Comparison of Holmium Laser Prostate Enucleation Outcomes in Patients with or without Preoperative Urinary Retention

Surgical outcomes of endoscopic enucleation of the prostate in community aging males with or without preoperative urinary retention

OBJECTIVES

This study aims to investigate the surgical outcomes of endoscopic enucleation of the prostate in older males with or without preoperative urinary retention (UR).

MATERIAL AND METHODS

We conducted a study on selected patients with symptomatic benign prostatic hyperplasia (BPH) who underwent either thulium:YAG laser (vela XL) prostate enucleation (ThuLEP) or bipolar plasma enucleation of the prostate (B-TUEP) at the geriatric urology department of our institution. The studied patients were categorized into two groups, namely the UR group and the non-UR group, on the basis of whether they experienced UR in the 1 month preceding their surgery. Their clinical outcomes following prostate endoscopic surgery were evaluated and analyzed.

RESULTS

Our results revealed comparable outcomes for operation time, length of hospital stay, percentage of tissue removed, re-catheterization rate, and urinary tract infection rate within the 1 month between the B-TUEP and ThuLEP surgery groups, regardless of UR history. However, the non-UR B-TUEP group experienced more blood loss relative to the non-UR ThuLEP group (P = .004). Notably, patients with UR exhibited significantly greater changes in IPSS total, IPSS voiding, and prostate-specific antigen values relative to those without UR.

CONCLUSIONS

Both ThuLEP and B-TUEP were effective in treating BPH-related bladder outlet obstruction. Our study identified more pronounced changes in IPSS total, IPSS voiding, and prostate-specific antigens within the UR group. Moreover, the rate of postoperative UR in this group was not higher than that observed in the non-UR group. Our study also revealed that the presumed benefits of laser surgery in reducing blood loss were less pronounced for patients with UR.

Open prostatectomy for benign prostatic hyperplasia: A critical analysis of patient presentation and surgical outcomes in a contemporary series

Background

Open prostatectomy (OP) is still a valid treatment option for benign prostatic hyperplasia (BPH), but it needs to be constantly reevaluated in the context of minimally invasive treatments (MITs).

Aim

Our purpose is to present contemporary data on patient presentation and surgical outcomes of OP with which other OP series and MITs can be compared.

Methods

A retrospective study of all OP was carried out in our institution from January 2011 to December 2020. All patients had a thorough preoperative workup and optimization of comorbidities before surgery. Data were collected in a predesigned pro forma and analyzed.

Results

The mean age of the 148 patients studied was 66.2 (±7.9) yrs. The mean duration of symptoms before surgery was 32.2 (±33.7) mos. The mean preoperative prostate volume was 118.0 (±67.1) cm3. There was a 54.4% comorbidity rate with diabetes mellitus (DM) topping the list (16.0%). An incidental prostate cancer rate of 6.1% was found. The overall complication rate was 45.3%. Perioperative hemorrhage requiring blood transfusion (BT) was the most common complication (26.1%). There was no significant difference in age, duration of surgery, and prostrate volume between subjects with and without BT (P > 0.05). Wound infection was significantly associated with diabetes (P = 0.043, OR = 3.507, 95% CI = 1.042-11.805). The reoperation rate was 1.4%, and mortality rate was 0.7%. The International Prostate Symptom Score (IPSS), quality-of-life (QOL) score, and post-void residual urine (PVR) volume were significantly improved (P < 0.001).

Conclusion

OP was found to be a safe and effective procedure for the relief of bladder outlet obstruction (BOO) secondary to BPH. However, it was associated with high morbidity and low reoperation rate.

Effect of urinary retention on the surgical outcome of holmium laser enucleation of the benign prostatic hyperplasia

PURPOSE

To evaluate the effect of urinary retention (UR) on holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms.

MATERIALS AND METHODS

A retrospective analysis of a prospective cohort of patients who underwent HoLEP between January 2010 and December 2016 was performed. The perioperative factors, including the International Prostate Symptom Score, Overactive Bladder Symptom Score, prostate-specific antigen, urodynamic study results, uroflowmetry results, transrectal ultrasound prostate volume, operative time, morcellation time, enucleation weight, and complications, were evaluated. Postoperative evaluation was performed at 2, 3, and 6 months.

RESULTS

Overall, 903 patients were identified. The mean age and follow-up were 68.3 years and 6 months, respectively. Among the patients, 135 (15.0%) patients had a history of acute UR (AUR), and 36 patients (4.0%) had chronic UR (CUR). The mean detrusor pressures at maximum flow were 64.4, 74.3, and 77.7 cmH₂O (p<0.001). The mean maximum flow rates (Qmax) were 7.6, 6.6, and 4.8 mL/s (p<0.001). Additionally, the mean bladder outlet obstruction indices were 49.5, 61.1, and 69.4 (p<0.001). The postoperative Qmax improved in all three groups. The mean postvoid residual volumes (PVRs) were 55, 75, and 333 mL preoperatively; 20, 29, and 66 mL at 2 weeks; 16, 23, and 45 mL at 3 months; and 15, 22, and 52 mL at 6 months (p<0.001).

CONCLUSIONS

Voiding symptoms, PVR, and Qmax of BPH patients with preoperative AUR and CUR significantly improved after Ho-LEP, similar to those without preoperative UR.

Predictive Value of Voiding Efficiency After Active Void Trial in Men Undergoing BPH Surgery

OBJECTIVES

To determine the predictive value of voiding efficiency on acute urinary retention after discharge from BPH surgery.

MATERIALS AND METHODS

We performed a prospective observational cohort study of three surgeons' practices from 2019 to present. All men included underwent trial of void on post-operative day one after transurethral resection of prostate or Holmium enucleation of prostate . Active filling void trials were performed on all patients and voiding efficiency (percent of bladder volume emptied) was calculated. Multivariable logistic regression was performed to determine predictors of developing acute urinary retention.

RESULTS

During the study period, 188 men met inclusion criteria. 110 (59%) men underwent Holmium enucleation of prostate , and 78 (41%) underwent transurethral resection of prostate. The median age of our cohort was 70 (IQR 65-75). The median prostate size was 100g (IQR 61-138g). Nineteen patients (10%) returned after discharge with acute urinary retention requiring catheterization. On post-operative day one, the median voiding efficiency was 75% (IQR 55%-94%). On multivariable analysis, patients with a voiding efficiency less than 50% were 3.8 times more likely (95% confidence interval 1.1-12.8) to develop subsequent retention compared to a voiding efficiency of greater than 75%. Increasing pre-operative prostate size was associated with lower risk of urinary retention after discharge (aOR 0.8, 95%CI 0.6-0.9).

CONCLUSIONS

Voiding efficiency after an active void trial helps stratify risk of urinary retention in patients undergoing benign prostate surgery. High-risk patients include those with voiding efficiencies less than 50% and smaller pre-operative prostate sizes (<80g).

Monopolar Transurethral Resection of Prostate for Benign Prostatic Hyperplasia in Patients With and Without Preoperative Urinary Catheterization: A Prospective Comparative Study

Background

A significant proportion of patients undergo surgery for benign prostatic hyperplasia following acute urinary retention. Studies have reported conflicting results of improvement following transurethral surgery in these patients.

Objective

To compare perioperative complications and postoperative voiding parameters in patients undergoing monopolar transurethral resection of prostate with and without preoperative Foley catheterization.

Methods

A prospective non-randomized study was conducted in patients undergoing monopolar transurethral resection of prostate for symptomatic benign prostatic hyperplasia. Patients were divided into those with Foley catheterization preoperatively (n=52), and those without catheters (n=90). Change in hemoglobin level, the resected volume of prostate, complications and the need for postoperative catheterization were compared. Postoperative symptoms score using International Prostate Symptom Score, maximum flow rate and post-void residual volume were assessed at three months follow up.

Results

The mean operative duration, length of stay and resected volume were higher in those patients with catheters; however, no significant differences were noted for mean hemoglobin level change and need for postoperative recatheterization. Three patients in each group required recatheterization and, all were catheter-free at one week postoperatively. Complications developed in 16.1% (n=23) with most of them being Clavien I. Patients with catheters had a lower postoperative maximum flow rate than those without it (16.90 vs 19.75 mL/sec). Patients with catheters had a significantly better postoperative quality of life and symptom score.

Conclusion

Monopolar transurethral resection of prostate in patients with preoperative per-urethral Foley catheter for acute urinary retention had similar postoperative voiding parameters with comparable complication rates to those without a catheter.

Differences in surgical and functional outcomes in benign prostate hyperplasia patients with only lower urinary tract symptoms versus those in retention: A systematic review and meta-analysis

AIMS

To evaluate outcomes after benign prostate hyperplasia (BPH) surgery among men with lower urinary tract symptoms (LUTS) only versus those with urinary retention (UR).

METHODS

The protocol was registered in PROSPERO with ID#232253. Eligible studies identified from four electronic databases. Search, data extraction and quality assessment were performed independently by two reviewers. Studies with perioperative, functional, early and late complication outcomes included.

RESULTS

Twenty-five studies, 14 593 patients including 1 randomized controlled trial, 11 prospective and 13 retrospective studies included for meta-analysis. This showed higher risk of immediate transient recatherization (risk ratio [RR]: 5.29, p < 0.00001), longer days to trial-off-catheter (mean difference [MD]: 0.25, p < 0.00001), longer hospitalization stay in the UR group (MD: 0.35, p < 0.00001), and higher risk of intraoperative blood transfusions (RR: 1.90, p = 0.002), postoperative urinary tract infections (RR: 1.49, p < 0.00001) and sepsis (RR: 8.15, p = 0.009) too. Failure of surgery like permanent recatheterization (RR: 5.27, p < 0.00001) was more in preoperative UR group. Negligible differences seen in long term functional outcomes between the two groups (International Prostate Symptom Score at 12 months, MD: -0.06, p = 0.68; Quality of Life at 12 months, MD: 0.20, p < 0.00001; maximum urinary flow rate at 12 months, MD: -0.33, p = 0.10; and postvoid residual volume at 12 months, MD: 4.32, p < 0.00001).

CONCLUSIONS

Preoperative UR patients undergoing surgery for BPH have higher risk of postoperative complications versus LUTS only group including the need for permanent catheterization. Both groups had similar long-term functional outcomes. We could infer that patients with UR on whom surgery is successful, with time may recover bladder function akin to patients with LUTS alone.

HoLEP for acute and non-neurogenic chronic urinary retention: how effective is it?

PURPOSE

To determine catheter status within 3 months of holmium laser enucleation of the prostate (HoLEP) for acute and non-neurogenic chronic urinary retention (AUR and NNCUR), to compare short-term outcomes of HoLEP for urinary retention (UR) versus lower urinary tract symptoms (LUTS), and to report long-term serum creatinine (SC) after HoLEP for high-pressure chronic urinary retention (HPCUR).

METHODS

A prospectively maintained database of the first 500 consecutive HoLEP cases performed under the care of a single surgeon was analysed retrospectively. Urodynamic studies (UDS) did not play a role in the decision making process for those with UR. NNCUR was defined as painless, with post-void residual volume (PVR) greater than 300 ml in men able to void and initial catheter drainage > 1000 ml in men unable to void.

RESULTS

280/500 (56%) were in UR: AUR (195), and NNCUR (85) including 22 with HPCUR. The UR cohort were older with higher enucleated tissue weight [median (IQR); 72 years (66-79 year) and 56 g (29.8-86.3 g)], than the LUTS cohort [70 years (64-75 year) and 38 g (18-67 g)] (p < 0.001). 98.9% with AUR and 98.8% with NNCUR were catheter-free 3 months after HoLEP. There were no significant differences in transfusion rates, hospital stay, or time to first trial without catheter (TWOC) between the LUTS and UR cohorts, nor in international prostate symptom score and quality of life scores, maximum urinary flow rate, post void residual volume or urinary incontinence at 3 months. Patients with NNCUR were less likely to pass their first TWOC (58.8%) than those with AUR (84.6%) or LUTS (87.7%), p < 0.001. None with HPCUR had a clinically significant deterioration in SC at a median of 60 months (IQR 36-82 months).

CONCLUSION

HoLEP has 3-month catheter-free rates in excess of 98.5% for AUR and NNCUR in patients not pre-selected by UDS. First TWOC is significantly more likely to fail after HoLEP for NNCUR than AUR or LUTS. HoLEP is a durable treatment for HPCUR and there is no need to monitor renal function to detect recurrence.

Efficacy, safety, and perioperative outcomes of holmium laser enucleation of the prostate-a comparison of patients with lower urinary tract symptoms and urinary retention

Holmium laser enucleation of the prostate (HoLEP) is a valid treatment option to relieve bladder outlet obstruction in patients with large prostate volumes (PV). Its efficacy, tolerability, and safety are comparable to the ones of other laser treatments of the prostate and resection techniques. However, safety and efficacy of HoLEP have not been compared between patients with and without preoperative urinary retention. We included 350 patients (mean age 71.2 years) who had undergone HoLEP due to lower urinary tract symptoms (LUTS) or urinary retention caused by prostatic hyperplasia. We evaluated the differences in peri- and postoperative outcomes and complications between patients with and patients without preoperative urinary retention. The mean PV was 115 cm³. PV was > 100 cm³ in 61.9% and < 100 cm³ in 38.1% of the patients. Perioperative complications occurred in 23 patients (6.6%), 15 of which (4.3%) required operative revision. We found no significant differences in terms of complication rates between patients with PV > 100 cm³ and patients with PV < 100 cm³. Mean catheterization-duration was 3.3 days. Preoperatively, 140 patients (40%) had a suprapubic or transurethral indwelling catheter; they did not differ from patients without preoperative catheter regarding postoperative catheter removal success rate, early postoperative complications, and functional outcomes. Prostate cancer was diagnosed in 43 patients (12.3%). Median postoperative PSA-decline was 6.1 ug/l (89.8% drop). HoLEP is a safe and effective treatment for patients with LUTS or urinary retention and large PV. PV > 100 cm³ was not associated with higher complication rates or successful catheter-removal. Furthermore, functional outcomes were independent of preoperative catheterization.

The low power effect on holmium laser enucleation of prostate (HoLEP); A comparison between 20W and 37,5W energy regarding apical enucleation efficacy and patient safety

INTRODUCTION

The Holmium laser has proven to be an invaluable tool for endoscopic prostate enucleation. The proper energy selection, during the different steps of the procedure, has always been a matter of debate. In this work we compare the effectiveness of the Holmium laser, using two different low-power energy settings, during enucleation and hemostasis (20W and 37.5W).

METHODS

One hundred and sixty patients underwent a HoLEP procedure with a 50Hz and 2J (100W) setting. During enuleation and hemostasis, two different low-power settings were applied (20W vs. 37.5W). In both groups, only the prostatic tissue in the bladder neck and enucleated tissue far away from the apex, were cut with a setting of 50Hz and 2J (100W).

RESULTS

The mean enucleation efficiency (0.78 vs. 1.2g/min-p:001) was significantly higher by utilizing 37.5W energy (group 2). Additionally, the mean enucleation rate (0.64 vs. 0.88%-P:0.001) and laser efficiency (2.07 vs. 2.12 joule/g-P:0.003) were significantly higher in group 2. The enucleation time was significantly shorter (54 vs. 75.5 mins-P:0.002), while the mean catheter removal time (27 vs. 42 hrs-P:0.008) and Hb decrease (0.5 vs. 0.6g/dl--P:0.019) were significantly lower in group 2.

CONCLUSIONS

HoLEP can be performed efficiently with 100 W-37.5W settings. Enucleation and hemostasis can be performed successfully with 37.5W, while the use of 100W during bladder neck dissection shortens the duration of the procedure.

LEVEL OF EVIDENCE

3.

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

INTRODUCTION

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.

EVIDENCE ACQUISITION

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.

EVIDENCE SYNTHESIS

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.

CONCLUSIONS

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.

Our clinic's first experience with HoLEP

OBJECTIVE:

The present study reports a retrospective evaluation of the first Holmium laser prostate enucleation (HoLEP) cases and their results in our clinic.

METHODS:

Twenty four patients who underwent HoLEP surgery between April 2017 and November 2017 were evaluated for demographic characteristics, duration of operation, amount of hemorrhage, amount of energy used, tissue weight removed, catheterization time and complications. IPSS and uroflowmetry results were compared before and after the surgery.

RESULTS:

Patients with hemoglobin, IPSS, uroflowmetry, and voiding speeds (Qmean, Qmax) were compared before and after the surgery. There was a significant difference in IPSS, Qmean and hemoglobin values but not in Qmax, statistically. Our complications rates were correlated with the literature.

CONCLUSION:

HoLEP stands out as a surgical method that can be applied with high confidence in the treatment of benign prostatic hyperplasia and it has similar functional results to gold standard surgeries, causes fewer complications, improves patient comfort due to short catheterization and hospitalization and is more advantageous regarding cost.

Current status of holmium laser enucleation of the prostate

There are several options for the surgical management of benign prostatic hyperplasia representatively from transurethral resection of the prostate. Holmium laser enucleation of the prostate is one of those options, and many institutions and urologists have initiated this technique, and most of them have accomplished better outcomes compared with transurethral resection of the prostate. In contrast to transurethral resection of the prostate, which requires a similar procedure to transurethral resection of bladder tumors, holmium laser enucleation of the prostate requires a special surgical technique: enucleation and morcellation with around 10 years' history of experience, even in Japan. The present review introduces the current status of holmium laser enucleation of the prostate, so that it surely contributes to the knowledge of International Journal of Urology readers who could be experienced surgeons or beginners as well.

Comparison of 120 W 2-μm laser resection of the prostate outcomes in patients with or without preoperative urinary retention

Introduction

The 2-μm (thulium) laser is a new surgical laser for benign prostatic hyperplasia (BPH).

Aim

To report on the long-term outcome of 120 W TmLRP-TT in BPH patients with or without preoperative urinary retention.

Material and methods

The study was conducted from May 2013 to April 2015 among patients who were diagnosed with BPH and underwent TmLRP-TT. Patients were divided into two groups: with and without preoperative urinary retention. Pre- and post-operative data were evaluated for prostate-specific antigens (PSA), International Prostate Symptom Score (IPSS), Quality Of Life Score (QOLS), maximum flow rate (Qmax), and post-void residual urine volume (PVR).

Results

A total of 310 patients were enrolled for a follow-up period of more than 12 months. Overall 95 (30.6%) patients had urinary retention before TmLRP-TT, while 215 (69.4%) did not. We found that patients with urinary retention tended to have larger prostates and a higher PSA score. So a longer operation time and catheterization time were observed in them. Yet there was no difference in other perioperative and postoperative parameters. Postoperatively IPSS, QOLS, Qmax, and PVR showed a significant improvement in each group, but no significant difference was identified between the two groups.

Conclusions

This study represents the first direct comparison of TmLRP-TT outcomes in patients with or without urinary retention. With safe use, resultant excellent homeostasis, high cutting efficiency and rapid vaporization, 120 W 2-μm laser resection of the prostate has been proved to be safe and effective, and there was no increased risk for patients with urinary retention.

Holmium laser enucleation of the prostate: patient selection and perspectives

Background

Multiple endoscopic surgical options exist to treat benign prostatic hyperplasia (BPH), including holmium laser enucleation of the prostate (HoLEP). HoLEP alleviates obstructive prostatic tissue via enucleation, both bluntly with a resectoscope and by cutting tissue with the holmium laser, and removal of adenoma via morcellation. This article reviews patient selection for HoLEP in order to optimize outcomes, costs, and patient satisfaction.

Methods

A literature review of all studies on HoLEP was conducted. Studies that focused on outcomes in regard to patient and procedural factors were closely reviewed and discussed.

Results

Various studies found that men with large or small prostates, on antithrombotic therapy, in urinary retention, with bladder hypocontractility, with prostate cancer, undergoing retreatment for BPH, or in need of concomitant surgery for bladder stones and other pathologies do well with HoLEP, as demonstrated by excellent functional and symptomatic outcomes as well as low complication rates. There is a 74–78% rate of retrograde ejaculation following HoLEP. Techniques to preserve ejaculatory function following enucleative techniques have not been able to demonstrate a significant improvement.

Conclusion

Patient selection for HoLEP can include most men with bothersome BPH who have evidence of bladder outlet obstruction and are healthy enough to undergo surgery. The ability to safely perform concomitant surgery with HoLEP benefits the patient by sparing them an additional anesthetic and also decreases costs. Patients should be made aware of the risk of retrograde ejaculation following HoLEP and counseled on treatment alternatives if maintaining ejaculatory function is desired.