Campbell-Walsh Urology, 11th Edition

PART XIV

Prostate

105

Minimally Invasive and Endoscopic Management of Benign Prostatic Hyperplasia

Kevin T. McVary; Charles Welliver

Questions

1. In the last 30 years of benign prostatic hyperplasia (BPH) management, which of the following has been a general trend in endoscopic surgical treatment?
2. With the widespread use of medical therapy for BPH, there has been a trend toward less use of surgical management.
3. The advent of the bipolar resection system increased the overall percentage of endoscopic procedures done as transurethral resections of the prostate (TURPs).
4. Socioeconomic factors involved in acceptance and use of laser technology have not been described.
5. Younger men are more likely to undergo treatment for BPH than older men.
6. Retreatment rates have not influenced the continued adoption of new endoscopic and minimally invasive treatments.
7. With regard to defining outcomes in BPH treatment, which of the following statements is NOT correct?
8. Intent to treat analyses are commonly reported.
9. Subjective symptoms (such as dysuria) can be influenced by observer reporting.
10. Reports of long-term treatment efficacy are highly influenced by a loss of patients to follow-up and, possibly, reporting of responder data only.
11. Comparisons across surgical techniques are often unfair because new technologies are frequently compared with a historic, and often inferior, data set.
12. In a randomized controlled trial (RCT), comparison with TURP assumes that the surgeon performing the TURP has been sufficiently trained and can produce predictable results.
13. The minimum antibiotic coverage for treatment of BPH according to the American Urological Association (AUA) best practice statement is:
14. ceftriaxone.
15. ampicillin.
16. fluoroquinolone.
17. trimethoprim.
18. acyclovir.
19. TURP should begin with resection of the:
20. apical portion of the prostate.
21. prostate floor.
22. bladder neck.
23. median lobe, if present.
24. anterior portion of the prostate.
25. Transurethral resection (TUR) syndrome is caused by:
26. absorption of fluid during procedures such as holmium laser enucleation of the prostate (HoLEP) and bipolar TURP.
27. absorption of non–sodium-containing irrigating fluid, leading to an acute dilutional hyponatremia.
28. irrigating fluid placed at a less than ideal height above the patient.
29. a serum sodium of greater than 130 mEq/L.
30. intraoperative ureteral injury.
31. Which of the following is TRUE of bipolar compared with monopolar TURP?
32. In a meta-analysis of patients undergoing bipolar TURP, authors concluded that by treating 50 patients with bipolar TURP, one case of TUR syndrome could be prevented.
33. A relative risk of 0.53 for blood transfusion with bipolar resection was found in meta-analysis.
34. Improved visualization during bipolar TURP may also lead to a decrease in capsular perforations and operating time.
35. Late complications such as bladder neck contracture and need for retreatment of BPH do not appear to be much different from those found with conventional TURP.
36. All of the above.
37. Which of the following is TRUE about transurethral vaporization of the prostate (TUVP)?
38. There is a large startup cost associated with the procedure due to the required purchase of new generators and equipment.
39. Frequently leads to lower hemostasis related complications (transfusion, clot retention) compared to monopolar TURP
40. Is available only as a monopolar technology
41. Was first described in 2005
42. It leads entirely to tissue vaporization.
43. Transurethral microwave therapy (TUMT) has been shown to:
44. frequently cause erectile dysfunction.
45. improve AUA Symptom Score (AUASS) by approximately 60% at 1 year.
46. have comparable results in both the low energy and high energy platforms.
47. increase density of nerve endings in the prostate.
48. induce changes in prostate volume of greater than 50%.
49. Sham studies on urologic procedures for lower urinary tract symptoms (LUTS) due to BPH:
50. frequently show statistically significant decreases in AUASS.
51. are poorly tolerated by the patient.
52. have significant side effects and should not be performed as part of research.
53. have never shown a statistically significant improvement in objective measures such as peak urinary flow.
54. have never been performed.
55. Which of the following is the most commonly reported complication/adverse event associated with TUMT?
56. Blood transfusion
57. Urinary tract infection
58. Erectile dysfunction
59. Urethral stricture
60. Incontinence
61. Transurethral needle ablation (TUNA):
62. now universally regulates temperature based on impedance.
63. is required to be done in a hospital-based operating room with overnight admission.
64. should only be performed on prostates less than 50 mL in size.
65. has an equivalent need for retreatment for lower urinary tract symptoms (LUTS) due to BPH compared to TURP.
66. is not recommended in patients with metallic pelvic prostheses.
67. Which of the following is TRUE regarding transurethral incision of the prostate (TUIP)?
68. It commonly results in TUR syndrome.
69. It is generally only used in prostates larger than 60 mL.
70. It causes retrograde ejaculation in 80% of cases.
71. It results in removal of a large volume of prostate adenoma.
72. It may have a lower rate of ejaculatory dysfunction in patients when done unilaterally.
73. With regard to laser safety, which of the following statements is correct?
74. Eye protection is required for the surgeon only.
75. All windows or wall openings from the operating room (OR) must be covered.
76. Signs denoting that a laser is in use need only be displayed on the most commonly used door for that operating room.
77. Eye protection is required only when a video camera is not used during the case.
78. All laser energy is readily absorbed by air/irrigating fluid, making it safe to use in the OR.
79. Holmium laser resection of the prostate (HoLRP) differs from HoLEP in that HoLRP:
80. follows anatomic planes to remove the prostate in lobes.
81. requires the use of a morcellator.
82. preceded HoLEP chronologically and conceptually.
83. has been shown to be superior to TURP in recent meta-analyses.
84. uses a thulium laser.
85. Which of the following is TRUE of HoLEP?
86. Transient urinary retention is seen in more than 50% of patients.
87. A morcellator-related bladder injury has never been reported.
88. Bladder neck contracture may be more common in smaller prostate glands.
89. Overall complication rates increase significantly with increasing prostate size.
90. When observed, urinary incontinence is generally permanent.
91. Prostate vaporization:
92. ideally uses a wavelength that is readily absorbed by hemoglobin for improved hemostasis.
93. utilizes coagulation of tissue over ablation of tissue.
94. was ideally suited for the neodymium laser.
95. increases with decreasing laser wattage.
96. occurs frequently during TURP.
97. Patients on anticoagulation who undergo photoselective vaporization of the prostate (PVP) have an increased risk of:
98. erectile dysfunction.
99. blood transfusion.
100. TUR syndrome.
101. ejaculatory dysfunction.
102. time in the hospital after procedure.
103. The mechanism of action of prostate urethral lift is:
104. implantation of a radiation-eluting implant that causes tissue ablation with time.
105. primarily in compression of peripheral zone of the prostate.
106. primarily in compression of the transition zone of the prostate.
107. delayed tissue necrosis of the prostatic urothelium causing a decrease in local irritative symptoms.
108. implantation of a stent within the lumen of the urethra to relieve obstruction by the lateral lobes.
109. When using the prostate lift for treatment of LUTS due to BPH, implants are placed where in the prostate anatomically?
110. Anterolaterally
111. Posterolaterally
112. Anteriorly
113. Posteriorly
114. In the peripheral zone
115. Which statement is TRUE of prostate embolization?
116. The pelvic vasculature is generally straightforward, and the procedure is technically not challenging.
117. It is achieved by occluding the internal iliac vessels.
118. It is applicable to a wide variety of patients.
119. It incurs no radiation to the patient.
120. Bilaterally achieved embolization yields better results.

Answers

1. a. With the widespread use of medical therapy for BPH, there has been a trend toward less use of surgical management.Although short periods of increase have been noted, the overwhelming trend in the past 30 years has been a decrease in endoscopic treatment of BPH, as shown in many Medicare database analyses. The market share of TURP has decreased, even with the common use of the bipolar technology. Payer data from Florida have displayed an irregular acceptance and use of lasers in BPH treatment depending on socioeconomic factors. Older men are more likely to display histologic findings of BPH and are more likely to undergo surgery for the disease; the widespread use of medications has also led to an overall more aged cohort seeking treatment after medical therapy is unsuccessful. Although initial acceptance of a new technology is common, frequently an unacceptable need for disease retreatment causes a technology to lose market share and fail.
2. a. Intent to treat analyses are commonly reported.The definition of outcomes and comparison of procedures in BPH treatment is fraught with many problems. Intent-to-treat analyses are exceedingly rare. Subjective symptoms (including comments on severity) are not frequently reported and are subject to both patient and observer reporting problems. Long-term reports may frequently skew toward patients who are responders to treatment, because patients who do not respond will either receive retreatment for disease (no longer included in data set) or seek treatment elsewhere and also be lost. Frequently, new technologies are compared with historic TURP data sets that use outdated equipment or techniques that are no longer in use and does not represent contemporary outcomes. Although RCTs generate a high level of evidence, the outcomes from the control group are subject to the training of the surgeon in the control procedure and many not represent commonly found outcomes.
3. c. Fluoroquinolone. The minimum antibiotic coverage according to the AUA best practice statement would include the use of either a fluoroquinolone or trimethoprim-sulfamethoxazole (TMP-SMX).In patients with a positive urine culture or indwelling Foley catheter, additional or extended antibiotic coverage should be considered.
4. d. Median lobe, if present. Although many different plans for resection exist, resection of the median lobe (when present) is generally accepted as the first step.
5. b. Absorption of non–sodium-containing irrigating fluid, leading to an acute dilutional hyponatremia.Absorption of non–sodium-containing irrigating fluid into the prostatic venous system that is exposed during resection is the etiology of the disease. This risk appears to be unique to monopolar TURP; other BPH techniques (such as bipolar TURP, HoLEP, and laser vaporization) use isotonic/iso-osmolar irrigating fluid such as normal saline. The ideal height of irrigating fluid was determined to be 60 cm above the patient, as this balanced the benefits of visualization with systemic absorption. Heights above this level will lead to an increased systemic absorption. Generally, symptoms of TUR syndrome begin with a serum sodium of less than 120 mEq/L. Ureteral injury is not associated with TUR syndrome.
6. e. All of the above.All of the findings in a through d have been demonstrated in studies. The use of a sodium-containing iso-osmolar irrigating fluid has essentially eliminated the risk of TUR syndrome in bipolar TURP. The "cut and seal" action of the technology improves intraoperative hemostasis with better visualization, leading to less blood transfusion and quicker operating times. Differences in many late complications such as bladder neck contracture and need for retreatment have not been demonstrated in comparison to monopolar technology.
7. b. Frequently leads to lower hemostasis related complications (transfusion, clot retention) compared to monopolar TURP.Fewer bleeding-related complications have been demonstrated in TUVP studies when compared to monopolar TURP. The technology is available in both monopolar and bipolar technology, with the monopolar technique described in 1995 by Kaplan and Te. The leading edge of the electrode uses primarily vaporization with the lagging edge causing tissue coagulation, leading to the improved hemostasis seen in many studies.
8. b. Improve AUA Symptom Score (AUASS) by approximately 60% at 1 year.Although the precise mechanism of action of transurethral microwave therapy is still debatable, it likely works by either inducing nerve degeneration in the prostate or leading to morphologic changes (apoptosis and necrosis) in the tissue. The technique infrequently leads to erectile dysfunction, with modest changes in prostate volume frequently exhibited (25% at the most). The high-energy and heat shock platforms are an improvement versus the low-energy protocol with regard to clinical efficacy. Improvements in AUASS are 60% to 65% at 1 year and 45% at 3 years.
9. a. Frequently show statistically significant decreases in AUASS.Multiple sham studies have been performed as part of clinical trials on TUMT and prostate lift. Significant improvements in both AUASS and peak flow have been shown. Side effects of treatment are infrequent, and the sham procedures are well tolerated.
10. b. Urinary tract infection.Urinary tract infection is a fairly common finding after TUMT, likely because of the frequently seen transient urinary retention and prolonged catheterization. The rest of these complications occur in less than 10% of cases.
11. e. Is not recommended in patients with metallic pelvic prostheses.The TUNA system can now measure temperatures at the end of the thermocouples, and close regulation of tissue impedance is less critical than in the previous impedance-based systems. The procedure can be performed in an office-based setting, and hospital admission is not required. Prostate sizes of up to 70 mL can be treated. Retreatment rates for TUNA are higher than for TURP (Odds ratio (OR) = 7.4 in the meta-analysis by Bouza et al). TUNA is not recommended in patients with active urinary tract infection (UTI), metallic pelvic prosthesis (e.g., artificial hip), cardiac implants (defibrillator or pacemaker), or a high bladder neck.
12. e. May have a lower rate of ejaculatory dysfunction in patients when done unilaterally. The procedure is relatively short and does not cause TUR syndrome. The procedure is only appropriate for small prostate glands (generally less than 30 mL), and no prostate adenoma is removed. Retrograde ejaculation occurs in up to 37% of patients. Although this is controversial, most authors believe that the risk of retrograde ejaculation is lower if done unilaterally as opposed to bilaterally.
13. b. All windows or wall openings from the operating room (OR) must be covered. Eye protection is required for all classes of lasers used in urology currently. Eye protection should be utilized by the patient and all personnel in the room even if a video camera is used during the case. Signs should be placed on all entries to the OR. Any and all openings to the OR from which laser energy could escape should be covered to preclude injury to persons outside of the OR. Although holmium laser energy is absorbed in irrigating fluid, KTP/LBO laser energy is not readily absorbed in either fluid. Both of these lasers can damage the eye when outside the body as neither are readily absorbed/dispersed in air.
14. c. Preceded HoLEP chronologically and conceptually.Both technologies utilize a holmium laser for prostate incision. Answers a, b, and d are true of HoLEP and not HoLRP. HoLRP advanced to HoLEP when the use of a morcellator became commonplace and conceptually predates HoLEP.
15. c. Bladder neck contracture may be more common in smaller prostate glands.Even transient urinary retention is an uncommon finding after HoLEP because of the complete removal of the adenoma. Morcellator injuries to the bladder have been reported and can be catastrophic. Overall complication rates do not appear to increase with increasing gland size, although the study by Kuo et al, 2003* found that bladder neck contractures may be more common in smaller glands. Urinary incontinence can occur in up to 10% of cases but is almost always transient.
16. a. Ideally uses a wavelength that is readily absorbed by hemoglobin for improved hemostasis.Currently, the most commonly used prostate vaporization systems use a laser wavelength that is ideally absorbed by hemoglobin (532 nm), as this is felt to improve hemostasis during the vaporization. Ablation and vaporization are essentially interchangeable terms, and ablation/vaporization is vapored over coagulation. The bulk of tissue is vaporized, but a thin rim of coagulated tissue is left in the prostate for hemostasis. Although originally thought to be the ideal laser for the prostate, the neodymium:YAG laser originally fell out of favor because of the wavelength’s partiality for tissue coagulation and not vaporization. Increasing laser wattage has increased vaporization rates, and TURP has minimal tissue vaporization as it removes the prostate through resection of prostate chips.
17. e. Time in the hospital after procedure.Patients who undergo PVP while on anticoagulation appear to be more likely to require longer times in the hospital. They also appear to require more continuous bladder irrigation and a longer time with a urethral catheter. Blood transfusions do not appear to be more frequent. TUR syndrome does not occur with PVP, as normal saline is used. Erectile dysfunction and ejaculatory dysfunction in patients on anticoagulation during PVP are not well studied.
18. c. Primarily in compression of the transition zone of the prostate.The prostate urethral lift system works by primarily compressing the transition zone of the prostate. The implants do no elute radiation or cause delayed tissue necrosis. The last answer describes prostate stents.
19. a. Anterolaterally.The implants in the prostate lift system are placed anterolaterally to avoid the neurovascular bundles (posterolateral) and the prostate veins (anterior). The implants work by primarily compressing the transition zone of the prostate and leading to an increased opening of the urethral lumen.
20. e. Bilaterally achieved embolization yields better results.The procedure is actually technically very challenging because of highly variable pelvic anatomy with small vessels feeding the prostate. Occlusion should be done a location much more distal than the internal iliac vessels. Radiation to the patient is considerable with the procedure. Because of strict inclusion criteria, patients frequently are deemed unacceptable for the procedure. When bilateral embolization is achieved, it appears that outcomes are improved.

Chapter review

1. Complications of urethral stent placement include hematuria, migration, infections, encrustation, epithelial hyperplasia, irritative urinary symptoms, and painful ejaculation.
2. With the use of TUNA, there is a 23% requirement for retreatment in 5 years. Thus long-term efficacy has not been clearly demonstrated.
3. Transurethral microwave therapy (TUMT) offers less morbidity than TURP but is not as effective in relieving outlet obstruction or improving symptoms.
4. A peak urinary flow rate of less than 15 mL/sec does not differentiate between outflow obstruction and detrusor impairment.
5. Venous bleeding after TURP can be controlled by filling the bladder with 100 mL of irrigating fluid and placing the catheter on traction for 5 to 10 minutes.
6. The TUR syndrome is secondary to dilutional hyponatremia (with volume overload) and may present as mental confusion, nausea, vomiting, hypertension, bradycardia, and visual disturbances. Iso-osmolar solutions such as glycine and sorbitol are just as likely to cause dilutional hyponatremia as water. The use of saline as the irrigant eliminates hyponatremia but not volume overload.
7. Intraoperative priapism is managed by injecting an α-adrenergic agent into the corpora.
8. Outcomes of a TURP are best for men who are most bothered by their symptoms.
9. TUIP is particularly effective for those with bladder neck occlusion, in patients with small prostates, and in those who are young.
10. Prostate-specific antigen (PSA) may be used as a surrogate for prostate volume.
11. 5α-Reductase inhibitors may successfully manage hematuria originating from the prostate.
12. Each centimeter above the normal 2.5-cm prostate urethral length equates to an additional 10 g in prostate weight.
13. Resection of the prostate apex is best performed at the termination of the procedure when hemostasis is adequate.
14. A routine TURP results in 800 to 1000 mL of fluid being absorbed into the systemic circulation.
15. After TURP, an improvement in symptoms occurs in 75% of patients; 16% require a reoperation in 7 years. Complications include bladder neck contracture in 2% (more common when small glands are resected), urethral stricture in 2% to 4%, and ejaculatory problems in the majority.
16. After TUMT, there is a 30% retreatment rate, and one third of patients remain obstructed on urodynamic assessment.
17. PVP can be performed safely in patients on anticoagulant medication.
18. When performing a TURP, resection of the median lobe (when present) is generally accepted as the first step.
19. The ideal height of irrigating fluid was determined to be 60 cm above the patient because this balanced the benefits of visualization with systemic absorption.
20. TUNA is not recommended in patients with active UTI, metallic pelvic prosthesis (e.g., artificial hip), cardiac implants (defibrillator or pacemaker), and a high bladder neck.
21. Eye protection is required for all classes of lasers used in urology currently.

^* Sources referenced can be found in Campbell-Walsh Urology, 11th Edition, on the Expert Consult website.