The state of TURP through a historical lens

Endoscopic enucleation of the prostate versus transurethral resection of the prostate for benign prostatic hyperplasia: a systematic review and meta-analysis

BACKGROUND

Endoscopic enucleation of the prostate (EEP) has emerged as a leading surgical treatment for benign prostatic hyperplasia (BPH), traditionally managed by transurethral resection of the prostate (TURP). EEP involves complete adenoma removal along the surgical capsule and can be performed using different energy sources, such as holmium, thulium, GreenLight and diode lasers, or bipolar electrocautery. This meta-analysis compares the efficacy and safety of EEP versus TURP.

METHODS

A comprehensive search of MEDLINE, EMBASE, CENTRAL, Web of Science, and Scopus (2003-present) identified randomised controlled trials (RCTs) comparing EEP with TURP in adult males (≥18 years) with BPH. Primary outcomes comprised functional measures (Qmax, PVR, IPSS, QoL, IIEF-5), while secondary outcomes included adverse events (incontinence, bleeding, infection, re-treatment rates, hospital stay duration). Two reviewers independently performed data extraction and assessed risk of bias using the Cochrane RoB2 tool.

RESULTS

Twenty-eight RCTs (n = 3085) met inclusion criteria: 1538 patients underwent EEP and 1547 underwent TURP. EEP was associated with significantly improved IPSS (at 12 months), Qmax (1, 6, 12, 24 months), and PVR (6, 12, 36 months) compared with TURP. Perioperative outcomes favoured EEP, including shorter catheterisation time (MD = -1.12 days), reduced hospital stay (MD = -0.92 days), and lower transfusion rates (RR = 0.22). No significant differences were observed in long-term incontinence or bladder neck contracture, though EEP yielded lower stricture rates (RR = 0.55) and reoperation rates for recurrent BPH (RR = 0.32). Heterogeneity was high in several outcomes, reflecting variability in patient characteristics, enucleation techniques, and surgeon experience.

CONCLUSIONS

EEP compares favourably with TURP for BPH, providing notable benefits in bleeding control, faster recovery and durable obstruction relief. Anatomical enucleation yields functional outcomes at least equal and often superior to TURP. Energy source choice may reflect resources and surgeon preferences. Future research should distinguish enucleation completeness from energy source.

Transurethral resection of the prostate across continents: a meta-analysis evaluating quality of gold standard in the twenty-first century

PURPOSE

To compare outcomes of transurethral resection of the prostate (TURP) across different regions worldwide over the past two decades.

METHODS

A systematic review and meta-analysis of randomized clinical trials indexed to PubMed that assessed TURP. A total of 102 studies with 8,454 patients were included and grouped by continents: Europe, Asia, Africa, and Others (North America, South America, and Australia). International Prostate Symptom Score (IPSS), peak flow (Qmax), postvoid residual urine (PVR), PSA levels, prostate volume, and Sexual Health Inventory for Men scores (at 3, 12, and 36 months) were assessed, along with postoperative complications. Heterogeneity across studies was classified as low (I2 < 25%), moderate (I2 = 25-75%), or high (I2 > 75%).

RESULTS

TURP consistently exhibited significant enhancements in IPSS, Qmax, and PVR across various regions. Notably, PVR demonstrated high heterogeneity (I²=100%). TURP presented low complication rates with TURP syndrome (2%), bleeding (8%), and blood transfusion (6%). However, significant heterogeneity was observed, particularly for clot evacuation (I2 = 87%), irritative symptoms (I2 = 96%), and incontinence (I2 = 84%). The retreatment rates at 1 and 3 years were 5% and 7%, respectively, with significant differences across regions.

CONCLUSION

Global outcomes of TURP lack a discernible trend. The substantial heterogeneity observed among continents suggests a lack of standardization. Nevertheless, uniform symptomatic improvements among patients still support TURP as the gold-standard surgical treatment for benign prostatic hyperplasia, despite variations in its results worldwide.

Evaluating the utility of the HAS-BLED bleeding-estimator tool for transurethral resection of prostate

Objectives

To evaluate the utility of the HAS-BLED bleeding risk-estimation tool to predict for clinically significant postoperative haematuria in patients receiving transurethral resection of prostate (TURP).

Patients and Methods

A single-centre, retrospective cohort analysis of patients underwent TURP from April 2019 to December 2023 for treatment of symptomatic benign prostate hyperplasia. The primary objective was to evaluate reliability of HAS-BLED score in predicting postoperative bleeding event. A focus sub-analysis was performed on anticoagulated patient cohort. Each patient was categorised in to HASBLED low-, moderate- and high-risk group according to the preestablished estimator tool. Patients' demographics, clinical, pathological and operative details were collected. Events of clinically significant haematuria within 3 months postoperatively were captured. Cohort characteristics and outcome were analysed with two-sided t test and ANOVA test. Further weight-adjusted multivariable analysis and ROC curve was performed to evaluate the predictive value of HAS-BLED score.

Results

Our analysis showed that patients assigned as high-risk by HAS-BLED were at 2.17-times higher chance of developing clinically significant haematuria compared to the low-risk patients. The risk for high-risk patient was 18.5% (95%CI 11.7-25.3%) and 8.5% (95%CI 4.6-12.4%) for low-risk patients. Moderate-risk did not demonstrate any significant difference relative to the low-risk group. Sub-analysis of 113 patients receiving long-term anticoagulation accentuates the utility of the tool. The risk of haematuria for high-risk patient was 32.7% (95%CI 20.7-44.7%), moderate-risk patient was 28.7% (95%CI 17.0-40.3%), and low-risk patient was 9.7% (95%CI 4.2-15.2%). In this cohort, the risk of haematuria was 3.37 and 2.96 times higher in the high and moderate-risk compared to the low-risk group, respectively.

Conclusion

This is the first study to validate a bleeding estimator tool for TURP patients. High HAS-BLED score positively predicts clinically significant post-TURP haematuria, particularly for patients receiving anticoagulation therapy.

Comparison of perioperative bleeding risk between direct oral anticoagulants in transurethral resection of prostate

OBJECTIVES

To evaluate the perioperative morbidity and mortality associated with direct oral anticoagulants (DOACs) and warfarin for patients receiving transurethral resection of prostate (TURP).

PATIENTS AND METHODS

This was a single-centre, retrospective cohort analysis of patients who underwent TURP for benign prostate hyperplasia from April 2019 to December 2023. The primary objective was to evaluate the perioperative bleeding and thromboembolic risk between anticoagulated (AC) vs no-AC patients. The secondary objective was to evaluate perioperative bleeding and thromboembolic risk between different formulations of DOACs. Patient demographics, prior treatment, prostate size, baseline bleeding risk, and operative details were collected. Bleeding and thromboembolic-related morbidity were captured within a 3-month postoperative period. Perioperative management of AC therapy was recorded, and all patients had their AC therapy withheld. Cohort characteristic between the AC vs no-AC, and DOAC groups were analysed with two-sided t-test, and chi-square test. Further logistic regression analyses were carried out to identified significant variables between the groups. These significant variables were used for adjustment in inverse probability-weighted treatment effect analysis to evaluate bleeding risk.

RESULTS

There were 629 patients in the cohort, and 113 (18%) patients were receiving AC therapy. The AC patients were at 1.6 times statistically significant increased risk of acute bleeding, and 11 times increased risk of prolonged haematuria for >14 days. When compared to apixaban, patients on rivaroxaban conferred a statistically significant increased risk of acute bleeding by 2.21 times. Patients receiving AC therapy had a statistically significant increased risk of stroke in the perioperative setting (no-AC vs AC: 0.4% vs 2.7%, P = 0.01).

CONCLUSION

This is the first study to evaluate risk of bleeding for TURP patients receiving DOACs. The AC patients are more likely to experience haematuria and stroke in the perioperative period despite withholding therapy. Apixaban appears to cause less bleeding-related complications than rivaroxaban.

Evaluating transurethral resection of the prostate over twenty years: a systematic review and meta-analysis of randomized clinical trials

PURPOSE

The goal of this systematic review is to assess the temporal changes in outcomes and complications of transurethral resection of the prostate (TURP) from 2000 to 2022.

METHODS

We conducted a systematic review and meta-analysis of 103 randomized clinical trials from PubMed on TURP, involving 8521 patients. Studies were grouped by years: 2000-2004, 2005-2009, 2010-2014, and 2015-2022. We assessed International Prostate Symptom Score (IPSS), Peak Flow (Qmax), Post-void residue of urine (PVR), and post-operative complications. Heterogeneity was ranked as low (I2 < 25%), moderate (I2 = 25-75%), or high (I2 > 75%).

RESULTS

TURP significantly improved IPSS, Qmax, and PVR, with the most recent studies showing superior results in IPSS and Qmax after 3 years compared to 2000-2004 studies. Heterogeneity in PVR was high (I2 = 100%). No negative impact on erectile function was observed. Complication rates included TURP syndrome (2%), bleeding (8%), and blood transfusion (6%), but elevated heterogeneity with difference between the groups was seen in clot evacuation (I2 = 83%) and urinary tract infections (I2 = 82%). Other complications were urinary retention (4%), incontinence (8%), urethral stricture (3%), bladder neck stenosis (2%).

CONCLUSION

In the last 20 years there has not been a clear trend in the results of TURP. The found heterogeneity may indicate a lack of standardization in TURP procedures. However, symptomatic improvement among patients is uniform, which supports this procedure as a historical benchmark surgical treatment for BPH.

Current era HOLEP with MOSES 2.0 technology compared to the gold standard TURP

PURPOSE

Bipolar TURP is regarded as the gold standard for treatment of BPH. Historically, when compared to HOLEP, bTURP has been found to have shorter operative times and is considered more efficient. We sought to compare the efficiency, efficacy, and safety of current era HOLEP with MOSES 2.0 technology (MOLEP) and bTURP.

METHODS

We performed a retrospective review of patients who underwent bTURP or MOLEP at our institution between 2018 and 2023. Preoperative, intraoperative, and postoperative characteristics were collected for analysis. Analysis was done with SPSS software with significance defined as p < 0.05.

RESULTS

We identified 195 bTURPs and 918 MOLEPs performed at our institution. Men undergoing MOLEP had significantly higher pre-op prostate volume and resected weight (61 ml v 123 ml and 15 g v 70 g, p < 0.001, respectively) when compared to bTURP patients. MOLEP was completed in significantly less OR and procedure time compared to bTURP (66 min vs. 73 min, p < 0.001; 90 min vs. 111 min, p = 0.026, respectively). These results remained significant when controlling for age and prostate volume. At a mean follow up of 3.7 months, HOLEP patients were significantly more likely to be medication (0 vs. 35.84% p < 0.001) and catheter free post-operatively (0.95% vs. 5.68%, p < 0.001) compared to bTURP.

CONCLUSION

In our contemporary cohort, MOLEP is faster and more efficient than bTURP. These findings remained significant despite being performed on larger prostates and in patients more likely to be anticoagulated. Furthermore, MOLEP patients are more likely to remain catheter and medication free at follow-up when compared to bTURP.

MRI-guided transrectal prostate laser ablation for benign prostatic hypertrophy: a retrospective cohort study

PURPOSE

To investigate whether MRI-guided transrectal laser ablation is safe and effective for the treatment of lower urinary tract symptoms caused by BPH.

MATERIALS AND METHODS

This single-center retrospective cohort study evaluated men who underwent MRI-guided transrectal laser ablation for BPH between February 2017 and July 2021. Age, prostate-specific antigen, prostate volume, prior surgical BPH treatments if any, International Prostate Symptom Score (IPSS) and Sexual Health Inventory of Men (SHIM) were collected. The primary outcome measures assessed were change in IPSS and SHIM 6, 12 and 24 months after laser ablation and adverse events.

RESULTS

Fifty-two patients were included, having completed at least one follow-up survey. The mean patient age was 62.9 ± 5.7 years, and mean prostate volume was 80.2 ± 39.2 cc. Eighteen patients (34.6%) had received a prior BPH treatment. The IPSS scores dropped an average of 16.7 ± 7.0 (p < 0.001), 16.9 ± 7.5 (p < 0.001) and 17.1 ± 7.2 (p < 0.001) points from baseline at 6, 12 and 24 months, respectively. There was no statistically significant difference in IPSS score drop between patients who had received a prior BPH procedure and those who had not (p = 0.628). The SHIM scores showed a statistically insignificant increase at all time points. Nineteen patients (36.5%) reported a complication. There were 12 grade II complications (23%) and seven grade I complications (13.5%). There were no grade III or higher complications.

CONCLUSION

Transrectal MRI-guided focal laser ablation is safe and effective for the treatment of lower urinary tract symptoms caused by BPH, with a significant improvement in symptom severity after 2 years.

A 27-Year Experience With Day Surgery Transurethral Resection of the Prostate

Introduction Transurethral resection of the prostate (TURP) is the standard surgical procedure for obstructive symptoms of the lower urinary tract when medical management fails. Progression in TURP procedures has led to reduced catheterization time following transurethral prostatic resection. This study describes the methods and results of TURP performed in the day surgery setting. Materials and methods This retrospective study was performed at a day surgical hospital serving a patient population of more than 200,000 people. Over a 27-year period, a total of 1,123 patients with a mean age of 73.6 years (range: 49 to 91 years) underwent same-day conventional (electrosurgical monopolar) transurethral prostatic resection. Of the procedure, 43 patients (11%) received spinal anaesthesia, and the remainder received general anaesthesia.  Results Over the years, there has been an increase in the use of medication to manage bladder outflow obstructive symptoms, which has led to the preoperative post-micturition volumes of urine being increased (>200 ml) at the time of surgical intervention. The mean American Urological Association (AUA) score was 22 (range: 10-35). Due to the reduced bladder tone preoperatively and the noted intraoperative distension of the bladder, early catheter removal is contraindicated in these patients. The mean duration of catheterization was 6.4 days (range: two to 28 days). No patient was readmitted to the hospital for retention of urine. However, 11 patients in the series had re-catheterization due to failure of micturition after the removal of the catheter. No patients were admitted to the hospital for clot retention or sepsis postoperatively. This resulted in the patients being discharged home with a catheter in place, which became our standard practice. Conclusion Conventional transurethral resection of the prostate can be effectively managed in the day surgery setting with minimal morbidity. This improves the patient's quality of life as well as the burden on hospital costs. Additionally, the outpatient nature of day surgery may lead to decreased overall healthcare expenses for both the patient and the healthcare system. As healthcare systems continue to prioritize streamlined and patient-centred approaches, day surgery for TURP emerges as a viable and advantageous option.

Minimally invasive techniques in quest of Holy Grail of surgical management of enlarged prostates: a narrative review

PURPOSE

Past decade has seen a renewed interest in minimally invasive surgical techniques (MISTs) for management of enlarged prostate. This narrative review aims to explore newer MIST for benign prostatic hyperplasia (BPH) which are not yet integrated into established societal guidelines.

METHODS

We conducted a literature search across PubMed, Google Scholar, and FDA ClinicalTrials.gov databases on June 1st, 2023, to identify studies published within the past decade exploring various MISTs for BPH. Additionally, we gathered insights from abstracts presented in meetings of professional associations and corporate websites. We broadly classified these procedures into three distinct categories: energy-based, balloon dilation, and implant/stent treatments. We collected detail information about the device, procedure details, its inclusion and exclusion criteria, and outcome.

RESULTS

Our review reveals that newer energy-based MISTs include Transperineal Laser Ablation, Transurethral Ultrasound Ablation, and High-Intensity Focused Ultrasound. In the sphere of balloon dilation, Transurethral Columnar Balloon Dilation and the Optilume BPH Catheter System were gaining momentum. The noteworthy implants/stents that are on horizon include Butterfly Prostatic Retraction Device, Urocross Expander System, Zenflow Spring System, and ProVee Urethral Expander System.

CONCLUSION

The exploration of various MISTs reflects ongoing efforts to enhance patient care and address limitations of existing treatments. This review provides a bird-eye view and valuable insights for urologists and researchers seeking to navigate the dynamic landscape of MISTs in the quest for effective and minimally invasive solutions for enlarged prostates.

Comparative RNA-sequencing analysis of the prostate in a mouse model of benign prostatic hyperplasia with bladder outlet obstruction

In ageing men, benign prostatic hyperplasia (BPH) is a chronic disease that leads to progressive lower urinary tract symptoms (LUTS) caused by obstruction of the bladder outlet (BOO). Patients with LUTS (such as increased frequency and urgency of urination) and complications of BOO (such as hydronephrosis and bladder stones) are at risk of serious health problems. BPH causes a rapidly rising burden of LUTS far exceeding that of other urological conditions. Treatment outcomes are unsatisfactory for BPH largely due to the lacking of fully understanding of the pathogenesis. Hormonal imbalances related to androgen and oestrogen can cause BPH, but the exact mechanism is still unknown, even the animal model is not fully understood. Additionally, there are no large-scale data to explain this mechanism. A BPH mouse model was established using mixed slow-release pellets of testosterone (T) and estradiol (E2), and we measured gene expression in mouse prostate tissue using RNA-seq, verified the results using qRT‒PCR, and used bioinformatics methods to analyse the differentially expressed genes (DEGs).

Network Meta-Analysis of the Treatment Safety and Efficacy of Different Lasers in Prostate Enucleation

Purpose: This study aimed to compare different laser systems for the enucleation of benign prostate hyperplasia. Methods: Randomized controlled trials (RCTs) on different lasers for prostate enucleation were searched from PubMed, Embase, and CNKI databases. Pairwise and network meta-analyis (NMA) were performed to analyze the outcome regarding surgery time, complications, short-term postvoid residual (PVR), long-term PVR, and short-term international prostate symptom score (IPSS), long-term IPSS, short-term maximum urine flow rate (Qmax), and long-term Qmax. RevMan software was used for paired meta-analysis. Considering the variance uncertainty caused by the different source regions of RCTs and the different primary conditions of surgeons and patients, this study uses Bayesian NMA conducted with ADDIS software to compare different treatment methods indirectly. Node-splitting analysis was used to test inconsistency for closed-loop indirect comparison. Results: Nine studies were included in this study, involving four types of lasers: diode laser, holmium laser, thulium laser, and greenlight laser. In safety paired meta-analysis, holmium laser could bring more complication risk than thulium laser (odds ratio: 2.70, 95% confidential interval [CI]: 1.79-4.00, p < 0.001), and no other significant result was detected. In the efficacy comparisons, holmium laser could offer better postoperative long-term PVR (standardized mean difference [SMD]: -0.35, 95%CI: -0.62, -0.09, p = 0.011), better postoperative long-term IPSS (SMD: -0.30, 95%CI: -0.57, -0.04, p = 0.011), better postoperative short-term Qmax (SMD: 0.44, 95%CI: 0.17, 0.70, p = 0.001) compared with greenlight laser. According to the results of NMA, greenlight laser may bring more complication risks when applied to prostate enucleation than the other three lasers. Thulium laser may be the recommended laser system for prostate enucleation. Conclusion: Thulium laser may be the recommended laser system since it can bring less complication risk with comparable efficacy. More RCTs are still needed to validate this study.