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Recent advances in prostatectomy for benign prostatic hyperplasia

[version 1; peer review: 2 approved]
PUBLISHED 29 Aug 2019
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OPEN PEER REVIEW
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Abstract

This review provides a brief overview of and commentary on currently available technology for the surgical treatment of obstructive benign prostatic hyperplasia causing lower urinary tract symptoms. This review provides references relevant to review and understand current technology that is clinically available.

Keywords

BPH, LUTS, Transurethral Prostatectomy, Laser, Aquablation, Retrograde Ejaculation, Vapor Ablation, Thermotherapy, Electrovaporization, TURP, Open prostatectomy, Prostatic Stents, Stents, Benign Prostatic Hyperplasia, Lower Urinary Tract Symptoms, Robotic Prostatectomy

In the last five years, advances in surgical options for obstructive benign prostatic hyperplasia (BPH) have progressed with new technologies and refinement of current options. These developments reflect the ongoing needs to still perfect this surgical approach. The most recent advancement is aquablation, the first non-thermal technology to resect prostate tissue; studies demonstrate efficacy and safety at least equivalent to those of transurethral resection of the prostate (TURP) in glands up to 150 mL and improved outcomes in retrograde ejaculation14.

As intermediate options to medical therapy and TURP, both prostatic urethral lift and vapor ablation are generally office procedures that demonstrate superior safety profiles, especially in regard to sexual function, and that have acceptable efficacy compared with TURP59. In the past, most studies-based superiority of procedures on efficacy outcome parameters such as International Prostate Symptom Score and urodynamic parameters assessing obstruction relief as well as intraoperative and perioperative safety parameters such as bleeding, lengths of hospital stay, and infections. However, with the increased availability of novel and minimally invasive procedures, there is an increasing perception/awareness of these therapies as viable alternatives to medical therapy. Studies such as the BPH-6 studies in which a combination of quality-of-life parameters have increased the importance in outcome parameters that affect procedure choice such as retrograde ejaculation, need for catheterization, and recovery time have made what were technically less efficacious procedures more “superior” in these studies10. As such, many novel and minimally invasive procedures, including various prostatic stents and new technologies to resect prostate tissue or relieve prostatic outlet resistance, are still being aggressively developed. Many of these novel techniques, such as prostatic urethral lift and vapor ablation, are also designed to be used in an outpatient or office setting with minimal or local anesthesia.

Not surprisingly, many currently used technologies, including many traditional therapies, have evolved. Because it removes the risk of dilutional hyponatremia by using normal saline as an irrigant, the standard TURP is now performed with bipolar technologies with equal efficacy and improved safety parameters1114. The open prostatectomy has also evolved to be incorporated in many robotic prostatectomy procedures, although its overall complication rate and hospital stay are still much higher than those of many transurethral procedures1517. The well-known laser-assisted enucleation of the prostate, holmium laser enucleation of the prostate (HoLEP), is one of the most well-studied procedures, demonstrating efficacy and safety superior to those of traditional open prostatectomy and TURP. However, its high learning curve has limited its widespread acceptance and utility1820. Despite being initially limited to centers of excellence, it has undergone growing popularity due to the increasing number of trainees who have come from these centers of excellence as well as the improved technology of morcellation and instrumentation. The procedure has been in use since its initial introduction 20 years ago. However, laser procedures did not undergo durable popularity and widespread clinical utility until the introduction of high-power 532-nm laser technology, or “GreenLight” laser. Initially known as photoselective vaporization (PVP) and introduced as a viable technology with the first multicenter article in 200421,22, it is now the most common laser procedure in the world as a pure laser vaporization procedure. This technology has also evolved from an 80-Watt technology to a 180-Watt technology capable of vaporizing prostate tissue more efficiently and faster23. Many studies have demonstrated the laser’s clear superior safety profile in anticoagulated patients, high risk patients (high American Society of Anaesthesiologists score or Charlson index) and in large prostates2428. Whereas most “GreenLight” procedures use pure vaporization techniques for glands up at about 80 g, vapoenucleations techniques have been applied to glands up to 376 mL29. Although there are many competing laser technologies, none has yet to compare in terms of ease of use, widespread utility, and short learning curve with a high safety profile.

Over the last decade, the superior outcome efficacy and durability of HoLEP in comparison with open prostatectomy have suggested a modification in technique to incorporate enucleation with various technologies. Not surprisingly, laser enucleation of the prostate with GreenLight has evolved to demonstrate better efficacy with a maintained safety profile, especially in very large glands. The enucleation technique has expanded to include thulium laser technology as well as bipolar electrovaporization technology3033. The vaporization enucleation technique with GreenLight has allowed enucleation and completion of prostatectomy without a mechanical morcellator with outcomes superior to those of standard PVP techniques, especially in larger glands29.

With the goal of preserving sexual function, the preservation of antegrade ejaculation has become an area of focus and interest with current evolving technologies. Studies with prostatic urethral lift and vapor ablation and aquablation incorporate ejaculation outcomes and demonstrate increased preservation of antegrade ejaculation compared with traditional techniques. Although preservation of bladder neck structures is often associated with preservation of antegrade ejaculation, especially in those with large intravesical middle lobes, the current modern approach is the preservation of paracollicular structures in laser, aquablation, and bipolar electrosurgical prostatectomy techniques34.

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Te AE. Recent advances in prostatectomy for benign prostatic hyperplasia [version 1; peer review: 2 approved]. F1000Research 2019, 8(F1000 Faculty Rev):1528 (https://doi.org/10.12688/f1000research.18179.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
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PUBLISHED 29 Aug 2019
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Reviewer Report 29 Aug 2019
David Lee, University of Pennsylvania, Philadelphia, PA, USA 
Approved
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Lee D. Reviewer Report For: Recent advances in prostatectomy for benign prostatic hyperplasia [version 1; peer review: 2 approved]. F1000Research 2019, 8(F1000 Faculty Rev):1528 (https://doi.org/10.5256/f1000research.19885.r52698)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 29 Aug 2019
Arthur Burnett, Department of Urology, Johns Hopkins School of Medicine, The James Buchanan Brady Urological Institute, Baltimore, MD, USA 
Approved
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I confirm that I have read this submission and believe that I have an ... Continue reading
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Burnett A. Reviewer Report For: Recent advances in prostatectomy for benign prostatic hyperplasia [version 1; peer review: 2 approved]. F1000Research 2019, 8(F1000 Faculty Rev):1528 (https://doi.org/10.5256/f1000research.19885.r52697)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Version 1
VERSION 1 PUBLISHED 29 Aug 2019
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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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