Does urodynamics predict voiding after benign prostatic hyperplasia surgery in patients with detrusor underactivity?

Objective:We sought to determine if urodynamic study(UDS)predicted voiding outcomes in men with detrusor underactivity(DU)and benign prostatic enlargement(BPE)who underwent photovaporization of the prostate(PVP).Methods:Between September 2010 and July 2015,106 male patients with BPE and DU were identified.All patients underwent PVP.Urinary retention was noted by the preoperative necessity for an indwelling or intermittent catheter.Data collection included comorbidities,quality of life(QoL)scores,prostate volume,prostate-specific antigen(PSA),UDS and perioperative outcomes.UDS parameters included volume at first desire to void,volume at first urge to void,volume of severe urge,volume at capacity,compliance,detrusor contractions,maximum urinary flow rate(Qmax),and postvoid residual(PVR).Results:A total of 106 men were included in this analysis,who had urinary retention with a Foley catheter or clean intermittent catheterization(CIC)at the time of surgery.At baseline we found patients who voided had a detrusor pressure at Qmax(Pdet@Qmax)of 10.05±6.45 cmH2O compared to 16.78±12.17 cmH2O in those who did not void(p=0.071).Postoperatively,96(90.6%,mean age 76.9±26.2 years)of patients voided successfully while 10(9.4%,mean age 80.52±9.61 years)of patients remained in urinary retention.Mean baseline Qmax was 4.895±5.452 mL/s and 2.900±3.356 mL/s(p=0.087)in those who voided and did not respectively.PVR was 319.23±330.62 mL in those who voided and 276.88
263.27 mL(p=0.344)in those who did not void.No UDS parameter predicted who would void postoperatively or improvements in QoL.Conclusions:The patients with DU and BPE might be able to successfully void after undergoing PVP regardless of UDS findings.All men who voided had improved international prostate symptom score and QoL scores compared to baseline and these parameters were durable up to 12 months.

The role of photovaporization of the prostate in small volume benign prostatic hyperplasia and review of the literature

Objective:Our objective was to characterize the safety and efficacy of the 180 W XPS-GreenLight laser in men with lower urinary tract symptoms secondary to a small volume benign prostatic hyperplasia(BPH).Methods:A retrospective analysis was performed for all patients who underwent 180 W XPSlaser photoselective vaporization of the prostate(PVP)vaporization of the prostate between 2012 and 2016 at two-tertiary medical centers.Data collection included baseline comorbidities,disease-specific quality of life scores,maximum urinary flow rate(Qmax),postvoid residual(PVR),complications,prostate volume and prostate-specific antigen(PSA).The secondary endpoints were the incidence of intraoperative and postoperative adverse events.Complications were stratified using the Clavien-Dindo grading system up to 90 days after surgery.Results:Mean age of men was 67.8 years old,with a mean body mass index of 29.7 kg/m2.Mean prostate volume as measured by transrectal ultrasound was 29 mL.Anticoagulation use was 47%and urinary retention with catheter at time of surgery was 17%.Mean hospital stay and catheter time were 0.5 days.Median follow-up time was 6 months with the longest duration of follow-up being 22.5 months(interquartile range,3-22.5 months).The International Prostate Symptom Score improved from 22.8±7.0 at baseline to 10.7±7.4(p<0.01)and 6.3±4.4(p<0.01)at 1 and 6 months,respectively.The Qmax improved from 7.70±4.46 mL/s at baseline to 17.25±9.30 mL/s(p<0.01)and 19.14±7.19 mL/s(p<0.001)at 1 and 6 months,respectively,while the PVR improved from 216.0±271.0 mL preoperatively to 32.8±45.3 mL(p<0.01)and 26.2±46.0 mL(p<0.01)at 1 and 6 months,respectively.The PSA dropped from 1.97±1.76 ng/mL preoperatively to 0.71±0.61 ng/mL(p<0.01)and 0.74±0.63 ng/mL at 1 and 6 months,respectively.No patient had a bladder neck contracture postoperatively and no capsular perforations were noted intraoperatively.Conclusion:The 180 W GreenLight XPS system is safe and effective for men with small volume BPH.PVP produced improvements in symptomatic and clinical parameters without any safety concern.It represents a safe surgical option in this under studied population.

Commentary on“Solving the benign prostatic hyperplasia puzzle”

Benign prostatic hyperplasia(BPH)is a common condition affecting over 50% of men as they reach the 5th decade of their life[1].While over half of these patients have symptoms,it is not clear why some of these men do while others do not.The article Solving the benign prostatic hyperplasia puzzle by Keong Tatt Foo[2],delves into the different conundrums urologists face when trying to treat their patients.

Effect of phosphodiesterase inhibitors in the bladder

Many aging men will experience lower urinary tract symptoms(LUTS).Phosphodiesterase type 5(PDE5)inhibitors have shown promise in treating LUTS in these patients.PDE5 inhibitors mediate their effects through several pathways including cAMP,NO/cGMP,Kchannel modulated pathways,and the L-cysteine/H2S pathway.PDE5 inhibitors exert their effect in muscle cells,nerve fibers,and interstitial cells(ICs).The use of PDE5 inhibitors led to improvement in LUTS.This included urodynamic parameters.PDE5 inhibitors may play a significant role in LUTS due to their effect on the bladder rather than the prostate.

Contemporary review of the 532 nm laser for treatment of benign prostatic hyperplasia

Benign prostatic hyperplasia(BPH)is a condition that occurs increasingly with age.The established gold standard treatment for BPH has been the electrocautery-based transurethral resection of the prostate(TURP).TURP,however,is associated with several complications and side effects.Therefore,there is an increasing interest in a number of emerging minimally invasive therapies as alterative treatment options.Laser therapy using the Greenlight laser is a promising alternative to the traditional TURP.Selective absorption by hemoglobin allows rapid,hemostatic vaporization of prostate tissue.Additional advantages include avoidance or minimization of complications such as intraoperative fluid absorption,and bleeding,retrograde ejaculation,impotence,and incontinence,as well as its use in treating high volume BPH.We review the use of the Greenlight laser in the treatment of BPH,when comparing complications and advantages in relation to TURP.

Comparison of 80 W versus 120 W 532 nm Laser Prostatectomy for BPH

Purpose: Improvements to photoselective vaporization of the prostate (PVP) have been made over time, particularly with the introduction of higher power systems. Few studies however have compared the performance of these systems to their predecessors. The purpose of this study was to compare the clinical and perioperative outcomes of 80 W vs. 120 W PVP. Materials and Methods: A series of 267 and 209 consecutive patients underwent 80 W and 120 W PVP, respectively, from September 2001 to May 2009 at Weill Cornell Medical College (GreenLightTM laser system, American Medical Systems, Inc., Minnetonka, MN). Data were collected on patient demographics, International Prostate Symptom Score (IPSS), prostate-specific antigen (PSA), and perioperative parameters. Maximum flow rate (Qmax), postvoid residual (PVR), and transrectal ultrasound prostate volume were recorded. Statistical analyses were carried out utilizing the Shapiro-Wilk, Mann-Whitney, Wilcoxon and unpaired t tests (SPSS 15.0, SPSS Inc., Chicago, IL, USA). Results: Baseline parameters were similar between the two groups except for greater median age (72.8 vs. 69.2 years, p = 0.01) and lower median PSA (2.0 vs. 3.3, p = 0.01) in the 80 W group. Median laser time was longer in the 80W group (85 vs. 51 minutes, p 0.001) with a higher median energy utilized (253 vs. 210 kJ, p = 0.001). Final IPSS, Qmax, PVR, and PSA were equivalent between the two groups. Conclusions: In our series, PVP was safe and effective. Durable and similar improvements in symptoms and objective parameters were achieved in patients with both 80 W and 120 W laser systems. PVP with the 120 W system, however, provided faster and more efficient vaporization compared to the 80 W system.