Surgical Treatment Options for Benign Prostatic Obstruction

Beyond Prostate Volume

Claudia Deyirmendjian; Dean Elterman; Bilal Chughtai; Kevin C. Zorn; Naeem Bhojani

Disclosures

Curr Opin Urol. 2022;32(1):102-108. 

In This Article

Ambulatory Procedures

Despite advances in surgical treatments for BPO, patients may still be at risk for postoperative complications, namely hematuria. To ensure maximal safety before patients are sent home, they are commonly admitted to the hospital for surveillance and continuous bladder irrigation. Same-day discharge, when it can safely be achieved, is advantageous for patients for multiple reasons, including less immobilization and risk of thrombotic events, less exposure to the potential pathogens in the hospital environment, and increased patient comfort. The aforementioned considerations are especially relevant for older patients, that largely constitute the patient population for surgical management of BPO.[34] The definition for day-case surgery however varies among countries, and may be defined as less than 12 h (e.g., in France) or less than 24 h (e.g., in the United States).

HoLEP typically involves an overnight hospitalization, but studies in small size prostates have demonstrated it to be safe and feasible as an ambulatory procedure.[35] An observational study evaluated 90 same-day HoLEP discharges. Over 40% of HoLEP patients were successfully discharged and the failure rate, including failure of discharge or readmission, was 20%. Risk factors associated with failure were increased age, high-prostate-specific antigen and low American Society Anesthesia (ASA) score.[36] In a prospective study by Abdul Muhsin et al., approximately 60% of patients who qualified for same-day discharge were successfully discharged after assessment by the urological team and after meeting PACU discharge criteria.[37] Overall, early readmission rates appear to range from 0% to 17.8%.[37–39] The variability of risk factors and readmission between studies highlights the subjectivity of assessment between sites.

In part due to its excellent hemostatic properties, same-day discharge is a suitable option following PVP. A retrospective analysis showed that among 56 patients treated with PVP, 93% were treated on an outpatient basis, which was significantly greater than bipolar TURP (0%) and TURP (6%). Length of hospitalization was also shorter in PVP patients compared to bipolar TURP and TURP (1.03 vs 1.45 days and 1.67, respectively).[40] A prospective study found that among 134 PVP patients that qualified for outpatient treatment, 90% were successfully discharged and less than 2% of same-day discharged patients were readmitted.[41]

Prostatic artery embolization (PAE) is an interventional radiological procedure used primarily in the context of clinical trials.[42] Symptom relief appears to favor established surgical treatments over PAE.[43,44] A retrospective review of 186 PAE procedures demonstrated successful same-day discharge with no readmissions due to adverse events.[45] Bagla et al. corroborated these results as all PAE patients were successfully discharged within 3 h, whereas TURP patients were hospitalized for 1.38 days on average (P < 0.0001) and contributed to PAE being overall the less costly procedure.[46]

Similar to the above UroLift, Rezūm, PAE and iTind can be performed as day procedures and under local anesthesia (see below).

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