Prostatic Obstruction Research Articles

Clinical Efficacy of Silodosin in Patients with Severe Lower Urinary Tract Symptoms Related to Benign Prostatic Obstruction: A Pooled Analysis of Phase 3 and 4 Trials

We performed a post hoc analysis of data from phase 3 and 4 studies to evaluate the efficacy of silodosin 8mg in patients with severe lower urinary tract symptoms (LUTS) related to benign prostatic obstruction (BPO). The presence of two or more of the following criteria was adopted to define severity: total International Prostate Symptom Score (IPSS) 20–35, quality of life (QoL) score 5–6, maximum urinary flow <5ml/s or postvoid residual volume ≥100ml, and prostate volume ≥50ml. Mean improvements in total (8.1 vs 4.7), storage (3.1 vs 2.0), voiding (5.0 vs 2.7), and QoL (1.3 vs 0.7) IPSS scores were significantly greater for patients receiving silodosin compared to placebo (all p< 0.0001). Mean improvements in total, storage, voiding, and QoL IPSS scores were similar for the severe and not severe LUTS cohorts. In conclusion, silodosin significantly improves symptoms and QoL in all LUTS/BPO patients, including those with severe symptoms. Patient summarySilodosin improves symptoms and quality of life for patients with severe lower urinary tract symptoms related to benign prostatic obstruction.

En-bloc endoscopic enucleation of the prostate: a systematic review of the literature.

Transurethral resection of the prostate (TURP) remains the gold standard for treatment of benign prostatic hyperplasia (BPH). Yet, the introduction of lasers for the treatment of LUTS due to BPO has dramatically changed the surgical landscape of benign prostatic obstruction (BPO) treatment. Recently, "en-bloc" techniques have shown to prove advantageous in terms of better visualization, more prompt identification of the surgical capsule and the correct plane to dissect. Herein we provide a comprehensive overview of available series of en-bloc enucleation of the prostate, focusing on surgical techniques, perioperative and functional outcomes. A systematic review of the literature was performed according to PRISMA recommendations and was conducted on surgical techniques and perioperative outcomes of minimally invasive en-bloc surgery for prostate adenoma detachment. Overall, 16 studies with 2750 patients between 2003 and 2019 were included. Specific technical nuances have been described to maximize perioperative outcomes of en-bloc prostatic enucleation, including early apical release, horse-shape incisions, inverted U-shape tractions and low power. Overall, regardless of the energy employed, en-bloc prostatic enucleation achieved favorable outcomes including low risk of major complications and quality of life improvement. However, a great heterogeneity of study design, patients' inclusion criteria, prostate volume and en-bloc surgical strategy was found. En-bloc endoscopic enucleation of the prostate has been shown to be technically feasible and safe, with potential technical advantages over the classic three-lobe technique. Larger comparative studies are needed to evaluate the ultimate impact of the en-bloc approach on postoperative outcomes, in light of the surgeon's learning curve.

Association between Nocturnal Frequency and Erectile Function in Eugonadal Men with Benign Prostatic Obstruction: A Cross Sectional Study.

PurposeWe aimed to evaluate the association between nocturnal frequency and erectile dysfunction in patients with benign prostatic obstruction.Materials and MethodsTo evaluate the association, we simultaneous evaluated urodynamic study, prostate ultrasound, nocturnal tumescence test (nocturnal penile tumescence) for sleep-related erection (SRE) and two questionnaires, international prostate symptom score (IPSS) and 5-item version of the international index of erectile function (IIEF-5). Patients with hypogonadism or nocturnal polyuria were excluded.ResultsForty-six patients were registered over 4 years. The mean age, prostate size, IPSS score, and IIEF-5 score were 67.65±5.51 years, 65.10±22.12 mL, 24.67±7.89, and 9.50±7.01, respectively. Among the IPSS subscores, nocturia was most significantly related to the total IIEF-5 score (p<0.001). More severe nocturia was associated with less frequent SRE (p=0.003) and shorter total duration of SRE (p=0.002), which in turn elucidated that nocturia was significantly related to the total amount of rigidity signals (rigidity activity unit, RAU) or tumescence signals (tumescence activity unit, TAU). Among objective urodynamic parameters, bladder compliance also correlated to RAU and TAU. Individual subjective erectile function (IIEF-5) was significantly related to both RAU and TAU.ConclusionsSleep fragmentation due to benign prostate obstruction related nocturnal frequency caused by reduced bladder compliance could decrease the frequency and duration of SRE, which decreases the total amount of SRE and reflects the patient's relevant erectile function.

Transperineal Laser Ablation Treatment for Lower Urinary Tract Symptoms Due to Benign Prostatic Obstruction: Protocol for a Prospective In Vivo Pilot Study.

BackgroundStandard surgical treatments for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) use a transurethral approach. Drawbacks are the need for general or spinal anesthesia and complications such as hematuria, strictures, and cloth retention. Therefore, a minimal invasive technique under local anesthesia is desired to improve patient safety. Recently, SoracteLite transperineal laser ablation (TPLA) has been introduced as a novel minimal invasive treatment for BPO. The system used is unique because 4 laser sources are independently available. This 1064-nm diode laser induces coagulative necrosis. Moreover, TPLA is unique because it has a transperineal approach and can be performed under local anesthesia in an outpatient setting.ObjectiveThe primary objective of this study is to determine the safety and feasibility of TPLA treatment for men, who are fit for standard surgery, with LUTS due to BPO. The secondary objectives are to determine functional outcomes by flowmetry and patient-reported outcome measures (PROMs), side effects, and tissue changes observed on imaging.MethodsThis study is a prospective, single center, interventional pilot study IDEAL framework stage 2a and will include 20 patients. Eligible patients are men ≥40 years of age, with a prostate volume of 30 to 120 cc, have urodynamically proven bladder outlet obstruction, and have a peak urinary flow of 5 to 15 mL per second. All patients will undergo TPLA of their prostate under local anesthesia by using the EchoLaser system. Depending on the prostate volume, 2 to 4 laser fibers will be placed bilaterally into the prostate. Patient follow-up consists of uroflowmetry, PROMs, and imaging by using contrast-enhanced ultrasound. Total follow-up is 12 months following treatment.ResultsPresently, recruitment of patients is ongoing. Publication of first results is expected by early 2020.ConclusionsTPLA offers the potential to be a novel minimal invasive technique for treatment of LUTS due to BPO in men fit for standard desobstruction. This study will evaluate the safety and feasibility of TPLA and report on functional outcomes and tissue changes observed on imaging following TPLA treatment.International Registered Report Identifier (IRRID)DERR1-10.2196/15687

"In-bore" MRI prostate biopsy is a safe preoperative clinical tool to exclude significant prostate cancer in symptomatic patients with benign prostatic obstruction before transurethral laser enucleation.

Purpose of our study was to investigate the role of a negative in-bore MRI-guided biopsy (MRI-GB) in comparison to a negative multiparametric prostate MRI (mpMRI) and a contextual negative transrectal ultrasound guided biopsy of the prostate with regard to incidental prostate cancer findings in the surgical specimen of men who underwent to Holmium Laser enucleation of prostate (HoLEP) with a preoperative suspicion of prostate cancer. Data of 117 of symptomatic patients for bladder outflow obstruction who subsequently underwent to HoLEP was retrospectively analyzed form a multicentric database. All patients had a raised serum PSA and/or an abnormal digital rectal examination (DRE) with a pre-interventional mpMRI. Prostate cancer was excluded either with an en-bore MRI-GB (group "IN-BORE MRI-GB" n = 57) in case of a suspect area at the mpMRI or with a standard biopsy (group "mpMRI + TRUS-GB" n = 60) in case of a negative mpMRI. Preoperative characteristic surgical and histological outcomes were analyzed. Univariate and multivariate logistic regression model was performed to investigate independent predictors of incidental Prostate Cancer (iPCa). Both groups presented moderate to severe lower tract urinary symptoms: median IPSS was 19 (IQR: 17.0-22.0) in the IN-BORE MRI-GB group and 20 (IQR: 17.5-22.0) in the mpMRI + TRUS-GB (p = 0.71). No statistically significant difference was found between the two groups besides total prostate volume with 68 cc (IQR: 58.0-97.0) in the IN-BORE MRI-GB group and 84 cc (IQR: 70.0-115.0) in the mpMRI + TRU-GB group (p = 0.01) No differences were registered in surgical time, removed tissue, catheterization time, hospital stay and complications rate. No different rates (p = 0.50) of iPCa were found in the IN-BORE MRI-GB group (14%) in comparison with mpMRI + TRUS-GB group (10 %); pT stage and ISUP Grade Group in iPCa stratification were comparable between the two groups. In multivariate analysis a statistically significant correlation with age as an independent predictive factor of iPCa was found (OR 1.14; 95% CI: 1.02-1.27; p = 0.02) while no correlations were revealed with PSA (OR 1.12; 95% CI: 0.99-1.28; p = 0.08) and a negative in-bore MRI-GB (OR 1.72; 95% CI: 0.51-5.77; p = 0.37). Including a mpMRI and an eventual in-bore MRIGB represents a novel clinical approach before surgery in patients with symptomatic obstruction with a concomitant suspicion of PCa, leading to low rate of iPCa and avoiding unnecessary standard TRUS-GB biopsies.

External validation of Cormio nomogram for predicting all prostate cancers and clinically significant prostate cancers.

Recently, the Cormio et al. nomogram has been developed to predict prostate cancer (PCa) and clinically significant PCa using benign prostatic obstruction parameters. The aim of the present study was to externally validate the nomogram in a multicentric cohort. Between 2013 and 2019, patients scheduled for ultrasound-guided prostate biopsy were prospectively enrolled at 11 Italian institutions. Demographic, clinical and histological data were collected and analysed. Discrimination and calibration of Cormio nomogram were assessed with the receiver operator characteristics (ROC) curve and calibration plots. The clinical net benefit of the nomogram was assessed with decision curve analysis. Clinically significant PCa was defined as ISUP grade group > 1. After accounting for inclusion criteria, 1377 patients were analysed. 816/1377 (59%) had cancer at final pathology (574/816, 70%, clinically significant PCa). Multivariable analysis showed age, prostate volume, DRE and post-voided residual volume as independent predictors of any PCa. Discrimination of the nomogram for cancer was 0.70 on ROC analysis. Calibration of the nomogram was excellent (p = 0.94) and the nomogram presented a net benefit in the 40-80% range of probabilities. Multivariable analysis for predictors of clinically significant PCa found age, PSA, prostate volume and DRE as independent variables. Discrimination of the nomogram was 0.73. Calibration was poor (p = 0.001) and the nomogram presented a net benefit in the 25-75% range of probabilities. We confirmed that the Cormio nomogram can be used to predict the risk of PCa in patients at increased risk. Implementation of the nomogram in clinical practice will better define its role in the patient's counselling before prostate biopsy.

The Initial Clinical Experience of a New Generation Bipolar Electrosurgical and Morcellator Unit for Bipolar Transurethral Enucleation of the Prostate

Background and Objective To assess the feasibility and safety of performing bipolar transurethral enucleation of the prostate (BIPO-LEP) with a new generation of bipolar electrosurgical and morcellator system. Material and Methods Forty-five consecutive patients scheduled for endoscopic surgery for benign prostatic obstruction were pro-spectively recruited. BIPOLEP was performed with the use of the third generation Karl Storz AUTOCON III 400 and morcellator unit. All patients had a trial without a catheter on Day-1 after surgery. Demographical, preoperative, intraoperative and follow-up data up to 3 months post-surgery were collected and analyzed. Results Between May 2018 and April 2019, 45 consecutive patients underwent BIPOLEP in our institution were prospectively recruited for this study. The mean age was 76 years old. Thirty-four patients (75.6%) were in refractory retention or obstructive uropathy. The mean enucleation efficiency was 1.76 grams per minute of enucleation time (SD = 0.7 gram per minute). The mean bladder irrigation and catheterization times were 5.3 hours and 20.7 hours respectively. Only one patient failed voiding trial on Day-1 after surgery. The postoperative Day-1 discharge rate was 73.3% (n = 33). The median length of hospital stay was 1 day. No patient required clot evacuation or blood transfusion. Seven patients (15.6%) were readmitted within thirty days postoperatively for complications, due to hematuria (8.9%, n = 4) and febrile urinary tract infection (6.7%, n = 3). Nevertheless, none was readmitted for acute urinary retention. Conclusion The use of a new generation of bipolar electrosurgical and morcellator unit for BIPOLEP was safe and the majority could be discharged without catheter within one day after surgery.

Surgical ablation of the prostate in the elderly: A comparison of efficacy and outcomes of open and endoscopic methods

Background: Prostatic obstruction is a common problem of elderly men. This will often times require surgical removal of the prostate. Geriatric surgeries are froth with risks and complications, partly due to depleted functional reserves and comorbities. This study is designed to compare the efficacy and outcomes of three methods of prostatic ablation amongst elderly men. Patients and Methods: This study was retrospective. The study population consisted of men who had surgery for relief of prostatic obstruction. Three surgeries were considered viz: Open prostatectomy/channelization, TURP, and transurethral diode laser vaporization of the prostate (DiLVP). Inclusion criteria were men aged ≥65 years, who had any of the above procedures. Exclusion criteria were synchronous urethral stricture, and prior history of prostatic, bladder or urethral surgery. Patients' demographic, pre-operative, intra-operative and post-operative details were extracted and filled into a proforma. The primary and secondary outcome measures were documented. Data analysis was done using SPSS version 20. Statistical significance was set at a P value of Results: Records of 70 patients were reviewed. Thirty-seven of the patients (52.9%) had open prostatectomy/channelization, 21 (30%) had TURP/channelization, while the remaining 12 (17.1%) had DiLVP. The mean ages were 69.5, 73, and 67 years for groups 1, 2, and 3, respectively. The mean duration of procedure in minutes was 87.5, 75, and 70.5 for groups 1, 2, and 3, respectively (p = 0.12). The groups did not differ in terms of need for blood transfusion (p = 0.81). The groups differed significantly in terms of time to catheter removal and hospital stay. The differences in rates of post-operative complications were statistically significant (p = 0.00). The procedures had comparable long-term rates for satisfactory voiding. Conclusion: Elderly men have significant peri-operative risks. As such, the choice of surgical options for management of prostatic obstruction in them should be carefully considered. Endoscopic methods, especially DiLVP, are associated with fewer peri-operative complications in the elderly.

Obstructive uropathy and intrinsic renal disease in patients with benign prostatic obstruction: analysis of burden and associations in a university teaching hospital in Nigeria

Background: Benign Prostatic Hyperplasia (BPH) is a disease of the elderly. Some of the patients with this pathology could develop renal impairment due to the direct effect of obstruction or as a result of intrinsic renal disease. This study aimed to determine the burden and associations of obstructive uropathy and intrinsic renal disease in patients with benign prostatic obstruction in a university teaching hospital in Nigeria. Methods: This was a retrospective study of patients with BPH in our center. Glomerular Filtration Rate (GFR) was calculated and the severity of renal disease computed. Patients were classified as normal or those with obstructive uropathy and intrinsic renal disease. Patients’ age, diabetes mellitus presence and treatment given were also documented. Results: Obstructive uropathy and intrinsic renal disease occurred in 14 (15.1%) and 12 (12.9%) of the patients respectively. Nephropathy in the setting of obstruction occurred in four (4.3%) of the patients while the GFR was at stage 2 in obstructive uropathy patients who did not have renal impairment. Eight (10.4%) of the patients without nephropathy had diabetes mellitus. There was a significant inverse relationship between the age of presentation and the GFR (P = 0.001, odds ratio = −1.129). Initial urinary drainage delayed definitive surgery in all patients with obstructive nephropathy. Conclusion: The burden of nephropathy in BPH patients is quite considerable. A proportion of those without renal impairment harbour diabetes mellitus which could rapidly tilt obstructive uropathy patients into renal failure.

UP04 - Transperineal laser ablation treatment of benign prostatic obstruction; preliminary results of a pilot study

UP04 - Transperineal laser ablation treatment of benign prostatic obstruction; preliminary results of a pilot study

Transurethral resection of the prostate: An initial experience in a tertiary health institution

Background: Transurethral resection of the prostate (TURP), is the gold standard treatment for prostatic obstruction. TURP is associated with less morbidity. Despite this obvious edge, limited availability, access, and affordability are major drawbacks to the utility of this treatment modality in our setting. The purpose of this study is to examine our initial experience with TURP. Patients and Methods: Patients undergoing TURP in our institution over a period of 20 months (April 2013–November 2014) were prospectively followed. Consecutive patients who hadprostatic obstruction and indication for TURP were included in this study. Patients with contra-indications to TURP were excluded from this study. Informed consent was routinely obtained preoperatively. Patients' demographics, pre-, intra- and post-operative clinical records, and outcome details were entered into pro formas. The results were analyzed using descriptive statistics. Results: Fourteen men with a median age of 66.5 years (50–102) were included in this study. The mean prostate size was 56 g (32–91). They all had bothersome lower urinary tract symptoms (LUTS). Nine (64.3%) were in the middle socioeconomic class, whereas five (35.7%) were in the lower class. The mean duration of hospital stay was 4.3 days. Thirteen of the patients (92.9%) stayed for ≤7 days. One of the patients (7.1%) had a duration of hospital stay of nine days. Three patients (21.3%) had postoperative complications. The mean follow-up was 10 months. All had a satisfactory patient-reported subjective outcome at follow-up. Conclusion: TURP was found to be effective, and associated with few peri-operative morbidities. These findings, however, remain to be verified with long-term studies involving a larger number of patients.

The changing role of lasers in urologic surgery.

To summarize recent publications on the topic of laser in urology and explore new developments which may impact the future role of lasers in surgery. Ho: Yttrium-aluminium garnet (YAG) laser with Moses technology allows less retropulsion during a lithotripsy, yet its efficacy needs to be tested in clinical trials. Data on the efficacy of this device for benign prostatic obstruction treatment is also pending. A new promising generation of laser systems - thulium-fiber (Tm-fiber) lasers - has been introduced. Tm-fiber has already been shown to be effective and well tolerated in endoscopic enucleation of the prostate and has demonstrated favorable outcome compared with Ho:YAG in preclinical lithotripsy studies. However, more studies are needed to better understand the use of this novel technology and elucidate its role within the armamentarium of available technologies. Lasers remain an integral part of benign prostatic hyperplasia surgery and stone treatment and gain popularity in en-bloc resection of bladder cancer. Current efficacy of laser systems in prostate cancer ablation and their place in laparoscopy remain unclear, despite promising initial reports.

Transurethral resection of the prostate stricture management.

For more than nine decades, transurethral resection of the prostate remains the gold standard for the surgical treatment of lower urinary tract symptoms due to benign prostatic obstruction. The occurrence of urethral strictures after transurethral resection of the prostate is one of the major late complications and has been reported as the leading cause of iatrogenic urethral strictures in patients older than 45 years who underwent urethroplasty. Although several postulations have been proposed to explain the urethral stricture after transurethral resection of the prostate, the exact etiology of urethral stricture after TURP is still controversial. Suggested etiological factors of urethral stricture formation after transurethral resection of the prostate include infection, mechanical trauma, prolonged indwelling catheter time, use of local anesthesia, and electrical injury by a stray current. One single treatment option is not appropriate for all stricture types. The management of urethral stricture following transurethral resection of the prostate includes minimally invasive endoscopic methods, including urethral dilation and direct visual incision, or open surgical procedures with varying urethroplasty techniques. Although scientific studies focusing on urethral strictures after transurethral resection of the prostate are relatively limited and sparse, we can apply the principles of urethral stricture management before making decisions on individual stricture treatment.

Comparison of Two Numerical Parameters to Assess Detrusor Contractility in Prognosing Short-Term Outcome after Transurethral Resection of the Prostate

Objective: To investigate and compare the influence of two numerical detrusor contractility parameters, the bladder contractility index (BCI) and the maximum Watts factor (WF_max), on transurethral resection of the prostate (TURP) outcome. Methods: A retrospective study was conducted on 236 patients who had undergone urodynamic assessment preoperatively and TURP for benign prostatic obstruction. They were evaluated by International Prostate Symptom Score (IPSS) and uroflowmetry preoperatively and 3 months postoperatively. Related criteria were established to determine the overall efficacy of TURP. Logistic regression analysis and receiver operating characteristic curves were made to investigate the influence of the BCI and WF_max on TURP efficacy. Results: Among the 236 patients, 195 treatments were effective and 41 ineffective. Multivariate analysis showed that both the BCI (OR 1.038) and the WF_max (OR 1.291) could influence TURP efficacy. For predicting TURP efficacy, the optimal cut-off values of the BCI and WF_max were 98.7 and 10.27 W/m², respectively. The AUC, sensitivity and specificity of the BCI were 0.722, 78.5% and 61.0%; those of the WF_max were 0.761, 73.9% and 73.2%, with no significant difference (p > 0.05). Conclusions: To some extent, the BCI and the WF_max can predict TURP efficacy equally well. A discrimination level of 10.27 W/m² may be a threshold value for detrusor underactivity (DU); as regards the BCI, the current threshold value is appropriate to diagnose DU.

Bipolar versus monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction.

Transurethral resection of the prostate (TURP) is a well-established surgical method for treatment of men with lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). This has traditionally been provided as monopolar TURP (MTURP), but morbidity associated with MTURP has led to the introduction of other surgical techniques. In bipolar TURP (BTURP), energy is confined between electrodes at the site of the resectoscope, allowing the use of physiological irrigation medium. There remains uncertainty regarding differences between these surgical methods in terms of patient outcomes. To compare the effects of bipolar and monopolar TURP. A comprehensive systematic electronic literature search was carried out up to 19 March 2019 via CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, PubMed, and WHO ICTRP. Handsearching of abstract proceedings of major urological conferences and of reference lists of included trials, systematic reviews, and health technology assessment reports was undertaken to identify other potentially eligible studies. No language restrictions were applied. Randomised controlled trials (RCTs) that compared monopolar and bipolar TURP in men (> 18 years) for management of LUTS secondary to BPO. Two independent review authors screened the literature, extracted data, and assessed eligible RCTs for risk of bias. Statistical analyses were undertaken according to the statistical guidelines presented in the Cochrane Handbook for Systematic Reviews of Interventions. The quality of evidence (QoE) was rated according to the GRADE approach. A total of 59 RCTs with 8924 participants were included. The mean age of included participants ranged from 59.0 to 74.1 years. Mean prostate volume ranged from 39 mL to 82.6 mL. Primary outcomes BTURP probably results in little to no difference in urological symptoms, as measured by the International Prostate Symptom Score (IPSS) at 12 months on a scale of 0 to 35, with higher scores reflecting worse symptoms (mean difference (MD) -0.24, 95% confidence interval (CI) -0.39 to -0.09; participants = 2531; RCTs = 16; I² = 0%; moderate certainty of evidence (CoE), downgraded for study limitations), compared to MTURP. BTURP probably results in little to no difference in bother, as measured by health-related quality of life (HRQoL) score at 12 months on a scale of 0 to 6, with higher scores reflecting greater bother (MD -0.12, 95% CI -0.25 to 0.02; participants = 2004; RCTs = 11; I² = 53%; moderate CoE, downgraded for study limitations), compared to MTURP. BTURP probably reduces transurethral resection (TUR) syndrome events slightly (risk ratio (RR) 0.17, 95% CI 0.09 to 0.30; participants = 6745; RCTs = 44; I² = 0%; moderate CoE, downgraded for study limitations), compared to MTURP. This corresponds to 20 fewer TUR syndrome events per 1000 participants (95% CI 22 fewer to 17 fewer). Secondary outcomes BTURP may carry a similar risk of urinary incontinence at 12 months (RR 0.20, 95% CI 0.01 to 4.06; participants = 751; RCTs = 4; I² = 0%; low CoE, downgraded for study limitations and imprecision), compared to MTURP. This corresponds to four fewer events of urinary incontinence per 1000 participants (95% CI five fewer to 16 more). BTURP probably slightly reduces blood transfusions (RR 0.42, 95% CI 0.30 to 0.59; participants = 5727; RCTs = 38; I² = 0%; moderate CoE, downgraded for study limitations), compared to MTURP. This corresponds to 28 fewer events of blood transfusion per 1000 participants (95% CI 34 fewer to 20 fewer). BTURP may result in similar rates of re-TURP (RR 1.02, 95% CI 0.44 to 2.40; participants = 652; RCTs = 6; I² = 0%; low CoE, downgraded for study limitations and imprecision). This corresponds to one more re-TURP per 1000 participants (95% CI 19 fewer to 48 more). Erectile function as measured by the International Index of Erectile Function score (IIEF-5) at 12 months on a scale from 5 to 25, with higher scores reflecting better erectile function, appears to be similar (MD 0.88, 95% CI -0.56 to 2.32; RCTs = 3; I² = 68%; moderate CoE, downgraded for study limitations) for the two approaches. BTURP and MTURP probably improve urological symptoms, both to a similar degree. BTURP probably reduces both TUR syndrome and postoperative blood transfusion slightly compared to MTURP. The impact of both procedures on erectile function is probably similar. The moderate certainty of evidence available for the primary outcomes of this review suggests that there is no need for further RCTs comparing BTURP and MTURP.

Can we predict the success of prostatic surgery for male lower urinary tract symptoms: ICI-RS 2018?

Male lower urinary tract symptoms (LUTS) are common and bothersome symptoms in the aging population, of which the etiology is multifactorial. Prostatic surgery may be considered to alleviate some of these LUTS, especially in patients in which benign prostatic obstruction is believed to be the underlying cause. The aim of this paper is to discuss underlying pathophysiology, signs, and conditions that may lead to success or failure after prostatic surgery in male patients with LUTS. The paper is a report of presentations and subsequent discussions at the annual International Consultation on Incontinence Research Society, in June 2018 in Bristol. Unfavorable outcomes after prostatic surgery are reported in 25% to 30% of the patients. This may be due to persistent or de novo symptoms, related to the multifactorial origin of symptoms. Specific underlying conditions such as with detrusor overactivity, detrusor underactivity, and nocturnal polyuria are discussed in their relationship with prostatic surgery. Knowledge gaps are addressed and specific research questions proposed.

Jackstone Calculus

A 75-year-old man presented with a 3-year history of poor urinary flow, recent hematuria, and urgency. He had been taking α-blockers for more than 10 years for lower urinary tract symptoms. He was a nonsmoker. Computed tomography revealed normal kidneys and ureters but a large intravesical extension of the prostate gland and calculi with a spiculated pattern (Figure 1A and B), characteristic of jackstone calculi. Cystoscopic examination revealed calculi with multiple spicules and characteristic dark bands (Figure 2). He underwent cystoscopy-guided laser lithotripsy, with complete fragmentation via holmium laser. He also had concurrent transurethral resection of the prostate gland. Postoperatively, he voided with a good stream.Figure 2Cystoscopic image showing jackstone calculi in the bladder.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Jackstone calculi are bladder calculi composed of calcium oxalate dihydrate, which gives them their irregular shape.1Singh K.J. Tiwari A. Goyal A. Jackstone: a rare entity of vesical calculus.Indian J Urol. 2011; 27: 543-544Google Scholar They get their name from their resemblance to toy “jacks” with multiple spicules. Bladder calculi are an important consideration in the differential diagnosis in older patients with hematuria and are often secondary to prostatic obstruction.2Douenias R. Rich M. Badlani G. Mazor D. Smith A. Predisposing factors in bladder calculi: review of 100 cases.Urology. 1991; 37: 240-243Google Scholar Primary care physicians should be aware of their characteristic appearance on plain radiography. It is imperative, however, to perform contrast-enhanced computed tomography of the abdomen and pelvis and a thorough cystoscopic examination to rule out malignancy as cause of the hematuria.

Re: Do Patients Have to Choose between Ejaculation and Miction? A Systematic Review about Ejaculation Preservation Technics for Benign Prostatic Obstruction Surgical Treatment.

Re: Do Patients Have to Choose between Ejaculation and Miction? A Systematic Review about Ejaculation Preservation Technics for Benign Prostatic Obstruction Surgical Treatment.

Predictors Of Postoperative Lower Urinary Tract Symptoms Improvements In Patient With Small-Volume Prostate And Bladder Outlet Obstruction.

ObjectiveTo explore the factors associated with improvement of lower urinary tract symptoms (LUTS) after transurethral plasmakinetic enucleation of the prostate (PKEP) and transurethral resection of the prostate (TURP) in patients with a small-volume prostate and bladder outlet obstruction (BOO).MethodsThe clinicopathologic data of 257 patients with BOO and a small-volume prostate from January 2013 to January 2018 were retrospectively collected preoperatively, 3 months postoperatively, and 12 months postoperatively. Patients were divided into postoperative success and failure groups based on the IPSS, IPSS-v, and IPSS-s. The relationship between each parameter and the improvement of postoperative LUTS was analyzed. Subgroup analysis was performed to compare the differences between the TURP and PKEP groups.ResultsAmong patients followed up for 3 months postoperatively, multivariate analysis demonstrated that IPP, PUA, and post-PCB were significant predictors of postoperative IPSS improvement; TZI, IPP, and PUA were significant predictors of postoperative IPSS-v improvement; post-PCB and the surgical procedure were significant predictors of IPSS-s improvement; and IPP and PUA were significant predictors of postoperative Qmax improvement. Among patients followed up for 12 months postoperatively, multivariate analysis revealed that IPP, PUA, and post-PCB were significant predictors of postoperative IPSS improvement; PUA was a significant predictor of postoperative IPSS-v improvement; post-PCB was a significant predictor of IPSS-s improvement; and IPP and PUA were significant predictors of postoperative Qmax improvement. The post-PCB was significantly lower in the PKEP than the TURP group and the prostatic calculi removal rate was significantly higher in the PKEP than the TURP group.ConclusionPatients with a greater preoperative IPP and PUA and smaller post-PCB showed greater improvement of postoperative LUTS. PKEP might help to remove calculi from between the transitional and peripheral zones of prostate. Compared with conventional TURP, PKEP may improve the early postoperative storage symptoms of LUTS in patients with a small-volume prostate and BOO.

Pyuria and Post-Operation Urinary Tract Infection after Diode Laser Vaporesection of the Prostate.

Background: Monopolar transurethral resection of prostate (m-TURP) remains the gold standard for benign prostate obstruction (BPO). Recently developed laser surgical technique provides fewer peri-operative complications with equivalent outcomes. Diode laser vaporesection (DiLRP) offers better hemostasis, shorter catheterization duration, and shorter hospital stay, however, deep thermal penetration might cause prolonged prostatic urethra inflammation and subsequent complications. We conducted a retrospective study to compare the pyuria duration and post-operative urinary tract infection sequelae (POUTIs) between DiLRP and m-TURP. Methods: From July 2011 to September 2015, we retrieved medical records for patients with lower urinary tract symptoms resulting from prostate obstruction who underwent m-TURP and DiLRP. Demographic characteristics were recorded from a computerized database. The duration of pyuria after operation was compared by Kaplan-Meier analysis and risk factors were evaluated by Cox regression analysis. Results: One hundred twelve patients underwent DiLRP and 81 underwent m-TURP performed by the same surgeon during the same period. The mean age of the patients was 72 ± 7.3 years in the DiLRP group and 70 ± 7.6 years in the m-TURP group (p = 0.069). There was a higher percentage of anticoagulant used in the DiLRP group than in the m-TURP group (18.5% vs. 7.4%, p = 0.028). Operation time was longer but post-operative normal saline irrigation interval was shorter in DiLRP compared with m-TURP, respectively (62.8 ± 20.6 vs. 47.4 ± 22.1 minutes, p < 0.001; 2.1 ± 0.3 vs. 2.5 ± 0.9 days, p < 0.001). The post-operative infections were statistically significantly higher in the DiLRP group, including epididymitis (10.2% vs. 1.2%, p = 0.013) and POUTIs-related hospitalization (8.3% vs. 1.2%, p=0.031).The DiLRP resulted in longer pyuria period (16 vs. 12 weeks, p = 0.0014), with factors including operative method by DiLRP (hazard ratio [HR]: 1.828, p = 0.003) and age (HR: 0.665, p = 0.040). Conclusions: According to our study, DiLRP associated with more POUTIs is possibly caused by a longer pyuria period. Further larger prospective studies are necessary for the evaluation of the association between post-operative pyuria and POUTIs.