Predictive Factors for a Successful Day Case Benign Prostatic Hyperplasia Surgery: A Review ()
1. 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.
2. 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 within the following paragraph.
The distal margin of the prostate lobes is marked with a cutting loop. Starting with the median lobe, the mark between the 5 o’clock and 7 o’clock positions is deepened right down to the surgical capsule. Next, the incision just proximal to the verumontanum is deepened in order that the plane between the adenoma and false capsule (i.e. the compressed normal prostatic tissue) might be identified with a thick resectoscope loop. The tip of the resectoscope is then inserted to further develop this plane. The adenoma is gradually dissected far away from the capsule within the avascular plane, toward the bladder neck, until the circular fibers of the bladder neck were seen. The perforating vessels are diathermied at the source and cut. Bleeding points noted during this mechanical dissection is definitely controlled with coagulation. The median lobe, which remains attached to the bladder neck, is then resected. The plane between the lateral lobe and false capsule is developed during a similar manner and resected. No morcellator is employed, the chips are then evacuated employing a bladder evacuator. On completion, a three-way Foley catheter is inserted and continuous bladder irrigation initiated. Bladder irrigation is kept overnight or until the effluent is obviously clear. Once the irrigation is stopped, the catheter is removed after two days, or when the urine is not bloody or had only a light pink coloration.
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 first step in the three-lobe technique is circumferential incision of the verumontanum in which an inverted U-incision close to the verumontanum is carried out using the 70 - 90 W power setting of the laser. The incision of prostatic tissue reaches until the distal third of the verumontanum. After incision of the mucosa, the incision is deepened till the surgical capsule of the prostate is reached.
The second step is the removal of the prostatic median lobe in which the prostatic median lobe is removed separately before enucleation of the lateral lobes. Bilateral bladder neck incisions close to the lateral margins of the prostatic median lobe are made approximately at the 5 and 7 o’clock positions. This incision is extended until the hemi-circumferential incision at the verumontanum and then deepened till the surgical capsule becomes visible which can clearly be identified as a white layer with superficial vessels. At this level, blunt retrograde enucleation of the prostatic median lobe is started while the laser energy is switched to 30 W. The resectoscope is moved under the edge of the median lobe and bluntly shifted towards the 12 o’clock direction, thereby mechanically disrupting the plane between surgical capsule and prostatic adenoma. During blunt disconnection, visual control of the surgical capsule and laser coagulation of perforating vessels at 30 W is necessary. Shifting and disconnection of the adenoma from the surgical capsule and coagulation of crossing vessels is continued until the bladder neck is reached. After complete disconnection of the median lobe from the surgical capsule, the liberated lobe is pushed into the bladder.
The third step is the apical incision of the lateral lobes in which the distal margin of the adenoma at the 12 o’clock position is marked and incised by the Thulium laser using 30 W. From the incision next to the verumontanum, two superficial incisions towards the 4 and 8 o’clock positions are carried out using the Thulium laser at 30 W. Superficial incisions with low laser energy prevents mucosal bleeding and ensures good visualization for the next steps.
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 capsule, the left lateral lobe is pushed into the bladder. The identical procedure is then identically repeated on the right side.
The last and fifth step is morcellation and removal of the prostatic tissue in which the rotating inner sheath and the working element of the laser armamentarium is replaced by a long nephroscope attached to the adapter and the morcellator with 5 mm blades is inserted through the resectoscope into the bladder. Continuous irrigation and a fully distended bladder are needed to avoid unintentional trauma to the bladder wall. Complete fragmentation of the prostatic adenoma in the bladder is carried out using combined morcellation and suction. The procedure is completed by removal of the instruments and insertion of a 22 F urethral catheter.
There have been some recent updates to both the ThuLEP technique and the equipment utilized. Newer techniques include complete en block enucleation and the more commonly used two lobes enucleation technique [10]. The two lobes enucleation technique, the median lobe is undermined at the capsular level and is enucleated with the lateral lobe as one unit. Initial reports on these newer techniques suggest a decrease in both enucleation and total operative time, and easier identification of the surgical capsule [11] [12]. Another big change in operative efficiency has come from the improvements in the type of morcellators available. Versacut, by luminis, was the first morcellator used with ThuLEP. Piranha, by Wolf, is the newer perhaps more advanced morcellator is also available.The versacut has reciprocating blades which are controlled by a foot pedal, while the Piranha has oscillating blades which rotate at a selected rate. The suction mechanism is different for each as well, with the lumenis allowing for continuous suction with or without morcellation, while the Wolf only provides microbursts of suction. Studies have compared the two morcellators [13] [14]. Comparisons revealed similar results between the two, though the Piranha had a lower cost of use and higher rates of morcellation with a negligible learning curve. Most ThuLEP surgeons prefer the Piranha to the VersaCut due to an advanced ergonomic design, efficient tissue removal properties and its safety profile. Lastly, recent improvement in laser technology in the form of ThuLEP which is a continuous wave as opposed to HoLEP which is a pulse wave provides a quicker enucleation, effective coagulation and 9 times lesser energy consumption.
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.
Table 1 summaries the benefits of TUERP, HoLEP and ThuLEP for a day-case Prostate.
3. Predictive Factors
Five relevant studies were selected from 2011 till date concerning the factors
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Table 1. Characteristics of the study population chronologically divided into 3 different groups (group 1 from January 2013 to July 2015, group 2 from August 2015 to June 2017 and group 3 from July 2017 to February 2019).
Mean (± standard deviation); Ψ Median Bold indicates p < 0.05. ASA = American Society of Anesthesiologists; BMI = Body Mass Index; PSA = Prostate Specific Antigen; Qmax = Maximum Urinary Flow Rate; PVR = Postvoid Residual; IPSS = International Prostatic Symptom Score, ns = Not Significant Klein et al. 2021.
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 surgery [15]. Day-case success was defined as discharge within less than 12 hours from admission without any readmission within 48 hours after discharge. A total of 266 patients were retrieved and dispatched as follows: group 1 (n = 88) from January 2013 to July 2015, group 2 (n = 89) from August 2015 to June 2017, and
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Table 2. Influential day case prostate surgery factors.
group 3 (n = 89) from July 2017 to February 2019. The overall success rate was 80.5% (214/266) over the study period. It significantly improved over time from 70% in group 1 to 84% in group 2 and 87% in group 3 (p = 0.014). In the meantime, the operating time and the total energy delivered to the tissue decreased from 77 minutes in the first group to 60.4 minutes in the second group and 55.4 minutes in the third group (p < 0.001), and from 95.2 kJ in the first group to 84 kJ in the second group and 77.9 kJ in the third group (p = 0.041). On multivariate analysis, the only risk factor significantly associated with day-case failure was prostate volume greater than 90 cc (odds ratio = 2.041, p = 0.047).
Patients presenting for HoLEP by a single surgeon from September 2013 to September 2016 were considered for day-case surgery which revealed that two factors were significantly associated with successful day case surgery: small volume prostate and morning theatre lists [15] [16]. In total, 210 patients (mean age 70.3 ± 8.5 years) underwent HoLEP, with 74 (35.3%) discharged as true day-cases and a further 84 (40.0%) discharged within 23 hours. Readmission rate was 5.5%, with all complications Clavien-Dindo grade I or II. Factors associated with successful day-case operation included low-volume prostates (≤40 g) (odds ratio, OR, 3.097, 95% confidence interval, CI, 1.619 - 5.924, P = 0.0001) and morning surgical lists (OR 6.124, 95% CI 2.526 - 14.845, p < 0.001).
From September 2011 to September 2013, a prospective study on 53 patients who underwent surgery with ThuLEP in a 1-day surgery showed that a short operation time of 71 minutes and a small prostatic adenoma volume of 56 cc was associated very high success rate of a day surgery which was estimated at 14.8 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.
4. 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]. A successful outcome to the relief of prostatic obstruction requires adequate tissue removal as demonstrated in these newer techniques. The utilization of higher laser energy settings is related to a far better coagulation leading to the increase success rate of day case prostate surgery as confirmed from some studies [22] [23] [24] [25] [26]. For the urologists, these are exciting technological advances; except for the patients, these might merely be strings of medical jargon, as they are more concerned about whether the improvements in the urinary tract symptoms are going to be significant and sustainable after surgery, whether the clinical safety is assured, whether they require prolonged hospitalization and whether their hospital bills are often reduced from a successful day case surgery. Day case BPH surgery leading to early discharge is an effort to translate the technological advances of enucleation into actual clinical outcomes that patients can appreciate. Overall, from 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.
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Table 3. Advantages of TUERP, HoLEP and ThuLEP for a day-case prostate surgery.
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Figure 1. Evolution of day case success over time.
5. 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%.