Open suprapubic versus retropubic prostatectomy in the treatment of benign prostatic hyperplasia during resident's learning curve: a randomized controlled trial

Benign prostatic hyperplasia surgical treatment trends in the Public Health System in São Paulo, Brazil

Objective

To describe and compare the number of surgeries, mortality rate, length of hospital stay, and costs of transurethral resection of the prostate and open prostatectomy for the treatment of benign prostatic hyperplasia, between 2008 and 2018, in the Public Health System in São Paulo, Brazil.

Methods

Ecological and retrospective study using data from the informatics department of the Brazilian Public Health System database. Procedure codes were “open prostatectomy” and “transurethral resection of the prostate.” The outcomes analyzed were compared between transurethral resection of the prostate and open prostatectomy according to the hospital surgical volume and presence or absence of a residency program.

Results

A total of 18,874 surgeries were analyzed (77% transurethral resection of the prostate) and overall mortality was not statistically different between procedures. Intermediate and high-volume centers had shorter length of hospital stay than low-volume centers for transurethral resection of the prostate (3.28, 3.02, and 6.58 days, respectively, p=0.01 and p=0.004). Length of hospital stay was also shorter for open prostatectomy in high-volume compared to low-volume centers (4.86 versus 10.76 days, p=0.036). Intrahospital mortality was inversely associated with surgical volume for transurethral resection of the prostate. Centers with residency program had shorter length of hospital stay considering open prostatectomy and less mortality regarding transurethral resection of the prostate. Open prostatectomy was 64% more expensive than transurethral resection of the prostate.

Conclusion

The findings suggest the importance of investing in specialized centers, which could be potential referral centers for surgical cases.

Minimally invasive simple prostatectomy: Robotic-assisted versus laparoscopy. A comparative study

PURPOSE

Robotic-assisted simple prostatectomy (RASP) is a novel surgical procedure for the management of obstructive symptoms caused by enlarged prostate glands. Before the introduction of minimally invasive techniques, the standard approach was the open simple prostatectomy (OSP). The aim of our study was to compare intraoperative and perioperative outcomes of robotic (RASP) and laparoscopic (LSP) simple prostatectomy.

METHODS

We retrospectively analyzed data from patients who underwent minimally invasive simple prostatectomy at the Urological Department of Portogruaro Hospital, Portogruaro, and at the Urological Department of "San Bassiano" Hospital, in Bassano del Grappa, from March 2015 to December 2020. Data collected from medical records included age, body mass index, prostate volume, operative time, preoperative International Prostatic Symptoms Score (IPSS), postoperative IPSS, time with drainage, blood transfusion, intraoperative complications, perioperative complications and length of hospital stay.

RESULTS

Robotic-assisted (n = 25) and laparoscopic simple prostatectomy (n = 25) were performed with a transvesical approach. No significant differences were observed regarding baseline characteristics, body mass index, prostate volume and IPSS. Operative time was lower in the laparoscopic group (122 min vs 139 min) (p = 0.024), while hospital stay was lower in the robotic group (4 days vs 6 days) (p = 0.047).

CONCLUSIONS

Robotic-assisted simple prostatectomy is a safe technique with results comparable to laparoscopic simple prostatectomy, encompassing the advantage of a shorter hospitalization. Considering the costs and the limited availability of robotic-assisted simple prostatectomy, laparoscopic simple prostatectomy is a valid and safe alternative for experienced surgeons.

Assessment of Level of Patient Satisfaction after Prostatectomy for Benign Prostatic Hyperplasia in Referral Hospitals in Addis Ababa

Background

Benign Prostatic hyperplasia is a very common problem in aging men. TURP comprises 95% of all surgical procedures and is the treatment of choice for prostates sized between 30ml and 80–100ml. Open surgery is the treatment of choice for large glands (bigger than 80–100ml) and for those with associated complications that have indication for open surgery. Many literatures show that the overall patient satisfaction rate and clinical outcome of TURP for BPH are very good. The objective of this study was ‘assessing the level of patient satisfaction after undergoing TURP and TVP for BPH.

Methods

In this research, convenient sampling technique was used. The study design was prospective cohort study. Standardized questioner was prepared in English and later translated into Amharic. Information about demographic characteristics, preoperative data, intraoperative data, and immediate postoperative data were taken while the patient was in the hospital. At the first and the third months after the prostatectomy, patients were inquired on their level of satisfaction about their disease specific satisfaction on the urinary function and their sexual function. We used HCAHPS Measure of Patient Satisfaction Tool, to collect data and analyzed using SPSS version 18.

Results

A total of 89 patients were enrolled in the study among which 65.2% had undergone TURP. The rate of major perioperative complication was found to be low. Over half of the patients had postoperative hospital stay of three or less days. Majority of the patients were satisfied with the care given by the nurses (68.2%) and doctors (84.3%) with relatively higher physicians' care satisfaction level. More than 60% of the patients were highly satisfied with their urinary surgical outcome. With regard to hospital environment, around 60% of the patients reported that they were very satisfied with cleanliness of the rooms, bath rooms and the quietness of the rooms at night.

Conclusions

Both TURP and TVP have high level of patient satisfaction associated with low perioperative major complications. Therefore both can be recommended for patients with clear indications for prostatectomy.

Endoscopic enucleation vs endoscopic vaporization procedures for benign prostatic hyperplasia: how should we choose: A protocol for systematic review and meta-analysis

OBJECTIVE

To assess the safety and efficacy of different endoscopic procedures of the prostate techniques, by comparing endoscopic enucleation (EEP) and endoscopic vaporization procedures (EVP) of the prostate; and laser enucleation procedures (L-EEP) vs laser vaporization procedures (L-EVP) surgeries for benign prostatic hyperplasia.

METHODS

A systematic literature review was performed in December 2019 using PubMed, Embase and the Cochrane Library to identify relevant studies. Two analyses were carried out: (1) EEP vs EVP; and (2) L-EEP vs L-EVP. Efficacy and safety were evaluated using perioperative data, functional outcomes, including maximum urinary flow rate (Qmax), quality of life (QoL), international prostate symptom score (IPSS), postvoiding residual urine volume (PRV), and rate of complications. Meta-analyses were conducted using RevMan5.3.

RESULTS

Sixteen studies (4907 patients) evaluated EEP vs EVP, and 12 of them (4392 patients) evaluated L-EEP vs L-EVP. EEP showed improved functional outcomes compared with EVP. EEP was always presented a better Qmax at various follow-up times. EEP also associated with a reduced PRV and IPSS at 12 months postsurgery, an increased Qmax, and reduced IPSS and QoL score at both 24 and 36 months postsurgery. In addition, EEP was associated with less total energy utilized and retreatment for residual adenoma, but a longer catheterization time. Among other outcomes, there was no significant difference. L-EEP favors total energy used, retreatment for residual adenoma, and functional outcomes. L-EEP was associated with reduced PRV at 1, 6, and 12 months postsurgery, a greater Qmax at 6 and 12 months postsurgery, a lower IPSS at 12 months postsurgery, and higher Qmax and lower IPSS and QoL scores at 24 and 36 months postsurgery. However, there was no difference at 3 months postsurgery. No significant differences were observed for other perioperative data and complications.

CONCLUSIONS

Both EEP and EVP displayed sufficient efficacy and safety for treating benign prostatic hyperplasia. EEP and L-EEP were favored in perioperative data, rate of complications, and functional outcomes. However, the clinical significance of those statistical differences was unclear. Hence, higher-quality randomized controlled trials may be needed to provide a clear algorithm.

Anatomical endoscopic enucleation of the prostate: The next gold standard? No! (or not yet!)

Most cases of lower urinary tract symptoms due to benign prostatic hyperplasia are initially managed through medical therapy. In cases that surgery is indicated, the anatomical endoscopic enucleation of the prostate (aEEP), first described in 1983, allegedly presents the same safety profile as the best endoscopic non-enucleating procedures and the same long-term functional outcomes as simple prostatectomy. Thus, why aEEP has not yet been consolidated as the gold-standard BPH surgical treatment? The main reasons are as follows: (a) Multiple energy sources and techniques; (b) High costs; (c) Steep learning curve; (d) Rare in-residency training; (e) Reimbursement issues; (f) Outcomes and (g) Complications. We do believe aEEP is an important advance and a "practice-changing" procedure that will play an important role in the BPH surgical options arsenal, especially for larger prostates. However, there is a need to start an in-residency training program, with a mentor guidance, and, over time, the cost will likely be reduced due to greater competition between companies and greater support from health insurers. Considering these points, in the future, EEP may be considered the gold-standard treatment for BPH… but not yet.

Same sized three-way indwelling urinary catheters from various manufacturers present different irrigation and drainage properties

Background:

The three-way indwelling urinary catheter (IUC) is used for continuous bladder irrigation and is considered the cornerstone for clinical treatment of patients with macroscopic hematuria. Although there seems to be a logical relationship between catheter size and efficacy of irrigation and drainage, we often observe relevant variations in these parameters between different brands of catheters available on the market. The aim of this study was to compare the mechanical properties of different models of latex and silicone three-way catheters in an in vitro setting that resembles clinical use.

Methods:

Three different three-way catheters were evaluated: Gold Silicone-Coated Rusch^® (Model A), 100% Silicone Rusch^® (Model B) and X-Flow Coloplast^® (Model C). Irrigation channel, drainage channel, and overall cross-sectional areas were all digitally measured. Irrigation and drainage channel flow rates were measured and correlated with their corresponding catheter cross-sectional area values.

Results:

Different catheter models of the same caliber have different internal irrigation port diameters, internal drainage port diameters and internal cuff port diameters. The Model C IUC internal irrigation port diameter is significantly larger than models A and B. When flows were evaluated, we found that in the same model, the increase in caliber of the IUC was related to an increased drainage flow, but not to an increased irrigation flow.

Conclusion:

Precise measurements of the internal architecture of the three-way catheter, rather than relying on the caliber itself, could assist surgeons in choosing the best product for each specific patient, while minimizing complications.

Comparison of Robot-Assisted Versus Open Simple Prostatectomy for Benign Prostatic Hyperplasia

PURPOSE OF REVIEW

Recent advancements in minimally invasive approaches for prostate surgery have provided numerous options for surgical management of benign prostatic hyperplasia (BPH). In the setting of a large prostate, an open simple prostatectomy was previously considered the gold standard surgical treatment. However, the recently updated American Urological Association (AUA) guidelines on surgical management of BPH now consider both open and minimally invasive approaches to simple prostatectomy viable alternatives for treating large glands, depending on expertise with the techniques. The purpose of our review is to discuss the minimally invasive robot-assisted approach and compare it to the classic open approach to simple prostatectomy.

RECENT FINDINGS

Despite longer operative times, the robotic approach is associated with shorter hospital stay and lower morbidity profile. The morbidity of an open approach remains significant. Blood transfusions are 3-4 times as likely compared to a robotic approach and major complications are twice as likely. Consistent with previous literature, our review shows functional outcome improvements like flow rate and symptom score to be comparable between the robotic and open approach. The amount of adenoma resected and PSA decline is also similar among robotic and open cases. Robot-assisted simple prostatectomy is a safe and effective procedure for BPH secondary to a large prostate gland. Appropriately, it is no longer deemed "investigational" by the latest AUA guidelines on BPH and recommended as an alternative to the open approach.