Management Of Benign Prostatic Obstruction Research Articles

Anatomic endoscopic enucleation of the prostate using a novel hybrid thulium:yttrium-aluminium-garnet laser generator: surgical technique and clinical outcomes.

We aim to report here the first clinical series of patients treated with AEEP using a novel hybrid thulium:yttrium-aluminium-garnet (Tm:YAG) laser generator (RevoLix HTL, LISA Laser Products, Germany), i.e. capable of emitting both in pulsated and continuous-wave. We included 39 consecutive patients who underwent hybrid Tm:YAG AEEP (hybrid ThuLEP) at a single center starting from July 2022 and were followed-up until 3months after surgery. Complete baseline, intraoperative, and follow-up demographic and clinical data were collected. The International Prostatic Symptoms Score (IPSS) questionnaire was used to quantify urinary symptoms at baseline and during follow-up. Post-operative follow-up further included a PSA test, uroflowmetry with post-void residual volume (PVR) measurement. Clavien-Dindo classification was used to classify complications. Median (IQR) age at surgery and prostate volume were 68 (IQR 63-74) years and 85 (60-105) cc. Both en-bloc or two-lobes technique enucleation were performed according to the intraoperative and endoscopic anatomy, with a median operative time of 85 (63-108) minutes. Bladder catheter was removed in all cases on postoperative day two. Intraoperative bleeding requiring conversion to bipolar enucleation was observed in two patients. After discharge, one patient developed arm phlebitis which was treated with anticoagulants leading to new onset haematuria requiring short term catheterisation (Clavien-Dindo grade II) and two more patients had a single episode of acute urinary retention (Clavien-Dindo grade I). Median pre- vs postoperative Qmax and IPSS were 8.0 (7.0-9.4) vs. 25.0 (22.5-32.5) ml/s and 22 (20-28) vs. 1 (0-2), whereas PVR decreased from 70 (50-115) to 0 (0-26) ml. Hybrid ThuLEP is a feasible and effective surgical procedure for the management of benign prostatic obstruction.

Treatment Algorithm for Management of Benign Prostatic Obstruction: An Overview of Current Techniques.

The management of benign prostatic obstruction (BPO) should involve a treatment algorithm that takes into account prostate size, and patient's symptoms and preference with the aim of helping with urinary symptoms and enhance quality of life. The diagnostic assessment for men with lower urinary tract symptoms (LUTS) should be comprehensive to help choose the best management strategy. Strategies from lifestyle modifications to medical treatment with alpha blockers and/or 5-alpha-reductase inhibitors to surgical procedures can all be used in the management algorithm. Surgical management ranges from transurethral resection of prostate (TURP) to minimally invasive surgical therapies (MIST) including laser therapies such as Holmium laser enucleation (HoLEP) and photoselective vaporisation (PVP), aquablation, Rezūm system, prostate artery embolisation (PAE), prostatic urethral lift (PUL), temporary implantable nitinol device (iTind) and Optilume BPH catheter system. BPO is a common urological condition that has a significant impact on quality of life and economic burden globally and is likely to become increasingly prevalent with an ageing population. Selecting the most appropriate treatment modality will depend on the individual patient preferences, availability of resources, cost, anatomical factors and the goals of treatment.

Contemporary surgical management of benign prostatic obstruction in Germany : Apopulation-wide study based on German hospital quality report data from 2006 to 2019

HintergrundDie operative Therapie des benignen Prostatatsyndroms (BPS) hat in den letzten Jahren an Diversität gewonnen.Ziel der ArbeitZiel dieser Studie ist die Darstellung aktueller Therapietrends sowie der Versorgungssituation in Deutschland.Material und MethodenAuf Basis der Qualitätsberichte der Krankenhäuser wurden mithilfe der Onlineplattform reimbursement.INFO Diagnose- wie Eingriffszahlen erhoben. Für die benigne Prostatahyperplasie (BPH) wurden die ICD-Codes N40 und D29.1 ausgewertet. Die Prozeduren wurden mittels der OPS-Codes 5‑600.0, 5‑601, 5‑603, 5‑609.4 und 5‑609.8 inklusive Subcodierungen extrahiert. Es erfolgten eine deskriptive Darstellung, Trend- und Korrelationsanalysen.ErgebnisseInsgesamt wurden 2019 83.687 BPS-Operationen in 473 urologischen Fachabteilungen durchgeführt. Am häufigsten wurde die transurethrale Prostataresektion (TURP; 71,7 %) angewendet. Die Holmiumlaserenukleation (HoLEP; 9,5 %) bzw. die chirurgische Adenomektomie (5,6 %) waren das zweit- bzw. dritthäufigste Verfahren. Seltener wurden Thuliumlaserenukleation (ThuLEP; 3,1 %), Laservaporisation (2,9 %) und elektrische Vaporisation (2,8 %) durchgeführt. Alle weiteren Verfahren machten jeweils < 1 % aus. HoLEP, ThuLEP und elektrische Vaporisation erlebten seit 2006 eine stetige Zunahme der Eingriffszahlen (HoLEP: +42,42 %/Jahr; p < 0,001, ThuLEP: +20,6 %/Jahr, p = 0,99; elektrische Vaporisation: +43,42 %/Jahr, p < 0,001), während die chirurgische Adenomektomie abnahm (−1,66 %/Jahr, p < 0,001). Die Krankenhausverweildauer lag 2019 bei mittleren 5,1 ± 0,1 Tagen.SchlussfolgerungDie TURP bleibt das am häufigsten durchgeführte Operationsverfahren. Während, insbesondere in Zentren, die Lasertherapien zunehmen, geht die chirurgische Adenomektomie zurück.Zusatzmaterial onlineDie Online Version dieses Artikels (10.1007/s00120-022-01777-9) enthält weitere Tabellen und Abbildungen zur Entwicklung der Eingriffszahlen für die chirurgische Adenomresektion, Urologische Fachabteilungen mit den höchsten Eingriffszahlen, Entwicklung der Eingriffe TURP, chirurgische Adenomektomie, HoLEP und ThuLEP in den 5 Häusern mit den meisten BPS-Eingriffen und zur Deutschlandweiten Verteilung der BPH-Diagnosen.

Contemporary surgical management of benign prostatic obstruction: does there remain a place in the toolbox for TURP?

Level of evidence: 5

Traitement chirurgical et interventionnel de l’obstruction sous-vésicale liée à une hyperplasie bénigne de prostate : revue systématique de la littérature et recommandations de bonne pratique clinique du Comité des Troubles Mictionnels de l’Homme

The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO). All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions. Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm3, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm3. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm3. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm3 without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols. Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.

Lasers in Transurethral Enucleation of the Prostate-Do We Really Need Them.

The acronym EEP, coding for transurethral Endoscopic Enucleation of the Prostate, was introduced in 2016 by the European Association of Urology (EAU) guidelines panel on management of non-neurogenic male lower urinary tract symptoms (LUTS) and benign prostatic obstruction (BPO). Since then, a laser-based treatment, Holmium Laser Enucleation of the Prostate (HoLEP), and the current-based treatment of bipolar enucleation of the prostate (BipoLEP) are equally appreciated as valuable options for the management of benign prostatic obstruction (BPO). This was mainly inspired by the results of two meta-analyses on randomized controlled trials, comparing open prostatectomy with either Holmium Laser Enucleation of the Prostate (HoLEP) or bipolar enucleation of the prostate (BipoLEP). Prior to that, HoLEP was embraced as the only valid option for transurethral enucleation, although evidence for equivalence existed as early as 2006, but was not recognized due to a plethora of acronyms for bipolar energy-based treatments and practiced HoLEP-centrism. On the other hand, the academic discourse focused on different (other) laser approaches that came up, led by Thulium:Yttrium-Aluminum-Garnet (Tm:YAG) Vapoenucleation (ThuVEP) in 2009 and, finally, transurethral anatomical enucleation with Tm:YAG support (thulium laser enucleation of the prostate, ThuLEP) in 2010. Initially, the discourse on lasers focused on the different properties of lasers rather than technique or surgical anatomy, respectively. In and after 2016, the discussion ultimately moved towards surgical technique and accepting anatomical preparation as the common of all EEP techniques (AEEP). Since then, the unspoken question has been raised, whether lasers are still necessary to perform EEP in light of existing evidence, given the total cost of ownership (TCO) for these generators. This article weighs the current evidence and comes to the conclusion that no evidence of superiority of one modality over another exists with regard to any endpoint. Therefore, in the sense of critical importance, AEEP can be safely and effectively performed without laser technologies and without compromise.

A review of surgery and new technology procedures for the management of benign prostatic obstruction

Level of evidence: Not applicable for this review article.

Surgical management of benign prostatic obstruction: 20-year population-level trends.

Benign prostatic obstruction (BPO) due to histological benign prostatic hyperplasia is highly prevalent among older men. Despite widespread use of medical therapy, surgical treatment remains a mainstay in the management of BPO. We sought to characterize trends in the surgical management of BPO in Ontario, Canada. We performed an interrupted time-series analysis using segmented regression among men aged 18 years and older undergoing surgical treatment for BPO between January 1, 1994 and December 31, 2014 in Ontario, Canada. The passage of time was considered the primary exposure. The primary outcome was the proportion of all BPO surgeries performed using each of the following modalities: transurethral resection of the prostate (TURP), endoscopic laser prostatectomy, open/laparoscopic prostatectomy, and others. We identified 136 459 men who underwent BPO surgery between 1994 and 2014. The annual age-adjusted rate of BPO surgery declined significantly over time (24 to 10 per 10 000 population in 1994 and 2014, respectively). From 1994-2001, there were no significant changes in the distribution of BPO surgical modalities, with TURP the most common throughout (97.2% and 97% in 1994 and 2001, respectively). From 2002-2014, there was a significant decline in the use of TURP (92.1% to 76.9%; p=0.027) with a corresponding increase in the use of endoscopic laser prostatectomy (3.5% to 21.9%; p=0.0008). This study demonstrates a shift in the management of BPO, with increasing use of endoscopic laser prostatectomy, beginning in 2002. However, TURP remains the most common treatment modality.

The impact of surgical duration on complications after transurethral resection of the prostate: an analysis of NSQIP data.

Transurethral resection of the prostate is the most commonly performed procedure for the management of benign prostatic obstruction. However, little is known about the effect surgical duration has on complications. We assess the relationship between operative time and TURP complications using a modern national surgical registry. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2006 to 2016 for patients undergoing TURP. Patients were separated into five groups based on operative time: 0-30 min, 30.1-60 min, 60.1-90 min, 90.1-120 min, and greater than 120 min. Standard statistical analysis, including multivariate regression, was performed to determine factors associated with complications. 31,813 patients who underwent TURP were included. The overall complication rate was 9.0% and increased significantly with longer surgical duration (p < 0.001). Longer operative time was associated with a greater risk of postoperative sepsis or shock, transfusion, reoperation, and deep vein thrombus or pulmonary embolism. Longer surgical duration was associated with increased odds of any complication and, specifically, blood transfusion after controlling for age, race, comorbidities, American Society of Anesthesia (ASA) class, type of anesthesia administered, and trainee involvement. The adjusted risk of each of the above complications remained significantly increased for surgeries lasting longer than 120 min. As surgical duration increases, there is a significant increase in the rate of complications after TURP. These data demonstrate that this procedure is safest when performed in under 90 min.

The role of urodynamics in the surgical management of benign prostatic obstruction

Benign prostatic obstruction (BPO) is a common cause of lower urinary tract symptoms (LUTS) in elderly men. However, such symptoms are often caused by primary detrusor overactivity or underactivity. Surgical management where BPO is absent or merely incidental has a lower chance of success, and exposes the patient to the potential complications of surgery. This review discusses the diagnostic challenges facing this common presentation. Most evidence comes from small, historical prospective cohort studies. A Cochrane review found only two studies that met the prespecified inclusion criteria. It concluded that urodynamics changed decision-making regarding surgery for LUTS but it was not possible to determine whether this impacted upon outcome. A systematic review of several noninvasive alternatives to urodynamics could not recommend any of them over urodynamic pressure-flow study assessment. Further research is currently in progress, the 'UPSTREAM' study, which is a randomized, multicentre trial. Men are randomized to undergo investigation with clinical evaluation and uroflowmetry, or to additionally receive urodynamics. The primary aim is to determine the impact of urodynamics on the assessment pathway. Assessment of BPO involves determining whether it has a contributory role in individual patients. This is a crucial factor in outcome, as surgery can give poor results if the symptoms are principally caused by detrusor dysfunction (overactivity or underactivity). Urodynamics can help determine this if undertaken to a suitable standard. Further research will identify the precise role of this test modality.

GreenLight Laser for benign prostatic hyperplasia

GreenLight photoselective vaporization (GL-PV) is now established in the treatment of benign prostatic enlargement. The present review outlines the available technical armamentarium and summarizes the current best evidence on functional and safety outcomes. Moreover, future technical developments and refinements are presented. GL-PV has evolved to be the most commonly performed procedure, second to conventional transurethral resection of the prostate (TURP) for surgical management of benign prostatic obstruction (BPO). On the basis of the data published in the randomized controlled Goliath study, GL-PV with 180-W technology is noninferior in terms of functional outcomes compared with TURP considering short and intermediate follow-up with a complication-free rate of around 80% after 24 months.The ongoing push towards high-power lasers can be explained by their more effective tissue ablative effect, leading to shorter operating times. Comparative analysis between high-power and low-power laser systems demonstrated similar retreatment rates and most institutions are, therefore, now performing 180-W GL-PV.Performed as an outpatient procedure, GL-PV is cost-effective with a low hospital re-admission rate. Plasma kinetic vaporization of the prostate (PKVP) has recently emerged as a potential contender in the field; also GreenLight enucleation of the prostate (GreenLEP) might be even more effective than GL-PV. GL-PV appears to be a well tolerated surgical alternative for patients suffering from BPO. Long-term follow-up data from 120-W and 180-W laser systems are still pending. Potential competitors have recently been brought to the market and further trials and long-term data will show, whether GL-PV will stand the test of time. Regardless of technical specifications, surgeon's experience remains essential to achieve good functional and safety outcomes.

Efficacy of bipolar ‘button’ plasma vaporisation of the prostate compared to green laser vaporisation for benign prostatic obstruction

Objective: Our objectives were to evaluate the efficiency of transurethral bipolar plasma vaporisation of the prostate (BPVP) using the button electrode and compare it to green laser vaporisation of the prostate (GLVP). Patients and methods: During the period March 2012 to January 2017, 155 patients with benign prostatic obstruction (BPO) were enrolled in our study. Overall, 80 patients underwent BPVP and 75 GLVP. All International Prostate Symptom Scores (IPSS), quality of life (QOL), uroflow Qmax, Qave and post-void residual (PVR) urine samples were evaluated 24 hours preoperatively and at three months postoperatively. Operative time, hospital stay, catheterisation time, and complications were reported. Mean serum haemoglobin, haematocrit and serum sodium changes were reported preoperatively and within 24 hours postoperatively in both groups. Statistical analysis was performed using the SPSS program version 20 for Windows. Results: Mean age at surgery was 62.8 ± 4 (53–82) years and 63 ± 6.6 (54–86) years for the BPVP and GLVP groups respectively. Mean prostatic volume was 45 ± 10 (36–90) and 43 ± 9 (32–85) in each group, respectively. Patients from both series had similar preoperative characteristics. The mean operative duration was 58 ± 21 (range: 20–70) minutes and 57 ± 13 (range: 24–75) minutes, hospital stay was 12.2 ± 6.4 (12–60) hours vs 7 ± 3.3 (6–48) hours ( p = 0.01), and catheterisation period was 48 ± 1.28 (24–72) hours vs 6 ± 6.2 (6–7) hours ( p = 0.001). Conclusions: Both BPVP and GLVP offer good options for management of BPO with less bleeding, one-day surgery, less catheterisation time with significant improvement of IPSS, QOL score and uroflow postoperatively. However, more studies comparing the cost of both techniques are needed for a solid conclusion. Level of evidence: Not applicable for this multicentre audit.

A Prospective Randomized Study Comparing Disposable with Reusable Blades for a Morcellator Device.

Transurethral enucleation of the prostate for the management of benign prostatic obstruction (BPO) involves two steps: the enucleation and morcellation procedure. The aim of our study was to assess the efficacy of a morcellator device using disposable and reusable blades with different settings of morcellation speed. A prospective randomized study was initiated for patients with symptomatic BPO undergoing Thulium laser enucleation of the prostate. Mechanical tissue morcellation was performed using the Piranha™ morcellator (R. Wolf, Knittlingen, Germany) with disposable or reusable blades at 850 (n = 24) or 1500 revolutions per minute (rpm) (n = 24). Patient characteristics, intraoperative complications, and the morcellation rate (g/min) were recorded. Data are expressed as median and interquartile range (IQR). Forty-eight patients were randomized using disposable (n = 24) or reusable blades (n = 24). For reusable blades, the morcellation rate did not increase when changing the morcellation speed from 850 to 1500 rpm (5 vs 4.53 g/min, p = 0.843). The morcellation rate increased significantly when changing the morcellation speed from 850 to 1500 rpm using single-use blades (4.77 vs 10 g/min, p ≤ 0.014). The morcellation rate was not different at 850 rpm between reusable and single-use blades (5 vs 4.77 g/min, p = 0.671). Conversely, the morcellation rate was significantly different at 1500 rpm between reusable and single-use blades (4.53 vs 10 g/min, p ≤ 0.017). The total morcellation rate (at 850 and 1500 rpm) was significantly increased using single-use blades compared to reusable blades (7.67 vs 4.8 g/min, p ≤ 0.026). Interestingly, enucleated weight (g) and the morcellation rate (g/min) correlated inversely using single-use blades at 1500 rpm (r = -0.742, p ≤ 0.004). Only one superficial bladder injury occurred at 1500 rpm, which needed no further interventions. The Piranha morcellator facilitates efficient tissue removal with single-use and reusable blades. Disposable morcellator blades increase tissue removal significantly at 1500 rpm.

579 Management of benign prostatic obstruction using bipolar plasma kinetic energy in coagulopathic patients: Initial series

579 Management of benign prostatic obstruction using bipolar plasma kinetic energy in coagulopathic patients: Initial series

Solifenacin/tamsulosin fixed-dose combination therapy to treat lower urinary tract symptoms in patients with benign prostatic hyperplasia.

Treatment of male lower urinary tract symptoms (LUTS) has traditionally focused on the management of benign prostatic obstruction, but the contribution of bladder dysfunction has been recently recognized. Therefore, it is well understood that LUTS have multifactorial etiology and often occur in clusters and not in isolation. Voiding LUTS are highly prevalent in men, but storage LUTS have been proved to be more bothersome. α1-Blockers are the most widely used pharmacologic agents for the treatment of symptoms relating to benign prostatic enlargement due to benign prostatic hyperplasia (BPH), while antimuscarinics are the drug class of choice for overactive bladder symptoms. A combination of the two drug classes would be a reasonable approach to treat men with both storage and voiding symptoms, and several short-term studies have proved the efficacy and safety of different combinations with an α1-blocker and an antimuscarinic. Following previous studies on the separate administration of solifenacin and tamsulosin, a fixed-dose combination tablet of tamsulosin oral controlled absorption system (OCAS) 0.4 mg and solifenacin succinate 6 mg has been recently introduced, and the current review evaluates the available data on the use of this fixed-dose combination in the treatment of LUTS in men with BPH.

Characterization of men with lower urinary tract dysfunction after surgical management of benign prostatic obstruction

Objective: To characterize the symptoms and urodynamic findings of men with lower urinary tract dysfunction after a transurethral resection of the prostate (TURP).Materials and Methods: A total of 123 consecutive men with lower urinary tract dysfunction after surgical treatment for lower urinary tract symptoms (LUTS) were analyzed. Men with prostate cancer, stricture, multiple TURPs, radical prostatectomy or prostate cancer treatment were excluded. Parameters assessed by urodynamics included bladder capacity, detrusor contractibility, pressure flow study, and post void residual. Analysis of the variance was used to compare outcomes of urodynamic parameters between the primary diagnoses.Results: Mean age at TURP was 68 years (range 39 to 88). Symptoms included frequency (68%), nocturia (53%), urgency (44%), and retention requiring catheterization (17%). A total of 72 men (59%) were diagnosed with bladder outlet obstruction (BOO), 30 (24%) with impaired detrusor contractility (DU), and 21 (17%) with detrusor over activity (DO). Among these groups, there was no difference in duration of recurrent symptoms, AUA symptom score, Quality of Life score, or prostate size. Maximum flow was significantly less and post-void residual significantly greater in both BOO and DU groups. Bladder capacity was significantly higher in DU.Conclusions: In the modern era, bladder outlet obstruction was the most common cause of recurrent lower urinary tract dysfunction after surgical management of BPO.

226 Surgical management of benign prostatic obstruction: Current practice patterns and attitudes in Europe

226 Surgical management of benign prostatic obstruction: Current practice patterns and attitudes in Europe

Transurethral Resection of the Prostate Syndrome: Almost Gone but Not Forgotten

Transurethral resection of the prostate (TURP) syndrome is a rare but potentially fatal syndrome with multifactorial pathophysiology that is now better understood. Unfortunately, despite this improved understanding, it is not yet obsolete and still remains a risk. Many reviews of TURP syndrome have been presented from an anesthetic perspective; this review reflects more the urologic perspective with emphasis on the importance of multidisciplinary management of this complex syndrome. We present a review of TURP syndrome that specifically assesses advances in the understanding of risk factors, pathophysiology, and techniques used to prevent this syndrome. The databases Medline, Embase, Cochrane Controlled Trial Register, and Database of Abstracts of Reviews of Effects were systematically reviewed from inception to April 2009 for the keywords TUR (P), TUR (P) syndrome, and transurethral resection of prostate. There was no language restriction for our search. Randomized controlled trials, review articles and case series were included in our search. Our review showed a declining trend in the incidence of TURP syndrome despite TURP remaining the gold standard for the management of benign prostatic obstruction. Technologic advances using an array of laser techniques, the use of bipolar circuitry, together with advances in training techniques have helped minimize the risk of development of this syndrome. This review demonstrates the complexity of TURP syndrome. Even with a greater understanding of the pathophysiology, it highlights the unpredictability of the syndrome from presenting symptoms, preventative measures, and management. TURP syndrome cannot be protocol driven and the need for vigilance, a high index of suspicion, intensive monitoring, and a multidisciplinary approach is vital.

UP-3.058: Transurethral Microwave Thermotherapy (TUMT) in the Management of Benign Prostatic Obstruction: Still a Functioning Method

UP-3.058: Transurethral Microwave Thermotherapy (TUMT) in the Management of Benign Prostatic Obstruction: Still a Functioning Method

UP-03.07: The management of benign prostatic obstruction (BPO) in the third world

UP-03.07: The management of benign prostatic obstruction (BPO) in the third world