Have You Read? June 2021
By: Daniel Shoskes, MD | Posted on: 01 Jun 2021
Gilfrich C, May M, Fahlenbrach C et al: Surgical reintervention rates after invasive treatment for lower urinary tract symptoms due to benign prostatic syndrome: a comparative study of more than 43,000 patients with long-term followup. J Urol 2021; 205: 855–863.
With the proliferation of choices to treat benign prostatic hyperplasia, patient choice should be driven by transparency of all outcomes. A choice dependent on type of anesthesia, convenience, chance of retrograde ejaculation, symptom improvement and time-dependent risk of recurrence all require good data for those variables. In this study the authors looked at reintervention outcomes for the surgical options available.
A total of 43,041 male patients with lower urinary tract symptoms who underwent transurethral resection (34,526), photoselective vaporization (3,050), laser enucleation (1,814) or open simple prostatectomy (3,651) between 2011 and 2013 were identified in the German local health care funds and followed for 5 years. Surgical reinterventions for lower urinary tract symptoms, urethral stricture or bladder neck contracture were evaluated. A total of 5,050 first reinterventions were performed within 5 years of primary surgery. Photoselective vaporization carried an increased hazard of reintervention (HR 1.31, 95% CI 1.17–1.46, p <0.001) relative to transurethral resection, open simple prostatectomy carried a lower hazard (HR 0.43, 95% CI 0.37–0.50, p <0.001) and laser enucleation of the prostate did not differ significantly (HR 0.84, 95% CI 0.66–1.08, p=0.2). This pattern was more pronounced regarding reintervention for lower urinary tract symptom recurrence.
The authors conclude that 5-year reintervention rates of transurethral resection and laser enucleation did not differ significantly, while photoselective vaporization had a substantially higher rate. Open simple prostatectomy remains superior to transurethral resection with respect to long-term efficacy.
Nabavizadeh R, Higins MI, Patil D et al: Overlapping urological surgeries at a tertiary academic center. Urology 2021; 148: 118–125.
Hitchens’s razor states: “What can be asserted without evidence can also be dismissed without evidence.” Sadly, this cannot apply to overlapping surgery restrictions which have been implemented without demonstration of patient harm. In this study the authors wished to evaluate whether the practice of procedure-time overlapping surgery (OS) is associated with inferior outcomes compared to nonoverlapping surgery (NOS) in urology. They reviewed all urological surgeries at a single tertiary-level academic center from July 2016 to July 2018. Patients who received OS were matched 1:2 to patients who had NOS. The primary outcomes were perioperative and postoperative complications and mortality. Of 8535 urological surgeries in-room time overlap was seen in 50.5% of cases and procedure-time overlap in 7.4%. Eleven out of the 13 attending urologists performed OS. The average time in the operating room was greater for OS by an average of 14 minutes. The average operative time was greater for OS than NOS by 11 minutes, but this did not reach statistical significance. There was no significant difference between the cohorts for rate of blood transfusions, ICU stay, need for postoperative invasive procedures, length of postoperative hospital stay, discharge location, emergency room visits, hospital readmission rate, 30-day and 90-day rates of postoperative complications, and mortality.
The authors conclude that procedure-time overlapping surgeries constituted a minority of urological cases. OS were associated with greater in-room time. They found no increased risk of perioperative or postoperative adverse outcomes in OS compared to matched NOS.
Summers SJ, Armstrong JM, Kaplan SA et al: Male voiding behavior: insight from 19,824 at-home uroflow profiles. J Urol 205:1126, April 2021
A lot of weight is placed on symptoms and signs compiled during an office visit, but is what we see in a snapshot of time really representative of the patient’s at-home behaviors? Certainly the advantage of 24-hour Holter monitor over an in office EKG are well known. In this study, the authors used a home uroflow device to assess individual voiding variability, temporal distribution of voiding parameters and the impact of age on voiding. A total of 19,824 unique voiding profiles were captured using the Stream Dx Uroflowmeter and retrospectively analyzed. A total of 637 patients were identified with 625 meeting inclusion criteria, producing 19,824 voids. Mean age was 67 years old, and each patient provided on average 5 (±3.3) voids a day through 7 days. Average intrapatient voiding parameters showed notable variability, where the coefficient of variation for maximum flow was 27.6% (95% CI 26.6–28.6). Early morning voids were associated with higher volume and lower number of voids. As age progressed, voiding profiles worsened in a linear fashion. Afternoon and evening voids were associated with reduced intrapatient variability relative to early morning voids.
The authors conclude that an individual’s voiding parameters vary greatly from day to day, throughout the day, and worsen with age. Multiple measurements performed at home provide a more realistic assessment of true voiding behavior by capturing individual voiding variability.