e. 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 Frequently, new technologies are compared with historic TURP data sets that use outdated equipment or techniques that are no longer in use and does not represent contemporary outcomes.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.

.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.

.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.

.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.

.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.

.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.

.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.

.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.

.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.

.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.

.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.

.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. Isoosmolar 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.

106

Simple Prostatectomy

Open and Robot-Assisted Laparoscopic Approaches

Misop Han; Alan W. Partin

1.The major advantage of simple prostatectomy over transurethral resection of the prostate (TURP) in the management of prostatic adenoma includes:

a.removal of the prostatic adenoma under direct vision.

b.decreased risk of hypernatremia.

c.shortened convalescence period.

d.decreased perioperative hemorrhage.

e.enhanced preservation of erectile function.

2.The suprapubic simple prostatectomy, in comparison to the retropubic simple prostatectomy, allows:

a.direct visualization of the prostatic adenoma during enucleation.

b.better visualization of the prostatic fossa after enucleation to obtain hemostasis.

c.easier management of a large median lobe and/or bladder calculi.

d.an extraperitoneal approach.

e.possible management of concomitant ureteral calculi.

3.The suprapubic approach to the prostatectomy is ideal for the patient with a large prostatic adenoma and:

a.multiple small bladder calculi.

b.total prostate-stimulating antigen (PSA) greater than 10.0 ng/mL.

c.erectile dysfunction.

d.symptomatic bladder diverticulum.

e.presence of dilated renal pelvis.

4.The most appropriate definitive treatment options for the patient with a 120-g prostatic adenoma and a symptomatic bladder diverticulum are: