Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART II-Surgical Evaluation and Treatment.

PURPOSE: Surgical therapies for symptomatic bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH) are many, and vary from minimally invasive office based to high-cost operative approaches. This Guideline presents effective evidence-based surgical management of male lower urinary tract symptoms secondary/attributed to BPH (LUTS/BPH). See accompanying algorithm for a detailed summary of procedures (figure[Figure: see text]). MATERIALS/METHODS: The Minnesota Evidence Review Team searched Ovid MEDLINE, Embase, Cochrane Library, and AHRQ databases to identify eligible studies published between January 2007 and September 2020, which includes the initial publication (2018) and amendments (2019, 2020). The Team also reviewed articles identified by Guideline Panel Members. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, information is provided as Clinical Principles and Expert Opinions (table[Table: see text]). RESULTS: Twenty-four guideline statements pertinent to pre-operative and surgical management were developed. Appropriate levels of evidence and supporting text were created to direct urologic providers towards suitable and safe operative interventions for individual patient characteristics. A re-treatment section was created to direct attention to longevity and outcomes with individual approaches to help guide patient counselling and therapeutic decisions. CONCLUSION: Pre-operative and surgical management of BPH requires attention to individual patient characteristics and procedural risk. Clinicians should adhere to recommendations and familiarize themselves with criteria that yields the highest likelihood of surgical success when choosing a particular approach for a particular patient.

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

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

The outcomes of transurethral incision/resection of the prostate (TUIP/TURP) performed early after renal transplantation.

OBJECTIVE: In the early period after renal transplantation, urinary retention stemming from bladder outlet obstruction (BOO) may directly affect graft success. The aim of this study was to evaluate the early and long-term outcomes of transurethral resection of the prostate (TURP) and transurethral incision of prostate (TUIP) procedures performed in the first month following RT due to BOO. MATERIAL AND METHODS: Between February 2009 and March 2016, 38 male patients underwent TURP/TUIP due to BOO within the first 30 days of renal transplantation. The urodynamic and renal function assessment results of all patients were collected during the pre-and postoperative periods. All patients were followed up for a minimum of 12 months for short and long-term complications. The results were evaluated retrospectively. RESULTS: The mean age of the patients who underwent operations was 59.2±12 years. The median duration of dialysis was 41 months (range 0-180). Before the operation the mean serum creatinine (sCr) level was 1.8±0.7 mg/dL, the mean total PSA level was 1.6±1.1 ng/mL. Of the voiding parameters, the mean Qmax and Qave were measured as 8.2±4.5 mL/sec and 4.6±2.5 mL/sec, respectively. The median post-micturition residual urine (PMR) was 105 mL (range 10-400). TURP/TUIP operations were performed at a median of 19 days (range 8-30) after renal transplantations. None of the patients experienced major complications. In the early postoperative period, 5 patients (13.1%) developed urinary tract infection. The mean decrease in sCr in the first month following TURP/TUIP was 1.4±0.4 mg/dL (p<0.001). The mean Qmax (22.4±11.1 mL/sec), and Qave (11.7±5.4 mL/sec) increased significantly (p<0.001), while the median PMR (15 mL, range 0-205) decreased significantly (p<0.001). The mean follow-up period after the procedure was 46.8±23.3 months. During the follow-up period, 3 (7.8%) patients suffered from urethral stricture and 2 (5.2%) patients from bladder neck obstruction. CONCLUSION: In the surgical treatment of urinary retention arising from BOO in the first month following renal transplantation, TURP/TUIP yield safe and successful results. In addition, regarding the short and long term outcomes, these procedures may be safely performed with low morbidity.