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Figure 1d Average BPH impact index preoperatively and postoperatively up to 12 months after transurethral resection of the prostate (TURP), contact laser prostatectomy (Laser) and electrovaporization (Vaportrode).

Figure 1 d Average BPH impact index preoperatively and postoperatively up to 12 months after transurethral resection of the prostate (TURP), contact laser prostatectomy (Laser) and electrovaporization (Vaportrode).

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1.1 ANATOMY AND PHYSIOLOGY
1.1 ANATOMY AND PHYSIOLOGY
The prostate is made up of several components: epithelial, stromal, and non-cellular components. The tubuloalveolar glands of the prostate form acini, which are lined with epithelium. Some of these cells, luminal cells, produce specific products like prostate specific antigen (PSA): a secretory proteinase found in high concentration in semen. Only small plasma levels are found in healthy men, unless the barrier between these cells and blood vessels is damaged by inflammation or prostate cancer. Each acinus is surrounded by stroma containing fibroblasts and smooth muscle cells’. These stromal cells are amid a background of extracellular matrix made up of a divers group of glycoproteins. It forms a necessary framework in which all cells interact.
The prostate is made up of several components: epithelial, stromal, and non-cellular components. The tubuloalveolar glands of the prostate form acini, which are lined with epithelium. Some of these cells, luminal cells, produce specific products like prostate specific antigen (PSA): a secretory proteinase found in high concentration in semen. Only small plasma levels are found in healthy men, unless the barrier between these cells and blood vessels is damaged by inflammation or prostate cancer. Each acinus is surrounded by stroma containing fibroblasts and smooth muscle cells’. These stromal cells are amid a background of extracellular matrix made up of a divers group of glycoproteins. It forms a necessary framework in which all cells interact.
1.2 PATHOFYSIOLOGY, EPIDEMIOLOGY AND NATURAL HISTORY OF BPH For unknown reasons, abnormal growth of the prostate is almost unique to human and dogs. It is not seen in other mammals. Also intriguing is the fact that this abnormal growth seems to be limited to the prostate. Embryologically related sex accessory tissues, like the seminal vesicles and bulbourethral glands, demonstrate only very rarely tumours. Many factors are involved in prostatic growth. The two long known etiologic factors for the development of BPH are aging and functional testes”. However, this concept is displaced by modern research which proposed a more complex concept of prostatic growth. Although this concept is unfinished, it involves
1.2 PATHOFYSIOLOGY, EPIDEMIOLOGY AND NATURAL HISTORY OF BPH For unknown reasons, abnormal growth of the prostate is almost unique to human and dogs. It is not seen in other mammals. Also intriguing is the fact that this abnormal growth seems to be limited to the prostate. Embryologically related sex accessory tissues, like the seminal vesicles and bulbourethral glands, demonstrate only very rarely tumours. Many factors are involved in prostatic growth. The two long known etiologic factors for the development of BPH are aging and functional testes”. However, this concept is displaced by modern research which proposed a more complex concept of prostatic growth. Although this concept is unfinished, it involves
Table 1 showing a subdivision of lower urinary tract symptoms (LUTS) m—ee UF UR Se wy Tia he bell aol a eee eee =a) oe oa eS ee Se: ~~ ww bated be Rol lt bothersome”. LUTS can be quantified by using questionnaires developed by the America Urological Association (AUA). The measurement committee of the AUA developec the International Prostate Symptom Score (I-PSS) to quantify the prevalence o symptoms”. The I-PSS consists of seven questions, concerning incomplet emptying, frequency, intermittency, urgency, weak urinary stream, hesitancy an nocturia. Questions can be answered on a scale of 0 (not at all) to 5 (almost always) The sum of the scores forms the index, varying from O to 35, and is also known a: the symptom score index. Of even more importance for treatment is the bothersomeness of these symptoms and their effect on the quality of life?‘ Therefore the AUA measurement committee also developed and validated « Symptom Problem Index (SPI) with 7 bothersomeness questions of which eacl corresponds to a symptom question of the |-PSS?’. Each question can be answere on a scale of 0 (not at all) to 4 (very much), leading to an index varying from 0 to 28 however, that symptoms could be found in men with one, two, three or none of the aforementioned entities. Even in old males it is possible to find symptoms without prostatic pathology. Their symptoms can be caused by other age related pathology, like detrusor instability or low bladder volumes due to hypersensitivity or bladder carcinoma’®"®. Other lower urinary tract pathology may also cause similar problems, like cystolithiasis, infection or prostate cancer'”"®. The finding that similar urinary problems can also occur in women, provides further evidence that these symptoms can arise independent of prostatic presence'’”°*' Therefore, the term lower urinary tract symptoms (LUTS) has been introduced”. It covers all voiding and storage symptoms, without stating anything about etiology or gender.
Table 1 showing a subdivision of lower urinary tract symptoms (LUTS) m—ee UF UR Se wy Tia he bell aol a eee eee =a) oe oa eS ee Se: ~~ ww bated be Rol lt bothersome”. LUTS can be quantified by using questionnaires developed by the America Urological Association (AUA). The measurement committee of the AUA developec the International Prostate Symptom Score (I-PSS) to quantify the prevalence o symptoms”. The I-PSS consists of seven questions, concerning incomplet emptying, frequency, intermittency, urgency, weak urinary stream, hesitancy an nocturia. Questions can be answered on a scale of 0 (not at all) to 5 (almost always) The sum of the scores forms the index, varying from O to 35, and is also known a: the symptom score index. Of even more importance for treatment is the bothersomeness of these symptoms and their effect on the quality of life?‘ Therefore the AUA measurement committee also developed and validated « Symptom Problem Index (SPI) with 7 bothersomeness questions of which eacl corresponds to a symptom question of the |-PSS?’. Each question can be answere on a scale of 0 (not at all) to 4 (very much), leading to an index varying from 0 to 28 however, that symptoms could be found in men with one, two, three or none of the aforementioned entities. Even in old males it is possible to find symptoms without prostatic pathology. Their symptoms can be caused by other age related pathology, like detrusor instability or low bladder volumes due to hypersensitivity or bladder carcinoma’®"®. Other lower urinary tract pathology may also cause similar problems, like cystolithiasis, infection or prostate cancer'”"®. The finding that similar urinary problems can also occur in women, provides further evidence that these symptoms can arise independent of prostatic presence'’”°*' Therefore, the term lower urinary tract symptoms (LUTS) has been introduced”. It covers all voiding and storage symptoms, without stating anything about etiology or gender.
Table 1 Preoperative characteristics and postoperative values together with significant differences.
Table 1 Preoperative characteristics and postoperative values together with significant differences.
Table 2 Reasons why 39 of 132 men were not followed at 6 months.
Table 2 Reasons why 39 of 132 men were not followed at 6 months.
No patient had a preoperative obstruction grade of 0. Table 4 Improvement in Schafer obstruction grade, symptom index, problem index, BPH impact index and quality of life in relation to preoperative obstruction grade.
No patient had a preoperative obstruction grade of 0. Table 4 Improvement in Schafer obstruction grade, symptom index, problem index, BPH impact index and quality of life in relation to preoperative obstruction grade.
Table 5 Postoperative improvement according to instability.
Table 5 Postoperative improvement according to instability.
Table 1 Baseline values in the enrolled group (n=132) versus those in the other groups undergoing transurethral surgery (n=109).
Table 1 Baseline values in the enrolled group (n=132) versus those in the other groups undergoing transurethral surgery (n=109).
Table 2 Baseline values of unobstructed and equivocal men (n=34) versus obstructed men (n=59 A large similarity was found between both groups, although statistically significant differences were also found. The baseline values (table 2) of the 9 equivocal or unobstructed men who did not undergo the six-month follow-up examinations did not differ significantly from those of the 34 equivocal or unobstructed followed-up men included in the study. Except for the quality of life score, the baseline values of the 30 obstructed men who did not undergo the six-month follow-up examinations also did not differ significantly from those of the 59 obstructed men. The quality of life score
Table 2 Baseline values of unobstructed and equivocal men (n=34) versus obstructed men (n=59 A large similarity was found between both groups, although statistically significant differences were also found. The baseline values (table 2) of the 9 equivocal or unobstructed men who did not undergo the six-month follow-up examinations did not differ significantly from those of the 34 equivocal or unobstructed followed-up men included in the study. Except for the quality of life score, the baseline values of the 30 obstructed men who did not undergo the six-month follow-up examinations also did not differ significantly from those of the 59 obstructed men. The quality of life score
Table 3 Improvements in unobstructed and equivocal men (n=34) versus those in the obstructed men (n=59). Except for obstruction grade and maximal free flow rate, the changes were very similar in both groups. In the obstructed men the median value of URA decreased from 46.0 to 15.0 cm water (p<0.001), in the equivocal group from 27.9 to 16.2 (p<0.001) and in the small group of 6 unobstructed men from 19.2 to 11.8 (p=0.03). No significant differences at all of improvements between the 6 unobstructed men and the 28 equivocal men could be detected. The different reasons why resection was performed in the equivocal and unobstructed men did not cause different postoperative benefits. lex all & :rneahatwriecnwtinal wm LOA AanennnnAd «fies Keematadanlbaescs lx A mnxar vf dian
Table 3 Improvements in unobstructed and equivocal men (n=34) versus those in the obstructed men (n=59). Except for obstruction grade and maximal free flow rate, the changes were very similar in both groups. In the obstructed men the median value of URA decreased from 46.0 to 15.0 cm water (p<0.001), in the equivocal group from 27.9 to 16.2 (p<0.001) and in the small group of 6 unobstructed men from 19.2 to 11.8 (p=0.03). No significant differences at all of improvements between the 6 unobstructed men and the 28 equivocal men could be detected. The different reasons why resection was performed in the equivocal and unobstructed men did not cause different postoperative benefits. lex all & :rneahatwriecnwtinal wm LOA AanennnnAd «fies Keematadanlbaescs lx A mnxar vf dian
Table 3 Reasons why included patients were not evaluated urodynamically after six months. With a Schafer grade of 2 or greater were included. The incidence of patients with a preoperative Schafer grade of 2 or greater who were also examined at six months was 71% for TURP, 66% for laser and 81% for EVAP. In the TURP group all patients showed a decrease in Schafer grade, including 94% who were unobstructed after TURP (Schafer grade 0 or 1). Only two patients were equivocal (Schafer grade 2). The Schafer grade had been 5 and 4 before surgery respectively.In the laser group all except one patient had a decrease in Schafer grade. In the laser group, 91% was unobstructed after laser therapy. The Schafer grade increased from 4 to 5 in one patient, decreased from 4 to 3 in a second patient and from 3 to 2 in a third patient. In the Vaportrode group all except two patients had a decrease in Schafer grade. These two patients showed no change with a Schafer grade of 2 (equivocal). Of all patients who underwent electrovaporization 72% were unobstructed, while Vaportrode, while the remaining 28% became (or staid: 2 patients) equivocal. Thus, no patients were obstructed after Vaportrode. Effartiva ranoarityv tc tha MaviImitm rvcetnmatrir viaAliima AiirTringn TIrnnd\vinamire miniic the
Table 3 Reasons why included patients were not evaluated urodynamically after six months. With a Schafer grade of 2 or greater were included. The incidence of patients with a preoperative Schafer grade of 2 or greater who were also examined at six months was 71% for TURP, 66% for laser and 81% for EVAP. In the TURP group all patients showed a decrease in Schafer grade, including 94% who were unobstructed after TURP (Schafer grade 0 or 1). Only two patients were equivocal (Schafer grade 2). The Schafer grade had been 5 and 4 before surgery respectively.In the laser group all except one patient had a decrease in Schafer grade. In the laser group, 91% was unobstructed after laser therapy. The Schafer grade increased from 4 to 5 in one patient, decreased from 4 to 3 in a second patient and from 3 to 2 in a third patient. In the Vaportrode group all except two patients had a decrease in Schafer grade. These two patients showed no change with a Schafer grade of 2 (equivocal). Of all patients who underwent electrovaporization 72% were unobstructed, while Vaportrode, while the remaining 28% became (or staid: 2 patients) equivocal. Thus, no patients were obstructed after Vaportrode. Effartiva ranoarityv tc tha MaviImitm rvcetnmatrir viaAliima AiirTringn TIrnnd\vinamire miniic the
1. Average of all individually calculated changes (posttreatment/ pretreatment value). Table 5 Changes in Symptom Score, Bother Score and Quality of Life (averages + standard deviations).
1. Average of all individually calculated changes (posttreatment/ pretreatment value). Table 5 Changes in Symptom Score, Bother Score and Quality of Life (averages + standard deviations).
Table 1 Mean + standard deviation of baseline characteristics of the 3 treatment groups. Table 2 Mean + standard deviation of perioperative parameters.
Table 1 Mean + standard deviation of baseline characteristics of the 3 treatment groups. Table 2 Mean + standard deviation of perioperative parameters.
Table 3 Number of intraoperative complications (all operations included, also when patients were excluded for further analysis).
Table 3 Number of intraoperative complications (all operations included, also when patients were excluded for further analysis).
Table 4 postoperative morbidity and mortality within 12 months (without urinary tract infections)
Table 4 postoperative morbidity and mortality within 12 months (without urinary tract infections)
Table 5 Mean + standard deviation of subjective scores from AUA questionnaires of the 3 treatment groups postoperatively, nor at any other time interval. For the quality of life (QoL) there was a significant difference (p=0.03) one week postoperatively, in favour of the group treated with contact laser. QoL changed one week postoperatively from 3.8 to 4.0 in the transurethral prostatic resection group, from 4.1 to 3.8 in the electrovaporization group and from 3.7 to 2.4 in the laser group. At six weeks postoperatively there was no significant difference among the three treatment modalities anymore, nor at any other time interval. For the BPH impact index (BIl) there were no significant differences among the three treatment modalities at any interval, although there was a trend suggesting a larger decrease in BIl for patients treated with the contact laser. Figure 2a shows a graphic representation of daytime frequency. There was a significant (p<0.02 in all groups) decrease from about 8.5 to about 6.5. There were no significant differences between the groups at any time interval. There was a slight increase of frequency during the first weeks postoperatively in all groups. After about six weeks the number of voids during daytime returned to the pre-operative value, after which it dropped further.
Table 5 Mean + standard deviation of subjective scores from AUA questionnaires of the 3 treatment groups postoperatively, nor at any other time interval. For the quality of life (QoL) there was a significant difference (p=0.03) one week postoperatively, in favour of the group treated with contact laser. QoL changed one week postoperatively from 3.8 to 4.0 in the transurethral prostatic resection group, from 4.1 to 3.8 in the electrovaporization group and from 3.7 to 2.4 in the laser group. At six weeks postoperatively there was no significant difference among the three treatment modalities anymore, nor at any other time interval. For the BPH impact index (BIl) there were no significant differences among the three treatment modalities at any interval, although there was a trend suggesting a larger decrease in BIl for patients treated with the contact laser. Figure 2a shows a graphic representation of daytime frequency. There was a significant (p<0.02 in all groups) decrease from about 8.5 to about 6.5. There were no significant differences between the groups at any time interval. There was a slight increase of frequency during the first weeks postoperatively in all groups. After about six weeks the number of voids during daytime returned to the pre-operative value, after which it dropped further.
Figure 1c Average quality of life score preoperatively and postoperatively up to 12 months after transurethral resection of the prostate (TURP), contact laser prostatectomy (Laser) and electrovaporization (Vaportrode).
Figure 1c Average quality of life score preoperatively and postoperatively up to 12 months after transurethral resection of the prostate (TURP), contact laser prostatectomy (Laser) and electrovaporization (Vaportrode).
Figure 2a Number of daytime voids (frequency during daytime) preoperatively and postoperatively up to twelve months after transurethral resection of the prostate (TURP), contact laser prostatectomy (Laser) and electrovaporization (Vaportrode).
Figure 2a Number of daytime voids (frequency during daytime) preoperatively and postoperatively up to twelve months after transurethral resection of the prostate (TURP), contact laser prostatectomy (Laser) and electrovaporization (Vaportrode).
Figures 5a and 5b Percentage of patients with haematuria in the last week (a) and average severity (score 1 to 5) times number of days (0 to 7) haematuria was present in the last week (b).
Figures 5a and 5b Percentage of patients with haematuria in the last week (a) and average severity (score 1 to 5) times number of days (0 to 7) haematuria was present in the last week (b).
Figures 6a and 6b Percentage of patients with incontinence in the last week (a) and average severity (score 1 to 5) times number of days (0 to 7) incontinence was present in the last week (b).
Figures 6a and 6b Percentage of patients with incontinence in the last week (a) and average severity (score 1 to 5) times number of days (0 to 7) incontinence was present in the last week (b).
Figure 1c Quality of life score at baseline and during follow-up. Data are presented as mean with standard deviation.
Figure 1c Quality of life score at baseline and during follow-up. Data are presented as mean with standard deviation.
Figure 1d BPH impact index at baseline and during follow-up. Data are presented as mean with standard deviation.
Figure 1d BPH impact index at baseline and during follow-up. Data are presented as mean with standard deviation.
Figure 2a Frequency during daytime at baseline and after follow-up. Data are presented as mean with standard deviation.
Figure 2a Frequency during daytime at baseline and after follow-up. Data are presented as mean with standard deviation.
Figure 2b Frequency during nighttime at baseline and after follow-up. Data are presented as mear with standard deviation.
Figure 2b Frequency during nighttime at baseline and after follow-up. Data are presented as mear with standard deviation.
Recalculations based on hospital stay of the last two years of the trial. Table 2 Costs in Euros (€) per patient after 12 months follow-up for the three different treatments. A sensitivity analysis is included showing the costs after recalculations with different assumptions.
Recalculations based on hospital stay of the last two years of the trial. Table 2 Costs in Euros (€) per patient after 12 months follow-up for the three different treatments. A sensitivity analysis is included showing the costs after recalculations with different assumptions.
Table 1 High-risk characteristics. In 1a only the main reason for using anti-coagulant therapy is presented.
Table 1 High-risk characteristics. In 1a only the main reason for using anti-coagulant therapy is presented.
Table 2 General, urodynamic and symptomatic characteristics of high-risk (HR) patients and normal- risk (NR) controls preoperatively. Data presented as means + standard deviation.
Table 2 General, urodynamic and symptomatic characteristics of high-risk (HR) patients and normal- risk (NR) controls preoperatively. Data presented as means + standard deviation.
1. Ratio = postvalue/ prevalue, and percent change = {(prevalue — postvalue)/ prevalue} * 100% Table 3 Urodynamic, symptomatic and subjective changes postoperatively of high-risk (HR) patients and normal-risk (NR) controls. Data presented as means + standard deviation.
1. Ratio = postvalue/ prevalue, and percent change = {(prevalue — postvalue)/ prevalue} * 100% Table 3 Urodynamic, symptomatic and subjective changes postoperatively of high-risk (HR) patients and normal-risk (NR) controls. Data presented as means + standard deviation.
Table 4 Perioperative parameters. Data presented as means + standard deviation.
Table 4 Perioperative parameters. Data presented as means + standard deviation.
Figure 3 Graphic representation of the effective capacity in the three different groups at baseline and six months postoperatively. Effective capacity is defined as the maximum cystometric capacity minus the post-void residual volume. Data presented as means + standard deviations.
Figure 3 Graphic representation of the effective capacity in the three different groups at baseline and six months postoperatively. Effective capacity is defined as the maximum cystometric capacity minus the post-void residual volume. Data presented as means + standard deviations.
Figure 4 Graphic representation of subjective and symptomatic parameters in the three different groups at baseline and six months postoperatively. SS: symptom score index, BS: bother score index or symptom problem index, BIl: BPH impact index, and QL: Quality of Life. Data presented as means + standard deviations. Subjective and Symptomatic parameters
Figure 4 Graphic representation of subjective and symptomatic parameters in the three different groups at baseline and six months postoperatively. SS: symptom score index, BS: bother score index or symptom problem index, BIl: BPH impact index, and QL: Quality of Life. Data presented as means + standard deviations. Subjective and Symptomatic parameters
Related topics:
NephrologySurgeryUrologyBenign Prostatic HyperplasiaLaser TherapyLower Urinary Tract SymptomsUrogenital System
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