Functional Urology
Holmium laser enucleation (HoLEP) and photoselective vaporisation of the prostate (PVP) for patients with benign prostatic hyperplasia (BPH) and chronic urinary retention Christopher D. Jaeger, Christopher R. Mitchell, Lance A. Mynderse and Amy E. Krambeck Department of Urology, Mayo Clinic School of Medicine, Rochester, MN, USA
Objectives To evaluate short-term outcomes of holmium laser enucleation of the prostate (HoLEP) and photoselective vaporisation of the prostate (PVP) in patients with benign prostatic hyperplasia (BPH) and chronic urinary retention (CUR).
Patients and Methods A retrospective chart review was performed of all patients with CUR who underwent HoLEP or PVP at our institution over a 3-year period. CUR was defined as a persistent post-void residual urine volume (PVR) of >300 mL or refractory urinary retention requiring catheterisation.
Results We identified 72 patients with CUR who underwent HoLEP and 31 who underwent PVP. Preoperative parameters including median catheterisation duration (3 vs 5 months, P = 0.71), American Urological Association Symptom Index score (AUASI; 18 vs 21, P = 0.24), and PVR (555 vs 473 mL,
Introduction BPH remains one of the most common conditions affecting older men with LUTS, often progressing slowly in the untreated male [1]. Sequelae include a decreased urinary flow, advancing symptoms, and ultimately may culminate in acute or chronic urinary retention [2]. Indeed, acute urinary retention is the primary indication for surgical treatment in 24–42% of patients [3,4]. Fortunately, many different surgical therapies for BPH, including TURP, holmium laser enucleation of the prostate (HoLEP), and photoselective vaporisation of the prostate (PVP), have proven effective in this specific patient population [5–10]. While men undergoing surgery for BPH initially presenting in acute urinary retention have been previously studied in depth, © 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12674 Published by John Wiley & Sons Ltd. www.bjui.org
P = 0.096) were similar between the HoLEP and PVP groups. The HoLEP group had a larger prostate volume (88.5 vs 49 mL, P < 0.001) and higher PSA concentration (4.5 vs 2.4 ng/mL, P = 0.001). At median 6-month follow-up, 71 (99%) HoLEP patients and 23 (74%) PVP patients were catheter-free (P < 0.001). Of the voiding patients, postoperative AUASI (3 vs 4, P = 0.06), maximum urinary flow rate (23 vs 18 mL/s, P = 0.28) and PVR (56.5 vs 54 mL, P = 1.0) were improved in both groups.
Conclusions Both HoLEP and PVP are effective at improving urinary parameters in men with CUR. Despite larger prostate volumes, HoLEP had a 99% successful deobstruction rate, thus rendering patients catheter-free.
Keywords prostatic hyperplasia, transurethral prostatectomy, laser therapy, prostate, transurethral resection of prostate
those with chronic urinary retention (CUR) or refractory urinary retention have not. CUR remains poorly described in the literature, with definitions consisting of variable post-void residual urine volumes (PVRs) ranging from >300 to >1000 mL or an asymptomatic palpable bladder after voiding [11–13]. Regardless, the possible effects of CUR include nocturnal incontinence, risk of UTIs, bladder calculi, and renal dysfunction. Although limited available data precludes standardised management recommendations, surgical therapy is often an effective treatment to avoid the need for indwelling or intermittent catheterisation [12,14,15]. In the present study, we sought to compare outcomes, with focus on successful cessation of catheter-dependency, of HoLEP and PVP for men with BPH and CUR at our institution.
BJU Int 2015; 115: 295–299 wileyonlinelibrary.com
Jaeger et al.
Patients and Methods After receiving Institutional Review Board approval, a retrospective analysis of all patients with BPH and CUR who had undergone HoLEP or PVP from 2009 to 2012 at our institution was performed. CUR was defined as a persistent PVR of >300 mL documented in the clinical setting on ultrasound or refractory urinary retention after multiple failed voiding trials making patients catheter-dependent. Catheterisation duration was at least 1 month in all patients with refractory retention. Patients with a history of prostate cancer, a solitary episode of acute urinary retention with subsequent ability to void spontaneously, urethral stricture, or a history of neuropathic bladder dysfunction secondary to other cause were excluded. In all, 72 and 31 patients with CUR who underwent HoLEP and PVP, respectively, were identified based on these criteria. All patients were evaluated preoperatively with complete medical history, DRE, urine analysis, PSA level, and TRUS for prostate volume measurement. Formal multichannel cystometry urodynamic studies were performed at the discretion of the surgeon. Bladder underactivity was defined as those with a bladder contractility index of 300 mL, maximum urinary flow rate (Qmax) was measured with uroflowmetry and PVR recorded with ultrasound. A single surgeon (A.E.K.) performed all HoLEP procedures and three surgeons performed the PVP procedures. HoLEP was performed as previously described after urethral dilatation [16,17]. After adenoma morcellation, a 24-F three-way catheter was placed and left overnight. Our PVP technique is similar to published reports using a GreenLight PV laser generator [18,19]. In August 2011, the XPS 180-watt generator supplanted the HPS 120-watt device. Once an adequate prostatic fossa cavity was created, a catheter was left indwelling. In both procedures, the urethral catheter was typically removed the following morning if minimal haematuria and the patient given a voiding trial with PVR measurement. Occasionally, the urethral catheter was left in situ for an extended duration after PVP based on surgeon preference. If unable to void, the catheter was replaced and the patient offered a voiding trial at a future date. Preoperative baseline characteristics, perioperative parameters, and postoperative outcomes were compared between the two groups. Patients in urinary retention requiring indwelling urethral catheterisation were not assessed with uroflowmetry or PVR measurements. The resected percentage was calculated from the resected weight at the time of the procedure and preoperative TRUS measurement. Postoperative outcomes, including assessment of AUA Symptom Index (AUASI), Qmax,
296
© 2014 The Authors BJU International © 2014 BJU International
and PVR, were collected at latest follow-up. Complications including UTI, haematuria requiring readmission, urethral stricture, bladder neck contracture, reoperation due to regrowth, and urinary incontinence were reported in both groups. All patients were questioned about the presence of urinary leakage before and after surgical intervention, with incontinence defined as any leakage reported on latest postoperative follow-up visit. Results are given as medians with interquartile ranges (IQRs). Comparative analysis was performed using the rank-sum test and chi-square or Fisher’s exact test for statistical validation when appropriate, with P < 0.05 considered to indicate statistical significance.
Results Table 1 summarises patient demographics for those treated in the comparative study. The median (IQR) patient age was 71 (62–77.75) years in the HoLEP group and 70 (62–76) years in the PVP group. Of the 44 HoLEP and 29 PVP patients who were spontaneously voiding, there was no significant difference in preoperative AUASI (18 vs 21, P = 0.24), Qmax (5.1 vs 5.6 mL/s, P = 0.26), or PVR (555 vs 473 mL, P = 0.096). Men in the HoLEP group had a significantly larger median prostate volume (88.5 vs 49 mL, P < 0.001) and higher median PSA concentration (4.5 vs 2.4 ng/mL, P = 0.001) compared with those in the PVP group. Overall, the mean duration of preoperative catheterisation was similar between groups (3 vs 5 months, P = 0.71). Preoperative multichannel cystometry was performed at the surgeon’s discretion and was not standardised. Bladder characteristics of those patients undergoing formal urodynamic study are included in Table 1. The HoLEP group had a lower median bladder contractility index than the PVP group (73 vs 90, P = 0.012). Of those 40 HoLEP and 23 PVP patients undergoing urodynamic study, more patients were found to have underactive or acontractile bladders in the HoLEP group compared with the PVP group, although this was not statistically significant (71% vs 59%, P = 0.34). Table 2 shows the perioperative parameters for both groups. The median (IQR) total applied energy in the PVP cohort was 265 (187–286) kJ or 4.7 kJ/g of prostate tissue. Catheterisation duration was longer in the PVP group, while hospital stay was longer in the HoLEP group. No patients required a blood transfusion. Median follow-up was 6 months. Postoperatively, 71 (99%) and 23 (74%) patients were voiding spontaneously with low PVRs resulting in a catheter-free state in the HoLEP and PVP groups, respectively (P < 0.001). Of voiding patients, there were no significant differences in AUASI (3 vs 4, P = 0.06), Qmax (23 vs 18 mL/s, P = 0.28), or PVR (57 vs 54 mL, P = 1.0). Results are outlined in Table 3.
HoLEP and PVP for BPH and chronic urinary retention
Table 1 Baseline characteristics. Variable
HoLEP
Number of patients N (%): Patients with indwelling catheter Patients on CIC Patients unable to void Median (IQR): Patient age, years AUASI Qmax, mL/s PVR, mL Prostate volume, mL Duration of catheterisation, months PSA level, ng/mL Bladder contractility index N (%): Patients with urodynamic study Underactive or acontractile bladder
PVP
72
31
17 (24) 53 (76) 28 (40)
4 (15) 22 (85) 3 (10)
71 (62–77.75) 18 (12.5–23) 5.1 (3–8.3) 555 (390–700) 88.5 (57–126) 3 (2–6) 4.5 (3.1–8.6) 73 (0–107) 40 (56) 27 (71)
P
0.004
70 (62–76) 21 (15.5–25.5) 5.6 (3.9–9.9) 473 (327–628) 49 (31–75) 5 (1–13) 2.4 (0.8–4.5) 90 (75–149)
0.80 0.24 0.26 0.096
Holmium laser enucleation (HoLEP) and photoselective vaporisation of the prostate (PVP) for patients with benign prostatic hyperplasia (BPH) and chronic urinary retention Christopher D. Jaeger, Christopher R. Mitchell, Lance A. Mynderse and Amy E. Krambeck Department of Urology, Mayo Clinic School of Medicine, Rochester, MN, USA
Objectives To evaluate short-term outcomes of holmium laser enucleation of the prostate (HoLEP) and photoselective vaporisation of the prostate (PVP) in patients with benign prostatic hyperplasia (BPH) and chronic urinary retention (CUR).
Patients and Methods A retrospective chart review was performed of all patients with CUR who underwent HoLEP or PVP at our institution over a 3-year period. CUR was defined as a persistent post-void residual urine volume (PVR) of >300 mL or refractory urinary retention requiring catheterisation.
Results We identified 72 patients with CUR who underwent HoLEP and 31 who underwent PVP. Preoperative parameters including median catheterisation duration (3 vs 5 months, P = 0.71), American Urological Association Symptom Index score (AUASI; 18 vs 21, P = 0.24), and PVR (555 vs 473 mL,
Introduction BPH remains one of the most common conditions affecting older men with LUTS, often progressing slowly in the untreated male [1]. Sequelae include a decreased urinary flow, advancing symptoms, and ultimately may culminate in acute or chronic urinary retention [2]. Indeed, acute urinary retention is the primary indication for surgical treatment in 24–42% of patients [3,4]. Fortunately, many different surgical therapies for BPH, including TURP, holmium laser enucleation of the prostate (HoLEP), and photoselective vaporisation of the prostate (PVP), have proven effective in this specific patient population [5–10]. While men undergoing surgery for BPH initially presenting in acute urinary retention have been previously studied in depth, © 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12674 Published by John Wiley & Sons Ltd. www.bjui.org
P = 0.096) were similar between the HoLEP and PVP groups. The HoLEP group had a larger prostate volume (88.5 vs 49 mL, P < 0.001) and higher PSA concentration (4.5 vs 2.4 ng/mL, P = 0.001). At median 6-month follow-up, 71 (99%) HoLEP patients and 23 (74%) PVP patients were catheter-free (P < 0.001). Of the voiding patients, postoperative AUASI (3 vs 4, P = 0.06), maximum urinary flow rate (23 vs 18 mL/s, P = 0.28) and PVR (56.5 vs 54 mL, P = 1.0) were improved in both groups.
Conclusions Both HoLEP and PVP are effective at improving urinary parameters in men with CUR. Despite larger prostate volumes, HoLEP had a 99% successful deobstruction rate, thus rendering patients catheter-free.
Keywords prostatic hyperplasia, transurethral prostatectomy, laser therapy, prostate, transurethral resection of prostate
those with chronic urinary retention (CUR) or refractory urinary retention have not. CUR remains poorly described in the literature, with definitions consisting of variable post-void residual urine volumes (PVRs) ranging from >300 to >1000 mL or an asymptomatic palpable bladder after voiding [11–13]. Regardless, the possible effects of CUR include nocturnal incontinence, risk of UTIs, bladder calculi, and renal dysfunction. Although limited available data precludes standardised management recommendations, surgical therapy is often an effective treatment to avoid the need for indwelling or intermittent catheterisation [12,14,15]. In the present study, we sought to compare outcomes, with focus on successful cessation of catheter-dependency, of HoLEP and PVP for men with BPH and CUR at our institution.
BJU Int 2015; 115: 295–299 wileyonlinelibrary.com
Jaeger et al.
Patients and Methods After receiving Institutional Review Board approval, a retrospective analysis of all patients with BPH and CUR who had undergone HoLEP or PVP from 2009 to 2012 at our institution was performed. CUR was defined as a persistent PVR of >300 mL documented in the clinical setting on ultrasound or refractory urinary retention after multiple failed voiding trials making patients catheter-dependent. Catheterisation duration was at least 1 month in all patients with refractory retention. Patients with a history of prostate cancer, a solitary episode of acute urinary retention with subsequent ability to void spontaneously, urethral stricture, or a history of neuropathic bladder dysfunction secondary to other cause were excluded. In all, 72 and 31 patients with CUR who underwent HoLEP and PVP, respectively, were identified based on these criteria. All patients were evaluated preoperatively with complete medical history, DRE, urine analysis, PSA level, and TRUS for prostate volume measurement. Formal multichannel cystometry urodynamic studies were performed at the discretion of the surgeon. Bladder underactivity was defined as those with a bladder contractility index of 300 mL, maximum urinary flow rate (Qmax) was measured with uroflowmetry and PVR recorded with ultrasound. A single surgeon (A.E.K.) performed all HoLEP procedures and three surgeons performed the PVP procedures. HoLEP was performed as previously described after urethral dilatation [16,17]. After adenoma morcellation, a 24-F three-way catheter was placed and left overnight. Our PVP technique is similar to published reports using a GreenLight PV laser generator [18,19]. In August 2011, the XPS 180-watt generator supplanted the HPS 120-watt device. Once an adequate prostatic fossa cavity was created, a catheter was left indwelling. In both procedures, the urethral catheter was typically removed the following morning if minimal haematuria and the patient given a voiding trial with PVR measurement. Occasionally, the urethral catheter was left in situ for an extended duration after PVP based on surgeon preference. If unable to void, the catheter was replaced and the patient offered a voiding trial at a future date. Preoperative baseline characteristics, perioperative parameters, and postoperative outcomes were compared between the two groups. Patients in urinary retention requiring indwelling urethral catheterisation were not assessed with uroflowmetry or PVR measurements. The resected percentage was calculated from the resected weight at the time of the procedure and preoperative TRUS measurement. Postoperative outcomes, including assessment of AUA Symptom Index (AUASI), Qmax,
296
© 2014 The Authors BJU International © 2014 BJU International
and PVR, were collected at latest follow-up. Complications including UTI, haematuria requiring readmission, urethral stricture, bladder neck contracture, reoperation due to regrowth, and urinary incontinence were reported in both groups. All patients were questioned about the presence of urinary leakage before and after surgical intervention, with incontinence defined as any leakage reported on latest postoperative follow-up visit. Results are given as medians with interquartile ranges (IQRs). Comparative analysis was performed using the rank-sum test and chi-square or Fisher’s exact test for statistical validation when appropriate, with P < 0.05 considered to indicate statistical significance.
Results Table 1 summarises patient demographics for those treated in the comparative study. The median (IQR) patient age was 71 (62–77.75) years in the HoLEP group and 70 (62–76) years in the PVP group. Of the 44 HoLEP and 29 PVP patients who were spontaneously voiding, there was no significant difference in preoperative AUASI (18 vs 21, P = 0.24), Qmax (5.1 vs 5.6 mL/s, P = 0.26), or PVR (555 vs 473 mL, P = 0.096). Men in the HoLEP group had a significantly larger median prostate volume (88.5 vs 49 mL, P < 0.001) and higher median PSA concentration (4.5 vs 2.4 ng/mL, P = 0.001) compared with those in the PVP group. Overall, the mean duration of preoperative catheterisation was similar between groups (3 vs 5 months, P = 0.71). Preoperative multichannel cystometry was performed at the surgeon’s discretion and was not standardised. Bladder characteristics of those patients undergoing formal urodynamic study are included in Table 1. The HoLEP group had a lower median bladder contractility index than the PVP group (73 vs 90, P = 0.012). Of those 40 HoLEP and 23 PVP patients undergoing urodynamic study, more patients were found to have underactive or acontractile bladders in the HoLEP group compared with the PVP group, although this was not statistically significant (71% vs 59%, P = 0.34). Table 2 shows the perioperative parameters for both groups. The median (IQR) total applied energy in the PVP cohort was 265 (187–286) kJ or 4.7 kJ/g of prostate tissue. Catheterisation duration was longer in the PVP group, while hospital stay was longer in the HoLEP group. No patients required a blood transfusion. Median follow-up was 6 months. Postoperatively, 71 (99%) and 23 (74%) patients were voiding spontaneously with low PVRs resulting in a catheter-free state in the HoLEP and PVP groups, respectively (P < 0.001). Of voiding patients, there were no significant differences in AUASI (3 vs 4, P = 0.06), Qmax (23 vs 18 mL/s, P = 0.28), or PVR (57 vs 54 mL, P = 1.0). Results are outlined in Table 3.
HoLEP and PVP for BPH and chronic urinary retention
Table 1 Baseline characteristics. Variable
HoLEP
Number of patients N (%): Patients with indwelling catheter Patients on CIC Patients unable to void Median (IQR): Patient age, years AUASI Qmax, mL/s PVR, mL Prostate volume, mL Duration of catheterisation, months PSA level, ng/mL Bladder contractility index N (%): Patients with urodynamic study Underactive or acontractile bladder
PVP
72
31
17 (24) 53 (76) 28 (40)
4 (15) 22 (85) 3 (10)
71 (62–77.75) 18 (12.5–23) 5.1 (3–8.3) 555 (390–700) 88.5 (57–126) 3 (2–6) 4.5 (3.1–8.6) 73 (0–107) 40 (56) 27 (71)
P
0.004
70 (62–76) 21 (15.5–25.5) 5.6 (3.9–9.9) 473 (327–628) 49 (31–75) 5 (1–13) 2.4 (0.8–4.5) 90 (75–149)
0.80 0.24 0.26 0.096
