Emergency department visits following transurethral resection of prostate in the elderly: Does duration of postoperative catheterization count?

Background: Elderly patients with benign prostatic hyperplasia are increasingly having minimally invasive surgeries due to their safety. There is also a drive to minimize the duration of postoperative catheterization following transurethral resection of the prostate to reduce hospital stay and encourage early ambulation. These are desirable in the elderly to improve outcomes. Can early catheter removal be done safely in the geriatrics without an increase in presentation to the emergency department with complications? We compare the emergency presentation of elderly patients who had early and delayed catheter removal following transurethral resection of the prostate. Materials and Methods: This was a retrospective review of transurethral resection of the prostate in the elderly (≥70 years) within 2 years in a single hospital. All the patients had monopolar transurethral resection of the prostate and were categorized based on the duration of postoperative catheterization as either early (third postoperative day) or delayed (> third postoperative day). The duration of catheterization was based on surgeon preference. Patients with intraoperative complications were excluded. Data on clinical presentation, comorbidities, and presentation at the emergency department were retrieved and analysed. Results: Forty-one patients were studied with the mean age of patients being 76 ± 4 years. Twenty patients had early catheter removal and 21 had delayed catheter removal. A total of nine patients presented to the emergency department within the 30-day postoperative period with either bleeding urinary retention or incontinence requiring re-catheterization, six had early catheter removal, and three had delayed catheter removal. The catheter duration, preoperative ASA status prostate volume, and preoperative indwelling catheter were not statistically significant determinants of presentation to the emergency department in these elderly men. The presence of comorbidities assessed using the Charlson Comorbidity Index was a statistically significant variable to presentation at the emergency department after surgery P = 0.006. Conclusion: Early catheter removal is safe in elderly patients following transurethral resection of the prostate, however, there is a risk of presentation to the emergency department with complications, especially in patients with comorbidities.

Non-Surgical Bleeding and Transurethral Resection of the Prostate (TURP) Syndrome after TURP Surgery: A Case Report and Literature Review.

Patients undergoing transurethral resection of the prostate (TURP) surgery can develop TURP syndrome and post-TURP bleeding. Post-TURP bleeding can be surgical, from arteries or venous sinuses, or non-surgical, due to coagulopathy preventing clot formation. Non-surgical post-TURP bleeding may be due to high concentrations of urokinase and tissue plasminogen activator (tPA) in the urine that cause fibrinolytic changes and increase bleeding risk. Urine urokinase and tPA may have both local and systemic fibrinolytic effects that may prevent blood clot formation locally at the site of surgery, and cause fibrinolytic changes systemically through leaking into the blood stream. Another post-TURP complication that may happen is TURP syndrome, due to absorption of hypotonic glycine fluid through the prostatic venous plexus. TURP syndrome may present with hyponatremia, bradycardia, and hypotension, which may be preceded by hypertension. In this case report, we had a patient with benign prostatic hyperplasia (BPH) who developed both TURP syndrome and non-surgical post-TURP bleeding. These complications were transient for one day after surgery. The local effect of urine urokinase and tPA explains the non-surgical bleeding after TURP by preventing clot formation and inducing bleeding. Coagulation studies showed fibrinolytic changes that may be explained by urokinase and tPA leakage into the blood stream. In conclusion, non-surgical bleeding after TURP can be explained by the presence of fibrinolytic agents in the urine, including urokinase and tPA. There is a deficiency in existing studies explaining the pathophysiology of the fibrinolytic changes and risk of bleeding after TURP. Herein, we discuss the possible pathophysiology of developing fibrinolytic changes after TURP. More research effort should be directed to explore this area to investigate the appropriate medications to treat and prevent post-TURP bleeding. We suggest monitoring patients' coagulation profiles and electrolytes after TURP because of the risk of developing severe acute hyponatremia, TURP syndrome, fibrinolytic changes, and non-surgical bleeding. In our review of the literature, we discuss current clinical trials testing the use of an antifibrinolytic agent, Tranexamic acid, locally in the irrigation fluid or systemically to prevent post-TURP bleeding by antagonizing the fibrinolytic activity of urine urokinase and tPA.

Incidence and Determinants of Catheter-Related Bladder Spasms Following Transurethral Resection of the Prostate; A Prospective Review of 80 Cases.

Background: Bladder spasms due to involuntary contraction of the bladder occur frequently following Transurethral resection of the prostate (TURP). They may be aggravated by the presence of a catheter, blood clots, preoperative overactive bladder, or preoperative ingestion of bladder stimulants like caffeine. These bladder spams are painful, associated with peri-catheter leakage of urine, increased post-operative bleeding, and often refractory to postoperative analgesia. The incidence and risk factors for the occurrence of bladder spasms following TURP need to be reviewed and validated to ensure adequate patient counseling and possible lifestyle modification before surgery. We conducted a prospective review of the determinants of bladder spasms in our patients following TURP. Methodology: The study population was patients with benign prostatic obstruction scheduled for TURP between March 2022 and April 2023. Monopolar transurethral resection of the prostate was done using a continuous flow resectoscope. The primary endpoint of the study was occurrences of bladder spasms postoperatively before the trial without a catheter. Pain perception during the spasms was assessed using a visual analog scale. Clinical data were collected and analyzed to determine their association with the occurrence of bladder spasms postoperatively using regression analysis. Sub-group analysis was also done to correlate significant variables with the severity of pain in patients with spasms. Results: The mean age of the 80 patients reviewed was 66.9 ±8 years. Bladder spasms were seen in 41(51.2%) of the patients. The presence of overactive bladder (OAB) symptoms and the use of bladder stimulants were statistically significant determinants with a p-value of 0.003 and 0.026 respectively. The age of the patient, preoperative indwelling catheter, prostate volume, and resection time were not statistically determinant variables in the occurrence of bladder spasms post-operatively. 61% had severe pains and 39% had mild pains. There was no significant correlation between the presence of OAB or the use of bladder stimulants with the severity of pains in patients with bladder spasms after TURP. Conclusions: Half of the patients are likely to have bladder spasms after TURP. The risk of having these spasms is higher in patients with preoperative OAB or patients who are exposed to bladder stimulants. The severity of spasms is however independent of these risk factors.

Sudden cardiac arrest in low-risk patient during transurethral resection of the prostate under spinal anesthesia: Acute myocardial infraction a possible cause? Case report.

INTRODUCTION AND IMPORTANCY: A patient experienced a sudden cardiac arrest (CA) during a transurethral resection of the prostate (TURP) under spinal anesthesia (SA), despite no conventional risk factors. The incident, which occurred during TURP without significant changes in vital signs or electrocardiogram (ECG), this report, contributes to accidents during SA for TURP in healthy patients. PRESENTATION OF CASE: A 53-year-old man with BMI 24.1 underwent TURP. SA was administered using bupivacaine 15 mg and fentanyl 10 µg. The patient had normal vital signs & sinus rhythm. However, around a hr. into the procedure, he experienced fatigue, severe chest pain, sweating, & nausea, leading to unconsciousness & CA. The anesthesia and surgical teams initiated cardiopulmonary resuscitation according to American Heart Association guidelines, but CA could not be reversed. CLINICAL DISCUSSION: The patient showed symptoms of acute MI while undergoing TURP but didn't exhibit typical changes on ECG. Early detection using a 5­lead ECG or troponin level may not be possible so make it challenging to get definitive diagnosis of MI to start managements. It's highlighted that some individuals might not meet standard MI diagnostic criteria. CONCLUSION: Diagnosing MI using only a 5-lead ECG can be challenging, as some patients may not exhibit MI findings. Modern monitors that numerically display ST segment depression, along with the availability of continuous 12­lead ECG in the operating theater, can improve emergency detection. In resource-limited countries, adopting new protocols for MI management is crucial. These protocols should include initiating MI treatments even without a confirmed diagnosis.

Robotic bladder diverticulectomy with concurrent management of bladder outlet obstruction: A choice to consider.

INTRODUCTION: Acquired bladder diverticula (BD) are associated with bladder outlet obstruction. The aim of our study is to analyse the improvement in lower urinary tract symptoms (LUTS) in patients who underwent robot-assisted bladder diverticulectomy (RABD) combined with transurethral prostatectomy (TURP). MATERIAL AND METHODS: A prospectively single-centre, single surgeon cohort of four patients with posterolateral BD due to bladder outlet obstruction (BOO) undergoing RABD combined with TURP between 2018 and 2023 was analysed. RESULTS: Median age and maximum BD diameter were 73.5 years and 16 cm, respectively. All patients had severe LUTS and elevated postvoid residual (PVR). Preliminary uroflowmetry revealed bladder outlet obstruction with a median of maximum urine flow rate of 8.5 ml/s. The median operative time and blood loss were 212 min and 100 ml, respectively. No intraoperative complications were recorded. The median length of stay was 4 days. The International Prostate Symptom Score (IPSS) and PVR were compared between baseline, 1 month and 6 months after surgery. IPSS significantly decreased from 24 (IQR 24-25) preoperatively compared to the postoperative, at 1 month follow up 7 (IQR 6-8) (p < 0.0001). PVR significantly decreased too from 165 (IQR 150-187) to 35 ml (IQR 25-42) (p < 0.0001). In transitioning from the 1-month follow-up to the 6-month follow-up, no substantial statistical improvement was observed. CONCLUSION: Concomitant performance of TURP with RABD is feasible and safe. Diverticulectomy in addiction at the endoscopic procedure should be discussed with patients who have obstructive lower urinary tract symptoms as viable alternative to single procedure individually performed.

Perioperative Dyselectrolytemia in Patients Undergoing Transurethral Resection of the Prostate Using 0.9% Normal Saline Irrigation.

BACKGROUND: The choice of irrigation fluid used in transurethral resection of the prostate (TURP) has a significant impact on serum electrolyte levels. Among the many available options, 0.9% normal saline (NS) is considered to be more physiological. MATERIAL AND METHODS: This observational study was conducted on 60 adult males aged 50-70 years, classified as American Society of Anesthesiologists grade 1 and 2, undergoing TURP with 0.9% NS irrigation under spinal anesthesia achieved with a mixture of 0.5% heavy bupivacaine. The patients' hematocrit and serum electrolyte levels were obtained after six hours and compared with preoperative values. RESULTS: Hematocrit reduced from 40.32 ± 6.27 to 31.07 ± 5.40 (p < 0.001). Both serum sodium and potassium decreased from 136.77 ± 3.27 to 128.31 ± 5.91 and from 4.02 ± 0.26 to 3.81 ± 0.36, respectively (p < 0.001). However, serum chloride showed only a minimal increase from 101.58 ± 2.88 to 102.25 ± 1.66 (p < 0.12). CONCLUSION: Although the changes in serum sodium and potassium were statistically significant, they did not have any physiological consequences in our study. However, this emphasizes the importance of vigilant electrolyte monitoring to identify and mitigate the risk of electrolyte disturbances during TURP surgeries.

Development of the UroARC Surgical Calculator: A Novel Risk Calculator for Older Adults Undergoing Surgery for Bladder Outlet Obstruction.

PURPOSE: Bladder outlet obstruction (BOO) is common in older adults. Many older adults who pursue surgery have additional vulnerabilities affecting surgical risk, including frailty. A clinical tool that builds on frailty to predict surgical outcomes for the spectrum of BOO procedures would be helpful to aid in surgical decision-making but does not currently exist. MATERIALS AND METHODS: Medicare beneficiaries undergoing BOO surgery from 2014 to 2016 were identified and analyzed using the Medicare MedPAR, Outpatient, and Carrier files. Eight different BOO surgery categories were created. Baseline frailty was calculated for each beneficiary using the Claims-Based Frailty Index (CFI). All 93 variables in the CFI and the 17 variables in the Charlson Comorbidity Index were individually entered into stepwise logistic regression models to determine variables most highly predictive of complications. Similar and duplicative variables were combined into categories. Calibration curves and tests of model fit, including C statistics, Brier scores, and Spiegelhalter P values, were calculated to ensure the prognostic accuracy for postoperative complications. RESULTS: In total, 212,543 beneficiaries were identified. Approximately 42.5% were prefrail (0.15 ≤ CFI < 0.25), 8.7% were mildly frail (0.25 ≤ CFI < 0.35), and 1.2% were moderately-to-severely frail (CFI ≥0.35). Using stepwise logistic regression, 13 distinct prognostic variable categories were identified as the most reliable predictors of postoperative outcomes. Most models demonstrated excellent model discrimination and calibration with high C statistic and Spiegelhalter P values, respectively, and high accuracy with low Brier scores. Calibration curves for each outcome demonstrated excellent model fit. CONCLUSIONS: This novel risk assessment tool may help guide surgical prognostication among this vulnerable population.

Impact of kidney disease on perioperative outcomes of endoscopic BPH surgery: a propensity score matched analysis from the NSQIP database.

INTRODUCTION: To assess the impact of kidney function in patients with BPH undergoing surgery prior to Transurethral resection of prostate (TURP), Laser enucleation of the prostate (LEP), and Laser Vaporization of the prostate (LVP) on operative and post-operative outcomes using the ACS-NSQIP database. METHODS: The ACS-NSQIP database was reviewed for patients that underwent TURP, LEP and LVP for treatment of patients with BPH between the years of 2008 and 2021. Demographics, comorbidities, bleeding disorders, operative time, and surgical procedure performed were collected for comparison between Kidney function groups: G1, normal/high function; G2-G3, mild/moderate kidney disease; and G4-G5, severe kidney disease. The 30-day peri-operative complications were measured and a multivariate logistic regression analysis was performed while adjusting for all confounding variables. Propensity score matching was performed between the G1 and G4-G5 cohorts. RESULTS: A total of 83,020 patients were included. On multivariable regression, in the G2-G3 cohort, patients were at significantly increased risk for renal complications with OR = 2.43[1.56-3.79]. After propensity score matching, the G4-G5 cohort showed increased odds of pneumonia OR = 4.02[1.343-12.056], renal complications with OR = 7.62[2.283-25.411], cardiac complications OR = 4.53[1.531-13.411], and sepsis/septic shock OR = 1.76[1.091-2.834]. They also had a higher need for blood transfusion OR = 3.58[2.242-5.714], and prolonged hospital stay with OR = 1.49[1.296-1.723]. CONCLUSION: Pre-operative kidney disease may pose an increased risk of complications for patients undergoing endoscopic BPH surgery. The literature lacks information on the effect of pre-operative kidney disease on endoscopic BPH surgeries. Further studies are required to compare post-operative outcomes of LEP and LVP as compared to TURP across kidney function status.

Comparative Study of Spinal, Epidural, and Sequential Combined Spinal Epidural Anesthesia in Geriatric Patients for Transurethral Resection of the Prostate.

BACKGROUND:  Sequential combined spinal epidural anesthesia (CSEA) is probably the greatest advancement in the central neuraxial block in this decade for geriatric patients due to the potential advantages of both spinal and epidural anesthesia. This study was designed to compare the clinical effects of sequential CSEA versus spinal and epidural anesthesia in geriatric patients undergoing transurethral resection of the prostate (TURP). METHODS:  Ninety patients aged 65 to 80 years were randomly allocated into three groups of 30 each. Group A (n=30) patients were administered spinal anesthesia with 2.5 ml of 0.5% hyperbaric bupivacaine, group B (n=30) received epidural anesthesia with 15 ml of 0.5% isobaric bupivacaine, and group C (n=30) received sequential CSEA with 1 ml of 0.5% hyperbaric bupivacaine and 6 ml of 0.5% isobaric bupivacaine given through epidural route to extend the block up to T10. Patients were observed for hemodynamic parameters, sensory and motor block, total dose required to establish the desired level, and patient satisfaction score. RESULTS: None of the patients were excluded in the study. Group A patients reported rapid onset of sensory block (3.08±11.57 minutes) compared to group B (11.57±1.48 minutes), and group C (5.47±1.25 minutes). The onset of motor block was expeditious in group A (8.08±1.0 minutes) compared to group B (20.33±1.86 minutes) and group C (15.53±1.31 minutes). Patients in group B had maximum hemodynamic stability but with delayed onset and were technically more complex than group A. Patients in group C were hemodynamically more stable than group A. They had a faster onset of action with decreased doses of local anesthetic drug required compared to group B. CONCLUSION: Sequential CSEA is a safe, effective, and reliable technique that combines the advantages of both spinal and epidural while minimizing their disadvantages. It has the advantage of stable hemodynamic parameters along with the provision of prolongation analgesia for geriatric patients undergoing TURP surgery.

The Impact of SARS-CoV-2 on Patients With Lower Urinary Tract Symptoms (LUTS).

INTRODUCTION: During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, the management of patients with lower urinary tract symptoms (LUTS) underwent dynamic adjustments in response to an evolving understanding of the virus's impact on different patient populations. Healthcare practitioners reevaluated therapeutic approaches for conditions like benign prostatic hyperplasia (BPH), considering the potential implications of this condition on the severity and progression of coronavirus disease 2019 (COVID-19). This study aims to investigate potential correlations between SARS-CoV-2 infection severity, exacerbation of LUTS, and BPH progression. MATERIAL AND METHODS: This retrospective study includes patients hospitalized in our Urology Department between January 2021 and January 2023, presenting with both SARS-CoV-2 and BPH. Their ages ranged from 57 to 88 years, with a mean age of 65.4 years. The diagnosis of BPH relied on a diagnostic triad consisting of digital rectal examination, biological markers (including prostate-specific antigen (PSA) and free PSA, and ultrasound examination, with both conditions confirmed based on test results. Transurethral resection of the prostate (TURP) procedures utilized monopolar Karl Storz resection equipment, using sorbitol and bipolar Olympus devices for transurethral resection of the prostate in saline (TURPis). Haemostasia was performed using roller balls. Anticoagulation followed a prescribed scheme by cardiologists and infectious disease specialists. Statistical analysis was conducted using IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. RESULTS: Among the 138 hospitalized patients affected by both BPH and COVID-19, 18 required emergency endoscopic procedures (specifically TURP or TURPis) to achieve hemostasis (Figures 1, 2). These individuals presented persistent hematuria despite conservative treatments. The mean duration of surgery was 57.9 minutes. Patients who underwent surgery had a longer average hospital stay compared to those who did not, with durations of 10.5 days versus 7.5 days, respectively. Additionally, urethrovesical catheter insertion was necessary in 29 cases due to acute urinary retention or worsening voiding symptoms during hospitalization. These patients are scheduled for further urological evaluation following the resolution of the COVID-19 episode. In a cohort of 53 patients for whom data were accessible, comparisons were made between the pre-COVID status and the levels of the International Prostate Symptom Score (IPSS), post-voiding residue (PVR), and quality of life (QoL). The findings revealed a mean pre-COVID IPSS value of 11.6 and a COVID-related value of 14.2, with a statistically significant difference noted (p < 0.05). The mean pre-COVID PVR was 42.3 cm2, whereas during the COVID-19 period, it measured 62.5 cm2, also exhibiting a significant difference (p < 0.05). Additionally, the QoL showed a mean pre-COVID-19 score of 2.4 and a COVID-19-associated score of 2.9, again demonstrating statistical significance (p < 0.05). CONCLUSION: The onset of the SARS-CoV-2 pandemic posed novel challenges in the medical realm, impacting the approach to BPH management. A common practice was delaying treatment for chronic BPH until viral infection remission to reduce associated risks. Additionally, our study revealed a worse evolution in LUTS among individuals with severe COVID-19 symptoms.

Survival benefit of radical prostatectomy in patients with advanced TURP-diagnosed prostate cancer: a population-based real-world study.

OBJECTIVES: A considerable number of patients are diagnosed with prostate cancer (PCa) by transurethral resection of the prostate (TURP). We aimed to evaluate whether radical prostatectomy (RP) brings survival benefits for these patients, especially in the elderly with advanced PCa. PATIENTS AND METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) database to obtain PCa cases diagnosed with TURP. After the propensity matching score (PSM) for case matching, univariate, multivariate, and subgroup analyses were performed to investigate whether RP impacts the survival benefit. RESULTS: 4,677 cases diagnosed with PCa by TURP from 2010 to 2019 were obtained, including 1,313 RP patients and 3,364 patients with no RP (nRP). 9.6% of RP patients had advanced PCa. With or without PSM, cancer-specific mortality (CSM) and overall mortality (OM) were significantly reduced in the RP patients compared to the nRP patients, even for older (> 75 ys.) patients with advanced stages (all p < 0.05). Except for RP, younger age (≤ 75 ys.), being married, and earlier stage (localized) contributed to a significant reduction of CSM risk (all p < 0.05). These survival benefits had no significant differences among patients of different ages, married or single, and at different stages (all p for interaction > 0.05). CONCLUSIONS: Based on this retrospective population-matched study, we first found that in patients diagnosed with PCa by TURP, RP treatment may lead to a survival benefit, especially a reduction in CSM, even in old aged patients (> 75 ys.) with advanced PCa.

The Headache of Post-Transurethral Prostate Surgery Pyuria: Pursuit for Evidence.

Objective: To prospectively assess early post-transurethral prostate surgery (TUPS) urinalysis changes and bacteriuria with its clinical relevance. Methods: Patients with benign prostate obstruction enrolled for TUPS were prospectively assessed. Patients were assessed at 2, 4, 8, 12, and 24 weeks postoperatively by the dysuria-visual-analogue-scale (DVAS), international prostate symptom scores (IPSS)-quality of life, uroflow, and postvoid residual. Routine urinalysis was performed before discharge and at all visits. Midstream urine culture (MSUC) was performed before discharge, and 4 and 12 weeks postoperatively. Results: At final analysis, 152 patients were evaluable. Significant pyuria was reported in 52%, 96.1%, 94.1%, 71.7%, 78.9%, and 52.5% in, before discharge, 2-, 4-, 8-, 12-, and 24-week urinalysis postoperative, respectively. The mean time to nonsignificant pyuria (95% confidence interval [CI]) was 19.1 (17.5-20.7), 20.1 (17.3-22.9), 15.8 (12.8-18.8), and 14 (10.3-17.8) weeks after prostate resection, vaporization, enucleation, and incision, respectively (p = 0.03). Regardless the TUPS technique, half of patients had significant pyuria at 24 weeks postoperative. MSUC was positive in 37/152 (24.3%), 3/152 (2%), 23/152 (15.1%), and 5/152 (3.3%) preoperatively, before discharge, and 4 and 12 weeks postoperative, respectively. Only positive preoperative urine leukocyte esterase independently predicted positive 4-week MSUC (odds ratio 3.8, 95% CI 1.3-11.1, p = 0.013). No significant correlation was found between IPSS or DVAS and positive MSUC, nor between IPSS and postoperative pyuria at different follow-up points (p > 0.05). However, the degree of postoperative dysuria was significantly correlated with postoperative pyuria count by urinalysis at 2 weeks (r = 0.69, p = 0.03), 8 weeks (r = 0.26, p = 0.001), and 12 weeks (r = 0.23, p = 0.004). Conclusion: There is a persistent but gradually declining pyuria and microhematuria following TUPS up to 6 months postoperative. An earlier resolution was noted following prostate incision and enucleation. While routine urine analysis screening in these months would be of no clear clinical value, a routine urine culture would be of a reasonable significance at 1 month postoperatively.

Mucinous Adenocarcinoma of the Prostate With Normal Prostate-Specific Antigen Levels, Pulmonary Metastasis, and the Absence of Nodal Disease: A Case Report.

A 74-year-old man was suffering from nine months of perineal pain and progressive worsening of urinary symptoms including nocturia and urgency. His prostate-specific antigen (PSA) levels were 1.48 ng/mL at the time of referral. Initially, a differential diagnosis of prostatitis or seminal vesicle inflammation was made, and four weeks of antibiotics were prescribed, which were later extended to six weeks due to failure of symptoms to resolve. Magnetic resonance imaging (MRI) of the prostate was then conducted. The impression was that there was ejaculatory duct obstruction caused by enlarged seminal vesicles with no evidence of significant prostate cancer. The prostate-specific antigen density (PSAd) was 0.04, and the prostate imaging reporting and data system (PIRADS) score was I-II. A CT chest with contrast was conducted for further investigation of pulmonary nodules found on the CT urogram. It revealed multiple calcified pulmonary nodules which were suspicious of malignancy. A CT-guided biopsy of one of the pulmonary nodules was taken, and histopathological analysis revealed a mucinous adenocarcinoma. A transurethral resection of the prostate (TURP) was then performed. Histopathological analysis of the prostatic surgical specimen revealed invasive mucinous adenocarcinoma. Based on the findings, a diagnosis of mucinous adenocarcinoma of the prostate with atypical lung metastasis without osseous or regional lymph node involvement was made, stage T4 N0 M1a. The patient is currently on a treatment regimen consisting of carboplatin, pemetrexed, and pembrolizumab.

Monopolar Transurethral Enucleoresection of Prostate: Feasibility of Modified Nesbit's Enucleoresection with Apical Release.

Background: Transurethral resection of the prostate (TURP) has been the standard surgical treatment for Benign Hyperplasia of the Prostate (BPH) for decades. Our objective was to evaluate the outcome of our new technique: Monopolar Transurethral Enucleoresection of the Prostate (TUERP) with apical release (bring it all to centre). Methods: A prospective study of all cases undergoing TUERP at a tertiary centre from January 2020 to October 2022 was performed. Patient demographics, intraoperative variables and postoperative results along with follow-up data were collected. Data of all the cases who had completed a one-year follow-up post-surgery were included and analysed. Results: A total of 240 patients with complete data including a one-year follow-up were included. Mean prostatic volume was 55.3 ± 11.6 gm, and 28 (11.67%) cases were >100 gm. The mean operative time was 31.7 ± 7.6, and mean haemoglobin drop at 24 h was 0.73 ± 1.21 gm/dL. The overall complication rate was 16.67%, with only two (0.83%) Clavien-Dindo III complications (haematuria and clots needing evacuation) and the other complications being Clavien-Dindo I/II complications. Sustained improvement at 1 year of follow-up was noted: Qmax: 25.2 ± 5.6 mL/s, IPSS: 4.7 ± 2.5 and PVR: 22.5 ± 9.6 mL. Conclusions: Monopolar TUERP with a modified Nesbit's enucleoresection with apical release can be considered a promising technique, which needs further studies to be validated with appropriate comparisons.

Post-Voided Residual Ratio Does Not Predict Trifecta Outcome after Transurethral Resection of Prostate.

The purpose of this study was to assess the importance of the post-void residual (PVR) ratio (PVR ratio) in achieving a favorable trifecta outcome for patients suffering from lower urinary tract symptoms and benign prostatic enlargement (LUTS-BPE) who undergo transurethral resection of the prostate (TURP). Starting from 2015, a series of patients with LUTS-BPE who underwent TURP were included in a forward-looking study. These patients were assessed using the international prostate symptom score (IPSS) screening tool, uroflowmetry, and a transrectal ultrasound to measure prostate volume (TRUS). Both the PVR urine volume and the PVR ratio (PVR-R), which is the PVR as a percentage of total bladder volume (voided volume + PVR), were measured. The assessment of outcomes was based on the trifecta favorable outcome, defined as meeting all of the following criteria: (1) absence of perioperative complications, (2) a postoperative IPSS of less than eight, and (3) a postoperative maximum urinary flow rate (Qmax) greater than 15 mL/s. A total of 143 patients were included, with a median age of 70 years (interquartile range 65-73). Of these, 58% (83/143) achieved a positive trifecta outcome. Upon conducting a multivariate analysis, both IPSS and Qmax were identified as predictors of a positive trifecta outcome, whereas the PVR-R did not prove to be an independent predictor. In summary, it was found that preoperative IPSS and Qmax are indicative of a trifecta outcome following TURP, whereas PVR-R is not.

Predictors for surgical treatment in male patients with non-neurogenic lower urinary tract symptoms (LUTS).

OBJECTIVE: This study aimed to identify clinical and biochemical predictors for future surgical intervention in male LUTS patients. MATERIALS AND METHODS: In a prospective cohort study, parameters as International Prostate Symptom Score (IPSS) and IPSS "bother question" (IPSS-BQ), prostate volume (PV), maximal urine flow (Qmax), Prostate specific antigen (PSA), post-voidal residual urine (PVR) were assessed alongside comorbidities quantified using Charlson Comorbidity Index without age adjustment and American Society of Anesthesiology (ASA) score. For the statistical analysis, patients were categorized based on subsequent treatment approaches: Group 1: underwent surgery during follow-up; Group 2: received medical or no treatment. T-test was used to test differences between the groups. Logistic regression models were used to identify independent predictors of the need for future surgery. Following this analysis, we calculated the probability of requiring surgical intervention, with this likelihood being determined based on the accumulation of identified predictive factors. RESULTS: Of 63 patients, 22 underwent surgery over a median follow-up of 42 months. Significant baseline differences were observed in IPSS (p = 0.003), International Prostatic Symptom Score-Voiding subscore (IPSS-VS) (p = 0.002), IPSS-BQ (p = 0.001), Qmax (p = 0.007), and PVR (p = 0.02) between the groups. Higher IPSS-BQ, IPSS-VS, and lower Qmax are emerging as independent surgical treatment predictors in logistic regression analyses. CONCLUSION: The study identified IPSS-VS, IPSS-BQ, and Qmax as baseline predictors of future surgical intervention. A clear pattern of a gradual increase in the likelihood of requiring surgery was directly proportional to the cumulative number of these identified predictive factors.

Surgical outcomes of endoscopic enucleation of the prostate in community aging males with or without preoperative urinary retention.

OBJECTIVES: This study aims to investigate the surgical outcomes of endoscopic enucleation of the prostate in older males with or without preoperative urinary retention (UR). MATERIAL AND METHODS: We conducted a study on selected patients with symptomatic benign prostatic hyperplasia (BPH) who underwent either thulium:YAG laser (vela XL) prostate enucleation (ThuLEP) or bipolar plasma enucleation of the prostate (B-TUEP) at the geriatric urology department of our institution. The studied patients were categorized into two groups, namely the UR group and the non-UR group, on the basis of whether they experienced UR in the 1 month preceding their surgery. Their clinical outcomes following prostate endoscopic surgery were evaluated and analyzed. RESULTS: Our results revealed comparable outcomes for operation time, length of hospital stay, percentage of tissue removed, re-catheterization rate, and urinary tract infection rate within the 1 month between the B-TUEP and ThuLEP surgery groups, regardless of UR history. However, the non-UR B-TUEP group experienced more blood loss relative to the non-UR ThuLEP group (P = .004). Notably, patients with UR exhibited significantly greater changes in IPSS total, IPSS voiding, and prostate-specific antigen values relative to those without UR. CONCLUSIONS: Both ThuLEP and B-TUEP were effective in treating BPH-related bladder outlet obstruction. Our study identified more pronounced changes in IPSS total, IPSS voiding, and prostate-specific antigens within the UR group. Moreover, the rate of postoperative UR in this group was not higher than that observed in the non-UR group. Our study also revealed that the presumed benefits of laser surgery in reducing blood loss were less pronounced for patients with UR.

Functional Outcome and Safety of Endoscopic Treatment Options for Benign Prostatic Obstruction (BPO) in Patients ≥ 75 Years of Age.

Background: The selection of suitable patients for the surgical treatment of benign prostatic obstruction (BPO) is a challenge in persons ≥75 years of age. Methods: After a systematic literature search of PubMed, 22 articles were included in this review. Clinical and functional parameters were evaluated statistically. Results: The mean age of the patients was ≥79 years. The mean duration of postoperative catheterization ranged between 2 (d) (ThuLEP, thulium laser enucleation of the prostate) and 4.4 days (TURP, transurethral resection of the prostate). Complication rates ranged between 6% (HoLAP, holmium laser ablation of the prostate) and 34% (PVP, photoselective vaporization of the prostate); the maximum rate of severe complications was 4% (TURP). The mean postoperative maximal urinary flow (Qmax) in mL/sec. ranged between 12.9 mL/sec. (HoLAP) and 19.8 mL/sec (Hol-TUIP, holmium laser transurethral incision of the prostate). The mean quality of life (QoL) score fell from 4.7 ± 0.9 to 1.8 ± 0.7 (HoLEP), from 4.1 ± 0.4 to 1.9 ± 0.8 (PVP), from 5.1 ± 0.2 to 2.1 ± 0.2 (TURP), and from 4 to 1 (ThuVEP, thulium laser vapoenucleation of the prostate). Pearson's correlation coefficient (r) revealed a positive linear correlation between age and inferior functional outcome (higher postoperative International Prostate Symptom Score (IPSS) [r = 0.4175]), higher overall complication rates (r = 0.5432), and blood transfusions (r = 0.4474) across all surgical techniques. Conclusions: This meta-analysis provides the summary estimates for perioperative and postoperative functional outcome and safety of endoscopic treatment options for BPO in patients ≥ 75 years of age. Of particular importance is that all surgical techniques significantly improve the postoperative quality of life of patients in this age group compared to their preoperative quality of life.

A 27-Year Experience With Day Surgery Transurethral Resection of the Prostate.

Introduction Transurethral resection of the prostate (TURP) is the standard surgical procedure for obstructive symptoms of the lower urinary tract when medical management fails. Progression in TURP procedures has led to reduced catheterization time following transurethral prostatic resection. This study describes the methods and results of TURP performed in the day surgery setting. Materials and methods This retrospective study was performed at a day surgical hospital serving a patient population of more than 200,000 people. Over a 27-year period, a total of 1,123 patients with a mean age of 73.6 years (range: 49 to 91 years) underwent same-day conventional (electrosurgical monopolar) transurethral prostatic resection. Of the procedure, 43 patients (11%) received spinal anaesthesia, and the remainder received general anaesthesia.  Results Over the years, there has been an increase in the use of medication to manage bladder outflow obstructive symptoms, which has led to the preoperative post-micturition volumes of urine being increased (>200 ml) at the time of surgical intervention. The mean American Urological Association (AUA) score was 22 (range: 10-35). Due to the reduced bladder tone preoperatively and the noted intraoperative distension of the bladder, early catheter removal is contraindicated in these patients. The mean duration of catheterization was 6.4 days (range: two to 28 days). No patient was readmitted to the hospital for retention of urine. However, 11 patients in the series had re-catheterization due to failure of micturition after the removal of the catheter. No patients were admitted to the hospital for clot retention or sepsis postoperatively. This resulted in the patients being discharged home with a catheter in place, which became our standard practice. Conclusion Conventional transurethral resection of the prostate can be effectively managed in the day surgery setting with minimal morbidity. This improves the patient's quality of life as well as the burden on hospital costs. Additionally, the outpatient nature of day surgery may lead to decreased overall healthcare expenses for both the patient and the healthcare system. As healthcare systems continue to prioritize streamlined and patient-centred approaches, day surgery for TURP emerges as a viable and advantageous option.

Other-cause mortality in incidental prostate cancer.

BACKGROUND: In incidental prostate cancer (IPCa), elevated other-cause mortality (OCM) may obviate the need for active treatment. We tested OCM rates in IPCa according to treatment type and cancer grade and we hypothesized that OCM is significantly higher in not-actively-treated patients. METHODS: Within the Surveillance, Epidemiology, and End Results database (2004-2015), IPCa patients were identified. Smoothed cumulative incidence plots as well as multivariable competing risks regression models were fitted to address OCM after adjustment for cancer-specific mortality (CSM). RESULTS: Of 5121 IPCa patients, 3655 (71%) were not-actively-treated while 1466 (29%) were actively-treated. Incidental PCa not-actively-treated patients were older and exhibited higher proportion of Gleason sum (GS) 6 and clinical T1a stage. In smoothed cumulative incidence plots, 5-year OCM was 20% for not-actively-treated versus 8% for actively-treated patients. Conversely, 5-year CSM was 5% for not-actively-treated versus 4% for actively-treated patients. No active treatment was associated with 1.4-fold higher OCM, even after adjustment for age, cancer characteristics, and CSM. According to GS, OCM reached 16%, 27%, and 35% in GS 6, 7, and 8-10 not-actively-treated IPCa patients, respectively and exceeded CSM recorded for the same three groups (2%, 6%, and 28%, respectively). CONCLUSION: Our results quantified OCM rates, confirming that in not-actively-treated IPCa patients OCM is indeed significantly higher than in their actively-treated counterparts (HR: 1.4). These observations validate the use of no active treatment in IPCa patients, in whom OCM greatly surpasses CSM (20% vs. 5%).