Indications

M-TURP is considered as a standard procedure for BPO relief, and has now been used for more than 7 decades. One of its main assets is the large clinical experience available in the literature, because nearly all urologists do M-TURP on a daily basis. M-TURP has thus been used as the reference treatment arm in more than 200 comparative studies in the past 30 years. However, owing to the need of glycine continuous flow irrigation the procedure, it is usually recommended to use M-TURP for prostates of less than 80 mL. Furthermore, several RCTs and metaanalyses have shown that M-TURP is associated with a higher risk of bleeding compared with laser surgery (either PVP or HoLEP). It may explain that no RCT have compared M-TURP with laser procedures in patients under anticoagulation, therapy likely owing to ethical reasons. At present, M-TURP remains an option for BPO relief in patients with small prostates (when the risk of bleeding is minimal) or in patients with voiding difficulties in the context of known prostate cancer.

Functional Results

It has been shown by numerous studies that M-TURP is able to relieve BPO with a high success rate. The procedure is associated with a drop in the I-PSS of around 70%, a reduction of prostate volume of around 45%, an increase of Q _max of around 12 mL/s, and a reduction is postvoid residual volume (PVR) of around 76%. Those results are durable with an overall estimated recurrence of BPO in about 10% of cases in the long term.

Complications

Intraoperative complications are dominated by bleeding, with rates between 3% and 8.6%, depending on the type of patients studied and whether it is in current clinical practice or clinical trials. The risk of bleeding is even greater under anticoagulation therapy. TUR syndrome may occur in as many as 1% to 2% of patients owing to dilutional hyponatremia and is characterized by mental confusion, nausea, vomiting, and visual disturbances. It has been reported to occur in as many as 1% and 2% of cases.

Postoperative clot retention owing to bleeding occurs in 1% to 7% of patients reported in the literature. This complication is influenced by technical difficulties, prostate size, venous injury, depth of resection, and irrigation quantity after the procedure. Obviously, patients under anticoagulation therapy are at greater risk. Postoperative acute urinary retention can occur in 3% to up to 9% of cases. It may be transient or impossible after further trials of voiding without catheter. In these cases, reevaluation of the patient by endoscopy and urodynamics is mandatory because many other factors can explain the situation (detrusor impairment, insufficient tissue removal). Urinary tract infections (UTIs) are usually successfully managed by antibiotics and occur in up to 20% of patients. Some authors have proposed that preoperative bacteriuria, duration of the procedure, postoperative stay duration, and postoperative invasive care were linked to an increased rate of UTIs. Further complications can occur but are not frequent, underreported, and not seen in small RCTs in the literature. Those include perforation of the bladder neck, injury of ureteral orifices, and bladder wall injury. Mortality of the procedure is estimated to be around 1 in 1000 in the largest case series.

Long-term complications include mainly bladder neck contracture, urethral strictures, incontinence, and sexual dysfunction. Bladder neck contracture occurs rather after TRUP in small prostates around 3% in the literature (≤10%), and are managed successfully by incisions. Urethral strictures occur in 2% to 10% of cases in the literature, and are probably influenced by the size of the scope, the technology used, as well as UTIs. Urethral stricture is usually managed by laser of cold knife incision. Incontinence after TURP is rather unusual, is mainly owing to sphincter injury, and occurs in up to 2% of cases. Reoperation rates depend on follow-up duration. It ranges from 3% to 14% in the long term (probably around 10%). Erection is probably not really impacted by the procedure. Retrograde ejaculation is common (around 50%).

Learning Curve

Despite its high popularity, the learning curve of TURP has not been deeply investigated in the literature. M-TURP has a learning curve like every urologic procedure. Some authors found that 80 procedures were needed to get a plateau in the learning curve, when postoperative outcomes were analysed. Some simulation models have been proposed but not thoroughly investigated.

Indications

Bipolar procedures have been proposed initially as a variant of TURP using electric energy but using a bipolar electrode, allowing power up to 400 W. Several devices have been marketed to date (Gyrus, ACMI, Olympus, Karl Storz). Thanks to saline irrigation, innovative design of the resection loops, resection (B-TURP), but also vaporization (TUVP) and enucleation (TUBE) are possible with bipolar devices.

Functional Results

B-TURP has been shown to provide similar results compared with M-TURP in all systematic reviews and metaanalyses. Level 1 evidence has shown that this procedure is associated with a decrease in the I-PSS of around 71%, a reduction of prostate volume of around 46%, an increase of Q _max of around 13 mL/s, and a reduction is PVR of around 82%. The limited evidence available about bipolar enucleation shows that the procedure removes more prostatic tissue and is probably more comparable with HoLEP, but more information from well-designed prospective studies are required. Long-term data are lacking for B-TURP and TUBE.

Complications

Intraoperative complications of B-TURP are minimal given the absence of TURP syndrome. Bleeding is the main concern, but the risk of transfusion is reduced by 50% compared with M-TURP. Hemoglobin loss is also significantly reduced, as well as clot retention. Other complication rates are similar than after M-TURP. Long-term complications are similar to TURP (urethral stenosis, bladder neck contracture, reoperation, and incontinence, which is very uncommon). Sexual dysfunction is mostly owing to ejaculatory dysfunction (around 60% of cases).

Learning Curve

Very few data have been published about the B-TURP and TUBE learning curves. One possible explanation for this is the absence of standardization of the technique, especially for the enucleation technique. Several groups reported different tools, various loops, energy settings, and occasionally morcellation (using a morcellator or the mushroom technique). B-TURP procedure is likely comparable with TURP, but the TUBE procedure is better described and standardized.

Indications

PVP has emerged in the last 10 years with 2 consecutive modifications of the device, that is now delivering a power up to 180W in a specially designed fiber with integrated cooling system. The intervention is made using a continuous flow resectoscope with saline irrigation. GreenLight laser (532 nm wavelength, quasicontinuous mode) is able to vaporize tissue and coagulate, so that no material is available for pathology. Prostate size is theoretically unlimited, but current level 1 evidence is only available for prostates of less than 100 mL. The main attribute of GreenLight laser is in its hemostasis properties. The targeted chromophore is hemoglobin, with a very high absorption coefficient. Tissue penetration of the laser is 0.8 mm. The main indication for GreenLight laser today is rather small prostates in frail patients with a high risk of bleeding (anticoagulation therapy or antiplatelets) or limited life expectancy and many comorbidities (level 1 evidence European Association of Urology guidelines ). There is no clear reference for what to do with anticoagulation therapy in these cases (suspend, bridging, or continue). Furthermore, there are no data about PVP and the new oral anticoagulants.

Functional Results

Short-term results have shown that PVP was noninferior to TURP for symptoms improvement and BPO relief, that had been anticipated by others before the release of the GOLIATH study. The procedure is associated with a decrease in the I-PSS of around 66%, a decrease of prostate volume of around 44%, an increase of Q _max of around 12 mL/s, and a decrease in PVR of around 84%. Long-term results are urgently awaited. This issue remains crucial as some reports about now 5 years of follow-up with the first generation of lasers were associated with a high recurrence rate.

Complications

Intraoperative complications are not frequent during PVP. Bleeding is significantly reduced with a very low rate of transfusion (1 case in the 7 RCTs available to date ). Intervention duration has been shown to be longer than TURP, but the difference was not clinically relevant (<10 minutes). The rate of UTIs was comparable with TURP as well as the risk of postoperative AUR. However, catheterization duration was reduced by almost 1 day and hospitalization duration reduced by 2 days. PVP is thus usually considered as a technique associated with the lowest hospital stay duration.

Delayed hematuria has been presented recently as a potential issue during the first postoperative month after PVP. Postoperative irritative symptoms are comparable with TURP when using appropriate evaluation. The major issue in long term follow-up with PVP is the reoperation rate that has been shown to be a bit higher than after TURP when evaluating medium term outcomes with the 120 W model, whereas 18% recurrence of adenoma has been shown after 5 years of follow-up with an 80 W device. Ejaculatory dysfunction has been reported in fewer case than after other techniques.

Learning Curve

The learning curve of PVP has not been yet adequately described. Although PVP is considered a relatively simple technique to learn, some authors have pointed out that appropriate training is necessary. The same authors have detailed PVP learning curve, and have shown that performance may continue to improve until up to 120 procedures. To our knowledge, no rigorous evaluation of a curriculum integration training modules on exercise on the PVP simulator has been conducted.