Evaluation of the short-term cessation and early initiation of antithrombotic therapy in high-risk patients undergoing HoLEP procedure for large prostates (> 100 mL): A critical evaluation

Background: To characterize the safety and efficacy of Holmium Laser Enucleation of Prostate (HoLEP) in patients with large prostates (>100ml) at high risk for thromboembolic events (TE) resuming antithrombotic treatment (AT) in the early postoperative period. Methods: Data for 378 men with large prostates treated with HoLEP for symptomatic benign prostatic hyperplasia between December 2016 and July 2020 were reviewed retrospectively. Of the patients, 134 had been receiving AT, (anticoagulant (AC), n=51; antiplatelet (AP), n=83). AT was resumed within 24 hours postoperatively. We determined pre-, peri-, and postoperative parameters, functional outcome, and adverse events for the 3-month period postoperatively in patients receiving AC and AP; and compared results with 203 patients without AT. Results: Patients receiving AC and AP were older (p=0.015) and had a higher median ASA score (p<0.001). Objective voiding parameters (Qmax, PVR) and urinary symptoms (IPSS, QoL) improved in the three groups (p<0.001). Median enucleation and morcellation efficiencies were 1.58 (IQR:0.87-3.13) and 5 (IQR:1-8.08), median catheterization and hospitalization time was 2 days (IQR:2-3) and 3 days (IQR:3-4), respectively. The perioperative results were similar in the three groups. Overall, one patient in the AP group required blood transfusion at 4 days postoperatively due to clot retention and significant hemoglobin decrease (p=0.216). There was no adverse TE in any patient within 3-month postoperatively. Conclusion: HoLEP is an effective and safe method in patients with a high risk of TE whose AT is discontinued for surgery, as it enables AT to be resumed as soon as possible.

Bipolar Transurethral Enucleation of the Prostate: Is it a size-independent endoscopic treatment option for symptomatic benign prostatic hyperplasia?

Background Bipolar Transurethral Enucleation of the Prostate (B-TUEP) is recommended as a first-choice treatment for benign prostatic obstruction in prostates >80 ml. Differently, B-TUEP is only considered as an alternative option after TURP for smaller prostates (30–80 ml). The aim of our study is to assess the relation between prostate size and surgical outcomes after B-TUEP. Methods We performed a retrospective analysis of data collected from 172 patients submitted to B-TUEP. Patients were segregated according to tertiles of prostate volume (PV) (≤60 ml, 61–110 ml, >110 ml). For each group we evaluated enucleation efficacy (enucleated weight/enucleation time), complication rates, urinary and sexual function parameters. Functional and sexual parameters were compared between groups at baseline, 1 and 3 months follow up. Descriptive statistics and linear and logistic regression models tested the association between PV and postoperative complications/outcomes. Results Operative time and weight of enucleated adenomas increased along with prostate volumes (all p≤0.01). Enucleation efficacy was higher in men with PV >110 ml compared to other groups (p≤0.001). Length of hospital stay, catheterization time and rates of postoperative complications, such as transfusion and clot evacuation rates and bladder neck/urethral strictures, were comparable between groups. Urinary symptoms improved at 1-and 3-months in each group as compared to baseline evaluation (all p<0.01) but they did not differ according to PV. In each group maximum urinary flow and post-void residual volume significantly improved at 3 months compared to baseline (all p≤0.01), without differences according to PV. Sexual symptoms were similar between groups at each follow up assessment. At multivariable linear and logistic regression analysis, prostate volume was not associated with postoperative functional outcomes and complications. Conversely, patient’s comorbid status and antiplatelet/anticoagulation use were independently associated with postoperative complications. Conclusion According to our findings, B-TUEP should be considered a “size independent procedure” as it can provide symptom relief in men with prostates of all sizes with the same efficacy and safety profile.

Superselective prostatic artery embolization in the treatment of large benign prostatic hyperplasia

Purpose: To evaluate the use of prostatic artery embolization (PAE) as a treatment option for patients with symptomatic benign prostatic hyperplasia (BPH) with prostate volumes of 80 cc and more. Materials and Methods: The study included 75 patients with high anesthesia-related risks for conventional surgery (TURP). All patients were surveyed for symptom burden, using IPSS and quality of life score. The prostate volume was determined by transrectal ultrasonography (TRUS). At baseline, prostate-specific antigen (PSA) level was obtained in all patients. Urodynamics was evaluated using uroflowmetry. Clinical outcomes were assessed at follow-up 1, 3, 6, 12, and 24 months after PAE. Results: The prostate volume decreased significantly at months 1 and 3 post-treatment; the prostate continued shrinking until month 12, and the size was then stabilized. At month 24, prostate volume decreased by 40.82%, from 134.0 ± 8.3 mL at baseline to 79.3 ± 6.6 mL. Postvoid residual (PVR) urine volume was significantly decreased from 55.9 ± 5.3 mL to 22.0 ± 1.8 mL 1 month after PAE ( p < 0.001). Qmax increased from 9.2 ± 0.3 mL/s to 15.7 ± 0.4 mL/s. IPSS score following PAE decreased from 28.2 ± 0.7 to 9.7 ± 0.8 ( p < 0.001). QoL improvement was observed from 4.8 ± 0.2 at baseline to 1.8 ± 0.2 at month 24 ( p < 0.001). Decreased activity and density of adenomatous tissue resulted in decreased total PSA levels: from 5.9 ± 1.1 ng/mL to 2.6 ± 0.2 ng/mL ( p < 0.001). TURP became feasible in 35 patients due to reduction of prostate volumes below 80 mL after PAE. Conclusions: PAE was effective in relieving LUTS and reducing prostate size, and may be considered as a preoperative approach for patients with large prostate.