National trends of surgery for benign prostatic hyperplasia in Finland

PURPOSE

To investigate national trends of surgical treatment for benign prostatic obstruction (BPO).

METHODS

The Care Register for Healthcare in Finland was used to investigate the annual numbers and types of surgical procedures, operation incidence and duration of hospital stay between 2004 and 2018 in Finland. Procedures were classified using the Nordic Medico-Statistical Committee Classification of Surgical Procedures coding. Trends in incidence were analyzed with two-sided Cochran-Armitage test. Trends in duration of hospital stay and patient age were analyzed with linear regression.

RESULTS

Transurethral resection of the prostate (TURP) was the most common operation type during the study period, covering over 70% of operations for BPO. Simultaneous with the implementation of photoselective vaporization of the prostate (PVP), the incidence of TURP, minimally invasive surgical therapies, transurethral vaporization of the prostate (TUVP) and open prostatectomies decreased (p < 0.05). The mean operation incidence rate in the population between 2004 and 2018 was 263 per 100,000. The duration of hospital stay shortened (p < 0.05), and the average age of operated patients increased by 2 years (p < 0.0001).

CONCLUSION

The implementation of PVP did not challenge the dominating position of TURP in Finland, but it has probably influenced the overall use of other surgical therapies, excluding transurethral incision of the prostate.  The results might suggest that the conservative treatment is accentuated, patient selection is more thorough, and surgical intervention might be placed at a later stage of BPO.

Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: systematic review and network meta-analysis

OBJECTIVE

To assess the efficacy and safety of different endoscopic surgical treatments for benign prostatic hyperplasia.

DESIGN

Systematic review and network meta-analysis of randomised controlled trials.

DATA SOURCES

A comprehensive search of PubMed, Embase, and Cochrane databases from inception to 31 March 2019.

STUDY SELECTION

Randomised controlled trials comparing vapourisation, resection, and enucleation of the prostate using monopolar, bipolar, or various laser systems (holmium, thulium, potassium titanyl phosphate, or diode) as surgical treatments for benign prostatic hyperplasia. The primary outcomes were the maximal flow rate (Qmax) and international prostate symptoms score (IPSS) at 12 months after surgical treatment. Secondary outcomes were Qmax and IPSS values at 6, 24, and 36 months after surgical treatment; perioperative parameters; and surgical complications.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted the study data and performed quality assessments using the Cochrane Risk of Bias Tool. The effect sizes were summarised using weighted mean differences for continuous outcomes and odds ratios for binary outcomes. Frequentist approach to the network meta-analysis was used to estimate comparative effects and safety. Ranking probabilities of each treatment were also calculated.

RESULTS

109 trials with a total of 13 676 participants were identified. Nine surgical treatments were evaluated. Enucleation achieved better Qmax and IPSS values than resection and vapourisation methods at six and 12 months after surgical treatment, and the difference maintained up to 24 and 36 months after surgical treatment. For Qmax at 12 months after surgical treatment, the best three methods compared with monopolar transurethral resection of the prostate (TURP) were bipolar enucleation (mean difference 2.42 mL/s (95% confidence interval 1.11 to 3.73)), diode laser enucleation (1.86 (-0.17 to 3.88)), and holmium laser enucleation (1.07 (0.07 to 2.08)). The worst performing method was diode laser vapourisation (-1.90 (-5.07 to 1.27)). The results of IPSS at 12 months after treatment were similar to Qmax at 12 months after treatment. The best three methods, versus monopolar TURP, were diode laser enucleation (mean difference -1.00 (-2.41 to 0.40)), bipolar enucleation (0.87 (-1.80 to 0.07)), and holmium laser enucleation (-0.84 (-1.51 to 0.58)). The worst performing method was diode laser vapourisation (1.30 (-1.16 to 3.76)). Eight new methods were better at controlling bleeding than monopolar TURP, resulting in a shorter catheterisation duration, reduced postoperative haemoglobin declination, fewer clot retention events, and lower blood transfusion rate. However, short term transient urinary incontinence might still be a concern for enucleation methods, compared with resection methods (odds ratio 1.92, 1.39 to 2.65). No substantial inconsistency between direct and indirect evidence was detected in primary or secondary outcomes.

CONCLUSION

Eight new endoscopic surgical methods for benign prostatic hyperplasia appeared to be superior in safety compared with monopolar TURP. Among these new treatments, enucleation methods showed better Qmax and IPSS values than vapourisation and resection methods.

STUDY REGISTRATION

CRD42018099583.

The changing practice of transurethral resection of the prostate

Introduction Transurethral resection of the prostate (TURP) is considered the gold standard surgical treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. The number of TURPs performed has declined significantly over the last three decades owing to pharmaceutical therapy. TURP data from a single institution for the years 1990, 2000 and 2010 were compared to assess the difference in performance. Methods A retrospective analysis was undertaken of all patients who underwent TURP between January and December 2010. These findings were compared with historical data for the years 1990 and 2000: 100 sets of case notes were selected randomly from each of these years. Results The number of TURPs performed fell from 326 in 1990 to 113 in 2010. The mean age of patients increased from 70.6 years to 74.0 years. There was also a significant increase in the mean ASA grade from 1.9 to 2.3. The most common indication for TURP shifted from LUTS to acute urinary retention. No significant change in operating time was observed. The mean resection weight remained constant (22.95g in 1990, 22.55g in 2000, 20.76g in 2010). A reduction in transfusion rates was observed but there were higher rates of secondary haematuria and bladder neck stenosis. There was an increase from 2% to 11.5% of patients with long-term failure to void following TURP. Conclusions The number of TURPs performed continues to decline, which could lead to potential training issues. Urinary retention is still by far the most common indication. However, there has been a significant rise in the percentage of men presenting for TURP with high pressure chronic retention. The number of patients with bladder dysfunction who either have persistent storage LUTS or eventually require long-term catheterisation or intermittent self-catheterisation has increased markedly, which raises the question of what the long-term real life impact of medical therapy is on men with LUTS secondary to benign prostatic hyperplasia who eventually require surgery.

Transurethral resection of the prostate achieves favorable outcomes in stroke patients with symptomatic benign prostate hyperplasia

OBJECTIVES

To evaluate the surgical outcomes of stroke patients with symptomatic benign prostatic hyperplasia (BPH) who underwent transurethral resection of the prostate (TURP) and compare the clinical outcomes between patients with stroke and those without stroke receiving this procedure.

METHODS

This retrospective cohort study analyzed claims data collected during the period of 1997-2012 from Taiwan National Health Insurance Research Database. We enrolled 6625 patients who had persistent lower urinary tract symptoms and underwent TURP for BPH. They were categorized into a stroke (n = 577) and nonstroke (n = 6048) group. Patient characteristics, postoperative clinical outcomes, medication records, and medical expenses were compared.

RESULTS

Compared with the stroke group patients, those in the nonstroke group were younger, had fewer comorbidities, and more favorable postoperative clinical outcomes. Nevertheless, TURP achieved favorable outcomes in stroke patients with symptomatic BPH. In the stroke group, the rate of urinary tract infection (UTI) decreased from 34.7% during 1 year preoperatively to 29.8% during 1 year postoperatively (p = .05). The rate of urinary retention (UR) also decreased from 55.5% during 1 year preoperatively to 22.5% during 1 year postoperatively (p = .05). TURP reduced the overall medical expenses of patients with stroke. Annual patient medical expense during 1 year preoperatively, 1 year postoperatively, 2 years postoperatively, and 3 years postoperatively was NT$659,000, NT$646,000, NT$560,000, and NT$599,000, respectively.

CONCLUSIONS

In patients with stroke, TURP reduces the risks of UTI and UR and annual total medical expense.

Hyperlipidemia is associated with an increased risk of clinical benign prostatic hyperplasia

BACKGROUND

A high fat diet is associated with risk of benign prostatic hyperplasia (BPH). However, whether hyperlipidemia is associated with BPH remains unclear. This population-based cohort study elucidated whether hyperlipidemia is associated with an increased risk of BPH.

METHODS

We used a new-exposure design and analyzed data retrieved from the Taiwan National Health Insurance Database between January 1, 2000 and December 31, 2013. The cohort of men with newly diagnosed hyperlipidemia and the age- and index-date-matched (1:3) nonhyperlipidemia cohort were tracked for incidence of BPH during a 1- to 14-year follow-up. Diagnosis of BPH using the International Classification of Diseases, Ninth Revision, Clinical Modification codes, and the occurrence of BPH diagnosis plus the use of alpha-blockers or 5-alpha reductase inhibitors or receipt of transurethral resection of the prostate were the primary and secondary endpoints, respectively. The confounders in this study were diabetes mellitus, hypertension, coronary heart disease, obesity, liver cirrhosis, nonsteroidal anti-inflammatory drugs, metformin, aspirin, and number of urologist visits. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using a multivariate Cox proportional hazards regression model adjusted for the propensity score.

RESULTS

A total of 35 860 subjects (aged 40-99 years)-including the hyperlipidemia cohort (n = 8,965) and nonhyperlipidemia cohort (n = 26 895)-were identified. Our data revealed that the hyperlipidemia cohort had significantly higher incidences of developing BPH (24.6% vs 12.3%, P < 0.001) and treated BPH (13% vs 5.7%, P < 0.001) compared with the nonhyperlipidemia cohort. The risk of developing BPH in the hyperlipidemia cohort was significantly higher than that in the nonhyperlipidemia cohort (HR = 1.73, 95% CI = 1.63-1.83, P < 0.001) after adjustment for the propensity score.

CONCLUSIONS

Hyperlipidemia is associated with an increased risk of clinical BPH.

[Transurethral diode laser enucleation versus transurethral electrovaporization resection of the prostate for benign prostatic hyperplasia with different prostate volumes]

OBJECTIVE

To compare the clinical effect of diode laser enucleation of the prostate (DIOD) with that of transurethral resection of the prostate (TURP) on benign prostate hyperplasia (BPH) with different prostate volumes.

METHODS

This retrospective study included 256 BPH patients treated by DIOD (n = 141) or TURP (n = 115) from March 2012 to August 2015. According to the prostate volume, we divided the patients into three groups: <60 ml (42 for DIOD and 31 for TURP), 60－80 ml (51 for DIOD and 45 for TURP), and >80 ml (48 for DIOD and 39 for TURP). We obtained the relevant data from the patients before, during and at 6 months after surgery, and compared the two surgical strategies in operation time, perioperative levels of hemoglobin and sodium ion, post-operative urethral catheterization time and bladder irrigation time, pre- and post-operative serum PSA levels, International Prostate Symptoms Score (IPSS), post-void residual urine (PVR) volume and maximum urinary flow rate (Qmax), and incidence of post-operative complications among different groups.

RESULTS

In the <60 ml group, there were no remarkable differences in the peri- and post-operative parameters between the two surgical strategies. In the 60－80 ml group, DIOD exhibited a significant superiority over TURP in the perioperative levels of hemoglobin (［3.25 ± 1.53］ g/L vs ［4.77 ± 1.67］ g/L, P <0.05) and Na+ (［3.58 ± 1.27］mmol/L vs ［9.67 ± 2.67］ mmol/L, P <0.01), bladder irrigation time (［30.06 ± 6.22］h vs ［58.32 ± 10.25］ h, P <0.01), and urethral catheterization time (［47.61 ± 13.55］ h vs ［68.01 ± 9.69］ h, P <0.01), but a more significant decline than the latter in the postoperative PSA level (［2.34 ± 1.29］ ng/ml vs ［1.09 ± 0.72］ ng/ml, P <0.05), and similar decline was also seen in the >80 ml group (［3.35 ± 1.39］ ng/ml vs ［1.76 ± 0.91］ ng/ml, P <0.05). No blood transfusion was necessitated and nor postoperative transurethral resection syndrome or urethral stricture observed in DIOD. However, the incidence rate of postoperative pseudo-urinary incontinence was significantly higher in the DIOD (22.7%, 32/141) than in the TURP group (7.83%, 9/115) (P <0.05).

CONCLUSIONS

DIOD, with its obvious advantages of less blood loss, higher safety, faster recovery, and more definite short-term effectiveness, is better than TURP in the treatment of BPH with medium or large prostate volume and similar to the latter with small prostate volume.

Factors related to receipt of non-cancer-related transurethral prostatectomy: findings from a large prospective study of 106 769 middle-aged and older Australian men

BACKGROUND

Transurethral prostatectomy (TURP) is a common surgical intervention for chronic lower urinary tract symptoms (LUTS). Little large-scale evidence exists on factors related to receipt of non-cancer-related TURP.

METHODS

A prospective study of men aged ≥45 years participating in the 45 and Up Study, a large Australian cohort study, without prior prostatectomy and/or bowel/genital/urinary-tract cancer; questionnaire data were linked to hospitalisations and deaths. HRs for TURP were estimated in relation to multiple factors, adjusting for confounders.

RESULTS

There were 3416 incident TURPs among 106 769 men (median follow-up 5.8 years), with rates of 1.8, 5.3, 9.1 and 11.4/1000 person-years for ages 45-54, 55-64, 65-74 and ≥75 years, respectively. Age-adjusted rates of TURP varied markedly according to baseline LUTS from 2.2/1000 person-years with no/mild symptoms to 30.7/1000 person-years with severe symptoms. Annual household income ≥$70 000 versus <$20 000, having private health insurance and living in major cities were associated with higher TURP rates; there were no significant differences according to baseline diabetes, stroke, high blood pressure or cardiovascular disease. Men reporting severe versus no physical functioning limitation, high versus low psychological distress or poor versus excellent self-rated health were 36-51% more likely to undergo procedures overall, but were 24-37% less likely to undergo procedures following additional adjustment for need (baseline LUTS).

CONCLUSIONS

TURP rates were most strongly related to baseline LUTS and age, consistent with appropriate health services targeting. Lower TURP rates in men experiencing socioeconomic disadvantage and with poor health/disability, after accounting for baseline LUTS, suggest inequity and factors such as frailty and risks related to surgery.

Economic Evaluation Study (Cheer Compliant) Laser Prostatectomy for Benign Prostatic Hyperplasia: Outcomes and Cost-effectiveness

To determine which surgical treatment for lower urinary tract symptoms, which is suggestive of benign prostatic hyperplasia (BPH), is more cost-effective and yields a better patient's preference. Treatment outcome, cost, and perioperative complications to assess the treatment effectiveness of using laser prostatectomy as a treatment for BPH were investigated in this study.This retrospective study included 100 patients who underwent transurethral resection of prostate (TUR-P) and another 100 patients who received high-powered 120 W (GreenLight HPS) laser prostatectomy between 2005 and 2011.International Prostate Symptom Score and uroflow parameters were collected before the surgery and the uroflow and postvoiding residual volumes were evaluated before treatment and at 3, 6, 12, and 24 months after treatment. The results of 100 treatments after HPS laser prostatectomy were compared with the results of 100 patients who received TUR-P from the same surgeon. Complication rates and admission costs were analyzed.From 2005 to 2011, 200 consecutive patients underwent endoscopic surgery. Study participants were men with BPH with mean age of 71.3 years old. The peak flow rate went from 8.47 to 15.83 mL/s for 3 months after laser prostatectomy. Laser therapy groups showed better improvement in symptom score, shortened length of stay, and quality of life score when compared with those of TUR-P procedures. The estimated cost for laser prostatectomy was high when compared with cost of any other TUR-P procedural option at Chang Gung Hospital (P = 0.001). All admission charges were similar except for the cost of the laser equipment and accessories (mainly the laser fiber) (P = 0.001). Due to this cost of equipment, it increased the total admission charges for the laser group and therefore made the cost for the laser group higher than that of the TUR-P group.Perioperative complications, such as the need for checking for bleeding, urinary retention rate or urosepsis rate within 30 days after the surgery, held no significant differences between both groups.Compared with alternative treatment options, laser prostatectomy of the prostate is clinically effective but yields a high cost of treatment for symptomatic BPH.

Transurethral resection of the prostate--"now and then"

The number of transurethral resections of the prostate (TURP) performed each year is decreasing. The aim of this study was to assess a cohort of patients undergoing TURP and compare this to one twenty years earlier in terms of procedure, complications and outcomes. A retrospective comparative analysis of one hundred consecutive TURPs performed in 2010 was compared to one hundred cases performed in 1990. Fifty-five (55%) had a urinary catheter (UC) in situ pre-operatively in 2010 compared to 22 (22%) in 1990. The length of catheterisation time was significantly longer in 2010 compared with 1990 (average 65 days vs 20 days). Infective complications occurred in six (6%) patients in 2010 and three (3%) in the 1990 cohort. Patients who had UCs in situ preoperatively for longer periods had a higher rate of infective complications and more serious complications. This highlights the importance of early specialist referral for patients diaqnosed with urinary retention.

Evaluation of changes in serum concentration of sodium in a transurethral resection of the prostate

INTRODUCTION AND OBJECTIVES

The purpose of this study was to evaluate changes in serum electrolytes during Transurethral resection of the prostate (TURP) and to evaluate the degree of correlation of hyponatremia and the factors that affect the incidence of TURP syndrome and to show the impact of the duration of the procedure on the severity of hyponatremia due to absorption of irrigation fluid in the systemic circulation.

MATERIALS AND METHODS

This study examined 60 male patients planned for elective TURP. The level of serum electrolytes are determined by taking venous blood samples preoperatively and Postoperatively and when the duration of the operation was longer than 60 minutes, the level of serum electrolytes was determined intraoperative. The amount of used irrigation fluid, the weight of resection prostate, and duration of surgery, were also followed. Patients were divided in two groups according to the length of the surgical procedure: Group 1 (30-60 min) and Group 2 (> 60 min).

RESULTS

Statistically significant reduction of serum sodium and the elevation of the potassium level in serum observed postoperatively and was directly proportional to the volume of of the used irrigation fluid, the duration of the procedure and volume of the resected prostate.

CONCLUSIONS

To evaluate changes in serum electrolyte during TURP is simple and economical method for the indirect estimation of irrigation fluid absorption into the systemic circulation during TURP and opportunity for early identification of TURP syndrome.

Population based trends in the surgical treatment of benign prostatic hyperplasia

PURPOSE

Laser prostatectomy has increased in popularity in the last decade. However, traditional transurethral resection of the prostate remains common. To understand decisions about the use of laser prostatectomy vs transurethral prostate resection, we evaluated trends in transurethral surgery for benign prostatic hyperplasia in an all payer data set, focusing on patient and provider factors associated with the receipt of laser prostatectomy.

MATERIALS AND METHODS

Using Florida State Inpatient Database and Ambulatory Surgery Database, we identified patients who underwent laser prostatectomy or transurethral prostate resection from 2001 to 2009. We calculated surgery rates with time, stratified by procedure type. We used multilevel regression to examine patient (age, race and comorbidity level) and provider (surgeon volume) factors associated with the receipt of laser prostatectomy vs transurethral prostate resection.

RESULTS

While the overall rates of transurethral surgery remained stable during the study period (p = 0.227), laser prostatectomy use increased 400% from 25 to 114 procedures per 100,000 men (p <0.001), replacing about half of all transurethral prostate resections. Patients were less likely to undergo laser prostatectomy if they were older (OR 0.65, 95% CI 0.61-0.70) and less healthy (OR 0.48, 95% CI 0.45-0.51). While these factors were predictive of surgery type, most of the variation in laser prostatectomy use (69%) was determined by the urologist seen by the patient.

CONCLUSIONS

Laser prostatectomy use has increased in the last decade at the expense of transurethral prostate resection, driven largely by provider effects. However, elderly and more infirm patients are least likely to undergo it, raising concern about underuse in this population.

National trends in surgical therapy for benign prostatic hyperplasia in the United States (2000-2008)

OBJECTIVE

To report an update of the change in usage trends for different surgical treatments of benign prostatic hyperplasia (BPH) among the United States Medicare population data from 2000-2008. The rate of usage of thermotherapy and laser therapy in the surgical treatment of BPH has been changing over the past decade in conjunction with a steady decrease of transurethral resection of the prostate (TURP).

METHODS

Using the 100% Medicare carrier file for the years 2000-2008, we calculated counts and population-adjusted rates of BPH surgery. Rates of TURP, thermotherapy, and laser-using modalities were calculated and compared in relation to age, race, clinical setting, and reimbursement.

RESULTS

After years of a steady rise, the total rate of all BPH procedures peaked in 2005 at 1078/100,000 and then declined by 15.4% to 912/100,000 in 2008. TURP rates continued to decline from 670 in 2000 to 351/100,000 in 2008. Rates of microwave thermoablation peaked in 2006 at 266/100,000 and then declined 26% in 2008. Laser vaporization almost completely replaced laser coagulation and in 2008 was the most commonly performed procedure second to TURP, with the majority performed as outpatient procedures (70%) and an increasing percentage in the office (12%). Men between ages 70 and 75 had the highest rate of procedures. Reimbursement rates correlate using some but not all procedures. Racial disparities reported previously appear to have resolved.

CONCLUSION

Surgical treatment of BPH continues to change rapidly. TURP continues to decline and laser vaporization is the fastest growing modality. There is a big shift toward outpatient/office procedures. Reimbursement rates do not appear to have a consistent effect on usage.

Trends and attitudes in surgical management of benign prostatic hyperplasia

INTRODUCTION

Surgical management of benign prostatic hyperplasia (BPH) has changed over the past 15 years with newer techniques emerging such as laser therapy that can be used with anticoagulation, an increasing issue with modern patients. We sought to evaluate current trends in procedure utilization based on age, location, type of practice, and experience. We also hoped to determine what factors influence surgeons' decisions to choose or reject particular surgical techniques.

METHODS AND MATERIALS

A 90-item on-line survey was sent via electronic mail to the American Urological Association (AUA), Veterans Administration, Society for Government Service Urologists, and Endourological Society. Data concerning utilization of 12 BPH surgical techniques were analyzed and compared to the surgeons' demographics using categorical data analysis and logistic regression.

RESULTS

Of approximately 5500 urologists contacted, 600 urologists replied with 570 currently performing BPH surgery. The two procedures that continue to be utilized by urologists are open prostatectomy (OP) at 78% and monopolar transurethral resection of prostate (TURP) at 73%. When stratified by urologist age and year of residency completion, there were no differences in procedure utilization. There were no differences in types of procedures utilized between AUA sections except in the Northeastern AUA section which utilized less monopolar TURP and the New York section which utilized less photoselective vaporization (PVP). Higher volume surgeons were more likely to perform holmium laser enucleation of the prostate (HoLEP), diode laser vaporization of the prostate, holmium laser ablation of the prostate (HoLAP), and thulium laser ablation. There were no trends for low volume surgeons. There were no differences in types of procedures performed in full time academic versus non-academic settings except for robotic prostatectomy and button TURP which were utilized more often in academic settings. Urologists were more likely to accept a technique that produces good clinical outcomes, is safe in practice, and minimally invasive. Urologists reject procedures most frequently due to preference for another technique or lack of training/equipment. Interestingly, reimbursement/cost issues were never reported as primary reasons for acceptance/rejection of any approach.

CONCLUSIONS

Change in technology has led urologists to change their approach to surgical treatment of BPH. OP and monopolar TURP are still the procedures utilized by most urologists, however, laser therapy is emerging as a commonly used technique. As more high-risk patients are treated, laser therapies may become a more popularized technique. Further larger scale studies evaluating surgeon attitudes might clarify how changing technology influences practice patterns.

Bipolar plasmakinetic transurethral resection of prostate in 132 consecutive patients with large gland: three-year follow-up results

OBJECTIVE

To assess the safety, efficacy, and medium-term durability of bipolar plasmakinetic transurethral resection of the prostate (PK-TURP) for the treatment of bladder outlet obstruction due to benign prostatic hyperplasia in a prospective study.

METHODS

From March 2007 to May 2008, 132 consecutive patients underwent PK-TURP at our institution. All patients were assessed perioperatively and followed up at 1, 3, 6, 12, 18, 24, and 36 months postoperatively. The parameters included the International Prostate Symptom Score, quality of life scores, maximal urinary flow rates, transrectal ultrasonography, postvoid residual urine volume, and serum prostate-specific antigen level.

RESULTS

The mean patient age was 64.55±4.03 years. The prostate volume was 79.66±12.36 g. The operative time was 78.83±17.41 minutes, and the resected weight was 58.12±7.29 g. The catheterization time was 69.00±17.99 hours, and the hospital stay was 117.00±17.99 hours. The decrease in hemoglobin and sodium was 1.55±0.48 g/dL and 1.57±0.38 mmol/L, respectively. A significant improvement occurred in the maximal urinary flow rate (22.34±3.1 mL/s), International Prostate Symptom Score (2.90±1.60), and quality of life (1.12±0.60) at the 3-year follow-up compared with baseline (P<.001). Of the 132 patients, 6 (4.5%) required reoperation.

CONCLUSION

PK-TURP represents an effective surgical intervention for the treatment of bladder outlet obstruction for large prostates. Furthermore, the functional results at 3 years demonstrated durability. Therefore, the PK-TURP technique could play an important role in the surgical treatment of patients with symptomatic benign prostatic hyperplasia with a large prostate gland.

Impact of pharmacotherapy on the incidence of transurethral prostatectomy for benign prostatic hyperplasia and the implications for surgical training

Medical therapy has become first line treatment for Benign Prostatic Hypertrophy (BPH) and in many cases TURP may no longer be required. Proof and quantification of this evolution in practice has been somewhat elusive and provided the principle impetus for this study. This is a retrospective study of BPH management in Republic of Ireland from 1995 to 2008. National treatment databases were sourced for numbers undergoing TURP and pharmacotherapy prescribing data was obtained from individual pharmaceutical companies. A total of 28,240 TURP's were performed nationally between 1995 and 2008. TURP's performed annually, decreased by 1,494 (51%), alpha-blocker prescriptions increased from 8,710 to 302,159 units and the number of urology trainees increased by 10 (60%). Clear association between decreases in TURP's and increases in pharmacotherapy for BPH is demonstrated. Implications on training likely exist and will require proper evaluation in order to maintain future standards in this surgical practice.

Laparoscopic repair of rectourethral fistulas after prostate surgery

OBJECTIVES

To present our experience with laparoscopic rectourinary fistula (RUF) repair. RUF is a rare entity that can develop after ablative or extirpative prostate surgery. Successful management often requires an aggressive approach. Several techniques have been described for surgical correction.

METHODS

From October 2004 to October 2005, 3 patients were treated for RUF. The mean age was 63 years (range 58 to 68). RUF developed after open simple prostatectomy, open radical prostatectomy, and transurethral prostate resection. The operative steps were dependent on the location of the fistulous tract (bladder-prostate-urethra). When the fistula involved the prostatic capsule, the technique included capsulectomy and urethrovesical anastomosis. When the bladder was involved, a transvesical approach was used, involving dissection of the fistulous tract, closure of the rectum, tissue interposition, and bladder closure.

RESULTS

The mean operative time was 247 minutes (range 230 to 270). The mean hospital stay was 2.6 days (range 2 to 3). No complications occurred. At a mean follow-up of 12 months (range 7 to 19), all patients were free of fistula recurrence.

CONCLUSIONS

Laparoscopic repair of RUF is feasible and represents an attractive alternative to the standard approaches. The laparoscopic technique facilitates concomitant colostomy and tissue interposition without the need for patient repositioning or an additional incision.

Predictors of Nocturia Quality of Life Before and Shortly After Prostatectomy

OBJECTIVES

To evaluate the predictors of nocturia-related quality of life and to assess the early effect of prostatectomy on these parameters in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction.

METHODS

The study group included 56 consecutive patients scheduled for prostatectomy to treat medical treatment-refractory lower urinary tract symptoms. Nocturia severity was assessed preoperatively and 2 to 3 months after prostatectomy by the number of nocturia events, time from falling sleep to first awakening to void (hours of undisturbed sleep [HUS]), longest sleep interval between voids, and score on the nocturia quality-of-life (N-QOL) questionnaire (range 0 to 48).

RESULTS

The mean age of the study group was 69 +/- 9 years. The preoperative N-QOL score correlated strongly with the number of nocturia events, HUS, and longest sleep interval between voids (r = -0.69, r = 0.67, and r = 0.69, respectively, and P <0.001). Of the 56 patients, 36 (65%) underwent transurethral prostatectomy and 20 (35%) underwent open prostatectomy. Significant improvement (P <0.001) was noted in all factors after treatment. The number of nocturia events decreased from 3.4 +/- 1.2 to 2.6 +/- 0.99; the HUS increased from 1.83 +/- 0.55 to 2.74 +/- 0.64 hours; the longest sleep interval between voids increased from 2.36 +/- 0.64 to 2.91 +/- 0.6 hours; and the N-QOL score increased from 24.1 +/- 7 to 34.4 +/- 7.5. On multivariate stepwise regression analysis, the factors predicting for improvement in the N-QOL score after prostatectomy were the number of nocturia events and HUS.

CONCLUSIONS

Prostatectomy is associated with an early postoperative improvement in nocturia indexes. The increases in the interval to first void and decrease in even less than one nocturia event were associated with significant improvement in nocturia quality of life.

[Surgical treatment of benign prostatic hyperplasia in Denmark--1993-2003]

INTRODUCTION

The treatment of BPH includes many possibilities, from medical treatment to open prostatectomy. During the last 20 years medical treatment has increasingly been used. Furthermore, new minimal invasive techniques have been developed. The aim of this study was to examine changes in the surgical treatment of BPH from 1993 to 2003.

MATERIALS AND METHODS

Data were drawn from the National Patient Register and Statistics Denmark from 1993 to 2003. For each operation case, the diagnosis, region, age group in decades, and the year of the operation were registered. BPH-related cases include prostatic hypertrophia, benign prostatic neoplasm, bladder stone, urinary retention, hematuria, LUTS, and bladder neck stenosis.

RESULTS

In the 10-year period 63,970 prostate operations were performed. 44,347 of these operations could be related to BPH. 21% fewer prostate operations were performed in 2003 than in 1993. Standard prostate operations constituted 93-97% of all operations during the entire period. The operation rate per 1,000 men older than 50 years was median 6.5 in 1993 and 4.5 in 2003. The rate differed considerably between regions. There was a large variation in the number of operations per region with the new techniques. The use of the new techniques has been constantly low during the entire period.

CONCLUSION

In 2003 21% fewer prostate operations were performed than in 1993. Standard prostate operations constituted more than 90% of operations during the entire period. The use of the new techniques has been constantly low.

Analysis of prognostic factors regarding the outcome after a transurethral resection for symptomatic benign prostatic enlargement

AIMS

To identify preoperative predictive variables regarding treatment outcomes following transurethral resection of the prostate (TURP) of patients with symptomatic benign prostatic enlargement (BPE).

METHODS

A retrospective study was conducted in 384 patients of 1,397 men who had undergone TURP for symptomatic BPE. All the patients had completed the evaluation of International Prostate Symptom Score (I-PSS), and quality of life (QOL) index, and had undergone full urodynamics before the surgery. Outcomes were assessed at 12 months after surgery. The association between baseline variables and the improvement in outcome variables was statistically analyzed.

RESULTS

Preoperative urodynamic abnormalities included bladder outlet obstruction (BOO) in 315 (82.0%), detrusor underactivity in 91 (23.7%), and detrusor overactivity (DO) in 160 (41.7%). Multivariate analysis showed that the presence of DO and a higher degree of BOO were both associated with postoperative improvement both in I-PSS and the QOL. The initial level of storage symptoms correlated with an improvement in the QOL.

CONCLUSIONS

The association between those variables obtained by preoperatively performed urodynamic analysis and the degree of improvement in lower urinary tract symptom and QOL following TURP was statistically elucidated in a large number of patients with symptomatic BPE. A higher degree of baseline BOO positively predicts the postoperative improvement in I-PSS and QOL, while the baseline DO negatively predict it.

Unequal Use of New Technologies by Race: The Use of New Prostate Surgeries (Transurethral Needle Ablation, Transurethral Microwave Therapy and Laser) Among Elderly Medicare Beneficiaries

PURPOSE

We compared the availability and use of transurethral microwave therapy, transurethral needle ablation, contact or noncontact laser therapy and transurethral resection of the prostate among elderly black and white Medicare beneficiaries.

MATERIALS AND METHODS

We examined 100% Medicare Inpatient, Outpatient, Carrier and Denominator files of men 65 years old or older who underwent these procedures in 1999 through 2001. White-to-black race rate ratios for each procedure were computed for the entire United States, as well as for a restricted set of counties in which procedures were available to black beneficiaries.

RESULTS

A total of 170,067 TURP, 16,953 TUMT, 5,353 TUNA and 12,134 Laser procedures were performed during 3 years. Nationally there was only a 3% difference in the age adjusted TURP rates between white and black men (6.13 and 5.94 per 1,000 person-years, respectively). However, the age adjusted rates for TUMT and TUNA among white men were about twice those among black men (0.63 vs 0.31 and 0.20 vs 0.10 per 1,000 person-years, respectively). Laser rates were 17% higher among white men than among black men (0.44 vs 0.38 per 1,000 person-years). Large geographic variation existed in the new procedure rates. Negative binomial regression analysis confirmed the national findings in those counties in which the procedures were available to black men. Adjusted white-to-black rate ratios were 1.96 (95% CI 1.70-2.25) for TUMT, 2.33 (95% CI 1.87-2.90) for TUNA and 1.36 (95% CI 1.16-1.59) for Laser.

CONCLUSIONS

After controlling for availability, elderly black Medicare beneficiaries were less likely to undergo the new BPH procedures than white beneficiaries, while the usage difference for TURP remained small.

[Incidental carcinoma of the prostate: can we and should we recommend radical prostatectomy?]

INTRODUCTION

There is controversy regarding tumor control of incidental prostate cancer (PC). We evaluated in a large cohort if we can recommend radical prostatectomy after TURP.

MATERIAL AND METHOD

In 52 (4.3%) from a total of 1207 patients undergoing radical prostatectomy the diagnosis had been made by TURP. In a retrospective analysis we evaluated morbidity, histopathological results, and tumor control of pT1a/b tumors.

RESULTS

The number of incidentally detected PC decreased with time. In 5.8% in the TURP group and in 0.5% of the needle biopsy group, there was no residual tumor found (p<0.001). Morbidity was similar +/- TURP with the exception of operation time (206 vs 188 min) and catheter duration (19.3 vs 17.3 days). Postoperative continence was identical. There was no difference in tumor control for local recurrence-free survival and PSA-free survival with and without TURP.

CONCLUSIONS

The rate of incidentally detected PC by TURP decreases over time, but in almost all cases we found clinically relevant cancer. TURP is not an adverse prognostic factor and morbidity is similar compared with patients who were diagnosed by needle biopsy. Our data confirm that we should recommend radical prostatectomy to patients who are candidates for further curative therapy.

SEEKING EVIDENCE THAT CELL KILL GUIDED THERMOTHERAPY GIVES RESULTS NOT INFERIOR TO THOSE OF TRANSURETHRAL PROSTATE RESECTION: RESULTS OF A POOLED ANALYSIS OF 3 STUDIES OF FEEDBACK TRANSURETHRAL MICROWAVE THERMOTHERAPY

PURPOSE

We compared ProstaLund Feedback Treatment (PLFT) to transurethral prostate resection (TURP) in terms of efficacy and safety in a pooled analysis of 3 clinical studies with 1-year followup.

MATERIALS AND METHODS

Overall raw data on 183 patients with PLFT and 65 with TURP were pooled. All studies had identical inclusion criteria, and the efficacy and safety of the method were evaluated using the International Prostate Symptom Score, maximum urine flow (Qmax), responder rate, bother score, prostate volume reduction and adverse events.

RESULTS

The response rate was 85.3% and 85.9% in the PLFT and TURP groups, respectively. One-sided 95% CI analysis showed the noninferiority of PLFT vs TURP for this variable. Mean International Prostate Symptom Score was significantly decreased in the PLFT and TURP groups after 12 months (from 20.9 to 6.4 and 20.7 to 7.1, respectively). The 1-sided upper 95% CI of PLFT was within the noninferiority definition compared with that of TURP. The bother score decrease in the PLFT and TURP groups was not significant different (70.9% and 64.0%, respectively). An increase in Qmax from 7.7 to 16.1 ml per second 12 months after PLFT was noted, while the improvement in Qmax in the TURP group was higher (from 7.5 to 18.6 ml per second). The 1-sided lower 95% CI was close (0.76) but it did not attain the predetermined level of noninferiority (0.80). Mean transurethral ultrasound determined volume 12 months after PLFT and TURP was reduced by 32.8% and 58.1%, respectively. A significant correlation between the transurethral ultrasound determined prostate volume reduction and estimated cell kill was found (r = 0.456, p <0.000001). Serious adverse events with causality occurred in 15.4% of patients with TURP compared with 6.0% in those with PLFT (p = 0.035).

CONCLUSIONS

Combined experience from our pooled analysis indicates that PLFT challenges TURP in terms of efficacy and safety after 1 year of followup.

INEQUALITIES IN RURAL HEALTH CARE: DIFFERENCES IN SURGICAL INTERVENTION BETWEEN METROPOLITAN AND RURAL WESTERN AUSTRALIA

BACKGROUND

To compare surgical procedure rates between metropolitan and rural/remote residents in Western Australia (WA).

METHODS

The WA Data Linkage System was used to identify all patients who underwent a procedure for cataract, ureteric calculi or urinary outflow obstruction symptoms for the time periods 1981-2000, 1981-1997 and 1981-1995, respectively. Age-standardized procedure rates were calculated and Poisson regression modelling was used to estimate effects of locality of residence and demographic covariates.

RESULTS

Overall, rural/remote patients underwent first-time procedures for cataract (IRR 0.92; 95% CI 0.90-0.94), ureteric calculi (0.76; 0.72-0.80), or urinary outflow obstruction (0.71; 0.69-0.74) less frequently than patients in the metropolitan area. They were also significantly less likely to undergo multiple procedures for cataracts (0.90; 0.88-0.91) and ureteric calculi (0.69; 0.67-0.73).

CONCLUSION

A distinctly reduced level of surgical intervention was found in rural patients for three generally non-life threatening conditions. The reasons for this require further investigation.

Urologic diseases in America project: benign prostatic hyperplasia

PURPOSE

Benign prostatic hyperplasia (BPH), the most common benign neoplasm in American men, is a chronic condition that is associated with progressive lower urinary tract symptoms and affects almost 3 of 4 men during the seventh decade of life. Approximately 6.5 million of the 27 million white men who are 50 to 79 years old in the United States in 2000 were estimated to meet the criteria for discussing treatment.

MATERIALS AND METHODS

The analytical methods used to generate these results have been described previously.

RESULTS

In 2000 approximately 4.5 million visits were made to physician offices to for a primary diagnosis of BPH and almost 8 million visits were made with a primary or secondary diagnosis of BPH. In the same year approximately 87,400 prostatectomies for BPH were performed in inpatients in nonfederal hospitals in the United States. While the number of outpatient visits for BPH increased consistently during the 1990s, there was a dramatic decrease in the use of transurethral prostatectomy, inpatient hospitalization and length of hospital stay for this condition. These trends reflect the changing face of medical management for BPH, ie increasing use of pharmacological agents and minimally invasive therapies. In 2000 the direct cost of BPH treatment was estimated to be $1.1 billion exclusive of outpatient pharmaceuticals.

CONCLUSIONS

Given the impact that BPH has on quality of life and health care cost in millions of American men, additional research into risk factors, diagnostic and therapeutic resource use, and effectiveness and cost benefit of therapies are warranted.

Radical prostatectomy: pathology findings in 1001 cases compared with other major series and over time

OBJECTIVE

To examine the preoperative features and pathological outcomes of clinical significance of 1001 consecutive essentially unscreened men who had a radical prostatectomy (RP) in the UK between 1988 and 2002, and their changes over time.

PATIENTS AND METHODS

The details of men whose RP specimen was submitted for analysis were entered into the RP database held at the University College Hospital, London; the National Health Service and private patients of 17 surgeons were included. The age, mode of diagnosis, preoperative prostate specific antigen (PSA) level, biopsy and RP findings were compared over time.

RESULTS

The mean (range) age of the men was 62 (40-76) years, the median PSA 8 (0.1-146) ng/mL and the median biopsy Gleason sum score 6; these preoperative features did not change over the study period. The diagnosis of prostate cancer was made by transurethral resection of the prostate alone in 48 men (5%). The maximum number of patients receiving neoadjuvant androgen ablation was 21 (33%) in 1996, and subsequently declined. The median (range) RP Gleason sum score was 7 (4-9). The biopsy Gleason score correlated with the prostatectomy Gleason score in 252 (47%) of 536 men, being lower in 170 (32%) and higher in 113 (21%). The median tumour volume was 2 mL (focus of invasive acini - 31 mL) and the incidence of positive intra- and extraprostatic margins was 52%. Both tumour volume and extraprostatic margin positivity declined with time.

CONCLUSIONS

The preoperative features and pathological findings from this UK series are similar to those of other reported cohorts from unscreened populations. The incidence of positive extraprostatic surgical margins, tumour volume and stage decreased with time.

Transurethral resection of prostate (TURP) through the decades--a comparison of results over the last thirty years in a single institution in Asia

INTRODUCTION

This study was conducted to evaluate the results and complications of transurethral resection of prostate (TURP) over the last 30 years in our institution.

MATERIALS AND METHODS

This retrospective study encompasses 3 different eras: 168 patients in the late 70s, 175 patients in the late 80s and 283 patients in the late 90s. All the patients had at least 18 months of follow-up.

RESULTS

The mean age from the 1970s, the 1980s and 1999 were 68.8 years, 69.2 years and 69.4 years respectively. The proportion of patients operated on for acute retention fell from 78.6% (132) in the 1970s, to 54% (96) in the 1980s, and 43% (122) in 1999. The mean resection time was 44.8 minutes in 1989 and 41.8 minutes in 1999. The mean weight of prostate resected was 22.1 g in the 1970s, 24.2 g in 1989 and 22.2 g in 1999. 44% (74) required blood transfusion in the 1970s, with 11% (19) in 1989 and 4% (11) in 1999. There were 2 deaths (acute myocardial infarction and pneumonia) in the 1970s, 1 (pneumonia) in 1989 and no mortality in 1999. There were 4 patients with TURP syndrome in the 1970s, 3 in 1989 and 1 in 1999. The incidence of postoperative urinary tract infection (UTI) was 25% (42) in the 1970s, 16% (29) in 1989 and 6% (17) in 1999.

CONCLUSIONS

As expertise and experience in TURP progress, the complication rates fall, as evidenced by the lower rates of transfusion, TURP syndrome and postoperative UTI in the later series.

Interstitial laser coagulation for management of benign prostatic hyperplasia: Long-term follow-up

AIM

We evaluated the long-term results of transurethral interstitial laser coagulation in the treatment of benign prostatic hyperplasia (BPH) with up to 9 years of follow up at the Kurashiki Central Hospital and determined the patient characteristics that predict a favorable outcome.

METHODS

From December 1993 to May 1997, a total of 82 patients were enrolled in the present study. Subjective and objective voiding parameters were collected from medical records and a self-administered questionnaire was sent to the patients. Kaplan-Meier plots were constructed to assess the risk of retreatment.

RESULTS

The mean follow-up period was 48.4 months (range, 3-108 months). A total of 59 patients (72%) did not need any additional treatment at 12 months and 30 patients (37%) did not require additional treatment during the entire follow-up period. A total of 29 patients (35%) were retreated during follow-up. Transurethral prostate resection (TURP) was performed in 18 patients (22%). The remaining 11 patients (13%) were offered additional pharmacotherapy. The minimum and median retreatment-free durations were 3 and 14 months, respectively. Seven patients died and 17 were lost to follow-up. Men aged 71 years or older had greater likelihood of requiring retreatment than those younger than 71 years (P = 0.0397). No significant differences were noted in the other baseline characteristics. Among postoperative parameters, a rate of decrease of the International Prostate Symptom Score of the patient of lower than 60% and a rate of decrease in patient quality of life of lower than 50% at 3 months were associated with greater likelihood of retreatment (P = 0.0083 and P = 0.0006, respectively).

CONCLUSIONS

Interstitial laser coagulation is effective for the treatment of BPH. Good long-term results and an acceptably low retreatment rate render this modality an effective alternative to TURP, especially for younger patients. Short-term improvement of subjective symptoms was predictive of favorable long-term outcome.

Long-term follow-up after transurethral resection of the prostate, contact laser prostatectomy, and electrovaporization

OBJECTIVES

To compare the long-term results of subjective changes, flowmetry, morbidity, and mortality after transurethral resection of the prostate, contact laser prostatectomy, and electrovaporization in men with lower urinary tract symptoms associated with benign prostatic hyperplasia.

METHODS

A prospective randomized controlled trial was conducted. Included in the study were men with lower urinary tract symptoms, who met the criteria of the International Scientific Committee on Benign Prostatic Hyperplasia, had a prostate volume between 20 and 65 cm(3), and a Schäfer obstruction grade of 2 or greater. The subjective changes were quantified using the International Prostate Symptom Score, Symptom Problem Index, quality-of-life question, and benign prostatic hyperplasia impact index. Morbidity was registered objectively and by patient questionnaire. Maximal flow was measured by free uroflowmetry. These parameters were measured at regular intervals for up to 1 year. At the end of 2002, all patients were invited for a long-term follow-up examination, including the aforementioned parameters.

RESULTS

Fifty men were randomized to undergo transurethral resection of the prostate, 45 laser treatment, and 46 electrovaporization. Of the 50 men, 70% were followed up for a maximum of 7 years. The values for the International Prostate Symptom Score, Symptom Problem Index, quality-of-life score, and benign prostatic hyperplasia impact index increased slightly after a mean follow-up of 4.3 years. The maximal uroflow decreased similarly in all treatment groups to about 150% of the preoperative values. Morbidity, reoperation rates, and mortality were also similar.

CONCLUSIONS

This study, with up to 7 years of follow-up, demonstrated durable subjective and objective results for patients with lower urinary tract symptoms associated with benign prostatic hyperplasia after transurethral resection of the prostate, contact laser prostatectomy, or electrovaporization. No clinically relevant differences were found among these modalities.

Transurethral resection vs microwave thermotherapy of the prostate: a cost-consequences analysis

OBJECTIVE

To compare the costs and outcome of high-energy transurethral microwave thermotherapy of the prostate (HE-TUMT) with transurethral resection of the prostate (TURP), as the former is considered to be the best minimally invasive method for managing lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Between January 1996 and March 1997, 144 patients were randomized to treatment with HE-TUMT (78) using the Prostatron device and Prostasoft 2.5 software (EDAP Technomed, Lyon, France), or TURP (66). At baseline and during the annual follow-up, patients were evaluated by the International Prostate Symptom Score and uroflowmetry (maximum flow rate and postvoid residual volume). Kaplan-Meier survival analyses were used to calculate the cumulative risk of re-treatment. A cost-consequences analysis was performed based on the prospective measurement of healthcare use, with costs expressed as Netherland guilders (NLG).

RESULTS

During a 3-year follow-up period, the mean (95% confidence interval) risk of re-treatment was 22.9 (12.5-33.2)% and 13.2 (4.5-21.9)% for HE-TUMT and TURP, respectively (P = 0.215). The mean direct cost of treatment was 3450 (3444-3456) and 6560 (5992-7128) NLG for HE-TUMT and TURP, respectively. The mean total (including re-treatments), discounted (4%) 3-year cost for the HE-TUMT and TURP group was 5300 (4692-5908) and 7800 (7118-8482) NLG, respectively.

CONCLUSIONS

In this prospective randomized trial, HE-TUMT and TURP had a comparable 3-year risk of re-treatment. Healthcare expenditure on HE-TUMT, mainly because it is an outpatient treatment, was significantly lower than for TURP.

Present practice and development of minimally invasive techniques, imaging and training in European urology: results of a survey of the European Society of Uro-Technology (ESUT)

OBJECTIVES

The European Society of Urological Technology (ESUT) conducted a survey in order to assess and record the current trend between European urologists with regard to the application of new technologies in BPH, stone disease and imaging and to identify differences amongst urologists.

MATERIAL AND METHODS

A total of 854 certified urologists and residents coming from European countries answered the ESUT survey during the XVIth Annual EAU Meeting in Geneva in 2001. The respondents were classified according to the geographical origin (Eastern, Southern and Northern Europe), year of certification (before 1980, and every 5 years hereafter) and power of the department in beds (less than 25, 26-50, and more than 50) in order to identify any differences in the replies mainly due to economical reasons, national or hospital policy and personal attitudes.

RESULTS

According to the replies, in Eastern Europe more procedures related to BPH and stones are performed comparing to Northern and Southern Europe (165.8 versus 77.1 and 100.6/month/department, respectively). However, the Northern European urologists have access to every type of lithotriptor and most of the different minimally invasive treatments for BPH in a higher percentage, followed by the Southern and the Eastern European urologists. The most widespread intracorporeal lithotriptor is the pneumatic and the most common alternative minimally invasive BPH treatment is electrovaporization (80.7% and 45.6%, respectively). Holmium laser is the most frequent choice (40.1%) when the surveyed urologists were asked to choose which of the minimally invasive techniques would like to have access to. In total 79.4% (54.1% alone and 25.3% in collaboration with the radiologists) of the respondents perform the ultrasound studies while the remaining 20.6% declare that only the radiologists do the studies. Of the surveyed urologists, 92.8%, 89.6% and 94.9% are interested in hands-on courses, simulators and live surgery, respectively.

CONCLUSIONS

The data obtained from the 854 surveyed European urologists and residents can be used as a tool to highlight the disparity between European countries and to advance training of European urologists.

Missing... presumed at random: cost-analysis of incomplete data

When collecting patient-level resource use data for statistical analysis, for some patients and in some categories of resource use, the required count will not be observed. Although this problem must arise in most reported economic evaluations containing patient-level data, it is rare for authors to detail how the problem was overcome. Statistical packages may default to handling missing data through a so-called 'complete case analysis', while some recent cost-analyses have appeared to favour an 'available case' approach. Both of these methods are problematic: complete case analysis is inefficient and is likely to be biased; available case analysis, by employing different numbers of observations for each resource use item, generates severe problems for standard statistical inference. Instead we explore imputation methods for generating 'replacement' values for missing data that will permit complete case analysis using the whole data set and we illustrate these methods using two data sets that had incomplete resource use information.

[Prevalence and preference with regard to various surgical treatments for benign prostatic hypertrophy: a survey for the Japanese endourology and ESWL society member]

BACKGROUND AND PURPOSE

We conducted a questionnaire survey concerning the prevalence and preference with regard to various types of surgical treatment for benign prostatic hypertrophy (BPH), in order to gather preliminary data that may be helpful for standardizing the surgical treatment of BPH.

METHOD

A questionnaire survey was mailed to institutes in which a council member of the Japanese Endourology and ESWL Society was present. The questions dealt with the type and volume of surgical treatment experienced previously, and the treatments which had been performed in each institute during 2000. Preferences concerning cost effectiveness, safety, degree of invasion, efficacy, overall usefulness, and the possibility of prevalence from now on at general hospitals were also asked with regard to each surgical treatment.

RESULTS

Of the 155 institutes to which the questionnaire was sent, 70 responded (45% response rate). TUVP (transurethral vaporization of the prostate by thick-loop) was second to TURP (transurethral resection of the prostate) both regarding the volume of the surgical treatment that had been experienced previously, and the volume that had been performed during 2000. TURP was recognized as the most preferred treatment with regard to both cost effectiveness and overall usefulness, while TURF (transurethral radiofrequency thermotherapy) was preferred both for safety and reduced invasiveness, and open surgery for efficacy. Minimal invasive surgical treatment, such as TUVP, followed by ILCP (interstitial laser coagulation of the prostate) and TUMT (transurethral microwave thermotherapy) was recognized as the most preferable treatment for dealing with the prevalence from now on at general hospitals.

CONCLUSION

Each minimal invasive surgical treatment was recognized as being safer and less invasive, but less effective and less useful compared to TURP. Among these surgical treatments, TUVP by thick-loop was recognized as being second choice to TURP with regard to efficacy and overall usefulness. As a matter of course, it would seem to be essential to evaluate long-term efficacy in addition to both safety and invasiveness when trying to standardize the surgical treatment for BPH.

Familial aggregation of bothersome benign prostatic hyperplasia symptoms

OBJECTIVES

To evaluate familial aggregation and the mode of inheritance of bothersome benign prostatic hyperplasia (BPH).

METHODS

During an extension of the North American Finasteride Trial, 301 of 895 patients and 158 spousal controls completed a family history questionnaire. Segregation analysis was performed to examine the mode of inheritance in first-degree relatives of the 301 probands.

RESULTS

The lifetime cumulative probability of bothersome BPH was similar in relatives of those with BPH (0.35; 95% confidence interval [CI] 0.28 to 0.44) and spousal controls (0.36; 95% CI 0.22 to 0.56), but the age of onset was significantly earlier in relatives of cases than controls (P = 0.001). Fathers of those with BPH had a significantly elevated risk of bothersome BPH (unadjusted odds ratio [OR] 2.1; 95% CI 1.2 to 3.8) and brothers had a significantly elevated risk of both bothersome BPH (OR 3.5; 95% CI 1.7 to 7.3) and transurethral resection of the prostate (OR 3.6; 95% CI 1.4 to 8.8). After adjusting for family size, the risk of bothersome BPH increased approximately twofold with each additional affected first-degree relative (0 relatives, OR 1.0; 1 relative, OR 1.7; 2 relatives, OR 4.7). Segregation analysis suggested a rare autosomal codominant allele (frequency 0.0004).

CONCLUSIONS

These findings confirm previous findings that family history and early age of onset are associated with an increased risk of BPH and that the most likely mode of inheritance is autosomal dominant or codominant. Bothersome BPH appears to have a weaker genetic component than more restrictive definitions of hereditary BPH. Thus, linkage studies are more likely to be successful if they focus on stricter definitions of hereditary BPH (eg, early onset, large volume, strong family history) rather than symptomatic or clinical BPH.

Incidental detection of population-based prostate cancer incidence rates through transurethral resection of the prostate

OBJECTIVE

To provide an updated assessment of the influence transurethral resection of the prostate (TURP) has on incidental detection of prostate cancer and to characterize stage, histologic grade, and treatment patterns among these cases.

METHODS

Analyses were based on 17,310 histologically confirmed prostate cancer cases ages 45 years and older recorded in the Utah Cancer Registry between 1980 and 1999 and 6426 TURP procedures recorded in the Utah Hospital Discharge Database from 1992 through 1999. An algorithm was developed for identifying TURP-detected prostate cancer incidence.

RESULTS

Age-specific TURP-detected prostate cancer incidence rates tended to be flat between 1980 and 1990, decline through 1994, and then level off. Much of the decrease corresponds to the prostate-specific antigen (PSA) screening induced peak and subsequent fall in total prostate cancer incidence rates. Leveling off in the TURP-detected rates between 1994 and 1999 corresponds with a leveling off in the total prostate cancer incidence rates. The percentage of prostate cancer detected by TURP significantly increases with age, within each age group, but decreases over calendar years. For ages 45 years and older, the percentage of TURP-detected cases was 39.0% in 1980 to 1984, 33.9% in 1985 to 1989, 12.2% in 1990 to 1994, and 7.4% in 1995 to 1999. TURP-detected cases were significantly less likely to undergo radical prostatectomy or radiation therapy across age groups, despite having lower stage and histologic grade at diagnosis.

CONCLUSION

TURP-detected prostate cancer rates have leveled off in the latter part of the 1990s, explaining about 10% of all detected cases. These cases have relatively good biologic potential and are less likely to pursue aggressive therapy.

A comparison of techniques for eliciting patient preferences in patients with benign prostatic hyperplasia

PURPOSE

We compared the Health Utility Index (HUI), EuroQol (EQ-5D) and time trade-off methods to identify the most suitable technique for collecting preference data in a clinical trial of patients with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

A total of 29 men with symptomatic BPH were interviewed by a single trained interviewer who collected demographic data and administered EQ-5D and time trade-off questionnaires. Participants self-administered the HUI and a symptom severity index, the International Prostate Symptom Score (I-PSS) questionnaire. Utility values for current patient health states obtained from the HUI, EQ-5D and time trade-off questionnaires were compared and their relationship with I-PSS data was examined using Spearman's correlation coefficients. Administration time and patient assessments of the relevance of the questions were also compared for the 3 methods.

RESULTS

Although mean utility values for HUI, EQ-5D and 1-year time trade-off were similar, only utility values elicited using time trade-off with a 1-year time frame significantly correlated with symptom scores. The 1 and 10-year time trade-off derived values were reasonable predictors of the I-PSS with multiple correlation coefficient values of 0.379 and 0.265, respectively. All participants indicated that the HUI and EQ-5D were appropriate for assessing BPH, while approximately 10% considered time trade-off questions irrelevant. Average completion time for the HUI, time trade-off and EQ-5D questionnaires was 31, 25 and 10 minutes, respectively.

CONCLUSIONS

Because only time trade-off resulted in utility values that significantly correlated with symptom scores, we recommend its use for estimating utility in clinical trials of BPH.

Impact of medical therapy on transurethral resection of the prostate: a decade of change

OBJECTIVES

To assess whether medical therapy has delayed the need for eventual transurethral prostatectomy (TURP), causing a shift in the population characteristics of men undergoing TURP (ie, older, more comorbidities, more advanced disease), resulting in more complications and poorer outcomes. The introduction of medical therapy for symptomatic benign prostatic hyperplasia (BPH) during the past decade may have changed the indications for TURP.

METHODS

All patients who underwent TURP for symptomatic BPH at our institution in 1988 (before general introduction of medical therapy for BPH) and 1998 (medical therapy the primary initial therapy for BPH) were reviewed. We compared the two groups with respect to the total number of TURPs, indications for surgery, patient age, health status, weight of resected tissue, and preoperative and postoperative complications.

RESULTS

Despite a 16% increase in men at risk of BPH-related events, a 60% decrease in the total number of TURPs performed for symptomatic BPH occurred in 1998 (n = 64) compared with 10 years earlier (n = 157). No significant difference was found in age between the two groups, and no increase in comorbid status was observed. Previous medical management had failed in 36% of men who required TURP in 1998. A significantly higher percentage of patients presented in acute urinary retention (55%) and upper tract obstructive uropathy (12.5%) in 1998 compared with 1988 (23% acute urinary retention and 1.3% obstructive uropathy). Patients in 1998 were healthier, underwent smaller resections, had their catheters removed earlier, and were discharged home earlier. Although they were more likely to be discharged home with a catheter in situ, no significant difference was observed in the incidence of postoperative complications.

CONCLUSIONS

There has been a dramatic decrease in the number of TURPs performed for symptomatic BPH at our institution since the advent of medical therapy. The proportion of TURP patients presenting with urinary retention and hydronephrosis increased, but the average age, medical comorbidities, operative parameters, and postoperative complications have not significantly changed.

Disappearance of well-differentiated carcinoma of the prostate: effect of transurethral resection of the prostate, prostate-specific antigen, and prostate biopsy

OBJECTIVES

To characterize the effect of prostate-specific antigen (PSA) and transurethral resection of the prostate (TURP) on the rate of diagnosis of well-differentiated (WD) prostate cancer (PCa) and PCa mortality.

METHODS

All cases of PCa and rates of TURP at both Wilford Hall and Brooke Army Medical Centers between 1984 and 1995 were reviewed. Tumor grade was compared between prostate needle biopsy and TURP. The pattern of diagnosis was analyzed annually and for two time periods: pre-PSA (1984 to 1988) and post-PSA (1989 to 1995).

RESULTS

The number of WD tumors fell by 50% over the period of study and was caused by a fall in number of TURPs as well as in WD tumors detected by TURP. PSA for early detection of PCa began in 1988, and within 5 years a more than 50% fall in the rate of metastatic disease was witnessed. These two events (PSA screening and fall in TURPs) led to an increase from 57% to 92% of tumors that were both clinically significant and potentially curable.

CONCLUSIONS

These data help explain the fall in the rate of diagnosis of WD PCa. The resultant increase in the diagnosis of moderately and poorly differentiated PCa, coupled with the dramatic fall in the rate of diagnosis of metastatic PCa, may explain the reports of a fall in PCa mortality. If this observation is replicated in other populations, it may provide further impetus for a stronger recommendation for early detection with PSA and digital rectal examination.

Transurethral resection of the prostate: failure patterns and surgical outcomes in patients with symptoms refractory to alpha-antagonists

BACKGROUND

alpha-Antagonists (AAs) are ineffective in some men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Transurethral resection of the prostate (TURP) may be required. Reasons for AA failure and surgical outcomes in these patients have not been reported.

METHODS

We retrospectively reviewed cases of TURP for LUTS due to bladder outlet obstruction from 1995 to 1998. The TURP patients in whom AA therapy had failed (group 1) were compared with those who had symptomatic BPH but were not taking AAs (group 2). Comorbid conditions that might influence treatment results were considered, as were sizes of resection and pathologic results.

RESULTS

No differences occurred between groups 1 (n = 38) and 2 (n = 25) in age, length of postoperative follow-up, or resection size. However, outcomes were poorer in group 1 than in group 2. A trend toward greater comorbidity that might lead to voiding dysfunction, though not statistically significant, was seen in group 1.

CONCLUSIONS

Postoperative results of TURP may be less successful after AA therapy failure. This may be due to preoperative risk factors that affect voiding function rather than to prostatic size.

Transurethral resection of the prostate among medicare beneficiaries: 1984 to 1997. For the Patient Outcomes Research Team for Prostatic Diseases

PURPOSE

We examine the epidemiology and associated risks of transurethral resection of the prostate among Medicare beneficiaries for the period 1984 to 1997.

MATERIALS AND METHODS

We used hospital claims for transurethral resection of the prostate from a 20% national sample of Medicare beneficiaries for the period 1991 to 1997. Risk of mortality and reoperation were evaluated using life table methods and compared to those for the period 1984 to 1990. We also examined the association between surgical volume and adverse outcomes following resection using unique urologist identifier codes from the 1997 part B Medicare claims.

RESULTS

Compared to 1984 to 1990, age adjusted rates of transurethral resection for benign prostatic hyperplasia (BPH) during 1991 to 1997 declined by approximately 50% for white (14.6 to 6.72/1,000) and 40% for black (11.8 to 6.58/1,000) men. Of the men who underwent resection for BPH during the recent period 53% were 75 years old or older but 30-day mortality in men 70 years old or older was significantly lower than that in 1984 to 1990. Since 1987 the 5-year risk for reoperation following transurethral resection for BPH has remained 5%. For resection performed in 1997 we observed no statistically significant association between urologist surgical volume and risks of reoperation or 30-day mortality.

CONCLUSIONS

Compared to the peak period of its use in the 1980s, older men are now undergoing transurethral resection of the prostate. Nevertheless, outcomes for men 65 years old or older continue to be good.

Prostate carcinoma trends in three counties in Sweden 1987-1996: results from a population-based national cancer register. South-East Region Prostate Cancer Group

BACKGROUND

To detect changes in the incidence rate and management of prostate carcinoma, all cases of the disease diagnosed in the southeast region of Sweden between 1987-1996 were recorded.

METHODS

The register is based on Swedish personal registration numbers, thereby minimizing the number of dropouts. All cases of prostate carcinoma detected in the southeast region have been recorded according to a defined protocol that has been updated successively to match recent views regarding the disease. To ensure a high number of presented cases, the National Cancer Register was checked for missing cases.

RESULTS

Six thousand seven hundred eighty-two cases of prostate carcinoma were registered in the region between 1987-1996. The age-adjusted incidence rate reached a peak in 1993, followed by a slight decrease. The mean age at diagnosis throughout the period was 74.2 years, with a peak age of 74.8 years in 1992. The number of incidental tumors followed the development of the number of transurethral resections of the prostate performed in the region, with a peak in 1991. The percentage of patients receiving gonadotropin-releasing hormone (GnRH) analogues increased from 3.9% to 37.8% whereas the percentage of patients treated with orchiectomy decreased from 40.0% to 12.8% and the percentage of those treated with radical prostatectomy decreased from 11.1% to 2.5%.

CONCLUSIONS

A diminishing pool of latent tumors may explain the decreasing incidence rate and lower age at diagnosis observed after 1993. Orchiectomy is rapidly being superseded by GnRH analogues. In contrast to trends reported in the U.S., the percentage of men with prostate carcinoma undergoing total prostatectomy appears to be declining in Sweden.

In-hospital mortality after transurethral resection of the prostate in Victorian public hospitals

BACKGROUND

The purpose of the present paper was (i) to identify trends in in-hospital mortality after transurethral resection of the prostate (TURP) in Victorian public hospitals; and (ii) to explore associations between in-hospital mortality after TURP and age, adverse events, type of admission (emergency/planned), location of the hospital (metropolitan/rural), teaching status of the hospital and length of stay.

METHODS

Trends in in-hospital mortality after TURP and the associations between in-hospital mortality and the aforementioned variables were studied using International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) coded Victorian hospital morbidity data from public hospitals between 1987-88 and 1994-95. Crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) were based on univariate and multivariate logistic regression, respectively.

RESULTS

After adjustment for age, comorbidity, and other confounding variables, the trend in mortality reduction over time was highly significant (P for trend < 0.0001, 95% CI for trend: 0.84-0.95). Highly significant associations with mortality were observed for emergency admissions (OR = 1.99, P < 0.0001), presence of adverse events (OR = 2.69, P < 0.0001), length of hospital stay (P for trend < 0.0001, 95% for trend: 1.88-2.15) and age (P for trend < 0.0001; 95% CI for trend: 1.26-1.48).

CONCLUSIONS

Routinely collected data from hospitals can provide tentative evidence of improved effectiveness of a surgical treatment, provided analysis takes careful account of potential sources of bias, especially those related to possible changes in case selection over time. These kinds of data should stimulate a joint effort between clinicians, quality assurance experts and epidemiologists to confirm this attribution, and to locate the causative factors.

Rising incidence of prostate cancer in Scotland: increased risk or increased detection?

OBJECTIVE

To assess the extent to which the increasing incidence of prostate cancer in Scotland can be explained by increased detection, particularly through transurethral resection of the prostate (TURP) and use of the prostate-specific antigen (PSA) test. Subjects and methods This population-based study was confined to men resident in Scotland and aged > or =50 years. Temporal trends were examined in age-specific and age-standardized incidence, mortality and TURP rates, and PSA testing rates during 1981-1996. Also analysed were the geographical variations in age-standardized incidence and mortality rates during two distinct periods, 1984-1986 (before PSA testing) and 1994-1996 (after PSA testing). Finally, incidence rates and relative survival at 5 years were calculated by age group and 5-year periods of diagnosis during 1968-1992.

RESULTS

The incidence of prostate cancer in men aged > or = 50 years increased from an age-standardized rate of 142.0 per 100 000 in 1981 to 240.9 in 1996, with the steepest increase occurring between 1992 and 1993. The mortality rate increased similarly until 1993, but was relatively stable thereafter, falling slightly in 1996. In 1981-1988, incidence rates were closely correlated with TURP rates (r = 0.98, P<0.001). In 1989-1996, incidence was closely correlated with PSA testing rates (r = 0.98, P<0.001). By 1994-1996, incidence rates varied substantially between Scottish mainland health boards (range 167.7-303.0 per 100 000), with much less variation in mortality rates (90.7-110.0). Relative survival has increased recently in all age groups although, in the era before PSA testing, survival was reasonably stable despite increasing incidence.

CONCLUSION

Although there may have been a true increase in risk, much of the observed increase in the incidence of prostate cancer in Scotland between 1981 and 1996 has been caused by increased detection, leading recently to considerable variation among different areas of the country. The extent to which this represents the early diagnosis of tumours which would eventually cause symptoms or be life-threatening, or detection of latent disease which would never have become symptomatic, is not clear. There is no evidence so far that the increased incidence is associated with any substantial reduction in mortality.

Role of transurethral resection of the prostate in population-based prostate cancer incidence rates

The extensive pool of asymptomatic prostate disease in the population, which increases substantially with age, suggests that the frequent use of transurethral resection of the prostate (TURP) in recent decades has had a large effect on prostate cancer incidence. The authors identified the effect of TURP-detected prostate cancer on the observed incidence rates between 1973 and 1993 for men aged 65 years and older. They linked population-based cancer registry data from the Surveillance, Epidemiology, and End Results Program to Medicare records between 1986 and 1993 to determine whether a TURP occurred sufficiently close to the time of a prostate cancer diagnosis for them to assume that it led to the diagnosis. TURP-detected cases prior to 1986 were calculated using an indirect method that involved multiplying the TURP procedure rate in the general population (from the National Hospital Discharge Survey) by estimates of the proportion of TURPs resulting in a prostate cancer diagnosis (from Medicare data and the literature). TURP explained much of the observed increase in overall prostate cancer incidence between 1973 and 1986 and possibly all of it in men aged 70 years and older. However, its influence on the trend and overall magnitude of the rates diminished between 1987 and 1993. The changing role of TURP in detecting prostate cancer is attributed to changes in medical technology and screening practices. The declining influence of TURP on prostate cancer incidence is likely to have continued beyond the study period due to the recent introduction and increasing use of medications for treating obstructive uropathy.