Predictive Factors for a Successful Day Case Benign Prostatic Hyperplasia Surgery: A Review

Introduction: Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is one among the foremost common diseases affecting the aging man with, almost 80% of the lads greater than 70 affected. BPH is caused by unregulated proliferation within the prostate, which may cause physical obstruction of the prostatic urethra and result in anatomic bladder outlet obstruction (BOO). Transurethral resection of the prostate (TURP) has been the historical gold standard up till now to which all endoscopic procedures for benign prostatic hyperplasia (BPH) are compared with a mean hospital stay of three days. This surgery although efficacious has been related with increased morbidity and increased day case failure rates as compared to newer techniques. These shortcomings have prompted the utilization of newer methods like Transurethral enucleation and resection of the prostate (TUERP), Holmium laser enucleation of the prostate (HoLEP) and Thulium laser enucleation of the prostate (ThuLEP). This review will discuss the enucleation techniques, advantages and therefore the predictive factors for a successful day case prostate surgery. Materials and Methods: During this review, we discuss the newer techniques utilized in day case BPH surgery as well as the predictive factors for a successful BPH surgery, both enucleation, benefits and morcellation are covered also. Results: TUERP, ThuLEP and HoLEP have literature supporting the advantages of these techniques, which demonstrates its ability in day case BPH surgeries in specially selected cases with favorable


Introduction
Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is one among the foremost common diseases affecting the aging man with, almost 80% of the lads greater than 70 affect [1]. BPH is caused by unregulated proliferation within the prostate, which may cause physical obstruction of the prostatic urethra and end in anatomic bladder outlet obstruction (BOO) [2].
Transurethral resection of the prostate (TURP) has been the historical gold standard up till now to which all endoscopic procedures for BPH are compared with a mean hospital stay of three days) [3] [4]. This surgery although efficacious has been related with increased morbidity and increased day case failure rates as compared to newer techniques [5]. This morbidity is related to many complications like prolonged postoperative catheterization, high retreatment rates and prolonged hospital stay which translates to increased cost of BPH management.
These shortcomings have prompted the utilization of newer methods like Transurethral enucleation and resection of the prostate (TUERP), Holmium laser enucleation of the prostate (HoLEP) and Thulium laser enucleation of the prostate (ThuLEP) [6]. These newer techniques are associated with an improved success in day case surgery mainly thanks to less perioperative bleeding, it takes advantage of the distinct anatomical planes to enucleate the whole transition zone with improved outcomes like shorter hospital stay, enucleation of BPH regardless of size and shorter catheterization times [7]. This review will discuss the enucleation techniques, benefits and the predictive factors for a successful day case prostate surgery.

New Techniques
Classical TUERP was first described in 2006 performed using the plasma kinetic bipolar system with normal saline irrigation, under spinal or general anesthesia [8]. All surgeries were performed or closely supervised by an equivalent surgeon.
Preprogrammed power settings for cutting (180 W) and coagulation (80 W) were used. Preliminary cystoscopy was done employing a 20-F-sized sheath, to assess both prostate size and shape, and visualize landmarks (including the 2 ureteric orifices and therefore the verumontanum). A 26-F-sized resectoscope was then introduced, and the TUERP procedure was performed as described There are two main sorts of laser enucleation, HoLEP and ThuLEP with same principle and similar steps for both procedures, this text will describe ThuLEP method which is a current laser technique [9]. 26 French (Fr) continuous flow resectoscope with a laser bridge adapter and an endoscopic camera are used. The laser fiber is passed through a 6Fr open-ended ureteral catheter, a 100-Watt Thulium laser with an end-firing 550-micron laser fiber are used with settings at, 30 watts for coagulation and 87.5 watts for cutting. After enucleation is completed, a morcellator is used to clear the bladder of any prostatic tissue.
The ThuLEP procedure can be divided into five distinct steps which should be followed meticulously for complete and safe removal of the entire prostate adenoma and for adequate haemostasis. Preparation of the patient the patient is placed in the lithotomy position with the legs moved laterally. After sterile preparation and draping, the urethra is irrigated with sterile gel. The 26 F continuous flow resectoscope is inserted into the bladder under vision so as to avoid urethral or prostatic trauma. The camera should be fixed in a loose position. Finally, the 550 micron laser fibre is inserted through the working channel of the resectoscope. It might be helpful to guide the loose part of the laser fibre through a mosquito clamp, thereby fixing the fibre to the draping and keeping it out of the working area of the surgeon. The outflow channel should always be open during the enucleation procedure for prevention of bladder overdistension. Cystoscopy is performed to exclude concomitant bladder pathologies and visualize the ureteral orifices. The resectoscope is then pulled back into the prostatic urethra, the bladder neck and the extent of lobar protrusion is assessed. Finally, the positions of the verumontanum and the borders of the external urethral sphincter are determined. The fourth step is the removal of the lateral lobes in which the lateral lobes are removed separately, beginning with the left lobe. The apical edges of the lateral lobes are then bluntly exposed by moving the resectoscope under the adenoma and pulling these towards the 2 o'clock position, thereby exposing the apical border of the surgical capsule. After the apical plane is opened, the entire lateral lobe is bluntly and progressively released towards the bladder neck. Because of the blunt dissection of the lateral lobes, the prostate is often ventro-caudally attached. This attachment appears like a broad mucosal band and must be dissected with low laser energy and not bluntly disrupted to prevent tearing at the apex and surrounding sphincter. Again, the surgical capsule can be easily identified by visualizing the small vessels which run in a parallel fashion next to the dissection plane. These vessels remain untouched unless they perforate the capsule and, in such cases, coagulation of capsule perforating vessels is performed with low laser energy in no-touch technique. The released lobe is then dissected from the bladder neck from the 12 to the 4 o'clock position and, afterwards, from the 6 to 4 o'clock position. After complete release from the surgical cap- The many expected advantages of TUERP, HoLEP and ThuLEP begin with a lower risk of hospital infections and thromboembolism and can lead to a satisfactory feeling linked to an early return home and the rapid resumption of activities as shown on Table 1.

Predictive Factors
Five relevant studies were selected from 2011 till date concerning the factors H. K. Yisa et al. influencing a day case prostate surgery with details described below, one prospective and four retrospective studies were carried out in France, Italy, United Kingdom and United States of America as shown in Table 2. A total of 1760 BPH patients underwent a day case surgery and 1074 patients were successfully discharged on the same day with no readmissions giving a success rate of 61%.
The factors that were studied and found significant included the surgeon's experience, age, prostate size, early morning surgery, operation time and ASA score.
A retrospective review of all consecutive day-case holmium laser enucleation of the prostate (HoLEP) performed by a single surgeon between January 2013 and February 2019 using a prospective database revealed that the surgeons experience seems to be crucial to improve perioperative outcomes and prostate volume of less than 90 cc is associated with a higher success rates of day case sur-  hours [17]. No complications or readmissions were recorded.
The exponential development of the day-case procedures seems to be linked with the advent of laser technology. 92% of day case surgeries in France in 2016 were Laser surgeries and only about 8% were non laser [18]. This tendency is expected to increase in the coming years according to the spreading of laser surgery. In a similar retrospective study of 473 adult males who underwent HoLEP from July 2018 to December 2019 at a tertiary referral center and high-volume HoLEP hospital, same day discharge was possible in 87.4% of the patients and positive predictive factors were younger age, low ASA score, shorter enucleation time, shorter resection time and in patients who did not use anticoagulants [19].
Patients with longer morcellation times and with post-procedure hematuria with clots were more likely to have an unplanned admission and were the main reason for a failed successful day case surgery.
It was demonstrated in a single-center HoLEP procedures performed between January 1, 2012 and December 31, 2016 that; age, ASA score, large prostate volume, anticoagulant intake, urologist experience and operation time were key factors for a successful day case surgery [19] [20]. Age, at procedure (P = 0.019), an ASA score > 2 (P = 0.0019), a high prostatic volume (P = 0.011), an anticoagulant intake (P ≤ 0.0001), a poor-urologist experience (P = 0.048) and a long operative time (P = 0.0144) were at risks of complications.

Discussion
The successful transfer of a standard inpatient operation to a day-case procedure demands that the treatment is equally effective, are often safely delivered which the patients are carefully selected to realize favorable outcome. TURP is the gold standard for the surgical relief of BPH. More advanced procedures designed to facilitate shorter hospitalization and particularly a successful day case surgery, e.g., TUERP, HoLEP and ThuLEP, have all shown to be superior to TURP with a future re-operation free rate of 95% at 10 years [21].  Tables 1-3 and Figure 1, the surgeons experience and a little prostate size is found to be the foremost important factor for a successful day case BPH surgery meanwhile, hematuria with clot is the most vital factor for failure. For patients with large (≥60 g) prostates, BP-TUERP and BP-TURP are safe options, but the former is a more effective choice in long-term follow-up outcomes. BP-TUERP is related to reduced CT and hemoglobin decrease with more removal of prostatic tissue at the expense of longer OT than BP-TURP.

Conclusion
In conclusion, TUERP and laser enucleation techniques are durable and effective treatment for patients affected by LUTS due to BPH during a day case setting.
The AUA guidelines highlight this by recommending laser enucleation as a size independent treatment option for those with moderate to severe symptoms from BPH. The literature shows that TUERP may be a superior solution to TURP for day case prostate surgery, meanwhile ThuLEP is superior to HoLEP in some respect with more favorable outcomes during a successful day case surgery. While there are some limitations to those newer techniques, such as the steep learning curve and high rate of retrograde ejaculation, these procedures have an outsized literature showing its efficacy and favorable outcomes in day case surgery. This research shows that the surgeons experience, the age of the patient, prostate size, operation time, anticoagulant intake, the ASA score and morning theatre list are predictive factors for a successful day case BPH surgery, with an overall success rate of 61%.