[Benign prostatic hyperplasia : New and treatment-relevant aspects from the DGU guidelines]. / Benignes Prostatasyndrom : Neues und Praxisrelevantes aus den DGU-Leitlinien.

The diagnosis and treatment of lower urinary tract symptoms (LUTS) due to benign prostatic enlargement plays an important role in daily urological practice. Therefore, a targeted and resource-saving approach is essential. A rational base-line work-up of our patients provides the necessary information for obtaining the diagnosis and only needs to be expanded in individual cases. In addition to drug therapy, the modification of lifestyle and the possibility of watchful waiting must not be underestimated. Simple measures such as a timed fluid intake, double micturition in the case of residual urine development, but also bladder reconditioning can significantly improve the quality of life of our patients. Regarding surgical treatment, laser procedures have found their way into many departments and have established themselves in daily routine as a reference procedure in addition to transurethral resection of the prostate (TUR-P) and simple open prostatectomy. New, minimally invasive procedures-such as prostatic artery embolization (PAE), the Rezum™- (NxThera Inc., Maple-Grove, MN, USA) or the Aquabeam® (Procept, Redwood City, CA, USA) procedure, but also nonablative procedures such as iTind© (TIND, Medi-Tate, Or Akiva, Israel) or Urolift® (Neotract Inc., Pleasanton, CA, USA)-offer new treatment options to those affected, with the potential to maintain patient's sexual function. As a result, individual risk assessment and advice on the advantages and disadvantages of all available treatment options-even more than today-will be an important part of LUTS treatment. An individual approach, similar to that used in the treatment of oncological disease, will become standard also in the treatment of benign prostatic syndrome.

Reducing readmissions and improving patient experience following urological surgery, through early telephone follow-up.

Readmission from urological surgery is common, with a readmission rate for day case surgery of 3.7% and 26% for robot-assisted cystectomy. Readmission to secondary care and representation to primary care are both expensive and preventable. This project aimed to reduce both and also enhance the care of patients following urological surgery in a large tertiary referral centre, within the National Health Service. A retrospective telephone follow-up (TFU) survey was set up in the early postoperatively period to measure reattendance and readmission rates and perception of care received. Patients were also asked to suggest how improvement could be made. Quality improvement tools were used to optimise and review the methods and timing of TFU. TFU was initiated as a strategy to enhance care and reduce readmission rates. Phone calls were targeted to occur between 48 and 72 hours following discharge. During the intervention period, 484 phone calls were attempted with 343 being successful. Reattendance rates were reduced by 13% and patient satisfaction improved by 19.6%, following TFU. This intervention also generated additional income for the organisation and enhanced patient satisfaction in the early postoperative period.

Laser enucleation of the prostate versus transurethral resection of the prostate: perioperative outcomes from the ACS NSQIP database.

PURPOSE: To compare the perioperative outcomes associated with laser enucleation of the prostate (LEP) and transurethral resection of the prostate (TURP) using a national database. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for patients who underwent TURP or LEP from 2008 to 2016. Baseline demographics, comorbidities, and predisposition to bleeding were compared between TURP and LEP. The 30-day perioperative outcomes including operative time, length of hospital stay (LOS), return to the operating room (OR), bleeding requiring transfusion, and organ system-specific complications were compared between the procedures. A multivariate logistic regression analysis was performed, adjusting for the type of surgery and other covariates. RESULTS: The series included 37,577 TURP and 2869 LEP procedures. While TURP was associated with a shorter operative time (55.20 ± 37.80 min) than LEP (102.80 ± 62.30 min), the latter was associated with a shorter hospital stay (1.29 ± 2.73 days) than TURP (2.05 ± 5.20 days). Compared to TURP, LEP had 0.52 (0.47-0.58) times the odds of a LOS > 1 day and 0.67 (0.54-0.83) times the odds of developing urinary tract infections. Nevertheless, no difference was found for other postoperative complications, need for transfusion, and return to OR. CONCLUSION: Real-life data from a large national database confirmed that LEP is a safe and reproducible procedure to treat benign prostatic obstruction. Compared to TURP, LEP was associated with a lower rate of infectious complications and a shorter LOS at the expense of an increased operative time.

Catheter management after benign transurethral prostate surgery: RAND/UCLA Appropriateness Criteria.

OBJECTIVES: To formally assess the appropriateness of different timings of urethral catheter removal after transurethral prostate resection or ablation. Although urethral catheter placement is routine after this common treatment for benign prostatic hyperplasia (BPH), no guidelines inform duration of catheter use. STUDY DESIGN: RAND/UCLA Appropriateness Methodology. METHODS: Using a standardized, multiround rating process (ie, the RAND/UCLA Appropriateness Methodology), an 11-member multidisciplinary panel reviewed a literature summary and rated clinical scenarios for urethral catheter duration after transurethral prostate surgery for BPH as appropriate (ie, benefits outweigh risks), inappropriate, or of uncertain appropriateness. We examined appropriateness across 4 clinical scenarios (no preexisting catheter, preexisting catheter [including intermittent], difficult catheter placement, significant perforation) and 5 durations (postoperative day [POD] 0, 1, 2, 3-6, or ≥7). RESULTS: Urethral catheter removal and first trial of void on POD 1 was rated appropriate for all scenarios except clinically significant perforations. In this case, waiting until POD 3 was deemed the earliest appropriate timing. Waiting 3 or more days to remove the catheter for patients with or without preexisting catheter needs, or for those with difficult catheter placement in the operating room, was rated as inappropriate. CONCLUSIONS: We defined clinically relevant guidance statements for the appropriateness of urethral catheter duration after transurethral prostate surgery. Given the lack of guidelines and this robust expert panel approach, these ratings may help clinicians and healthcare systems improve the consistency and quality of care for patients undergoing transurethral surgery for BPH.

Trends and Perioperative Outcomes Across Major Benign Prostatic Hyperplasia Procedures from the ACS-NSQIP 2011-2015.

BACKGROUND AND PURPOSE: There are currently several different surgical options for patients with benign prostatic hyperplasia (BPH). The literature has demonstrated equivalent or superior results for holmium laser enucleation of prostate (HoLEP) but with exceptional long-term durability compared to other minimally invasive options. Despite this, HoLEP is not widely practiced. Herein, we investigate trends and outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to support a need for further adoption of HoLEP. METHODS: Using ACS-NSQIP data from 2011 to 2015, trends, baseline characteristics, and perioperative outcomes were collected for major BPH procedures: transurethral resection of prostate (TURP), TURP for regrowth, photovaporization of prostate (PVP), HoLEP, and simple prostatectomy. RESULTS: The most common procedure performed every year was TURP with PVP performed about half as often, while HoLEP (4%-5%) was performed about as infrequently as simple prostatectomy (3%). More African American men underwent simple prostatectomy except in 2011. International normalized ratio (INR) was highest every year for PVP. Hospital stay and transfusion rates were lowest with PVP and HoLEP. Transfusion rates for simple prostatectomy were high (16.0%-25.4%). Lower rates of readmission, reoperation, and urinary tract infection were seen in some years with HoLEP. CONCLUSIONS: Given the previously reported favorable outcomes and long-term durability of HoLEP, these ACS-NSQIP data further support that HoLEP should be more often practiced for patients undergoing surgery for BPH.

What's New in Aquablation.

Transurethral resection of the prostate (TURP) is considered the gold standard for minimally invasive treatment of lower urinary tract symptoms due to benign prostate enlargement of <80ml. Although durable and effective, TURP carries the risk of significant side effects, including infection and bleeding, and the risk of dilutional hyponatremia. The Aquabeam system uses high-velocity water jets to robotically ablate prostatic tissue under real-time ultrasound guidance, with hemostasis achieved via a catheter balloon tamponade and a novel traction device or electrocautery. In this mini-review, we assess early clinical experience with the device. Short-term outcomes appear to be promising, with significant improvements in urinary symptoms and bother. Operative times have been roughly equivalent to those for TURP, while surgical complication rates have been low. Future studies are required to assess long-term effectiveness.

Development of a Nationally Representative Coordinated Registry Network for Prostate Ablation Technologies.

PURPOSE: The accumulation of data through a prospective, multicenter coordinated registry network is a practical way to gather real world evidence on the performance of novel prostate ablation technologies. Urological oncologists, targeted biopsy experts, industry representatives and representatives of the FDA (Food and Drug Administration) convened to discuss the role, feasibility and important data elements of a coordinated registry network to assess new and existing prostate ablation technologies. MATERIALS AND METHODS: A multiround Delphi consensus approach was performed which included the opinion of 15 expert urologists, representatives of the FDA and leadership from high intensity focused ultrasound device manufacturers. Stakeholders provided input in 3 consecutive rounds with conference calls following each round to obtain consensus on remaining items. Participants agreed that these elements initially developed for high intensity focused ultrasound are compatible with other prostate ablation technologies. Coordinated registry network elements were reviewed and supplemented with data elements from the FDA common study metrics. RESULTS: The working group reached consensus on capturing specific patient demographics, treatment details, oncologic outcomes, functional outcomes and complications. Validated health related quality of life questionnaires were selected to capture patient reported outcomes, including the IIEF-5 (International Index of Erectile Function-5), the I-PSS (International Prostate Symptom Score), the EPIC-26 (Expanded Prostate Cancer Index Composite-26) and the MSHQ-EjD (Male Sexual Health Questionnaire for Ejaculatory Dysfunction). Group consensus was to obtain followup multiparametric magnetic resonance imaging and prostate biopsy approximately 12 months after ablation with additional imaging or biopsy performed as clinically indicated. CONCLUSIONS: A national prostate ablation coordinated registry network brings forth vital practice pattern and outcomes data for this emerging treatment paradigm in the United States. Our multiple stakeholder consensus identifies critical elements to evaluate new and existing energy modalities and devices.

Economic Value of the Transurethral Resection in Saline System for Treatment of Benign Prostatic Hyperplasia in England and Wales: Systematic Review, Meta-analysis, and Cost-Consequence Model.

CONTEXT: Monopolar transurethral resection of the prostate (M-TURP) is the current UK surgical standard of care for benign prostatic hyperplasia, a condition estimated to affect >2 million men in the United Kingdom. Although M-TURP efficacy in prostate resection is established, potential perioperative complications and associated costs remain a concern. OBJECTIVE: To present up-to-date and robust evidence in support of bipolar transurethral resection in saline (TURis) as an alternative surgical option to M-TURP. EVIDENCE ACQUISITION: A systematic review (SR) of electronic databases (up to 2015) for randomised controlled trials (RCTs) comparing TURis with M-TURP was conducted, followed by evidence synthesis in the form of a meta-analysis of hospital stay, catheterisation time and procedure duration, transurethral resection (TUR) syndrome, blood transfusion, clot retention, and urethral strictures. An economic analysis was subsequently undertaken from the UK National Health Service hospital perspective with costs and resource use data from published sources. EVIDENCE SYNTHESIS: The SR identified 15 good-quality RCTs, of which 11 were used to inform the meta-analysis. TURis was associated with improved safety versus M-TURP, eliminating the risk of TUR syndrome and reducing the risk of blood transfusion and clot retention (relative risks: 0.34 and 0.43, respectively; p<0.05). TURis also reduced hospital stay (mean difference: 0.56 d; p<0.0001). The economic analysis indicated potential cost savings with TURis versus M-TURP of up to £204 per patient, with incremental equipment costs offset by savings from reduced hospital stay and fewer complications. CONCLUSIONS: The TURis system is associated with significant improvements in perioperative safety compared with M-TURP while ensuring equivalent clinical outcomes of prostate resection. The safety benefits identified may translate into cost savings for UK health services. PATIENT SUMMARY: Our review of bipolar transurethral resection in saline, the new prostate resection technique, indicates that it offers equal efficacy while reducing complications and length of hospital stay.

The impact of training on the perioperative and intermediate functional outcomes after holmium laser enucleation of the prostate.

INTRODUCTION: To systemically measure the impact of trainees' participation on the perioperative and functional outcomes after holmium laser enucleation of the prostate (HoLEP). MATERIALS AND METHODS: Benign prostatic hyperplasia patients who underwent HoLEP at our department between January 2007 and January 2013 were classified based on trainee's level. Perioperative outcomes and complications were collected. Functional outcomes were assessed using the Sexual Health Inventory for Men (SHIM), International Prostate Symptom Score (IPSS), and International Continence Society-Short Form (ICSmaleSF) questionnaires. Voiding and incontinence domains of ICSmaleSF were assessed separately. Patients were divided into group 1 if no trainee participated in the operation, group 2 if a senior trainee performed the operation, and group 3 if a junior trainee participated in the operation. The patient's baseline characteristics, complications, and perioperative outcomes were compared. RESULTS: There were no differences in the baseline characteristics. There were significant differences in overall operative and enucleation time (p = 0.0186, p = 0.0047, respectively) with shorter times noticed with more experienced operators. There were no differences in resected tissue weight, hemoglobin change, and transfusion rates. Postoperatively, all patients had a similar length of stay and catheterization. Complications (graded by Clavien grading system) were not different. All patients were followed up at regular intervals starting at 6 weeks, 3 months , 6 months, 1 year, and every year after that and there were no differences in flow rates or post void residual volumes at any time point. There were no differences in SHIM, IPSS, and ICSmale voiding scale among the groups. However, ICSmale continence scale was significantly different where the highest score seen in group 2. CONCLUSION: Trainee participation in HoLEP in a controlled training environment does not compromise the safety of the procedure.

[Transurethral resection of the prostate]. / Die transurethrale Resektion der Prostata.

Symptoms related to benign prostatic hyperplasia (BPH) are the most common reason why patients consult a urologist. Despite the rise of new minimally invasive technologies, transurethral resection of the prostate (TURP) remains the most commonly used procedure (at 84 %) to treat BPH patients in Germany. The continued popularity of this procedure can be explained by three main reasons: a robust, simple technique, an until now unsurpassed efficacy and-with regard to the risk-benefit ratio-a low morbidity. Following TURP, the mean Qmax is 19-20 ml/s and the mean IPSS is 6. BPH recurrence occurs in 2-7 % of patients within 8-22 years following TURP. Regarding clinical efficacy, meta-analyses now show relevant differences between monopolar and bipolar (B) TURP. However, B­TURP seems to be favourable considering potential complications. Clot retention with an incidence of 1-5 % is the most common acute complication and urethral strictures with an incidence of 2-9 % are the most common long-term complications of TURP. TUR syndrome is nowadays a clinical rarity. However, many complications can be avoided by a proper resection technique. TURP is still the standard in surgical BPH therapy.

Hospital-level Variation in the Quality of Benign Inpatient Urologic Surgery.

OBJECTIVE: To examine hospital-level variation in outcomes following benign urologic surgeries given that hospital-level variation in surgical outcomes can portend quality and appropriateness of care concerns and identify quality improvement opportunities in perioperative care. MATERIALS AND METHODS: Using the Washington State Comprehensive Hospital Abstract Reporting System, we identified patients who underwent transurethral resection of the prostate (TURP), percutaneous nephrostolithotomy (PCNL), and pyeloplasty from 2003 to 2008. We classified prolonged postoperative length of stay (LOS) as that exceeding the 75th percentile, and we measured the rate of Agency for Healthcare Quality Patient Safety Indicators, readmissions, and death. We calculated hospital-specific observed-to-expected event rates using random effects multilevel multivariable models adjusted for age and comorbidity. RESULTS: We identified 6699 TURP patients at 54 hospitals, 2541 PCNL patients at 45 hospitals, and 584 pyeloplasty patients at 36 hospitals. Complication rates were highest after PCNL (22.9% prolonged LOS vs 17.3% for TURP and 13.9% for pyeloplasty, P < .001; 3.4% 90-day mortality vs 0.6% for TURP and 0% for pyeloplasty). Hospital-level variation was most substantial for LOS after TURP and pyeloplasty (8.1% and 14.3% of variance in prolonged LOS, respectively). CONCLUSION: Hospital-level variation is common after benign inpatient urologic surgeries and may relate to difference in perioperative provider practice patterns. The morbidity of PCNL in this study was higher than expected and merits further investigation.

Instrumentación transuretral en portadores de esfínter urinario artificial. Presentación y discusión de tres casos clínicos / Transurethral instrumentation in patients with artificial urinary sphincter. Presentation and discussion of three clinical cases

El tratamiento para la incontinencia urinaria masculina de esfuerzo severa es la colocación de un esfínter urinario artificial (EUA). La etiología de la incontinencia con frecuencia es la cirugía prostática previa. Los resultados funcionales son buenos con una tasa aceptable de complicaciones. Las complicaciones son más frecuentes si existe radioterapia previa o se realizan procedimientos transuretrales sin tener en cuenta la presencia del manguito del EUA. Cuando es necesaria la cirugía transuretral, por ejemplo por tumor vesical, es necesario realizar el desabrochado del manguito esfinteriano. Los sondajes uretrales precisan también desactivar el manguito y manipular la uretra con sumo cuidado, evitando su manipulación siempre que sea posible. Se presentan tres casos muy complejos de pacientes portadores de EUA que han precisado diversas soluciones ante manipulación uretral y presencia de complicaciones como estenosis de uretra (AU)

Artificial urinary sphincter (AS) is the gold standard treatment for severe male urinary stress incontinence. The etiology of incontinence is often previous prostate surgery as a radical prostatectomy. Functional results are good with an acceptable rate of complications. If there is prior radiotherapy complications are more frequent. When transurethral surgery, for example for bladder tumor is needed, it is necessary unbuttoned the sleeve. Urethral soundings need also turn off the sleeve and manipulate the urethra carefully, avoiding handling whenever possible. We present three very complex cases of patients with US showing several solutions to urethral manipulation and to resolve complications such as urethral perforation and stricture (AU)

Vaporization vs. enucleation techniques for BPO: do we have a standard?

PURPOSE OF REVIEW: This article discusses enucleation and vaporization procedures which have been developed on the surgical techniques of holmium laser enucleation of the prostate (HoLEP) and photoselective vaporization of the prostate (PVP) by reviewing the most recent publications. RECENT FINDINGS: Enucleation procedures have been described using holmium, thulium, diode or GreenLight lasers in addition to bipolar energy sources. Most of the current literature for these enucleation procedures consists of initial descriptions of the surgical techniques or prospective series from single centres, although the availability of prospective randomized trial for these procedures other than HoLEP is limited. PVP have been described using 80-W, 120-W, or 180-W GreenLight lasers. To date, only sparse literature is available for thulium or bipolar vaporization of the prostate. SUMMARY: A variety of alternative vaporization and enucleation procedures are available for transurethral treatment of benign prostatic obstruction. Only very few PRT have been published for these procedures limiting their evidence for the treatment of benign prostatic obstruction. To date, best evidence is still available for the HoLEP and PVP procedure.

Visual control strategies of surgeons: a novel method of establishing the construct validity of a transurethral resection of the prostate surgical simulator.

OBJECTIVE: To examine novice and expert differences in visual control strategies while performing a virtual reality transurethral resection of the prostate (TURP) task and to determine if these differences could provide a novel method for assessing construct validity of the simulator. SUBJECTS AND METHODS: A total of 11 novices (no TURP experience) and 7 experts (>200 TURPs) completed a virtual reality prostate resection task on the TURPsim (Simbionix USA Corp, Cleveland, OH) while wearing an eye tracker (ASL, Bedford, MA). Performance parameters and the surgeon's visual control strategy were measured and compared between the 2 groups. RESULTS: Experts resected a greater percentage of prostate than novices (p < 0.01) and had less active diathermy time without tissue contact (p < 0.01). Experts adopted a target-locking visual strategy, employing fewer visual fixations (p < 0.05) with longer mean fixation duration (p < 0.005). With multiple learning trials, novices' performance improved and the adoption of a more expertlike gaze strategy was observed. CONCLUSION: Significant differences between experts and novices in both performance and visual control strategy were observed. The study of visual control strategies may be a useful adjunct, alongside measurements of motor performance, providing a novel method of assessing the construct validity of surgical simulators.

EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction.

OBJECTIVE: To present a summary of the 2013 version of the European Association of Urology guidelines on the treatment and follow-up of male lower urinary tract symptoms (LUTS). EVIDENCE ACQUISITION: We conducted a literature search in computer databases for relevant articles published between 1966 and 31 October 2012. The Oxford classification system (2001) was used to determine the level of evidence for each article and to assign the grade of recommendation for each treatment modality. EVIDENCE SYNTHESIS: Men with mild symptoms are suitable for watchful waiting. All men with bothersome LUTS should be offered lifestyle advice prior to or concurrent with any treatment. Men with bothersome moderate-to-severe LUTS quickly benefit from α1-blockers. Men with enlarged prostates, especially those >40ml, profit from 5α-reductase inhibitors (5-ARIs) that slowly reduce LUTS and the probability of urinary retention or the need for surgery. Antimuscarinics might be considered for patients who have predominant bladder storage symptoms. The phosphodiesterase type 5 inhibitor tadalafil can quickly reduce LUTS to a similar extent as α1-blockers, and it also improves erectile dysfunction. Desmopressin can be used in men with nocturia due to nocturnal polyuria. Treatment with an α1-blocker and 5-ARI (in men with enlarged prostates) or antimuscarinics (with persistent storage symptoms) combines the positive effects of either drug class to achieve greater efficacy. Prostate surgery is indicated in men with absolute indications or drug treatment-resistant LUTS due to benign prostatic obstruction. Transurethral resection of the prostate (TURP) is the current standard operation for men with prostates 30-80ml, whereas open surgery or transurethral holmium laser enucleation is appropriate for men with prostates >80ml. Alternatives for monopolar TURP include bipolar TURP and transurethral incision of the prostate (for glands <30ml) and laser treatments. Transurethral microwave therapy and transurethral needle ablation are effective minimally invasive treatments with higher retreatment rates compared with TURP. Prostate stents are an alternative to catheterisation for men unfit for surgery. Ethanol or botulinum toxin injections into the prostate are still experimental. CONCLUSIONS: These symptom-oriented guidelines provide practical guidance for the management of men experiencing LUTS. The full version is available online (www.uroweb.org/gls/pdf/12_Male_LUTS.pdf).