Surgical Benign Prostatic Hyperplasia Research Articles

Systematic review and network meta-analysis of re-intervention rates of new surgical interventions for benign prostatic hyperplasia.

To assess the re-intervention rates of new surgical benign prostatic hyperplasia (BPH) interventions, as the clinical durability of new surgical interventions for BPH is not widely known. A critical review of new surgical BPH therapies namely 'UroLift®', 'Aquablation', 'Rezum', 'prostatic artery embolisation (PAE)' and 'temporary implantable nitinol device (iTIND)' was performed on PubMed, the Cochrane Library, and Embase databases between May 2010 and December 2022 according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement. All relevant articles were reviewed, and the risk of bias was evaluated using the Cochrane risk assessment tool and Newcastle-Ottawa Scale. Of the 32 studies included, there were 10 randomised controlled trials and 22 prospective observational cohorts. A total of 2400 participants were studied with a median patient age of 66 years, a median prostate volume of 51.9 mL, and a median International Prostate Symptom Score of 22. The lowest re-intervention rate at 12 months was for Aquablation at 0.01%, followed by Rezum at 0.02%, iTIND at 0.03%, and PAE at 0.05%. Network meta-analysis (NMA) showed that the best-ranked treatment at 12 months was transurethral resection of the prostate (TURP), followed by Aquablation, iTIND, Rezum, and UroLift. Re-intervention rates with these new BPH interventions are comparable, although some interventions reported better outcomes than TURP in the shorter term. While this systematic review and NMA showed that the re-intervention rate with these new surgical BPH interventions appears to be comparable to TURP in the short term, further studies are required to directly compare these various BPH procedures.

Evaluation of Current Surgical BPH Interventions for Young and Elderly Men.

Benign prostatic hyperplasia affects the quality of life of a significant number of men, especially as they age. There are continuous innovations in the surgical management of benign prostatic hyperplasia, but many of these innovations are studied in the core population of men 50-70years of age. This review focuses on the outliers of men aged 18-50 and 70 and older. Older populations have more comorbidities, higher rates of antithrombotic medications, and advanced symptoms. Properly selected older men can safely have significant objective and subjective improvement in their symptoms. The literature was scarce when evaluating younger men; however, ejaculatory preserving techniques are promising providing improvement in symptoms and preserving ejaculation. This review demonstrates that in properly selected elderly patients, improvements in quality of life while also providing safe surgical interventions can be achieved. Ejaculatory preservation techniques demonstrate promising results, but further studies are required to elucidate true outcomes.

(221) Outcomes of Transurethral Surgery After IPP

Abstract Introduction Inflatable penile prosthesis (IPP) effectively restores erectile function with very high patient satisfaction rates. However, some patients may require subsequent treatments for urethral stricture, enlarged prostate and bladder tumors. These underlying conditions oftentimes coexist with erectile dysfunction (ED). Transurethral surgery (TUS) treatment of coexisting conditions in patients with IPP can be challenging and associated with a theoretical risk of mechanical injury and infection of the implant. There is a lack of literature reporting on IPP issues after TUS. Objective The aim of this study was to evaluate postoperative outcomes in patients who underwent TUS following IPP placement. Methods After IRB approval, we reviewed the medical records of all patients who underwent Greenlight laser enucleation of the prostate (GLEP)(Wolf© 26 Fr cystoscope), Rezum© vaporization ( 21 Fr delivery device), transurethral bladder tumor resection (TURBT)(21 and 22 Fr cystoscopes) and Optilume balloon dilation surgeries (19 Fr cystoscope and 24 Fr balloon) after IPP placement at our institution from 2014 to 2023. We excluded patients who underwent TUS prior to IPP placement and only included patients who had an in situ IPP at the time of the TUS procedure. Parameters such as IPSS score, PSA, postvoid residual volume (PVR) and transrectal ultrasound were used for assessment before and after surgery. All surgeries were performed by a single surgeon. Postoperative progress was assessed at multiple follow-up visits. Results Seven patients with IPP underwent eight TUS. Four patients (71%) received surgical BPH treatment, one patient was treated for bladder tumors and one patient developed a bladder neck contracture (BNC) after GLEP and required a second TUS. One patient developed a pendulous stricture after erosion from an IPP cylinder placed by a different surgeon 23 years prior. The patient underwent IPP removal and replacement at our facility 63 months prior to Optilume® balloon dilation. The mean time between IPP placement and TUS was 34.86 ± 30.96 months. The average prostate volume was 41.3 ± 25.9 mL, and the mean parameters of PVR, Maximum flow rate (Q max), IPSS, and PSA before surgery were 140.6 ± 100.8 mL, 8.4 ± 7.2 ml/s, 16.3 ± 4.3, and 2.7± 2.7 ng/ml, respectively. An average of 31.6 ± 26.7 grams of prostate tissue was resected during GLEP. Postoperative parameters of PVR, Q max and PSA were 35.5 ± 31.3 ml, 17.2 ± 8.8 ml/s and 0.8 ± 0.65 ng/dl, respectively. There were no cases of postoperative infections or IPP malfunctions reported during a mean follow-up of 34.14±36 months. Conclusions Our experience shows that TUS performed after IPP placement is effective and safe in addressing underlying conditions such as BPH, bladder tumors and urethral strictures. Our findings indicate favorable postoperative outcomes in terms of PVR and PSA levels, without any reported infections or malfunctions of the IPP. However, it is important to consider the limitations of this study, including the small sample size. Further research with larger sample sizes would be beneficial to validate these findings and provide more comprehensive insights into the outcomes of TUS following IPP placement. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Irrisept.

Transcriptomic analysis of benign prostatic hyperplasia identifies critical pathways in prostatic overgrowth and 5-alpha reductase inhibitor resistance.

The medical therapy of prostatic symptoms (MTOPS) trial randomized men with symptoms of benign prostatic hyperplasia (BPH) and followed response of treatment with a 5α-reductase inhibitor (5ARI), an alpha-adrenergic receptor antagonist (α-blocker), the combination of 5ARI and α-blocker or no medical therapy (none). Medical therapy reduced risk of clinical progression by 66% but the reasons for nonresponse or loss of therapeutic response in some patients remains unresolved. Our previous work showed that prostatic glucocorticoid levels are increased in 5ARI-treated patients and that glucocorticoids can increased branching of prostate epithelia in vitro. To understand the transcriptomic changes associated with 5ARI treatment, we performed bulk RNA sequencing of BPH and control samples from patients who received 5ARI versus those that did not. Deconvolution analysis was performed to estimate cellular composition. Bulk RNA sequencing was also performed on control versus glucocorticoid-treated prostate epithelia in 3D culture to determine underlying transcriptomic changes associated with branching morphogenesis. Surgical BPH (S-BPH) tissue was defined as benign prostatic tissue collected from the transition zone (TZ) of patients who failed medical therapy while control tissue termed Incidental BPH (I-BPH) was obtained from the TZ of men undergoing radical prostatectomy for low-volume/grade prostatic adenocarcinoma confined to the peripheral zone. S-BPH patients were divided into four subgroups: men on no medical therapy (none: n = 7), α-blocker alone (n = 10), 5ARI alone (n = 6) or combination therapy (α-blocker and 5ARI: n = 7). Control I-BPH tissue was from men on no medical therapy (none: n = 8) or on α-blocker (n = 6). A human prostatic cell line in 3D culture that buds and branches was used to identify genes involved in early prostatic growth. Snap-frozen prostatic tissue taken at the time of surgery and 3D organoids were used for RNA-seq analysis. Bulk RNAseq data were deconvoluted using CIBERSORTx. Differentially expressed genes (DEG) that were statistically significant among S-BPH, I-BPH, and during budding and branching of organoids were used for pathway analysis. Transcriptomic analysis between S-BPH (n = 30) and I-BPH (n = 14) using a twofold cutoff (p < 0.05) identified 377 DEG (termed BPH377) and a cutoff < 0.05 identified 3377 DEG (termed BPH3377). Within the S-BPH, the subgroups none and α-blocker were compared to patients on 5ARI to reveal 361 DEG (termed 5ARI361) that were significantly changed. Deconvolution analysis of bulk RNA seq data with a human prostate single cell data set demonstrated increased levels of mast cells, NK cells, interstitial fibroblasts, and prostate luminal cells in S-BPH versus I-BPH. Glucocorticoid (GC)-induced budding and branching of benign prostatic cells in 3D culture was compared to control organoids to identify early events in prostatic morphogenesis. GC induced 369 DEG (termed GC359) in 3D culture. STRING analysis divided the large datasets into 20-80 genes centered around a hub. In general, biological processes induced in BPH supported growth and differentiation such as chromatin modification and DNA repair, transcription, cytoskeleton, mitochondrial electron transport, ubiquitination, protein folding, and cholesterol synthesis. Identified signaling pathways were pooled to create a list of DEG that fell into seven hubs/clusters. The hub gene centrality was used to name the network including AP-1, interleukin (IL)-6, NOTCH1 and NOTCH3, NEO1, IL-13, and HDAC/KDM. All hubs showed connections to inflammation, chromatin structure, and development. The same approach was applied to 5ARI361 giving multiple networks, but the EGF and sonic hedgehog (SHH) hub was of particular interest as a developmental pathway. The BPH3377, 5ARI363, and GC359 lists were compared and 67 significantly changed DEG were identified. Common genes to the 3D culture included an IL-6 hub that connected to genes identified in BPH hubs that defined AP1, IL-6, NOTCH, NEO1, IL-13, and HDAC/KDM. Reduction analysis of BPH and 3D organoid culture uncovered networks previously identified in prostatic development as being reinitiated in BPH. Identification of these pathways provides insight into the failure of medical therapy for BPH and new therapeutic targets for BPH/LUTS.

Search trends in the treatment for benign prostatic hyperplasia: A twenty-year analysis

ObjectiveMinimally invasive treatments for benign prostatic hyperplasia (BPH) have seen an increase in usage in recent years. We aimed to determine what types of events may influence patient search habits related to surgical BPH treatments. MethodsGoogle Trends was used to determine the frequency of searches for different minimally invasive and prostatic ablative treatments for BPH in the United States. The procedures including transurethral resection of the prostate (TURP), Aquablation therapy (Aquablation), Greenlight laser therapy (Greenlight), transurethral needle ablation, transurethral microwave thermotherapy, Urolift (prostatic urethral lift [PUL]), Rezum, iTind, holmium laser enucleation of the prostate, simple prostatectomy, and prostatic artery embolization were compared. ResultsFrom January 1, 2004 to February 28, 2023, the number of internet search queries have increased for TURP, PUL, Rezum, prostatic artery embolization, and holmium laser enucleation of the prostate. There has been a slight decrease in searches for Greenlight, transurethral needle ablation, transurethral microwave thermotherapy, iTind, simple prostatectomy, and Aquablation. ConclusionsDespite increased searches of alternatives, TURP remains the most searched BPH procedure. Additionally, search habits may be influenced by several factors including government approval, corporate acquisition, and marketing campaigns. It is important for physicians to understand the types of events that may cause patients to inquire about certain treatments for better quality health information and clinical visits.

Persistent need for ongoing medical or surgical therapy despite UroLift: Data from an academic center.

The prostatic urethral lift (PUL) is a popular surgical option for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). Prior 5-year data from the multicenter L.I.F.T. trial suggested durability and a surgical retreatment rate of 13.6% at five years. We assessed the proportion of patients who had ongoing medical or surgical BPH management following PUL. With institutional review board approval, cases of PUL performed from 2015-2020 at our academic institution were retrospectively reviewed for management of BPH following PUL. A total of 209 men were identified, with followup available for 198 (95%). Mean age was 68.9 years and mean followup was 18.5 months. Mean prostate size was 43 g. Patients were discharged from recovery in 97% of cases, with 29% discharged with indwelling or intermittent catheterization. The rate of 30-day complications was 18%, with 89% graded Clavien I-II. Postoperatively, mean improvements in International Prostate Symptom Score (IPSS) and quality of life subscore (QoL) were 5.3 and 1.1 points, respectively. Unplanned emergency room or clinic visits within 30 days of the procedure occurred in 14% and 17% of men, respectively, with 4% requiring hospital readmission. In followup, α-blockers and/or 5α-reductase inhibitors were continued or initiated postoperatively for 44% of men; 20% of men required repeat surgical intervention at a mean of 19.2 months (1.4-56.4), consisting of repeat PUL (30%), transurethral resection of prostate (28%), or thulium laser enucleation (18%). Overall, 53% of men needed medication and/or repeat surgery for BPH following PUL, and this was independent of age, race, prostate volume, intravesical prostate protrusion, baseline IPSS and QOL, stricture, number of implants used, or a history of urinary retention (p>0.05). Most men undergoing PUL require ongoing medical and/or surgical management for BPH. Patients should be counseled as to the likelihood of failure as a unimodal therapy long-term.

Benign prostatic hyperplasia surgical re-treatment after prostatic urethral lift: A narrative review.

Prostatic urethral lift (PUL) accounts for approximately one-quarter of all surgical benign prostatic hyperplasia (BPH) procedures performed in the U.S.1 Within five years of a patient's PUL procedure, approximately 1/7 patients will require surgical BPH re-treatment.2 We aimed to highlight the evidence of surgical BPH re-treatment modalities after PUL, with a focus on safety, short-term efficacy, durability, and relative costs. A literature review was performed using PubMed, and an exhaustive review of miscellaneous online resources was completed. The search was limited to English, human studies. Citations of relevant studies were reviewed. No study has examined the efficacy, safety, or durability of transurethral resection of the prostate (TURP) or repeat PUL in the post-PUL setting. Recently, groups have examined laser enucleation (n=81), water vapor thermal therapy (WVTT) (n=5), robotic simple prostatectomy (SP) (n=2), and prostatic artery embolization (PAE) (n=1) in the post-PUL setting. Holmium enucleation of the prostate (HoLEP) after PUL appears to be safe and has similar functional outcomes to HoLEP controls. Other treatment modalities examined appear safe but have limited efficacy evidence supporting their use. Photo-selective vaporization of the prostate (PVP) and robotic waterjet treatment (RWT) have no safety or efficacy studies to support their use in the post-PUL setting. Despite increasing numbers of patients expected to require surgical re-treatment after PUL in North America, there is currently limited evidence and a lack of recommendations guiding the evaluation and management of these patients. HoLEP is associated with the strongest evidence to support its use in the post-PUL setting.

Risk Factors for Persistent Lower Urinary Tract Symptoms 1 Month Following Convective Water Vapor Thermal Therapy (CWVTT-Rezum)

To investigate the incidence and risk factors of persistent lower urinary tract symptoms (LUTS) 1 month and later following convective water vapor thermal therapy (CWVTT) in men with LUTS secondary to benign prostatic hyperplasia (BPH). Patients who underwent CWVTT from 11/2018-5/2021 at a single institution were eligible for inclusion and retrospectively identified. Pertinent patient, operative, and outcomes data were extracted. The primary outcome was clinically significant LUTS improvement at 4 weeks following CWVTT. Persistent LUTS was defined as failure to reach a minimally clinical important difference of 25% reduction on International Prostate Symptom Score at 4 weeks. One hundred nine patients qualified. Fifty percent of patients experienced persistent LUTS at 1 month. Eighty-two percent of men ultimately reached the minimally clinical important difference. For each additional month following CWVTT, the odds of achieving clinically significant LUTS improved by 9% (Odds ratio (OR)=0.91, P=.0033). Bladder outlet obstruction index and prior surgical BPH therapy were associated with persistent LUTS on multivariate logistic regression. Every 10-unit increase in Bladder outlet obstruction index noted at baseline was associated with a 15% increased likelihood of achieving minimally clinical important difference in LUTS at 4 weeks following CWVTT (OR=0.85, P=.01). Patients receiving prior surgical BPH therapy were 3.5 times more likely to experience persistent LUTS at 1 month (OR=3.47, P=.01). Fifty percent of men experienced persistent LUTS 1 month following CWVTT. However, LUTS improved with time and the majority of men ultimately achieved clinically significant LUTS improvement. A lower baseline Bladder outlet obstruction index and prior BPH procedures are risk factors for persistent LUTS following CWVTT.

(293) Limitations in Reporting and Assessment Tools for Retrograde Ejaculation after Surgical BPH treatment: A Scoping Review

Abstract Introduction Antegrade ejaculation is a fundamental aspect of sexual satisfaction for many individuals, but retrograde ejaculation (RE) occurs in up to 75 % of some surgical treatments of benign prostatic hyperplasia. Unfortunately, clinicians commonly focus only primarily on erection strength, and existing tools inadequately characterize rates and bother associated with RE after BPH treatment. Objective This review provides critical appraisal of existing tools used to assess RE and emphasizes the importance of preoperative counseling of this complication prior to surgical BPH treatment. Methods A literature review was conducted in June of 2022 using Embase, Medline, and Web of Science to identify relevant manuscripts on “men sexual health”, “men’s sexual health questionnaire (MSHQ), and “retrograde”, “dry”, or “backward” “ejaculate” or “orgasm” from 1946 to June 2022. Eligibility criteria were established by using Population, Intervention, Control, and Outcome (PICO) tool for men with BPH symptoms treated with surgical intervention and developed postoperative RE. Criteria for exclusion were manuscripts in non-English language and studies reporting rates of RE without specifying the criteria used to diagnose the condition. Results A literature review was conducted in June of 2022 using Embase, Medline, and Web of Science to identify relevant manuscripts on “men sexual health”, “men’s sexual health questionnaire (MSHQ), and “retrograde”, “dry”, or “backward” “ejaculate” or “orgasm” from 1946 to June 2022. Eligibility criteria were established by using Population, Intervention, Control, and Outcome (PICO) tool for men with BPH symptoms treated with surgical intervention and developed postoperative RE. Criteria for exclusion were manuscripts in non-English language and studies reporting rates of RE without specifying the criteria used to diagnose the condition. Conclusions Significant limitations exist in the tools presently available for the reporting of RE related to BPH treatment. With ejaculation playing a very important role in sexual satisfaction for many men, more robust and specific instruments are needed to help with the diagnosis. Through development of such tools, patients will be better counseled and satisfaction with treatments will be improved. Optimized questioning needs to take into consideration both baseline and post-treatment ejaculatory function – including granular specifics on force, volume, sensation, and level of bother rather than general questions on ejaculatory functioning measured on a very broad scale. Disclosure No

MP76-20 TRENDS IN SURGICAL MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA: DATA FROM THE AUA QUALITY (AQUA) REGISTRY

You have accessJournal of UrologyCME1 Apr 2023MP76-20 TRENDS IN SURGICAL MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA: DATA FROM THE AUA QUALITY (AQUA) REGISTRY Charles Jones, Benjamin Breyer, Rachel Mbassa, William Meeks, Raymond Fang, and Matthew Cooperberg Charles JonesCharles Jones More articles by this author , Benjamin BreyerBenjamin Breyer More articles by this author , Rachel MbassaRachel Mbassa More articles by this author , William MeeksWilliam Meeks More articles by this author , Raymond FangRaymond Fang More articles by this author , and Matthew CooperbergMatthew Cooperberg More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003350.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The list of surgical options for benign prostatic hyperplasia (BPH) has exploded in recent years, but little is known about the uptake of these new procedures in community urology practice. In this study we aimed to examine surgical BPH practices and trends across the country using the American Urological Association Quality Registry (AQUA). METHODS: The AQUA Registry was launched in 2014 to centralize quality reporting and improvement, primarily among community-based urology practices. Data regarding surgical BPH management from 2014-2021 were accessioned directly from electronic health records at 245 practices across the country. Procedures were grouped by CPT code. These included prostatic urethral lift (Urolift), transurethral incision of the prostate (TUIP), transurethral resection of the prostate (TURP), repeat TURP, laser coagulation of the prostate, laser vaporization of the prostate, holmium laser enucleation of the prostate (HoLEP), transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), transurethral destruction of the prostate by water vapor thermal therapy (Rezum), simple prostatectomy, and other genitourinary procedure. Patients were characterized by race and age. Practice location was also examined. RESULTS: The mean age of BPH diagnosis was 66.4 years old. 72% were White, 7% Black, 1% Asian, and 20% unknown. A total of 300,215 BPH procedures were recorded from 2014-2021. TURP had the greatest overall decline from a relative incidence of 40.1% of total BPH procedures in 2016 to 25.6% in 2021. TURP was used for 32% of White patients, 34% of Black patients, and 26% of Asian patients. Urolift use grew from 0.7% of cases in 2014 to 30.1% in 2021. HoLEP comprised approximately 1% of procedures throughout the time period studied. CONCLUSIONS: There has been a large shift in the procedures of choice for surgical management of BPH within community urology practices in the United States, with Urolift having a significant increase in total and relative proportions of procedures performed since its FDA approval in 2013. There has been a concurrent decrease in TURP, while HoLEP has stayed relatively consistently uncommon in community practice. Source of Funding: AQUA Registry is funded by the American Urological Association © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1100 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Charles Jones More articles by this author Benjamin Breyer More articles by this author Rachel Mbassa More articles by this author William Meeks More articles by this author Raymond Fang More articles by this author Matthew Cooperberg More articles by this author Expand All Advertisement PDF downloadLoading ...

PD41-01 TRENDS IN THE DIAGNOSTIC AND SURGICAL MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA (BPH) IN THE UNITED STATES: ANNUAL CHANGES IN THE SELECTION OF TREATMENT OPTIONS AND AVERAGE COSTS DIFFERENTIAL FOR DIAGNOSTIC/SURGICAL TECHNIQUE

You have accessJournal of UrologyCME1 Apr 2023PD41-01 TRENDS IN THE DIAGNOSTIC AND SURGICAL MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA (BPH) IN THE UNITED STATES: ANNUAL CHANGES IN THE SELECTION OF TREATMENT OPTIONS AND AVERAGE COSTS DIFFERENTIAL FOR DIAGNOSTIC/SURGICAL TECHNIQUE Jin-Kyu Oh, Francesco Del Giudice, Eugenio Bologna, Vincenzo Asero, Carlo Maria Scornajenghi, Ettore De Berardinis, Alessandro Sciarra, Satvir Basran, Shufeng Li, Federico Belladelli, and Benjamin I. Chung Jin-Kyu OhJin-Kyu Oh More articles by this author , Francesco Del GiudiceFrancesco Del Giudice More articles by this author , Eugenio BolognaEugenio Bologna More articles by this author , Vincenzo AseroVincenzo Asero More articles by this author , Carlo Maria ScornajenghiCarlo Maria Scornajenghi More articles by this author , Ettore De BerardinisEttore De Berardinis More articles by this author , Alessandro SciarraAlessandro Sciarra More articles by this author , Satvir BasranSatvir Basran More articles by this author , Shufeng LiShufeng Li More articles by this author , Federico BelladelliFederico Belladelli More articles by this author , and Benjamin I. ChungBenjamin I. Chung More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003346.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Transurethral resection of the prostate (TURP) is the gold standard treatment for benign prostatic hyperplasia (BPH). However, laser surgery techniques (e.g., photoselective vaporization of the prostate [PVP], holmium laser, thulium laser enucleation of the prostate [HoLEP or ThuLEP]), and minimally invasive treatment options (e.g., UroLift®) are increasingly replacing TURP. The aim of the study is to present the annual rates of BPH surgery and to analyze recent trends in the utilization of newer surgical modalities and any changes in medical costs related to these treatments over a 15-year period in the US. METHODS: Patient data was collected from the Optum Clinformatics® Data Mart Claims Database. Trends and distribution of surgical BPH techniques over the years of enrollment were analyzed across US regions. We then reviewed trends in adoption of diagnostic BPH methods including urodynamic studies, cystourethroscopy, transrectal ultrasound, prostatic biopsy, uroflowmetry, and the measurement of post-void residual urine volume (PVR). Finally, incidental diagnoses of prostate cancer (PCa) detected during BPH procedures were recorded over the years to depict the trends in PCa detection as well as median prostate specific antigen (PSA) values associated with BPH patients ultimately treated with a procedure. RESULTS: N=51,448 patients underwent BPH procedures from 2004 to 2017. There was a significant increase in the annual rate from 770 in 2004 to 6,571 in 2017. The mean patient age (±SD) increased from 67.6 years old (± 8.4) in 2004 to 73.4 years old (±8.4) in 2017. More than 60% of patients underwent cystourethroscopy and post-void residual urine check for workup prior to surgical management. TURP was the most common and PVP was the second most common BPH procedure. The total number of BPH diagnoses were 44,820 and the median cost for each procedure was $1459, $1875, $1419, and $3284 for TURP, PVP, HOLEP/ThULEP, Urolift, respectively. The median overall cost was $2471. With regard to the costs of treating BPH surgically, the diagnostic and treatment costs demonstrated annual increases while the detection rate of prostate cancer after BPH surgery gradually decreased from 19.87% in 2004 to 5.78% in 2017. CONCLUSIONS: We found recent trends in BPH management that demonstrates that alternative methods are starting to replace the traditional TURP technique, although TURP still remains the most common procedure. Future studies should assess whether these newer methods are both efficacious and cost effective over the long term. Of note, the cumulative incidence of PCa diagnosis was reduced over time, likely multifactorial in nature. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1058 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jin-Kyu Oh More articles by this author Francesco Del Giudice More articles by this author Eugenio Bologna More articles by this author Vincenzo Asero More articles by this author Carlo Maria Scornajenghi More articles by this author Ettore De Berardinis More articles by this author Alessandro Sciarra More articles by this author Satvir Basran More articles by this author Shufeng Li More articles by this author Federico Belladelli More articles by this author Benjamin I. Chung More articles by this author Expand All Advertisement PDF downloadLoading ...

Aquablation Treatment for Benign Prostatic Obstruction

Aquablation Treatment for Benign Prostatic Obstruction Abstract: The surgical BPH treatment is one of the most common urological procedures. With our reference methods: transurethral resection of the prostate (TUR-P), open surgical adenomenucleation over a transabdominal access, and also modern laser procedures. Various effective surgical options are available. However, the quality of the surgical outcome is highly dependent on the surgeons' experience. At the same time, all of the above-mentioned reference methods are associated with a high rate of sexual dysfunction, especially postoperative anejaculation, a symptom complex which is relevant for men, regardless of age [1]. Robotic Aquablation® was developed with the goal to reduce the dependency of the surgical outcome on the expertise of the surgeon, but at the same time achieving a comparable outcome and reduced morbidity. After the "first in human treatment" by Peter Gilling in 2013, the Aquabeam® robot has been used in its current form in clinical studies since 2015 (Water, Water II and Open Water Study) and finally was introduced in clinical routine in August 2017 by Thorsten Bach in Hamburg. The safety and effectiveness of Aquablation® therapy has been proven in various studies and in everyday clinical practice.

Residency Surgical BPH Training Paradigms from MIST to HOLEP.

Benign prostatic hyperplasia (BPH) is a common medical condition of older men that often requires medical or surgical therapy. Surgical options for BPH have grown exponentially over the last two decades. The numerous options and/or lack of access to them can make it challenging for new trainees to gain proficiency. We examine the literature for available BPH surgical simulators, learning curves, and training pathways. Each BPH surgical therapy has a learning curve which must be overcome. There is an abundance of TURP simulators which have shown face, content, and construct validity in the literature. Similarly, laser therapies have validated simulators. Newer technologies do have available simulators, but they have not been validated. There are strategies to improve learning and outcomes, such as having a structured training program. Simulators are available for BPH surgical procedures and some have been implemented in urology residencies. It is likely that such simulation may make urologists more facile on their learning curves for newer technologies. Further studies are needed. Future directions may include integration of simulator technology into training pathways that include surgical observation and proctorship.

Single-port transvesical versus open simple prostatectomy: a perioperative comparative study.

To compare the initial perioperative outcomes of single-port transvesical simple prostatectomy (SP RASP) patients to those of open simple prostatectomy (OSP). Perioperative data from 42 consecutive patients with BPH who underwent SP RASP were prospectively reviewed. Similarly, data from forty-three consecutive patients who underwent the standard OSP, were retrospectively collected. Through direct suprapubic bladder access, prostatic enucleation was performed using the prostatic capsule as a landmark. Then a complete vesicourethral mucosal advancement flap was accomplished. OSP was performed according to the standard approach. Demographics, Intra- and perioperative data were analyzed and assessed with a descriptive analysis. Baseline characteristics were comparable between the two groups, except for the preoperative median post-void residual volume, which was higher in the OSP group (p = 0.004). The SP RASP group had less intraoperative estimated blood loss (p < 0.001), no need for continuous bladder irrigation (p < 0.001), and less in-hospital opioid use (p < 0.001). Patients in the SP RASP group were discharged on postoperative day zero, compared to a median of 2 days for OSP (p < 0.001). The median Foley catheter duration was 7 days for SP RASP, compared to a median of 10 days for OSP (p < 0.001). SP RASP group had fewer postoperative complications, however, this did not reach statistical significance. SP RASP is an alternative approach in treating surgical BPH. It may offer patients less morbidity in comparison to OSP.

PD16-10 5-ALPHA REDUCTASE INHIBITORS SUPPRESS DIHYDROTESTOSTERONE IN BENIGN PROSTATE HYPERPLASIA REQUIRING SURGERY, AND CAUSE STEROIDOGENESIS VIA 5ARI INDUCED PATHWAY

You have accessJournal of UrologyCME1 May 2022PD16-10 5-ALPHA REDUCTASE INHIBITORS SUPPRESS DIHYDROTESTOSTERONE IN BENIGN PROSTATE HYPERPLASIA REQUIRING SURGERY, AND CAUSE STEROIDOGENESIS VIA 5ARI INDUCED PATHWAY Connor Forbes, Nicole L Miller, Thomas Case, Douglas Strand, Qi Liu, Marisol Ramirez-Solano, Justin M. Cates, Ned A. Porter, Hye-Young H. Kim, Phillip Wages, James L. Mohler, Robert J. Matusik, and Ren Jie Jin Connor ForbesConnor Forbes More articles by this author , Nicole L MillerNicole L Miller More articles by this author , Thomas CaseThomas Case More articles by this author , Douglas StrandDouglas Strand More articles by this author , Qi LiuQi Liu More articles by this author , Marisol Ramirez-SolanoMarisol Ramirez-Solano More articles by this author , Justin M. CatesJustin M. Cates More articles by this author , Ned A. PorterNed A. Porter More articles by this author , Hye-Young H. KimHye-Young H. Kim More articles by this author , Phillip WagesPhillip Wages More articles by this author , James L. MohlerJames L. Mohler More articles by this author , Robert J. MatusikRobert J. Matusik More articles by this author , and Ren Jie JinRen Jie Jin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002548.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: 5-alpha reductase inhibitors (5ARIs) reduce the concentration of the active metabolite dihydrotestosterone (DHT) by inhibiting the conversion of testosterone (T) to DHT. Some patients have progression despite maximal medical therapy including with 5ARIs. How these patients escape 5ARI suppression of DHT is not previously established. METHODS: With Institutional Review Board approval, tissue from patients with BPH requiring surgery was collected (Surgical BPH; S-BPH). For controls, non-cancerous transitional zone tissue from patients who underwent radical prostatectomy for low grade prostate cancer was collected (Incidental BPH; I-BPH). Concentrations of androgens and androgen precursors were analyzed, as were other steroid levels. In vitro BPH cell lines were stimulated with the steroid dexamethasone based upon results and assessed for morphologic changes. RNA-sequencing was performed on patient and in vitro cells. RESULTS: Patients who underwent surgery for BPH who were taking 5ARIs had low DHT and elevated precursor T. Other DHT precursors dehydroepiandrosterone (DHEA) and androstenedione (ASD) were also elevated. A 5ARI induced pathway was noted in patients on this medicine, whereby certain glucocorticoids were elevated, through a suggested mechanism in Figure 1. Dexamethasone induced morphologic changes to in vitro cells lines; branching-type morphology was induced compared to controls in 4 BPH cell lines. RNA-sequencing of patient tissue and in vitro cells yielded a unique signature of upregulated genes. CONCLUSIONS: Patients on 5ARIs who progress to requiring surgery for BPH have elevated precursor T and lowered DHT. This confirms that there is no successful escape mechanism either through direct or backdoor pathways for DHT synthesis for patients on 5ARIs who fail medical therapy. A 5ARI-induced glucocorticoid pathway was observed. Glucocorticoids induce morphologic changes in vitro stimulating prostate branching. Source of Funding: The Bray Foundation, NIDDK 5R01 DK111554 to RJ, R01 DK115477 to DWS. This work was supported by National Cancer Institute (NCI) grant P30CA016056 and used the Roswell Park Comprehensive Cancer Center Bioanalytical, Metabolomics, and Pharmacokinetics Shared Resource (BMPK) © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e272 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Connor Forbes More articles by this author Nicole L Miller More articles by this author Thomas Case More articles by this author Douglas Strand More articles by this author Qi Liu More articles by this author Marisol Ramirez-Solano More articles by this author Justin M. Cates More articles by this author Ned A. Porter More articles by this author Hye-Young H. Kim More articles by this author Phillip Wages More articles by this author James L. Mohler More articles by this author Robert J. Matusik More articles by this author Ren Jie Jin More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP01-09 RISK FACTORS FOR A DELAYED IMPROVEMENT IN LOWER URINARY TRACT SYMPTOMS FOLLOWING CONVECTIVE WATER VAPOR THERMAL THERAPY

You have accessJournal of UrologyCME1 May 2022MP01-09 RISK FACTORS FOR A DELAYED IMPROVEMENT IN LOWER URINARY TRACT SYMPTOMS FOLLOWING CONVECTIVE WATER VAPOR THERMAL THERAPY Sarang Janakiraman, Michael Felice, Aya Bsatee, Gaurav Pahouja, and Kevin T. McVary Sarang JanakiramanSarang Janakiraman More articles by this author , Michael FeliceMichael Felice More articles by this author , Aya BsateeAya Bsatee More articles by this author , Gaurav PahoujaGaurav Pahouja More articles by this author , and Kevin T. McVaryKevin T. McVary More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002513.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Convective water vapor thermal therapy (CWVTT) is a minimally invasive surgical therapy (MIST) for LUTS/BPH that has been shown to produce clinically significant results up to 5 years. We aimed to identify the incidence and risk factors for delayed improvement in LUTS and retreatment following CWVTT in men with LUTS/BPH. METHODS: Patients who underwent CWVTT from 1/2018 to 12/2020, at a single institution, were identified by CPT code. Pertinent patient, treatment, and outcomes data were extracted. Pressure flow studies were done in 73% of eligible patients. Patients missing pre- or immediate post- operative International Prostate Symptom Score (IPSS) were excluded. Delayed LUTS improvement was defined as failure to reach a minimally important clinical difference (MCID) of 25% on the IPSS after 4 weeks following CWVTT. Potential risk factors of delayed LUTS improvement were assessed by logistic regression. RESULTS: 109 patients were qualified for analysis. 50% of patients experienced delayed LUTS improvement (failure to reach MCID at 4 weeks), although, 82% of men reached the MCID by 12 months. Time from CWVTT, bladder outlet obstruction index (BOOI), and prior surgical BPH therapy were associated with delayed LUTS improvement on multivariate logistic regression. For each additional month following CWVTT, the odds of achieving MCID in LUTS increases by 9% (OR=0.91, 95% CI 0.86-0.97, p=.003). Every 10-unit increase in BOOI was associated with a 15% chance increase in achieving MCID in LUTS at 4 weeks following CWVTT (OR=0.85, 95% CI 0.75-0.96 , p=.01). Patients receiving prior surgical BPH therapy were 3.5 times more likely to experience a delayed improvement in LUTS (OR=3.47, 95% CI 1.36-8.90, p=.01). CONCLUSIONS: 50% of men undergoing CWVTT experienced delayed LUTS improvement (failure to reach MCID at 4 weeks). The odds of reaching a MCID increases by 9% with each subsequent month. Men with a high BOOI indicative of more severe obstruction are more likely to reach the MCID. Men with failed prior BPH surgery are at risk of failing to reach MCID. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e4 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sarang Janakiraman More articles by this author Michael Felice More articles by this author Aya Bsatee More articles by this author Gaurav Pahouja More articles by this author Kevin T. McVary More articles by this author Expand All Advertisement PDF DownloadLoading ...

Reimbursement of surgical procedures for benign prostatic hyperplasia: are we disincentivizing complex care?

To provide an overview of how surgical benign prostatic hyperplasia (BPH) procedures are compensated in the United States and the implications of the current reimbursement system on the care of patients. The resource-based relative value care system is Medicare's current reimbursement model. There is strong evidence that the current system does not adequately account for complex care. Consequently, for BPH surgical procedures, treatment options best suited for complex patients are not adequately reimbursed which may have implications on healthcare delivery and outcomes. Inadequate reimbursement for certain BPH procedures may disincentivize the care of complex patients. Procedures such a holmium laser enucleation of the prostate are well suited for complex patients but have a steep learning curve. The incentive to learn and offer such procedures to complex patients may be unfairly influenced by reimbursement levels, which in the end penalizes patients and the treatments available to them.

PD23-03 FAILURE OF PROSTATIC URETHRAL LIFT BASED ON SUBSEQUENT MEDICAL AND/OR SURGICAL MANAGEMENT: DATA FROM A L.I.F.T. STUDY CENTER

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology IV (PD23)1 Sep 2021PD23-03 FAILURE OF PROSTATIC URETHRAL LIFT BASED ON SUBSEQUENT MEDICAL AND/OR SURGICAL MANAGEMENT: DATA FROM A L.I.F.T. STUDY CENTER Rahul Dutta, Ethan Matz, Nicholas Deebel, Elizabeth Boes, and Ryan Terlecki Rahul DuttaRahul Dutta More articles by this author , Ethan MatzEthan Matz More articles by this author , Nicholas DeebelNicholas Deebel More articles by this author , Elizabeth BoesElizabeth Boes More articles by this author , and Ryan TerleckiRyan Terlecki More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002016.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The prostatic urethral lift (PUL) is a popular surgical option for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). Prior 5-year data from the multicenter L.I.F.T. trial suggested durability and a surgical retreatment rate of 13.6%. To determine the rate of definitive correction, we sought to assess the need for ongoing medical or surgical BPH management following PUL. METHODS: With IRB approval, all cases of PUL performed from 2015-2020 at our academic center, notably a participating institution for the L.I.F.T. trial, were retrospectively reviewed. Data extracted included: demographics, medication use, symptomatology, operative details, and surgical reinterventions. RESULTS: 209 men were identified, with follow-up data available for 198 (95%). Mean age was 68.9 years (42–92) and mean follow-up was 18.5 months (0.5–66.4). Mean prostate size was 43.0 grams (8–138). Prior to PUL, significant intravesical protrusion and urethral stricture were noted cystoscopically in 22% and 8% of men, respectively. Mean procedure time was 19 minutes (2–60) and mean number of implants was 5.0 (1–10). Patients were discharged from recovery in 97% of cases, with 29% requiring indwelling or intermittent catheterization. The rate of 30-day complications was 18%, with 89% graded Clavien I or II. Postoperatively, mean improvements in International Prostate Symptom Score (IPSS) and quality of life (QOL) were 5.3 and 1.1 points, respectively. Unplanned emergency room or clinic visits occurred in 14% and 17% of men, respectively, with 4% requiring hospital readmission. Medication for LUTS attributed to BPH (α-blocker or 5α-reductase inhibitor) was continued or initiated postoperatively for 44% of men. 20% of men required repeat surgical intervention at a mean of 19.2 months (1.4–56.4), consisting of repeat PUL (30%), transurethral resection of prostate (28%), or thulium laser enucleation (18%). Overall, 53% of men needed medication and/or repeat surgery for BPH following PUL, and this was independent of age, race, prostate volume, intravesical prostate protrusion, baseline IPSS and QOL, stricture, number of implants used, or a history of urinary retention (p>0.05). CONCLUSIONS: Our data indicate that the majority of men undergoing PUL require ongoing medical and/or surgical management for BPH. Patients should be counseled as to the likelihood of failure as a unimodal therapy long-term. As this does not appear related to patient selection, the overall value of PUL to men with LUTS attributed to BPH should be carefully assessed. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e421-e421 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rahul Dutta More articles by this author Ethan Matz More articles by this author Nicholas Deebel More articles by this author Elizabeth Boes More articles by this author Ryan Terlecki More articles by this author Expand All Advertisement Loading ...

Global Greenlight Group: largest international Greenlight experience for benign prostatic hyperplasia to assess efficacy and safety.

Greenlight photo-selective vaporization of the prostate (GL-PVP) has gained international acceptance as a safe and effective alternative procedure for the treatment of benign prostatic hyperplasia (BPH), especially in anticoagulated men. This descriptive analysis aims to characterize the current state of GL-PVP, pooling data from international centers. Data from 3627 patients who underwent GL-PVP with the XPS-180W system in seven international centers performed by eight expert surgeons between 2011 and 2019 were retrospectively analyzed. Demographic, perioperative, and postoperative data were collected, including IPSS, QoL, Qmax, PVR, and PSA, and complications. At baseline, median age, prostate volume, PSA, and IPSS were 70years (interquartile range 64-77), 64 (47-90), 3.1ng/mL (1.8-6), and 22 (19-27), respectively. Median lasing and operative time were 34 (23-48) and 62min (46-85), respectively. Median energy use was 250.0kJ (168.4-367.9), with 92.6% of procedures being completed with one laser fiber. In 60.1% of cases, catheter was removed on postoperative day 1 with median length of 2days. All-cause mortality within 30days was 0.3%. Median PSA reduction at 3months and 60months compared to baseline was 43.9 and 46.4%, respectively (p < 0.001). All functional outcomes (IPSS, QoL, Qmax, and PVR) were significantly improved across study period when compared to baseline (p < 0.001). For those men with longer follow-up available, the observed surgical BPH retreatment rate was 1.5% CONCLUSION: Using the largest multi-user, international database of GL-PVP, Greenlight XPS laser treatment in experienced hands is a safe, effective, and durable BPH treatment option.

Prostatic osteopontin expression is associated with symptomatic benign prostatic hyperplasia.

Male lower urinary tract symptoms (LUTS) occur in more than half of men above 50 years of age. LUTS were traditionally attributed to benign prostatic hyperplasia (BPH) and therefore the clinical terminology often uses LUTS and BPH interchangeably. More recently, LUTS were also linked to fibrogenic and inflammatory processes. We tested whether osteopontin (OPN), a proinflammatory and profibrotic molecule, is increased in symptomatic BPH. We also tested whether prostate epithelial and stromal cells secrete OPN in response to proinflammatory stimuli and identified downstream targets of OPN in prostate stromal cells. Immunohistochemistry was performed on prostate sections obtained from the transition zone of patients who underwent surgery (Holmium laser enucleation of the prostate) to relieve LUTS (surgical BPH, S-BPH) or patients who underwent radical prostatectomy to remove low-grade prostate cancer (incidental BPH, I-BPH). Images of stained tissue sections were captured with a Nuance Multispectral Imaging System and histoscore, as a measure of OPN staining intensity, was determined with inForm software. OPN protein abundance was determined by Western blot analysis. The ability of prostate cells to secrete osteopontin in response to IL-1β and TGF-β1 was determined in stromal (BHPrS-1) and epithelial (NHPrE-1 and BHPrE-1) cells by enzyme-linked immunosorbent assay. Quantitative polymerase chain reaction was used to measure gene expression changes in these cells in response to OPN. OPN immunostaining and protein levels were more abundant in S-BPH than I-BPH. Staining was distributed across all cell types with the highest levels in epithelial cells. Multiple OPN protein variants were identified in immortalized prostate stromal and epithelial cells. TGF-β1 stimulated OPN secretion by NHPrE-1 cells and both IL-1β and TGF-β1 stimulated OPN secretion by BHPrS-1 cells. Interestingly, recombinant OPN increased the mRNA expression of CXCL1, CXCL2, CXCL8, PTGS2, and IL6 in BHPrS-1, but not in epithelial cell lines. OPN is more abundant in prostates of men with S-BPH compared to men with I-BPH. OPN secretion is stimulated by proinflammatory cytokines, and OPN acts directly on stromal cells to drive the synthesis of proinflammatory mRNAs. Pharmacological manipulation of prostatic OPN may have the potential to reduce LUTS by inhibiting both inflammatory and fibrotic pathways.