Surgery for benign prostatic obstruction

Abstract

Almost all men have some form of benign prostatic hyperplasia as they age, often resulting in lower urinary tract symptoms due to benign prostatic obstruction. Most patients with bothersome lower urinary tract symptoms are treated with drugs (eg, α blockers or 5α-reductase inhibitors) and surgery is usually reserved for patients who do not respond to drug treatment. Both the safety issues of medication and surgery-related morbidity must be weighed against the efficacy of these treatments. The main reasons for discontinuation of drug treatment are serious adverse effects, such as postural hypotension, asthenia, dizziness, and impairment of sexual function, or loss of efficacy over time. Subsequently, surgery can be considered, with novel minimally invasive techniques striving for equally effective relief of lower urinary tract symptoms compared with classic surgical approaches, but with a more favourable safety profile.1Magistro G Chapple CR Elhilali M et al.Emerging minimally invasive treatment options for male lower urinary tract symptoms.Eur Urol. 2017; 72: 986-997Summary Full Text Full Text PDF PubMed Scopus (47) Google Scholar Transurethral resection of the prostate (TURP) has been done for around 90 years and has continuously improved over time. TURP has a high rate of success, but has a perioperative morbidity rate of around 20% and long-term complications that should be acknowledged, including ejaculatory dysfunction (65%), erectile dysfunction (10%), urethral strictures (7%), urinary tract infection (4%), urinary incontinence (2%), and bleeding requiring transfusion (2%).2Gravas S Bach T Bachmann A et al.EAU guidelines on the management of non-neurogenic male lower urinary tract symptoms (LUTS), incl. benign prostatic obstruction (BPO).https://uroweb.org/wp-content/uploads/EAU-Guidelines-Management-of-non-neurogenic-male-LUTS-2016.pdfDate: 2016Date accessed: March 24, 2020Google Scholar, 3McVary KT RC Avins AL American Urological Association guideline: management of benign prostatic hyperplasia (BPH). American Urological Association Education and Research, 2010https://www.auanet.org/guidelines/benign-prostatic-hyperplasia-(bph)-guideline/benign-prostatic-hyperplasia-(2010-reviewed-and-validity-confirmed-2014)Date accessed: May 26, 2020Google Scholar To overcome these adverse effects, many alternative surgical approaches, including laser-based techniques, have been introduced. Most of these approaches have shown efficacy in randomised trials;4Wettstein MS Pazhepurackel C Neumann AS et al.Photoselective vaporization of the prostate: study outcomes as a function of risk of bias, conflicts of interest, and industrial sponsorship.World J Urol. 2020; 38: 741-746Crossref PubMed Scopus (2) Google Scholar however, in daily clinical practice, the efficacy of laser-based techniques falls short of expectations. This discrepancy could be explained by patient selection and the chosen outcome variables for specific trials that are designed to show the benefit of a specific approach.4Wettstein MS Pazhepurackel C Neumann AS et al.Photoselective vaporization of the prostate: study outcomes as a function of risk of bias, conflicts of interest, and industrial sponsorship.World J Urol. 2020; 38: 741-746Crossref PubMed Scopus (2) Google Scholar Conclusions from such highly selective scenarios cannot necessarily be translated to the general patient population. Therefore, prospective randomised clinical trials are needed to evaluate new surgical approaches to treat benign prostatic obstruction compared with TURP using clinically meaningful outcome variables. In The Lancet, Hashim Hashim and colleagues5Hashim H Worthington J Abrams P et al.Thulium laser transurethral vaporesection of the prostate versus transurethral resection of the prostate for men with lower urinary tract symptoms or urinary retention (UNBLOCS): a randomised controlled trial.Lancet. 2020; 396: 50-61Summary Full Text Full Text PDF PubMed Scopus (10) Google Scholar report the results of the UNBLOCS trial. Patients with clinically significant benign prostatic obstruction were prospectively randomly assigned to undergo either classic TURP or thulium laser transurethral vaporesection of the prostate (ThuVARP). 410 men were randomly assigned to ThuVARP or TURP (205 per study group) and underwent surgery in seven UK hospitals during a 30-month period. Perioperative complications and long-term efficacy and complications at 3 months and 12 months were carefully monitored using objective outcome measures and standardised patient-reported symptom questionnaires. Coprimary outcomes were maximum urinary flow rate (Qmax) and International Prostate Symptom Score (IPSS) at 12 months post surgery. Secondary outcomes included complications and measures of quality of life and sexual function. TURP was superior for Qmax (mean 23·2 mL per s for TURP and 20·2 mL per s for ThuVARP; adjusted difference in means −3·12, 95% CI −5·79 to −0·45). Equivalence was shown for IPSS (mean 6·3 for TURP and 6·4 for ThuVARP; adjusted difference in means 0·28, −0·92 to 1·49). 91 (45%) of 204 patients in the TURP group and 96 (47%) of 203 patients in the ThuVARP group had at least one complication. The patient groups were similar regarding all meaningful clinical parameters. The only unbalanced factor was the experience of individual surgeons with laser vaporesection. All participating surgeons had done more than 100 TURP procedures, but only between five and 12 ThuVARP procedures. The authors argue that this would not play an important role because of the similarity of ThuVARP compared with TURP, and that all surgeons were assessed by an expert to prove their proficiency. However, surgical experience with a specific procedure is of paramount importance when considering that 36 (18%) of 205 patients allocated to ThuVARP converted to TURP. Furthermore, application of high energy (median 148 kJ; IQR 120–197) for a medium sized prostate (35 g) also suggests suboptimal performance that might affect storage symptoms like nocturia, which was slightly more frequent after ThuVARP. Finally, tissue retrieval by laser technique was inferior to TURP (7 g vs 20 g). A vaporising effect of the laser needs to be acknowledged, but even this does not explain the major difference in resected tissue. This difference could again indicate insufficient surgical experience with ThuVARP, which might affect urodynamic outcomes such as Qmax. Although this study was well designed, these limitations and absence of parameters to evaluate surgical performance suggest a comparison of well done TURP with somewhat suboptimal ThuVARP. The results of the UNBLOCS trial showed similar perioperative complication rates and length of hospital stay for both study groups (mean 48 h). A lower transfusion rate for the laser-based approach, as reported in meta-analyses, was not shown.6Lan Y Wu W Liu L et al.Thulium (Tm:YAG) laser vaporesection of prostate and bipolar transurethral resection of prostate in patients with benign prostate hyperplasia: a systematic review and meta-analysis.Lasers Med Sci. 2018; 33: 1411-1421Crossref PubMed Scopus (7) Google Scholar, 7Deng Z Sun M Zhu Y et al.Thulium laser VapoResection of the prostate versus traditional transurethral resection of the prostate or transurethral plasmakinetic resection of prostate for benign prostatic obstruction: a systematic review and meta-analysis.World J Urol. 2018; 36: 1355-1364Crossref PubMed Scopus (8) Google Scholar The 2% transfusion rate in this study was very low compared with the 2·9% transfusion rate in a state-wide survey,8Reich O Gratzke C Bachmann A et al.Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10 654 patients.J Urol. 2008; 180: 246-249Crossref PubMed Scopus (502) Google Scholar showing that the UNBLOCS trial was done in centres of excellence. As for primary outcomes, urinary flow rates were somewhat better for TURP compared with ThuVARP, which could be attributed to the difference in surgical experience with the procedures. All other outcome parameters were similar between the two groups. Regarding preoperative counselling of individual patients, preservation of erectile function is of utmost importance. Before the results of UNBLOCS, no clear answer could be given as to the optimal treatment. Now, it is clear that erectile function will be improved by TURP or ThuVARP in around a quarter of patients, remain unchanged in around a half, and deteriorate in the remaining quarter. The UNBLOCS trial is a much awaited and well designed trial that evaluates the efficacy and side-effects of two surgical approaches to treat lower urinary tract symptoms due to benign prostatic obstruction in a setting that reflects daily clinical practice. These results will help improve individual patient care and patient treatment patterns in urological departments and the guidelines of various scientific associations. We declare no competing interests. Thulium laser transurethral vaporesection of the prostate versus transurethral resection of the prostate for men with lower urinary tract symptoms or urinary retention (UNBLOCS): a randomised controlled trialTURP and ThuVARP were equivalent for urinary symptom improvement (IPSS) 12-months post-surgery, and TURP was superior for Qmax. Anticipated laser benefits for ThuVARP of reduced hospital stay and complications were not observed. Full-Text PDF Open Access

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