Perioperative management of transurethral surgery for benign prostatic hyperplasia: a nationwide survey in Japan

OBJECTIVES

Various types of minimally invasive surgical treatments, including transurethral resection of prostate (TURP), are being carried out in Japan for patients with benign prostatic hyperplasia (BPH). The aim of the present study was to elucidate the current status of perioperative care for these treatments by carrying out a nationwide survey.

METHODS

Assisted by the Japanese Endourology and ESWL Association, perioperative data from 157 institutions participating in this survey were collected and analyzed.

RESULTS

This survey included 3918 patients undergoing TURP, 242 TUR in saline (TURis), 638 holmium laser enucleation of the prostate (HoLEP), 90 holmium laser ablation (HoLAP) and 241 photoselective vaporization (PVP). Mean operative time was shorter in TURP (71 min) and longer in HoLEP (127). Although no transfusions were required in cases undergoing HoLAP or PVP, blood was frequently transfused in those undergoing TURis (25.6%), TURP (10.2%) and HoLEP (7.8%), and the difference was significant. During the hospital stay, the incidence of TUR-syndrome, postoperative bleeding requiring bladder irrigation, acute urinary retention/difficulty on micturition and pad use at discharge was highest in TURP (2.3%), TURis (7.9%), HoLAP (16.7%) and HoLEP (15.1%), respectively. Two patients undergoing TURP died (0.05%). The shortest mean postoperative hospital stay was for PVP (1.6 days, even if the readmission rate within 90 days was the highest in this same group; 6.2%). Perioperative care during hospital stay varied among the five types of procedures.

CONCLUSIONS

This survey provides useful documentation on the current status of minimally invasive treatments for BPH in Japan. Complication rates for TURP are not significantly higher as compared with other procedures. Thus, TURP can still be considered as the gold standard for BPH treatment.

GreenLight Laser™ Photovaporization versus Transurethral Resection of the Prostate: A Systematic Review and Meta-Analysis

GreenLight laser™ photovaporization of the prostate (GLL-PVP) has become a valid alternative to traditional transurethral resection of the prostate (TURP) in men requiring surgery for benign prostatic hyperplasia. We aimed to review systematically the safety and efficacy of studies comparing GLL PVP and TURP in the medium-term. A comprehensive literature search was performed. Twelve studies were identified for meta-analysis. Meta-analyses showed a longer postoperative catheterization time (risk ratio (RR): 1.12, 95% CI:1.09–1.14, p<0.00001) and length of stay (RR: 1.16, 95% CI:1.12–1.19, p<0.00001) in the TURP group; higher risk of transfusion in the TURP group (RR: 6.51, 95% CI: 2,90–14,64 p<0.00001); no difference in the risk of urinary tract infections (RR: 0.83, 95% CI: 0.58–1.18, p=0.30) and transient re-catheterization (RR: 1.11, 95% CI: 0.76–1.60, p=0.60). Regarding reoperation rate, no difference was found in term of postoperative urethral stricture (RR: 1.13, 95% CI: 0.73–1.75, p=0.59) and bladder neck contracture (RR: 0.66, 95% CI: 0.31–1.40, p=0.28). A significantly higher incidence in reoperation for persistent/regrowth adenoma was present in the GLLL-PVP (RR: 0.64, 95% CI: 0.41–0.99, p=0.05). Data at 2-year follow-up showed significant better post-voiding residual (PVR) (MD: -1.42, 95% CI: -2.01, -0.82, p<0.00001) and International Prostate Symptom Score (IPSS) (MD: -0.35, 95% CI: -0.50, -0.20, p<0.00001) after TURP. No difference was found in the mean PVR at 2 years after TURP, in the mean maximum flow rate (Qmax) (MD: 0.30, 95% CI: -0.02–0.61, p=0.06) and quality of life QoL score (MD: 0.05, 95% CI: -0.02–0.42, p=0.13). At 5-year follow-up, data showed better IPSS (MD: -1.70, 95% CI: -2.45,-0.95, p<0.00001), QoL scores (MD: -0.35, 95% CI: -0.69, -0.02, p=0.04) and Qmax (MD: 3.29, 95% CI: 0.19–6.38, p=0.04) after TURP. Data of PVR showed no significant difference (MD: -11.54, 95% CI: -29.55–6.46, p=0.21). In conclusion, our analysis shows that GLL-PVP is a safer and more efficacious procedure than standard TURP in the early and medium-term. However, in the long term period GLL-PVP showed a higher incidence of reoperation rate due to incomplete vaporization/regrowth of prostatic adenoma.

Clinical Outcome of Immediate Transurethral Surgery for Benign Prostate Obstruction Patients with Acute Urinary Retention: More Radical Resection Resulted in Better Voiding Function

Introduction: Transurethral surgery of the prostate is currently the gold standard treatment modality for patients with benign prostatic hyperplasia (BPH) with recurrent acute urinary retention. This study aimed to evaluate the outcome and predictors of patients receiving immediate surgery after acute urinary retention (AUR) episodes. Materials and Methods: From January 2016 to January 2017, we retrospectively included 714 patients who received transurethral surgery of prostate due to BPH. Among them, 158 patients received surgeries immediately after an AUR episode. General characteristics data including age, Body mass index (BMI), International prostate symptom score (IPSS score), prostate volume and Prostate-specific antigen (PSA) were reviewed. We also collected surgery-related parameters including surgical types, operation time, and specimen weight. Resection ratio was defined as (resected specimen weight)/(Transurethral ultrasound (TRUS) volume). The catheterization status on discharge, post-operative medication for BPH, and AUR within 3 months after operation were evaluated. Statistical analysis was performed with Statistical product and service solutions (SPSS). Results: The mean age of the patients was 73.5 years, with a BMI of 24 kg/m². IPSS total score was 25 with a Voiding symptom/Storage symptom score (V/S score) of 14.6 and 10.4, respectively. A total of 74 (46.8%) patients still took medication for BPH for over 1 month after the surgeries, 28 (17.7%) patients were not catheter-free at the time of discharge, and 14 (8.9%) patients had AUR within 3 months after the surgeries. Surgical type did not impact the outcome of surgeries. In patients who received Transurethral resection of the prostate (TURP), the resection ratio is the only predictor for the catheterization status on discharge and post-operative medication for BPH within 3 months after operation. Conclusions: In patients with BPH-related AUR followed by immediate transurethral surgeries, more radical resection is significantly correlated with short-term medication-free and catheter-free status.

The Transparency of Irrigation Fluids Used in Endoscopic Surgery

PURPOSE

Transurethral surgery has been traditionally done using the nonelectrolyte, isotonic 1.5% glycine solution as irrigation fluid. The emergence of modern technologies, which can be applied with electrolyte solutions, such as bipolar resection and LASER evaporation, as well as the worry of transurethral resection (TUR) syndrome have driven urologists away from glycine toward the use of physiologic solution. Differences in the transparencies of these fluids have not been studied.

MATERIALS AND METHODS

The ability to resolve two bars at 1 mm apart using a 30° cystoscope lens immersed in different solutions was studied. Physiologic solution, distilled water (DW), and 1.5% glycine solutions containing increasing concentrations of blood, from 0.5% to 2%, were tested. Solutions containing 2% blood were inspected with magnification and microscopy.

RESULTS

One-millimeter resolution was reached in as much as 2% blood in 1.5% glycine solution and as much as 1% blood in DW, but in none of the blood-saline solutions. Magnified and microscopic views of 2% blood solutions showed an even distribution of red blood cells (RBCs) in physiologic solution, clumps of RBCs in 1.5% glycine, and an almost complete hemolysis in DW.

CONCLUSIONS

Glycine solution increases the transparency compared to physiologic solution or DW owing to the clumping of RBCs. When the risk of TUR syndrome is low, as in resection of bladder tumors or small prostates, we propose that 1.5% glycine solution should be preferred over saline, owing to its improved visibility.

Case of vascular air embolism during holmium laser enucleation of the prostate

Vascular air embolism is a rare complication during transurethral surgery. A case of air embolism during holmium laser enucleation of the prostate in a 76-year-old man is presented. During the step of morcellation, the patient's blood pressure suddenly oscillated up and down, and end-tidal CO2 and arterial saturation decreased. Transesophageal and transthoracic echocardiography showed air collection in the right atrium. It was also discovered that incorrect assembly of the tube from the morcellator caused rapid entrainment of air into the vein. Computed tomography and abdominal X-ray showed niveau formation in the femoral vein and air collection in the pelvic retroperitoneal space. The patient recovered with careful observation and was discharged 7 days after the operation with no sequelae. This report is presented to remind urologists of this unusual complication that can occur during holmium laser enucleation of the prostate procedures.

Prospective results of the minimally invasive laser enucleation of the prostate (MiLEP)

BACKGROUND

The objective of the present study is to prospectively analyze the prostate enucleation procedure with Holmium Laser using the minimally invasive technique (MiLEP), comparing the outcomes and their variables pre- and postoperatively.

METHODS

We studied men aged 40 years or over, with prostate volumes greater than or equal to 35 cm³ with lower urinary tract symptoms due to BPH. We performed flowmetry and administered the IPSS questionnaire before and 6 months after the MiLEP procedure. The patients were operated on with a 60 W Holmium Laser (Cyber-Ho Quanta System®) using 54 W of power (energy 1.8 J and frequency of 30 Hz). Enucleation was performed using the en bloc technique with early sphincter release. After enucleation, the tissue was morcellated using a 22 Fr morcescope (RZ-Medizintechnik GmbH, Tuttlingen, Germany) and Piranha (Richard Wolf) morcellator. The final Hemostasis after morcelation was made using laser with 30wW power, energy at 1,0 joules and frequency at 30 Hertz. Student's T test and Man-Whitney was used to statistical analysis (p < 0.05).

RESULTS

After selection we submitted 73 patients (mean age= 68.2 years) to MiLEP procedure with a follow up of 6 months. The prostate volume presented an average of 94.53 cm³ (65 to 112 cm³, SD = 5.363) preoperatively. The urinary continence rate after the procedure was greater than 95% after 1 week and 99% in the 1st month. All patients were continent after 6 months. The IPSS questionnaire before (mean = 21.18 points/SD = 6.557) and after (mean = 7.92 points/SD = 2.408) the MiLEP had statistical significance (p < 0.001). The flowmetry(ml/s) before (9.02/SD = 2.842) and after (21.07/SD = 6.228) the MiLEP had statistical significance (p < 0.001). The average time of the procedure was 78.5 min and the bladder catheter was removed after 18 h in mean. In 4 patients (5.8%) we observed hematuria and in 1 case (1.47%) the patient needs urinary catheterization.

CONCLUSION

MiLEP is a safe and effective procedure, with significant improvement in urinary flow and symptoms in the short term. Although the results of this study were satisfactory and the urinary incontinence rate was lower compared to HoLEP data found in the literature, multicenter studies with longer follow-up are needed to confirm these findings.

Preventing Postoperative Catheter-Related Bladder Discomfort (CRBD) with Bladder Irrigation Using 0.05% Lidocaine Saline Solution: Monitoring with Analgesia Nociception Index (ANI) after Transurethral Surgery

(1) Background and Objectives: Catheter-related bladder discomfort (CRBD), a common and distressing consequence of indwelling urinary catheters, can significantly impact postoperative recovery. This study aimed to determine the effectiveness of bladder irrigation with a 0.05% lidocaine normal saline solution for the prevention of CRBD following transurethral surgery. (2) Materials and Methods: In this randomized, double-blind, placebo-controlled trial, patients were assigned to either a control group receiving normal saline or a treatment group receiving 0.05% lidocaine (2% lidocaine 25 mL in 1000 mL saline) for bladder irrigation. Both groups were administered fentanyl (1 μg/kg) for analgesia at the end of the procedure. The primary endpoint was the assessment of the incidence and severity of CRBD upon awakening within the first 6 h postoperatively, using a four-grade scale based on the patients' reports of discomfort. (3) Results: Out of 79 patients completing the study, the incidence of moderate to severe CRBD was significantly lower in the lidocaine group (5.1%, 2/39) compared to the control group (25%, 10/40) at 10 min after waking from anesthesia (p = 0.014). Furthermore, the lidocaine group experienced significantly less CRBD at 1 and 2 h postoperative (2.6% and 0%, respectively) compared to the control group (20% and 10%, respectively) (p = 0.015, p = 0.043), with no significant differences at 6 h (p = 0.317). (4) Conclusions: The results suggest that bladder irrigation with 0.05% lidocaine reduces the occurrence of moderate to severe CRBD by nearly 80% in the initial 2 h postoperative period after transurethral surgery.

Within State Variability of Antimicrobial Susceptibility: Missouri as an Archetype to Assess Guidelines for Antimicrobial Prophylaxis for Transurethral Procedures

OBJECTIVE

To evaluate variability among hospitals in susceptibility of common uropathogens to antimicrobial agents frequently used in transurethral procedures in order to examine whether state-based guidelines might be more appropriate than national prophylactic guidelines.

METHODS

Hospital-level antibiograms were requested from all hospitals throughout the state of Missouri. We studied Escherichia coli, Klebsiella, and Proteus sensitivities to evaluate common guideline recommended antimicrobials including trimethoprim sulfamethoxazole (TMP-SMX), 3rd generation cephalosporins, cefazolin, penicillin combinations, gentamicin and fluoroquinolones. We evaluated variability and association between hospital characteristics and antimicrobial sensitivities.

RESULTS

Data was requested from 81 hospitals across the state and 38 provided the requested data (47% response rate). Susceptibility was highest for 3^rd generation cephalosporins for E coli (mean of 94%), Proteus (96%), and Klebsiella (96%). Gentamicin also had high susceptibility for the bacteria studied; 94% for E coli and 96% for Klebsiella. Current first line recommended agents showed more modest coverage for E coli (cefazolin 84%, TMP-SMX 78%), Proteus (cefazolin 82%, TMP-SMX 71%), and Klebsiella (cefazolin 90%, TMP-SMX 89%).

CONCLUSION

Post transurethral procedure infections are common. Rates can be limited with appropriate prophylaxis. Deciding on empirical coverage must take into account local resistance patterns. There is substantial variability among and within states in antimicrobial susceptibility for common uropathogens. When selecting antimicrobial prophylaxis, urologists should consider local- rather than state- or nation-level antibiograms, given the considerable variability. Future studies should consider the merits of very-broad spectrum prophylaxis and the potential role of molecular urinary pathogen (and pathogen-resistance) testing when selecting an optimal regimen.

Urinary retention in adult hypospadias patient resolved by unroofing of a mildly enlarged prostatic utricle

INTRODUCTION

A prostatic utricle is a congenital saccular indentation in the prostatic urethra and frequently enlarged in hypospadias patients. We present a case of urinary retention associated with a mildly enlarged utricle.

CASE PRESENTATION

A 20-year-old male, who underwent multiple repair procedures for hypospadias during childhood, was referred to us for dysuria. Retrograde urethrogram, voiding cystourethrogram, and cystoscopy results revealed only a mildly enlarged prostatic utricle, with no apparent lower urinary tract obstruction or urethral valves. A meatotomy was performed under suspicion of meatal stenosis, though urinary retention occurred following that procedure. Transrectal ultrasonography revealed flapping of the prostatic urethra floor over the utricle. Transurethral unroofing of the utricle relieved the dysuria.

CONCLUSION

A mildly enlarged prostatic utricle can cause dysuria. To the best of our knowledge, no case similar to the present has been previously reported.

Effectiveness of Y-V-plasty for refractory bladder neck stenosis after transurethral prostate surgery

OBJECTIVES

To evaluate the surgical and patient-reported outcomes of YV-plasty in patients with refractory bladder neck stenosis (BNS) following transurethral prostate surgery.

METHODS

This retrospective study reviewed five patients who underwent YV-plasty for BNS between January 2021 and October 2023. The surgical procedure involved a midline lower abdominal incision to expose the bladder neck. A V-shaped incision was made in the anterior bladder wall to create a bladder flap. The bladder neck was then incised from the apex of the V-shape to the healthy urethra, forming a Y-shaped incision. Fibrotic tissue was excised, and the posterior side of the urethra and bladder were anastomosed. The bladder flap was mobilized and sutured to the healthy urethra using 4-0 PDS interrupted sutures. Follow-up assessments included uroflowmetry, postvoid residual urine volume measurement (PVR), and questionnaires on daily pad use and patient satisfaction. Success was defined as cystourethroscope passage through the anastomosis without resistance and no need for additional procedures.

RESULTS

The median patient age was 69. All patients had a history of failed endoscopic treatments. The median follow-up was 13 months, with all considered successful. The median postoperative maximum flow rate was 26.6 mL/s, and the median PVR was 12 mL. Postoperatively, two (40%) were pad-free, and three (60%) used 1-2 pads daily. Three (60%) patients were 'very satisfied,' one (20%) 'satisfied,' while one (20%) was 'dissatisfied.'

CONCLUSIONS

Y-V-plasty is an effective option for refractory BNS, improving urinary function and quality of life.

Acupuncture for Analgesia During Transurethral Resection of Bladder Tumor

Background: Acupuncture has been widely studied, and theories regarding its analgesic mechanism of action have been proposed. It has been used for procedural analgesia; however, no reports of its use in urologic surgery have been reported. In this case report, we demonstrate how acupuncture can be used as an alternative to general anesthesia for transurethral resection of bladder tumor (TURBT). This may serve as an attractive option for bladder cancer patients with medical comorbidities, which predispose them to high risk for general anesthesia. Case Presentation: A 65-year-old Caucasian female with toxicant-induced loss of tolerance (TILT) was found to have a bladder mass. TURBT was discussed, and in light of her TILT syndrome, she elected to undergo the procedure with acupuncture in lieu of general anesthesia for fear of an adverse reaction. Acupuncture was performed by a trained practitioner with therapeutic needles placed in the ears, hands, abdomen, and lower extremities bilaterally. She was subsequently taken to the operating room where we performed a TURBT of a bladder tumor overlying the left ureteral orifice. The procedure was generally well tolerated and the patient experienced mild pain. There were no perioperative complications. The tumor was estimated to be 3 cm in largest diameter, and a total of 8 g of aggregate tissue was sent to our pathologists. Pathology analysis demonstrated adequate resection with detrusor muscle present in the sample. The bladder tumor was low-grade papillary urothelial cell carcinoma (Stage Ta). She has had tumor recurrence and has undergone repeat TURBT, but to date, she is 22 months free of bladder cancer. Conclusion: In this case report, we demonstrate that acupuncture is a safe and effective alternative to general anesthesia for patients undergoing TURBT. Since tobacco use is prevalent among bladder cancer patients, many of these individuals have associated medical comorbidities, which predispose them to high risk with general anesthesia. Therefore, acupuncture may serve as an attractive alternative for certain patients in this population.

An Autonomous Continuous Bladder Irrigation System

Introduction and Objective: Continuous bladder irrigation (CBI) is used in a variety of clinical settings, including post-transurethral surgery and the emergency department. Currently, CBI administration relies on nurses to diligently monitor and switch irrigation bags, as well as titrate the inflow rate based on effluent color. Inappropriate administration can result in discomfort to patients, clot urinary retention, repeat injury to the pathologic or surgical site, extended hospital stays, and even operative management. Our objective was to create an autonomous CBI system that decreases the incidence of disrupted irrigation flow and monitors the outflow to alert clinicians of critical events. Methods: 3D printing and off-the-shelf microcontrollers were used to design a device to fit the needs identified by stakeholders at our institution. An in vitro model of the bladder was created to test our design. The mechanical, electrical, and software subsystems were adjusted accordingly to meet our design requirements. Results: Our in vitro CBI model was able to simulate routine CBI administration with sudden bleeding. Bovine blood was used to simulate the bleeding events. A device was created that met identified stakeholder needs. Accurate detection of critical bleeding events, catheter blockage, and empty irrigation bags were achieved. The device responds to bleeding appropriately by increasing the irrigation rate. When the catheter is blocked, it stops the irrigation and alerts the nurse. Our system accurately titrated the irrigation rate to match a set outflow blood level parameter, conserving irrigation and minimizing nursing workload. Continuous monitoring of CBI effluent was recorded. Conclusions: We anticipate our device will decrease the cognitive load on nurses in busy clinical settings and improve workflow. Moreover, the detection of critical events will likely decrease patient morbidity. Continuous monitoring of the CBI outflow may prove to be a new clinical decision-making tool for ongoing hematuria. Clinical trial is pending.

Impact of Prostate Specific Antigen and Testosterone Hormone Levels in Patients of Benign Prostatic Hyperplasia in Khartoum State-Sudan

BACKGROUND AND OBJECTIVE

Lower Urinary Tract Symptoms (LUTS) and Benign Prostatic Hyperplasia (BPH) are progressive ailments resulting from androgenic imbalances and aging that can lead to serious long term complications. Objective of this study was to determine the relationship between prostate-specific antigens and testosterone hormone levels in patients with BPH before transurethral surgery.

MATERIALS AND METHODS

This case control study was done on 112 serum samples collected from two secondary care centres in Khartoum, Sudan. Collected serum samples were analyzed by ELISA and fluorescence enzymes immunoassay to measure testosterone, total PSA level and free PSA levels, respectively.

RESULTS

Out of 112 patients, 56 BPH diagnosed patients were included in the study with mean age 67.10±7.90 years. Total PSA (T. PSA) levels were higher in patients (14.1±10.6 ng mL-1) than the control group (2.21±1.01 ng mL-1). Total 52% of patients had total PSA level in the gray zone (4-10 ng mL-1) and 33% had total PSA more than 10 ng mL-1. Testosterone levels were low in patients 3.97±2.84 ng mL-1 when compared to the control group 4.95±0.59 ng mL-1.

CONCLUSION

The present study revealed that, there was a strong association between T. PSA level and testosterone hormone in BPH patients, which suggested that monitoring of testosterone level is useful in patients with prostate enlargement.

Catheter-Related Bladder Discomfort: Insights Into Pathophysiology, Clinical Impact, and Management

Catheter-related bladder discomfort (CRBD) is a frequent postoperative complication that significantly impacts the quality of recovery in patients undergoing transurethral surgeries. It manifests as suprapubic pain, an intense urge to void, and bladder spasms due to muscarinic receptor activation. This narrative review provides a comprehensive analysis of CRBD, with a particular focus on bladder spasms in patients treated with transurethral resection of bladder tumors (TURBT) or the prostate (TURP). The review explores the underlying pathophysiology, clinical implications, and evidence-based management strategies, including pharmacological interventions such as antimuscarinics and nerve blocks, as well as non-pharmacological measures.