Impact of medical therapy on transurethral resection of the prostate: two decades of change

Outcomes of transurethral resection of prostate for benign prostatic obstruction stratified as per duration of prior medical therapy

INTRODUCTION/AIMS OF STUDY

This original work done in patients with Benign Prostatic Obstruction aims to find out the impact of duration of medication therapy on the outcomes of TURP. Medical management of BPO is recommended as the first line of treatment and surgery is usually reserved for those who have failure of medical management and/or complications of BPO (refractory retention, vesical calculus, recurrent UTI or hematuria). However, there is some pointing evidence that delay in the surgery may affect the overall outcomes of transurethral resection of prostate (TURP) [1, 2] Presently, there is a lacuna on the impact of delay in surgery owing to prolonged duration of preoperative medical therapy on the outcomes of surgery. We aimed to find this impact with the hypothesis that patients who are on long term medication therapy have less improvement in their subjective symptoms and objective bladder function parameters compared to patients who undergo surgery earlier.

METHODS

An observational prospective cohort study was conducted to evaluate the outcomes after TURP with respect to prior duration of pre operative medical management as < 3, 3-12 and > 12 months. Baseline characteristics (age, comorbidities, ASA grade, duration and type of medical therapy, indication of surgery, serum PSA, IPSS, Ultrasound imaging with post-void residual urine {PVR}, UDS storage and voiding pressures) were collected for all patients undergoing TURP. Operative details (surgical time, resected prostate weight) and post-operative outcomes (post-operative stay, catheter duration and Clavien-Dindo grade of complications) were noted. Follow up was done at 6 weeks, 3 months and 6 months with IPSS, PVR and UDS storage/voiding pressures. Primary outcome was patient-reported outcome measure (PROM) of IPSS based improvement of symptoms at 3 months. Secondary outcome measures included PROM at 6 weeks and 6 months, complete emptying of bladder (as measured by Ultrasound based PVR), Urodynamics Storage and Voiding pressures and comparison between patients who received only alpha blockers and those who also received 5-alpha reductase inhibitors. One way ANOVA was used for testing of mean between three independent groups whereas Repeat measure ANOVA was used for repeated observations. A p-value of < 0.05 was considered statistically significant. All analysis was done using SPSS software, version 25.0.

RESULTS

87 men undergoing TURP from Jan 2022-Dec 2023 were divided into three groups based on duration of preoperative medical therapy - <3 months (n = 24), 3-12 months (n = 27) and > 12 months (n = 36). Baseline parameters including age, co-morbidities, prostate size, ASA grade, serum PSA, resection time, resected prostate weight, post-operative stay, catheter duration and post-operative complications were found to be similar across all three groups. However, the patients in > 12 months group had poorer percent reduction in IPSS [30 ± 14.3 vs. 42.4 ± 10.3 vs. 39.1 ± 15.9, p = 0.002], PVR [40.8 ± 16.6 vs. 48.9 ± 20.6 vs. 63.3 ± 14, p < 0.001], and UDS storage [14.8 ± 12.4 vs. 16.7 ± 18.1 vs. 32.1 ± 21, p = 0.002] and voiding pressures [9.2 ± 11.4 vs. 19.7 ± 12.6 vs. 18.8 ± 13.1, p = 0.005] compared to the other group of patients. This difference in outcomes was consistent irrespective of the type of medication therapy (alpha blockers vs. combination therapy). There was a significant negative correlation between duration of medical therapy and IPSS reduction [r (86):-0.25, p = 0.008].

CONCLUSION

The delay in surgery due to prolonged preoperative medical therapy is associated with poorer IPSS, PVR, Urodynamic storage and voiding pressure improvements.

Is there a best timing for benign prostatic hyperplasia surgery?

INTRODUCTION

Treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH) has shifted over the last decades, with medical therapy becoming the primary treatment modality while surgery is being reserved mostly to patients who are not responding to medical treatment or presenting with complications from BPH. Here, we aim to to discuss the optimal timing of surgical management of LUTS/BPH.

MATERIALS AND METHODS

A literature search was conducted on Pub-Med/MEDLINE database to identify reports published from January 1990 until January 2022 by combining the following MeSH terms: "Lower Urinary Tract Symptoms"; "Prostatic Hyperplasia"; "Prostatic Hyperplasia/therapy"; "Prostatic Hyperplasia/complications"; "Treatment Outcome"; "Time-to-Treatment". Evidence supporting or not early surgical treatment of BPH was examined and reported in a pros and cons form.

RESULTS

The "pro early surgery" highlighted the superior efficacy and cost-effectiveness of surgery over medical treatment for BPH, as well as the possibility of worse postoperative outcomes for delayed surgical treatment. The "con early surgery" considered that medical therapy is efficient in well-selected patients and can avoid the serious risks inherent to surgical treatment of BPH including important sexual side effects.

CONCLUSIONS

Clinical trials comparing the outcomes for prolonged medical therapy versus early surgical treatment could determine which approach is more beneficial in the long-term in context of the aging population. Until then, both approaches have their advantages and patients should be involved in the treatment decision.

The decline in transurethral resection of the prostate gland in Irish public hospitals between 2005 and 2021

BACKGROUND

Lower urinary tract symptoms due to an enlarged prostate is a common condition. Transurethral resection of the prostate gland (TURP) has been the gold standard treatment. The objective of this study was to assess the trends in the prevalence of TURP procedures in Irish public hospitals within the period of 2005-2021. In addition, we explore the attitudes and practices of urologist in Ireland on this topic.

METHODS

An analysis using the Hospital In-Patient Enquiry (HIPE) system using code 37203-00 was undertaken. 16,176 discharges contained the code of interest and had undergone a TURP procedure. The data from this cohort was further analysed. In addition, members of the Irish Society of Urology undertook a bespoke questionnaire to understand the TURP surgery practices.

RESULTS

There has been a substantial decline in the prevalence of TURP procedures in Irish public hospitals from 2005 to 2021. The number of patients discharged from Irish hospitals with a TURP procedure was 66% less in 2021 compared to 2005. 75% (n = 36) of urologist surveyed felt that the declining TURP numbers were due to lack of resources, access to theatre/inpatient beds and outsourcing. 91.5% (n = 43) felt that the declining TURP numbers would result in a lack of training opportunities for trainees, 83% (39) felt this has increased morbidity for patients.

CONCLUSIONS

TURP procedures in Irish public hospitals has declined over the 16-year period studied. This decline is a concern for patient morbidity and urology training.

Shared Inherited Genetics of Benign Prostatic Hyperplasia and Prostate Cancer

Background

The association between benign prostatic hyperplasia (BPH) and prostate cancer (PCa) remains controversial, largely due to a detection bias in traditional observational studies.

Objective

To assess the association between BPH and PCa using inherited single nucleotide polymorphisms (SNPs).

Design setting and participants

The participants were White men from the population-based UK Biobank (UKB).

Outcome measurements and statistical analysis

The association between BPH and PCa was tested for (1) phenotypic correlation using chi-square, (2) genetic correlation (r _g) based on genome-wide SNPs using linkage disequilibrium score regression, and (3) cross-disease genetic associations based on known risk-associated SNPs (15 for BPH and 239 for PCa), individually and cumulatively using genetic risk score (GRS).

Results and limitations

Among 214 717 White men in the UKB, 24 623 (11%) and 14 311 (6.7%) had a diagnosis of BPH and PCa, respectively. Diagnoses of these two diseases were significantly correlated (χ² = 1862.80, p < 0.001). A significant genetic correlation was found (r _g = 0.16; 95% confidence interval 0.03-0.28, p = 0.01). In addition, significant cross-disease genetic associations for established risk-associated SNPs were also found. Among the 250 established genome-wide association study-significant SNPs of PCa or BPH, 49 were significantly associated with the risk of the other disease at p < 0.05, significantly more than expected by chance (N = 12, p < 0.001; χ² test). Furthermore, significant cross-disease GRS associations were also found; GRS_BPH was significantly associated with PCa risk (odds ratio [OR] = 1.26 [1.18-1.36], p < 0.001), and GRS_PCa was significantly associated with BPH risk (OR = 1.03 [1.02-1.04], p < 0.001). Moreover, GRS_BPH was significantly and inversely associated with lethal PCa risk in a PCa case-case analysis (OR = 0.58 [0.41-0.81], p = 0.002). Only White men were studied.

Conclusions

BPH and PCa share common inherited genetics, which suggests that the phenotypic association of these two diseases in observational studies is not entirely caused by the detection bias.

Patient summary

For the first time, we found that benign prostatic hyperplasia and prostate cancer are genetically related. This finding may have implications in disease etiology and risk stratification.

Venous thromboembolism (VTE) prophylaxis following transurethral resection of the prostate (TURP): An audit of practice in Scotland

Objectives:

To establish the current practice of urologists in Scotland with regard to venous thromboembolism (VTE) prophylaxis following transurethral resection of the prostate (TURP).

Methods:

An electronic survey was distributed to all practicing urology consultants and trainees in Scotland. Participants were asked questions regarding their current practice with regard to peri-operative VTE prophylaxis and were offered free-text responses. Findings were compared with a previous UK-wide study from 2002, and with current European Association of Urology (EAU) guidelines.

Results:

56/113 (49.6%) of urologists responded to the survey. Overall, 71.4% of responding urologists prescribed pharmacological VTE prophylaxis following TURP. No urologists routinely prescribe VTE prophylaxis on discharge. 94.6% of responding urologists utilise mechanical prophylaxis in the form of thromboembolic deterrent (TED) stockings, with 35.7% of urologists discharging patients with TED stockings. No urologists reported a death from uncontrollable bleeding after TURP in the previous 10 years, whereas 10% of respondents had a patient whom had suffered a death or serious complication from a thromboembolic event following TURP in the past 10 years. A range of free-text responses were given.

Conclusion:

Our national audit has identified a wide variation between practice and current published guidance. These results contrast dramatically with a previous UK wide audit from 2002, which found 14% of urologists utilised pharmacological prophylaxis, 50% utilised mechanical prophylaxis only and 23% used no thromboprophylaxis at all. Recent guidance from the EAU recommends against using pharmacological prophylaxis due to the increased bleeding risk. Given that current practice does not marry with published recommendations; we believe that further research is required in this area for stronger evidence-based guidelines to be developed.

Level of evidence:

4

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.

Is Early Surgical Treatment for Benign Prostatic Hyperplasia Preferable to Prolonged Medical Therapy: Pros and Cons

Background and objectives: Treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH) has shifted over the last decades, with medical therapy becoming the primary treatment modality while surgery is being reserved mostly to patients who are not responding to medical treatment or presenting with complications from BPH. Here, we aim to explore the evidence supporting or not early surgical treatment of BPH as opposed to prolonged medical therapy course. Materials and Methods: The debate was presented with a “pro and con” structure. The “pro” side supported the early surgical management of BPH. The “con” side successively refuted the “pro” side arguments. Results: The “pro” side highlighted the superior efficacy and cost-effectiveness of surgery over medical treatment for BPH, as well as the possibility of worse postoperative outcomes for delayed surgical treatment. The “con” side considered that medical therapy is efficient in well selected patients and can avoid the serious risks inherent to surgical treatment of BPH including important sexual side effects. Conclusions: Randomized clinical trials comparing the outcomes for prolonged medical therapy versus early surgical treatment could determine which approach is more beneficial in the long-term in context of the aging population. Until then, both approaches have their advantages and patients should be involve in the treatment decision.

The state of TURP through a historical lens

In 1926 Maximilian Stern introduced a new instrument to treat obstructions at the vesical orifice and baptized it resectoscope. With reference to astonishing historical statements about the new instrument and surgical technique made by the pioneers and their critics we will value why transurethral resection of the prostate (TURP) remains the gold standard for most men suffering from lower urinary tract symptoms (LUTS) due to benign prostatic enlargement. TURP is currently challenged by recently introduced new instruments and techniques claiming advantages over TURP. However, TURP offers an excellent balance between high efficacy in symptom relieve and low morbidity along with low costs and favorable long term outcome compared to other treatment options. We will outline these arguments demonstrating that even after a century has elapsed, since its introduction into the urologists armamentarium, TURP continues to stand the passage of time.

New Endoscopic In-office Surgical Therapies for Benign Prostatic Hyperplasia: A Systematic Review

CONTEXT

In recent years, new technologies have been developed to treat benign prostatic enlargement (BPE). Three of these devices may be utilized in office and are promising additions.

OBJECTIVE

To systematically review all clinical trials investigating prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), and temporary implantable nitinol device (TIND), with emphasis on clinical efficacy and complications.

EVIDENCE ACQUISITION

We performed a systematic review of PubMed/Medline database in November 2020 according to Preferred Reporting Items for Systematic Review and Meta-analysis guidelines.

EVIDENCE SYNTHESIS

Of 168 articles identified, 18 met the inclusion criteria. Evidence consisted of few randomized controlled trials, and multiple single-arm prospective and retrospective studies. Among the three modalities, PUL demonstrates rare occurrence of serious complications but higher retreatment rates at short- and long-term follow-up. WVTT offers lower retreatment rates with a similar safety profile. TIND studies report varying rates of retreatment and complications. All technologies offer low rates of erectile and ejaculatory dysfunction, although the risk appears to be highest for WVTT (<10.8%).

CONCLUSIONS

Among the emerging technologies introduced to treat BPE, the in-office PUL, WVTT, and TIND systems are valuable additions to the current surgical options. These systems offer unique advantages that should be considered in the shared decision-making process.

PATIENT SUMMARY

In this report, we identified all clinical trials reporting on the efficacy and safety of the in-office prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), and temporary implantable nitinol device (TIND) systems for the treatment of benign prostatic enlargement. We found that PUL and WVTT demonstrate acceptable outcomes in terms of functional improvement, retreatment, and complications. More data with longer follow-up are required to further evaluate TIND, but early results are promising.

Changes in Prevalence and Treatment Pattern of Benign Prostatic Hyperplasia in Korea

Purpose

Benign prostatic hyperplasia (BPH) is associated with lower urinary tract symptoms and negatively affects the quality of life. We aimed to investigate the treatment pattern of BPH in South Korea.

Methods

Information on treatment modalities and diagnoses of BPH was obtained from the Health Insurance Review and Assessment Service-Aged Patient Sample. Data on BPH patients aged >60 years from 2012 to 2016 were obtained. We surveyed the treatment pattern of BPH, including the types of drugs used and surgeries performed, according to the type of institution.

Results

In this study, 18,260-24,657 BPH patients treated between 2012 and 2016 were included. The number of patients showed an increasing pattern, and drug therapy was the major treatment method used for BPH (98.77%). Moreover, the pattern of increased pharmacotherapy use for BPH was reinforced by the increasing number of patients. Prescription of α-blockers only was dominant in this cohort (45.7%). Transurethral resection of the prostate (TURP) was the most commonly used surgical treatment for BPH (53.6%), but it showed a decreasing pattern over time. In contrast, holmium laser enucleation of the prostate (HoLEP) showed an increase from 19.4% to 39.7%.

Conclusions

The most common treatment for BPH was drug therapy, predominantly only α-blocker therapy. The surgical treatment trend has changed from TURP to HoLEP.

Does Prostatic Urethral Lift Reduce Urinary Medications? Trends in Medical Treatment Before and After Prostatic Urethral Lift

Objectives: To analyze medications used to treat urinary symptoms in patients before and after prostatic urethral lift (PUL) and determine if there are any significant relationships between several patient factors and onset of overactive bladder (OAB) symptoms requiring treatment. Methods: A retrospective chart review of 226 patients who underwent PUL was performed. Data were collected on age, urinary medications, voiding questionnaires, and prostate volume from 6 months before to 6 months after the intervention. Patients were broken up into groups for analysis with age <60 age (group 1), age 60-75 years (group 2), and age >75 years (group 3). A t-test was used to obtain p-values of the changes in questionnaire answers and urinary medication use after the procedure. To look for significant linear correlations between variables, a Pearson correlation was obtained and a randomization test was performed to obtain p-values. Results: Significant International Prostate Symptom Score (IPSS) and Quality of Life (QOL) improvements were noted in all groups (p < 0.01). Total medication and Alpha-blocker decrease was significantly correlated with age (p = 0.02 and p < 0.01, respectively). Older groups had a significant increase in Beta 3 agonist usage, with a significant decrease in usage in younger patients preoperatively. However, no significant linear increase was noted with age (p = 0.147). Prostate volume correlated with preoperative alpha-blocker use (p = 0.04). Conclusions: Older patients appear to have a higher incidence of medical treatment for de novo OAB symptoms after PUL. Prolonged medical therapy may delay surgical intervention, and intervention at an earlier age, unrelated to prostate volume, is postulated to be preventative of these symptoms. Further studies are needed to delineate long-term effects of medications, obstruction, and environmental factors that may lead to OAB after the obstruction is treated as well as the effect of early intervention on obstruction.

A Systematic Review on the Timing of Surgical Intervention for Benign Prostatic Enlargement (BPE)

PURPOSE OF REVIEW

Surgical intervention for benign prostatic enlargement (BPE) is typically reserved for those who fail medical therapy (i.e., α-blocker or 5-α reductase inhibitor treatment). We conducted a systematic review to determine whether timing of surgical intervention for BPE affects patient outcomes.

RECENT FINDINGS

The studies we reviewed suggested that patients who undergo surgical intervention for BPE after failing medical therapy may have worse outcomes. Increased age, worsened bladder function, and worse overall health may contribute to worsened outcomes. To date, there are few high-quality studies on the timing of surgical intervention for BPE in the literature. Further prospective trials are needed to determine ideal timing for intervention.

Admission of patients with acute urinary retention leads to a definitive management decision

BACKGROUND

Acute urinary retention (AUR) is a common urologic emergency. However, its management is not standardized due to lack of clinical guidelines.

AIMS

We retrospectively reviewed the treatment of all male patients admitted to our institution with AUR over 12 months.

METHODS

Data was obtained from the HIPE (Hospital Inpatient Enquiry) data system, each patient's electronic discharge summary and from patient medical records.

RESULTS

There were 130 AUR admissions during the period. About 74 admissions were due to benign prostatic enlargement (BPE). Of these, 45.9% (n = 34) passed their trial without catheter (TWOC). The remainder (n = 40) failed their TWOC necessitating recatheterization and consideration for transurethral resection of prostate (TURP) or re-TWOC. An indwelling urinary catheter (IDC) was inserted for 27.5% (n = 11) of patients with a failed TWOC secondary to comorbidities. This group had a mean age of 78 years (range 68-96 years). Of those who failed their TWOC, 32.5% (n = 13) had a TURP on index admission. Of the remaining 16 patients with failed TWOC, 75% (n = 12) were discharged with an IDC and readmitted for an elective TURP with a median waiting time of 55 days (range 17-138 days). 18.75% (n = 3) passed a re-TWOC and thus offset the need to have any surgical intervention and 6.25% (n = 1) proceeded to a radical retropubic prostatectomy for biopsy proven prostate adenocarcinoma.

CONCLUSION

Admission of patients with acute urinary retention leads to a definitive management decision and reduced prolonged catheterization.

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

INTRODUCTION

Benign prostatic obstruction (BPO) due to histological benign prostatic hyperplasia is highly prevalent among older men. Despite widespread use of medical therapy, surgical treatment remains a mainstay in the management of BPO. We sought to characterize trends in the surgical management of BPO in Ontario, Canada.

METHODS

We performed an interrupted time-series analysis using segmented regression among men aged 18 years and older undergoing surgical treatment for BPO between January 1, 1994 and December 31, 2014 in Ontario, Canada. The passage of time was considered the primary exposure. The primary outcome was the proportion of all BPO surgeries performed using each of the following modalities: transurethral resection of the prostate (TURP), endoscopic laser prostatectomy, open/laparoscopic prostatectomy, and others.

RESULTS

We identified 136 459 men who underwent BPO surgery between 1994 and 2014. The annual age-adjusted rate of BPO surgery declined significantly over time (24 to 10 per 10 000 population in 1994 and 2014, respectively). From 1994-2001, there were no significant changes in the distribution of BPO surgical modalities, with TURP the most common throughout (97.2% and 97% in 1994 and 2001, respectively). From 2002-2014, there was a significant decline in the use of TURP (92.1% to 76.9%; p=0.027) with a corresponding increase in the use of endoscopic laser prostatectomy (3.5% to 21.9%; p=0.0008).

CONCLUSIONS

This study demonstrates a shift in the management of BPO, with increasing use of endoscopic laser prostatectomy, beginning in 2002. However, TURP remains the most common treatment modality.

Complications after surgery for benign prostatic enlargement: a population-based cohort study in Ontario, Canada

OBJECTIVES

To examine the complication rates after benign prostatic enlargement (BPE) surgery and the effects of age, comorbidity and preoperative medical therapy.

DESIGN

A retrospective, population-based cohort study using linked administrative data.

SETTING

Ontario, Canada.

PARTICIPANTS

52 162 men≥66 years undergoing first BPE surgery between 1 January 2003 to 31 December 2014.

INTERVENTION

Medical therapy preoperatively and surgery for BPE.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was overall 30-day postoperative complication rates. Secondary outcomes included BPE-specific event rates (bleeding, infection, obstruction, trauma) and non-BPE specific event rates (cardiovascular, pulmonary, thromboembolic and renal). Multivariable analysis examined the association between preoperative medical therapy and postoperative complication rates.

RESULTS

The 30-day overall complication rate after BPE surgery was 2828 events/10 000 procedures and increased annually over the study period. Receipt of preoperative α-blocker monotherapy (relative rate (RR) 1.05; 95% CI 1.00 to 1.09; p=0.033) and antithrombotic medications (RR 1.27; 95% CI 1.22 to 1.31; p<0.0001) was associated with increased complication rates. Among the ≥80-year-old group, the rate of complications increased by 39% from 2003 to 2014 (RR 1.39; 95% CI 1.21 to 1.61; p<0.0001). The mean duration of medical and conservative management increased by a mean of 2.1 years between 2007 and 2014 (p<0.0001 for trend).

CONCLUSIONS

Thirty-day complication rates after BPE surgery have increased annually between 2003 and 2014. Preoperative medical therapy with alpha blockers or antithrombotics was independently associated with higher rates of complications. Over this time, the duration of conservative therapy also increased.

Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: systematic review and network meta-analysis

OBJECTIVE

To assess the efficacy and safety of different endoscopic surgical treatments for benign prostatic hyperplasia.

DESIGN

Systematic review and network meta-analysis of randomised controlled trials.

DATA SOURCES

A comprehensive search of PubMed, Embase, and Cochrane databases from inception to 31 March 2019.

STUDY SELECTION

Randomised controlled trials comparing vapourisation, resection, and enucleation of the prostate using monopolar, bipolar, or various laser systems (holmium, thulium, potassium titanyl phosphate, or diode) as surgical treatments for benign prostatic hyperplasia. The primary outcomes were the maximal flow rate (Qmax) and international prostate symptoms score (IPSS) at 12 months after surgical treatment. Secondary outcomes were Qmax and IPSS values at 6, 24, and 36 months after surgical treatment; perioperative parameters; and surgical complications.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted the study data and performed quality assessments using the Cochrane Risk of Bias Tool. The effect sizes were summarised using weighted mean differences for continuous outcomes and odds ratios for binary outcomes. Frequentist approach to the network meta-analysis was used to estimate comparative effects and safety. Ranking probabilities of each treatment were also calculated.

RESULTS

109 trials with a total of 13 676 participants were identified. Nine surgical treatments were evaluated. Enucleation achieved better Qmax and IPSS values than resection and vapourisation methods at six and 12 months after surgical treatment, and the difference maintained up to 24 and 36 months after surgical treatment. For Qmax at 12 months after surgical treatment, the best three methods compared with monopolar transurethral resection of the prostate (TURP) were bipolar enucleation (mean difference 2.42 mL/s (95% confidence interval 1.11 to 3.73)), diode laser enucleation (1.86 (-0.17 to 3.88)), and holmium laser enucleation (1.07 (0.07 to 2.08)). The worst performing method was diode laser vapourisation (-1.90 (-5.07 to 1.27)). The results of IPSS at 12 months after treatment were similar to Qmax at 12 months after treatment. The best three methods, versus monopolar TURP, were diode laser enucleation (mean difference -1.00 (-2.41 to 0.40)), bipolar enucleation (0.87 (-1.80 to 0.07)), and holmium laser enucleation (-0.84 (-1.51 to 0.58)). The worst performing method was diode laser vapourisation (1.30 (-1.16 to 3.76)). Eight new methods were better at controlling bleeding than monopolar TURP, resulting in a shorter catheterisation duration, reduced postoperative haemoglobin declination, fewer clot retention events, and lower blood transfusion rate. However, short term transient urinary incontinence might still be a concern for enucleation methods, compared with resection methods (odds ratio 1.92, 1.39 to 2.65). No substantial inconsistency between direct and indirect evidence was detected in primary or secondary outcomes.

CONCLUSION

Eight new endoscopic surgical methods for benign prostatic hyperplasia appeared to be superior in safety compared with monopolar TURP. Among these new treatments, enucleation methods showed better Qmax and IPSS values than vapourisation and resection methods.

STUDY REGISTRATION

CRD42018099583.

Correlation between prostatic urethral angulation and symptomatic improvement after surgery in patients with lower urinary tract symptoms according to prostate size

PURPOSE

To investigate the effect of prostate anatomical factors on the changes in lower urinary tract symptoms (LUTS) and uroflowmetric values after surgery.

METHODS

The medical records of 448 patients who underwent transurethral resection of the prostate (TURP) from January 2006 to December 2018 were analyzed retrospectively. Changes in the International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and post-void residual urine volume (PVR) at 3 months after TURP were evaluated. Prostate volume, intravesical prostatic protrusion (IPP), and prostatic urethral angulation (PUA) were measured using transrectal ultrasonography, and their effect on the changes in LUTS after TURP was analyzed using multivariable linear regression.

RESULTS

Among patients with prostate volume < 50 mL, preoperative IPSS total score (IPSS-t), voiding symptom score (IPSS-vs), and storage symptom score (IPSS-ss) were significantly better in patients with a smaller PUA (< 51°) than in those with a larger PUA (≥ 51°) (p = 0.001, < 0.001, and 0.020, respectively). Changes in IPSS-t, IPSS-vs, IPSS-ss, and PVR at 3 months after TURP were significantly correlated with PUA (p ≤ 0.001, < 0.001, 0.048, and 0.012, respectively). Multivariable linear regression revealed PUA to be independently associated with changes in IPPS-t and IPSS-vs (p = 0.025 and < 0.001, respectively) only in patients with prostate volume < 50 mL.

CONCLUSION

Prostatic urethral angulation was significantly associated with postoperative changes in LUTS only in patients with small prostate, and had no clinical significance in patients with large prostate. In patients with small prostate and large PUA, surgery should actively be considered.

Changing profiles of patients undergoing transurethral resection of the prostate over a decade: A single-center experience

Context:

Patients with benign prostatic hyperplasia (BPH) usually form the bulk in urology outpatient departments. The management options include medical therapy or surgery. Transurethral resection of the prostate (TURP) has been the mainstay of surgical management. The use of medical therapy has increased over the years. This has led to a shift in the profiles of patients undergoing surgical management of BPH.

Aims:

We conducted this study to analyze the differences in profiles of patients undergoing TURP over a decade.

Settings and Design:

This was a retrospective study.

Subjects and Methods:

We retrospectively reviewed the medical records of all patients who underwent TURP from January 1 to December 31 in 2006 and 2016. The age, preexisting comorbidities, prostate volume, operative time, mean prostatic tissue removed, duration of hospitalization, and complications were evaluated among the two groups of patients. Charlson comorbidity index was used to evaluate the preexisting comorbidities, and the modified Clavien classification system was used for evaluating the perioperative and postoperative complications.

Results:

A total of 114 and 125 patients underwent TURP in 2006 and 2016, respectively. The mean age of the patients was 62.1 ± 8.22 and 66.94 ± 9.12 years in 2006 and 2016, respectively. The serum prostate-specific antigen levels increased from 4.39 ± 4.425 to 5.59 ± 7.61 ng/ml a decade apart. A number of patients taking medical therapy before surgical intervention increased from 62.23% to 75.2% (P < 0.05). There was a significant increase in the mean prostatic volume and weight. There was only a modest increase of 1.94% in the total number of complications (P > 0.05) and no significant change in the rates of complications.

Conclusions:

Medical therapy for BPH patients has resulted in delayed surgical interventions. The complication rates have not increased. Thus, the increased use of medical therapy in BPH patients is justified though TURP may still be considered the gold standard.

National trends in surgical therapy for benign prostatic hyperplasia in Australia

BACKGROUND

To determine national trends in the utilization of surgical procedures for the treatment of benign prostatic hyperplasia (BPH) in Australia over the last 20 years.

METHODS

The Medicare Australia and Australian Institute of Health and Welfare databases were used to determine the annual number of surgical procedures and hospital admissions for BPH.

RESULTS

From 1998 to 2017, surgical procedures for BPH have increased by 79% which is largely commensurate with population growth. From 1998 to 2008, transurethral resection of the prostate (TURP) was the predominant surgical therapy, accounting for 96% of all surgical treatments. From 2008 to 2017, TURP use reduced to 70% and in the last 5 years has been replaced with photoselective vaporization (16%), UroLift (8%) and holmium laser prostatectomy (6%). UroLift is used significantly more in younger men (P < 0.001).

CONCLUSION

There has been a substantial increase in surgical treatments for BPH over the last 20 years. In the last 5 years, TURP use has declined due to an increase in laser prostatectomy and UroLift procedures.

Clinical Implications for the Early Treatment of Benign Prostatic Enlargement (BPE): a Systematic Review

PURPOSE OF REVIEW

Therapeutic options for the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement (BPE) have considerably increased in recent years. However, the ideal timing to initiate medical treatment of LUTS/BPE has not been fully established. The aim of this review was to systematically collect available evidence on the influence of early treatment on the natural history of LUTS/BPE patients.

RECENT FINDINGS

A systematic literature search from January 1996 until April 2018 was performed by combining the following MESH terms: Lower Urinary Tract Symptoms, Benign Prostatic Enlargement, male, medical treatment, surgical treatment, early treatment/intervention, and early intervention/treatment. The Medline, PubMed, and Scopus databases were searched. Each article title and abstract was reviewed for relevance and appropriateness with regard to the topic of this review. In recent years, the medical armamentarium for the management of LUTS secondary to BPE has been extensively implemented, significantly improving treatment outcomes and markedly reducing the need for BPE surgery. Early intervention in patients at risk for disease progression may offer better clinical outcomes compared to a deferred approach. However, evidences supporting early treatment are scarce, and criteria to discriminate patients that could mostly benefit from immediate treatment remain poorly defined. Moreover, as a result of delayed surgery after prolonged medical treatment, patients undergoing surgical relief show larger prostates, older age, and comorbidities. Nevertheless, technological advancements in surgical techniques have largely counterweighed this critical scenario, and commonly, a non-pejorative trend has been reported in perioperative complications. The timeliest moment to start a medical treatment in LUTS/BPE patients is still undefined, and unexpectedly, peer-reviewed evidence remains scarce. Further studies are awaited to better discriminate patients who mostly benefit from early treatment of LUTS/BPE.

The changing practice of transurethral resection of the prostate

Introduction Transurethral resection of the prostate (TURP) is considered the gold standard surgical treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. The number of TURPs performed has declined significantly over the last three decades owing to pharmaceutical therapy. TURP data from a single institution for the years 1990, 2000 and 2010 were compared to assess the difference in performance. Methods A retrospective analysis was undertaken of all patients who underwent TURP between January and December 2010. These findings were compared with historical data for the years 1990 and 2000: 100 sets of case notes were selected randomly from each of these years. Results The number of TURPs performed fell from 326 in 1990 to 113 in 2010. The mean age of patients increased from 70.6 years to 74.0 years. There was also a significant increase in the mean ASA grade from 1.9 to 2.3. The most common indication for TURP shifted from LUTS to acute urinary retention. No significant change in operating time was observed. The mean resection weight remained constant (22.95g in 1990, 22.55g in 2000, 20.76g in 2010). A reduction in transfusion rates was observed but there were higher rates of secondary haematuria and bladder neck stenosis. There was an increase from 2% to 11.5% of patients with long-term failure to void following TURP. Conclusions The number of TURPs performed continues to decline, which could lead to potential training issues. Urinary retention is still by far the most common indication. However, there has been a significant rise in the percentage of men presenting for TURP with high pressure chronic retention. The number of patients with bladder dysfunction who either have persistent storage LUTS or eventually require long-term catheterisation or intermittent self-catheterisation has increased markedly, which raises the question of what the long-term real life impact of medical therapy is on men with LUTS secondary to benign prostatic hyperplasia who eventually require surgery.

Efficacy of Holmium Laser Enucleation of the Prostate in Patients with a Small Prostate (≤30 mL)

Purpose

We investigated the effects of holmium laser enucleation of the prostate (HoLEP) in patients with a small prostate (≤30 mL) in whom medical treatment was ineffective.

Materials and Methods

Data from 132 patients who underwent HoLEP by a single surgeon between 2012 and 2015 were retrospectively analyzed. All patients received benign prostatic hyperplasia medication for at least 6 months before surgery. The patients were divided into 2 groups according to prostate size: group 1, ≤30 mL (n=30); and group 2, >30 mL (n=102). Clinical characteristics and the International Prostate Symptom Score (IPSS), including quality of life (QoL), peak urinary flow rate (Qmax), and postvoid residual urine (PVR), before surgery and 3 months postoperatively, were compared between the 2 groups.

Results

In group 1, the IPSS, QoL, and PVR significantly decreased and the Qmax significantly increased 3 months after surgery. The voiding subscore also significantly decreased 3 months after surgery (p<0.001), but the storage subscore was not significantly different (p=0.055). In group 2, hemoglobin, the IPSS, QoL, and PVR significantly decreased and the Qmax significantly increased 3 months after surgery. In these patients, both the storage subscore and voiding subscore significantly decreased after surgery (both p<0.001). There were no significant differences between the groups in hemoglobin, IPSS, QoL, Qmax, and PVR either before or 3 months after surgery.

Conclusions

When other medical treatments are ineffective, HoLEP is an effective intervention for patients with a small prostate.

Is early benign prostatic hyperplasia (BPH) treatment worthwhile?

BACKGROUND

The medical armamentaria for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) have been extensively implemented over the past decade. Nevertheless, the timeliest moment for a possible treatment has not been fully established.

EVIDENCE ACQUISITION

A systematic literature search in January 1996 until June 2016 was performed to answer the following question: in men with LUTS due to BPH, does early treatment result in better outcome? An ad hoc Population/patient Intervention/indicator Comparator/control Outcome (PICO) was developed.The Medline, PubMed and Scopus databases were searched. Each article title and abstract were reviewed for relevance and appropriateness with regard to the topic of this review.

EVIDENCE SYNTHESIS

Overtime, the introduction of novel medications and the implementation of surgical techniques have significantly improved the treatment outcomes and markedly reduced the rate of BPH surgery. Early treatments in patients at risk of disease progression may result in better clinical outcomes than a delayed approach. However, the evidence to support early intervention remains weak and criteria to identify the patient phenotype that could best benefit from immediate treatment remain ill-defined.On the contrary, the patients who ultimately undergo surgery following prolonged pharmacological treatment present with larger prostates, older age and comorbidities. At the same time, the technological progress has partly compensated this critical scenario, and commonly, a nonpejorative trend has been recorded in perioperative complications.

CONCLUSIONS

The ideal moment to begin a treatment in LUTS/BPH patients is still uncertain, and surprisingly, rare good quality studies are available on this topic.

Medical management of benign prostatic hyperplasia: Results from a population-based study

INTRODUCTION

In men with bothersome lower urinary tract symptoms (LUTS), medical treatment usually represents the first line. We examined the patterns of medical management of benign prostatic hyperplasia (BPH) in the Montreal metropolitan area, within the context of a case control study focusing on incident prostate cancer.

METHODS

Cases were 1933 men with incident prostate cancer. Population controls included 1994 age-matched men. In-person interviews collected sociodemographic characteristics and medical history, including BPH diagnosis, its duration, and type of medical treatment received. Baseline characteristics were compared by the chi-square likelihood test for categorical variables and by the students t-test for continuously coded variables.

RESULTS

Overall, 1120 participants had history of BPH; of those 53.7% received medical treatment for BPH. Individuals with medically treated BPH, compared to individuals with medically untreated BPH, were older at index date [mean: 66.9 vs. 64.9 years, p<0.001)] and at diagnosis of BPH [mean: 62.3 vs. 60.3 years, p<0.001]. They also had a longer duration of BPH-history [mean: 4.7 vs. 4.0 years, p=0.02]. Regarding medical treatment, mono-therapy was more often used than combination therapy [87.6% vs. 12.4%, p<0.001]. Alpha-blockers (69.9%) were most commonly used as monotherapy, followed by 5alpha-reductase inhibitors (5ARIs) (26.6%). Alpha-blockers plus 5ARIs were the most common combination therapy (97.3%).

CONCLUSIONS

Despite evidence from randomized, controlled trials for better efficacy with use of combination therapy, monotherapy consisting of alpha-blockers or 5ARI, in that order, is most frequently used. Additionally, 5ARI use was more common than previously reported (27% vs. 15%).

In Utero and Lactational TCDD Exposure Increases Susceptibility to Lower Urinary Tract Dysfunction in Adulthood

Benign prostatic hyperplasia, prostate cancer, and changes in the ratio of circulating testosterone and estradiol often occur concurrently in aging men and can lead to lower urinary tract (LUT) dysfunction. To explore the possibility of a fetal basis for the development of LUT dysfunction in adulthood, Tg(CMV-cre);Nkx3-1(+/-);Pten(fl/+) mice, which are genetically predisposed to prostate neoplasia, were exposedin uteroand during lactation to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD, 1 μg/kg po) or corn oil vehicle (5 ml/kg) after a single maternal dose on 13 days post coitus, and subsequently were aged without further manipulation, or at 8 weeks of age were exposed to exogenous 17 β-estradiol (2.5 mg) and testosterone (25 mg) (T+E2) via slow release subcutaneous implants.In uteroand lactational (IUL) TCDD exposure in the absence of exogenous hormone treatment reduced voiding pressure in adult mice, but otherwise had little effect on mouse LUT anatomy or function. By comparison, IUL TCDD exposure followed by exogenous hormone treatment increased relative kidney, bladder, dorsolateral prostate, and seminal vesicle weights, hydronephrosis incidence, and prostate epithelial cell proliferation, thickened prostate periductal smooth muscle, and altered prostate and bladder collagen fiber distribution. We propose a 2-hit model whereby IUL TCDD exposure sensitizes mice to exogenous-hormone-induced urinary tract dysfunction later in life.

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

PURPOSE

We determine whether outcomes of holmium laser enucleation of the prostate are similar in patients with and those without preoperative urinary retention.

MATERIALS AND METHODS

From May 2008 to July 2014, 231 patients underwent holmium laser prostate enucleation for symptomatic benign prostatic hyperplasia. Retrospective analysis was performed to evaluate for differences in postoperative outcomes for patients with and those without preoperative urinary retention.

RESULTS

Overall 95 patients (41%) had urinary retention before holmium laser prostate enucleation while 136 (59%) did not. Mean followup for all patients was 15.3 months. Patients with retention tended to be older, have larger prostates, and have higher scores on the AUA SS and bother questionnaires (all p <0.05). Postoperatively there was no difference in rates of complications, including urinary retention. Both groups showed significant improvement in AUA SS and bother score after the procedure at all postoperative points. Median post-void residual was less than 60 ml and median maximum flow rate on uninstrumented uroflow was greater than 18 ml per second at all postoperative points for all patients regardless of preoperative retention status. No patients required long-term catheterization and rates of postoperative complications did not differ significantly during the followup period.

CONCLUSIONS

This study represents the first direct comparison to our knowledge of holmium laser prostate enucleation outcomes in patients with or without urinary retention. There was no increased risk of postoperative urinary retention in patients with preoperative retention, and both groups demonstrated significant postoperative improvement in subjective and objective voiding measures.

Trends and Utilization of Laser Prostatectomy in Ambulatory Surgical Procedures for the Treatment of Benign Prostatic Hyperplasia in New York State (2000-2011)

INTRODUCTION

There has been a significant change in surgical treatment of benign prostatic hypertrophy (BPH) over the last two decades. Most importantly, laser surgery (coagulation, vaporization, or enucleation) has been growing in popularity as an alternative to standard transurethral prostatectomy (TURP) or other procedures. Our goal was to analyze the trends of BPH surgeries and compare outcomes of laser surgery to TURP, the two most common alternative surgeries.

MATERIALS AND METHODS

We used the New York Statewide Planning and Research Cooperation System (SPARCS) data to identify patients diagnosed as having BPH who underwent BPH-related surgery from October 2000 to December 2011. Age, insurance, individual comorbidities, and average hospital volumes were assessed. Bivariate and multivariate regression models were used to analyze predictors of laser use. In-hospital outcomes were then compared between laser and TURP in a balanced propensity-matched cohort.

RESULTS

Ninety thousand six hundred seventy patients underwent BPH surgery. Laser surgery usage increased from 6.4% to 44.5% over 10 years (p<0.0001). TURP declined significantly from 72.2% to 48.3% (p<0.0001). Patients with Medicaid were less likely to undergo laser therapy than those with private insurance (odds ratio [OR]: 0.58, 95% confidence interval [CI]: 0.48, 0.69). Mid- and high-volume institutions were more likely to use laser treatment than low-volume centers (OR: 2.26, 95% CI: 1.22, 4.2; OR: 4.07, 95% CI: 1.75, 9.46, respectively). In the matched cohort, both laser and TURP patients had similar complication rates with more frequent electrolyte disorders in TURP patients (2.9% vs 2.3%, p=0.001).

CONCLUSIONS

TURP remains the most common procedure. However, the rate of use has declined over time. In contrast, laser use has significantly increased. Laser treatment was utilized more in younger patients, in those privately insured, in hospitals with high volumes of BPH procedures, and in patients with fewer comorbid conditions. Both surgeries are safe with no differences in terms of occurrences of morbidity and complications.

Tolterodine to relieve urinary symptoms following transurethral resection of the prostate: a double-blind placebo-controlled randomized clinical trial

Purpose

To evaluate the effect of tolterodine on early storage symptoms following transurethral resection of the prostate.

Materials and Methods

Seventy patients over 55 years of age who underwent transurethral resection of the prostate owing to benign prostatic hyperplasia were randomly assigned to receive either 2 mg of tolterodine twice daily (treatment group) or matched placebo during a 1-month study period. Before and 1 month after the procedure, they were asked to complete the International Prostate Symptom Score (IPSS) questionnaire and quality of life subscale to assess their symptoms. Also, analgesic use and adverse drug events were determined at follow-up.

Results

Of 70 allocated patients, 64 patients (91.4%), including 33 in the treatment group and 31 in the placebo group, completed the study. The mean age of the patients was 67 years. None of the patients' basic clinical characteristics were significantly different. At the end of the follow-up period, the total IPSS and quality of life score had significantly improved in the patients receiving tolterodine compared with those receiving placebo (p=0.001 and p=0.036, respectively). The treatment group compared with placebo demonstrated significant improvements in frequency and urgency but not in nocturia. The amount of consumed painkiller was also significantly lower in the tolterodine group than in the placebo group (p=0.0001). The rate of side effects was not significantly different between the groups.

Conclusions

Administering 2 mg of tolterodine twice daily is an effective and well-tolerated regimen to relieve early storage symptoms, quality of life, and the amount of analgesic consumption following transurethral resection of the prostate.

Holmium laser enucleation of the prostate: a paradigm shift in benign prostatic hyperplasia surgery

Holmium laser enucleation (HoLEP) was developed in the 1990s as a more efficient and cost effective method of benign prostatic hyperplasia surgery than laser vaporization and resection techniques. As a true anatomical enucleation it mimics open prostatectomy and is as durable. There is a significant body of level 1 evidence in support of HoLEP, including 2 meta-analyses and 14 randomized trials which compare HoLEP with a number of other procedures. This review describes the development of and summarizes the evidence for HoLEP.

Bladder outlet obstruction in men with acute urinary retention: an urodynamic study

OBJECTIVE

To identify clinical predictors of bladder outlet obstruction (BOO) in men with the first episode of spontaneous acute urinary retention (AUR), in order to facilitate patient selection for early de-obstructive prostate surgery.

METHODS

A multichannel urodynamic investigation was performed in 156 consecutive men ≥ 50 years five days following AUR. Clinical routine parameters were evaluated for their ability to predict BOO, which was defined as a BOO-index (BOOI) >40. Univariable and multivariable logistic regression models were fitted. A nomogram was constructed from significant variables of a reduced multivariable model. Discrimination and calibration of the nomogram were assessed.

RESULTS

The mean age of the 156 men was 71.6 years, and the mean drained volume was 953 mL. Seventy-two men (46.2 %) had severe AUR-associated pain. On urodynamic evaluation, 79 (50.6 %) were obstructed (BOOI > 40). In multivariable regression analysis, age (p = 0.014) drained volume (p = 0.044) and pain intensity (p < 0.001) were independently associated with BOO. These variables formed the basis of the nomogram, which predicted BOO with a bootstrap-corrected accuracy of 78.2 %. The positive predictive value, sensitivity, and specificity of a 70 % nomogram cutoff was 83, 51, and 90 %, respectively. Decision-curve analysis demonstrated a net benefit with use of the nomogram.

CONCLUSIONS

The routine clinical parameters age, drained volume, and pain intensity are independent predictors of BOO in men with AUR. According to our model, patients with a nomogram predicted BOO probability of >70 % might be candidates for early surgery. External validation of the nomogram is advocated.

Impact of changing trends in medical therapy on surgery for benign prostatic hyperplasia over two decades

PURPOSE

Following the introduction of medical therapy for benign prostatic hyperplasia (BPH), we determined the effect of the change in trends in medical therapy on the indication and outcome of surgical intervention for BPH.

MATERIALS AND METHODS

We compared the basic characteristics of, weight of resected tissue of, transfusions in, and postoperative complications of patients who underwent surgery between 1985 and 1989 (before the advent of medical therapy for BPH), between 1995 and 1999 (when medical therapy was developed and became widely used as alternative treatment), and between 2005 and 2009 (when medical therapy superseded surgical intervention to become first-line treatment and when combination therapy became widely adopted).

RESULTS

At our institution, the mean age and BMI of patients increased over the past two decades (p<0.001). Hypertension, operation history, and other comorbidities also increased significantly (p<0.001, p=0.005, and p<0.001, respectively). The indications for surgery in 1985 to 1989, 1995 to 1999, and 2005 to 2009 were as follows: acute urinary retention in 34.7%, 20.2%, and 15.1% of patients and symptomatic deterioration in 61.1%, 72.3%, and 73.0% of patients, respectively. Prostate volume and the weight of resected tissue increased from 34.4±14.5 ml to 61.3±32.4 ml and from 7.2±6.4 g to 10.8±7.6 g, respectively, over two decades. Patients who underwent surgery in 2005 to 2009 had their catheters removed earlier (p<0.001). Secondary hemorrhage within four postoperative weeks and repeat transurethral resection of the prostate within 1 year decreased significantly (p=0.03 and p=0.003, respectively). No statistically significant change in impaired detrusor contractility was found (p=0.523).

CONCLUSIONS

Although patients who underwent surgery were older after widespread use of medical therapy for BPH, advancements in surgical techniques have benefitted these patients.

Management of acute urinary retention: a worldwide survey of 6074 men with benign prostatic hyperplasia

OBJECTIVES

To evaluate the management of acute urinary retention (AUR) associated with benign prostatic hyperplasia (BPH) in real-life practice.

To identify predictors of successful trial without catheter (TWOC).

MATERIALS AND METHODS

In all, 6074 men catheterized for painful AUR were enrolled in a prospective, cross-sectional survey conducted in public and private urology practices in France, Asia, Latin America, Algeria and the Middle East.

Patient clinical characteristics, type of AUR and its management (type of catheterization, hospitalization, TWOC, use of α₁-blockers, immediate or elective surgery) and adverse events observed during the catheterization period were recorded.

Predictors of TWOC success were also analysed by multivariate regression analysis with stepwise procedure.

RESULTS

Of the 6074 men, 4289 (71%) had a spontaneous AUR and 1785 (29%) had a precipitated AUR, mainly as the result of loco-regional/general anaesthesia (28.5%) and excessive alcohol intake (18.2%).

Presence of BPH was revealed by AUR in 44% of men. Hospitalization for AUR varied between countries, ranging from 1.7% in Algeria to 100% in France. A urethral catheter was inserted in most cases (89.8%) usually followed by a TWOC (78.0%) after a median of 5 days. Overall TWOC success rate was 61%.

Most men (86%) received an α₁-blocker (mainly alfuzosin) before catheter removal with consistently higher TWOC success rates, regardless of age and type of AUR. Multivariate regression analysis confirmed that α₁-blocker before TWOC doubled the chances of success (odds ratio 1.92, 95% CI 1.52–2.42, P < 0.001).

Age ≥70 years, prostate size ≥50 g, severe lower urinary tract symptoms, drained volume at catheterization ≥1000 mL and spontaneous AUR favoured TWOC failure. Catheterization >3 days did not influence TWOC success but was associated with increased morbidity and prolonged hospitalization for adverse events.

In the case of TWOC failure, 49% of men were recatheterized and had BPH surgery and 43.5% tried another TWOC with a success rate of 29.5%. Elective surgery was preferred to immediate surgery.

CONCLUSIONS

TWOC has become a standard practice worldwide for men with BPH and AUR.

In most cases, an α₁-blocker is prescribed before TWOC and significantly increases the chance of success.

Prolonged catheterization is associated with an increased morbidity.