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737Holmium laser enucleation of the prostate is more cost effective than open prostatectomy: Results of a randomized prospective study
737
738
HOLMIUM LASER ENUCLEATION OF THE PROSTATE IS MORE C O S T EFFECTIVE T H A N OPEN P R O S T A T E C T O M Y : R E S U L T S O F A RANDOMIZED PROSPECTIVE STUDY
E X P E R I E N C E S OF A N E W DEVICE F O R MEDIATING PROSTATIC INJECTIONS OF DRUGS VIA THE URETHRA
Salonia A., Suardi N., Mazzoccoli B., Naspro R., Zanni G., Briganti A., Scattoni V., Bua L., Rigatti E, Montorsi F.
ILjungbyHospital, Departmentof Surgery,Ljungby, Sweden,2KalmarCounty Hospital, Department of Urology, Kalmar, Sweden
University Vita-Salute San Raffaele, Dept. Urology, Milan, Italy I N T R O D U C T I O N & OBJECTIVES: A peri-operative economic impact analysis was carried out comparing open prostatectomy (OP) and Holmium Laser enucleation (HoLEP) in patients (pts) with symptomatic high volume benign prostatic hyperplasia (BPH). MATERIAL & METHODS: Between February and May 2004, 63 pts matched for age-, ASA, serum total-PSA, and prostate weight were randomized into: Group 1:29 pts (mean age +/-SD: 68.0+/-6.4 yrs) undergoing OP and Group 2 : 3 4 pts (67.4+/-6,7 yrs) undergoing HoLEE A detailed hospital cost comparison of the critical pre-, intra- and post-operative data and a net cost savings (%) calculation were performed. RESULTS: Patients' characteristics. Group 1 vs. Group 2: mean+/-SD age: 68.0+/-6.4 vs. 67.4+/-6.7, p=0.75; ASA: 1.8:t:0.1 vs 1.7~-0.1, p=0.31; PSA: 7.2+/4.7 vs. 8.0+/-8.4, p=0.71; prostate weight: 120.9+/-34.9 vs. 113.8+/-36.9, p=0.60. The costs analysis model showed a mean cost of 62797.8 for Group 1 and 62288.2 for Group 2. A direct comparison analysis showed that the most significant cost factors were the operative time, which contributed 16.5% on average to the cost of open prostatectomy and 25.8% to the cost of HoLEP and length ofpost-op hospital stay, which contributed 54.6% on average to the cost of Group 1 and 32.9% to the cost of Group 2. The calculated net cost saving (%) of HoLEP versus open prostatectomy was 617362.4 (9.9%). C O N C L U S I O N S : These data show that HoLEP promotes a significant hospital net cost saving (%) compared to OP in patients suffering from symptomatic high volume benign prostatic hyperplasia.
INTRA-
RichthoffJ. I, Schelin S.~
INTRODUCTION& OBJECTIVES: The Schelin CatheterT M is a new device for injection of drags into the prostate via the urethra. There are several possible applications for this device. In our clinics the Schelin Catheter has been used for local anaesthesia of the prostate prior to microwave thermotherapy in patients with benign prostatic hyperplasia (BPH). Local anaesthesia with epinephrine was administered with two intentions: 1) Local anaesthesia, 2) Minimizing the intraprostatic blood flow. MATERIAL & METHODS: A total of 113 patients with BPH, 41 in Ljungby and 72 in Kalmar,were treated with ProstaLund Feedback Treatment® (PLFT®).Prior to treatment injectionsof mepivacaine epinephrine (ME) were administered using the Schelin Catheter. In Kalmar a total amount of 30 ml of the drug, 10 ml of 1% and 20 ml of 0.5% solution, was infiltrated into 4 different positions in the prostate, i.e. into every quadrant. However,in Ljungby different injection techniques were used. Mean treatment time, energy consumption,maximum intraprostatic temperature and the amount of tissue necrosis as calculated by the device for these patients were comparedwith the same variables for the PLFT patients (not given ME) in three prospective clinical studies: study A, B and C. RESULTS: Treatment time and energy consumptionwere considerably lower in the Ljungby and Kalmar group than in the three prospective studies. However, maximum intraprostatic temperature and tissue destruction were in the same range for all five patient groups (see table). Moreover, none of the patients in Ljungby and Kalmar required additional medication during the treatment. Variables Schelin Catheter Treatment Time (min.) Energy Consumption(kJ) Max Intrapmstatic Temp (°C) Tissue Des~uction (g)
Study A n= 100 No 57.2 164
Study B n=42 No 54.6 179
Study C n=40 No 45.8 169
Ljungby n=41 Yes 21.9 61.4
Kalmar n=72 Yes 11.6 31.3
57.7
61.3
58.2
58.0
59.1
16.4
22.2
18.4
16.2
16.2
:ONCLUSIONS:The results suggest that treatment time and energy consumptionare significantly reduced after intraprostatic injections of mepivacaine epinephrine prior to PLFT. Good anaesthesia was attained in all the eases. Since the amount of tissue destruction and maximum intraprostatic temperatures are not affected, the efficacy of the treatment seems to be the same as the prolonged treatment without the Schelin Catheter.
739
740
B L A D D E R OUTLET OBSTRUCTION DUE TO BENIGN PROSTATIC E N L A R G E M E N T : U R O D Y N A M I C EVALUATION OF S U R G I C A L OUTCOME
TRANSURETHRAL PROSTATECTOMY USING 22FR SIZED CONTINUOUS RUNNING IRRIGATION SYSTEM RESECTOSCOPE Yoo T.K. 1, Cho J.M. l, Kang J.Y/, Jung J.YJ, Kim D.Y.2
Kalantzis A., Argiropoulos A., Aristas O., Doumas K., Gkialas I., Lykourinas M. General Hospital of Athens "G.Gennimatas", Urology, Athens, Greece INTRODUCTION & OBJECTIVES: We correlated urodynamic findings to the clinical features of with bladder outlet obstruction due to benign prostatic hyperplasia (BPH) and compared them in terms of outcome after successful removal of bladder neck obstruction by transurethral prostatectomy (TUR-P) or surgical enucleation of the prostate. MATERIAL & METHODS: 410 male patients with BPH aged 53-83 (mean 69.4) years were operated by TUR-P or surgical enucleation of the prostate. All the patients showed Detrusor Hyperflexia (D.H.) pre-operatively. The patients, were considered to have (D.H.) because of BPH. The patients were classified according to their urodynamic findings. Group 1 was the continual sporadic onset and offset of (D.H.), Group 2 was a single episode of DH at a bladder volume of<160 mL, and Group 3 was a single DH episode at a bladder volume >160 mL. All the patients were evaluated with the International Prostatic Symptom Score (IPSS), Quality of Life (QOL) score and urodynamic study up to 6 and 12 months postoperatively. RESULTS: Urodynamic study findings at 6 and 12 months postoperatively were compared with the pre-operative findings. (82%) from the patients of Group 2 and all the patients of Group 3 showed an absence of DH after surgery and the QOL score, average improved significantly (p<0.0001). In contrast, (62.5%) from the patients of Group 1 showed persistent DH. Compared with Group 2 and 3 patients, Group 1 patients more frequently complained of urgency before surgery and their symptoms and urodynamic parameters did not improve afterward. Low bladder compliance correlated significantly with an increase in age and prostate volume, detrusor instability and impaired contractility. Low compliance also correlated with in'itative symptoms, decreased maximum flow rate, increased post-void residual urine and an increase in the total IPSS score. CONCLUSIONS: Among the urodynamic parameters investigated, low compliance was the most relevant to the clinical features of BPH and had some predictive value for the outcome after prostatectomy. When DH occurs repeatedly Group 1) or occurs at a bladder volume of <160 mL (Group 2), there is a greater risk ofpost-operative irritation symptoms. Abnormal urodynamic findings can also predict the post-operative persistence of DH.
1Eulji University School of Mediciene, Dept of Urology, Seoul, South Korea, 2Taegu Catholic University School of Mediciene, Dept of Urology, Daegu, South Korea INTRODUCTION & OBJECTIVES: Continuous running irrigation system enables the surgeons to reduce the time of emptying bladder while they resect prostate adenoma and give them a chance of more convenient and effective operation. Twenty-six Fr or bigger sheath has been used in this system so far, therefore there has been a relatively high risk of postoperative urethral stricture in Korean. Recently, 22Fr sized continuous running system with 12-degree telescope became available. We tried to evaluate the efficacy and safety of 22Fr sized continuous running irrigation system in Korean. MATERIAL & METHODS: Total of seventy patients with severe symptomatic BPH underwent transurethral prostatectomy (TURP) under general or spinal anesthesia. In 31 cases, 26Fr system was used (group I) and 22Fr system was used in 39 patients (group 2). Urethral catheter was removed 1 to 3 days postoperatively. Total resection weight, resection rate, intraoperative complication rate such as capsular injury and severe bleeding were compared between 2 groups. Immediate postoperative complication rate was also compared. Patients were followed in 2 weeks, 4 weeks, 3 months and 6 months postoperatively with careful evaluation of uroflow and development of urethral stricture. RESULTS: Total resection weight were ll.2J:10.2gm in group I and 14.8±9.5gm in group 2(p>0.05). Resection rate were 0.ig±0.11gm/min in group 1 and 0.24+0.10gin/rain in group 2. There was no big difference in the size of resected chips. Urethral stricture requiring any type of management were noted in 38.7% (12/31) of group 1 and 15.4% (6/39) of group 2(io<0.05). While the most frequently affected site was bulbomembranous urethra (50%) in group 1, that was meatus (66%) in group 2. Urethroscopic internal urethrotomy was performed in 9.7% (3/31) and 2.6% (1/39), respectively. Other complications were 1 intaoperative fever and 1 epididymitis in group 1, and 1 capsular perforation, 1 TUR syndrome, 1 epididymitis and 1 delayed bleeding in group 2. CONCLUSIONS: TURP using 22Fr sized continuous running irrigation system enabled the surgeon to resect prostate adenoma in a similar speed and effectiveness compared with using 26Fr system. Instead, it significantly reduced the risk of postoperative urethral sticture. Thus, TURP using this system can be considered first line therapy for the patients with severe BPH requiring surgery.
European Urology Supplements 4 (2005) No. 3, pp. 187
738
HOLMIUM LASER ENUCLEATION OF THE PROSTATE IS MORE C O S T EFFECTIVE T H A N OPEN P R O S T A T E C T O M Y : R E S U L T S O F A RANDOMIZED PROSPECTIVE STUDY
E X P E R I E N C E S OF A N E W DEVICE F O R MEDIATING PROSTATIC INJECTIONS OF DRUGS VIA THE URETHRA
Salonia A., Suardi N., Mazzoccoli B., Naspro R., Zanni G., Briganti A., Scattoni V., Bua L., Rigatti E, Montorsi F.
ILjungbyHospital, Departmentof Surgery,Ljungby, Sweden,2KalmarCounty Hospital, Department of Urology, Kalmar, Sweden
University Vita-Salute San Raffaele, Dept. Urology, Milan, Italy I N T R O D U C T I O N & OBJECTIVES: A peri-operative economic impact analysis was carried out comparing open prostatectomy (OP) and Holmium Laser enucleation (HoLEP) in patients (pts) with symptomatic high volume benign prostatic hyperplasia (BPH). MATERIAL & METHODS: Between February and May 2004, 63 pts matched for age-, ASA, serum total-PSA, and prostate weight were randomized into: Group 1:29 pts (mean age +/-SD: 68.0+/-6.4 yrs) undergoing OP and Group 2 : 3 4 pts (67.4+/-6,7 yrs) undergoing HoLEE A detailed hospital cost comparison of the critical pre-, intra- and post-operative data and a net cost savings (%) calculation were performed. RESULTS: Patients' characteristics. Group 1 vs. Group 2: mean+/-SD age: 68.0+/-6.4 vs. 67.4+/-6.7, p=0.75; ASA: 1.8:t:0.1 vs 1.7~-0.1, p=0.31; PSA: 7.2+/4.7 vs. 8.0+/-8.4, p=0.71; prostate weight: 120.9+/-34.9 vs. 113.8+/-36.9, p=0.60. The costs analysis model showed a mean cost of 62797.8 for Group 1 and 62288.2 for Group 2. A direct comparison analysis showed that the most significant cost factors were the operative time, which contributed 16.5% on average to the cost of open prostatectomy and 25.8% to the cost of HoLEP and length ofpost-op hospital stay, which contributed 54.6% on average to the cost of Group 1 and 32.9% to the cost of Group 2. The calculated net cost saving (%) of HoLEP versus open prostatectomy was 617362.4 (9.9%). C O N C L U S I O N S : These data show that HoLEP promotes a significant hospital net cost saving (%) compared to OP in patients suffering from symptomatic high volume benign prostatic hyperplasia.
INTRA-
RichthoffJ. I, Schelin S.~
INTRODUCTION& OBJECTIVES: The Schelin CatheterT M is a new device for injection of drags into the prostate via the urethra. There are several possible applications for this device. In our clinics the Schelin Catheter has been used for local anaesthesia of the prostate prior to microwave thermotherapy in patients with benign prostatic hyperplasia (BPH). Local anaesthesia with epinephrine was administered with two intentions: 1) Local anaesthesia, 2) Minimizing the intraprostatic blood flow. MATERIAL & METHODS: A total of 113 patients with BPH, 41 in Ljungby and 72 in Kalmar,were treated with ProstaLund Feedback Treatment® (PLFT®).Prior to treatment injectionsof mepivacaine epinephrine (ME) were administered using the Schelin Catheter. In Kalmar a total amount of 30 ml of the drug, 10 ml of 1% and 20 ml of 0.5% solution, was infiltrated into 4 different positions in the prostate, i.e. into every quadrant. However,in Ljungby different injection techniques were used. Mean treatment time, energy consumption,maximum intraprostatic temperature and the amount of tissue necrosis as calculated by the device for these patients were comparedwith the same variables for the PLFT patients (not given ME) in three prospective clinical studies: study A, B and C. RESULTS: Treatment time and energy consumptionwere considerably lower in the Ljungby and Kalmar group than in the three prospective studies. However, maximum intraprostatic temperature and tissue destruction were in the same range for all five patient groups (see table). Moreover, none of the patients in Ljungby and Kalmar required additional medication during the treatment. Variables Schelin Catheter Treatment Time (min.) Energy Consumption(kJ) Max Intrapmstatic Temp (°C) Tissue Des~uction (g)
Study A n= 100 No 57.2 164
Study B n=42 No 54.6 179
Study C n=40 No 45.8 169
Ljungby n=41 Yes 21.9 61.4
Kalmar n=72 Yes 11.6 31.3
57.7
61.3
58.2
58.0
59.1
16.4
22.2
18.4
16.2
16.2
:ONCLUSIONS:The results suggest that treatment time and energy consumptionare significantly reduced after intraprostatic injections of mepivacaine epinephrine prior to PLFT. Good anaesthesia was attained in all the eases. Since the amount of tissue destruction and maximum intraprostatic temperatures are not affected, the efficacy of the treatment seems to be the same as the prolonged treatment without the Schelin Catheter.
739
740
B L A D D E R OUTLET OBSTRUCTION DUE TO BENIGN PROSTATIC E N L A R G E M E N T : U R O D Y N A M I C EVALUATION OF S U R G I C A L OUTCOME
TRANSURETHRAL PROSTATECTOMY USING 22FR SIZED CONTINUOUS RUNNING IRRIGATION SYSTEM RESECTOSCOPE Yoo T.K. 1, Cho J.M. l, Kang J.Y/, Jung J.YJ, Kim D.Y.2
Kalantzis A., Argiropoulos A., Aristas O., Doumas K., Gkialas I., Lykourinas M. General Hospital of Athens "G.Gennimatas", Urology, Athens, Greece INTRODUCTION & OBJECTIVES: We correlated urodynamic findings to the clinical features of with bladder outlet obstruction due to benign prostatic hyperplasia (BPH) and compared them in terms of outcome after successful removal of bladder neck obstruction by transurethral prostatectomy (TUR-P) or surgical enucleation of the prostate. MATERIAL & METHODS: 410 male patients with BPH aged 53-83 (mean 69.4) years were operated by TUR-P or surgical enucleation of the prostate. All the patients showed Detrusor Hyperflexia (D.H.) pre-operatively. The patients, were considered to have (D.H.) because of BPH. The patients were classified according to their urodynamic findings. Group 1 was the continual sporadic onset and offset of (D.H.), Group 2 was a single episode of DH at a bladder volume of<160 mL, and Group 3 was a single DH episode at a bladder volume >160 mL. All the patients were evaluated with the International Prostatic Symptom Score (IPSS), Quality of Life (QOL) score and urodynamic study up to 6 and 12 months postoperatively. RESULTS: Urodynamic study findings at 6 and 12 months postoperatively were compared with the pre-operative findings. (82%) from the patients of Group 2 and all the patients of Group 3 showed an absence of DH after surgery and the QOL score, average improved significantly (p<0.0001). In contrast, (62.5%) from the patients of Group 1 showed persistent DH. Compared with Group 2 and 3 patients, Group 1 patients more frequently complained of urgency before surgery and their symptoms and urodynamic parameters did not improve afterward. Low bladder compliance correlated significantly with an increase in age and prostate volume, detrusor instability and impaired contractility. Low compliance also correlated with in'itative symptoms, decreased maximum flow rate, increased post-void residual urine and an increase in the total IPSS score. CONCLUSIONS: Among the urodynamic parameters investigated, low compliance was the most relevant to the clinical features of BPH and had some predictive value for the outcome after prostatectomy. When DH occurs repeatedly Group 1) or occurs at a bladder volume of <160 mL (Group 2), there is a greater risk ofpost-operative irritation symptoms. Abnormal urodynamic findings can also predict the post-operative persistence of DH.
1Eulji University School of Mediciene, Dept of Urology, Seoul, South Korea, 2Taegu Catholic University School of Mediciene, Dept of Urology, Daegu, South Korea INTRODUCTION & OBJECTIVES: Continuous running irrigation system enables the surgeons to reduce the time of emptying bladder while they resect prostate adenoma and give them a chance of more convenient and effective operation. Twenty-six Fr or bigger sheath has been used in this system so far, therefore there has been a relatively high risk of postoperative urethral stricture in Korean. Recently, 22Fr sized continuous running system with 12-degree telescope became available. We tried to evaluate the efficacy and safety of 22Fr sized continuous running irrigation system in Korean. MATERIAL & METHODS: Total of seventy patients with severe symptomatic BPH underwent transurethral prostatectomy (TURP) under general or spinal anesthesia. In 31 cases, 26Fr system was used (group I) and 22Fr system was used in 39 patients (group 2). Urethral catheter was removed 1 to 3 days postoperatively. Total resection weight, resection rate, intraoperative complication rate such as capsular injury and severe bleeding were compared between 2 groups. Immediate postoperative complication rate was also compared. Patients were followed in 2 weeks, 4 weeks, 3 months and 6 months postoperatively with careful evaluation of uroflow and development of urethral stricture. RESULTS: Total resection weight were ll.2J:10.2gm in group I and 14.8±9.5gm in group 2(p>0.05). Resection rate were 0.ig±0.11gm/min in group 1 and 0.24+0.10gin/rain in group 2. There was no big difference in the size of resected chips. Urethral stricture requiring any type of management were noted in 38.7% (12/31) of group 1 and 15.4% (6/39) of group 2(io<0.05). While the most frequently affected site was bulbomembranous urethra (50%) in group 1, that was meatus (66%) in group 2. Urethroscopic internal urethrotomy was performed in 9.7% (3/31) and 2.6% (1/39), respectively. Other complications were 1 intaoperative fever and 1 epididymitis in group 1, and 1 capsular perforation, 1 TUR syndrome, 1 epididymitis and 1 delayed bleeding in group 2. CONCLUSIONS: TURP using 22Fr sized continuous running irrigation system enabled the surgeon to resect prostate adenoma in a similar speed and effectiveness compared with using 26Fr system. Instead, it significantly reduced the risk of postoperative urethral sticture. Thus, TURP using this system can be considered first line therapy for the patients with severe BPH requiring surgery.
European Urology Supplements 4 (2005) No. 3, pp. 187