Curr Urol Rep (2015) 16: 55 DOI 10.1007/s11934-015-0525-7
BENIGN PROSTATIC HYPERPLASIA (K MCVARY, SECTION EDITOR)
Comparison of Patients Undergoing PVP Versus TURP for LUTS/BPH Blake B. Anderson 1 & Joseph J. Pariser 1 & Brian T. Helfand 2
Published online: 17 June 2015 # Springer Science+Business Media New York 2015
Abstract Transurethral resection of the prostate (TURP) and photoselective vaporization of the prostate (PVP) are currently the two most commonly performed procedures for the treatment of benign prostatic hyperplasia (BPH). While each procedure has been shown to be efficacious, TURP or PVP may be preferred in certain clinical scenarios. A number of factors may influence the choice of which patients undergo PVP or TURP. This decision may take into account patient characteristics, such as age, co-morbidities, predominance of irritative symptoms, and/or ongoing anticoagulation. Additionally, balancing desired outcomes with possible risks is critical. Considerations should include possible effects on sexual function, rates of reoperation, cost, and need for tissue specimen in those at risk for prostate cancer. The primary objective of this article is to summarize the comparative research of PVP and TURP and the implications on differences between patients who undergo either procedure.
This article is part of the Topical Collection on Benign Prostatic Hyperplasia * Blake B. Anderson [email protected] Joseph J. Pariser [email protected] Brian T. Helfand [email protected] 1
Section of Urology, Department of Surgery, School of Medicine, University of Chicago Pritzker, 5841 S. Maryland Ave. MC 6038, Chicago, IL 60637, USA
2
Division of Urology, Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Evanston, IL 60201, USA
Keywords LUTS . BPH . TURP . PVP . Comparison . Greenlight
Introduction Benign prostatic hyperplasia (BPH) is a histologic diagnosis that is characterized by smooth muscle and epithelial cell proliferation within the transition zone of the prostate [1]. Lower urinary tract symptoms (LUTS) secondary to BPH remains a highly prevalent problem among men in the USA. From the Third National Health and Nutrition Examination Survey (NHANES III), 59.9 % of men 60 to 69 years old and 75.1 % of men over 70 years old had at least one BPHrelated symptom [2]. Surgical treatment of BPH was reported in 8.0 % of men 60 to 69 years old and 22.4 % of men over 70 years old. Surgical intervention for BPH is often done to address bothersome LUTS, defined as Burinary frequency, urgency, nocturia, decreased or intermittent force of stream and the sensation of incomplete bladder emptying^ [3], but other indications include urinary retention, bladder calculi, recurrent urinary tract infections, impairment of renal function, and/or need to stop medical therapies for BPH. The historical gold standard of surgical treatment for BPH, monopolar transurethral resection of the prostate (TURP) [4], has been challenged by the introduction of the less morbid laser surgeries such as photovaporization of prostate (PVP). Photovaporization of the prostate was first performed using a 60-W potassium titanyl phosphate (KTP) laser in 2000 [5], which was quickly replaced by the 80-W KTP laser in 2002 [6]. Based on Medicare data, by 2008, prevalence of PVP had become second only to TURP for surgical treatment of BPH [7]. The introduction of bipolar TURP has encouraged the continued use of TURP as it has shown advantages compared to monopolar TURP with regards to postoperative maximum
55 Page 2 of 8
urine flow rates, fewer intraoperative complications (e.g., bleeding, hyponatremia) and decreased perioperative clot retention [8]. Herein, we describe the recent updates in the literature regarding factors that may influence the decision to undergo either TURP or PVP.
Comparative Outcomes: Bipolar TURP Versus PVP Many studies have demonstrated that both TURP and PVP procedures can be safely used for the successful treatment of LUTS related to BPH [9•]. Comparative studies of the two surgeries generally demonstrate few differences in long-term urologic outcomes with each having sustained improvements in LUTS. For example, the GOLIATH study reported 6 month [10••] and 12 month [11] outcomes for their prospective, multicenter randomized trial of 180-W XPS Greenlight PVP (n= 139) and bipolar TURP (n=142). They found no significant differences between PVP and TURP in intraoperative or perioperative complications or re-intervention rates, maximum urinary flow rate (Qmax), post-void residual volume (PVR), and PSA or prostate volume (see Table 1). Interestingly, both PVP and TURP also had similar rates of abnormal postoperative irritative symptoms, pain, and discomfort (6 months= 21.8 vs.19.1 %, respectively, p=0.651; 12 months=18.4 vs. 18 %, p=1.000). This is contradictory to previous reports of higher rates of transient dysuria (8.5 vs. 0.8 %) [12] and urgency/urge incontinence [13] after PVP compared to TURP. As mentioned in the GOLIATH study, inconsistencies in defining dysuria make comparisons between prior reports potentially difficult to make meaningful conclusions. A large systematic review by Thangasamy et al. examined nine randomized comparison studies of PVP and bipolar TURP between 2002 and 2012, and their results showed that PVP was associated with shorter catheter time (−1.91 days), decreased hospital stay (−2.13 days), and decreased risk of transfusion (OR=0.016, 95 % CI 0.05–0.53) and clot retention (OR=0.14, 95 % CI 0.05–0.40) [14••]. TURP was superior with regards to operative time, being shorter than PVP by an average of 19.64 min (95 % CI 9.05–30.23). Regarding functional outcomes, three out of the nine trials in their review had 12-month postoperative data for Qmax and International Prostate Symptom Score (IPSS), and no significant differences were reported in these variables in the PVP and TURP groups. A recent study by May et al. reported higher rates of postoperative urinary tract infection (UTI) with PVP compared to TURP [15]. Specifically, the authors documented a postoperative fever in 8 % after TURP compared to 16 % after PVP. For PVP, 75 % with fever were found to have a positive urine culture compared to 0 % with fever after TURP, but 60 % with fever after TURP had no available culture data, suggesting this may not have been an adequate comparison. Their finding was in contrast to the large analysis by
Curr Urol Rep (2015) 16: 55
Thangasamy, which showed no differences in rates of postoperative infections. Guo et al. recently reported a higher reoperation rate (i.e., requiring an additional bladder outlet procedure for prostate regrowth) for PVP compared to TURP (33 vs. 3 %, p
BENIGN PROSTATIC HYPERPLASIA (K MCVARY, SECTION EDITOR)
Comparison of Patients Undergoing PVP Versus TURP for LUTS/BPH Blake B. Anderson 1 & Joseph J. Pariser 1 & Brian T. Helfand 2
Published online: 17 June 2015 # Springer Science+Business Media New York 2015
Abstract Transurethral resection of the prostate (TURP) and photoselective vaporization of the prostate (PVP) are currently the two most commonly performed procedures for the treatment of benign prostatic hyperplasia (BPH). While each procedure has been shown to be efficacious, TURP or PVP may be preferred in certain clinical scenarios. A number of factors may influence the choice of which patients undergo PVP or TURP. This decision may take into account patient characteristics, such as age, co-morbidities, predominance of irritative symptoms, and/or ongoing anticoagulation. Additionally, balancing desired outcomes with possible risks is critical. Considerations should include possible effects on sexual function, rates of reoperation, cost, and need for tissue specimen in those at risk for prostate cancer. The primary objective of this article is to summarize the comparative research of PVP and TURP and the implications on differences between patients who undergo either procedure.
This article is part of the Topical Collection on Benign Prostatic Hyperplasia * Blake B. Anderson [email protected] Joseph J. Pariser [email protected] Brian T. Helfand [email protected] 1
Section of Urology, Department of Surgery, School of Medicine, University of Chicago Pritzker, 5841 S. Maryland Ave. MC 6038, Chicago, IL 60637, USA
2
Division of Urology, Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Evanston, IL 60201, USA
Keywords LUTS . BPH . TURP . PVP . Comparison . Greenlight
Introduction Benign prostatic hyperplasia (BPH) is a histologic diagnosis that is characterized by smooth muscle and epithelial cell proliferation within the transition zone of the prostate [1]. Lower urinary tract symptoms (LUTS) secondary to BPH remains a highly prevalent problem among men in the USA. From the Third National Health and Nutrition Examination Survey (NHANES III), 59.9 % of men 60 to 69 years old and 75.1 % of men over 70 years old had at least one BPHrelated symptom [2]. Surgical treatment of BPH was reported in 8.0 % of men 60 to 69 years old and 22.4 % of men over 70 years old. Surgical intervention for BPH is often done to address bothersome LUTS, defined as Burinary frequency, urgency, nocturia, decreased or intermittent force of stream and the sensation of incomplete bladder emptying^ [3], but other indications include urinary retention, bladder calculi, recurrent urinary tract infections, impairment of renal function, and/or need to stop medical therapies for BPH. The historical gold standard of surgical treatment for BPH, monopolar transurethral resection of the prostate (TURP) [4], has been challenged by the introduction of the less morbid laser surgeries such as photovaporization of prostate (PVP). Photovaporization of the prostate was first performed using a 60-W potassium titanyl phosphate (KTP) laser in 2000 [5], which was quickly replaced by the 80-W KTP laser in 2002 [6]. Based on Medicare data, by 2008, prevalence of PVP had become second only to TURP for surgical treatment of BPH [7]. The introduction of bipolar TURP has encouraged the continued use of TURP as it has shown advantages compared to monopolar TURP with regards to postoperative maximum
55 Page 2 of 8
urine flow rates, fewer intraoperative complications (e.g., bleeding, hyponatremia) and decreased perioperative clot retention [8]. Herein, we describe the recent updates in the literature regarding factors that may influence the decision to undergo either TURP or PVP.
Comparative Outcomes: Bipolar TURP Versus PVP Many studies have demonstrated that both TURP and PVP procedures can be safely used for the successful treatment of LUTS related to BPH [9•]. Comparative studies of the two surgeries generally demonstrate few differences in long-term urologic outcomes with each having sustained improvements in LUTS. For example, the GOLIATH study reported 6 month [10••] and 12 month [11] outcomes for their prospective, multicenter randomized trial of 180-W XPS Greenlight PVP (n= 139) and bipolar TURP (n=142). They found no significant differences between PVP and TURP in intraoperative or perioperative complications or re-intervention rates, maximum urinary flow rate (Qmax), post-void residual volume (PVR), and PSA or prostate volume (see Table 1). Interestingly, both PVP and TURP also had similar rates of abnormal postoperative irritative symptoms, pain, and discomfort (6 months= 21.8 vs.19.1 %, respectively, p=0.651; 12 months=18.4 vs. 18 %, p=1.000). This is contradictory to previous reports of higher rates of transient dysuria (8.5 vs. 0.8 %) [12] and urgency/urge incontinence [13] after PVP compared to TURP. As mentioned in the GOLIATH study, inconsistencies in defining dysuria make comparisons between prior reports potentially difficult to make meaningful conclusions. A large systematic review by Thangasamy et al. examined nine randomized comparison studies of PVP and bipolar TURP between 2002 and 2012, and their results showed that PVP was associated with shorter catheter time (−1.91 days), decreased hospital stay (−2.13 days), and decreased risk of transfusion (OR=0.016, 95 % CI 0.05–0.53) and clot retention (OR=0.14, 95 % CI 0.05–0.40) [14••]. TURP was superior with regards to operative time, being shorter than PVP by an average of 19.64 min (95 % CI 9.05–30.23). Regarding functional outcomes, three out of the nine trials in their review had 12-month postoperative data for Qmax and International Prostate Symptom Score (IPSS), and no significant differences were reported in these variables in the PVP and TURP groups. A recent study by May et al. reported higher rates of postoperative urinary tract infection (UTI) with PVP compared to TURP [15]. Specifically, the authors documented a postoperative fever in 8 % after TURP compared to 16 % after PVP. For PVP, 75 % with fever were found to have a positive urine culture compared to 0 % with fever after TURP, but 60 % with fever after TURP had no available culture data, suggesting this may not have been an adequate comparison. Their finding was in contrast to the large analysis by
Curr Urol Rep (2015) 16: 55
Thangasamy, which showed no differences in rates of postoperative infections. Guo et al. recently reported a higher reoperation rate (i.e., requiring an additional bladder outlet procedure for prostate regrowth) for PVP compared to TURP (33 vs. 3 %, p
