weeks. Surgery is recommended in case of PVE complicated by heart failure, severe prosthetic dysfunction, abscess or persistent fever. We present a case of PVE after transurethral resection of the prostate in a 63-year-old male patient with a history of mitral valve replacement. The patient was treated by appropriate antimicrobials for 6 weeks and recovered completely.

Design, implementation, and evaluation of a novel curriculum to teach transurethral resection of the prostate (TURP): a 3-year experience of urology simulation bootcamp course

OBJECTIVES

To present the three-year experience of the multi-component TURP module at Urology Simulation Bootcamp Course (USBC) and demonstrate trainee's competence progression and satisfaction.

METHODS

During the USBC, a 4-h TURP module was developed and consisted of (a) familiarisation and assembly of resectoscope instrument, (b) didactic lecture on TURP operative techniques and postoperative complications, (c) learning hands-on resection on validated simulators [Samed, GmBH, Dresden, Germany; TURP Mentor™, Simbionix, Israel], and (d) practicing clot evacuation using the Ellik bladder Evacuator. Trainee's level of instrument knowledge, operative competence, and confidence were assessed pre- and post-course. Trainee's feedback was also collected.

RESULTS

One hundred thirty trainees participated in the USBC between 2016 and 2018. Eighty-seven percent of trainees scored themselves as 1-3 (low confidence in resection) on a 5-point Likert scale. Trainees significantly improved in their ability to perform resectoscope assembly for resection, coagulation and incision by 33.6% (p < 0.001), 28.1% (p < 0.001) and 34.0% (p < 0.001), respectively. There was a significant improvement in scores in itemised technical skill on the TURP simulator following completion of the TURP module (Mean difference = 3.4 points, 95% CI 2-4, p < 0.001). Ninety-one percent of trainees agreed that the TURP module was useful for their development in urological training.

CONCLUSION

Our results demonstrated that it is feasible to develop and implement a focussed module for teaching TURP with significant improvement in learning. Trainee feedback suggests that they were highly satisfied with the teaching provided and models used. This style of training can be implemented for other common surgical procedures.

[Endoscopic enucleation of the prostate]

The spectrum of surgical procedures for the minimally invasive treatment of benign prostatic hyperplasia (BPH) has significantly increased over the last two decades. The simple suprapubic prostatectomy (subtotal prostatectomy, SP) has largely lost relevance in current practice. On the other hand, transurethral resection of the prostate (TURP) has been further standardized and potentially made safer by the introduction of the bipolar technique and low-pressure systems.Transurethral (endoscopic) enucleation techniques (endoscopic enucleation of the prostate, EEP) are increasingly competing with the current gold standard TURP and are replacing SP for treatment of larger adenomas. This approach is especially related to the rapid development of laser technology, which has sustainably changed the face of modern BPH treatment in a similar way to stone therapy. This has been incorporated in the clinical patient management, clinical studies and standardization of numerous surgical techniques that are systematically described in this article. Additionally, efforts have also been made to use other energy sources, such as bipolar current in EEP. With respect to scientific objectivity, high-quality clinical trials are regularly published which further strengthen the position of EEP.

Current surgical techniques of enucleation in holmium laser enucleation of the prostate

Holmium laser enucleation of the prostate (HoLEP) has been accepted as the most efficient method of transurethral surgery for benign prostatic hyperplasia. The originally developed three-lobe technique has popularized this surgery; this method is based on three longitudinal incisions, by which the median lobe is removed, and subsequently, both lateral lobes are enucleated. To maintain a consistent surgical plane and to minimize sphincteric damage, the traditional three-lobe technique is continuously being refined and evolving. A few modifications of the original technique have been developed, and several en bloc enucleation methods have been introduced. However, more clinical evidence is required to show the superiority of newer techniques over the original three-lobe technique in terms of efficacy and long-term side effects. To date, none of the newer techniques have been accepted as a standard technique for HoLEP.

Is transurethral needle ablation of prostate out of fashion? Outcomes of single session office-based transurethral needle ablation of prostate in patients with symptomatic benign prostatic hyperplasia

Purpose

Transurethral needle ablation (TUNA) is a minimally invasive procedure for the treatment of symptomatic benign prostatic hyperplasia (BPH). Compared to transurethral resection of the prostate (TURP), office-based TUNA is an attractive alternative as it is minimally invasive and avoids general anaesthesia. The aim of this study is to evaluate the efficacy of single session office-based TUNA.

Materials and Methods

Data of 121 patients who had undergone TUNA was retrieved from June 2008 to March 2017. Patients were followed-up with visits at 1, 3, 6, and 12-months with the International Prostate Symptom Score (IPSS), quality of life (QoL) scoring and uroflowmetry.

Results

Patients were 39 to 85 years old. The prostate volumes were 20.00 to 96.90 mL with a median of 26.95 mL. The median IPSS score pre-TUNA was 19, median QOL score pre-TUNA was 4 and median maximum urinary flow (Qmax) pre-TUNA was 10.3 mL/s. There is 65% improvement of IPSS post-TUNA (p<0.001). There is 75% improvement of QOL post-TUNA QOL (p<0.001). There is 35% improvement of Qmax post-TUNA Qmax (p<0.001). The mean relapse-free survival for TUNA is 6.123 years. The 1st, 3rd, and 5th year relapse-free survival rate were 91.7%, 76.6% and 63.7% respectively.

Conclusions

Our study is the first to investigate the use of a single-setting office-based TUNA requiring minimal sedation in the Asian community. Complication rates were low in our series, with no associated mortality. When applied to selected patients, TUNA is an effective and reasonably safe alternative for the treatment of symptomatic BPH.

Analysis of Present Status for Surgery of Benign Prostatic Hyperplasia in Korea Using Nationwide Healthcare System Data

Purpose

There are no established statistical data available for the comparison of different surgical methods adopted for the resection of benign prostatic hyperplasia (BPH). This study investigates the present status related to BPH surgery in Korea for the past 8 years.

Methods

National-level data from the National Health Insurance Service and National Statistical Office were analyzed in this study. From 2010 to 2017, the trends of surgeries for BPH were reviewed according to the procedure code including transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP), or high-power potassium titanyl phosphate (KTP), and this trend also analyzed by age, geographic distribution, and hospital type.

Results

Over the past 8 years, there was not much change in the total number of BPH-related surgeries (range, 10,393– 11,072). Although there was not much alteration in the number of conventional TURP (from 6,801 in 2010 to 6,645 in 2017), the number of HoLEP has dramatically increased (from 278 in 2010 to 3,805 in 2017). The number of HoLEP surgeries after 2011 exceeded the number of surgeries using KTP, and the gap is anticipated to rise. The number of surgeries by age group was most common in the 70s and the total number of surgeries is decreasing in all age groups; for HoLEP, the trend is steadily increasing over the age of 60 years. Most of the BPH surgeries were performed in metropolitan areas, such as Seoul, Gyeonggi-do, and Busan, and in larger hospitals compared to smaller hospital settings.

Conclusions

Through the data of the National Health Insurance Service, we could apprehend the present status of BPH-related surgery in Korea. Then, we could know about the trend according to several factors and we think these results will be valuable as academic references as well.

[Clinical study of "point-line-surface-volume" four dimensional holmium laser enucleation of prostate for benign prostatic hyperplasia]

Objective: To investigate application value of "point-line-surface-volume" four dimensional holmium laser enucleation of prostate (HoLEP) in the treatment of benign prostatic hyperplasia (BPH). Methods: From December 2016 to November 2017, the clinical data of 60 cases of BPH with the treatment of "Point-line-surface-volume" four dimensional HoLEP at Department of Urology, Peking University Third Hospital were analyzed retrospectively. The age was (73.8±8.0) years (range: 60 to 96 years), body mass index was (23.2±3.6) kg/m(2) (range: 14.9 to 31.1 kg/m(2)), volume of prostate was (64.5±36.9) ml (range: 15.5 to 197.9 ml). All the cases were operated by the same chief surgeon expert in endoscopic surgery. First of all, taking verumontanum as the anchor point, crossing point between the outer 45° line of verumontanum and middle line of the lateral lobe and verumontanum was made as the breakthrough point. The "blasting and paddling" method was used to find prostatic surgery capsule, and the two sides of the capsule plane were connected in front of the verumontanum. Secondly, the plane was maintained by the "fan tunnel" method, and the middle lobe and the lateral lobes were divided at the 5 o'clock and 7 o'clock positions. The glands of the middle lobe were first removed and pushed into the bladder. Then, on the anteroinferior inclined coronal plane through 12 o'clock point right above of verumontanum, the urethral mucosa was cut apart in a semi-curved shape in advance. Bilateral semi-curved incision confluenced above the verumontanum, and extend to the bladder neck to form an inverted Y-shaped groove which completely divided the bilateral lobes. Finally, the bilateral lobes were enucleated respectively, and glands in the bladder were removed by tissue morcellator. Clinical data included operative time, hemoglobin decrease, catheterization duration, postoperative hospital stay, preoperative and postoperative international prostate symptom score and quality of life (QOL) score. The efficiency of enucleation was calculated as prostatic volume divided by enucleation time (not including morcellation time). The efficiency of morcellation was calculated as prostatic volume divided by morcellation time. Paired t-test was used to compare the indexes before and after surgery. Results: All the operations of 60 cases were sumlessful, one of which prostate tissue was removed by conversion to transurethral resection prostate due to malfunction of tissue morcellator. The operative time was (115.2±52.9) minutes (range: 25 to 276 minutes). The enucleation efficiency was (0.81±0.35) ml/minutes (range: 0.17 to 1.58 ml/minutes). The morcellation efficiency was (6.60±4.28) ml/minutes (range: 0.89 to 17.42 ml/minutes). The hemoglobin was decreased by (15.9±12.3) g/L (range:-10 to 57 g/L). Meanwhile, catheterization duration was (5.2±2.9) days (range: 0.8 to 19.8 days), and postoperative hospital stays were (5.0±1.5) days (range: 1.9 to 11.9 days). Preoperative and postoperative IPSS scores (10.92±6.98 vs. 23.37±7.49, t=10.357, P=0.000) and QOL scores (1.75±1.62 vs. 4.53±1.47, t=9.373, P=0.000) were significantly different. Postoperative complications included: 4 cases of fever (greater than 38.5 ℃), 1 case of acute epididymitis, 1 case of bladder mucosal injury, and 1 case of active bleeding need blood transfusion therapy. Conclusion: "Point-line-surface-volume" four dimensional HoLEP is an effective and safe minimally invasive method in the treatment of BPH.