Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years.

OBJECTIVE: To assess the durability of holmium laser enucleation of prostate in comparison to transurethral resection of the prostate (TURP). PATIENTS AND METHODS: Patients were enrolled in the present study between June 1997 and December 2000 and followed per protocol. All patients were urodynamically obstructed with a prostate volume of between 40 and 200 mL. At long-term follow-up, variables assessed included Benign Prostatic Hyperplasia Impact Index (BPHII), International Continence Society Short Form Male questionnaire (ICSmale-SF) and the International Index of Erectile Function (IIEF). Adverse events, including the need for retreatment, were specifically assessed. RESULTS: Thirty-one (14 holmium laser enucleation of the prostate [HoLEP] and 17 TURP) of the initial 61 patients were available, with 12 deceased and 18 lost to follow-up. The mean (range) follow-up was 7.6 (5.9-10.0) years and the mean (±sd) age at follow-up was 79.8 (±6.2) years. The mean (±sd) values (HoLEP vs TURP) were as follows: maximum urinary flow rate (Q(max)), 22.09 ± 15.47 vs 17.83 ± 8.61 mL/s; American Urological Association (AUA) symptom score, 8.0 ± 5.2 vs 10.3 ± 7.42; quality of life (QOL) score 1.47 ± 1.31 vs 1.31 ± 0.85; BPHII, 1.53 ± 2.9 vs 0.58 ± 0.79; IIEF-EF (erectile function), 11.6 ± 7.46 vs 9.21 ± 7.17; ICSmale Voiding Score (VS), 4.2 ± 3.76 vs 3.0 ± 2.41; ICSmale Incontinence Score (IS), 3.07 ± 3.3 vs 1.17 ± 1.4. There were no significant differences in any variable between the two groups beyond the first year. Of the assessable patients, none required re-operation for recurrent BPH in the HoLEP arm and three (of 17) required re-operation in the TURP arm . CONCLUSION: The results of this randomized trial confirm that HoLEP is at least equivalent to TURP in the long term with fewer re-operations being necessary.

Post-prostatectomy urinary incontinence: a review of surgical treatment options.

OBJECTIVES: • To review the urological literature regarding the management of Post-Prostatectomy Incontinence (PPUI). METHODS: • A Pubmed literature search was performed. RESULTS: • The definition of Post-Prostatectomy Incontinence varied widely. • The artificial urinary sphincter has proven efficacy and durability. • Newer devices, in particular the AdVance sling, lack quality studies despite its apparent popularity. CONCLUSION: • Currently there is insufficient evidence to determine whether newer devices approach the efficacy and durability of the artificial urinary sphincter.

A double-blind randomized controlled trial of electromagnetic stimulation of the pelvic floor vs sham therapy in the treatment of women with stress urinary incontinence.

OBJECTIVE: To compare the efficacy of extracorporeal electromagnetic stimulation (ES) of the pelvic floor for treating stress urinary incontinence (SUI) vs sham ES. PATIENTS AND METHODS: In all, 70 women with urodynamically confirmed SUI were randomized to receive active (35) or sham (35) ES. The NeoControl chair (NeoTonus, Marietta, GA, USA) was used, and treatment consisted of three sessions per week for 6 weeks. data were collected before and after treatment on all women, including a 20-min provocative pad-test with a predetermined bladder volume (primary outcome measure), a 3-day bladder diary and 24 h pad-test. Circumvaginal muscle (CVM) rating score, perineometry using two separate instruments and video-urodynamics were also used, and the Urinary Incontinence Quality of Life Scale (I-QOL) and King's Health Questionnaires. Patients were fully re-evaluated 8 weeks after treatment, and the bladder diary, pad-test and questionnaires were repeated at 6 months. The urotherapist and physician were unaware to which treatment group the patient was assigned. RESULTS: In the overall group of 70 patients there were significant improvements in each of the primary and secondary outcome measures at 8 weeks. There were also significant improvements in primary and secondary outcome measures in the active treatment group when compared with baseline measures. At 8 weeks, there were improvements in the mean (sd) values for the 20-min pad-test, of 39.5 (5.1) vs 19.4 (4.6) g (P < 0.001); the 24-h pad-test, of 24.0 (4.7) vs 10.1 (3.1) g (P < 0.01); the number of pads/day, of 0.9 (0.1) vs 0.6 (0.1) (P < 0.01), the I-QOL score, of 63.7 (2.8) vs 71.2 (3.3) (P < 0.001); and King's Health Questionnaire score, of 9.6 (0.8) vs 6.9 (0.7) (P < 0.001). However, these improvements were not statistically significant when compared with the sham-treatment group. In those patients on active treatment who had a poor pelvic floor contraction at the initial assessment (defined by the CVM score and perineometry), there was a significant reduction (P < 0.05) in the 20-min pad-test leakage when compared with the sham-treatment group. CONCLUSIONS: ES was no more effective overall than sham treatment in this patient group. However, in those women who were unable to generate adequate pelvic floor muscle contractions, there was an objective improvement in provocative pad testing when compared to sham treatment.

Robot-assisted laparoscopic radical prostatectomy (RALP)--a new surgical treatment for cancer of the prostate.

AIM: To examine the safety and efficacy of robotic-assisted laparoscopic prostatectomy (RALP) in the early cases of this new technique from a single institution. METHOD: A prospective database was created to monitor perioperative and postoperative outcomes of men undergoing RALP for clinically localised carcinoma of the prostate. RESULTS: The first 30 consecutive cases were followed prospectively. There were no conversions to open surgery, perioperative transfusions, re-operations, or major complications. The mean operating time was 280 minutes, with reductions in time between cases 1-10 and 10-20, and a smaller improvement between cases 10-20 and 20-30. The mean hospital stay was 1.4 days. There was one delayed discharge (4 days) due to an acute anxiety event. One patient required readmission for severe bladder spasm, and one patient had a failed trial of removal of catheter requiring re-catheterisation. One patient had a minor wound infection. The majority of patients had moderately-well differentiated, organ-confined disease on specimen histology. CONCLUSION: The early results suggest that RALP is a safe and oncologically effective procedure. The local results are at least comparable with other early series in the literature. It is an important addition to the armamentarium available for treating prostate cancer in New Zealand.

An adjustable continence therapy device for treating incontinence after prostatectomy: a minimum 2-year follow-up.

OBJECTIVE: To evaluate the efficacy and safety of the ProACT (Uromedica, Inc., MN, USA) balloon device, an alternative for the surgical management of incontinence after prostatectomy. PATIENTS AND METHODS: The initial patients who received this device at our institution were evaluated, using urodynamics at baseline and at 6 months. Perioperative variables were recorded and pad usage, volume adjustments, an estimate of Incontinence Quality of Life (I-QoL) and adverse events were recorded at baseline, and 1, 3, 6, 12 and 24 months after surgery. RESULTS: In all, 37 patients were treated on this protocol between November 2001 and March 2005. Of these, 30 had had radical prostatectomy and seven holmium laser enucleation of the prostate. The mean (range) pad usage decreased from 2.81 (1-12) at baseline to 0.7 (0-4) pads at 24 months, and the I-QOL increased from 49.7 (4.5-77) to 81.3 (13.6-100) over the same period. At 24 months, 62% of 34 men were pad-free and 81% required one pad or less. Bilateral explantation was required in three patients (11%) for infection (one) and balloon migration (two). All other adverse events were mild and transient. CONCLUSIONS: The ProACT balloon device is an acceptable therapy for the surgical management of incontinence after prostatectomy.

Randomized trial comparing holmium laser enucleation of prostate with plasmakinetic enucleation of prostate for treatment of benign prostatic hyperplasia.

OBJECTIVES: To compare the alternative energy sources of the holmium:yttrium-aluminum-garnet laser and bipolar plasmakinetic energy for endoscopic enucleation. METHODS: A prospective, randomized controlled trial was undertaken, with 20 patients assigned to each group. The preoperative and postoperative measures included transrectal ultrasound-assessed prostate volume, postvoid residual urine volume, and urodynamic evaluation findings. The intraoperative measures included procedure length, energy use, and specimen weight. All adverse events were recorded at each postoperative visit in a 1, 3, 6, and 12-month protocol. RESULTS: No differences were found in the preoperative characteristics between the two groups. The significant differences favoring holmium laser enucleation of the prostate compared with plasmakinetic enucleation of the prostate were seen in the operative time (43.6 versus 60.5 minutes), recovery room time (47.1 versus 65.6 minutes), and bladder irrigation requirement (5% versus 35%). The outcomes after holmium laser enucleation of the prostate and plasmakinetic enucleation of the prostate were in all other respects similar by the postoperative outcome measures assessed. CONCLUSIONS: Plasmakinetic enucleation of the prostate is a safe and technically feasible procedure for the enucleation of prostatic adenomata. Plasmakinetic enucleation of the prostate is limited by the longer operative and recovery room times, as well as a more pronounced postoperative irrigation requirement because of reduced visibility and a greater propensity for bleeding. The transfusion rates and catheterization and hospitalization times were similar. The optimal energy source for enucleation should still be considered the holmium laser, but bipolar energy can be considered by users already experienced with holmium laser enucleation of the prostate.

A randomised trial comparing holmium laser enucleation versus transurethral resection in the treatment of prostates larger than 40 grams: results at 2 years.

OBJECTIVE: To compare holmium laser enucleation of the prostate (HoLEP) with transurethral resection of the prostate (TURP) for treatment of men with bladder outflow obstruction (BOO) secondary to benign prostatic hyperplasia with a minimum of 24-month follow-up. PATIENTS AND METHODS: Sixty-one patients were randomised to either HoLEP or TURP. All patients had BOO proven on urodynamic studies pre-operatively (prostate size 40-200 g). One patient died before treatment, which left 30 patients in each group. Perioperative data, as well as symptom scores, Quality of Life (QoL) scores, and maximum urinary flow rates (Qmax) were obtained at one, three, six,12, and 24 months. Post-void residual volumes, transrectal ultrasound (TRUS) volumes, and pressure flow studies were obtained six months post-operatively. Continence and potency data were also recorded. RESULTS: There were no significant differences between the two surgical groups pre-operatively. Mean pre-operative TRUS volume was 77.8+/-5.6 g (42-152) in the HoLEP group and 70.0+/-5.0 g (46-156) in the TURP group. Patients in the HoLEP group had shorter catheter times and hospital stays. More prostate tissue was retrieved in the HoLEP group. At six months, HoLEP was urodynamically superior to TURP in relieving BOO. At 24 months, there was no significant difference between the two surgical groups with respect to American Urology Association scores, QoL scores, or Qmax values; however, two patients in the TURP group required re-operation. CONCLUSIONS: HoLEP has less perioperative morbidity and produces superior urodynamic outcomes than TURP, when treating prostates >40 g. At 24 months of follow-up, HoLEP is equivalent to TURP.

From coagulation to enucleation: the use of lasers in surgery for benign prostatic hyperplasia.

The application of lasers for the treatment of benign prostatic hyperplasia has evolved over the past 15 years. Early-generation neodymium:yttrium aluminum garnet lasers were used to coagulate and ablate prostatic tissue, but significant postoperative irritative symptoms and high reoperation rates meant that this approach did not seriously challenge the status quo for long. Ablative techniques have recently become popular again with the marketing of the newer-generation, higher-power potassium titanyl phosphate and holmium lasers. Although short-term data are encouraging, there are no comparative trials of significant duration, so it is not yet possible to draw conclusions with regard to efficacy and durability. The holmium laser can also be used as an incisional and dissecting tool that allows resection or enucleation of whole lobes of the prostate, mimicking the action of the index finger in open prostatectomy. The safety, efficacy, durability and cost-effectiveness of the holmium laser have been shown in well-designed randomized controlled trials.

Laparoscopic radical prostatectomy: early safety and efficacy.

BACKGROUND: To evaluate the initial results of laparoscopic radical prostatectomy at this institution. METHODS: Between January 2000 and September 2003, 30 patients underwent laparoscopic radical prostatectomy. Peri- and postoperative data were accumulated prospectively and maintained in a database. All patients have a minimum of 6 month follow up. RESULTS: There were no conversions to open surgery, and there were no re-operations. Mean operating time was 328 (195-490) min. There was one intraoperative rectal injury which was repaired laparoscopically. Three patients (10%) required blood transfusion. Postoperatively, there were two cases of respiratory depression, one case of haemoptysis and one upper gastrointestinal bleed. Two anastomotic leaks were successfully treated conservatively, one of which was the only readmission to hospital. There was one case of clot retention requiring manual irrigation of the bladder. Mean hospital stay was 2.75 (1-10) days, with six of the last 10 patients being discharged on the first postoperative day. Continence rates at 6 months are 83%. Positive surgical margins occurred in seven patients (23%). At 12 months of follow up, one patient (4.5%) has had biochemical recurrence. CONCLUSIONS: Our initial results are comparable to, or better than, the initial series in high volume centres. The procedure is feasible in appropriately selected cases in the Australasian environment.