钬激光剜除术和经尿道前列腺切除术治疗症状性前列腺梗阻的meta分析

目的比较钬激光前列腺剜除术（HoLEP）与经尿道前列腺电切术（TURP）两种术式的优缺点。方法检索Medline，Embase及Cochrane图书馆报道的HoLEP和TURP治疗症状性前列腺尿路梗阻的随机对照研究（RCTs）。主要观察指标包括最大尿流率（Qmax）、残余尿量、症状评分及生活质量评分，次要观察指标包括手术时间、住院时间、失血量、留置导尿管时间及并发症。结果6—12个月的术后随访中，Qmax在HoLEP和TURP治疗两组间没有统计学差异。但HoLEP术中失血量更少，留置导尿管时间及住院时间更短；而TURP手术时间小于HoLEP。两者在术后尿道狭窄、尿失禁、输血率及再次手术的发生率无统计学差异。结论HoLEP和TURP改善患者Qmax疗效相当。HoLEP手术时间比TURP长，但HoLEP失血量少，留置导尿管时间及住院时间较TURP短。术后各种并发症的发生率两者没有差别。     

同时保留膀胱颈和前列腺尖部尿道黏膜的经尿道前列腺等离子剜除术对BPH患者术后逆行射精的影响

目的:探讨同时保留膀胱颈和前列腺尖部尿道黏膜的经尿道前列腺等离子剜除术对良性前列腺增生(BPH)患者术后逆行射精发生率的影响。方法:回顾性分析2018年1月至2020年6月金华市人民医院收治的77例BPH患者的临床资料。77例排尿困难均>1年,伴尿线变细、夜尿增多等下尿路不适症状,口服药物治疗症状无改善。术前尿动力学或...     

Lower urinary tract symptoms, benign prostatic obstruction and the overactive bladder

Lower urinary tract symptoms (LUTS), benign prostatic obstruction (BPO), and the overactive bladder have increasing prevalence with age in both men and women (with the obvious exception). The question is, are they interrelated or independently related to age? The specific issue is whether BPO causes the overactive bladder. There are two pieces of evidence that might appear to suggest such a cause and effect. First, the overactive bladder is more common in men than in women of the same age, although physiologically, men are 5-10 years older at the same biological age. Second, the overactive bladder resolves in two-thirds of individuals after surgical interventions such as transurethral prostatectomy. The symptoms suggestive of an overactive bladder are the most troublesome, even though they may not be the most prevalent. Long-term follow-up studies with repeated urodynamic investigations have shown that the incidence of the overactive bladder and its attendant symptoms increases despite there being no deterioration in outlet obstruction over follow-up periods of 10 and 20 years. These data, and others, indicate that the situation is not as straightforward as some believe. The statement that 'the overactive bladder is secondary to BPO' cannot be made, as there are too many unanswered questions and pieces of the puzzle that do not fit. The overactive bladder is undoubtedly associated with BPO, and it leads to the most troublesome LUTS in older men. Epidemiological research, coupled with urodynamic evaluation, may provide further evidence. We also need better and more relevant models (e.g. ageing animals), together with further histological and other biological data before the waters become crystal clear.     

The natural history of lower urinary tract dysfunction in men: minimum 10-year urodynamic followup of transurethral resection of prostate for bladder outlet obstruction

PURPOSE: Despite long-term symptomatic and uroflowmetry studies following transurethral prostate resection (TURP) there are sparse pressure flow data. Consequently there is minimal information to account for the long-term symptomatic failure and flow rate decrease seen with time following early improvements after surgery. MATERIALS AND METHODS: Men older than 45 years who were investigated at our department between 1972 and 1986, diagnosed with bladder outlet obstruction and elected surgical intervention were invited for repeat symptomatic and urodynamic assessment. Identical methods were used, allowing direct comparison of results. RESULTS: A total of 1,068 men were initially diagnosed with bladder outlet obstruction, of whom 428 (40%) died in the interim. Of the men who were followed 217 underwent TURP with a mean followup since surgery of 13.0 years. A significant, sustained decrease in the majority of symptoms and improvements of urodynamic parameters was seen. Long-term symptomatic failure and decreased flow rate were principally associated with detrusor under activity (DUA) rather than obstruction. Presentation predictive factors for the future development of DUA were decreased detrusor contractility and a lesser degree of obstruction. CONCLUSIONS: This unique long-term study provides valuable information on surgically treated bladder outlet obstruction. The association of long-term failure following surgery with DUA emphasizes the importance of pressure flow studies before repeat surgery. However, our faith in the long-term efficacy of TURP is justified.     

Correlation between lower urinary tract symptoms and urethral function in benign prostatic hyperplasia

AIM: To examine the potential correlation between urethral function and lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). METHODS: Thirty-one patients with clinical BPH, who were confirmed to have benign prostatic enlargement (BPE) of 20 ml or more, were enrolled into the study. A mark-sheet questionnaire was used for obtaining the LUTS history. Multichannel pressure-flow urodynamic studies were performed and external urethral sphincter pressure (PEUS), intravesical pressure (PVES), and bladder neck pressure (PBN) were recorded both at maximum cystometric capacity and during voiding with 5-microtip transducers, for the purpose of detecting BPE-specific urodynamic findings at different levels within the urethra. RESULTS: There was a positive correlation between hesitancy and detrusor bladder neck dyssynergia (DBND) (P = 0.0011) and between incomplete emptying and low PBN at maximum cystometric capacity (P = 0.0425). The hesitancy proved to have no correlation with bladder neck opening time (TBNO). CONCLUSION: Urodynamic evaluation of urethral function was beneficial for attributing LUTS to clinical BPH. Among various parameters, DBND was the most specific to clinical BPH, suggesting it to be a situation where a steep rise in PBN or prostatic urethral pressure remains greater than the increasing PVES, resulting in sustained difficulty in opening the bladder neck and subsequently the subjective sensation of hesitancy.     

Transurethral electrovaporization vs transurethral resection for symptomatic prostatic obstruction: a meta-analysis

OBJECTIVE: To compare the effectiveness and safety of transurethral electrovaporization (TUEVP) and transurethral resection of the prostate (TURP) for symptomatic bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH). METHODS: Publications comparing TUEVP and TURP were identified systematically using Medline, the Cochrane Controlled Trial Register and other database search engines. From a total of 25 randomized controlled trials, 20 studies met the predefined inclusion criteria and were subjected to a formal meta-analysis. Primary endpoints were symptom scores and peak urinary flow rates. Secondary endpoints included transfusion requirements, operative time, duration of catheterization, incidence of adverse events, hospital stay, re-operation rates and sexual dysfunction. RESULTS: After 1 year of follow-up there was no significant difference between TUEVP and TURP in urinary symptom scores and peak urinary flow rates. There was heterogeneity at baseline for both primary outcome measures. TUEVP was associated with significantly lower transfusion requirements, a shorter catheterization time, and a shorter length of stay. TURP was associated with a lower risk of urinary retention afterward and re-operation than was TUEVP. CONCLUSION: This formal meta-analysis suggests that both TUEVP and TURP in patients with symptomatic bladder outlet obstruction provide comparable improvements in maximum urinary flow rates and symptom scores. While comparative analysis is limited by the methodological shortcomings of the underlying studies and the short follow-up, both TURP and TUEVP may offer distinct advantages in terms of secondary outcomes. A future, well-designed, multicentre randomized clinical trial with extended follow-up may be needed to better define the role of vaporization techniques in treating patients with symptomatic BPH.     

经尿道治疗下尿路结石现状与进展

膀胱结石发病率约占整个泌尿系结石的5%,随着腔内器械和碎石设备不断改进,绝大多数膀胱结石可通过内镜下处理。钬激光的出现使直径4cm的结石碎石成功率有了较大提高。超声气压弹道碎石比钬激光更高效,操作时间更短,损伤更小,出血更少。碎石通道也不乏创新之处,如AH-1取石系统、JQL鞘等。本文就经尿道治疗下尿路结石的现状与进展做一综述。     

Head-to-head comparison of prostatic urethral lift and water vapor thermal therapy for the treatment of symptomatic benign prostatic hyperplasia: a real-life study

Purpose

This study aimed at reporting a head-to-head comparison between water vapor thermal therapy using the Rezūm? system and prostatic urethral lift using the Urolift? system in men with lower urinary tract symptoms due to benign prostatic hyperplasia (BPH).

Patients and methods

From December 2017 to November 2019, consecutive patients who underwent Rezūm? and Urolift? procedures in two urology centers have been retrospectively considered. Only patients with a prostate size less than 80 mL were included. We used the PSM method to adjust baseline differences between both groups. The co-primary endpoint included the change in International Prostate Symptom Score (IPSS) and IPSS- quality of life (QoL) from baseline to 12 months.

Results

A total of 61 (52.1%) and 56 (47.9%) patients underwent Rezum? and Urolift? procedures, respectively. After PSM adjustment, 24 patients were included in both groups. No serious adverse events occurred (>?Clavien II) in both groups. At 12 months, higher IPSS improvement was observed in the Rezum? group (median:4 [IQR 3–5]) than in the Urolift? group (median:8 [IQR 7–12]), without statistical difference (p?=?0.08). The improvement in term of QoL at 12 m was similar (p?=?0.43). The retreatment rates were 25% (Urolift?) and 8.3% (Rezum?), p?=?0.24. Erection and ejaculatory function scores did not change significantly in either treatment group. Results in the full cohort showed that Rezum? appeared to deliver greater improvements for IPSS and IPSS-QoL (p?<?0.001 and p?=?0.006, respectively) and lower reintervention rate (p?=?0.006) than Urolift?.

Conclusions

In this small retrospective study, our results indicate that both Rezum? and Urolift? provide a clinically significant improvement in symptoms and QoL, although some of these improvements were greater in the Rezum? arm. Future studies are needed to definitively assess which treatment would be best suited for each patient.

     

The 12‐year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To investigate whether bladder outlet obstruction (BOO), detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long‐term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction.

PATIENTS AND METHODS

Of 92 patients who had TURP after a urodynamic study between 1995 and 1997, 43 (47%) were alive at the time of the survey in February 2008. Nine patients were excluded because of prostate cancer, neurological diseases and the impossibility of symptomatic examination. The International Prostate Symptom Score (IPSS) and quality‐of‐life (QoL) index were determined at baseline, 3 months, 3, 7 and 12 years after surgery for 34 patients.

RESULTS

Although the improved IPSS and QoL index at 3 months gradually deteriorated with time, patients at 12 years were still significantly better than those at baseline. The IPSS in patients without BOO deteriorated faster than in those with it, whereas neither DUA nor DO influenced the slope of change in IPSS. Regardless of the preoperative urodynamic findings, the QoL index remained improved for 12 years. Two‐thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years.

CONCLUSION

The symptomatic improvement provided by TURP lasts for >10 years, although there is a gradual deterioration with time. The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings.     

Reprint – Bipolar vs. monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction: A Cochrane review

IntroductionThere remains uncertainty regarding the differences in patient outcomes between monopolar transurethral resection of the prostate (MTURP) and bipolar TURP (BTURP) in the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO).MethodsA systematic literature search was carried out up to March 19, 2019. Methods in the Cochrane Handbook were followed. Certainty of evidence (CoE) was assessed using the GRADE approach.ResultsA total of 59 randomized controlled trials (RCTs) with 8924 participants were included. BTURP probably results in little to no difference in International Prostate Symptom Score (IPSS) at 12 months (mean difference −0.24, 95% confidence internal [CI] −0.39–−0.09; participants=2531; RCTs=16; moderate CoE) or health-related quality of life (HRQOL) at 12 months (mean difference −0.12, 95% CI −0.25–0.02; participants=2004, RCTs=11; moderate CoE), compared to MTURP. BTURP probably reduces TUR syndrome (relative risk [RR] 0.17, 95% CI 0.09–0.30; participants= 6,745, RCTs=44; moderate CoE) and blood transfusions (RR 0.42, 95% CI 0.30–0.59; participants=5727, RCTs=38; moderate CoE), compared to MTURP. BTURP may carry similar risk of urinary incontinence at 12 months (RR 0.20, 95% CI 0.01–4.06; participants=751; RCTs=4; low CoE), re-TURP (RR 1.02, 95% CI 0.44–2.40; participants=652, RCTs=6, I²=0%; low CoE) and erectile dysfunction (International Index of Erectile Function [IIEF-5]) at 12 months (mean difference 0.88, 95% CI −0.56–2.32; RCTs=3; moderate CoE), compared to MTURP.ConclusionsBTURP and MTURP probably improve urological symptoms to a similar degree. BTURP probably reduces TUR syndrome and blood transfusion slightly postoperatively. The moderate certainty of evidence available for primary outcomes suggests no need for further RCTs comparing BTURP and MTURP.     

经尿道等离子电切联合内分泌治疗晚期前列腺癌致下尿路梗阻

目的探讨晚期前列腺癌患者的治疗。方法25例病人均采用经尿道等离子电切术（TUPKP）加行双侧睾丸切除术和口服氟他胺的联合内分泌疗法。结果所有患者术后均排尿通畅,下尿路梗阻情况明显缓解,4例骨痛患者治疗后疼痛消失,6例曾有尿潴留病史的患者无一例再次发生尿潴留,术后4周国际前列腺症状评分（IPSS）和身体一般功能状态评分（Karnofsky）手术前后,分别为（30&#177;5）分,（9&#177;4）分和（50&#177;20）分,（75&#177;20）分,P均〈0.05,症状均明显改善。结论晚期前列腺癌患者行TUPKP能解除下尿路梗阻,联合内分泌明显抑制肿瘤生长而延长生命。