World J Urol DOI 10.1007/s00345-014-1254-0

Original Article

Safety and feasibility of concomitant surgery during holmium laser enucleation of the prostate (HoLEP) Amar Patel · Rafael Nunez · Chinedu O. Mmeje · Mitchell R. Humphreys 

Received: 10 October 2013 / Accepted: 27 January 2014 © Springer-Verlag Berlin Heidelberg 2014

Abstract  Purpose To determine the feasibility and outcomes associated with performing simultaneous surgical procedures during holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia and concomitant urologic conditions. Methods A retrospective review of patients that underwent a HoLEP was performed. Patients undergoing a concomitant procedure at the time of HoLEP were selected and stratified based on complexity of the secondary procedure (simple, intermediate, and complex) and matched based on age and prostate volume to patients undergoing only a HoLEP. Baseline characteristics, preoperative, operative, and postoperative outcomes were collected. Results A total of 372 HoLEPs were performed. Thirtyeight (10.2 %) patients underwent concomitant procedures at the time of HoLEP. Compared to the simple and intermediate secondary surgical procedures, the matched control group that underwent a HoLEP alone did not demonstrate statistically significant differences in the preoperative, operative, or postoperative outcomes. Patients with a complex secondary surgical procedure at the time of HoLEP had statistically significant differences in operative time (221 vs. 65 min, p = 0.007), estimated blood loss (92 vs. 33 mL, p = 0.012), catheter time (8.5 vs. 1 day, p = 0.041), and length of hospitalization (2 vs. 1 day, p = 0.032) compared to the control group. Conclusions  Obstructive voiding symptoms secondary to BPH are common in older patients and may coincide with other concomitant lower urinary tract pathology that may A. Patel (*) · R. Nunez · C. O. Mmeje · M. R. Humphreys  Department of Urology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA e-mail: [email protected]

require surgical intervention. Rather than staging surgical interventions, it appears that definitive treatment for BPH with HoLEP is safe and efficacious in those patients that also require secondary procedures. Keywords  Holmium laser enucleation of the prostate · BPH · Simultaneous surgery · Concomitant procedure

Introduction Benign prostatic hyperplasia (BPH) is an age related phenomenon with a prevalence of 60, 80, and 90 % for men in their 6th, 7th, and 8th decade of life, respectively [1]. The Olmsted County Study of Urinary Symptoms and Health Status has shown that prostate enlargement and the clinical manifestation of lower urinary tract symptoms (LUTS) is an age-dependent process [2]. It is the fifth most prevalent non-cancer disorder among men aged 50 years and older and accounts for the 7th highest 1-year disease-specific medical costs [3]. In 2007, the estimated life expectancy in the United States was 77.9 years [4]. The fact that Americans are living longer makes the elderly the fastest growing segment of the US population [5]. As such, they present with BPH and LUTS that may severely impact the quality of their lives. Most surgical therapies for BPH are associated with significant risks. Early reports of TURP showed a 1.3–2.5 % mortality rate [6]. Mebust et al. [7] reported on 3,885 patients after TURP and correlated postoperative morbidity with resection time over 90 min, gland size over 45 cm3, acute urinary retention, and age over 80 years. Given the fact that most men are treated with medications for symptomatic relief of LUTS, thus allowing continued prostate growth, more men are presenting with larger prostate

13



glands at the time of surgery [6]. The HoLEP is a minimally invasive treatment option for men with BPH that has been shown to be safe in patients with large gland volumes (>200 cm3), as well as in men on anticoagulation [8, 9]. It offers all the advantages of an open prostatectomy without the associated morbidities [10]. In randomized trials and meta-analysis, it has been shown to be superior to other surgical treatments [9]. Evidence continues to grow showing the benefits of HoLEP for both BPH in a variety of simple and complex scenarios. Patients who experience BPH often have concomitant conditions that may be due to their bladder outlet obstruction (BOO) or manifestations of a secondary disease processes. These conditions include but are not limited to urolithiasis, tumors, diverticula, strictures, and inguinal hernias. Having multiple comorbid conditions can affect treatment decisions or outcomes. Many patients undergoing surgery for BPH often have to undergo additional and separate surgical procedures for the treatment of those other conditions. Given the high safety profile and minimal complication rate associated with HoLEP, we endeavored to analyze the risks and outcomes of performing simultaneous surgical procedures at the time of HoLEP. To our knowledge, this is the first study that examines the complications and safety of performing concomitant surgeries at the time of HoLEP in patients with BPH and other medical conditions requiring surgical intervention.

Materials and methods We performed a retrospective analysis of an institutional review board (IRB) approved prospectively generated database of all patients who underwent a HoLEP at our institution between August 2007 and March 2012. Patients that had undergone a secondary surgical procedure at the time of HoLEP, under the same anesthetic, were then identified. In order to allow comparison of patient outcomes and complications, a control group of individuals that had undergone a HoLEP without a secondary procedure were matched to the study group, 2:1 based on age/ prostate volume. Patient demographics included age, body mass index (BMI), American Society of Anesthesiologists score (ASA), prostate volume by transrectal ultrasound (TRUS), and prostate-specific antigen (PSA). Operative variables included operating room (OR) time, estimated blood loss (EBL), enucleation time, and morcellation time. Functional outcomes prior to and 3 months after surgery included International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), average flow rate (Qavg), and postvoid residual (PVR)). Pathological variables included histopathologic diagnosis and total tissue removed (weight). Thirty-day postoperative complications

13

World J Urol

were also compared using the Clavien classification system [18]. All HoLEPs were under the direct supervision of or performed by a single surgeon (MRH) according to the previously published reports of the technique. The concomitant procedures were separated by level of complexity into the following designations: simple (other procedures done at the same time that would likely have little impact on the ability to perform HoLEP), intermediate (procedures done that could impact ability to perform HoLEP, that some would consider doing as a separate procedure, or have the potential to cause bleeding and impaired visualization), or complex (advanced procedures done at the time of HoLEP requiring bladder reconstruction, for which an argument could be made to approach the patient in a different way—open or with robot assistance). All data were statistically analyzed with chi-square and Student’s t test for categorical and continuous variables, respectively. A two-sided p value

Safety and feasibility of concomitant surgery during holmium laser enucleation of the prostate (HoLEP).

To determine the feasibility and outcomes associated with performing simultaneous surgical procedures during holmium laser enucleation of the prostate...
198KB Sizes 2 Downloads 0 Views