Ejaculations and Benign Prostatic Hyperplasia: An Impossible Compromise? A Comprehensive Review

Background: Benign prostatic hyperplasia (BPH) is commonly responsible for lower urinary tract symptoms (LUTS) in men aged 50 or over. Sexual dysfunctions, such as ejaculatory disorders (EjD), go along with LUTS but are frequently overlooked in the initial evaluation. This review aimed to detail BPH-related EjD, as well as their modifications by medical, surgical, and interventional treatments. Methods: We conducted a narrative review looking for publications between 1990 and 2020, regarding physiopathology, epidemiology, evaluation, and therapeutic management (medical, surgical, and interventional) of BPH-related EjD. Results: Sixty-five articles were included in our final analysis. Forty-six percent of men presenting with LUTS reported EjD. If the prevalence increases with age and LUTS severity, the functional impairment is not correlated with age. Several self-questionnaires evaluated the sexual function, but only four approaches are specific to EjD. Medical therapies were exposed to anejaculation, rather than retrograde ejaculation (RE) (4–30% (alpha-blockers), 4–18% (5-alpha-reductase inhibitors)). Regarding surgical therapies, trans-urethral resection of the prostate (TURP) and incision of the prostate (TUIP) are associated with 50–70% and 21–35% of RE. The RE rate is important after open simple prostatectomy but can be reduced with robotic approaches and urethral sparing techniques (19%). Anatomic endoscopic enucleation of the prostate (AEEP) with or without a laser source is associated with an 11–36% RE rate, according to supramontanal preservation. Recent surgical techniques (Rezum©, Aquablation©, or Urolift©) were developed to preserve antegrade ejaculation with promising short-term results. Regardless of the surgical approach, anatomic studies suggest that the preservation of peri-montanal tissue (7.5 mm laterally; 10 mm proximally) is primordial to avoid post-operative RE. Finally, prostate artery embolization (PAE) limits the RE rate but exposes it to a 12 months 10% re-intervention rate. Conclusion: EjD concerns almost half of the patients presenting BPH-related LUTS. Initial evaluation of EjD impairment is primordial before medical or surgical therapy. Peri-montanal tissue preservation represents a key point for antegrade ejaculation preservation, regardless of the surgical option.

Comparison of the Efficacy and Safety of Minimally Invasive Simple Prostatectomy and Endoscopic Enucleation of Prostate for Large Benign Prostatic Hyperplasia

Background: Minimally invasive simple prostatectomy (MISP) and endoscopic enucleation of the prostate (EEP) are the two most commonly used methods for large benign prostatic hyperplasia (BPH), but it remains unclear which of the two is superior. This study aims to perform a pooled analysis to compare efficacy and safety profiles between MISP and EEP.Methods: We conducted a comprehensive search of PubMed, Embase, Web of Science, and ClinicalTrials.gov databases to identify eligible studies comparing MISP with EEP. Parameters including efficacy and safety outcomes were compared using Stata 14.0 version.Results: Eight comparative trials with 1,504 patients were included. Compared to MISP, EEP demonstrated shorter operative time (mean difference [MD] 46.37, 95% confidence interval [CI] 19.92 to 72.82, p = 0.0006), lesser hemoglobin decrease (standardized MD [SMD] 0.59, 95% CI 0.23 to 0.95, p = 0.001), lower catheterization time (SMD 4.13, 95% CI 2.16 to 6.10, p < 0.001), and shorter length of stay (SMD 2.38, 95% CI 1.40 to 3.36, p < 0.001). However, overall complications and blood transfusions did not differ between the two groups. Moreover, EEP had better postvoid residual volume (PVR) at 6-month (MD 14.39, 95% CI 11.06 to 17.72, p < 0.001) and comparable 3- and 6-month International Prostate Symptom Score, 3- and 6-month maximum flow rate, 3-month PVR, and 3-month quality of life compared with MISP.Conclusion: Both MISP and EEP are effective and safe surgical procedures for the treatment of large BPH. EEP appears to have a superior perioperative profile compared to MISP. This should be interpreted with caution due to the significant heterogeneity between studies. Hence, treatment selection should be based on the surgeon's experience and availability.

Clinical Outcome of Endoscopic Enucleation of the Prostate Compared With Robotic-Assisted Simple Prostatectomy for Prostates Larger Than 80 cm3 in Aging Male

This study investigated and compared the surgical outcomes of using endoscopic enucleation (thulium: YAG laser and bipolar plasma; ThuLEP) with robotic-assisted simple prostatectomy (RASP) in the treatment of prostates larger than 80 cm3. Records were obtained for the period from January 2014 to December 2020 for selected patients with BPO who underwent RASP, ThuLEP, or bipolar transurethral enucleation of the prostate (B-TUEP). Patients were excluded if they had active malignant disease, neurogenic bladder, lower urinary tract syndrome for reasons other than BPO, and a history of prostate surgery. Data of 396 patients who underwent B-TUEP, ThuLEP, and RASP were examined. A total of 112 patients met the including criteria, 85 of whom (B-TUEP: 29; ThuLEP: 41; RASP: 15) completed the final visit. The mean operation time and duration of postoperative hospital stays in the RASP group were significantly longer than those of the B-TUEP and ThuLEP groups. Only 1 patient in the RASP group required blood transfusion. The RASP group was superior to the other groups in voiding improvement including Qmax and IPSS voiding score. The pain score of the ThuLEP group after surgery was significantly lower than that of the other two groups during hospitalization, whereas the QoL scores were identical between the three groups at 2 weeks, 3 months, and 6 months post operation. The rates of returning to ER within the first postoperative month did not differ significantly between the three groups, and all the reasons for return involved minor complications that required no additional invasive treatment. These three surgical methods (B-TUEP, ThuLEP, and RASP) are all effective and safe for treating prostates larger than 80 cm3, with each having its particular advantages. B-TUEP requires the shortest operation time, ThuLEP causes the lowest postoperative pain, and RASP results in superior voiding function improvement.

Evaluating the acceptability of an online patient decision aid for the surgical management of lower urinary tract symptoms secondary to benign prostatic hyperplasia

Introduction: The growing number of surgical options available to treat benign prostatic hyperplasia (BPH), may overwhelm patients and urologists when deciding on an optimal treatment. Therefore, we developed an online patient decision aid (PtDA) that includes all guideline-approved surgical modalities. The objective of this study was to assess the acceptability of the PtDA among former BPH surgery patients and urologists that treat BPH surgically. Methods: The International Patient Decision Aids Standards were used to develop a PtDA that includes monopolar transurethral resection of the prostate (TURP), bipolar TURP, GreenLight photovaporization, endoscopic enucleation of the prostate, Rezum, Urolift, Aquablation, open retropubic prostatectomy, and robotic simple prostatectomy as management options. Eleven urologists that regularly treat BPH and 19 patients who received BPH surgery were recruited. Alpha-testing was performed using a validated acceptability scoring system. Results: For all sections of the PtDA, most urologists agreed that the language used was easy to follow (91.9%), that the amount of information provided was adequate (63.6%), that the length of the PtDA was appropriate (63.6%), and that the outcomes reported were correct (81.8%). All 19 patient participants agreed that the language used was easy to follow, and most found that the amount of information provided was adequate (84.2%), that the length of the PtDA was appropriate (84.2%), and that the outcomes reported were well-explained (89.5%). Conclusions: Our PtDA was found to be acceptable among urologists and patients. These results demonstrate that most of the participants either recommend the use of this tool or plan to incorporate it in their clinical practice.

Perioperative Outcomes of Anatomic Endoscopic Enucleation of the Prostate, Robotic and Open Simple Prostatectomy From a Multi-Institutional Database

Objective: To compare the perioperative morbidity of robotic-assisted simple prostatectomy (RASP), anatomical endoscopic enucleation of the prostate (AEEP) and open simple prostatectomy (OSP) for the treatment of benign prostatic obstruction (BPO). Methods: The national surgical quality improvement program database was queried for AEEP, RASP, and OSPprocedures. Clavien-Dindo-graded complications, length of hospital stay (LOS), and operative time were compared among the procedures. To control for the potentially confounding variables, we first conducted a multivariate backward conditional logistic regression, and then resorted to propensity score matching. Results: We identified 2867 AEEP, 234 RASP, and 1492 OSP procedures. After matching, the risk of pulmonary, renal, infectious, and thromboembolic adverse events was lower after AEEP but not RASP in comparison with OSP (P < 0.05). In comparison with RASP, AEEP had lower cardiac and thromboembolic events (P < 0.05). When compared with OSP, AEEP had reduced odds of Clavien-Dindo grade I (OR = 0.12; 95% CI 0.10 to 0.16) and II (OR = 0.38; 95% CI 0.24 to 9.58) complications. Also, AEEP had lower odds for grade I and II as well as grade IV complications (OR = 0.30; 95% CI 0.19 to 0.48, and OR = 0.05; 95% CI 0.01 to 0.24, respectively) compared with RASP. Conclusion: AEEP and RASP were associated with fewer perioperative adverse events, a shorter LOS and a reduced risk of transfusion compared with OSP. AEEP was associated with overall lower complication rates than RASP and OSP.