Page 5 - Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia (MLUTS/BPH): 2018 update

Guideline: Male LUTS/BPH

IPSS, peak flow rate (Qmax), PSA reduction, as well as reduced setting. The data suggests superior safety in men on anti-
operative time, catheterization time, and hospital stay were coagulation and/or high cardiovascular risk. 55
observed with BPKVP compared to M-TURP in men with We recommend PVP as an alternative to TURP in men
prostate volume <60 cc. 46,47 Long-term efficacy of BPKVP, with moderate to severe LUTS (strong recommendation
especially for prostate volume >60 cc, is still required. based on high-quality evidence). We suggest Greenlight PVP
We suggest BPKVP as an alternative first-line surgical therapy as an alternate surgical approach in men on anti-
therapy for men with moderate to severe MLUTS/BPH coagulation or with a high cardiovascular risk (conditional
and prostate volume <60 cc (conditional recommendation recommendation based on moderate quality evidence).
based on moderate-quality evidence). Diode laser vaporization of the prostate: Diode laser
vaporization (and enucleation) of the prostate provides
2.4.2. Open simple prostatectomy (OSP) improved IPPS, Qmax, and PVR compared to baseline. 56,57
OSP is an appropriate and effective treatment alternative While providing strong hemostatic properties, high rates of
for men with moderate to severe LUTS with substantially dysuria, high-reoperation rates (8–33%), and persisting stress
enlarged prostates >80–100 cc and who are significant - urinary incontinence (9.1%) have been reported.
ly bothered by symptoms. 48 Other indications for OSP We suggest diode laser vaporization of the prostate as an
include plans for concurrent bladder procedure, such as alternative to TURP in men with moderate to severe LUTS
diverticulectomy or cystolithotomy, and in men who are (conditional recommendation based on low-quality evidence).
unable to be placed in dorsal lithotomy position due to We suggest diode laser vaporization of the prostate as an
49
severe hip disease. OSP is the most invasive surgical alternate surgical approach in men on anticoagulation (con-
method requiring longer hospitalization and catheteriza- ditional recommendation based on low-quality evidence).
tion. The estimated transfusion rate has been reported from Thulium laser: Tm:YAG vaporization (also enucleation
7–14%. 48,49 Long-term complications include transient and vapoenucleation) has comparable efficacy and safety
urinary incontinence (8–10%), bladder neck contracture, outcomes to TURP, PVP, and HoLEP for a wide range of
and urethral stricture (5–6%). 48,49 Less invasive techniques, prostate gland sizes and in patients taking oral anticoagu-
including laparoscopic and robotic approaches have dem- lants with lower complication and bleeding rates compared
onstrated equivalent efficacy and potentially fewer compli- to TURP and open simple prostatectomy. 58,59
cations compared to OSP, but require specialized equip- We suggest Tm:YAG vaporization of the prostate as an
ment and relevant skills. 50 alternative to TURP in men with moderate to severe LUTS
We recommend OSP as a first-line surgical therapy for with prostate volume <60 cc. Thulium enucleation may be
men with moderate to severe MLUTS/BPS and enlarged an alternative to OSP and HoLEP in men with moderate
prostate volume >80 cc (strong recommendation based on to severe LUTS with prostate volume >80 cc (conditional
moderate- to high-quality evidence). recommendation based on moderate-quality evidence).

2.4.3. Laser prostatectomy 2.4.4. Transurethral incision of the prostate (TUIP)
Holmium laser enucleation of the prostate (HoLEP): HoLEP TUIP is an appropriate therapy for men with a small prostate
60
provides significant and durable improvements in Qmax, PVR size <30 cc without a middle lobe. Symptoms and voiding
volume, quality of life, IPSS, and PSA reduction 51,52 and can be parameters are improved, the risk of retrograde ejaculation
used to treat men on anticoagulation and those with bleeding and TUR syndrome is reduced (18.2% and 0%) compared
dyscrasia. There is a low reoperation rate (approximately 4% to TURP, however, the risk of surgical retreatment for LUTS
for recurrent LUTS) within series with long followup (up to related to BPH are significantly higher for TUIP (18.4%) than
7–8 years). 52,53 The procedure requires a steep learning curve after TURP (7.2%).
(estimated >20–50 cases) often requiring fellowship training. We recommend TUIP to treat moderate to severe LUTS
53
We recommend HoLEP as an alternative to TURP or OSP in men with prostate volume <30 cc without a middle
in men with moderate to severe LUTS if performed by a lobe (strong recommendation based on moderate- to high-
HoLEP-trained surgeon (strong recommendation based on quality evidence).
high-quality evidence).
Photoselective vaporization of the prostate (PVP): 2.4.5. Minimally invasive techniques
Greenlight-PVP (180W XPS and 120W HPS systems) Transurethral microwave therapy (TUMT): TUMT is a true
provides comparable outcomes to TURP in terms of dur- outpatient procedure and an option for elderly patients with
able improvements in IPSS and Qmax with similar overall significant comorbidities or greater anaesthesia risks. 61,62
complication rate. Five-year mid-term durability of XPS Although short-term success for LUTS improvement have been
54
reported a 1.6% retreatment rate. PVP has been shown reported, the long-term durability of TUMT is limited with
55
to be a cost-effective alternative to TURP in the Canadian five-year cumulative retreatment rates between 42 and 59%. 63

CUAJ • October 2018 • Volume 12, Issue 10 307