Rezum water vaporization therapy versus transurethral resection of the prostate in the management of refractory urine retention: matched pair comparative multicenter experience.

PURPOSE: To compare the efficacy of Rezum with a matched cohort of patients undergoing transurethral resection of the prostate (TURP) for catheter-dependent urine retention secondary to benign prostate hyperplasia (BPH). METHODS: A retrospective review was performed for consecutive catheter-dependent patients who underwent Rezum for BPH. Patients were matched and compared with a similar cohort undergoing TURP, using non-inferiority analysis on propensity score-matched patient pairs. Patients were followed up at 1, 3, 6 and 12 months by international prostate symptoms score (IPSS), quality of life (QoL) index, peak flow rate (Qmax) and postvoid residual urine (PVR). RESULTS: Eighty-one patients undergoing Rezum were compared with equal number of matched patients who undergoing TURP. Patients undergoing Rezum experienced significantly shorter operation time (25.5 ± 8.7 vs. 103.4 ± 12.6 min; p < 0.001), lower intraoperative bleeding (2.4% vs. 20.7%, p < 0.001), shorter hospital stay (1.2 ± 0.9 vs. 2.4 ± 1.3 d, p < 0.001) and longer catheter time (12.6 ± 6.0 vs. 2.3 ± 1.2 d, p < 0.001), with no need for transfusion. Successful postoperative voiding was comparable between both arms (90.2% vs. 92.7%, p = 0.78), respectively. Despite patients undergoing TURP had significantly better voiding outcomes after 1 and 3 months, both groups were comparable after six and 12 months in terms of mean IPSS (11.1 ± 6.4 vs. 10.8 ± 3.4, p = 0.71), QoL indices (2.4 ± 1.6 vs. 2.1 ± 2.3, p = 0.33) and Qmax (22.0 ± 7.7 v. 19.8 ± 6.9 ml/sec, p = 0.06). CONCLUSION: This study supports the safety and efficacy of Rezum in the management of catheter-dependent patients secondary to BPH, with comparable functional outcomes to TURP. Until a randomized clinical comparison is available, long-term data are crucially recommended to compare the recurrence and reoperation rates.

Management of Benign Prostatic Hyperplasia Larger than 100 ml: Simple Open Enucleation Versus Transurethral Laser Prostatectomy.

Benign prostatic hyperplasia (BPH) is one of the most common causes of lower urinary tract symptoms (LUTS) in aging men. Over the age of 60, more than a half of men have BPH and/or bothersome LUTS. Contemporary guidelines advocate surgery as the standard of care for symptomatic BPH after failure of medical therapy, where the choice of the appropriate surgical procedure depends on the prostate size. Transurethral resection of the prostate (TURP) and simple open prostatectomy (OP) have been considered for decades the reference-standard techniques for men with prostate smaller and larger than 80 ml, respectively. However, both procedures are potentially associated with considerable perioperative morbidity which prompted the introduction of a variety of minimally invasive surgical techniques with comparable long-term outcomes compared to TURP and OP. Nevertheless, the management of prostates larger than 100 ml remains a clinical challenge. Transurethral anatomical enucleation of the prostate utilizing different laser energy represents an excellent alternative concept in transurethral BPH surgery. These procedures gained popularity and demonstrated similar outcomes to OP with the advantages of favorable morbidity profiles and shorter catheter time and hospital stay. Despite the fact that OP remains a viable treatment option for patients with bothersome LUTS secondary to very large prostates, this procedure has been to a large extent replaced by these emerging enucleation techniques. Given the advent of surgical alternatives, the current review presents an evidence-based comparison of the efficacy and safety profile of the currently available transurethral laser techniques with the standard OP for the management of BPH due to adenomas larger than 100 ml.

Post-Transurethral Resection of the Prostate Inflation of Pressure-Controlled Endorectal Balloon-Impact on Postoperative Bleeding: A Preliminary Experimental Pilot Study.

OBJECTIVE: To evaluate the impact of rectal balloon (RB) inflation on post-transurethral resection of the prostate (TURP) bleeding in patients with symptomatic benign prostatic hyperplasia. METHODS: After institutional review board approval, patients who were eligible for TURP were randomized into two equal groups, depending on whether they received postoperative endorectal balloon (RB) (GII) or not (GI). The tip of three-way Foley catheter was fixed to a balloon by a blaster strip to prepare air-tight RB. Postoperatively, the RB was inflated for 15 minutes by a pressure-controlled sphygmomanometer. Perioperative data were compared between both groups, including hemoglobin (Hb) deficit 24-hour postoperatively and at time of discharge. Functional outcomes, anorectal complaints, and adverse events were assessed perioperatively and after 1 and 3 months. RESULTS: Fifty patients were enrolled, including 13 (26%) patients who presented with indwelling urethral catheters. Baseline data and mean resected tissue weight were comparable between both groups, including preoperative Hb (p = 0.17). Immediate postoperative Hb deficit was, comparable between GI and GII patients (0.58 ± 0.18 vs 0.60 ± 0.2, p = 0.56) before RB inflation, respectively. However, compared to GI patients, mean Hb deficit significantly decreased in GII patients 24-hour postoperatively (0.2 ± 0.2 vs 0.7 ± 0.3 g, p = 0.002) and at time of discharge (0.8 ± 0.2 vs 1.3 ± 0.4 g, p = 0.003). GII patients needed significantly less postoperative irrigation (2.1 ± 1.6 vs 8.3 ± 1.8 L, p < 0.001), shorter catheterization time (2.3 ± 0.8 vs 3.8 ± 1.3 days, p < 0.001), and shorter hospital stay (2.6 ± 0.5 vs 4.3 ± 1.0 days, p < 0.001). Both groups were comparable in all functional outcomes at the most recent follow-up. Blood transfusion was needed in only one patient (4%) in GI. No patient needed recystoscopy for hematuria or clot retention in either group, while there were no anorectal complaints reported by GII patients. CONCLUSIONS: Post-TURP endorectal balloon inflation seems to be simple, safe, and an efficient procedure to reduce postoperative bleeding and irrigation volume. It is significantly associated with shorter catheterization time and hospital stay.

Incidental Prostate Cancer Diagnosis During Holmium Laser Enucleation: Assessment of Predictors, Survival, and Disease Progression.

OBJECTIVE: To determine the prevalence and predictors of incidental prostate cancer (IPCa) after Holmium laser enucleation of the prostate (HoLEP) and to assess its functional and oncological outcomes. METHODS: A prospectively maintained database was reviewed for cases with IPCa at the time of HoLEP. Patients with preoperative PCa were excluded. Patients were divided into two groups based on the presence (group I [GI]) or absence of cancer (group II [GII]) in histopathology. Univariate and multivariate logistic regression analyses were performed. RESULTS: Of 1242 patients, 70 (5.64%) were identified to have IPCa. Prostate size was comparable between both groups. GI patients had significantly higher preoperative prostate-specific antigen (PSA) and total PSA density (tPSAD) compared to cancer-free patients. T1a and T1b adenocarcinomas were detected in 54 (77.1%) and 16 (22.9%) patients, respectively. After a median follow-up of 48 (1-171) months, both groups were comparable in all functional outcomes but the quality of life was significantly better in GII. Patients' age and preoperative tPSAD independently predicted IPCa after HoLEP. A tPSAD cutoff value of 0.092 has a sensitivity and specificity of 0.83 and 0.67, respectively. Seven patients (11.7%) needed adjuvant therapy while other GI patients opted for active surveillance. The Kaplan-Meier analysis demonstrated an overall survival of 72.8% at 5 years and 63.5% at 10 years for patients with PCa. CONCLUSION: PCa is not uncommonly identified after HoLEP, even in those with negative preoperative biopsies. In older patients, total PSAD could be a predictor using a cutoff <0.1. After HoLEP, active surveillance for low-grade PCa carries good functional and oncological outcomes.

Postoperative Lower Urinary Tract Storage Symptoms: Does Prostate Enucleation Differ from Prostate Vaporization for Treatment of Symptomatic Benign Prostatic Hyperplasia?

PURPOSE: To assess the degree of postoperative storage symptoms after GreenLight™ laser photoselective vaporization of the prostate (PVP) and Holmium laser enucleation of the prostate (HoLEP) for management of benign prostatic hyperplasia (BPH) and its predictors. METHODS: A retrospective review was performed for patients who underwent HoLEP or PVP for non catheter-dependent patients with BPH. Patients were followed up at 1, 3, 6, and 12 months and then annually by International Prostate Symptoms Score (IPSS), quality of life index, peak flow rate, residual urine volume, and prostate-specific antigen (PSA) level. Moderate or severe storage symptoms were defined as IPSS storage subscore ≥ 9. RESULTS: Of 1673 laser procedures, a total of 1100 procedures met the inclusion criteria including 809 HoLEPs and 291 PVPs. The HoLEP group had significantly larger preoperative prostates and longer operative time. In the HoLEP group, postoperative IPSS was significantly better than in the PVP group at all follow-up points (P<0.05). Storage subscore was significantly higher after PVP and did not improve until 6 months postoperatively when it became comparable with that of the HoLEP group. The number of patients with IPSS-storage score ≥ 9 were significantly higher in the PVP group at 1 and 3 months follow-up (37.3% vs 15.1%, P<0.001) and (26.4% vs 17.5%, P=0.004), respectively. XPS-180W was associated with the lowest storage symptoms among the three GreenLight generations at all follow-up visits. In multivariate analysis, baseline IPSS-storage subscore ≥ 9, prolonged operative time >100 minutes, and lower percent of postoperative PSA level reduction significantly predicted less improvement of postoperative storage symptoms regardless of the laser procedure. CONCLUSION: Storage urinary symptoms significantly improved more after HoLEP compared with PVP, irrespective of the generation of GreenLight laser used. Recovery from bothersome storage urinary symptoms after prostate vaporization is time dependent, and baseline degree of storage symptoms, prolonged operative time, and lower percent of postoperative PSA level reduction negatively predicts postoperative improvement of storage symptoms regardless of the laser procedure.

Reoperation After Holmium Laser Enucleation of the Prostate for Management of Benign Prostatic Hyperplasia: Assessment of Risk Factors with Time to Event Analysis.

PURPOSE: To determine risk factors of reoperation after holmium laser enucleation of the prostate (HoLEP) for management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) with time to event analysis. METHODS: A prospectively maintained database was reviewed for patients undergoing HoLEP. Baseline and follow-up data were compared in terms of International Prostate Symptoms Score, quality of life, peak flow rate, residual urine, and prostate-specific antigen (PSA) at 1, 6, and 12-months and then annually. Perioperative and late adverse events were recorded. Reoperation was defined as the need for any surgical intervention to relieve bothersome LUTS after HoLEP. Multivariate logistic regression was used to determine covariates associated with reoperation and the Kaplan-Meier curve assessed the time to reoperation. RESULTS: A total of 1216 HoLEP procedures were performed between March 1998 and October 2013 with a mean prostate volume of 94.8 ± 52.7 cc. Catheter time and hospital stay were 1.4 ± 1.9 and 1.3 ± 1.6 days, respectively. After a median follow-up of 7.6 years (1-14 years), 52 (4.3%) patients needed reoperation for recurrent LUTS, including 13 (1.07%) for residual/recurrent adenoma, 14 (1.15%) for bladder neck contracture (BNC), and 25 (2.05%) for de novo urethral stricture. In multivariate regression, smaller prostate size (< 62 cc), PSA reduction < 50%, and history of previous prostate surgery were significantly associated with recurrence of adenoma. BNC was significantly associated with smaller glands (< 54 cc) while longer operative time and postoperative catheterization were significantly associated with urethral stricture. Kaplan-Meier curve demonstrates post-HoLEP freedom from reoperation of 96.9% at 5 years and 95.1% at 10 years. CONCLUSIONS: In a single center large series, HoLEP has 95% reoperation-free probability at 10 years. Relatively small-size prostate may have an impact on recurrence of adenoma and bladder neck contracture. PSA reduction < 50% was significantly associated with recurrence of adenoma while longer operative time and postoperative catheterization were significantly associated with postoperative urethral stricture.

Combined vitamin D and calcium supplementation in vitamin D inadequate patients with urolithiasis: Impact on hypercalciuria and de novo stone formation.

INTRODUCTION: We examined the effect of combined vitamin D and calcium supplementation (VDCS) on urinary calcium excretion and de novo stone formation in vitamin D inadequate (VDI) urolithiasis patients. METHODS: We retrospectively reviewed the data of VDI patients (serum 25-hydroxyvitamin D <75 nmol/L) followed at a tertiary stone centre between September 2009 and December 2014. VDI patients with history of urolithiasis, who were placed on VDCS for abnormal bone mineral density or hyperoxaluria, were included. Hypercalciuric patients and patients on thiazide diuretics were excluded. Metabolic stone workup and two 24-hour urine collections were performed before and after VDCS. RESULTS: In total, we included 34 patients, with a mean age of 54.8 years and a mean body mass index of 25.7 kg/m(2). After VDCS, there was a significant increase in the mean serum 25-hydroxyvitamin D (52.0 vs. 66.4 nmol/L, p < 0.001) and the mean urinary calcium excretion (3.80 vs. 5.64 mmol/d, p < 0.001). Eight (23.5%) patients developed de novo hypercalciuria. After a median follow-up of 39 (range: 7-60) months, 50% of hypercalciuric patients developed stones compared with 11.5% of non-hypercalciuric patients (p = 0.038). CONCLUSION: This study showed a significant effect of combined VDCS on mean urinary calcium excretion, de novo hypercalciuria, and stone development in VDI patients with history of urolithiasis. Therefore, VDI urolithiasis patients receiving VDCS are advised to have monitoring with 24-hour urine collections and imaging studies. Although small, our sample size was good enough to validate the statistical outcomes. Prospective studies are needed to confirm these results.

Long-term incidence of symptomatic urolithiasis post-bariatric surgery.

INTRODUCTION: The risk of urolithiasis post-Roux-en-Y gastric bypass (RYGB) surgery is higher when compared to the general population. Calcium and vitamin D supplementation is routinely prescribed to these patients, yet compliance with these supplements is unknown. The aim of this study was to assess the incidence of symptomatic de novo urolithiasis post-RYGB and compliance with calcium and vitamin D supplementation. METHODS: A standardized telephone questionnaire was administered to patients who underwent RYGB between 1996 and 2011. Personal and medical histories were obtained with emphasis on episodes of symptomatic urolithiasis and calcium and vitamin D supplementation. RESULTS: The response rate was 48% with 478 patients completing the telephone questionnaire. After a mean follow-up of 7.0 years (range: 1-15), the incidence of post-RYGB symptomatic urolithiasis was 7.3%, while the rate of de novo symptomatic urolithiasis was 5%. The overall median time to present with symptomatic urolithiasis was 3.1 years, with 3.3 years for de novo stone-formers, and 2.0 years for recurrent stone-formers (p = 0.38). In de novo stone-formers, 33% presented with symptomatic urolithiasis 4 to 14 years postoperatively. Compliance with calcium and vitamin D supplementation was 56% and 51%, respectively. CONCLUSIONS: Despite recall bias and lack of confirmatory imaging studies, a high postoperative incidence of symptomatic urolithiasis was found in a large sample of post-RYGB patients. A third of patients with de novo stones, presented with symptomatic urolithiasis 4 to 14 years postoperatively. Compliance with postoperative calcium and vitamin D supplementation was poor and needs improvement.

Holmium:YAG transurethral incision versus laser photoselective vaporization for benign prostatic hyperplasia in a small prostate.

PURPOSE: We assess the perioperative, short-term and long-term functional outcomes of treating bladder outlet obstruction secondary to a small prostate by 1 of 2 laser techniques. MATERIALS AND METHODS: A retrospective review using a prospectively maintained database was performed of patients treated for bladder outlet obstruction secondary to a prostate smaller than 40 ml. Patients who were treated with GreenLight™ photoselective vaporization of the prostate or holmium laser transurethral incision of the prostate were included in the study. RESULTS: From January 2002 through December 2010, 191 cases of 1,682 laser prostate surgeries were described. GreenLight photoselective vaporization of the prostate was performed in 144 (75.4%) cases and holmium laser transurethral incision of the prostate was performed in 47 (24.6%) cases. A significantly shorter mean operating time, hospital stay and catheter duration were observed in the holmium laser transurethral incision of the prostate group (30.3 ± 16 minutes, 0.8 ± 0.8 days and 1.3 ± 1.9 days, respectively) than in the photoselective vaporization of the prostate group (45.8 ± 22 minutes, 0.3 ± 0.4 days and 0.4 ± 0.6 days, respectively, p <0.05). At 1 and 5 years after photoselective vaporization of the prostate there were reductions in mean International Prostate Symptom Score, quality of life score and residual urine with improvement in mean maximal flow rate of 57.7% and 62.8%, 58.3% and 57.2%, 65.4% and 73%, and 127.6% and 167.1%, respectively. At 1 and 5 years after holmium laser transurethral incision of the prostate there were reductions in mean International Prostate Symptom Score, quality of life score and residual urine with improvement of mean maximal flow rate of 55.3% and 52.8%, 49.2% and 49%, 45% and 78.1%, and 67.4% and 35.4%, respectively. Subjective and objective urine flow parameters were comparable at different followup points. There was no significant difference between the 2 groups in terms of early and late complications (p >0.05). Reoperation rates were 10.4% and 6.4% in the photoselective vaporization of the prostate and holmium laser transurethral incision of the prostate groups, respectively (p >0.05). The mean estimated cost per holmium laser transurethral incision of the prostate procedure was significantly lower than per photoselective vaporization of the prostate procedure (509.34CAD vs 1,765.92CAD, p = 0.002). CONCLUSIONS: Holmium laser transurethral incision of the prostate and GreenLight photoselective vaporization of the prostate seem to be equally effective, safe and durable surgical treatment options for small prostates even in high risk patients.

Male sexual function outcome after three laser prostate surgical techniques: a single center perspective.

OBJECTIVE: To assess the change and predictors of sexual-related outcomes after laser prostate surgery. METHODS: This is a longitudinal study of 216 sexually active men who underwent laser prostatectomy between 2005 and 2010. The International Index of Erectile Function-15 questionnaire was used both preoperatively and during the first year of follow-up. Cases with unreliable answers or patients without interested partners were excluded. All relevant data of both groups were depicted and statistically analyzed. RESULTS: We identified 191 patients that met the inclusion criteria, 99 holmium laser enucleation of the prostate, 34 holmium laser ablation, and 58 photoselective vaporization of the prostate (GreenLight-532-mm laser photoselective vaporization of the prostate). There were significant differences among the 3 groups regarding the International Index of Erectile Function-15 direction of change at 1 year, being unchanged in (22.2%, 24.4%, and 29.3%), improved in (60.6%, 29.4%, and 41.4), and declined in (17.2%, 41.2%, and 29.3%) in the 3 groups, respectively (P < .05). After adjusting for clinical and perioperative variables, the independent risk factors for decline in the International Index of Erectile Function score were basal International Index of Erectile Function ≥ 55 and energy to prostate ratio. In holmium laser enucleation of the prostate group, there was significant improvement of the mean overall score, erectile function, desire, and intercourse satisfaction domains (P < .05). In holmium laser ablation and photoselective vaporization of the prostate groups, there were no significant changes between mean preopeative and postoperative scores (P > .05). The incidence of new onset retrograde ejaculation in the holmium laser enucleation of the prostate group was (77.3%) significantly different compared to (31.1%) in the holmium laser ablation group and (33.2%) in photoselective vaporization of the prostate group (P < .05). CONCLUSION: Laser prostate surgery using more size-related laser energy might have possible negative influence on sexual function. Patients with normal preoperative sexuality are more at risk.