Incidence, predictive factors and oncological outcomes of incidental prostate cancer after endoscopic enucleation of the prostate: a systematic review and meta-analysis.

INTRODUCTION: This systematic review aims at reporting the incidence, predictive factors, and the oncological outcomes of incidental prostate cancer (IPCa) in men who underwent endoscopic enucleation of prostate (EEP). METHODS: A literature search was performed using the following Medical Subject Heading (MeSH) terms and keywords: "Prostatic Neoplasms", "Prostate Cancer", "Transurethral Resection of Prostate", "Prostate resection", "Prostate enucleation". Meta-analysis was performed if there were two or more studies reporting the same outcome under the same definition. In case of insufficient data, results were presented in a narrative manner. RESULTS: Sixty-one studies were included in qualitative synthesis and 55 were included in meta-analysis. The pooled IPCa rate was 0.08 (95% CI 0.073-0.088). Increasing age, higher preoperative serum prostate-specific antigen (PSA) level, higher preoperative PSA density (PSAD), smaller prostate volume, higher postoperative PSA velocity and lower enucleated prostate weight, were reported to have significant correlation with IPCa. In BPH patients, the mean pre-operative and post-operative PSA levels were 5.58 ± 1.48 ng/dL and 1.06 ± 0.27 ng/dL, respectively. In patients with IPCa, the mean pre-operative and post-operative PSA levels were 7.72 ± 2.90 ng/dL and 2.77 ± 1.66 ng/dL, respectively. The mean percentage PSA reduction was 82.0% ± 1.8% for BPH patients and 68.2% ± 12.1% for IPCa patients. IPCa was most commonly managed by active surveillance (68.7%). CONCLUSIONS: The pooled incidence of IPCa after EEP was 8%. An absolute post-operative PSA level of < 2.0 and a percentage PSA reduction of > 70% should be expected in BPH patients after EEP.

Bladder neck stenosis after transurethral prostate surgery: a systematic review and meta-analysis.

PURPOSE: Bladder neck stenosis (BNS) is a long-term complication of surgical procedures for benign prostatic hyperplasia (BPH). We performed a systematic literature review and a meta-analysis of the incidence of BNS after transurethral procedures for BPH. METHODS: We performed a systemic literature review using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. We accepted only randomized trials comparing transurethral resection of the prostate (TURP) vs. other transurethral surgery for BPH that were grouped in Ablation vs. Enucleation modalities. The incidences of BNS were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and expressed as Risk Ratios, 95% Confidence Intervals, and p values. Study heterogeneity was assessed utilizing the I2 value. RESULTS: 72 studies were identified for meta-analysis, 46 comparing TURP vs. Ablation and 26 TURP vs. Enucleation. The pooled incidence of BNS was 1.3% after TURP, 0.66% after enucleation and 1.2% after Ablation. The incidence of BNS was higher after TURP than after Enucleation but the difference was not statistically significant (RR 1.75 95% CI 0.81-3.79, p = 0.16). There was no significant heterogeneity among the studies (I2 0%, Chi2 4.11, p = 0.90). The incidence of BNS was higher after TURP than after Ablation, but the difference was not statistically significant (RR 1.31, 95% CI 0.82-2.11, p = 0.26) with no significant heterogeneity (I2 0%, Chi2 21.1, p = 0.51). CONCLUSION: Our study showed no difference in the rate of BNS incidence among randomized trials comparing TURP vs. Ablation vs. Enucleation and can be used as a reference to counsel patients undergoing BPH surgery.

Sexual outcomes of endoscopic enucleation of prostate.

The emergence of various endoscopic enucleation techniques in the past decade has provided surgeons with more options and opportunities in performing enucleation. With the same surgical principle as holmium laser enucleation of prostate, the early results of different techniques were comparable. However, sexual outcomes of endoscopic enucleation of the prostate (EEP) were less commonly reported than the voiding and urodynamic outcomes. In this review, the sexual outcomes including erectile function, ejaculatory and orgasmic function of various endoscopic enucleation technique would be studied. The overall sexual outcomes were heterogeneous and inconclusive. Outcomes measurement, sample size calculation, hypothesis generation and selection criteria were not specifically designed for sexual outcomes or even available. There were also limitations in the individual sexual assessment tools. Nonetheless, most studies showed no significant deterioration of erectile function after EEP, and ejaculation dysfunction was common. Looking forward in the field of benign prostatic enlargement surgery, the 'one size fits all' notion should be abandoned. Treatment should be tailor-made according to the prostate size, co-morbidities and sexual needs. The sexual outcomes of enucleation have to be better studied and defined. More prospective controlled studies focusing primarily on sexual functions are needed. For enucleation surgeons, exploring different ejaculatory-sparing technique could be the golden opportunities in further consolidating the role and expanding the indication of enucleation surgery.