Effect of Transurethral Resection of the Prostate on Storage Symptoms in Patients with Benign Prostatic Hyperplasia of Less than 30 ml

Comparative efficacy and safety of prostatic urethral lift vs prostatic artery embolization for benign prostatic hyperplasia: a systematic review and network meta-analysis

OBJECTIVE

To assess and compare the clinical efficacy and safety of prostatic urethral lift (PUL) and prostatic artery embolization (PAE) for the treatment of lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia (BPH) by means of a systematic review and network meta-analysis.

METHODS

A systematic literature search was performed using PubMed and Web of Science from inception to March 2021 to identify randomized controlled trials (RCTs) that compared PUL or PAE with either transurethral resection of the prostate (TURP) or sham procedures as control interventions. Qualitative and quantitative analyses were performed to pool the data on direct and indirect comparisons between interventions using STATA 14.

RESULTS

Eight RCTs with 675 participants were included in our network meta-analysis. Quantitative synthesis revealed that TURP was the most efficacious intervention for clinical (International Prostate Symptoms Score and quality of life) and functional outcomes (maximum urinary flow rate and post-void residual urine volume), and was associated with a lower reintervention rate compared with PAE (risk ratio [RR] 2.08 with 95% confidence interval [CI] 0.96 to 4.51) and PUL (RR 2.33 with 95% CI 0.50 to 10.86), although the difference were not statistically significant. Indirect comparison indicated that PUL and PAE resulted in similar outcomes. PAE was associated with fewer minor adverse events (AEs; RR 0.75 with 95% CI 0.48 to 1.18) and PUL with fewer major AEs (RR 0.72 with 95% CI 0.17 to 3.13) when compared with TURP. Whilst PAE had a better ranking with regard to improvement of most clinical and functional outcomes, PUL was the best ranked procedure regarding erectile function, as measured by the International Index of Erectile Function 5, but no significant difference was observed.

CONCLUSION

Current evidence suggests that PUL and PAE have similar clinical efficacy and safety profiles in the management of LUTS associated with BPH. However, the quality of evidence is relatively low because of the paucity of RCTs available, and results should be interpreted with caution.

Voiding and Storage Domain-Specific Symptom Score Outcomes After Prostate Artery Embolization for Lower Urinary Tract Symptoms and Urinary Retention

OBJECTIVE

To characterize voiding and storage symptom domain-specific outcomes after prostate artery embolization (PAE) to treat lower urinary tract symptoms (LUTS) or urinary retention caused by benign prostatic hyperplasia (BPH).

METHODS

Two hundred forty patients (age = 74.5 ± 8.6 years) underwent PAE between May 2013 and March 2020 at a single center for LUTS (n = 161) or urinary retention (n = 79). Total International Prostate Symptom Score (IPSS-t), voiding domain score (IPSS-v), storage domain score (IPSS-s), and Quality of Life score (QoL) were obtained pre-PAE for LUTS patients (IPSS-t = 21.7 ± 6.2, IPSS-v = 11.9 ± 4.3, IPSS-s = 9.6 ± 3.1, QoL = 4.5 ± 1.2), and post-PAE through 36 months (mean = 22.9 ± 15.2 months) for LUTS and retention patients. Mean relative changes in IPSS-t, IPSS-v, IPSS-s, and QoL were calculated for LUTS patients. Mean voiding or storage component scores were calculated for retention patients.

RESULTS

For evaluable LUTS patients (n = 147), IPSS-t showed sustained substantial improvement through 36 months (6.3 ± 4.2-8.6 ± 7.6), as did QoL (1.1 ± 1.1-1.8 ± 1.5). One month after PAE, improvements in IPSS-v (69% ± 29%) were greater than in IPSS-s (46% ± 33%; P < .000001), and remained so through 36 months (68% ± 31% vs 53% ± 28%, P = .004). Among evaluable retention patients (n = 75), 84% passed voiding trials. Both IPSS-t (6.0 ± 3.9-8.2 ± 6.7) and QoL (0.9 ± 1.2-1.5 ± 1.6) remained low through 36 months. One month after PAE, mean IPSS-v component score (0.9 ± 1.3) was lower than mean IPSS-s component score (1.7 ± 1.4; P = .003) and remained so through 24 months (0.9 ± 1.2 vs 1.3 ± 1.1, P = .02), with similar trend at 36 months (0.7 ± 1.1 vs 1.1 ± 1.1, P = .07).

CONCLUSIONS

PAE effectively treated BPH-related LUTS and retention. IPSS-v improved more than IPSS-s in LUTS patients, and remained lower in LUTS and retention patients through 36 months.

Prostatic Artery Embolization (PAE) and Transurethral Resection of the Prostate (TURP) have a Differential Impact on Lower Urinary Tract Symptoms (LUTS): Retrospective Analysis of the Multicentre UK-ROPE (UK Register of Prostate Embolization) Study

PURPOSE

To compare the relative IPSS (International Prostate Symptom Score) improvement in storage and voiding symptoms between prostatic artery embolization (PAE) and transurethral resection of the prostate (TURP).

METHOD

Retrospective analysis of the UK-ROPE (UK Register of Prostate Embolization) multicentre database was conducted with inclusion of all patients with full IPSS questionnaire score data. The voiding and storage subscore improvement was compared between interventions. Student's t-test (paired and unpaired) and ANOVA (Analysis of variance) were used to identify significant differences between the groups.

RESULTS

146 patients (121 PAE, 25 TURP) were included in the analysis. Storage symptoms were more frequently the most severe symptom ('storage' in 75 patients vs 'voiding' in 17 patients). Between groups, no significant difference was seen in raw storage subscore improvement (TURP 4.9 vs PAE 4.2; p = 0.34) or voiding subscore improvement (TURP 8.4 vs PAE 6.7; p = 0.1). ANOVA demonstrated a greater proportionate reduction (relative to total IPSS) towards voiding symptoms in the TURP group (27.3% TURP vs 9.9% PAE, p = 0.001).

CONCLUSION

Although both TURP and PAE improve voiding symptoms more than storage, a significantly larger proportion of total symptom reduction is due to voiding in the TURP cohort, with PAE providing a more balanced improvement between voiding and storage.

Efficacy of holmium laser enucleation in patients with a small (less than 30 mL) prostate volume

Purpose

To evaluate the efficacy of holmium laser enucleation of the prostate (HoLEP) in patients with a small prostate volume (≤30 mL).

Materials and Methods

We retrospectively evaluated 1,135 patients who underwent HoLEP at two institutions between July 2007 and March 2020. Patients who were not evaluated for the International Prostate Symptom Score (IPSS) before or after HoLEP were excluded. We divided patients into two groups according to estimated prostate volume (ePV): ≤30 (n=198) and >30 mL (n=539). The patient characteristics, IPSS, peak urinary flow rate (Qmax), postvoid residual urine volume (PVR), and other data were compared before and after surgery in each group and between the two groups. Multivariate analysis was performed to identify the factors associated with the efficacy of HoLEP in the group with ePV ≤30 mL.

Results

A total of 737 patients were included in this retrospective study. ePV (23.4 mL vs. 50 mL; p<0.001) and PVR differed significantly between the two groups. The IPSS, IPSS-quality of life, PVR, and Qmax significantly improved after HoLEP in both groups. Improvements in the IPSS, IPSS-quality of life, Qmax, and PVR were greater in the >30 mL group (p<0.001), whereas operation time and morcellation time were significantly shorter in the ≤30 mL group. In the multivariate analysis, age <70 years was independently associated with improvement by HoLEP.

Conclusions

HoLEP is an effective treatment for patients with a small prostate, even though the extent of improvement after HoLEP was greater in those with a larger prostate.

The relation between the storage symptoms before and after transurethral resection of the prostate, analysis of the risk factors and the prevention of the symptoms with solifenacin

OBJECTIVE AND HYPOTHESIS

We aimed to investigate the reasons of storage symptoms ( SS) after transurethral resection of the prostate (TURP). The hypothesis was that a positive correlation would be identified between preoperative and postoperative SS in patients with undergoing TURP and starting early solifenacin treatment in patients with high preoperative SS would be reasonable. In addition, we aimed to analyze multiple other risk factors for post-TURP SS.

MATERIALS AND METHODS

A total of 160 patients undergoing TURP were prospectively evaluated and divided into two groups according to their OABS. Those with a score of ≥10 points were Group 1 (G1), and those with < 10 points Group 2 (G2). In addition, patients in each group were randomly further divided into two subgroups: those who were started on 5 mg solifenacin succinate in the early postoperative period (G1/G2 A) and those who were not (G1/G2 B). In additions to SS Preop, perop and at the 3rd-month of postoperatively 14 variable were evaluated. The effects of these factors, surgery and the efficacy of an early medical treatment on the postoperative SS were investigated. LUTS were assessed by International Prostate Symptom Score (IPSS) and SS were assessed by sum of IPSS 2, 4 and 7 questionnaires (Storage, S- IPSS).

RESULTS

Preoperative IPSS and S-IPSS were significantly higher in G1 (p< 0.001); there was a significant improvement at IPSS, S-IPSS, QoL score, Qmax, and PVR for all groups after surgery. Only preoperative S-IPSS was found to have significant effect on postoperative SS (p< 0.001). There was a significant difference between G1A and G1B but no significant difference between G2A and G2B in terms of SS at postoperatively. In addition to this, prostatic volume was found smaller than non-symptomatic patients in de novo SS patients.

CONCLUSION

TURP provides significant improvement in both storage and voiding symptoms. The predictive value of the preoperative S-IPSS on postop SS is significant. These results suggest that 5 mg solifenacin succinate treatment in the early postoperative period may be beneficial for patients with high preoperative SS and may not be beneficial in others. Small prostatic volume may bode ill for postoperative SS in the patients with de novo SS.

The role of photovaporization of the prostate in small volume benign prostatic hyperplasia and review of the literature

Objective

Our objective was to characterize the safety and efficacy of the 180 W XPS-GreenLight laser in men with lower urinary tract symptoms secondary to a small volume benign prostatic hyperplasia (BPH).

Methods

A retrospective analysis was performed for all patients who underwent 180 W XPS-laser photoselective vaporization of the prostate (PVP) vaporization of the prostate between 2012 and 2016 at two-tertiary medical centers. Data collection included baseline comorbidities, disease-specific quality of life scores, maximum urinary flow rate (Q_max), postvoid residual (PVR), complications, prostate volume and prostate-specific antigen (PSA). The secondary endpoints were the incidence of intraoperative and postoperative adverse events. Complications were stratified using the Clavien-Dindo grading system up to 90 days after surgery.

Results

Mean age of men was 67.8 years old, with a mean body mass index of 29.7 kg/m². Mean prostate volume as measured by transrectal ultrasound was 29 mL. Anticoagulation use was 47% and urinary retention with catheter at time of surgery was 17%. Mean hospital stay and catheter time were 0.5 days. Median follow-up time was 6 months with the longest duration of follow-up being 22.5 months (interquartile range, 3–22.5 months). The International Prostate Symptom Score improved from 22.8 ± 7.0 at baseline to 10.7 ± 7.4 (p < 0.01) and 6.3 ± 4.4 (p < 0.01) at 1 and 6 months, respectively. The Q_max improved from 7.70 ± 4.46 mL/s at baseline to 17.25 ± 9.30 mL/s (p < 0.01) and 19.14 ± 7.19 mL/s (p < 0.001) at 1 and 6 months, respectively, while the PVR improved from 216.0 ± 271.0 mL preoperatively to 32.8 ± 45.3 mL (p < 0.01) and 26.2 ± 46.0 mL (p < 0.01) at 1 and 6 months, respectively. The PSA dropped from 1.97 ± 1.76 ng/mL preoperatively to 0.71 ± 0.61 ng/mL (p < 0.01) and 0.74 ± 0.63 ng/mL at 1 and 6 months, respectively. No patient had a bladder neck contracture postoperatively and no capsular perforations were noted intraoperatively.

Conclusion

The 180 W GreenLight XPS system is safe and effective for men with small volume BPH. PVP produced improvements in symptomatic and clinical parameters without any safety concern. It represents a safe surgical option in this under studied population.

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.

Efficacy and safety of tamsulosin hydrochloride 0.2 mg and combination of tamsulosin hydrochloride 0.2 mg plus solifenacin succinate 5 mg after transurethral resection of the prostate: a prospective, randomized controlled trial

Objective

The objective of this study was to evaluate the safety and efficacy of tamsulosin hydrochloride 0.2 mg (TAM) and its combination with solifenacin succinate 5 mg (SOL) after transurethral resection of the prostate (TURP).

Patients and methods

The patients were randomized into three groups: TURP (group 1), TURP plus TAM (group 2), and TURP plus TAM + SOL (group 3). Patients in group 2 and group 3 received medication for 4 weeks. The primary efficacy end points were the mean change in total International Prostate Symptom Score (IPSS) and IPSS subscores. The secondary end points included quality-of-life score, Overactive Bladder Symptom Score, and short-form voiding and storage score of International Continence Society.

Results

In total, 37 men (31.8%) in group 1, 37 men (31.8%) in group 2, and 42 men (36.2%) in group 3 completed the study. In total IPSS, no significant improvement was seen from baseline to the end of treatment in groups 2 and 3 compared with group 1. However, in group 2, the decrement in the IPSS storage score was smaller than group 1 (P=0.02), and in group 3, the decrement in the IPSS voiding score was smaller than group 1 (P=0.05). In groups 2 and 3 compared with group 1, improvements in the quality of life score, total score of Overactive Bladder Symptom Score, and short-form voiding score and storage score of International Continence Society were not statistically significant.

Conclusion

Treatment with TAM and combination of TAM and SOL did not have significant additional benefits for lower urinary tract symptoms during the early recovery period after TURP.