Erectile and ejaculatory functions changes following bipolar versus monopolar transurethral resection of the prostate: a prospective randomized study.

OBJECTIVES: To compare monopolar and bipolar transurethral resection of the prostate (M-TURP and B-TURP, respectively) focusing on erectile and ejaculatory functions in a randomized trial. METHODS: Between January 2013 and December 2014, all consecutive TURP candidates with benign prostatic hyperplasia (BPH) were prospectively randomized 1:1 into M-TURP/B-TURP arms and followed up at 2, and 4 weeks, 6 and 12 months after surgery. All patients were assessed using IIEF-15 (International index of erectile function-15) and Ej-MSHQ (ejaculatory domain-male sexual-health inventory). Changes in IIEF-15, its subdomains and Ej-MSHQ scores were compared between both intervention groups. RESULTS: Following M.TURP and B.TURP; 122 and 124 patients were included respectively and were considered for analysis at 1 year. Sexual function did not differ significantly between arms during follow-up (erectile function, P = 0.82; orgasmic function, P = 0.46; sexual desire, P = 0.29; intercourse satisfaction, P = 0.18; overall satisfaction, P = 0.92). There were no differences between arms in the distribution of EF evolution at any time compared with base line (at 12 months: M-TURP vs. B-TURP = improved, 24.5 vs. 26.6%; stable, 66.4 vs. 64.5%; deteriorated, 9.1 vs. 8.9%; P = 0.41). Newly developed erectile dysfunction (ED) was present in 8.2 and 7.3% of patients following M.TURP and B.TURP respectively and was related to presence of DM and obesity. Orgasm perception significantly reduced following M.TURP and B.TURP (P < 0.001). Newly reported ejaculatory dysfunction (Ej-MSHQ < 22) was significantly associated with low orgasm perception. CONCLUSIONS: There were no differences between M-TURP/B-TURP in any aspect of sexual function.

Prospective controlled assessment of men's sexual function changes following Holmium laser enucleation of the prostate for treatment of benign prostate hyperplasia.

OBJECTIVES: To assess how much Holmium laser enucleation of the prostate (HoLEP) is detrimental on men sexuality. METHODS: Between January and December 2013, all patients presented for BPH surgery were assessed using IIEF-15 (international index of erectile function-15) and Ej-MSHQ (ejaculatory domain-male sexual health questionnaire). Changes in men's sexuality following HoLEP in relation to control procedure were prospectively assessed. Intervention group included legible consecutive patients treated by HoLEP. Control group included legible patients presented for diagnostic cystoscopy. Changes in IIEF-15, its subdomains and Ej-MSHQ scores were compared between HoLEP group and control. RESULTS: At one year 80 and 70 subjects were included for final analysis following HoLEP and control groups, respectively. Regardless of the baseline erectile function (EF/IIEF) score, there was an increase in EF score similar to control following HoLEP (P = 0.6). However, among subjects with normal preoperative EF (score >25), in comparison with control, there was similar decline in EF score following HoLEP (P = 0.07). Regarding the orgasm domain, there was a significant reduction in orgasm perception following HoLEP in relation to control (P = 0.01). Patients reported desire changes, intercourse satisfaction and overall satisfaction scores similar to control following HoLEP. Using Ej-MSHQ score, there was no statistically significant difference between HoLEP and control groups in percentage of subjects reporting ejaculatory dysfunction at baseline. However, at 12 months, there was statistically significant more ejaculatory dysfunction reporting following HoLEP. The most common ejaculatory abnormality was volume abnormality. Orgasm perception was significantly decreased among subjects with newly reported ejaculatory dysfunction (5.3 ± 1.4 vs. 8.6 ± 1.3, P = 0.001). CONCLUSIONS: Controlled short-term assessment of HoLEP showed potential negative impact on EF in patients with normal preoperative EF. Apart from orgasm perception, sexual function changes following HoLEP were similar to control. High prevalence of postoperative ejaculatory dysfunction following HoLEP remained notable finding.

Prospective Assessment of Learning Curve of Holmium Laser Enucleation of the Prostate for Treatment of Benign Prostatic Hyperplasia Using a Multidimensional Approach.

PURPOSE: Despite being endorsed in most guidelines, wide adoption of holmium laser enucleation of the prostate is hindered by learning difficulties. We prospectively assessed the learning curve using a multidimensional approach. MATERIALS AND METHODS: We prospectively report all perioperative safety and efficacy outcome measures as well as the need for reoperation and continence status. Case difficulty and learning curve characterization variables were considered, looking for predictors of different outcome measures. Our analysis included the first 313 procedures done by a total of 3 surgeons. RESULTS: Prostate volume and the number of previously performed cases independently predicted operative and enucleation efficiency (mean ± SD 0.76 ± 0.36 and 1.2 ± 0.6 gm per minute, respectively). Both measures plateaued only after the first 40 procedures. The mean percent reduction in postoperative prostate specific antigen was 80% ± 19%. A significantly lower decrease was independently predicted by the transrectal ultrasound depiction of a grossly multinodular prostate (p = 0.000, R2 = 0.59). Perioperative safety measures showed significant improvement after the first and second 20 procedures apart from hospital stay and catheter time. Urinary incontinence was reported in 89 (28.5%), 26 (8.3%) and 7 cases (2.2%) at 1, 4 and 12 months, respectively. Only the number of previously performed cases predicted urinary incontinence at 1 month, which was significantly reduced following the first 20 procedures (plateau) (OR 0.99, 95% CI 0.98-0.999, p = 0.03). The I-PSS (International Prostate Symptom Score) preoperative storage subdomain (OR 0.7, 95% CI 0.4-0.9, p = 0.04), case density (OR 0.3, 95% CI 0.2-0.6, p = 0.01) and number of previously performed cases (OR 0.97, 95% CI 0.98-0.999, p = 0.02) predicted urinary incontinence at 4 months, which was significantly reduced after the first and second 20 procedures. Persistent urinary incontinence at 12 months was significantly associated with fewer previously performed cases (median 60, range 0 to 211 vs 20, range 0 to 99, p = 0.04) with no plateauing through the curve. CONCLUSIONS: Plateauing through the learning curve of holmium laser enucleation of the prostate is a moving target. Looking at different outcome measures, different levels of experience are needed to reach the plateau. Preoperative prostate volume, the number of previously performed cases and case density are the main influential factors in the curve. Urinary incontinence is the most relevant clinical outcome that was significantly affected by learning, although its transient nature is assuring.

Prostate tissue retrieval after holmium laser enucleation of the prostate; assessment of non-morcellation approaches.

OBJECTIVES: To review non-morcellation approaches for tissue retrieval after holmium laser enucleation of the prostate (HoLEP) and whether these approaches demolish the advantages of the HoLEP procedure. PATIENTS AND METHODS: We reviewed our prospectively maintained laser prostate database for HoLEP procedures where non-morcellation approaches were used for retrieval of the enucleated adenoma. Non-morcellation approaches were adopted in cases of morcellator malfunction or whenever concomitant pathology indicated laparotomy. Patients were stratified into the laparotomy group (Group I) or the transurethral resection (TUR) group (Group II). Safety and efficacy of each approach were assessed and compared. RESULTS: Between August 2012 and July 2015, of 392 HoLEP procedures non-morcellation approaches were used for tissue retrieval in 37 (9.4%). In 19 procedures a laparotomy approach was adopted (17 mini-laparotomies and two conventional laparotomies for concomitant diverticulectomy). TUR of the enucleated adenoma was adopted in 18 patients. Baseline demographic data and indications for surgery were comparable between the groups. However, significantly larger prostates were treated in Group I. There were no significant differences between the groups for tissue retrieval time, histopathological findings of retrieved tissue, and peri-procedure biochemical changes. However, significantly more tissue was retrieved (median tissue weight 115 vs 38 g) and at a faster rate (4.6 vs 1.09 g/min) in Group I. The median hospital stay was similar in both groups, but the median time to catheter removal was longer in Group I (5 vs 2 days). Minimal and similar peri-procedure complications were reported in both groups and in both groups there was a significant and comparable improvement in all urinary outcome measures. CONCLUSION: In the absence or malfunction of a tissue morcellator, or whenever concomitant pathology indicates laparotomy, non-morcellation tissue retrieval approaches are feasible options for endourologists practicing transurethral enucleation of prostate adenoma. These approaches are valid alternatives retaining most of the advantages of the transurethral prostate enucleation procedure.

Holmium laser enucleation of the prostate for treatment for large-sized benign prostate hyperplasia; is it a realistic endourologic alternative in developing country?

OBJECTIVES: To assess the functional outcome and cumulative health-resource-related cost of holmium laser enucleation of the prostate (HoLEP) in comparison with transvesical open prostatectomy (TVOP) in a developing country. METHODS: Matching of 92 HoLEP and 91 TVOP procedures was performed using resected prostate tissue weight as a sole matching criterion. Safety, efficacy, and accordingly health-related cost-efficiency of both procedures were statistically compared. RESULTS: Preoperative criteria and mean prostate size (166.7 ± 49.7, 161.4 ± 35.7 ml) were similar in HoLEP and TVOP, respectively; however, HoLEP treated more comorbid patients. Blood transfusion was 2.1 and 26.1 % after HoLEP and TVOP, respectively (P = 0.001). Median time to catheter removal and hospital stay was 2 days after HoLEP and 5 and 9 days, respectively, after TVOP (P < 0.001). On modified Clavien scale, grade per grade, there was no statistically significant difference between the two groups apart from local wound complications in TVOP group. High-grade complications (≥ grade 3) were reported in 3.2 and 6.5 % in HoLEP and TVOP, respectively (P = 0.49). Resected prostate tissue weight was independently associated with high-grade periprocedure complications (OR[95 %CI] 1.22[1.02:1.49], P = 0.03). Last follow-up symptom score, peak urine flow rate, residual urine, % PSA reduction, and need for reoperation were comparable between the two groups. HoLEP costs the hospital in the first 3 months 4111.8EP (575US$) versus 4305.4EP (602US$) for TVOP (P = 0.09). CONCLUSION: In high-volume hospital, HoLEP procedure seems to be equally safe and effective as TVOP with the advantages of minimally invasive procedures. Two years after adopting the technique, HoLEP equally costs the hospital as TVOP. Significant hospital cost savings are anticipated in subsequent cases.

Towards optimizing prostate tissue retrieval following holmium laser enucleation of the prostate (HoLEP): Assessment of two morcellators and review of literature.

INTRODUCTION: We assess different approaches to retrieve the enucleated adenoma after transurethral enucleation of the prostate, particularly using the holmium laser. METHODS: A retrospective review through our prospectively maintained database was performed looking for safety and efficacy of two morcellators. The enucleation phase of the holmium laser enucleation of the prostate (HoLEP) was classically performed followed by retrieval of the intravesical adenoma using either the Piranha (Wolf Inc., Knittlingen, Germany) or VersaCut (Lumenis) morcellator. A PubMed-MEDLINE search was conducted for all transurethral enucleation procedures and relevant data regarding methods of prostate tissue retrieval were extracted. RESULTS: Strictly limiting the study to 3 reusable blades with each morcellator, we performed 67 and 55 consecutive procedures with Piranha and VersaCut, respectively. There was no significant difference between the two morcellators regarding perioperative complications, apart from 5 bladder mucosal injuries with the VersaCut (9%). Furthermore, there were similar retrieved tissue weight, mechanical problems-rate, catheter-time and hospital-stay in both morcellators. However, the Piranha morcellator needed significantly less morcellation-time, needed to use cold loop to remove non-morcellated pieces and to score the adenoma by laser for better bite of the adenoma, and had a higher median morcellation-rate 6.2 (rate: 2.8-12) g/min. Despite little reporting on morcellation, we had data on the tissue retrieval rate (2.6 to 6.5 g/min with Piranha and 1.9 to 11 g/min with VersaCut. Furthermore, bladder mucosal injury was reported in 1.4% and 0.7 to 5.7% with Piranha and VersaCut, respectively; bladder perforation with VersaCut was experienced in about 0.1 to 1.5% of patients. Our study is limited by its non-randomization. CONCLUSION: The Piranha morcellator was the most efficient and safe way to retrieve tissue after a transurethral enucleation of a prostate adenoma.