National trends of surgery for benign prostatic hyperplasia in Finland.

PURPOSE: To investigate national trends of surgical treatment for benign prostatic obstruction (BPO). METHODS: The Care Register for Healthcare in Finland was used to investigate the annual numbers and types of surgical procedures, operation incidence and duration of hospital stay between 2004 and 2018 in Finland. Procedures were classified using the Nordic Medico-Statistical Committee Classification of Surgical Procedures coding. Trends in incidence were analyzed with two-sided Cochran-Armitage test. Trends in duration of hospital stay and patient age were analyzed with linear regression. RESULTS: Transurethral resection of the prostate (TURP) was the most common operation type during the study period, covering over 70% of operations for BPO. Simultaneous with the implementation of photoselective vaporization of the prostate (PVP), the incidence of TURP, minimally invasive surgical therapies, transurethral vaporization of the prostate (TUVP) and open prostatectomies decreased (p < 0.05). The mean operation incidence rate in the population between 2004 and 2018 was 263 per 100,000. The duration of hospital stay shortened (p < 0.05), and the average age of operated patients increased by 2 years (p < 0.0001). CONCLUSION: The implementation of PVP did not challenge the dominating position of TURP in Finland, but it has probably influenced the overall use of other surgical therapies, excluding transurethral incision of the prostate.  The results might suggest that the conservative treatment is accentuated, patient selection is more thorough, and surgical intervention might be placed at a later stage of BPO.

What Is New with Rezum Water Vapor Thermal Therapy for LUTS/BPH?

PURPOSE OF REVIEW: Rezum® is a novel convection-based thermal therapy for benign prostatic hyperplasia (BPH) induced lower urinary tract symptoms (LUTS). This review provides an overview of its safety, efficacy, cost, and potential role in the paradigm of BPH/LUTS therapies. RECENT FINDINGS: Data regarding Rezum® stems primarily from one large randomized controlled trial of 197 patients with 4 years of follow-up. The efficacy and safety of Rezum® is further supported by 4 additional studies including 1 prospective pilot study, 1 crossover study, and 2 retrospective studies. Durable improvements in IPSS (47-60%), QoL (38-52%), Qmax (45-72%), and PVR (11-38%) were seen without causing deterioration of sexual function. Rezum® offers a cost-effective and safe approach to treating BPH/LUTS and should be considered as a possible first-line therapy for patients with moderate to severe symptoms.

National Trends in the Management of Lower Urinary Tract Symptoms Associated with Benign Prostatic Hyperplasia.

PURPOSE OF REVIEW: To gain an understanding of current practices in the management of lower urinary tract symptoms (LUTSs) in the setting of benign prostatic hyperplasia (BPH). Including both medication therapy and emerging minimally invasive options including peri-procedure considerations, expected outcomes, and value-based considerations. RECENT FINDINGS: Medical therapy, primarily alpha blockers (ABs), and 5 alpha reductase inhibitors (5-ARI) remain the most commonly utilized intervention for LUTS associated with BPH. Several minimally invasive surgical treatments (MISTs) have emerged to provide efficacious and durable results, while largely sparing men from the sexual adverse effects of more invasive surgical options. The introduction of value-based health care has led to more cost-conscious medical care and is poised to influence the landscape of LUTS associated with BPH treatment. As the population-based and societal needs continue to influence medical care for men with LUTS associated with BPH, a paradigm shift in management is expected.

Fotovaporización próstata (FVP) con láser Greenlight. Pasado, presente y... futuro / Greenlight laser vaporization: Past, present and future?

La Fotovaporización Prostática (FVP) con láser Greenlight es considerada como una alternativa válida a la Resección Transuretral de Próstata (RTU) para el tratamiento de los pacientes con sintomatología de tracto urinario inferior (STUI) condicionado por la hiperplasia benigna de próstata (HBP). En este artículo revisamos la evidencia actual de la técnica y el papel o estado actual de la misma. Analizamos los distintos puntos de mayor interés clínico, como son la limitación de tamaño prostático de los pacientes a intervenir, las consecuencias o repercusiones económicas de su aplicación o la posibilidad de realizar la misma en régimende Cirugía Mayor Ambulatoria (CMA). Por otra parte detallamos las cambios evolutivos en loque respecta a la tecnología Greenlight desde su introduccción hasta la época actual, con el impacto asociado en las nuevas técnicas de vaporización. SITUACIÓN ACTUAL: En base a la evidencia obtenida con el ensayo clínico Goliath, la FVP Greenlight 180W se considera como una técnica no inferior a la RTU de Próstata, con similares resultados funcionales, a medio plazo, con beneficio respecto a la misma en lo que respeta esencialmente a la estancia hospitalaria, manteniendo una tasa de ausencia de complicaciones mayor del 80% a los 2 años. Con los nuevos generadores láser, de mayor potencia, se puede coseguir un efecto de ablación tisular más eficaz, lo que se asocia a menor tiempo operatorio. Una de las claras ventajas de la FVP Greenlight es la posibilidad de realizar la intervención quirúrgica en régimen de CMA, con una muy baja tasa de re-ingresos hospitalarios, lo que la hace una técnica más coste-efectiva que la RTU de Próstata. CONCLUSIONES: Pese el avance de nuevas técnicas, minimamente invasivas, aún en fase de experimentación, o las técnicas de enucleación láser que se están expandiendo en los últimos años, la FVP Greenlight sigue siendo actualmente una alternativa válida y plenamente vigente respecto a la RTU de Próstata

Greenlight laser prostate vaporization is considered a valid alternative to transurethral prostate resection (TURP) for patient with LUTS due to BPH. The current review highlights the current evidence on greenlight technique and current state of-the-art. We will review clinically relevant concerns such as size limitation, economic issues and same-day surgery options. We will also describe technological improvements over time and its relationship with current vaporization practices. CURRENT SITUATION: Based on clinical trial Goliath, Greenlight 180W vaporization showed non-inferiority to TURP and similar mid-term functional outcomes. A benefit towards length of hospital stay, similar complication rate (below 80% at 2 years). The current laser generators (higher potency) are able to provide an ablative effect on tissue that is associated to a shorter operative time. The major advantage of greenlight laser is the same day discharge, with a low readmission rates. Greenlight laser is more cost-effective than TURP. CONCLUSIONS: Green light laser remains as an alternative valid option despite the technological improvements in the field

Current use of thulium lasers in endourology and future perspectives / Uso actual del láser de tulio en endourología y perspectivas de futuro

Thulium lasers operate at wavelengths between 1940-2013 nm either in a continuous wave or in a pulsed mode, which enables smooth incisions with fast vaporization or effective laser lithotripsy for urolithiasis. Thulium laser enucleation is a minimally invasive and size-independent treatment for benign prostatic hyperplasia (BPH) with excellent long-term results. Since its introduction, several modifications in the technology and surgical techniques have been proposed such as vaporesection, vaporization and enucleation with regard to BPH treatment. Recent developments in the thulium laser technology include the introduction of a super pulsed thulium fiber laser. This technique delivers the laser energy through an active fiber with an absorption maximum in water at a wavelength of 1940 μm. Preclinical studies showed a significantly higher stone fragmentation rate in different ex vivo models compared to the Ho:YAG laser. Another innovative thulium laser that works, as a hybrid laser has yet not been tested clinically, however, will soon be introduced. With the introduction of both new thulium lasers as novel devices, the armamentarium in the field of endourology for lithotripsy and enucleation increases. We here present different thulium lasers and surgical techniques that are possible to perform with each device including the reasons and advantages of each modification

El láser de tulio opera entre 1940 y 2013 nm en onda continua o pulsada. Esto permite incisiones sencillas y una vaporización rápida o una litotricia láser para el tratamiento de las litiasis urinarias. La enucleación con láser tulio es mínimamente invasiva e independiente del tamaño de la hiperplasia benigna de próstata con excelentes resultados a largo plazo. Desde su introducción, varias modificaciones en la tecnología y en la técnica quirúrgica se han propuesto como la vaporesección, la vaporización y la enucleación. El desarrollo reciente de la tecnología del láser tulio incluye la introducción de una fibra de láser de superpulsación. Esta técnica administra la energía del láser a través de una fibra activa con una absorción máxima a 1940 nm. Estudios preclínicos han demostrado una mejor fragmentación de las litiasis en diferentes modelos ex vivo en comparación con láser Ho:YAG. Otra innovación del laser tulio es que funciona como un láser híbrido, pero aun no se ha testado clínicamente. Con la introducción de nuevas tecnologías en láser, el conjunto de técnicas en endourología y enucleación incrementa. En este resumen presentamos los diferentes lásers tulio y las técnicas quirúrgicas que son posibles de realizar con cada aparato, incluyendo el racional y las ventajas para cada modificación

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.

Expression and clinical significance of Caveolin-1 in prostate Cancer after transurethral surgery.

BACKGROUND: Prostate cancer is a common malignancy of the male genitourinary system that occurs worldwide. The current research aims to investigate caveolin-1 expression in prostate cancer tissue and its relationship with pathological grade, clinical pathologic staging, and preoperative prostate-specific antigen (PSA) levels. METHODS: From January 2012 to December 2014, samples from 47 patients with prostate cancer who had received transurethral prostatic resection (TURP) and 20 patients with benign prostatic hyperplasia were collected at the First Affiliated Hospital of Guangxi Medical University. Caveolin-1 was detected by streptavidin-perosidase (SP) immunohistochemical staining in pathological tissue slices. The results were statistically analyzed for pathological grade, clinical stage, and preoperative PSA level. RESULTS: The expression of caveolin-1 was significantly higher in prostate cancer samples than in benign prostatic hyperplasia samples (P < 0.05), and caveolin-1 expression was significantly different among the pathological grades of poorly, moderately and well-differentiated prostate cancer (P < 0.05). The difference in caveolin-1 expression was significant for different clinical stages (T1-T2 and T3-T4) of prostate cancer (P < 0.05). The difference in caveolin-1 expression was not significant among samples with different preoperative PSA levels (0-10, 10-100 and > 100 µg/L) (P > 0.05). CONCLUSIONS: Caveolin-1 is closely related to the pathological grade and clinical stage of prostate cancer after transurethral surgery, and it may be a novel tumor marker for prostate cancer. The expression of caveolin-1 is not associated with preoperative serum PSA levels.

The changing practice of transurethral resection of the prostate.

Introduction Transurethral resection of the prostate (TURP) is considered the gold standard surgical treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. The number of TURPs performed has declined significantly over the last three decades owing to pharmaceutical therapy. TURP data from a single institution for the years 1990, 2000 and 2010 were compared to assess the difference in performance. Methods A retrospective analysis was undertaken of all patients who underwent TURP between January and December 2010. These findings were compared with historical data for the years 1990 and 2000: 100 sets of case notes were selected randomly from each of these years. Results The number of TURPs performed fell from 326 in 1990 to 113 in 2010. The mean age of patients increased from 70.6 years to 74.0 years. There was also a significant increase in the mean ASA grade from 1.9 to 2.3. The most common indication for TURP shifted from LUTS to acute urinary retention. No significant change in operating time was observed. The mean resection weight remained constant (22.95g in 1990, 22.55g in 2000, 20.76g in 2010). A reduction in transfusion rates was observed but there were higher rates of secondary haematuria and bladder neck stenosis. There was an increase from 2% to 11.5% of patients with long-term failure to void following TURP. Conclusions The number of TURPs performed continues to decline, which could lead to potential training issues. Urinary retention is still by far the most common indication. However, there has been a significant rise in the percentage of men presenting for TURP with high pressure chronic retention. The number of patients with bladder dysfunction who either have persistent storage LUTS or eventually require long-term catheterisation or intermittent self-catheterisation has increased markedly, which raises the question of what the long-term real life impact of medical therapy is on men with LUTS secondary to benign prostatic hyperplasia who eventually require surgery.

Enucleación con láser de tulio (ThuLEP) frente a resección transuretral de la próstata en solución salina (TURis): un ensayo prospectivo aleatorizado para comparar resultados intra y postoperatorios tempranos / Thulium laser enucleation (ThuLEP) versus transurethral resection of the prostate in saline (TURis): A randomized prospective trial to compare intra and early postoperative outcomes

Objetivo: Comparar los resultados clínicos intra y postoperatorios tempranos entre la enucleación transuretral con láser de tulio de la próstata (ThuLEP) y la resección bipolar transuretral de la próstata (TURis) para el tratamiento de la hiperplasia prostática benigna (HBP) en un ensayo prospectivo aleatorizado. Métodos: El estudio aleatorizó a 208 pacientes consecutivos con HBP a ThuLEP (n = 102) o TURis (n = 106). Para todos los pacientes se evaluaron preoperatoriamente en cuanto a pérdida de sangre, tiempo de cateterización, volumen de irrigación, estancia hospitalaria y tiempo operatorio. A los 3 meses después de la cirugía también fueron evaluados por la International Prostate Symptom Score (IPSS) el flujo máximo (Qmáx) y el volumen de residuo posmiccional (RPM). Resultados: Los pacientes en cada brazo de estudio no mostraron diferencias significativas en los parámetros preoperatorios. En comparación con TURis, ThuLEP tuvo el mismo tiempo quirúrgico (53,69±31,44 vs 61,66±18,70min; p = 0,123), pero resultó en menos disminución de la hemoglobina (0,45 vs 2,83g/dl, p = 0,005). ThuLEP también necesitó menos tiempo de cateterización (1,3 vs 4,8 días, p = 0,011), volumen de irrigación (29,4 vs 69,2l; p = 0,002) y estancia hospitalaria (1,7 vs 5,2 días, p = 0,016). Durante los 3 meses de seguimiento, los procedimientos no demostraron una diferencia significativa en Qmáx, IPSS, RPM y ECDV. Conclusión: ThuLEP y TURis alivian los síntomas del tracto urinario inferior igualmente, con alta eficacia y seguridad. ThuLEP fue estadísticamente superior a TURis en la pérdida de sangre, el tiempo de cateterización, el volumen de irrigación y la estancia hospitalaria. Sin embargo, los procedimientos no difirieron significativamente en Qmáx, IPSS, RPM y ECDV a través de 3 meses de seguimiento

Objective: To compare clinical intra and early postoperative outcomes between thulium laser transurethral enucleation of the prostate (ThuLEP) and transurethral bipolar resection of the prostate (TURis) for treating benign prostatic hyperplasia (BPH) in a prospective randomized trial. Methods: The study randomized 208 consecutive patients with BPH to ThuLEP (n = 102) or TURis (n = 106). For all patients were evaluated preoperatively with regards to blood loss, catheterization time, irrigation volume, hospital stay and operative time. At 3 months after surgery they were also evaluated by International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and postvoid residual urine volume (PVR). Results: The patients in each study arm each showed no significant difference in preoperative parameters. Compared with TURIS, ThuLEP had same operative time (53.69±31.44 vs 61.66±18.70 minutes, P = .123) but resulted in less hemoglobin decrease (0.45 vs 2.83g/dL, P = .005). ThuLEP also needed less catheterization time (1.3 vs 4.8 days, P = .011), irrigation volume (29.4 vs 69.2 L, P = .002), and hospital stay (1.7 vs 5.2 days, P = .016). During the 3 months of follow-up, the procedures did not demonstrate a significant difference in Qmax, IPSS, PVR, and QOLS. Conclusion: ThuLEP and TURis both relieve lower urinary tract symptoms equally, with high efficacy and safety. ThuLEP was statistically superior to TURis in blood loss, catheterization time, irrigation volume, and hospital stay. However, procedures did not differ significantly in Qmax, IPSS, PVR, and QOLS through 3 months of follow-up

The Continuing Story of the Cost-Effectiveness of Photoselective Vaporization of the Prostate versus Transuretheral Resection of the Prostate for the Treatment of Symptomatic Benign Prostatic Obstruction.

BACKGROUND: In 2008, a UK assessment of technologies for benign prostatic obstruction concluded negatively about photoselective vaporization of the prostate (PVP), and the 2010 National Institute for Health and Care Excellence guidance caused several UK institutions to abandon PVP. OBJECTIVE: To reassess the costs and effects of PVP versus transurethral resection of the prostate (TURP) on the basis of most recent data. METHODS: The same model was used as in 2008. Transition probabilities were estimated using a Bayesian approach updating the 2008 estimates with data from two meta-analyses and data from GOLIATH, the latest and largest trial comparing PVP with TURP. Utility estimates were from the 2008 assessment, and estimates of resource utilization and costs were updated. Effectiveness was measured in quality-adjusted life-years gained, and costs are in UK pounds. The balance between costs and effects was addressed by multivariate sensitivity analysis. RESULTS: If the 2010 National Institute for Health and Care Excellence analysis would have updated the cost-effectiveness analysis with figures from its own meta-analysis, it would have estimated the change in quality-adjusted life-years at -0.01 (95% confidence interval [CI] -0.05 to 0.01) instead of at -0.11 (95% CI -0.31 to -0.01) as in the 2008 analysis. The GOLIATH estimate of -0.01 (95% CI -0.07 to 0.02) strengthens the conclusion of near equivalence. Estimates of additional costs vary from £491 (£21-£1286) in 2008 to £111 (-£315 to £595) for 2010 and to £109 (-£204 to £504) for GOLIATH. PVP becomes cost saving if more than 32% can be carried out as a day case in the United Kingdom. CONCLUSIONS: The available evidence indicates that PVP can be a cost-effective alternative for TURP in a potentially broad group of patients.

La fotovaporización prostática con láser (PVPL) podría constituir una alternativa eficaz y segura a la resección transuretral (RTUP) en pacientes / Greenlight-XPS laser vaporization, the new standard of treatment in men with myasthenia gravis and benign prostatic obstruction?

OBJETIVOS: Los pacientes con miastenia gravis (MG) diagnosticados de sintomatología del tracto urinario inferior (STUI) secundaria a hiperplasia benigna de próstata (HBP), presentan una elevada incidencia de incontinencia urinaria al ser sometidos a resección transuretral de próstata (RTUp), secundaria a la lesión inadvertida de las fibras musculares del esfínter externo. La fotovaporización prostática con Láser podría ser una alternativa de tratamiento, ya que podría evitar el daño inadvertido del esfínter debido a que la energía no se transmite más allá de la punta de la fibra. MÉTODOS: Presentamos el caso de un varón con antecedente de MG y HBP sintomática tratado de forma satisfactoria mediante fotovaporiazación selectiva con Láser verde (GreenLight-XPS). RESULTADOS: El paciente no presentó incontinencia urinaria tras la cirugía. CONCLUSIONES: La fotovaporización prostática con Láser verde (GreenLight-XPS) podría ser el tratamiento estándar de aquellos varones con MG y HBP candidatos a tratamiento quirúrgico, con volumen prostático menor de 60 cc. A pesar de la baja incidencia de estos pacientes, futuros casos son necesarios para corroborar esta afirmación

Patients with Benign Prostatic Obstruction (BPO) and Myasthenia Gravis (MG) treated with Transurethral Resection of the prostate (TURP) show a high incidence of urinary incontinence due to unnoticed damage to muscle fibres of the external sphincter. Photoselective laser vaporization could be an alternative treatment based on the hypothesis that using Laser as energy source in the treatment of BPH prevents sphincter damage because the energy is not transmitted outside the fiber tip. METHODS: We report the case of a man diagnosed of MG and symptomatic BPO treated satisfactorily with photoselective laser vaporization (GreenLight-XPS). Results Patient did not experienced postoperative secondary incontinence. CONCLUSION: Laser photoselective vaporization (GreenLight-XPS) could be the standard treatment for men with MG and BPO, whose prostate volume is less than 60 cc who are candidates for surgical treatment. Despite the extremely low incidence of these cases, further investigations are needed to confirm this affirmation

Bipolar transurethral resection of the prostate: Darwinian evolution of an instrumental technique.

Bipolar transurethral resection of the prostate (B-TURP) represents a Darwinian evolution of an instrumental technique that has been justified by reinforcing the leading position of monopolar transurethral resection of the prostate. Notwithstanding limitations, the best available evidence recommends B-TURP as an attractive alternative. It may serve as a reliable training platform for modern residents. High-quality evidence is lacking to definitely define its position in treating special subpopulations (anticoagulation dependence, comorbidities, and large adenomas). Regarding economic issues, preliminary evidence supports B-TURP, warranting further investigation. Future perspectives include attempts toward improvements of the existing technology, combining advantages with those of other new techniques, and evolution to novel, potentially safer, or more efficient techniques to address remaining challenges.

[History of laser in BPH therapy]. / Storia del Laser nella terapia dell'IPB.

Laser technology has been used in the treatment of BPH for more than 15-20 years in order to challenge transurethral resection of the prostate. The aim of this review article is to analyze the evolution of laser in BPH therapy, from early coagulative techniques - progressively abandoned for their elevated postoperative morbidity and unfavorable outcomes - to the newer techniques of vaporization, resection and enucleation of the prostate. A better comprehension of tissue-laser interactions, the improvement of laser technology and a growing clinical experience have lead to the development of different laser systems (Holmium, KTP, Thulium laser) that challenge TURP. Today, HoLEP and, secondarily, PVP are the laser techniques supported by more clinical evidences and represent valid alternatives to TURP.

Papel actual de la cirugía en el cáncer de próstata de alto riego / Current role of surgery for high risk prostate cancer

En esta revisión se discute el papel de la cirugía en los pacientes con tumor de características adversas y alto riesgo de progresión tumoral. En la actual era del PSA, la proporción de pacientes que presentan cáncer de próstata (CaP) de alto riesgo se estima que es entre el 15% y 25%, con una supervivencia de 10 años cáncer-específica en el rango de 80-90% de los que recibieron tratamiento local activo. El tratamiento del cáncer de próstata de alto riesgo es un reto contemporáneo. La cirugía en este grupo está ganando popularidad, dado que se han publicado datos de 10 años de supervivencia cáncer-específica del 90%. La prostatectomía radical se debe combinar con linfadenectomía extendida. Los tratamientos adyuvantes o de rescate pueden ser necesarios en más de la mitad de los pacientes, basándose en los hallazgos anatomo-patológicos y el PSA postoperatorio. Lamentablemente no hay ensayos aleatorios controlados que comparen la prostatectomía radical y la radioterapia y no hay ningún tratamiento que pueda ser recomendado universalmente. Este grupo de pacientes de cáncer de próstata de alto riesgo debería ser considerado como un desafío multidisciplinario; sin embargo, la prostatectomía radical, para el paciente adecuadamente seleccionado, ya sea como primer o como único tratamiento puede ser considerada un tratamiento excelente(AU)

In this review, the role of surgery in patients with adverse tumor characteristics and a high risk of tumor progression are discussed. In the current PSA era the proportion of patients presenting with high risk prostate cancer (PCa) is estimated to be between 15% and 25% with a 10-year cancer specific survival in the range of 80-90% for those receiving active local treatment. The treatment of high risk prostate cancer is a contemporary challenge. Surgery in this group is gaining popularity since 10-year cancer specific survival data of over 90% has been described. Radical prostatectomy should be combined with extended lymphadenectomy. Adjuvant or salvage therapies may be needed in more than half of patients, guided by pathologic findings and postoperative PSA. Unfortunately there are no randomized controlled trials comparing radical prostatectomy to radiotherapy and no single treatment can be universally recommended. This group of high risk prostate cancer patients should be considered a multi-disciplinary challenge; however, for the properly selected patient, radical prostatectomy either as initial or as the only therapy can be considered an excellent treatment(AU)

[Transurethral resection of the prostate and current modifications (bipolar, electrovaporization)]. / Transurethrale Resektion der Prostata und Modifikationen (bipolar, Elektrovaporisation).

Transurethral resection of the prostate (TURP) is the surgical standard which is truly minimally invasive by using a natural orifice and is also of durable efficacy. The use of TURP removes tissue from benign prostatic hyperplasia (BPH) and leads to clinically relevant improvement in symptoms and quality of life as well as in micturition parameters and obstruction. Tissue is removed by high frequency (HF) current with synchronous hemostasis. Many modifications of TURP, such as the use of video, have become generally accepted and improved the standard. Other modifications were developed because the balance between cutting and hemostasis needed improvement in favor of hemostasis. Several modifications of TURP, such as modulation of HF pulses, band loops and bipolar resection and new procedures, such as vaporization and enucleation showed improved hemostasis. These modifications and procedures, however, have not yet replaced standard TURP but have become established as additional options.

Population based trends in the surgical treatment of benign prostatic hyperplasia.

PURPOSE: Laser prostatectomy has increased in popularity in the last decade. However, traditional transurethral resection of the prostate remains common. To understand decisions about the use of laser prostatectomy vs transurethral prostate resection, we evaluated trends in transurethral surgery for benign prostatic hyperplasia in an all payer data set, focusing on patient and provider factors associated with the receipt of laser prostatectomy. MATERIALS AND METHODS: Using Florida State Inpatient Database and Ambulatory Surgery Database, we identified patients who underwent laser prostatectomy or transurethral prostate resection from 2001 to 2009. We calculated surgery rates with time, stratified by procedure type. We used multilevel regression to examine patient (age, race and comorbidity level) and provider (surgeon volume) factors associated with the receipt of laser prostatectomy vs transurethral prostate resection. RESULTS: While the overall rates of transurethral surgery remained stable during the study period (p = 0.227), laser prostatectomy use increased 400% from 25 to 114 procedures per 100,000 men (p <0.001), replacing about half of all transurethral prostate resections. Patients were less likely to undergo laser prostatectomy if they were older (OR 0.65, 95% CI 0.61-0.70) and less healthy (OR 0.48, 95% CI 0.45-0.51). While these factors were predictive of surgery type, most of the variation in laser prostatectomy use (69%) was determined by the urologist seen by the patient. CONCLUSIONS: Laser prostatectomy use has increased in the last decade at the expense of transurethral prostate resection, driven largely by provider effects. However, elderly and more infirm patients are least likely to undergo it, raising concern about underuse in this population.

[Evolution of prostatic surgical interventions: analysis of French national coding database]. / Évolution de la prise en charge chirurgicale des pathologies prostatiques : analyse nationale du codage.

INTRODUCTION: Prostatic diseases are very important in urologist's practice. We wanted to study evolution of prostatic procedures using French national coding database. METHODS: We searched the Agence Technique d'Information sur l'Hospitalisation (ATIH) web server for prostatic procedures between 1997 and 2011 for both private and public sectors. RESULTS: The procedures were more often performed in private sector (up to 70%). There was a sustained increase (+332%) of the number of prostatectomies between 1997 and 2007 (more than 27,000 procedures), followed by a slight decrease. There is a rising use of laparoscopic approach from 35% in 2006 up to 58% in 2011. The use of brachytherapy and HIFU was marginal. Transurethral resection of the prostate number was stable between 56,000 and 60,000 procedures a year (for cancer for less than 7%). Adenomectomies number decreased from 9832 to 7963 procedures a year. CONCLUSION: The most noticeable data were upon prostatectomies number, with a peak effect in 2007. Laparoscopic procedures were more and more frequent. TURP number was stable, whereas adenomectomies number decreased.