Endoscopic Treatment of Prostatic Hyperplasia in Elderly Patients: A Comparative Analysis of Resection and Enucleation Technique

Introduction. The pharmacological market, which is rapidly developing, as well as the appearance of combined forms of drugs, determine the trend in the conservative treatment of patients with symptoms of the lower urinary tract due to benign prostatic hyperplasia (BPH). However, simultaneous administration of drugs from several drug groups, by the patients, who are burdened with concomitant diseases (cardiovascular disease, diabetes) in certain cases, makes surgical treatment of BPH preferable and sometimes the only possible option. In this instance, the doctor’s task is to choose the optimal method of surgery that minimizes the risks of complications and provides a long-term clinical effect. The actively developing technique of endoscopic enucleation of prostate corresponds to the current needs. Various types of energies, which have appeared lately in urological practice for enucleation of the prostate, have become an attractive alternative to transurethral resection of the prostate (TURP). The introduction of a bipolar technology into clinical practice has allowed to significantly expand the use of operations among elderly patients with comorbidities. Laser endourology has gone further in reducing the risks of possible complications. Currently we are witnessing a lack of research, which compares the use of modern methods with bipolar TURP (B-TURP) in elderly patients, i.e. groups with a high risk of intraoperative & postoperative complications.

Purpose of the study. To compare the results of various types of BPH endoscopic surgical treatment in elderly patients (> 60 years old).

Materials and methods. The study included patients who underwent three different operations treating BPH (B-TURP, B-TUEP, HoLEP) from October 2017 to September 2018. The criteria for inclusion in the study were as follows: the presence of moderate or severe obstructive symptoms of the lower urinary tract, prostate volume > 40 cm3, maximum urine flow <15 ml/s. Exclusion criteria were as follows: the presence of cystostomy drainage, the presence of the oncological process in urinary tract, active inflammatory process of urogenital system, earlier received surgical interventions on the organs of the urinary system. Each group of patients has been assessed on following criteria: International Prostate Symptom Score (IPSS and QoL), international index of erectile function (IIEF-5), the dynamics of postoperative changes in prostate specific antigen (PSA), maximum flow of urine, postvoid residual urine volume, intraoperative and postoperative parameters.

Results. 190 patients operated during the year were examined in the current study. Duration of operation, extent of resection, time of postoperative catheterization and duration of hospital stay rates were significantly lower in the HoLEP group. There have been no cases of complications above the 3 level by the Clavien‒Dindo scale.

Conclusions. HoLEP is the preferred method of surgical treatment of prostatic hyperplasia over 40 cm3 in terms of surgical safety, efficacy, and the duration of the patient’s recovery period. This method can serve as an alternative to electrosurgical techniques in elderly patients.

1. Lim KB. Epidemiology of clinical benign prostatic hyperplasia. Asian J Urol. 2017;4(3):148‒151. https://doi.org/10.1016/j.ajur.2017.06.004

2. Vishnevskij E.L., Loran O.B., Vishnevskij A.E. Klinicheskaja ocenka rasstrojstv mocheispuskanija. M.: Terra; 2001. (In Russ.). ISBN 5-273-00170-6

3. Lopatkin N.A. Oslozhnenija TUR predstatel’noj zhelezy i adenomjektomii. V kn.: Dobrokachestvennaja giperplazija predstatel’noj zhelezy. Pod red. Lopatkina N.A. M.; 1997: 210‒214. (In Russ.).

4. Loh SY, Chin CM. A demographic profile of patients undergoing transurethral resection of the prostate for benign prostate hyperplasia and presenting in acute urinary retention. BJU Int. 2002;89(6):531‒533. https://doi.org/10.1046/j.1464410x.2002.02662.x

5. Enikeev D.V., Glybochko P.V., Alyaev Y.G., Rapoport L.M., Enikeev M.E., Spivak L.G., Tsarichenko D.G., Sorokin N.I., Sukhanov R.B., Dymov A.M., Khamraev O.K., Gaas M.Y., Taratkin M.S. Endoscopic enucleation of the prostate – a new standard in surgical treatment of benign prostatic hyperplasia. Andrology and Genital Surgery. 2017;18(3):83‒88. (In Russ.). https://doi.org/10.17650/2070-9781-2017-18-3-83-88

6. Al-Shukri S.K., Giorgobiani T.G., Amdiy R.E., Al-Shukri A.S. Urinary dysfunction in patients with unsatisfactory results of surgical treatment of benign prostatic hyperplasia. Grekov’s Bulletin of Surgery. 2017;176(6):66‒70. (In Russ.). https://doi.org/10.24884/0042-4625-2017-176-6-66-70

7. Mudrakovskaya E.V., Gorelick S.D., Kolpakovа N.A. Structure of concomitant pathology in the elderly and senile patients with urological diseases. Journal of new medical technologies. 2013;20(1):101‒103. (In Russ.). eLIBRARY ID: 18957088

8. Gacci M, Corona G, Sebastianelli A, Serni S, De Nunzio C, Maggi M, Vignozzi L, Novara G, McVary KT, Kaplan SA, Gravas S, Chapple C. Male Lower Urinary Tract Symptoms and Cardiovascular Events: A Systematic Review and Meta-analysis. Eur Urol. 2016;70(5):788‒796. https://doi.org/10.1016/j.eururo.2016.07.007

9. Reich O, Seitz M, Gratzke C, Schlenker B, Walther S, Stief C. Benign prostatic hyperplasia (BPH): surgical therapy options. Urologe A. 2010;49(1):113‒126. https://doi.org/10.1007/s00120-009-2183-1

10. Herr M, Robine J-M, Pinot J, Arvieu J-J, Ankri J. Polypharmacy and frailty: prevalence, relationship, and impact on mortality in a French sample of 2350 old people. Pharmacoepidemiol Drug Saf. 2015;24(6):637‒646. https://doi.org/10.1002/pds.3772

11. Wolak T, Toledano R, Novack V, Sharon A, Shalev A, Wolak A. Doxazosin to treat hypertension: it’s time to take it personally— a retrospective analysis of 19, 495 patients. J Hypertens. 2014;32(5):1132‒1137; discussion 1137. https://doi.org/10.1097/HJH.0000000000000119

12. Ulchaker JC, Martinson MS. Cost-effectiveness analysis of six therapies for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Clinicoecon Outcomes Res. 2017;10:29‒43. https://doi.org/10.2147/CEOR.S148195

13. Vertkin A.L., Loran O.B., Vovk E.I., Zimin O.N., Naumov A.V., Pak A.D., Konstanov G.P., Keshokov R.H., Alekseev I.D. Dobrokachestvennaja giperplazija predstatel’noj zhelezy i ejo oslozhnenija v obshhemedicinskoj praktike. Spravochnik poliklinicheskogo vracha. 2009;(11):3‒7. (In Russ.). eLIBRARY ID: 22834280

14. Disantostefano, R.L., Biddle, A.K., Lavelle, J.P. An evaluation of the economic costs and patient-related consequences of treatments for benign prostatic hyperplasia. BJU Int. 2006;97:1007–1016. https://doi.org/10.1111/j.1464-410X.2006.06089.x

15. Hovstadius B, Petersson G, Hellstrom L, Ericson L. Trends in inappropriate drug therapy prescription in the elderly in Sweden from 2006 to 2013: assessment using national indicators. Drugs Aging. 2014;31(5):379–386. https://doi.org/10.1007/s40266-014-0165-5

16. Rossi C, Kortmann BB, Sonke GS, Floratos DL, Kiemeney LA, Wijkstra H, de la ROSETTE JJ. alpha-Blockade improves symptoms suggestive of bladder outlet obstruction but fails to relieve it. J Urol. 2001;165(1):38‒41. https://doi.org/10.1097/00005392-200101000-00010

17. Krasulin V.V., Gluhov V.P., Vasilev K.S. Surgical treatment of benign prostatic hyperplasia: modern methods and potentials. Urology Herald. 2019;7(2):85‒92. (In Russ.). https://doi.org/10.21886/2308-6424-2019-7-2-85-92

18. de Lucia C, Femminella GD, Rengo G, Ruffo A, Parisi V, Pagano G, Liccardo D, Cannavo A, Iacotucci P, Komici K, Zincarelli C, Rengo C, Perrone-Filardi P, Leosco D, Iacono F, Romeo G, Amato B, Ferrara N. Risk of acute myocardial infarction after transurethral resection of prostate in elderly. BMC Surg. 2013;13 Suppl 2(Suppl 2):S35. https://doi.org/10.1186/1471-2482-13-S2-S35

19. Hiraoka Y, Akimoto M. Transurethral enucleation of benign prostatic hyperplasia. J Urol. 1989;142(5):1247‒1250. https://doi.org/10.1016/s0022-5347(17)39047-x

20. Gilling PJ, Kennett K, Das AK, Thompson D, Fraundorfer MR. Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience. J Endourol. 1998;12(5):457‒459. https://doi.org/10.1089/end.1998.12.457

21. Liu CX, Xu AB, Zheng SB, Li HL. Real endo-enucleation of prostate for treatment of benign prostatic hyperplasia. J Urol. 2010;184(6):2440‒2445. https://doi.org/10.1016/j.juro.2010.08.037

22. Blandy JP, Notley RG, Reynard JM. Transurethral Resection. 5th ed. London: Taylor & Francis; 2005.

23. Gratzke C, Bachmann A, Descazeaud A, Drake MJ, Madersbacher S, Mamoulakis C, Oelke M, Tikkinen KAO, Gravas S. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. Eur Urol. 2015;67(6):1099‒1109. https://doi.org/10.1016/j.eururo. 2014.12.038

24. Martov A.G., Maksimov V.A., Yarovoj S.Yu., Ergakov D.V., Kornienko S.I., Fahredinov G.A.. Transurethral holmium enucleation of prostatic adenoma. Urologiia. 2011;(1):38–43. (In Russ.). eLIBRARY ID: 16335687

25. Lee MH, Yang HJ, Kim DS, Lee CH, Jeon YS. Holmium laser enucleation of the prostate is effective in the treatment of symptomatic benign prostatic hyperplasia of any size including a small prostate. Korean J Urol. 2014 Nov;55(11):737‒741. https://doi.org/10.4111/kju.2014.55.11.737