Combination Robotic Simple Prostatectomy and HoLEP for Morbidly Enlarged Prostates > 400g
Alison Levy, MD, David Canes, MD, Jessica Mandeville, MD.
Lahey Hospital and Medical Center, Burlington, MA.
Background: Studies have established the effectiveness of Prostatic Urethral Lift (PUL) with relieving bladder outlet obstruction; however, predictors of success or failure with this new modality are not well documented. We sought to determine factors that may impact PUL outcomes.
Methods: A retrospective review of prospectively maintained Benign Prostatic Hyperplasia (BPH) database for patients who underwent PUL at University of Vermont Medical Center between 2017-2020 was performed. Demographic data, procedure characteristics, International Prostate Symptom Score (IPSS), and Post Void Residuals (PVR) pre and post PUL were collected. Associations between the change in IPSS score (IPSS pre PUL - IPSS post PUL) were analyzed.
Results: A total of 121 consecutive patients underwent PUL. Patients who did not have IPSS pre or post PUL (N=13) or underwent median lobe Transurethral Resection of the Prostate (TURP) (N=3) or Direct Vision Internal Urethrotomy (DVIU) (N=1) in the same setting were excluded. One hundred and five patients were included. The median age was 71 years (interquartile [IQR] 63-77), with a median BMI of 28 (IQR 25-31). Most patients (76%) were on BPH medications pre PUL. Of those, 54 (67.5%) were able to stop taking BPH medications post PUL. 9.5% of patients had previous BPH surgeries and 2.9% of patients required chronic Foley or clean intermittent catheterization (CIC) pre PUL. Median number of sutures placed at PUL was 4 (IQR 4-5). Median follow up time post PUL was 3.3 months (IQR 2.4-14.5). IPSS decreased from a pre-operative median of 19 (IQR 13-23) to 11 (IQR 6-17), p<0.001, while PVR decreased from 37mL (IQR 10-116) to 35 mL (IQR 12-66), p=0.046, respectively. In a multivariate regression analysis after adjusting for age, Body Mass Index, prostate volume, BPH medication at time of PUL or prior BPH surgery, prior chronic catheter or CIC, high median bar or lobe, number of sutures during PUL, median lobe transurethral incision, postoperative catheter due to retention, continued BPH medications on follow up, and follow up time, we found that increasing age is associated with less change in IPSS (Coef. Mean= -0.3, 95% confidence interval -0.4 - -0.1, p=0.010).
Conclusions: Our results showed that even though PUL still has good effect in all ages, there was less change in IPSS in older patients. Although PUL is less invasive compared to other BPH surgical treatments, it may have less favorable outcomes specifically in patients older than 80 years. This may be due to bladder dysfunction from a more chronic obstructive process, and could potentially support earlier intervention for some patients. It may also sway surgeons toward performing TURP in older eligible patients. Regardless, we believe further study is needed to fully establish this relationship and to assess if the difference in efficacy is large enough to merit a change in clinical practice.
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