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ORIGINAL ARTICLE
Year : 2022 | Volume
: 33
| Issue : 2 | Page : 70-76
Monopolar transurethral resection of the prostate versus holmium laser enucleation in men with prostate volume greater than 100 mL
Chun-Kai Chang1, Cheng-Hsueh Lee1, Chun-Hsuan Lin1, Ching-Chia Li1, Sheng-Chen Wen1, Hsin-Chih Yeh2, Jiun-Hung Geng3
1 Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
2 1Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Department of Urology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung City, Taiwan
3 Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Department of Urology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung City, Taiwan
Correspondence Address:
Jiun-Hung Geng
Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan 100, Shih-Chuan 1st Road, Kaohsiung 80708
Taiwan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_114_21
Purpose: The surgical treatment for severe benign prostatic hyperplasia is challenging. The aim of our study was to compare the safety and efficacy of monopolar transurethral resection of the prostate (M-TURP) and holmium laser enucleation of the prostate (HOLEP) for prostate size >100 ml. Materials and Methods: We retrospectively evaluated our database of two groups of patients. Thirteen patients underwent M-TURP (group 1), and 27 underwent HOLEP (group 2). Results: The mean prostate size was 163.1 ± 49.0 ml in group 1 and 143.4 ± 40.9 ml in group 2 (P = 0.19). There was no significant difference in resected tissue volume, days of catheter removal, admission days, and postoperative serum hemoglobin between treatment groups. However, in group 1, mean postoperative serum sodium dropped from 137.1 mmol/L to 131.4 mmol/L, which was significantly lower than postoperative serum sodium in group 2 (P < 0.0001). There were more complications in group 1 than group 2, especially for patients undergoing transfusion (76.9% in group 1 and 22.2% in group 2) and with hyponatremia (15.4% in group 1 and 0% in group 2). At 3-month follow-up, the international prostate symptom score, quality of life score, and residual urine volume revealed no significant differences between groups. Conclusion: M-TURP and HOLEP in men with prostate volume greater 100 ml had similar operative time, admission days and postoperative functional outcomes. However, higher transfusion rates and postoperative hyponatremia were noted in the M-TURP group comparing to the HOLEP group.
Keywords: Complications, laser therapy, prostatic hyperplasia, transurethral resection of prostate, treatment outcome
Treatment for severe benign prostatic hyperplasia (BPH), especially with prostate volume >100 mL, is challenging. When pharmacological treatments fail,[1] further management includes surgery. In the guidelines, the recommended surgery for severe BPH (>80–100 mL) is laser enucleation of the prostate using Ho: YAG laser holmium laser enucleation of the prostate (HOLEP) or open prostatectomy. Monopolar transurethral resection of the prostate (M-TURP) is reserved for prostate glands between 30 mL and 80 mL.[2],[3],[4] However, various devices and approaches to improve the efficacy and safety of M-TURP have been proposed, including continuous-flow resectoscopes, video-assisted resection, high-frequency cutting/coagulating systems, microprocessor-controlled electrical units, and modified shape of cutting loops, which allow M-TURP to be performed in larger glands than previously reported and make it rational to be compared with laser enucleation.[5] Muzzonigro et al. prospectively compared patients with prostate volume <70 mL and prostate volume between 70 and 150 mL who underwent M-TURP.[6] The results showed that both groups had significant improvement in international prostate symptom score (IPSS), maximum flow rate (Qmax), and postvoid residual (PVR) volume after 1 year of follow-up and there was no difference in complication rates between groups. They concluded that M-TURP is a reliable surgery for large prostate glands with similar complication rate.[6] Moreover, there have been several reports on the application of M-TURP on large prostate glands with volume >80–100 mL.[7],[8] In the surgical management of severe BPH, M-TURP remains the reference standard.[9] Several studies have attempted to evaluate the efficacy and safety of various procedures in prostate glands with volume >80–100 mL, as shown in [Table 1]. Kuntz and Lehrich[10] and Naspro et al.[11] compared the efficacy and safety of HOLEP and open surgery. They concluded that HOLEP had similar functional results and less perioperative morbidity compared with open surgery. Based on these large, randomized controlled trials, the urologic community has embraced HOLEP as the standard surgical therapy for BPH, especially with large prostate glands. Another laser prostatectomy surgery, photoselective potassium titanyl phosphate (KTP), has also attempted to deal with large prostate glands. However, Horasanli et al. compared the results of KTP and M-TURP and concluded that M-TURP was superior to KTP in patients with large prostate glands. In early 2000, bipolar TURP in the saline system technique was developed. Kwon et al.,[8] Bhansali et al.,[12] and Raghuvanshi et al.[13] evaluated the functional results and morbidities of bipolar versus M-TURP in men with large prostate glands and deduced that bipolar TURP had all features of gold-standard M-TURP, along with added safety and efficacy. Then, a randomized control trial analyzed the surgical outcomes of open versus M-TURP for prostate glands >80 g and found that transvesical prostatectomy might be more effective than M-TURP.[14] However, another study by Persu et al.[5] showed different results, which revealed comparable safety and efficacy between open surgery and M-TURP.
Table 1: Summary of characteristics and outcomes comparing various procedures in prostate glands larger than 80 mLWe found other comparisons of various procedures[15],[16] in large prostate glands, as shown in [Table 1], but no study directly compared M-TURP and HOLEP for large prostate glands with volume >100 mL. Despite the more prevalent use of bipolar TURP and HOLEP for large BPH, we considered whether M-TURP could deal with large prostate conditions well because not every hospital has a new technology and not every patient could pay for the treatment. Bipolar TURP has reduced risk of hyponatremia and TUR syndrome than M-TURP, but evidence indicates that complications of M-TURP, especially TUR syndrome, have decreased from 1989 (1.1%) to 2005 (0%).[17] Herein, we present our clinical experiences on the safety and efficacy of M-TURP versus HOLEP for large prostate glands with volume >100 mL.
Materials and MethodsPatients
From July 2009 to January 2019, we retrospectively found 13 patients who underwent M-TURP (group 1) and 27 patients who underwent HOLEP (group 2). All patients had lower urinary tract symptoms (LUTS) due to BPH at our department, and all of them had prostate gland volume >100 mL. Preoperatively, all subjects underwent a regular and urological evaluation by digital rectal examination (DRE), suprapubic ultrasonography with assessment of prostate volume using the prostate ellipse formula (height × width × length × 0.52), urinalysis, serum prostate-specific antigen (PSA) level, and blood analysis (e.g., serum Na + and hemoglobin levels). Symptom severity was evaluated preoperatively by IPSS, quality of life (QOL), Qmax and PVR. In patients with PSA level >4 ng/dL, abnormal DRE finding and suspicious hypoechoic lesions were detected when ultrasonography and transrectal ultrasonographic-guided prostate biopsy were performed. If patients have urine retention before surgery, we will collect the Qmax and PVR data closest to the surgery for analysis. The inclusion criteria were prostate gland volume >100 mL and provision of informed consent. The exclusion criteria were evidence or suspicion of prostate or bladder malignancy, IPSS <15, Qmax >15 mL/s, and willingness to receive another treatment. Ethical approval for the study was provided by the Institutional Review Board (IRB) of Kaohsiung Medical University Hospital (KMUHIRB-E (II)-20190363).
Treatment
M-TURP was performed by using standard 26-Fr resectoscope (unipolar standard resectoscope set, KARL STORZ Gmbh and Co. KG) with a standard loop and continuous sterile water irrigation solution. HOLEP used included 100-W holmium laser (Lumenis, Santa Clara, California), 26-Fr continuous flow laser resectoscope (Olympus, Hamburg, Germany), 550-μm end-firing fiber, and morcellator (VersaCut, Lumenis). Prostatic adenoma was enucleated by en bloc one-lobe technique. Both procedures were introduced through the working channel of the STORZ nephroscope, a ConMed Electrosurgery (SYSTEM 5000TM). None of the patients had cystostomy because the resectoscope set has connecting tubes for inflow and outflow. All patients accepted intravenous antibiotic prophylaxis, and none of them had suprapubic trocar perioperatively.
All procedures were performed by two experienced urologists, and both surgeons had been performing more than 30 HOLEP surgeries before dealing with a large prostate gland. The operative time and weight of the tissue were calculated during the procedure. Postoperatively, we inserted a 22-Fr irrigation catheter, and the balloon, with 30 mL sterile water, was situated in the prostatic fossa. Bladder irrigation was maintained until bleeding stopped; then, the irrigation catheter was removed the next day, and the patient was discharged. Postoperative complications, Qmax, QOL, IPSS, and PVR were assessed at the 3-month follow-up.
Statistical analysis
Statistical analysis was performed using SPSS version 19.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to analyze patient characteristics, and the Student t-test was used to compare preoperative, perioperative, and postoperative data and complications. A two-sided P < 0.05 indicated statistical significance.
ResultsPreoperative results
Forty patients, including 13 patients in the M-TURP group (group 1) and 27 patients in the HOLEP group (group 2), were enrolled in the study. Patients' demographic characteristics before surgery are presented in [Table 2]. There was no difference in preoperative data between groups 1 and 2. The mean ages were 69.7 ± 10.1 years in group 1 and 72.7 ± 8.6 years in group 2. The mean prostate volumes were 163.1 ± 49.0 g in group 1 and 143.4 ± 40.9 g in group 2. The mean IPSS, QOL, Qmax, and PVR were 26.8 ± 5.7, 5.3 ± 0.9, 4.5 ± 4.7 mL/s, and 227.4 ± 186.4 mL, respectively, in group 1 and 25.1 ± 8.4, 4.7 ± 1.1, 2.2 ± 1.0 mL/s, and 165.8 ± 122.7 mL, respectively, in group 2. All patients had LUTS secondary to BPH for more than 6 months, and seven patients in group 1 and 14 patients in group 2 required Foley catheter insertion preoperatively.
Perioperative and postoperative results
The perioperative and postoperative data are shown in [Table 3]. The mean operative times were 108.9 ± 17.6 min in group 1 and 132.4 ± 62.7 min in group 2. The mean resected tissue weights were 119.2 ± 18.9 mL in group 1 and 105.5 ± 31.8 mL in group 2. The days of catheter removal were 5.5 ± 4.7 days in group 1 and 3.5 ± 1.7 days in group 2, while admission days were 5.1 ± 0.3 days in group 1 and 5.0 ± 1.5 days in group 2. The postoperative serum hemoglobin levels were 10.5 ± 1.8 g/L in group 1 and 10.8 ± 1.6 g/L in group 2. No significant differences in operative time, resected tissue volume, days of catheter removal, admission days, and preoperative and postoperative serum hemoglobin levels were found between groups; however, postoperative serum sodium (mmol/L) level were 131.4 ± 3.4 mmol/L in group 1 and 137.4 ± 2.8 in group 2; a significantly lower postoperative serum sodium level was noted in the M-TURP group than in the HOLEP group (P < 0.0001).
Three-month follow-up
The follow-up data of 40 patients (at 3 months postoperatively) are presented in [Table 4]. In the 3 months follow-up, the IPSS decreased from 26.8 ± 5.7 to 6.3 ± 3.3, the QOL decreased from 5.3 ± 0.9 to 1.3 ± 0.9, the Qmax increased from 4.5 ± 4.7 mL/s to 24.9 ± 12.5 mL/s, and the PVR decreased from 227.4 ± 184.6 mL to 51.0 ± 35.1 mL in group 1, which showed significant improvement in IPSS (P < 0.001), QOL (P < 0.001), Qmax (P < 0.001), and PVR (P < 0.001). In group 2, the IPSS decreased from 25.1 ± 8.4-4.3 ± 3.0, the QOL decreased from 4.7 ± 1.1 to 1.5 ± 1.0, the Qmax increased from 2.2 ± 1.0 mL/s to 18.0 ± 10.5 mL/s, and the PVR decreased from 165.8 ± 122.7 mL to 33.8 ± 26.2 mL, which also showed significant improvement from baseline (P < 0.001). There were no significant differences in the IPSS, Qmax, QOL, and PVR between groups 1 and 2 at baseline and 3-month follow-up.
Complications
As shown in [Table 5], ten patients (76.9%) and six patients (22.2%) who had received blood transfusion in groups 1 and 2, respectively. Two patients (15.4%) in group 1 had hyponatremia, but both had no symptoms or signs of TUR syndrome, and no hypertonic solution (3% NaCl) was administered. No hyponatremia was noted in group 2. The other complications included recatheterization in three patients (23.1%) in group 1 and four patients (14.8%) in group 2, urethral stricture in one patient (7.7%) in group 1 and one patient (3.7%) in group 2, and transient partial incontinence in five patients (38.5%) in group 1 and seven patients (25.9%) in group 2. No patient had TUR syndrome, total incontinence, or hydronephrosis. None of the 40 patients had incidental prostate cancer detected on histopathological evaluation.
Table 5: Complications of monopolar transurethral resection of the prostate and holmium laser enucleation of the prostate Discussion There are many available new contemporary procedures for BPH, including bipolar TUPR, KTP laser, diode laser, thulium laser, single-port transvesical simple prostatectomy, and robot-assisted laparoscopic simple prostatectomy. However, patients might be not willing to undergo laparoscopic surgeries and cannot afford the costs of bipolar TURP or laser surgeries. For these patients, M-TURP is still one of the best choices.
The efficacy of M-TURP has been questioned, and several studies have compared M-TURP and open prostatectomy for prostate glands with volume >80 mL. Ou et al. compared the surgical outcomes of transvesical prostatectomy (n = 34) and M-TURP (n = 35) for prostate size >80 g in a prospective randomized trial[14] and found that there was no significant difference in operative time and adverse events in both groups; however, postoperative outcomes, including IPSS, Qmax, QOL, and PVR, were much better in the TVP group than in the M-TURP group at the 3-and 12-month follow-up. They concluded that TVP might be safer and more effective than M-TURP for prostate glands with volume >80 mL. Concerning the poorer outcomes in the M-TURP group, we considered that the difference might be due to the amounts of resected prostate tissue. In TVP and M-TURP groups, a mean of 116.8 ± 33.2 g (84.4% of the preoperative calculated transrectal total prostate volume) and 69.7 ± 24.9 g (53.2% of the preoperative calculated transrectal total prostate volume) of prostatic tissue were resected, respectively (P < 0.001). Insufficient prostate tissue removal could result in unsatisfactory postoperative results. In our study, a mean of 119.2 ± 18.9 mL of prostatic tissue was resected in the M-TURP group and 105.5 ± 31.8 mL of prostatic tissue was resected in the HOLEP group, indicating that 73.0% and 73.6% of the preoperative calculated total prostate volumes were resected after M-TURP and HOLEP, respectively. These results were similar to the ratio of resected prostatic tissue in TVP groups in other studies.[6],[14] More importantly, all functional parameters improved significantly compared to baseline values in both groups. Accordingly, we posit that the differences between M-TURP, HOLEP, and open prostatectomy are not in the efficacy of these procedures but due to other reasons.
According to the literature review and our presenting study, the safety of M-TURP should be the most important concern. A meta-analysis of functional outcomes and complications following M-TURP, bipolar TURP, KTP, or HOLEP for LUTS from any size BPH showed M-TURP had similar functional outcomes with other transurethral procedures. However, for intraoperative complications, M-TURP (3.2%) and HOLEP (3.5%) measures were higher than other transurethral procedures. Intraoperative complications that were dominant in M-TURP included bleeding, capsular perforation, need for transfusion, and TUR syndrome. Capsular perforation was also noted in HOLEP. Moreover, the specific risk of bladder injury caused by morcellator occurred in HOLEP.[18] Another meta-analysis study that compared the safety of M-TURP and HOLEP showed that patients in HOLEP had less blood loss and lower blood transfusion rate than in M-TURP.[19] Li et al. had similar results, which demonstrated that M-TURP led to higher blood transfusion requirements compared with HOLEP.[20] Our study confirmed such findings that the transfusion rate was higher in the M-TURP group than in the HOLEP group in prostate glands with volume >100 mL. Furthermore, we also showed that the mean postoperative serum sodium level decreased from 137.1 mmol/L to 131.4 mmol/L in M-TURP, which was significantly lower than postoperative serum sodium level in HOLEP (P < 0.0001).
HOLEP showed similar efficacy to M-TURP in large prostate glands while rendering better safety. However, the disadvantages of HOLEP include high cost[21] and high surgical learning curve.[10],[22] Regarding the cost, many studies have compared the cost-effectiveness of HoLEP with M-TURP or open prostatectomy. One study showed that HoLEP is more cost-effective than M-TURP in a 1-year follow-up due to fewer complications and shorter hospital stay.[23] Another study compared HOLEP and open prostatectomy and found the average cost of HOLEP was 637 USD less than in open prostatectomy.[24] Regarding the learning curve, many studies have shown that there is a steep learning curve for HOLEP;[25],[26] however, several publications reported the number of cases to expertise for HOLEP was 40–100[27],[28] and a systemic review suggested that the time to expertise for HOLEP is similar to M-TURP and open prostatectomy.[29]
In this retrospective study, we compared the safety and efficacy of M-TURP and HOLEP for prostate volumes >100 mL in men with bladder outlet obstruction. To the best of our knowledge, this is the first study that focused on the comparisons between M-TURP and HOLEP for such large prostate glands. Nevertheless, we note several limitations in the present study. First, this was not a randomized control trial and the patient numbers were rather small (n = 40), which is the major limitation of the present study. However, there is still an important role for small cohort studies in uncommon surgeries. We emphasized that the study is “observational” and suggestive rather than confirmatory. It has certainly a merit to add up to the evidence in this topic and could provide valuable data for further studies. Second, there were just 3 months of follow-up, because all data were obtained from previous medical records, and most of them did not have long-term follow-ups. Third, we did not collect the concomitant conditions and medical prescriptions, such as hypertension, diabetes mellitus, alpha-1-adrenoreceptor blockers, and 5-alpha-reductase inhibitors, which might have affected the results. Fourth, the surgeons' skills and experiences in our study might be different, which might influence the outcomes of our study. Moreover, we recruited patients from 2009 to 2019, when laser enucleation was not extremely popular in the early 2010 s, an immature technique might be one of the biases. To clarify these technical and personal factors, we further analyzed the impact of operating years and surgeons on perioperative and postoperative outcomes [Table S1] and [Table S2]. We found that there was no significant difference between different years of surgical experiences and surgeons. Fifth, we did not unify the indications for blood transfusions. Patients might have blood transfusions during a surgery because of decreased blood pressure or acidemia. As a result, postoperative serum hemoglobin levels may not accurately represent blood loss. Therefore, we used both blood transfusion rates and postoperative hemoglobin values to explore the safety of surgery. Finally, there was no standard operating procedure in M-TURP for prostatic glands with volume >100 mL. In some patients, 20 mg furosemide (1 vial) was routinely administered intravenously if resection time exceeded 60 min or continuous sterile water irrigation >20000 mL was administered to protect them from TUR syndrome.
ConclusionIn this retrospective study, we compared the safety and efficacy of M-TURP and HOLEP for prostate volumes >100 mL in men with bladder outlet obstruction. We found that both procedures had similar operative time, admission days, days of catheter removal, and resected tissue volume. All functional parameters improved significantly compared to baseline values in both groups. However, high transfusion rates and postoperative hyponatremia were noted in the M-TURP group compared to the HOLEP group.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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