Management of Obstructive Benign Prostatic Hyperplasia With a >200 mL Gland

Late February 2018

Case of the Month Management of Obstructive Benign Prostatic Hyperplasia With a >200 mL Gland NYU Case of the Month, Late February 2018 Christopher E. Kelly, MD Department of Urology, NYU Langone Health, New York, NY [Rev Urol. 2018;20(1):43–45 doi: 10.3909/riu0795] ® © 2018 MedReviews, LLC A 78-year-old man presented with longstanding and progressive lower urinary tract symptoms (LUTS). Predominant symptoms were decreased flow, sensation of incomplete emptying, and nocturia x1-3. The patient’s LUTS progressed despite his being on a high-dose alphablocker and a 5-alpha reductase inhibitor. He had one episode of acute urinary retention and one urinary tract infection in the past 6 months. His American Urological Association Symptom Score (AUASS) was 24. Laboratory Report • Cr: 1.33 mg/dL • eGFR: 52 mL/min/1.73 m2 • PSA: 1.8 ng/mL • Hct: 40.4 % • Hgb: 13.3 g/dL • PT: 11.5 sec • PTT: 25.9 sec • UA: Negative blood, nitrite, leukocyte esterase, protein Relevant Prior Medical History Date • • • • 7/3/2014 580 8/26/2014 374 7/8/2015 283 7/6/2016 511 Hypertension Hyperlipidemia Obesity No prior abdominal surgeries Evaluation at NYU Langone Physical Examination • Abdomen: soft, non-tender, non-distended • DRE: 50+ g, smooth, non-tender prostate; no rectal masses Post-Void Residual (PVR) (mL) Imaging Urinary tract ultrasound images were reviewed and showed normal kidneys without masses or hydronephrosis with normal-caliber ureters bilaterally. The bladder was distended to 335 mL without any masses. The prostate had a prominent median lobe Vol. 20 No. 1 • 2018 • Reviews in Urology • 43 4170018_10_RIU0795_V1_rev03.indd 43 5/2/18 12:41 PM Management of Large-gland BPH continued and measured 209 g. Following void, there was a 305 mL post-void residual (PVR) volume. Videourodynamics Videourodynamics were performed in the standing position using a 7 Fr dual-lumen catheter. The filling phase revealed normal bladder capacity (485 mL) and compliance with mild but suppressible detrusor overactivity noted only at end-fill. The voiding phase showed a highpressure, low-flow-rate relationship consistent with bladder outlet obstruction. Voiding cystourethrogram confirmed obstruction to be at the bladder neck/prostatic urethra. No vesicoureteral reflux, diverticula, or other sphincter dyssynergia was noted. Following review of the patient’s symptoms, the failure of BPH medical management, and the videourodynamic results, the patient was given the options of a simple prostatectomy—open or robotic— or holmium laser enucleation of the prostate (HoLEP). Prostate arterial embolization (PAE), also done at our medical center, was also discussed as an option for the management of large prostate glands. Monopolar transurethral resection of the prostate (M-TURP), bipolar transurethral resection of the prostate (B-TURP), and photovaporization of the prostate were not considered appropriate given the large gland size. The patient underwent an uncomplicated HoLEP procedure with morcellation. A 550 µ SlimLine laser fiber (Boston Scientific) was used. Blood loss was approximately 100 mL. Pathological examination revealed nodular benign prostatic hyperplasia (BPH) with chronic and acute inflammation. He was discharged on postoperative day 2 because of the need for postoperative continuous bladder irrigation. At 1-month follow-up, his AUASS dropped from 24 to 10. A postoperative urine culture was negative. A PVR was 20 mL. The patient was fully continent of urine. He had postoperative retrograde ejaculation but no change in his erectile function. Office visit at 6 months showed continued durable symptom relief. A PVR was 44 mL, and his urinalysis was negative. Discussion According to current American Urological Association (AUA) and European Association of Urology (EAU) guidelines, surgical therapy is the standard of care and the most effective approach for BPH when LUTS are refractory to medical management. Glands smaller than 100 g are typically treated with endoscopic transurethral therapies; glands greater than 100 g have traditionally been treated with open simple prostatectomy (OSP). OSP can be approached suprapubically/ transvesically or retropubically, depending on patient anatomy and surgeon preference. Despite its standard use for large glands, OSP is associated with relatively high perioperative morbidity: transfusion rate up to 24%, longer hospitalization stays, and longer catheterization time. The National Inpatient Sample recently analyzed the national use of OSP and found it to have decreased yearly between 2008 and 2012; the overall complication rate for OSP was reported as high as 28%, with a 0.4% in-hospital mortality rate.1 Because of the complications of OSP, alternative approaches for larger prostate glands have emerged in recent years. The robotassisted simple prostatectomy (RASP) and a variety of minimally invasive endoscopic approaches using holmium, holmium:YAG, 532 nm (GreenLight), thulium, or diode lasers are gradually gaining acceptance because evidence suggests these techniques yield comparable efficacy and less perioperative morbidity than OSP. HoLEP, GreenLight Laser, Thulium Laser, and Diode Laser Current AUA and EAU BPH Guidelines mention lasers, particularly as alternatives to transurethral resection of the prostate (TURP) and OSP in the management of BPH. These laser techniques dissect the plane between the surgical capsule and the obstructing adenoma in much the same way that a surgeon’s index finger would do this during an OSP. Evidence, including a meta-analysis of nine randomized controlled trials, shows that HoLEP has comparable efficacy to OSP and fewer complications.2-5 Similarly the thulium:yttriumaluminum-garnet (Tm:YAG) laser, with its continuous 2013 nm wavelength and shallow penetration depth of 0.2 nm, also has comparable efficacy and is associated with minimal blood loss, short catheterization time, and less residual tissue compared to OSP.6,7 GreenLight photovaporization is not recommended for glands over 100 mL, but GreenLight enucleation has been described to treat large glands using two different laser fibers and a 70°-angle side-firing laser.8,9 However, supportive clinical data for GreenLight enucleation are sparse. Similarly, diode lasers have shown equivalent efficacy and fewer complications compared to OSP but in smaller, shorter trials. Laparoscopic-Assisted Simple Prostatectomy (LASP) LASP was described by Sotelo and colleagues.10 When LASP was compared with open approaches, the mean operative time was greater in the LASP group (115 vs 54 minutes), whereas blood loss, catheter duration, and hospital stay were 44 • Vol. 20 No. 1 • 2018 • Reviews in Urology 4170018_10_RIU0795_V1_rev03.indd 44 5/2/18 12:41 PM Management of Large-gland BPH greater with the open procedure. There were no differences in the rate or severity of complications, and the efficacies were comparable at 3 years. With the emergence of the robot, most laparoscopic approaches have given way to robot-assisted ones. Robot-Assisted Simple Prostatectomy (RASP) RASP was also first described by Sotelo and colleagues.11 RASP approaches vary: suprapubic, retropubic, and preperitoneal; and no evidence in the literature exists to suggest one technique is superior to the others. But compared to OSP, these techniques show comparable efficacy, lower perioperative transfusion rates, and decreased hospital stays.12 Prostatic Arterial Embolization (PAE) PAE has been described as an alternative for the patient who cannot or chooses not to have surgical therapy for medically refractory BPH with obstruction. Spherical or nonspherical polyvinyl alcohol particles are typically used. Although early results show some efficacy, this outpatient technique is not widely used. In one large prospective nonrandomized study, clinical improvement was seen in the International Prostate Symptom Score (IPSS), the Quality of Life (QoL) index, the International Index of Erectile Function (IIEF), uroflow, and prostate volume. However, randomized studies are few, and although some large prostates were treated (up to 200 mL), larger prostates like the one our patient had were not the focus of PAE studies. Common causes of PAE failure are prostatic artery tortuosity, lack of a dominant prostatic artery, atherosclerosis, or hypovascularization of the prostate.13,14 4. 5. 6. 7. 8. 9. 10. 11. References 1. 2. 3. 12. Pariser JJ, Pearce SM, Pater SG, Bales GT. National trends of simple prostatectomy for benign prostatic hyperplasia with an analysis of risk factors for adverse perioperative outcomes. Urology. 2015;86:721-725. Naspro R, Suardi N, Salonia A, et al. Holmium laser enucleation of the prostate versus open prostatectomy for prostates >70 g: 24-month follow-up. Eur Urol. 2006;50:563-568. Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year followup results of a randomised clinical trial. Eur Urol. 2008;53:160-166. 13. 14. Cornu JN. Bipolar, monopolar, photovaporization of the prostate, or holmium laser enucleation of the prostate: how to choose what’s best? Urol Clin N Am. 2016;43:377-384. Lin Y, Wu X, Xu A, et al. Transurethral enucleation of the prostate versus transvesical open prostatectomy for large benign prostatic hyperplasia: a systematic review and meta-analysis of randomized controlled trials. World J Urol. 2016;34:1207-1219. Iacono F, Prezioso D, Di Lauro G, et al. Efficacy and safety profile of a novel technique, ThuLEP (thulium laser enucleation of the prostate) for the treatment of benign prostate hypertrophy. Our experience on 148 patients. BMC Surg. 2012;12(suppl 1):S21. Sun F, Han B, Cui D, et al. Long-term results of thulium laser resection of the prostate: a prospective study at multiple centers. World J Urol. 2015;33:503508. Gomez Sancha F, Rivera VC, Georgiev G, et al. Common trend: move to enucleation—is there a case for GreenLight enucleation? Development and description of the technique. World J Urol. 2015;33:539-547. Elshal AM, Elkoushy MA, El-Nahas AR, et al. GreenLight™ laser (XPS) photoselective vapo-enucleation versus holmium laser enucleation of the prostate for the treatment of symptomatic benign prostatic hyperplasia: a randomized controlled study. J Urol. 2015;193:927-934. Sotelo R, Spaliviero M, Garcia-Segui A, et al. Laparoscopic retropubic simple prostatectomy. J Urol. 2005;173:757-760. Sotelo R, Clavijo R, Carmona O, et al. Robotic simple prostatectomy. J Urol. 2008;179:513-515. Holden M, Parsons JK. Robotic-assisted simple prostatectomy: an overview. Urol Clin North Am. 2016;43:385-391. Pisco JM, Rio Tinto H, Campos Pinheiro Let al. Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of short- and mid-term follow-up. Eur Radiol. 2013;23:2561-2572. Bilhim T, Bagla S, Sapoval M, et al. Prostatic arterial embolization versus transurethral resection of the prostate for benign prostatic hyperplasia. Radiology. 2015;276:310-311. Vol. 20 No. 1 • 2018 • Reviews in Urology • 45 4170018_10_RIU0795_V1_rev03.indd 45 5/2/18 12:41 PM