Tag Archive for: BPH

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Article of the week: Critical analysis of a multicentric experience with holmium laser enucleation of the prostate for BPH

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

There is also an editorial written by a prominent member of the urological community. Please use the comment buttons if you would like to join the conversation.

If you only have time to read one article this week, we recommend this one. 

Critical analysis of a multicentric experience with holmium laser enucleation of the prostate for benign prostatic hyperplasia: outcomes and complications of 10 years of routine clinical practice

Javier Romero-Otero*†‡, Borja García-Gómez*, Lucía García-González*, Esther García-Rojo*, Pablo Abad-López*, Juan Justo-Quintas, José Duarte-Ojeda* and Alfredo Rodríguez-Antolín*

*Urology Department, Grupo de Investigación Salud Integral del Varón imas12, Hospital Universitario 12 Octubre, Hospital Universitario HM Montepríncipe, and Hospital Universitario La Luz, Madrid, Spain

Abstract

Objective

To assess the perioperative outcomes of holmium laser enucleation of the prostate (HoLEP) in real‐life practice and investigate the factors influencing the safety and effectiveness of the technique.

Patients and Methods

Critical analysis of patients with benign prostate hyperplasia (BPH) treated with HoLEP over 10 years of routine practice in three hospitals. Analysed variables included: preoperative characteristics (prostate size, active antiplatelet/anticoagulant therapy, blood parameters. prostate‐specific antigen (PSA) level, maximum urinary flow rate [Qmax], and International Prostate Symptom Score [IPSS]), intraoperative variables (operation time, concomitant removal of bladder calculi, and complications), early postoperative outcomes (change in blood parameters, catheterisation time, and hospital stay), and 12‐month follow‐up outcomes (change in IPSS, PSA level, and Qmax).

Results

The analysis included 963 patients, aged 48–91 years, with a mean (range) prostate size of 91 (35–247) mL. The mean (sd ) operation time was 77 (29) min, and the hospital stay and catheterisation time were 4 (2) and 1.3 (2) days, respectively. In all, 56 patients (5.6%) required concomitant removal of bladder calculi and 36 (3.7%) were converted to open prostatectomy or transurethral resection of the prostate due to intraoperative complications. Patients had a significant decrease in haemoglobin and haematocrit, but no differences were seen between patients with and without anticoagulant/antiplatelet therapy and those with prostates ≥ and <100 mL. The concomitant removal of bladder calculi and having a prostate ≥100 mL resulted in a longer operation time, but did not influence the safety and effectiveness outcomes.

Conclusions

HoLEP is suitable for real‐life patients with BPH, irrespective of the presence of active treatment with anticoagulant/antiplatelet, bladder lithiasis or a prostate ≥100 mL.

Editorial: HoLEP is the complete technique for treating BPH

Ten years of experience with holmium laser enucleation of the prostate (HoLEP) are documented by Romero‐Otero et al. [1] and offer valuable insight into the real‐world use of this technique. No information on the 10‐year durability is available, however, as only the 12‐month data are presented, but there is a wealth of other information concerning both peri‐operative outcomes and complications. A particular strength of this paper is that all‐comers were studied, including patients with catheters, those with prostates larger than 100 g and those taking anti‐coagulants, plus there is the addition of the cases the three surgeons performed during their ‘learning curve’, although these are not analysed separately.

The authors’ technique almost certainly evolved over the study period. Personally, I currently find a one‐ or two‐piece enucleation to be more efficient than the three‐lobe technique originally described [2]. Enucleation efficiency of 1–2 g/min, as was achieved in this series (73 g in 40 min), is a good benchmark for tissue removal for those new to the technique and is a good measure of surgical proficiency. Being less aggressive anteriorly seems to have an impact on continence. It is often tempting to completely enucleate circumferentially in one continuous plane which is sometimes well beyond the commissure anteriorly. A more moderate dissection in this area can reduce the transient incontinence sometimes seen [3]. The incontinence rates in the current series of 12.8% at 3 months and 2.3% at 12 months are probably representative [1]. An analysis of the factors predisposing to moderate‐to‐severe incontinence in the six patients in this series would have been useful, particularly regarding prostate size, presence of a catheter and age.

The main contribution of HoLEP to the urological armamentarium is its ability to safely treat large prostates endoscopically [4]. Although robot‐assisted techniques have also decreased the morbidity of open prostatectomy [5], the attraction of the obvious ‘natural orifice’ for access and the use of laser technology for the enucleation with HoLEP is probably the least morbid and most cost‐effective way to treat these patients. Tackling a prostate larger than 100 g involves applying the same principles as for smaller prostates, with a few provisos. Firstly, having a consistent strategy for these large prostates is important and can be reassuring when things become difficult. Secondly, it is even more important to maintain the correct plane religiously as it is easier to get lost in these glands. A good sense of direction is important! Thirdly, stay ahead of the bleeding rather than trying to catch up as it can further compound an already difficult situation. Patience is a virtue.

The learning curve of HoLEP has historically been regarded as a major barrier to the uptake of the technique [6]. This has, of course, been exaggerated by proponents of other techniques, but it is important to emphasize that during this learning phase the excellent outcomes are maintained and that conversion to TURP, if necessary (3.4% in this series), can be safely done, as these authors’ have demonstrated. The length of the learning curve has been variously described as being between 20 and 80 cases and is almost entirely due to the way training is done. A modular mentored approach appears to be the best method and could equally be applied to endoscopic enucleation using any of the other energy sources that have been described [7].

HoLEP and all its progeny are here to stay, but which of these enucleation energy sources will gain ascendancy remains to be seen. Sadly, this will likely be more to do with the depth of the corporate pockets and their commitment to the cause rather than proper scientific appraisal [8].

by Peter Gilling

References

  1. Romero‐Otero J, Garcia‐Gomez B, Garcia‐Gonzalez L et al. Critical analysis of a multicentric experience with holmium laser enucleation of the prostate for benign prostatic hyperplasia: outcomes and complications of 10 years of routine clinical practice. BJU Int 2020; 126: 177-182
  2. Gilling PJ, Kennett K, Das AK, Thompson D, Fraundorfer MR. Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience. J Endourol 1998; 12: 457– 9
  3. Tunc L, Yalcin S, Kaya E et al. The “Omega Sign”: a novel HoLEP technique that improves continence outcomes after enucleation. World J Urol 2020 https://doi.org/10.1007/s00345-020-03152-9
  4. Gilling PJ, Kennett KM, Fraundorfer MR. Holmium laser enucleation of the prostate for glands larger than 100 g: an endourologic alternative to open prostatectomy. J Endourol 2000; 14: 529– 31
  5. Mourmouris P, Keskin SM, Skolarikos A et al. A prospective comparative analysis of robot‐assisted vs open simple prostatectomy for benign prostatic hyperplasia. BJU Int 2019; 123: 313– 7
  6. Placer J, Gelabert‐Mas A, Vallmanya F et al. Holmium laser enucleation of prostate: outcome and complications of self‐taught learning curve. Urology 2009; 73: 1042– 8
  7. Kuronen‐Stewart C, Ahmed K, Aydin A et al. Holmium Laser Enucleation of the prostate: simulation based training curriculum and validation. Urology 2015; 86: 639– 46.
  8. Herrmann TR. Enucleation is enucleation is enucleation is enucleation. World J Urol 2016; 34: 1353– 5

Article of the week: Information on surgical treatment of benign prostatic hyperplasia on YouTube is highly biased and misleading

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to this post, there is an editorial written by a prominent member of the urological community and a visual abstract for a swift overview of the article. Please use the comment buttons below to join the conversation.

If you only have time to read one article this week, we recommend this one. 

Information on surgical treatment of benign prostatic hyperplasia on YouTube is highly biased and misleading

Patrick Betschart*, Manolis Pratsinis*, Gautier Müllhaupt*, Roman Rechner*, Thomas RW Herrmann, Christian Gratzke, Hans–Peter Schmid*, Valentin Zumstein* and Dominik Abt*

*Department of Urology, Cantonal Hospital St Gallen, St Gallen, Urology Clinic, Spital Thurgau AG, Frauenfeld, Switzerland, and Department of Urology, Albert–Ludwigs–University, Freiburg, Germany

Abstract

Objectives

To assess the quality of videos on the surgical treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) available on YouTube, given that such video‐sharing platforms are frequently used as sources of patient information and the therapeutic landscape of LUTS/BPH has evolved substantially during recent years.

Materials and Methods

A systematic search for videos on YouTube addressing treatment options for LUTS/BPH was performed in May 2019. Measures assessed included basic data (e.g. number of views), grade of misinformation and reporting of conflicts of interest. The quality of content was analysed using the validated DISCERN questionnaire. Data were analysed using descriptive statistics.

Fig. 1. Degree of misinformation compared to currently available evidence on surgical BPH treatment 7 (no: green; very little: light green; moderate: light blue; high: light red; extreme: dark red), rate of commercial bias (yes: red; no: light green) and rate of declaration of conflicts of interests (COI; yes: blue; no: orange) for the analysed videos divided by topics. BipolEP, bipolar enucleation of the prostate; HoLEP, holmium laser enucleation of the prostate; iTIND, temporary implantable Nitinol device; PAE, prostatic artery embolization; ThuLEP, thulium laser enucleation of the prostate

Results

A total of 159 videos with a median (range) of 8570 (648–2 384 391) views were included in the analysis. Only 21 videos (13.2%) were rated as containing no misinformation, 26 (16.4%) were free of commercial bias, and two (1.3%) disclosed potential conflicts of interest. According to DISCERN, the median overall quality of the videos was low (2 out of 5 points for question 16). Only four of the 15 assessed categories (bipolar and holmium laser enucleation of the prostate, transurethral resection of the prostate and patient‐based search terms) were scored as having moderate median overall quality (3 points).

Conclusion

Most videos on the surgical treatment of LUTS/BPH on YouTube had a low quality of content, provided misinformation, were subject to commercial bias and did not report on conflicts of interest. These findings emphasize the importance of thorough doctor–patient communication and active recommendation of unbiased patient education materials.

Editorial: Fake news about benign prostatic hyperplasia on YouTube

YouTube is a widely used video‐sharing and social networking platform. It contains a large volume of content about medical topics, including urological conditions. In this issue of BJUI, Betschart et al. [1] examined the quality of 159 YouTube videos about surgical treatment of BPH with ≥500 views. The median overall quality of videos was poor (2 out of 5 possible points) based on validated criteria for the assessment of consumer health information. Nearly 87% of videos contained some misinformation and 84% had commercial bias.

We previously reported similar findings in the first 150 videos in a YouTube search for prostate cancer [2]. The median overall quality of videos was moderate (3 out of 5 points), and 77% contained biased and/or misinformative content in the video or comments beneath it. Furthermore, videos with lower expert‐rated quality had higher user engagement.

In the study by Betschart et al. [1], most of the YouTube videos about BPH had very good production quality, and 69% were posted by healthcare providers (e.g., doctor, clinic, hospital or university). These attributes might lead health consumers to have more trust in the information that is provided. In fact, they found that two‐thirds of videos with the most views in each topic had a quality score below the median score for videos about that topic.

Unfortunately, these issues are pervasive across many health domains. A recent review article reported on the prevalence of commercial bias and misinformation in social media posts about a variety of urology topics, including female pelvic medicine, endourology, sexual medicine, and infertility [3].

What can be done to combat the large quantity of misinformative urological information circulating online? For BPH on YouTube alone, Betschart et al. [1] reported that there were >12 000 videos as of May 2019. It is not practical for medical experts to manually vet the vast and continually changing repository of online medical information.

One future possibility is the development of computational tools to help evaluate the quality of information. For example, using an annotated dataset of 250 YouTube videos about prostate cancer, we created an automatic classification model for the identification of misinformation with an accuracy of 74% [4]. Further study is warranted to develop and test the use of machine learning to help filter the quality of online content.

As healthcare providers, what can we do to address these problems in the near‐term? We previously reported that USA adults who perceive worse patient‐physician communications are significantly more likely to watch health videos on YouTube [5]. This highlights the importance of shared decision‐making and proactively directing our patients to trusted sources of information. A curated list of reputable sources of online urological health information is presented in a recent review [6]. In addition, healthcare providers should be encouraged to actively participate in social media to flag any content that is inaccurate or dangerous and to help provide accurate information to the public. The BJUI, European Association of Urology, and AUA have all published guidance regarding best practices for social media engagement, which should be incorporated into urological education in the future [7].

In conclusion, social networks have a huge global audience and offer great potential to benefit the care of BPH and other urological conditions. However, to meet this potential and offset the risks will require significant ongoing efforts from the urological community.

by Stacy Loeb

References

  1. Betschart P, Pratsinis M, Müllhaupt G et al. Information on surgical treatment of benign prostatic hyperplasia on YouTube is highly biased and misleading. BJU Int 2020; 125: 595-601
  2. Loeb S, Sengupta S, Butaney M et al. Dissemination of misinformative and biased information about prostate cancer on YouTube. Eur Urol 2019; 75: 564– 7
  3. Loeb S, Taylor J, Borin JF et al. Fake News: Spread of misinformation about urological conditions on social media. Eur Urol Focus 2019 [Epub ahead of print].
  4. Hou R, Perez‐Rosas V, Loeb S, Mihalcea R. Towards Automatic Detection of Misinformation in Online Medical Videos. International Conference on Multimodal Interaction. Suzhou, Jiangsu, China: ACM, 2019. Available at: https://arxiv.org/abs/1909.01543. Accessed January 2020
  5. Langford A, Loeb S. Perceived patient‐provider communication quality and sociodemographic factors associated with watching health‐related videos on YouTube: a cross‐sectional analysis. J Med Internet Res 2019; 21: e13512. 
  6. Langford AT, Roberts T, Gupta J, Orellana KT, Loeb S. Impact of the internet on patient‐physician communication. Eur Urol Focus 2019: 31582312 [Epub ahead of print].
  7. Taylor J, Loeb S. Guideline of guidelines: social media in urology. BJU Int 2020; 125: 379-382

Article of the week: A randomized trial comparing bipolar TUVP with GreenLight laser PVP for treatment of small to moderate benign prostatic obstruction

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community and a podcast prepared by one of our Resident podcasters; we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, we recommend this one. 

A randomized trial comparing bipolar transurethral vaporization of the prostate with GreenLight laser (xps‐180watt) photoselective vaporization of the prostate for treatment of small to moderate benign prostatic obstruction: outcomes after 2 years 

Fady K. Ghobrial, Ahmed Shoma, Ahmed M. Elshal, Mahmoud Laymon, Nasr El-Tabey, Adel Nabeeh and Ahmed A. Shokeir

Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Abstract

Objective

To test the non‐inferiority of bipolar transurethral vaporization of the prostate (TUVP) compared to GreenLight laser (GL) photoselective vaporization of the prostate (PVP) for reduction of benign prostatic hyperplasia‐related lower urinary tract symptoms in a randomized trial.

Methods

Eligible patients with prostate volumes of 30–80 mL were randomly allocated to GL‐PVP (n = 58) or bipolar TUVP (n = 61). Non‐inferiority of symptom score (International Prostate Symptom Score [IPSS]) at 24 months was evaluated. All peri‐operative variables were recorded and compared. Urinary (IPSS, maximum urinary flow rate and post‐void residual urine volume) and sexual (International Index of Erectile Function‐15) outcome measures were evaluated at 1, 4, 12 and 24 months. Need for retreatment and complications, change in PSA level and health resources‐related costs of both procedures were recorded and compared.

Results

Baseline and peri‐operative variables were similar in the two groups. At 1, 4, 12 and 24 months, 117, 116, 99 and 96 patients, respectively, were evaluable. Regarding urinary outcome measures, there was no significant difference between the groups. The mean ± sd IPSS at 1 and 2 years was 7.1 ± 3 and 7.9 ± 2.9 (P = 0.8), respectively, after GL‐PVP and 6.3 ± 3.1 and 7.2 ± 2.8, respectively, after bipolar TUVP (P = 0.31). At 24 months, the mean difference in IPSS was 0.7 (95% confidence interval −0.6 to 2.3; P = 0.6). The median (range) postoperative PSA reduction was 64.7 (25–99)% and 65.9 (50–99)% (P = 0.006) after GL‐PVP, and 32.1 (28.6–89.7)% and 39.3 (68.8–90.5)% (P = 0.005) after bipolar TUVP, at 1 and 2 years, respectively. After 2 years, retreatment for recurrent bladder outlet obstruction was reported in eight (13.8%) and 10 (16.4%) patients in the GL‐PVP and bipolar TUVP groups, respectively (P = 0.8). The mean estimated cost per bipolar TUVP procedure was significantly lower than per GL‐PVP procedure after 24 months (P = 0.01).

Conclusions

In terms of symptom control, bipolar TUVP was not inferior to GL‐PVP at 2 years. Durability of the outcome needs to be tracked. The greater cost of GL‐PVP compared with bipolar TUVP is an important concern.

Image courtesy of BJUI Knowledge

Editorial: Vaporization is vaporization, but not at any cost…

The paper by Ghobrial et al. [1] confirms that bipolar electrocautery vaporization is more cost‐effective than GreenLight Laser vaporization, as the two techniques are equally effective but GreenLight vaporization is more costly in the smaller prostates being studied.

Underpinning the analysis was a well‐conducted randomized controlled trial, showing equivalent peri‐operative and postoperative measures with the two procedures and no difference in the primary endpoint of IPSS reduction at 2 years. The two techniques were performed in a similar manner and were equally efficient and safe as expected.

Philosophically, the clinical results are both unsurprising and expected, and confirm the long‐held belief that the energy source employed for vaporization and, for that matter, enucleation, is of secondary concern compared to the skill and dedication of the operator. The technique in either case should result in comparable efficacy, leaving cost‐effectiveness to be an important way to help both urologists and administrators discriminate between them.

Although the costs are not necessarily going to be comparable with those in other jurisdictions, this will apply equally to both treatments and this study therefore represents an excellent attempt to cost both procedures, removing equivalent costs. Importantly, this assessment included the costs of both readmissions and interventions over the full 24‐month period. This captures the bulk of the important complications after these types of procedures and adds to the validity of the findings.

The big difference between the costs of the two treatments being studied is, of course, ‘capital equipment including maintenance’. The single‐use fibre model rather than the cost of the machine has been the mainstay for the profitability of laser companies since the inception of laser prostatectomy. The maintenance contract has been a further cost, which is always underestimated. Reusability of the laser fibres is one way of diminishing per‐procedure costs, but is only consistently possible for Holmium end‐fire fibres [2]. The fact that the authors estimate of these costs was a ‘case share in 5‐year budget plan’ also suggests that the true cost of the use of the GreenLight laser is underestimated.

With the burgeoning number of new techniques and technologies for the treatment of BPH emerging, and new treatment paradigms being proposed, let alone the increasingly negative focus on medical waste [3] and the increasing use of single‐use disposable handpieces/tubing/drapes/fibres, articles such as this are timely. A standardized methodology for assessing the cost‐effectiveness of treatments for BPH is needed and should be an essential part of pivotal studies and therefore the regulatory approval processes.

by Peter Gilling

 

References

  1. Ghobrial FKShoma AElshal AM et al. A randomized trial comparing bipolar transurethral vaporization of the prostate with GreenLight laser (xps‐180watt) photoselective vaporization of the prostate for treatment of small to moderate benign prostatic obstruction: outcomes after 2 years. BJU Int2020124144– 52
  2. Fraundorfer MRGilling PJKennett KMDunton NGHolmium laser resection of the prostate is more cost effective than transurethral resection of the prostate: results of a randomized prospective study. Urology 200157454– 8
  3. Rose EDModlin DMCiampa MLMangieri CWFaler BJBandera BCEvaluation of operative waste in a military medical center: analysis of operating room cost and waste during surgical cases. Am Surg. 201985717– 20

 

Residents’ podcast: A randomized trial comparing bipolar TUVP with GreenLight laser PVP for treatment of small to moderate benign prostatic obstruction: outcomes after 2 years

Maria Uloko is a Urology Resident at the University of Minnesota Hospital.

A randomized trial comparing bipolar transurethral vaporization of the prostate with GreenLight laser (xps‐180watt) photoselective vaporization of the prostate for treatment of small to moderate benign prostatic obstruction: outcomes after 2 years

Abstract

Objective

To test the non‐inferiority of bipolar transurethral vaporization of the prostate (TUVP) compared to GreenLight laser (GL) photoselective vaporization of the prostate (PVP) for reduction of benign prostatic hyperplasia‐related lower urinary tract symptoms in a randomized trial.

Methods

Eligible patients with prostate volumes of 30–80 mL were randomly allocated to GL‐PVP (n = 58) or bipolar TUVP (n = 61). Non‐inferiority of symptom score (International Prostate Symptom Score [IPSS]) at 24 months was evaluated. All peri‐operative variables were recorded and compared. Urinary (IPSS, maximum urinary flow rate and post‐void residual urine volume) and sexual (International Index of Erectile Function‐15) outcome measures were evaluated at 1, 4, 12 and 24 months. Need for retreatment and complications, change in PSA level and health resources‐related costs of both procedures were recorded and compared.

Results

Baseline and peri‐operative variables were similar in the two groups. At 1, 4, 12 and 24 months, 117, 116, 99 and 96 patients, respectively, were evaluable. Regarding urinary outcome measures, there was no significant difference between the groups. The mean ± sd IPSS at 1 and 2 years was 7.1 ± 3 and 7.9 ± 2.9 (P = 0.8), respectively, after GL‐PVP and 6.3 ± 3.1 and 7.2 ± 2.8, respectively, after bipolar TUVP (P = 0.31). At 24 months, the mean difference in IPSS was 0.7 (95% confidence interval −0.6 to 2.3; P = 0.6). The median (range) postoperative PSA reduction was 64.7 (25–99)% and 65.9 (50–99)% (P = 0.006) after GL‐PVP, and 32.1 (28.6–89.7)% and 39.3 (68.8–90.5)% (P = 0.005) after bipolar TUVP, at 1 and 2 years, respectively. After 2 years, retreatment for recurrent bladder outlet obstruction was reported in eight (13.8%) and 10 (16.4%) patients in the GL‐PVP and bipolar TUVP groups, respectively (P = 0.8). The mean estimated cost per bipolar TUVP procedure was significantly lower than per GL‐PVP procedure after 24 months (P = 0.01).

Conclusions

In terms of symptom control, bipolar TUVP was not inferior to GL‐PVP at 2 years. Durability of the outcome needs to be tracked. The greater cost of GL‐PVP compared with bipolar TUVP is an important concern.

 

BJUI Podcasts are available on iTunes: https://itunes.apple.com/gb/podcast/bju-international/id1309570262

 

 

Residents’ podcast: NICE Guidance – Transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia

Nikita Bhatt is a Specialist Trainee in Urology in the East of England Deanery and a BURST Committee member @BURSTUrology

NICE Guidance – Transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia

Recommendations

  • 1.1 The evidence on transurethral water jet ablation for lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) raises no major safety concerns. The evidence on efficacy is limited in quantity. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research.
  • 1.2 Clinicians wishing to do transurethral water jet ablation for LUTS caused by BPH should:
    • Inform the clinical governance leads in their NHS trusts.
    • Ensure that patients understand the uncertainty about the procedure’s efficacy and provide them with clear written information to support shared decision‐making. In addition, the use of the National Institute for Health and Care Excellence (NICE) information for the public is recommended.
    • Audit and review clinical outcomes of all patients having transurethral water jet ablation for LUTS caused by BPH. NICE has identified relevant audit criteria and has developed an audit tool (which is for use at local discretion).
  • 1.3 The procedure should only be done by clinicians who have been trained in the technique.
  • 1.4 NICE encourages further research into transurethral water jet ablation for LUTS caused by BPH and may update the guidance on publication of further evidence. Further research should report long‐term follow‐up and include re‐intervention rates.

BJUI Podcasts now available on iTunes, subscribe here https://itunes.apple.com/gb/podcast/bju-international/id1309570262

Article of the week: Aquablation for benign prostatic hyperplasia in large prostates: 6‐month results from the WATER II trial

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

We invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, it should be this one.

Aquablation for benign prostatic hyperplasia in large prostates (80–150 mL): 6‐month results from the WATER II trial

Mihir Desai*, Mo Bidair, Kevin C. Zorn, Andrew Trainer§, Andrew Arther§, Eugene Kramolowsky, Leo Doumanian*, Dean Elterman**, Ronald P. Kaufman Jr.††, James Lingeman‡‡, Amy Krambeck‡‡, Gregg Eure§§, Gopal Badlani¶¶, Mark Plante***, Edward Uchio†††, Greg Gin†††, Larry Goldenberg‡‡‡, Ryan Paterson‡‡‡, Alan So‡‡‡, Mitch Humphreys§§§, Claus Roehrborn¶¶¶, Steven Kaplan****, Jay Motola**** and Naeem Bhojani

*Institute of Urology, University of Southern California, Los Angeles, San Diego Clinical Trials, San Diego, CA, USA, University of Montreal Hospital Center, Université de Montréal, Montréal, QC, Canada, §Adult Pediatric Urology and Urogynecology, P.C., Omaha, NE, Virginia Urology, Richmond, VA, USA, **University of Toronto – University HealthNetwork, Toronto, ON, Canada, ††Albany Medical College, Albany, NY, ‡‡Indiana University Health Physicians, Indianapolis, IN, §§Urology of Virginia, Virginia Beach, VA, ¶¶Wake Forest School of Medicine, Winston-Salem, NC, ***University of Vermont Medical Center, Burlington, VT, †††VA Long Beach Healthcare System, Long Beach, CA, USA, ‡‡‡University of British Columbia, Vancouver, BC, Canada, §§§Mayo Clinic Arizona, Scottsdale, AZ, ¶¶¶UT Southwestern Medical Center, Department of Urology, University of Texas Southwestern, Dallas, TX, and ****Icahn School of Medicine at Mount Sinai, New York, NY, USA

 

Abstract

Objective

To present 6‐month safety and effectiveness data from a multicentre prospective study of aquablation in men with lower urinary tract symptoms (LUTS) attributable to benign prostatic hyperplasia (BPH) with prostate volumes between 80 and 150 mL.

Methods

Between September and December 2017, 101 men with LUTS attributable to BPH were prospectively enrolled at 16 centers in Canada and the USA.

Results

The mean prostate volume was 107 mL. The mean length of hospital stay after the aquablation procedure was 1.6 days (range: same day to 6 days). The primary safety endpoint (Clavien–Dindo grade 2 or higher or any grade 1 event resulting in persistent disability) at 3 months occurred in 45.5% of men, which met the study design goal of < 65% (P < 0.001). At 6 months, 22% of the patients had experienced a Clavien–Dindo grade 2, 14% a grade 3 and 5% a grade 4 adverse event. Bleeding complications requiring intervention and/or transfusion were recorded in eight patients prior to discharge and in six patients after discharge. The mean International Prostate Symptom Score improved from 23.2 ± 6.3 at baseline to 6.7 ± 5.1 at 3 months, meeting the study’s primary efficacy endpoint goal (P < 0.001). The maximum urinary flow rate increased from 8.7 to 18.8 mL/s (P < 0.001) and post‐void residual urine volume decreased from 131 at baseline to 47 at 6 months (P < 0.0001). At 6 months, prostate‐specific antigen concentration reduced from 7.1 ± 5.9 ng/mL at baseline to 4.0 ± 3.9 ng/mL, a 44% reduction.

Conclusions

Aquablation is safe and effective in treating men with larger prostates (80–150 mL), without significant increase in procedure or resection time.

Article of the week: WATER II (80–150 mL) procedural outcomes

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, it should be this one.

WATER II (80–150 mL) procedural outcomes

Mihir Desai*, Mo Bidair, Naeem Bhojani, Andrew Trainer§, Andrew Arther§Eugene Kramolowsky, Leo Doumanian*, Dean Elterman**, Ronald P. Kaufman Jr.††James Lingeman‡‡, Amy Krambeck‡‡, Gregg Eure§§, Gopal Badlani¶¶, Mark Plante***Edward Uchio†††, Greg Gin†††, Larry Goldenberg‡‡‡, Ryan Paterson‡‡‡, Alan So‡‡‡Mitch Humphreys§§§, Claus Roehrborn¶¶¶, Steven Kaplan****, Jay Motola**** and Kevin C. Zorn

 

*Institute of Urology, University of Southern California, Los Angeles, San Diego Clinical Trials, San Diego, CA, USA, University of Montreal Hospital Centre, University of Montreal, Montreal, QC, Canada, §Adult Paediatric Urology and Urogynecology, P.C., Omaha, NE, Virginia Urology, Richmond, VA, USA, **University Health Network University of Toronto, Toronto, ON, Canada, ††Albany Medical College, Albany, NY, ‡‡Indiana University Health Physicians, Indianapolis, IN, §§Urology of Virginia, Virginia Beach, VA, ¶¶Wake Forest School of Medicine,Winston-Salem, NC, ***University of Vermont Medical Centre, Burlington, VT, †††VA Long Beach Healthcare System, Long Beach, CA, USA, ‡‡‡University of British Columbia, Vancouver, BC, Canada, §§§Mayo Clinic Arizona, Scottsdale, AZ, ¶¶¶Department of Urology, UT Southwestern Medical Centre, University of Texas Southwestern, Dallas, TX and ****Icahn School of Medicine at Mount Sinai, New York, NY, USA

 

Abstract

Objectives

To present early safety and feasibility data from a multicentre prospective study (WATER II) of aquablation in the treatment of symptomatic men with large‐volume benign prostatic hyperplasia (BPH).

Methods

Between September and December 2017, 101 men with moderate‐to‐severe BPH symptoms and prostate volume of 80–150 mL underwent aquablation in a prospective multicentre international clinical trial. Baseline demographics and standardized postoperative management variables were carefully recorded in a central independently monitored database. Surgeons answered analogue scale questionnaires on intra‐operative technical factors and postoperative management. Adverse events up to 1 month were adjudicated by an independent clinical events committee.

Results

The mean (range) prostate volume was 107 (80–150) mL. The mean (range) operating time was 37 (15–97) min and aquablation resection time was 8 (3–15) min. Adequate adenoma resection was achieved with a single pass in 34 patients and with additional passes in 67 patients (mean 1.8 treatment passes), all in a single operating session. Haemostasis was achieved using either a Foley balloon catheter placed in the bladder under traction (n = 98, mean duration 18 h) or direct tamponade using a balloon inflated in the prostate fossa (n = 3, mean duration 15 h). No patient required electrocautery for haemostasis at the time of the primary procedure. The mean length of stay after the procedure was 1.6 days (range same day to 6 days). The Clavien–Dindo grade ≥2 event rate observed at 1 month was 29.7%. Bleeding complications were recorded in 10 patients (9.9%) during the index procedure hospitalization prior to discharge, and included six (5.9%) peri‐operative transfusions.

Conclusions

Aquablation is feasible and safe in treating men with large prostates (80–150 mL). The 6‐month efficacy data are being accrued and will be presented in future publications (ClinicalTrials.gov number, NCT03123250).

 

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