GreenLight Laser™ Photovaporization versus Transurethral Resection of the Prostate: A Systematic Review and Meta-Analysis

The impact of kidney disease on peri-operative outcomes of novel BPH surgeries across the board: a propensity score matched analysis using the ACS-NSQIP database

BACKGROUND

Pre-operative kidney disease was shown to impact peri-operative outcomes of endoscopic BPH surgeries. We aim to assess the effect of novel surgical techniques (Laser Enucleation of the Prostate (LEP) and Laser Vaporization of the Prostate (LVP)) compared to Transurethral Resection of Prostate (TURP), on post-operative outcomes stratified based on kidney function.

METHODS

The ACS-NSQIP database was reviewed from 2008 to 2021 for 83,020 patients that underwent TURP, LEP, and LVP. Pre-operative variables were compared across kidney function groups: G1(normal/high function); G2-G3(mild/moderate kidney disease); and G4-G5(severe kidney disease). Multivariate logistic regression was performed on 30-day peri-operative complications adjusting for pre-operative variables. Propensity score matching was done between LEP and LVP to TURP.

RESULTS

LEP showed a protective effect against UTIs (p < 0.05) in the G1 and G2-G3 categories but lost that protective effect in the G4-G5 category when compared to TURP. It had longer operative time (p < 0.05) across all kidney function groups, and demonstrated shorter hospital stay (p < 0.05) in the G1 and G2-G3 categories compared to TURP. LVP had a persistent protective effect against bleeding (p < 0.05) across all kidney function groups and shorter hospital stay (p < 0.05) when compared to TURP. LVP had a protective effect against return to OR (p < 0.05) in the G1 and G2-G3 kidney function group but lost that protective effect in the G4-G5 category. LVP had significant protective effect against thromboembolic events (p < 0.05) in the G2-G3 category and against cardiac complications (p < 0.05) in the G4-G5 category.

CONCLUSION

LEP and LVP are superior to TURP in terms of post-operative complications. The type of endoscopic surgery technique should be tailored according to patient's pre-operative kidney status and risk.

Perioperative outcomes and trends of transurethral surgeries for benign prostatic hyperplasia in octogenarians: a comprehensive analysis using the NSQIP database (2011-2022)

INTRODUCTION

Advances in health care have resulted in an increasing octogenarian population in the United States. The prevalence of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) in this subgroup exceeds 70%. This study attempts to evaluate perioperative outcomes of different transurethral techniques in octogenarians and define their utilization trends from 2011 to 2022.

METHODS

We extracted data from the American College of Surgeons NSQIP for octogenarian patients who underwent prostatectomy for BPH. Procedures were categorized using CPT codes, and outcomes included postoperative complications, readmission, 30-day reoperation, and utilization trends from 2011 to 2022.

RESULTS

A total of 21,314 octogenarians were included. TURP was the most performed procedure (53.13-71.17%), followed by PVP and HoLEP. HoLEP utilization increased reaching up to 19% by year 2022. Higher American Society of Anesthesiologists (ASA) scores were observed more frequently in the TURP group. HoLEP consistently exhibits the longest operative times. Initially relatively higher transfusion rates for HoLEP decreased to 0% by 2022. Urinary tract infection rates did not significantly differ among the procedures most years.

RESULTS

TURP remained the most performed modality for BPH management in octogenarians amongst NSQIP-participating institutions. However, from 2011 to 2021, the utilization of HoLEP increased nearly by 2.5 folds, from 2.5 to 6.4%.

[How good are we really? Incidence of postoperative bleeding requiring intervention and intraoperative electrocoagulation during Thulium laser enucleation of the prostate]

The need for intervention due to postoperative bleeding represents a significant complication in Thulium Laser Enucleation of the Prostate (ThuLEP). This study aimed to retrospectively analyse this complication in the treatment of benign prostatic enlargement. This study focuses on investigating potential causative factors for postoperative bleeding requiring intervention as well as the use of intraoperative electrocoagulation. A total of 503 ThuLEP procedures performed between 08/2021 and 07/2022 were examined. Postoperatively, 4.2% (n=21) of patients experienced bleeding requiring intervention. Study data revealed a significant association between these instances of bleeding and a high prostate volume (p=0.004), high enucleation weight (p=0.004), and intraoperative electrocoagulation (p=0.048). In total, intraoperative electrocoagulation was applied in 41.2% (n=207) of cases. In these cases, statistically significant factors leading to the application of electrocoagulation included intraoperative capsule perforation (p=0.005) and high enucleation weight (p=0.002).

Reoperation Rate for Residual/Regrowth Adenoma Following Transurethral Interventions for Benign Prostatic Enlargement: Results from a Systematic Review and Meta-Analysis of Comparative Randomized Studies

Objective: To perform a systematic review to assess the incidence of reoperation rate for residual/regrowth adenoma after transurethral surgeries for benign prostatic enlargement. Materials and Methods: A systematic literature search was performed on November 12, 2023, using Cochrane Central Register of Controlled Trials, PubMed, and Scopus. We only included randomized studies comparing monopolar (M)/bipolar (B) transurethral resection of the prostate (TURP) vs ablation vs enucleation procedures. Incidence of reoperation was assessed using the Cochran-Mantel-Haenszel Method and reported as risk ratio (RR), 95% confidence interval (CI), and p-values. Statistical significance was set at p < 0.05. Evidence synthesis: Forty-eight studies were included. Six studies compared enucleation vs TURP, 41 ablation vs TURP, and 1 study enucleation vs ablation vs TURP, encompassing 457 patients in enucleation, 2259 in ablation, and 2517 in the TURP group. The pooled incidence of reoperation was 6.2%, 0.7%, 2.3%, and 4.3% after ablation, enucleation, M-TURP, and B-TURP, respectively. Meta-analysis showed that the incidence of reoperation was significantly lower in the enucleation group (RR 0.28, 95% CI 0.10-0.81, p = 0.02), but the difference accounted only in studies with follow-up between 1 and 3 years (RR 0.18, 95% CI 0.04-0.85, p = 0.03). The incidence of reoperation was significantly lower in the enucleation compared with the B-TURP group (RR 0.14, 95% CI 0.03-0.77, p = 0.02). Meta-analysis showed that the incidence of reoperation was significantly higher in the ablation group (RR 1.81, 95% CI 1.33-2.47, p = 0.0002), but there was no difference in studies with follow-up up to 1 year (odds ratio 1.78 95% CI 0.97-3.29, p = 0.06) longer than 5 years (RR 2.02, 95% CI 0.71-5.79, p = 0.19). The incidence of reoperation was significantly higher in the ablation compared with the M-TURP group (RR 1.91, 95% CI 1.44-2.54, p < 0.0001). Conclusions: In mid-term follow-up, reoperation rate for residual/regrowth adenoma was significantly lower after enucleation, although was significantly higher after ablation compared with TURP.

A systematic review and meta-analysis of efficacy and safety comparing greenlight laser vaporization with transurethral resection of the prostate for benign prostatic hyperplasia with prostate volume less than 80 ml

We conducted a meta-analysis to evaluate the efficacy and safety of photo selective vaporisation of the prostate (PVP) with the GreenLight Laser versus transurethral resection of the prostate (TURP) for the treatment of small-volume benign prostatic hyperplasia (BPH). As of July 2022, relevant literature in online databases such as Cochrane Library, PubMed, and Embase was searched, including studies published on or before that date, and there were 9 studies in total, including 5 RCTs and 4 non-RCTs. In total 1525 patients were included to compare the efficacy of PVP and TURP in treating BPH. The Cochrane Collaboration criteria were used to evaluate the risk of bias. The software was used for random effect meta-analysis with RevMan 5.3. Data extraction included: clinical baseline characteristics, perioperative parameters, complication rates, International Prostate Symptom Score (IPSS), prostate specific antigen (PSA), post-void residual urine (PVR), maximum flow rate (Qmax), and quality of life (QoL). The pooled analysis showed that PVP was associated with reduced blood loss, blood transfusion, clot retention, catheterization time, definitive catheter removal, and hospital stay, but was associated with longer operative time and more severe dysuria (all p < 0.05). The results of this meta-analysis show that PVP as a technique for the treatment of benign prostatic hyperplasia with a volume of less than 80 cc has similar efficacy to standard TURP in IPSS, PSA, PVR, Qmax and QoL, and is an effective alternative. It outperformed TURP in terms of blood transfusion, catheterization time and hospital stay, while TURP is superior to PVP in terms of operation time.

Cost-utility of minimally invasive therapies vs. pharmacotherapy as initial therapy for benign prostatic hyperplasia A Canadian healthcare payer perspective

INTRODUCTION

Recently, minimally invasive surgical therapies (MIST s) have become an alternative to surgery or pharmacotherapy to manage benign prostatic hyperplasia (BPH ). This study evaluated the cost-utility of water vapor thermal therapy (WVTT ) and prostatic urethral lift (PUL) compared to pharmacotherapy as initial treatment for patients with moderate-to-severe BPH.

METHODS

In this model-based economic evaluation, we simulated BPH progression in men (mean age 65 years, average International Prostate Symptom Score 16.6) over their lifetime and estimated healthcare costs (from the Canadian healthcare payer perspective) per quality-adjusted life year (QALY), discounted at 1.5% annually. In the model, men could receive up to three lines of therapy: 1) initial pharmacotherapy with MIST as second-line, and TURP or pharmacotherapy as third-line; 2) initial MIST (WVTT or PUL) with MIST again, TURP, or pharmacotherapy as second-line, and TURP as third-line. The model was populated using data from the published literature.

RESULTS

The expected lifetime QALYs and costs were 15.50 QALYs and $14 626 for initial treatment with WVTT, 15.35 QALYs and $11 795 for pharmacotherapy followed by WVTT, 15.29 QALYs and $13 582 for pharmacotherapy followed by PUL, and 15.29 QALYs and $19 151 for initial treatment with PUL. Strategies involving PUL procedures were dominated by strategies involving WVTT. The incremental cost per QALY gained was $18 873 for initial WVTT compared to initial pharmacotherapy followed by WVTT.

CONCLUSIONS

WVTT appears to be a cost-effective procedure and may be an appropriate first-line alternative to pharmacotherapy for patients with BPH and prostate volume less than 80 cm3 who seek faster improvement and no lifelong commitment to daily medications.

Assessment and management of lower urinary tract symptoms in men

Lower urinary tract symptoms (LUTS) is a broad term that covers a range of urinary issues, which are often categorised as storage and voiding symptoms. Storage symptoms include increased frequency, nocturia, urgency and urge incontinence, while voiding symptoms include hesitancy, suboptimal flow, dribbling and incomplete emptying. In men, the most common causes of LUTS are benign prostatic hyperplasia (prostate enlargement) and overactive bladder. This article provides an overview of the anatomy of the prostate and outlines the assessment process for men presenting with LUTS. It also explains the recommended lifestyle modifications, medicines and surgical interventions available to male patients who are experiencing these symptoms.

Pharmacotherapy vs. minimally invasive therapies as initial therapy for moderate-to-severe benign prostatic hyperplasia: a cost-effectiveness study

BACKGROUND

Recently, minimally invasive therapies (MITs), such as water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL) have become an alternative to surgery or pharmacotherapy to manage benign prostatic hyperplasia (BPH), offering symptom relief with a favorable safety profile. The objective of this study was to evaluate the cost-utility of MITs (WVTT and PUL) compared to pharmacotherapy as initial treatment for patients with moderate-to-severe BPH.

METHODS

In this model-based economic evaluation we simulated BPH progression in men (mean age 65 years, average International Prostate Symptom Score 16.6) over their lifetime and estimated healthcare costs (from the US public payer perspective) per quality-adjusted life year (QALY), discounted at 3% annually. Various clinical scenarios were evaluated given that most men undergo several lifelong therapies up to surgical intervention and potentially thereafter. As such, in the study model men could receive up to three lines of therapy: (1) initial pharmacotherapy with MIT as second-line, and transurethral resection of the prostate (TURP) or pharmacotherapy as third-line; (2) initial MIT (WVTT or PUL) with MIT again, TURP or pharmacotherapy as second-line, and TURP as third-line. Model was populated using data from the published literature. Probabilistic analyses were performed.

RESULTS

Initial treatment with WVTT led to the highest QALYs (13.05) and the lowest cost ($15,461). The cumulative QALYs and lifetime costs were 12.92 QALYs and $20,280 for pharmacotherapy followed by WVTT, 12.87 QALYs and $22,424 for pharmacotherapy followed by PUL, 12.86 QALYs and $20,930 for initial treatment with PUL. In the cost-utility analysis, WVTT as initial treatment dominated all three strategies, i.e., generated more QALYs at a lower cost.

CONCLUSION

WVTT is an effective and cost-saving procedure, and may be an appropriate first-line alternative to pharmacotherapy for moderate-to-severe BPH patients who seek faster improvement and no lifelong commitment to daily medications.

Photoselective sharp enucleation of the prostate with a front-firing 532-nm laser versus photoselective vaporization of the prostate in the treatment of benign prostatic hyperplasia: a randomised controlled trial with 1-year followup results

BACKGROUND

We designed a new surgical procedure to treat benign prostatic hyperplasia(BPH). In order to verify its effectiveness and safety, we constructed this randomized controlled trial to compare the efficacy of our innovative enucleation technique- photoselective sharp enucleation of the prostate (PSEP), with a front-firing 532-nm laser and the traditional technique-photoselective vaporization of the prostate (PVP) in the treatment of BPH.

METHODS

A total of 154 consecutive patients diagnosed with bladder outlet obstruction secondary to BPH in our center from June 2018 to April 2019 were randomly divided into the PSEP group (n = 77) and the PVP group (n = 77) and were treated surgically with either PSEP or PVP. All patients were assessed preoperatively and followed up at 1, 6, and 12 months postoperatively. The international prostate symptom score,quality-of-life score, postvoid residual urine volume, maximum urine flow rate, prostate volume, prostate-specific antigen, and adverse events were compared.

RESULTS

The lower urinary tract symptoms in both groups were significantly improved compared with the baseline at 1, 6, and 12 months postoperatively. The PSEP and PVP groups had an equivalent International Prostate Symptom Score, quality-of-life score, postvoid residual urine volume, maximum urine flow rate, prostate-specific antigen at each follow-up (P > 0.05). The median operative time in the PSEP group was significantly shorter than that in the PVP group (35 min vs. 47 min, P < 0.001). At 6 and 12 months after surgery, the median PV in the PSEP group was smaller than that in the PVP group (P < 0.05). Complication rates were comparable between the groups.

CONCLUSION

Both PSEP and PVP can achieve good efficacy and safety in the treatment of BPH. PSEP can remove more tissue than PVP and is associated with higher efficiency. In addition, PSEP eliminates the problem of lack of tissue samples associated with PVP.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, identifie:ChiCTR1800015867, date:25/04/2018.

Comparison of Emergency Room Visits and Rehospitalization for Bleeding Complications following Transurethral Procedures for the Treatment of Benign Prostatic Hyperplasia: A Population-Based Retrospective Cohort Study

Background: The postoperative bleeding complications associated with laser surgery of the prostate and transurethral resection of the prostate (TURP) were compared. Methods: We used the Taiwan National Health Insurance Research Database to conduct an observational population-based cohort study. All eligible patients who received transurethral procedures between January 2015 and September 2018 were enrolled. Patients who received laser surgery or TURP were matched at a ratio of 1:1 by using propensity score matching, and the association of these procedures with bleeding events was evaluated. Results: A total of 3302 patients who underwent elective transurethral procedures were included. The multivariable Cox regression analysis revealed that diode laser enucleation of the prostate (DiLEP) resulted in significantly higher emergency room risks within 90 days after surgery due to clot retention than the Monopolar transurethral resection of the prostate (M-TURP) (Hazard Ratio: 1.52; 95% Confidence Interval [CI], 1.06–2.16, p = 0.022). Moreover, GreenLight photovaporization of the prostate (PVP) (0.61; 95% CI, 0.38–1.00 p = 0.050) and thulium laser vaporesection of the prostate (ThuVARP) (0.67; 95% CI, 0.47–0.95, p = 0.024) resulted in significantly fewer rehospitalization due to clot retention than did M-TURP. No significant increase in blood clots were observed in patients using comedications and those with different demographic characteristics and comorbidities. Conclusions: Among the investigated six transurethral procedures for Benign prostatic hyperplasia, PVP and ThuVARP were safer than M-TURP because bleeding events and clot retention were less likely to occur, even in patients receiving anticoagulant or antiplatelet therapy. However, DiLEP and holmium laser enucleation of the prostate (HoLEP) did not result in fewer bleeding events than M-TURP.

Correlation between transurethral interventions and their influence on type and duration of postoperative urinary incontinence: results from a systematic review and meta-analysis of comparative studies

Objective To perform a systematic review to assess the incidence of transient (<6-month) and persistent (>6-month) stress (SUI), urge (UUI), and mixed urinary incontinence (MUI) after transurethral surgeries for benign prostatic hyperplasia (BPH). Materials and Methods A systematic literature search was performed using Embase, PubMed, and Web of Science. We included studies comparing monopolar(M)/bipolar(B) TURP vs ablation vs enucleation procedures. Incidence of incontinence was assessed using Cochran-Mantel-Haenszel Method and reported as odds ratio (OR), 95% confidence interval (CI), and p-values. Statistical significance was set at p <0.05 Evidence synthesis 28 studies were included. Incidence of transient SUI was 4.6%, 6.0%, 3.0%, 2.4% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent SUI was 1.1% after ablation, 1.7%, after enucleation and M-TURP, 1.0% after B-TURP. Incidence of transient UUI was 2.0%, 7.3%, 4.4%, 2.8% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent UUI was 2.2% after M-TURP. The incidence of transient MUI was 5.1%, 0.8%, 5.4%, 0.9% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent MUI was 3.1% after ablation, and 4.8% after M-TURP. Incidence of transient and persistent SUI and UUI did not differ after TURP vs enucleation. Incidence of transient (OR 3.32, 95% CI 0.41-26.65, p=0.26) and persistent SUI (OR 4.79, 95%CI 0.52-43.89,p=0.17) was not significantly higher after ablation. Incidence of transient UUI was not significantly higher after ablation (OR 2.62, 95%CI 0.04-166.01,p=0.65), whilst persistent UUI did not differ. Incidence of transient MUI was significantly higher after enucleation (OR 3.26, 95%CI 1.51-7.05,p=0.003). Incidence of transient and persistent MUI did not differ after TURP vs ablation. Conclusions Ablation, enucleation, and TURP have an impact on all forms of incontinence but this is transient in most cases with no difference between the groups, except for MUI which was higher after enucleation vs M-TURP.