EAU 2023: Preventing Complications of Male LUTS/BPO Surgical Management: The Male Health Challenge
The session discusses ten abstracts on surgical techniques in the management of Lower urinary tract symptoms (LUTS)/ benign prostatic obstruction (BPO) and their outcomes.
A prospective, comparative group studied the functional outcomes after ejaculation-sparing anatomic photoselective vaporization (ESa-PVP), standard vaporization or transurethral resection of the prostate in sexually active patients. The patients were followed up for 6 and 12 months. At 6 months, there was a homogeneous drop in the International Prostate Symptom Score (IPSS) values among the groups and a substantial stability of the International Index of Erectile Function - 5 (IIEF5). In contrast, 25-item Male Sexual Health Questionnaire (MSHQ) (MSHQ) ejaculation values and antegrade ejaculation rates were significantly different post-operatively, always favoring the ejaculation sparing group. At 6 months, nearly 61% ejaculation sparing patients reported antegrade ejaculation preservation at 12 months. Pre-operative MSHQ-Ej score and type of surgery were the predictors of preserved antegrade ejaculation. In conclusion, the ejaculation sparing anatomic people technique was superior to standard PVP and transurethral prostate resection (TURP) in preserving antegrade ejaculation, both at six and 12 months after benign prostatic hyperplasia (BPH) surgery.
A consensus meeting with the objective to define a common surgical technique for ejaculation for the preservation to be used by the investigators of the PARTURP study was convened. The PARTURP study had 2 surgical groups- endoscopic surgery and ejaculation sparing surgery. The discussion concluded that the apex, anterior and posterior part of the verumontanum and 1-2 cm from the verumontanum should be preserved. The consensus achieved on surgical landmarks and areas to preserve state the importance of the apex and the supra-montanal urethra.
A prospective study was conducted on patients with lower urinary tract symptoms (LUTS) due to BPH who wish to preserve ejaculation with Thulium-YAG laser versus Thulium-fiber laser. It was demonstrated that ejaculation-sparing laser enucleation of the prostate effectively preserved sexual function in a majority of patients with high subjective satisfaction and no significant differences on erectile function and ejaculation before and after surgery. Post-operative ejaculation was seen in 72.4% and and 74.3% cases in the Thulium-YAG laser and Thulium Fiber laser groups respectively. In conclusion, ejaculation-sparing laser enucleation of the prostate effectively preserved sexual function in the majority of patients with highest subjective satisfaction and no significant differences on erectile dysfunction and occlusion before and after surgery.
A study conducted on the predictors of BPH6 achievement for urethral-sparing robot-assisted prostatectomy (usRASP). The patients were analyzed according to the BPH6 composite end point and a logistic regression model was used to identify the predictors of the BPH6 achievement in this population. It was found that prostate volume between 110-180 milliliters and impaired pre-operative sexual function assessed by the SHIM score are independent predictors of the BPH6 achievement. As per the standard BPH6 metric, usRASP is a valid and effective procedure for bladder obstruction resolution and to preserve the ejaculatory function.
Transperineal interstitial laser ablation (TPLA) of the prostate is a promising, ultra, minimally invasive technique for BPO. A study on the peri-operative and short-term sexual outcomes of patients with BPO treated with TPLA using EchoLaser. The median prostate volume was 48 ml and there were no perioperative complications. In all patients, ejaculation and sexual function were preserved. In summary, TPLA is a safe procedure for carefully selected patients with LUTS due to BPO.
A sun-analysis of a prospective trial investigated the factors associated with the risk of causing erectile function (EF) worsening after Holmium laser enucleation of the prostate (HoLEP) in men with normal preoperative EF. There was a median erectile function score decrease by 4 points. The estimated rate of erectile function decrease was as high as 53% at 1 year. The patients who experienced worsening of orgasmic function after surgery were also those with a bigger risk of erectile function decrease at follow up. Thus, patients with normal sexual function may experience a non-negligible risk of erectile function decrease and retrograde ejaculation could play a major role in post-HoLEP sexual function.
Urolift is a non-ablative technique to preserve the ejaculatory function. A study conducted on this fertility sparing technique has demonstrated an improvement of the bladder obstruction parameters in terms of the peak flowmax, post-void residual volume and IPSS. There were no statistically significant differences in ejection function and erectile function. In conclusion, Urolift is a safe and effective technique to correct LUTS in young men desirous of fatherhood and suffering from symptomatic BPH.
A study investigated the outcomes categorization for current minimally invasive ejaculation-sparing treatments of BPH. The treatments used were usRASP, waterjet ablation and Rezum. A multivariable logistic regression model identified 3 independent predictors of success achievement at 12 months which were a prostate volume range between 80 and 110ml, unimpaired sexual function and a lower length of catheterization.
A study investigated the patient characteristics and dynamic variables predictive of meaningful quality of life (QOL) and sexual function improvement after prostatic urethral pull. This minimally invasive surgical procedure provides significant and durable improvement in LUTS and quality of life. It demonstrated an improvement in QOL in 66% patients, those with lower IPSS scores and who were UTI free at the time of the procedure, had a better QOL. Forty-two percent of sexually active PUL subjects had minimal clinically important difference (MCID) improvement after treatment as seen by better erectile function and improvements in MSHQ-EjD, IPP scores. In conclusion, the earlier treatment of the disease continuum impacts quality of outcomes.
The ExpHo trial assessed the results and complications after HoLEP performed by a highly experienced surgeon. The medium post-operative volume was 87 ml and about 30% of patients had preoperative indwelling urinary catheter. At 3 months follow-up, patients had a peak flow rate >20 ml/s and 74.9% patients had null residual urine volume. Urinary incontinence recovery was slow with estimated rates of 68% at one month and 94% at one year. The erectile function recovery and orgasmic function recovery was good and progressive after surgery.
In patients with BPH with increased risk of bleeding due to hepatic dysfunction, the outcome of Greenlight laser PVP (GL.PVP) prostatectomy was evaluated. The time to catheterization, time to hospital discharge and preoperative haemoglobin deficit as well as hematocrit value deficit were comparable between those with low risk (group 1) and intermediate/ high risk (Group 2) of bleeding. Blood transfusion rate was higher for group 2; with respect to functional urinary outcome measures, all patients had significant improvement from baseline parameters with comparable outcomes at different follow up points. In conclusion, GL.PBP is a safe and effective technique for patients with uncorrected bleeding tendency due to hepatic dysfunction.
A retrospective data determined whether pre-treatment with prostate artery embolization (PAE) prior to aqua ablation lowers reduced perioperative morbidity. It was found that 73% of patients with PAE went home the same as compared to 45% patients who were not pre-treated. PAE was not associated with adverse bleeding events or major complications.
The clinical experience with Aquablation in terms of perioperative and 1-year functional outcomes focusing on postoperative LUTS was demonstrated. In the preoperative phase there were higher rates of voiding symptoms while in the postoperative phase there were high rates of filling phase symptoms which had a statistical significance. In conclusion, LUTS of the filling phase were more prevalent than the voiding phase in the first 3 months after Aquablation.
European Association of Urology (EAU) Annual Congress 2023, 10th March - 13th March 2023, Milan, Italy
