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. 2015 Oct;7(Suppl 3):S232–S258.

Benign Prostatic Hyperplasia

PMCID: PMC4678519
Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Time for benign prostatic hyperplasia investigation and therapy shakedown

Anwar Halim

Department of Urology, Tawam Hospital, United Arab Emirates

Confusion clouds enlarged Prostate investigation and treatment, as worldwide studies produce mixed results with surgery, balloons and drugs. A personal series of 1200 patients over a 10 year period indicate that innovative alternative methods of investigations and advances in non-invasive therapy is significant for a group of patients who may not be candidates for surgery. Intravenous urography and prostatectomy represents a significant portion of the National Health expenditure and with rising cost in health care properly controlled, clinical trials will provide more direct long term information.

In our generation, we will likely witness an evolution in the common male ailment which was first described in the 15th century B.C. Papyrus and where one out of every 4 males in a 50 year age group has a chance of undergoing prostatectomy during his lifetime. Following an overview of our work in Tawam Hospital, new modalities of investigation and treatment will be discussed.

This study tends to highlight the outstanding features of this development.

Presented at the: 6th Saudi Urological Conference

National Guard King Khalid Hospital, Jeddah

27–28 November 1991

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Obstructive benign prostatic hyperplasia, Security Forces Hospital experience in over 1000 cases

G.M. Rifai, S. Kona, A. Botros

Department of Surgery, Division of Urology, Security Forces Hospital, Riyadh, Saudi Arabia

BPH is very common in males over 50 years old. However, in more than 50% of cases no management, or minimal one, is needed. For management to be implemented, two factors have to be established. First, that hyperplasia is benign and second, that hyperplasia is causing reasonable obstruction interfering with quality of life. Since December 1985 to December 1990 over 1000 patients with BPH were managed with different modalities including TURP, open prostatectomies, TUIBN and alphablocker. Discussion and conclusion of different management options available will be presented.

Presented at the: 7th Saudi Urological Conference

Riyadh Armed Forces Hospital

11–12 November 1992

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Hormonal profile in benign prostatic hyperplasia

M.A. Taha, H. El Damassy, M.H. El Shazly, B. Kabbani

Department of Urology, Hail General Hospital, Hail, Saudi Arabia

Radio-immune assay of Testosterone, Oestradiol, Sex hormone binding globuline, FSH, LH, and Prolactin has been carried on for estimating the concentration of these hormones in peripheral venous in benign prostatic hyperplasia (BPH) patients. The test was done for three groups.

Group A, 26 cases of age matched controls. Group B, 26 cases with objective and subjective evidence of BPH. Group C, 26 cases with objective evidence of BPH but no Symptoms - "Asymptomatic Group."

The results showed decreased Serum "T" in all the three groups. However, this "T" depression was the least in group (B) patients in comparison to that for groups A and C.

Serum oestradiol (E2) was found to be significantly higher in BPH patients (B and C). Also, patients with BPH showed significant increase in E2/T ratio (X 100). This increase was maximum in group (B).

Sex hormone binding globulin (SHBG) was high in all the three groups compared to the reference mean.

Also, FSH and LH levels showed high figure in all groups compared to the reference mean. This increase was within the reported increased levels with aging.

No significant change in Serum Prolactin level were detected.

The above mentioned findings fit with most of the currently accepted data in the recent literature. The exact mechanisms for BPH pathogenesis are still not fully clear. However, the DHT concept, E2 synergistic role and the embryonic reawakening theory from the main platforms in this respect.

Presented at the: 9th Saudi Urology Conference

King Fahad Hospital, Jeddah

14–16 November 1995

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Recent advances in the management of benign prostatic hyperplasia

M.S. Abomelha

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

Benign prostatic hyperplasia (BPH) is a disease in middle-aged and elderly men. Histological, clinical and symptomatic BPH are the three forms of presentation. Around 50% of men over the age of 65 suffer from BPH symptoms. The percentage of the population in this age group are 13% in the States, 16% in England and only 2.6% in Saudi Arabia. The figure for Saudi Arabia explains in part the low incidence of BPH among Saudi patients, keeping in mind that 49% of the Saudi population are below 15 years of age. The magnitude of the disease in North America and Europe is very high causing a problem to health care providers. The low incidence in Saudi Arabia is related to young aged populations and may be related to the type of BPH (relation between glandular and stromal component). It is worth to notice that the inpatient workload for BPH is only 10% in Saudi hospitals compared to 30–40% in Europe.

The management of BPH is undergoing a lot of development over the last 5 years. The standard surgical modalities e.g. open prostatectomy, TURP, TUIP, are efficient and safe treatments. These surgical methods have lost some of their indications because of the high cost and morbidity. TURP used to be the gold standard, nevertheless, it is still the standard for large BPH with severe obstructive symptoms.

Until recently, urologists could manage BPH by a single choice between watchful waiting and TURP. Now new treatment modalities emerged. These new treatment modalities can be divided into two categories, namely, medical treatment and minimal invasive procedures.

The medical treatment utilizes α-1 blockers and 5-α-reductase inhibitors for the management of mild BPH. Each can be used alone or combined with evidence of significant improvement of symptoms even after 3 years of treatment duration. During treatment, the urologist should not forget to screen for cancer of the prostate, keeping in mind that PSA is decreased by the use of finasteride. New advancement is the existing discovery of α1A-adrenoreceptor subtype which is more specific for prostate with less side effect. Another future advancement is the theory of the existence of two active 5α-reductase Iso-enzymes, based on the fact that finasteride reduces the PSA level by only 50%.

Minimal invasive procedures for the treatment of moderate symptomatic BPH includes coils, balloons, lasers, TUNA, evaporation, thermal therapy, hyperthermia and high-intensity focused ultrasound. As yet, none of these new techniques have shown durable improvement of symptoms, increased flow rates and low re-operation rates, as achieved by TURP.

To avoid a cascade of treatments, any new emerging treatment methods should prove its long-term durability and its cost efficacy before adopting it as an accepted mode of treatment.

Presented at the: 10th Saudi Urology Conference

King Fahad National Guard Hospital

26–28 November 1996

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

New medical treatment modalities for benign prostatic hyperplasia

T. Senge

Department of Urology, University of Bochum, Marienhospital Universitatklinik, Germany

The efficacy of treatment of benign prostatic hyperplasia (BPH) is presently under critical consideration. In addition, various new therapeutic modalities are currently being evaluated. When medicamentous treatment is planned, in particular, the natural history of the disease must be carefully considered. Summarized data from several studies indicate that spontaneous improvement of symptoms may occur within 3–6 months, while in most cases deterioration takes a longer period of time. As intraprostatic urethral pressure depends on prostatic volume as well as on tone of the prostate smooth muscle, different medical treatment modalities seem reasonable. The dynamic component of the smooth muscle cells may be influenced by α-blockers. Administration of selective α1-blockers will be advantageous as these have fewer side effects. Prostate volume represents the static component, which can be influenced by hormone treatment. Androgen deprivation via surgical castration must now be regarded as of historical interest only. Antiandrogens or LH-RH analogues have undesirable side effects and are expensive, making such treatment unacceptable for routine use. 5α-Reductase inhibitors may emerge as a new treatment form allowing androgen suppression with a low rate of side effects. As it has been proposed that estrogens play an important role in the regulation of prostatic growth, aromatase inhibitors, which metabolization from androgens to estrogens, may receive special attention in the near future.

Based on the theory that androgens may be of special importance for the epithelium, while estrogen action may be concentrated on the stroma, a combined treatment with inhibitors of 5α-reductase plus aromatase may be even more effective. The results available now, however, are not sufficient to indicate that transurethral resection of the prostate will be replaced by medicamentous treatment regimens in the near future.

Presented at the: 7th Saudi Urological Conference

Riyadh Armed Forces Hospital

11–12 November 1992

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Clinical experience of medical therapy for benign prostatic hyperplasia

Timothy J. Christmas

Department of Urology, Charing Cross and Westminster Medical School, London, UK

Trans-urethral prostatectomy (TURP) has been the predominant therapy for benign prostatic hyperplasia (BPH) for the last twenty years or more. However, dissatisfaction with the sexual dysfunction and other complications from TURP and the necessity for re-operation had driven the search for effective alternative treatments. This concept of a "prostate pill" an attractive idea that has stimulated increasing interest in drug therapy for BPH. Pharmaco-therapy for BPH began with the use of alpha-adrenoceptor blockers which were found to relax the smooth muscle component of BPH and hence reduce bladder outflow resistance. Initially, non-selective agents such as postural hypotension. More selective agents with a longer half-life such as terazosin, doxazosin and tansulosin have less side effects and are able to produce long-term improvement in symptoms and increase the maximum urinary flow rate by approximately 2 ml/s in men with BPH. However, these agents do not slow down the inexorable increase in size of the prostate.

In BPH prostate growth is dependent upon androgen stimulation and inhibition of this by LHRH analogues or anti-androgens such as flutamide has been shown to reduce prostate size by about 30% but also leads to untoward side-effects such as loss of libido, gynecomastia and hot flushes. The new 5-alpha-reductase agent finasteride, inhibits the conversion of testosterone to dihydro-testerone (the more active stimulant of prostatic growth) and thereby reduces the size of the prostate without lowering circulating testosterone level. Five year follow up of men taking finasteride has revealed a 24% reduction in prostate volume maintained over the long-term. Predictably this was accompanied by significant improvement in symptoms and an increase in the maximum flow rates of 2-1ml/s. There have been remarkably few side effects. A trial of combined finasteride and alpha-blocker is currently under way.

Presented at the: 9th Saudi Urology Conference

King Fahad Hospital - Jeddah

14–16 November 1995

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Medical management of benign prostatic hyperplasia

A. Al Jasser, G. Rifai, A. Al Hussein

Department of Urology, Security Forces Hospital, Riyadh, Saudi Arabia

Introduction: We started medical treatment for patient with BPH by Proscar and Minipress for more than two years. We will review our result.

Analysis: >200 cases of patients with BPH treated with this kind of therapy using AUA symptoms score-flowmetry and sometimes U/S plus routine investigation or U/E urinalysis. Routine rectal examination and PSA were done.

Summary and Conclusion: Proscar is well accepted. The main problem with Minipress is hypotension. 20–40% partial to complete response.

Presented at the: 9th Saudi Urology Conference

King Fahad Hospital, Jeddah

14–16 November 1995

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Transurethral resection of the prostate in very elderly patients

Saoud A. Taha, Adel Abdel Kader, Baher Kamal, Raymond Anikwe

Department of Urology, King Faisal University. Dammam, Saudi Arabia

152 patients with intravesical obstruction due to benign prostatic hyperplasia were evaluated and treated in King Fahd Hospital of King Faisal University, Dammam within the period of 8 years, from January 1982 to December 1989. An appreciable proportion of the patients were over the age of 80 years and a few over 100 years of age. Most of the patients had transurethral resection of the prostate (TURP) since the patients over 80 years of age did equally as well as those in younger age groups.

Presented at the: 6th Saudi Urological Conference

National Guard King Khalid Hospital, Jeddah

27–28 November 1991

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Minimizing the risk of prostatic surgery in the elderly patients

Farouk Ghany

Department of Urology, King Fahad Hospital, Medina Al Munawarah, Saudi Arabia

The majority of elderly patients requiring prostatic surgery have one or more medical diseases. This results in the patients being classified as high risk for anaesthesia and surgery. He will thus be condemned to live the rest of his life with a catheter with all it's inherent complications.

This paper shows how the risk of prostatic surgery (TURP, TU incision of prostate) can be greatly reduced by using assisted local anaesthesia in the gland less than 30 grams in size. Thus elderly patients can be operated upon with reasonable safety and enjoy a catheter-free life.

It is suggested that this technique should be in the armamentarium of the modern day Urologist to help his elderly high risk patients.

Presented at the: 6th Saudi Urological Conference

National Guard King Khalid Hospital, Jeddah

27–28 November 1991

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

The source of organisms in the post-prostatectomy bacteriuria of patients with pre-operative sterile urines

A.I.A. Ibrahim, N.E. Bilal, S.D. Shetty, K.P. Patil, H. Gomaa

Department of Surgery, College of Medicine, King Saud University, Abha, Saudi Arabia

90 patients undergoing prostatectomy with pre-operative sterile urines were prospectively studied for post-prostatectomy bacteriuria (PPB). 26 patients underwent open prostatectomy (OP) and the remaining 65 patients had transurethral resection (TUR). 26/90 patients (29%) developed PPB (18 post TUR and 8 following OP) of whom 15 had pre-operative in dwelling urethral catheters. Organisms isolated were gram negative in 17 cases (65%) and staphepidermidis in 9 cases (35%). In an attempt to locate the source of organisms PPB was correlated with several factors namely; the presence of a histological inflammatory reaction within the prostatic adenoma (HIR), prostatic tissue culture (PTC), intra-operative fluid irrigate culture (FIC), per-operative blood culture (PBC) and post-operative external meatus urethral swab culture (EMS). The only significant correlation was found to exist between PPB and EMS (P < 0.05). HIR, PTC, FIC and PBC did not significantly correlate with PPB (P < 0.05).

It is concluded that post-prostatectomy bacteriuria is most likely caused by ascending infection along urethral catheters. In our opinion, diligent post-operative urethral catheters care may be sufficient to prevent PPB. Our study did not find enough evidence to attribute PPB to pre-existing septic foci within the adenoma. Intraoperative contamination and infection from distant foci are also unlikely causes of PPB.

Presented at the: 7th Saudi Urological Conference

Riyadh Armed Forces Hospital

11–12 November 1992

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Comparative evaluation of infection rate following transurethral surgery (transurethral resection-P and transurethral resection of bladder tumors) using three different closed drainage systems urobags

Akhileshwar Jha, John Flynn

Department of Urology, King Fahd Central Hospital, Gizan, Saudi Arabia

A random prospective trial was conducted for one year period in the Department of Urology, Leicester Royal/General Hospital, teaching hospital of U.K. Aim of the study was to evaluate (i) over all infection rate following transurethral prostatic and bladder surgery, in a standard situation with all patient having 24 hrs irrigation and 48 hrs post operative catheterisation. (ii) Three common close drainage Urobag system in use in the hospital, were also randomly allocated as bag A, B and C to evaluate their efficacy and effect on the infection rate.

Out of 152 cases studied, 16 were discarded having had preoperative infection, leaving 136 cases in the trial, 126 had TUR-P and 10 had TURBT. Age range of noninfected patient varied from 51 years to 84 years, average 70.26 years. All range in the infected cases varied from 55 years to 92 years, average 63.6 years.

Comparative evaluation of relative infection rate - showed - Bag A (Bardic) had infection rate (of 51 bags used 13 infected) 25.49%, Bag B (simple of 47 used 12 infected) 25.53%, Bag C (Aldon of 38 bags used 11 infected) 28.94%. Of all types of bags 136, total of 36 were infected, 26.47%. Organisms were same in the urine and bag sample on removal of catheter. Statistical analysis CHI squared test for types of bag and infection rate gave a x2= 0.17 on 2 degrees of freedom with a P = <0-0.95, no significant difference, using 3 different bags, with or without self sealing cuff, with or without drip chamber with non return valve, was noted. All were closed system. Over all infection rate in different reports after such surgery have varied from 5% to 52%. The wide variance is due to variable age group, criteria of infection and sepsis procedure, duration of catheter. Comparative evaluation of bag showed no significant difference. P(x22 > 1.17) <0.50. Findings compare favourably with other similar studies.

Presented at the: 8th Saudi Urological Conference

King Fahd Military Medical Complex

9–10 November 1993

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Balloon dilatation of the prostate: Early experience

M.S. Abomelha, I. Khan, M. Baqai and K.E. Al Otaibi

Department of Urology, Riyadh Armed Forces Hospital. Riyadh, Saudi Arabia

Treatment of benign prostatic hyperplasia (BPH) has been a matter of controversy during the last years. One of the alternative treatment of BPH is the dilatation, which in fact, has been used intermittently over the last 150 years. The current technique of balloon dilatation is simple and can be performed as an outpatient procedure. It has few complications and encouraging outcome. In this paper, we present our early experience with this technique. Retrospectively, we evaluated 21 patients 54 to 79 years old (mean 65 years) who underwent endoscopic balloon dilatation of the prostate under general anaesthesia between July 1990 and May 1992. The patients presented with symptoms and cystoscopic evidence of outlet obstruction. The size of prostate were small in 10 patients and moderate in 11 with no middle lobe enlargement. 5 patients (24%) had small bladder calculi, which were crushed at time of dilatation and 1 patients had short soft post. Urethral stricture was also managed at time of the procedure. 51% of patients had significant residual urine confirmed by I.V.U. or ultrasound. Catheter drainage post dilatation ranged from 2 to 17 days (mean 6 days). 10 patients (48%) developed retention of urine, 4 of them (19%) underwent TURP. Post dilatation complications were minor. 81% (17 patients) had satisfactory results with an average flow rate of 20 ml/sec. (range 9–30). In conclusion, balloon dilatation of prostate is a simple, safe alternative procedure for the treatment of small to moderate BPH in high risk patients with satisfactory results.

Presented at the: 7th Saudi Urological Conference

Riyadh Armed Forces Hospital

11–12 November 1992

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

First results with the tulip system – transurethral ultrasound-guided laser-induced prostatectomy - in treatment of benign prostatic hyperplasia

Th. Senge, H. Schulze

Department of Urology, University of Bochum, Marienhospital Universitatklinik, Herne, Germany

Transurethral resection of the prostate (TURP) is well-established procedure and represents the "Gold Standard" for treating prostatic obstruction secondary to BPH. However, although within the last 20 years the mortality rate following TURP has dropped to less than 1 percent, there is a well-documented constant morbidity rate of about 20 percent (incontinence, impotence, urethral stricture, TUR syndrome, significant bleeding). The outcome of any alternative therapy must compare to TURP. The TULIP procedure is a transurethral ultrasound-guided laser-induced prostatectomy. Tissue removal is accomplished through Nd:YAG laser coagulation necrosis under ultrasound visualization and is basically bloodless. The coagulation necrosis causes treated tissue to slough into the urine over time. The system consists of an ultrasound imager and a transurethral probe which is connected to a continuous wave Nd:YAG laser. At the distal end of the probe is the ultrasound transducer and laser window. Up to now 18 patients with a minimal follow up of 6 weeks have been treated at the University of Bochum (age 65.5 yrs., prostate volume 50.6 grms.). After a follow up of 6 months the peak flow rate increased from 7.5 to 18.2 ml/sec., the residual volume decreased from an average of 86 to 20 ml and the Boyarsky Symptom Score decrease from 15.7 to 3.5. There has been a very low complication rate (epididymitis 1x., retrograde ejaculation 2x). Our first date indicate that TULIP may provide results comparable to those reported after TURP with a low complication rate.

Presented at the: 7th Saudi Urological Conference

Riyadh Armed Forces Hospital

11–12 November 1992

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Transurethral microwave thermotherapy - The optimum technique for prostatic heating?

Simon St. Clair Carter

Prostate Unit, Charing Cross Hospital and Institute of Urology, London, UK

Introduction: Transurethral Microwave Thermotherapy (TUMT) has been developed as a minimally invasive treatment for symptomatic benign prostatic hypertrophy (BPH). Early investigations have shown a significant improvement in symptoms and objective criteria without major complications. Randomized sham studies have demonstrated that it is not due to a placebo response. A comparison to transurethral resection (TURP) showed the symptomatic relief achieved by (TUMT) to be akin to that from TURP. In an effort to improve the response rate and to further understand the mechanism by which heat works in the treatment of BPH we have conducted a number of investigations which we report here.

Interstitial Thermometry Studies: We have studied 43 patients with proven obstructive BPH (Masden score [MSS] >8, restricted peak flow rate [PFR] <10 ml/sec, and residual urine of between 100 and 200 mls) undergoing single-session TUMT by placing 2 fibreoptic thermosensors within the prostate under ultrasound guidance. Intraprostatic temperatures were recorded throughout the treatment. The temperature mapping has demonstrated that TUMT produces as defined field of prostatic heating well within safety limits. 74% of patients achieve substantial heating of >45oC. Great heating may be temperature threshold. It is clear from this study that any desired temperature profile can be obtained within the prostate by altering the parameter power, cooling time of exposure. The data also demonstrates a significant relationship between the degree of prostatic heating and clinical outcome as shown by peak urinary flow-rate and symptom score. Techniques to increase the level of prostatic heating can now be evolved with the certain knowledge that an improvement in clinical outcome can be expected.

Intraprostatic Heat Distribution: Preliminary urodynamic studies were undertaken in a multicentre series of 109 patients undergoing TUMT. The tracings were analyzed to divide patients into those with compressive and constrictive obstruction. The pressure flow parameters were compared to the outcome as given by the follow up of MSS < PFR and residual urine estimation. The observations suggest that patients with compressive obstruction were less suitable for TUMT and that by using urodynamic selection criteria a very high predictive value of success can be obtained.

TUMT has been shown to be an effective minimally invasive technique for the relief of symptoms in many individuals previously treated by TURP. It remains the only single session anaesthesia free ambulatory care treatment for obstructive BPH. A better understanding of the mechanism of action and the complex biophysics involved allows a significantly improved response rate and paves the way for further modifications of the heating profile to treat more patients.

Presented at the: 8th Saudi Urological Conference

King Fahd Military Medical Complex

9–10 November 1993

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Transurethral microwave in benign prostatic hyperplasia

E. Riad

Department of Urology, Al Mouwasat Hospital, Dammam, Saudi Arabia

This prospective study was conducted for efficacy evaluation of transurethral microwave thermotherapy (TUMT) in benign prostatic hyperplasia, utilizing the prostatron device (Technomed Int.). Between January 1992 and June 1993, a single session was delivered as an ambulatory procedure without anaesthesia to 119 patients (Mean age 65 ± 7 years). Patients were divided into group I; 25 patients with urine retention and indwelling catheter before treatment. Group II; 94 patients with symptomatic outflow obstruction in compliance to inclusion criteria; Madeson symptom score (SS) >8, maximum urinary flow rate (MFR) <15 ml/s and post void residual urine (PVR) <300 ml. exclusion criteria; renal dysfunction, upper urinary tract abnormalities, coexistent bladder pathology and cancer prostate. The prostate was heated to in excess of 45 C using power between 20 and 60 watts for 60 min. In group I; 8 patients voided after catheter withdrawal, 4 re-catheterised and 13 underwent TURP. Group II with pre-treatment mean SS 11.67 ± 4.91, MFR 8.9 ± 4.17ml/s, PVR 127 ± 17.2 cc. Follow up after TUMT at 1,3,6,12 months for 82,73,44,19 patients respectively showed mean SS 8.32 ± 4.19, 4.89 ± 3.25 (P ≤ 0.001), 4.37 ± 3.20 (P ≤ 0.001) and 4.17 ± 3.46 (P ≤ 0.001) respectively; MFR 8.15 ± 3.68 ml/s, 11.03 ± 4.11 ml/s (P ≤ 0.01), 11.83 ± 4.33 ml/s (P ≤ 0.01) and 12.03 ± 4.81 ml/s (P ≤ 0.01) respectively; PVR 138 ± 20.1 cc, 84 ± 27.3 cc (P ≤ 0.01) and 40 ± 41 cc (P ≤ 0.01) respectively. 23 patients with unsatisfactory treatment outcome required TURP after 6 months. No significant changes in prostatic volume were detected. Patients with pre-treatment SS <10, MFR >8 ml/s and PVR <100 cc. benefited better from TUMT. TUMT is not seen as a replacement for all surgery, but could provide a safe and less invasive alternative for selected patients.

Presented at the: 8th Saudi Urological Conference

King Fahd Military Medical Complex

9–10 November 1993

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Transurethral electrovaporization of the prostate: Early experience

Faris Ayyat

Dhahran Health Center, Surgical Services Division, Urology Section, Saudi Aramco, Saudi Arabia

TUVP is a relatively new procedure. The aim of this study is to compare the long term follow up with the standard TURP. TUVP is becoming the treatment of choice for symptomatic benign prostatic hypoplasia.

Materials and Methods: Thirty-eight patients, 42–83 years of age with a mean age of 62 years, underwent TUVP at Dhahran Health Center between May 1995 and July 1996, with an average follow up of 6.5 months. All patients underwent the standard laboratory and radiological evaluation for BPH. Patients with a high PSA (7 patients) underwent transrectal ultrasound and needle biopsy and one patient had adeno-carcinoma of the prostate but he underwent TUVP. Symptomatology included mild, moderate and severe symptoms of prostatism, including 6 patients with urinary retention. All patients underwent initially cystoscopy, 2–9 chips were resected with a resectoscope for a tissue diagnosis. This was then followed by TUVP. TUVP involves a slight modification in the roller electrode, replacing the standard lobe in the standard resectoscope with an upsurge of the cutting electrical current up to 300 watts.

Results: All patients improved significantly. Two patients had postoperative dysuria. One of them had a repeat TUVP because of incomplete resection. One resolved spontaneously. Two patients had gross hematuria postoperatively and both subsided spontaneously. No serum hyponatremia and no blood transfusion with a mean operative time at 23 minutes (15 minutes up to 47 minutes range), 4 patients had a cystoscopy at least one month post surgery, 1 for dysuria, 1 for a repeat evaporization and 2 patients for gross hematuria and there was complete hilalization of the prostate.

Conclusion: TUVP had the same results as the conventional TURP and with a less morbidity i.e. no blood transfusion, shorter operative time and hospital stay. With the new double barrel grooved electrode, a larger prostate can be evaporized as it will be shown on a video tape strip. This was achieved with less irrigation fluid, less hospital stay and less catheterization, i.e. we get the benefit of laser at very much less expense.

Presented at the: 10th Saudi Urology Conference

King Fahad National Guard Hospital

26–28 November 1996

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Prostatitis

S.D. Chowdhury

Department of Urology, Riyadh Military Hospital, Riyadh, Saudi Arabia

This paper highlighted the problems in the diagnosis of prostatitis. The nomenclature of prostatic inflammatory disease continues to be a very confused subject because of the inadequate criteria for classifying the condition.

An outline of the prevalence of Urinary Tract Infection in general and of prostatitis in particular (including the number of patients referred to urology clinics in Saudi Arabia with this diagnosis) was given. Various classifications for prostatitis were mentioned and the classification suggested by Drach and his colleagues (1978) was outlined and elaborated upon. This classification is based upon the characteristics and examination of the Expressed Prostatic Fluid (E.P.S.): Acute Bacterial Prostatitis, Chronic Bacterial prostatitis, Non-bacterial Prostatitis and Prostatodynia.

The method of obtaining the various urethral swabs, urine samples and E.P.S. was discussed.

The paper discussed the advantages of the above classification and urged its acceptance as a working basis for patients with prostatitis.

Presented at the: 1st Saudi Urological Conference

Riyadh Armed Forces Hospital

12 May 1983

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Management of chronic prostatitis

A. Al Jasser, G. Rifai, S. Ragheb, I. Thubaiti

Department of Urology, Security Forces Hospital, Riyadh, Saudi Arabia

Introduction: Chronic prostatitis is a Urologist's nightmare. We reviewed some of our experience regarding this dilemma.

Analysis: Over 2000 chronic prostatitis patients reviewed by method of diagnosis, treatment and patient's satisfaction.

Summary and Conclusions: Under investigation, Under and over treatment, Poor results and Unsatisfaction of the patients

Presented at the: 9th Saudi Urology Conference

King Fahad Hospital, Jeddah

14–16 November 1995

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Digital rectal examination: Are we doing enough?

W. Al Khudair, M.A. Al Fehaily

Department of Urology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia

To determine whether DRE is being performed by admitting physicians in a tertiary care hospital, we performed retrospective review of 400 charts selected randomly from medical and surgical admissions of males aged 45 years and over. The randomization was for the years 1986 and 1996. The admitting service (medical or surgical), age of patient, and diagnosis on admission and discharge were included. The H and P was checked for mention of DRE and if performed, whether the prostate gland was described or not.

Results: Out of 400 admissions 74 DRE were performed (18%). There was a drop in the number of DRE performed in 1996 (24) 12% as compared to 1986 (50) 25%. Physicians in medical services performed only 6 DRE out of 200 admissions while surgical services performed 68 DRE. Out of the 68 examinations done, 42 (62%) were performed on urology admissions, while out of the 74 DRE only 39 examinations described the prostate consistency.

Conclusion: In a tertiary care teaching hospital both medical and surgical services underutilized the cheapest and most available diagnostic tool for prostatic carcinoma detection. By presenting these data we aim to stimulate physicians to perform DRE so that prostatic carcinoma detection improves.

Presented at the: 11th Saudi Urological Conference

King Fahd Military Medical Complex, Dhahran

24–26 February 1998 (27–29 Shawwal 1418)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Transurethral vaporization-resection of the prostate: Preliminary results on safety and efficacy in the treatment of men with benign prostatic hyperplasia

R.F. Talic, A.E. El Traifi

Department of Urology, College of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia

Objective: Novel TURP electrodes that differ from their previous analogues in thickness, shape and coating coupled with high energy electrocuting current achieve simultaneous resection, vaporization and enhanced coagulation of prostatic tissue. We evaluate the early results of transurethral electrovaporization and resection of the prostate (TUVRP) in the treatment of patients with symptomatic prostatism utilizing the "Wing" resection loop and electrovaporization current.

Patients and Methods: The first 31 patients (19 in retention and 12 with lower urinary tract symptoms) that we treated with TUVRP are reported. Symptomatic patients were assessed at base line with international prostate symptom score (IPSS) and flow rate (Qmax), the same parameters were evaluated at 3 months for the entire group. Safety parameters included changes in serum hematocrit and sodium concentration, incidence of side effects and changes in sexual function.

Results: Mean resection weight was 27.9 ± 18.4 g (range 10–95). Mean post operative catheter time was 24.1 hours with minimal postoperative irritative symptoms. Mean change in hematocrit concentration was 2.5 ml/dl, no blood transfusion was required. The change in sodium concentration was 0.8 meq/l. All patients were followed up for an average of 6 months (range 3–6). The mean IPSS and Qmax for patients at 3 months were 3.9 ± 3.1 and 18.8 ± 9.4 ml/s respectively. Complications included bladder neck contracture in 1 patient, 1 clot retention and 1 patient developed transurethral syndrome. No change in sexual function was noted in this group.

Conclusions: TUVRP is a promising new modification of TURP. This procedure combines the excellent resection capabilities of TURP (with preservation of the entire resected specimen for histopathological examination) while adding the benefits of electrovaporization resulting in minimal blood loss and electrolyte disturbances. Furthermore, the reduced intraoperative bleeding potentially results in better visibility and a faster procedure.

Presented at the: 12th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospitals Program

23–25 February 1999 (7–9 Dhu Al Qa'dah 1419)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Pattern of presentation and findings in patients with chronic prostatitis/chronic pelvic pain syndrome

Ammar A. Ghobish

Department of Urology, Al Amen Hospital, Taif, Saudi Arabia

The clinical diagnosis (Dx) of chronic prostatitis (CP) is imprecise in that it includes several entities from bacterial infection to chronic pelvic pain syndrome (CPPS). We attempted to categorize the clinical presentation, clinical findings and laboratory and flowmetry results of our patients to guide the future diagnostic work up and treatment.

Subjects and Methods: Eighty-four patients with symptom complex suggestive of CP were included in this study. Symptomatic severity score and bothersome score were used. DRE and standard 3 glass microscopy and culture were done for all patients as well as flowmetry and post voiding residual urine measurement.

Results: Patient's age range from 18 to 50 years old. Clinical presentation was CPPS in 45 (53.5%) patients, voiding disorder in 30 (35.7%) patients and sexual dysfunction in 9 (10.7%) patients. Of the studied patients, 86%, 88% and 66% had CPP, voiding disorder and sexual dysfunction associated with their main symptom. On DRE 42% had normal prostate but 60% of patients had palpable seminal vesicle. Fifty-six patients had <10 WBC/HPF in their EPS and no growth on culture (PD), 16 patients had >10 WBC/HPF in their EPS (CAP) and only 12 patients had G-ve bacilli grown on culture (CBP). Flowmetry findings showed Qmax 4.4–22.0 ml/s, Q ave 2.2–12 ml/s, voided volume 92–473 ml and residual urine (RU) zero–215 ml. Only 9 patients had Qmax ≥ 15 ml/s and 19 patients had RU ≥ 50 ml of them, 10 patients had RU >100 ml. No differences were found between patients with PD and CAP but patients with CBP had 2 subgroups one with low flowmetry and the other with normal flowmetry.

Conclusion: What is called CP is complex group of disorders with different presentation and typical findings. PD and CAP patients probably presents a functional voiding disorder associated with or without CPPS, while CBP patients present 2 different subgroups: those with bacterial infection only and those with functional voiding disorder with super imposed bacterial infection. This subgroup has its implication on diagnostic work up and treatment.

Presented at the: 12th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospitals Program

23–25 February 1999 (7–9 Dhu Al Qa'dah 1419)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

The detection rate of digital rectal examination and prostatic specific antigens in prostate cancer: Result of 175 patients with prostatic biopsy

H. Al Hazmi, M.S. Abomelha, M.T. Said, S.A. Orkubi

Department of Urology, Riyadh Armed Forces Hospital, Saudi Arabia

Objective: We studied the ability of DRE and PSA in detecting prostatic cancer and confirmed those results with the obtained prostatic biopsies finding.

Patients and Methods: We tested 175 consecutive patients who underwent transrectal trucut needle biopsy of the prostate because of either abnormal digital rectal examination (DRE) and/or elevated prostatic specific antigens (PSA). PSA was measured by Abbott kit with a normal ranged up to 4ng/ml.

Result: Of the 175 patients, 113 (65%) had BPH and 62 (35%) had prostate cancer. Hard prostate detected only 12% of the cancer cases, while the elevated PSA detected 25%. By combining hard prostate with elevated PSA, the detection rate increases to 65%. With elevated PSA, the detection rate of suspicious DRE findings was 22% while suspicious prostate alone did not detect any cancer cases.

Conclusion: The detection rate of elevated PSA is significantly higher than abnormal DRE findings. Combined PSA and DRE will increase detection rate to 65%. Suspicious DRE finding alone or with elevated PSA is a poor detection method.

Presented at the: 14th Saudi Urological Conference

King Fahd Military Medical Complex, Dhahran

13–15 February 2001 (19–21 Dhu Al Qa'dah 1421)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Rotoresection: Short term results of a new modality in the treatment of benign prostatic hyperplasia

A.B. Shehab El Dein, B.S. Wadie, A.M. Mosbah, S.M. Halwagy, M.A. Ghoneim

Urology and Nephrology Center, Mansoura, Egypt

Objective: The aim is to assess safety and efficacy of Rotoresection, as a method of treatment of BPH.

Patients and Methods: Thirty patients were prospectively enrolled between September 2000 and May 2001. Mean age was 61 ± 6 years (range: 52–78 years). All patients were having AUA 7 score of >12, Qmax <12 ml/s, prostate size of 20–80 cc and PSA 0–4 ng/ml. Patients with prostate or bladder cancer, PSA >10 ng/ml, previous prostate surgery, previous pelvis surgery, urethral stricture, active UTI, acute urine retention, neuropathic bladder and serum creatinine >1.8 mg/ml, were excluded. Mean operative time was 45.2 ± 9.9 minutes. The procedure was conducted using Rotoresect system®. Catheter was removed after 1.97 ± 0.3 days. Patients were seen 1, 3 and 6 months after surgery. AUA 7 score, Qmax, blood Hb, urinalysis and TRUS were carried out at each visit. All patients but 3 completed the follow up.

Results: Mean AUA 7 score decreased from a preoperative value of 20.5 ± 3.8 to a value of 0, mean Qmax rose from 8.7 ± 2 ml/s to 25.3 ± 12.6 ml/s, mean total prostate volume from 36.5 ± 13 cc to 20.5 ± 7.8 cc at 6 months. Mean preoperative hemoglobin level was 13.8 ± 1 g/dl and at 1 month postoperative 13.5 ± 1.2 g/dl. No patient required blood transfusion or had the manifestations of TUR syndrome. Early complications were UTI and mild degree of SUI in 10 and 11 patients respectively. At 6 months, those patients had sterile urine and perfect continence. 2 patients had urethral stricture and posterior urethral stone at 6 months and were treated successfully.

Conclusion: At short term, Rotoresection is a safe and effective method for the treatment of BPH. No significant blood loss or TUR syndrome was encountered. Short hospital stay and excellent functional results were achieved.

Presented at the: 15th Saudi Urological Conference

King Fahd Hospital, Madinah Al Munawarah

7–9 May 2002 (24–26 Safar 1423)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Update on surgical and medical management of benign prostatic hyperplasia

Th. Senge, R. Berges, G. Haupt

Department of Urology, Ruhr-Universitat, Bochum, Germany

Among the various treatment options for benign prostatic hyperplasia, conservative therapy today is widely accepted. Watchful waiting, alpha 1-receptor blockade, and 5-alpha-reductase inhibition are considered to be valuable options. In addition, phytotherapy is traditionally implemented as treatment strategy in Europe, especially in France and Germany.

Finasteride, the only available 5-alpha-reductase inhibitor, has been shown effective in reducing prostate size and symptoms, and to some extent in increasing maximum uroflow. Selective alpha-1-receptor blockers like Alfuzosin, Doxazosin, Tamsulosin and Terazosin are efficient in reducing BPH-related symptoms as well. However, even when flow improvement is significant and surpasses that of finasteride, alpha-1-blockers have failed so far to show a major reduction of obstruction. Plant extracts have become fashionable also in other parts of the world, since new clinical data suggested effectiveness. Typically, these drugs have low or no side effects and are therefore often used in patients with mild symptoms.

However, it is difficult to say whether conservative management in regards to drug therapy will reduce BPH-related morbidity and number of surgical interventions. This has recently been suggested for finasteride treatment. No such data are available as of today for alpha-1-receptor blockers and plant extracts. In general, these treatment endpoints should be evaluated with all conservative drug treatment, as efficiency and cost effectiveness are a major concern in a growing and aging population.

Surgical therapy is known to be effective in relieving obstruction as well as symptoms. Transurethral resection of the prostate (TURP) is still called the gold standard of surgical treatment of BPH. However, due to a published complication rate, which remained unchanged over the last decades at around 18% a number of alternative treatments have been developed.

Laser therapy seems useful for selected patients with small glands. Electro-vaporization has to be considered experimental. Transurethral microwave treatment and intraprostatic stents may be useful in high risk patients. Balloon dilatation, HIFU, hypertherapy and thermotherapy can not be recommended for obstructing BPH.

In summary, TURP still achieves best treatment results in objective and subjective measures. TURP has been further developed too. With modifications like the vaporizing loop and – most importantly – the development of new computer-controlled electrosurgical units, complication rates are reduced. Therefore, TURP remains the standard treatment and all new methods have to be compared to this standard.

Presented at the: 11th Saudi Urological Conference

King Fahd Military Medical Complex, Dhahran

24–26 February 1998 (27–29 Shawwal 1418)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Evaluation, diagnosis and management of benign prostatic hyperplasia in Saudi Arabia: A survey of practicing urologists

M.S. Abomelha, A. Al Jasser, S.A. Taha, H.A. Mosli

Department of Urology, Saudi Prostate Health Council, Riyadh, Saudi Arabia

The Saudi Prostate Health Council was established in 1993 with the aim to create awareness of prostatic diseases. One of the SPHC activities is the collection of information about the practiced way of diagnosis and management of BPH by urologists working in Saudi Arabia.

A questionnaire was designed to obtain the required information about the magnitude of prostatic diseases and the evaluation, diagnosis and treatment of BPH. The questionnaire was sent to 70 urologists all over the Kingdom. The response rate was 41% (70/170).

Of the urologists who responded, 33% are working in MOH Hospitals, 57% in governmental and 10% in private clinics. The survey covers all parts of the country 56% central, 23% west, 11% east, 6% north and 4% south. 64% of the urologists were consultants, 26% specialists and 10% urology residents.

The results of clinical evaluation, diagnosis and treatment of BPH practiced by these 70 urologists will be presented in detail.

Presented at the: 11th Saudi Urological Conference

King Fahd Military Medical Complex, Dhahran

24–26 February 1998 (27–29 Shawwal 1418)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Vaportome resection prostatectomy: Early results of safety and efficacy

R.F. Talic

Department of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Introduction: Vaportome resection prostatectomy (VRP) is a promising new advance in the management of prostatic outflow obstruction. VRP should theoretically retain excellent resection capabilities of TURP with preservation of the entirely resected prostatic tissue for histological examination while adding the benefits of transurethral electrovaporization (TUVP), namely, minimizing the blood loss and reducing the incidence of TURP syndrome. This report looks at the safety and efficacy of VRP and report on the very early results of an ongoing phase 1 trial to evaluate this technique.

Methods: Standard transurethral resection of the prostate using a vaportome loop was carried out on all patients. 12 patients have been recruited so far in the study starting October 1997. 6 with urinary retention and 6 with lower urinary tract symptoms. Pre and post operative data collected included: U and E, CBC, Qmax, post void residue (PVR), IPSS symptom score including quality of life (QOL) and sexual function.

Results: Mean resection chip weight 21.6 gm. Mean post operative catheterization time 28 hours. Mean decrease in Hb 0.5 g/dl. Na concentration unchanged. No patient required blood transfusion and no complications encountered. Mean change in IPSS symptom score, Qmax, QOL, PVR in the pre and post operative follow up will be reported in the meeting.

Conclusions: VRP appears to be a safe procedure. Efficacy is expected to be as good as TURP. Vaportome resection prostatectomy combines the advantages of TURP and TUVP and eliminates the shortcomings of each procedure when used alone. Longer term follow up with larger number of patients and prospective randomized trials are required.

Presented at the: 11th Saudi Urological Conference

King Fahd Military Medical Complex, Dhahran

24–26 February 1998 (27–29 Shawwal 1418)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Neodymium: Yattrium-aluminum-garnet laser prostatectomy versus electrovaporization of the prostate

I. Khalaf

Department of Urology, Al Azhar University, Cairo, Egypt

Seventy two high risk patients scheduled for prostatectomy for BPH were randomized into 2 groups were:

Group I (36 patients) were treated by Nd:YAD Laser coagulation of the prostate.

Group II (36 patients) were treated by Transurethral Electrovaporization of the prostate (TVP).

The mean age, clinical presentation, and the mean volume of the transition zone (Tz) were comparable in both groups. Complications, IPSS, Qmax, post voiding residue (PVR), reduction in Tz volume were the parameters used for evaluating both techniques 6 months after prostatectomy. IPSS improvement was comparable in both groups. While Qmax showed better improvement in Group II as compared to Group I (116% and 60% respectively). The PVR was reduced by 42% and 61% in groups I and II respectively. The reduction in the Tz was significant (52%) only after Electrovaporization of the prostate.

The following table demonstrates the complications in both groups.

graphic file with name UA-7-232-g001.jpg

Failure of laser prostatectomy and TVP was noted in 2 and 1 cases respectively and all were retreated by TURP.

Conclusion: Although both procedures were encountered with a high rate of complications, yet TVP is attended with good functional results than laser prostatectomy.

Presented at the: 11th Saudi Urological Conference

King Fahd Military Medical Complex, Dhahran

24–26 February 1998 (27–29 Shawwal 1418)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

The age-related prostate gland size as measured by transrectal ultrasound and transurethral resection of the prostate specimens in more than 500 patients with different prostatic diseases seen at King Abdulaziz University Hospital in Jeddah

H.A. Mosli, M.A. Atwa

Department of Urology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

More than three hundred and eight patients were examined using TRUS over the past 5 years at our medical institute. The prostate gland size was measured among other parameters during scanning of the gland. TRUS was performed in the work up for BPH, prostatitis and infertility. Two groups of patients were characterized. Table 1 shows the age-related average gland size in those below 50 years, while table 2 reveals the data for those older than 50 years.

Table 1.

Age-related average gland size

graphic file with name UA-7-232-g002.jpg

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Table 2.

Age-related average gland size more than 50 g

graphic file with name UA-7-232-g003.jpg

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We also examined the resected gland weight in another group of patients (no. 205), resected adenoma weight was determined in 161 patients.

graphic file with name UA-7-232-g004.jpg

Percentage of gland weight >or to 30 grams in 120 specimens

graphic file with name UA-7-232-g005.jpg

To our knowledge, this is the first report to determine the prostate gland size in the different age groups in Saudi Arabia. The use of this information in the design for therapeutic strategies will be discussed.

Presented at the: 12th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospitals Program

23–25 February 1999 (7–9 Dhu Al Qa'dah 1419)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

The role of alpha-blocker in the treatment of benign prostatic hyperplasia related acute retention of urine

M.T. Said, M.S. Abomelha, M. Al Numi, A. Jad, S. Orkubi, K.E. Al Otaibi

Department of Urology, Riyadh Armed Forces Hospital, Saudi Arabia

Ninety-seven (97) patients with BPH related acute retention of urine (AUR) treated medically with Prazosin Alpha-Blocker during a 5-year period (1993–1998) at the Riyadh Armed Forces Hospital was retrospectively reviewed. All patients were Saudi with age range 55–100 years and mean of 72.4 years. LUTS prior to AUR were 6% mild, 76.5% moderate and 17.5% severe symptoms. The prostate size was small in 16.5%, moderation 70% and large in 13.5%. 73 patients (75.5%) voided on catheter removal with a Qmax range 3.8–13.9 ml/sec (mean 8.5 ml/sec). 24 patients (24.5%) needed TURP as 13 patients (13.5%) went into AUR and 11 patients (11%) had worsened symptoms, low Qmax of <3 mls/sec and a PVR of >300 ml/sec. 47 patients (65.5%) of those who voided after catheter removal were followed up for a period range 2–60 months (mean 20.38 months) and had constant improved symptoms, a mean Qmax of 8.6 mls and a mean PVR of 58 ml/sec.

In conclusion, this study shows an encouraging and promising role of alpha-blocker in the treatment of BPH related AUR and it also helps in avoiding surgery in a substantial number of patients.

Presented at the: 12th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospitals Program

23–25 February 1999 (7–9 Dhu Al Qa'dah 1419)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Medical treatment of Saudi patients with symptomatic benign prostatic hyperplasia

M.S. Abomelha, M.T. Said, M. Al Numi, A. Jad, S. Orkubi, K.E. Al Otaibi

Department of Urology, Riyadh Armed Forces Hospital, Saudi Arabia

A retrospective study of medically treated 403 Saudi patients with symptomatic BPH during a 5-year period (1993–1998) was undertaken at the Riyadh Armed Forces Hospital. Their age range was 50–100 years with a mean of 65.7 years. All presented with LUTS; mild 31%, moderate 67% and severe 2%. The prostate size was small in 37.5%, moderate in 58% and large in 4.5%. The baseline Qmax ranged from 3 to 14.3 ml/sec (mean 9.5 mls) and post void residue (PVR) ranged from 50 to 300 ml/sec (mean 106 ml/sec).

All patients were treated with Prazosin alpha-blocker and for those who did not improve, Finasteride was added. Follow up period ranged from 3 to 60 months (mean 21.7 months) and 335 (83.2%) patients were followed up. Only 6 patients (1.4%) had adverse effects of dizziness mainly. 250 patients (75%) on Prazosin alone had improved symptoms, increased Qmax of 3.5 ml/sec and 55% decrease in PVR. The remaining 85 patients (25%), who did not improve, had combined Prazosin and Finasteride treatment. Of these, 73 patients (86%) had improved symptoms; increased Qmax of 3.7 ml/sec and 61% decrease in PVR. The rest of 12 patients (14%) had failed to improve and had TURP.

In conclusion, medical treatment of symptomatic BPH patients with Prazosin alpha-blocker is efficient in the majority of patients with minimal adverse effects. Combined therapy of alpha-blocker and Finasteride can further increase success rate and the need for surgery is significantly reduced.

Presented at the: 12th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospitals Program

23–25 February 1999 (7–9 Dhu Al Qa'dah 1419)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Benign prostatic hyperplasia – The Saudi perspective

Hisham A. Mosli

Department of Urology, King Abdulaziz University, Jeddah, Saudi Arabia

Data from BPH prevalence studies have demonstrated that there are no significant geographical or ethnic variations and that the prevalence of BPH increases with age. BPH is the most common benign neoplastic condition affecting elderly men. The make up of Saudi population is that of a predominantly young generations but the proportion of BPH affected men would be expected to be the same as other countries in the aged male populations. At the age of 80 years, 90–100% of men have evidence of microscopic BPH, 50% have evidence of macroscopic enlargement and only 25% have evidence of clinical BPH. The importance of BPH is related not only to the size of the problem but mainly to its effect on the quality of life. The size of the problem can be estimated according to the percentages derived from western studies but best be determined by locally conducted epidemiological studies. Since ageing and the presence functioning testes are the two main risk factors for developing histo-pathological BPH, no differences would be expected to be observed between the Western and Saudi prevalence rates within comparable age matched groups of populations. However, there are profound cultural differences that may affect many aspects of symptomatic and clinical BPH. The quality of daily life is also affected differently. The voiding habits among Saudis, their perception of symptoms, motivation for seeking medical advices, clinical presentation, acceptance of diagnostic methods and treatment modalities certainly differ from their Western peers of elderly men.

This aim of lecture is to highlight the Saudi perspective on BPH. The progress of knowledge and medical care given were reflected by the types and among of studies published or presented over the recent years. The data will be presented herein a chronological order, discussing the various clinical aspects of BPH from the Saudi point of view. Those included the epidemiological data available, clinical presentation, current methods of diagnosis, and the available treatment modalities.

Epidemiology

  • Exact prevalence rates based upon properly conducted epidemiological study: Unknown

  • Estimation of the size of the problem: Current and Future

  • Proposal for a national epidemiological study: Mosli et al., 1994

  • Hospital based reports: Abomelha et al.

  • Workload study: Abomelha et al., 1998

  • Community based study: Current Efforts, Mosli and Badawood, 1999

  • Related co-morbidities: 10% of Saudi population with HTN and DM

  • Related sexual behaviors

  • Characteristics of age related adenoma and gland size: Mosli et al., 1999

Presentation

Symptoms:

  • General perception of urinary symptoms and fear to seek medical care

  • Frequency of symptoms in a primary care clinic

  • Geriatric care

  • Screening for LUTS

  • Screening for prostate cancer

  • Most bothersome symptoms

  • Most frequent presenting symptom

  • Symptom score indices and measurement of severity

Complications:

  • AUR

  • Upper tract dilatation and renal failure

  • Bladder stones

  • Bladder diverticulae

  • Recurrent infection and hematuria

Diagnostic Modalities in Use:

  • Symptom score indices

  • Physical examination and DRE

  • Laboratory work-up

  • Imaging

  • Qmax

  • Pressure/flow studies

Therapeutic Modalities in Use:

  • Watchful waiting

  • Medical treatment

  • Minimally invasive intervention

  • Microwaves and deep heat

  • Lasers

  • Open surgery

  • TURP

BPH – Saudi Perspective:

  • What has been done so far: SPHC

  • Current activities

  • The future

  • Other prostatic diseases:

    • Prostatitis
    • Chronic pelvic testicular syndrome
    • Prostate cancer

  • Other important related diseases:

    • Erectile Dysfunction.

Conclusions

  • Little is known about the epidemiology of BPH in the Saudi culture.

  • Workload is increasing.

  • The diagnostic modalities have improved and need to further improve.

  • Most advanced methods of treatment are available but need to eliminate misuse.

  • Screening programs and enhancement of awareness to ensure early presentation.

  • Late and complicated presentation still a problem.

  • More studies researching all aspects of BPH are needed.

Presented at the: 13th Saudi Urological Conference

Riyadh Armed Forces Hospital

14–17 February 2000 (09–12 Dhu Al Qa'dah 1420)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Natural history and therapeutic management of benign prostatic hyperplasia

Mostafa M. Elhilali

Division of Urology, McGill University Montreal, Canada

Over the last 10 years our understanding of the problems associated with benign prostatic hyperplasia has undergone major changes. The problem is not simply offering an operation (TURP) for the patient presenting with lower urinary symptoms which becomes the most frequently performed urologic operation. With the introduction of alternate therapies the incidence of TURP plummeted as the urologists and the patients became better informed. It became evident that we need to identify the patient who really needed surgery, and all others were either observed or treated by medical treatment of alternative therapy. The patients that were followed conservatively helped us determine the natural history of the disease.

It became obvious that even though 90–100% of 80-year-old males have evidence of microscopic BPH, 50% have evidence of macroscopic enlargement of the prostate and only 25% have evidence of clinical BPH. Three components constitute clinical BPH namely an enlarged gland, prostatic obstruction reducing flow rate and bothersome symptoms of the lower urinary tract. Population studies have confirmed that these 3 components of clinical BPH correlate with the risk of acute urinary retention. Risk factors for developing BPH are age and normal testicular function. Studies have demonstrated that there are no significant geographical or ethnic variations, which is quite different from prostate cancer prevalence data.

BPH is the most common benign neoplastic condition affecting elderly men. The prevalence increases with age. The rate of growth increases with age with a maximum growth rate between 50–70 years of age. The prostate is estimated to grow by 0.6 cc/year on average. Parallel to this the maximum flow rate declines by 0.2 ml/sec/year.

The Baltimore longitudinal study of aging provided valuable information linking the increasing incidence of obstructive urinary symptoms and age when the prostate was clinically enlarged. In the same study the incidence of prostatectomy was related to the presence of prostatic enlargement and symptoms particularly reduction in urinary stream and sensation of incomplete emptying. These patients have 5–8 times more likelihood of requiring a prostatectomy. The incidence of surgery was also higher with age.

Other complications related to BPH include acute urinary retention, which is equally distressing and reflects the degree of obstruction induced by the (AUR) underlying disease process. The Olmsted County Survey (2115 men) demonstrated that 1/10 men aged 70–79 years of age will experience acute urinary retention over 5 years. An enlarged prostate, reduced peak urinary flow rate and LUTS at baseline were also positively correlated with risk of AUR.

The Olmsted County data also evaluated the risk of AUR according to size of the prostate in 537 men. Those with prostates larger than 30 ml were 3 times more likely to experience AUR as were men with smaller prostates.

Traditionally urologists have been told that prostate size is not important. The severity of symptoms is more important. What counts is patient improvement of quality of life. All this is true, but we cannot ignore the other end points, which are definitely impacting on the quality of life of these patients, such as the incidence of acute urinary retention or the need for surgery. These have been correlated to the age, the size of the prostate, and the severity of symptoms. Treatment options that could impact favorably on symptoms, flow, size of the prostate as well as reduction of these complicating end points should be considered more seriously. BPH is a progressive disease and we should aim at halting this progression as a treatment goal.

Recently, data on a long term double blind, randomized study using finasteride versus placebo in 3040 patients with moderate – severe urinary symptoms were released 2760 patients were evaluable at the end of 4 years. In addition to the traditional change in symptom score, maximum flow rate and prostate size which were all significant, other end points included the incidence of urinary retention and the incidence of transurethral prostatectomy (TURP) in two groups. 152/1503 patients in the placebo arm (10%) underwent surgery compared to 69/1523 (5%) in the finasteride arm. Acute urinary retention developed in 99 men in the placebo arm (7%) versus 42 men (3%) in the finasteride group. The difference was even more pronounced if we compared patients with larger prostate glands.

This study for the first time shows that medical treatment in the form of finasteride can impact on outcome reducing the incidence of such complications such as urinary retention or the necessity for surgery.

These data will be presented in detail and open discussions on the state of the art of medical management of BPH will be freely discussed during the seminar.

Newer technologies such as Holmium Laser prostatectomy will be discussed.

Presented at the: 13th Saudi Urological Conference

Riyadh Armed Forces Hospital

14–17 February 2000 (09–12 Dhu Al Qa'dah 1420)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Siu symposium on benign prostatic hyperplasia controversy surgical aspects

Peter Ekman

Department of Urology, Karolinska Hospital, Stockholm, Sweden

The introduction of the Hopkins glass after fiber system was of paramount importance for the popularization of transurethral resection of the prostate, TUR-P. The technique, which was previously quite complicated with rather high morbidity, could now be carried out with great safety under good visual control. As of today, mortality linked to the procedure is below 0.5%, and the reoperation frequency in 10 years less than 10%. The previously much feared TUR-syndrome, due to absorption of irrigating fluid, does hardly ever occur any longer. The results following open surgery (retropubic or transvesical adenoma enucleation) are slightly superior to the results achieved by TUR-P. Since morbidity is only slightly higher in open surgery versus TUR-P, this procedure which was for several years almost abandoned, has regained a renewed interest, at least in glands weighing 60 to 80 gram or more.

Even when surgery is the golden standard in more severe symptomatic patients, the rather high morbidity has created an interest for less invasive therapies, in particular in moderately symptomatic patients. Most alternatives in minimally invasive therapies are based on creating heat, causing tissue destruction in the gland. While laser prostatectomy has failed to gain wide popularity, due to troublesome side-effects and high cost, other minimally invasive therapies are increasingly much asked for Transurethral Microwave Therapy (TUMT), which with the original software 2.0, fell into some disrepute, with the new high energy forms, (software 2.5) apparently in many instances causes significant reduction in symptom score, despite the size of the gland is little influenced. Another widely used alternative is the transurethral needle ablation (TUNA), which causes even higher temperatures inside the gland. Which alternative that is the most effective is presently under investigation in randomized trials. The efficacy when it comes to urinary flow, frequency and reduction in symptom score are quite comparable. The third millennium will certainly see many other alternatives less invasive therapeutic models, and the future will tell which techniques that will survive.

Presented at the: 13th Saudi Urological Conference

Riyadh Armed Forces Hospital

14–17 February 2000 (09–12 Dhu Al Qa'dah 1420)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Benign Prostatic Hypertrophy

Amin Moh′d Al Masry

Department of Urology, Prince Saud Bin Jalawi Hospital, Al Ahsa, Saudi Arabia

BPH causes considerable morbidity among aged males. This is a 10-year retrospective study of knowing the outcome results of the treatment.

Findings:

  • Total patients treated for BPH: 246

  • Age: 50–87 years

  • 86 (35%) admitted with urinary retention and 65% with dysuria, polyuria and some with hematuria

  • PVR: 250–400 cc

  • IPSS more than 21

  • Low maximum urine flow rate

  • PSA: 2–200 ng/ml

  • 7 (2.8%) with carcinoma and the rest with BPH with different size of prostate (239, 97.2%)

  • 43% (17.5) with changing urinary tract by IVU and Sonogram

  • 15 (63.4%) had bladder stones

Treatment:

  • 156 (63.4%) underwent TURP

  • 43 (17.5%) by suprapubic open operation

  • 2 (0.8%) died due to ca. prostate (not operated)

  • The rest 45 (18.3%) discharged with medical management

Result:

  • 120 (76.9%) TURP cases passed urine freely

  • Of the TURP, 23 (14.7%) developed with UTI

  • 13 (8.3%) reresected after 5–7 years

  • 14 (9%) had different complaints relating to weak erection but does not have any significant

Histopathology:

  • 7 (2.8%) cases with Carcinoma of the Prostate

  • 239 (97.2%) cases with Benign Prostatic Hyperplasia

Conclusion: From my experience and from the foregoing, TURP is the best method of treatment in the management of BPH.

Presented at the: 13th Saudi Urological Conference

Riyadh Armed Forces Hospital

14–17 February 2000 (09–12 Dhu Al Qa'dah 1420)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

A prospective epidemiological community based study of lower urinary tract symptoms and BPH

H.A. Mosli, A. Badawood

Department of Urology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Objective: To recognize the prevalence of LUTS and BPH in a community indwelling males in Jeddah, Saudi Arabia.

Method: A house-hold cross sectional epidemiological study of a large numbers of apartments in one community was conducted by a single researcher. The tools used to evaluate LUTS included the I-PSS. Patients with a symptom score more than 8 were referred to KAUH for urological work-up for BPH.

Results: 15% of the studied population had LUTS and 2.5% had BPH.

Conclusion: LUTS were much more frequently encountered and the most bothering symptoms affecting the quality of life (QoL) were recognized in this study.

Presented at the: 15th Saudi Urological Conference

King Fahd Hospital, Madinah Al Munawarah

7–9 May 2002 (24–26 Safar 1423)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Minimally invasive therapy for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: Evidence based evaluation

Mostafa M. Elhilali

Department of Surgery, McGill University, Department of Urology, McGill University Health Care, Montreal, Quebec, Canada

The management of LUTS secondary to BPH has been undergoing many changes with medical treatment in the forefront. Unfortunately, the widespread use of medications is not always successful in the long term. The ultimate result is that we are faced with having to operate on older, sicker patients, frequently anticoagulated and with indwelling catheters.

Many technologies have been tried and then abandoned. We will review the evidence and particularly cover some of the data on Green light laser and Holmium laser ablation and enucleation. The recommendations of the committee on MIT of the consultation on BPH will be summarized.

Presented at the: 18th Saudi Urological Conference

King Abdulaziz University Hospital

20–23 February 2006 (21–24 Muharram 1427)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Benign prostatic hyperplasia patients undergoing surgical treatment: Comparison between patients with retention of urine with those presented with other symptoms

M.A. Banakhar, H.A. Mosli, A.M.S. Al Tayib, A.K. Twairgi

Department of Urology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Acute retention of urine (AUR) is seen in about 0.4–25% of men yearly seen in urological practice. In pharmaceutical trials, it was shown that the incidence of AUR was 7% in the placebo arm compared to 3% in the treatment (drug) arm of PLESS study conducted on North American men while the incidence of AUR was 2.5% in the placebo arm compared to 1.0% of the treatment (drug) arm in the PROWESS study conducted on European men. Retention of urine was reported to constitute the indication for TURP in 25–30% of the patients.

We analyzed the data from the records of 354 men with BPH subjected to surgical treatment to relieve prostatic bladder outlet obstruction. The study period was 15 years from 1990–2005. In the first ten years, from 1990 to 2000 the incidence of retention of urine as a presenting indication for surgery was 41%. From 2000 to 2005 the incidence of retention of urine in patients undergoing prostatic surgery was 40.3% despite the wide-spread use of medical therapy.

We will present our data comparing the two groups of patients regarding their age, previous symptom severity, PSA level, gland size, types of prior medical therapy, and finally histopathological patterns of resected prostatic tissues.

Presented at the: 17th Saudi Urological Conference

King Fahd Military Medical Complex

8–10 March 2005

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Finasteride reduces blood loss at transurethral prostate resection

Abdulaziz Althunayan, Danny Rabah

Department of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Introduction and Objective: We aimed to evaluate the efficacy of pre-treatment with Finasteride in reducing blood loss in patients undergoing transurethral prostate surgery.

Methods: A retrospective chart review of all patients undergoing transurethral prostate surgery at King Khalid University Hospital from 1999–2004 was conducted. 221 patients were identified. The patients were categorized based on the use of Finasteride, the period of use and the surgical modality they received. We recorded patients' age, degree of hemoglobin (Hb) drop, need for blood transfusion, clot retention, and need for cystoscopy.

Results: Forty one patients received Finasteride prior to surgery. Of those, 36 patients received the treatment for a period exceeding 3 months. Patients pre-treated with Finasteride had an average Hb drop of 6.3% vs 10.4% for those who did not. The mean Hb drop for the Finasteride group was 0.87 vs 1.4 (t = 2.36, p = 0.02). The blood transfusion rate was 2.4% vs 6.1 (p = 0.31). Clot retention was found in 3 patients (7.3%) vs 21 patients (11.7%) (p = 0.31). No patient was in need of cystoscopy in the Finasteride group, whereas 8 patients (4.4%) required it in the other group (p = 0.19).

Conclusions: In patients pre-treated with Finasteride, Hb drop was significantly less. Other proxies of bleeding showed a trend towards a difference although not statistically significant. The results indicate that, Finasteride may be effective in reducing the post-operative bleeding complications of TURP.

Presented at the: 18th Saudi Urological Conference

King Abdulaziz University Hospital

20–23 February 2006 (21–24 Muharram 1427)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

The clinical response of Botulinum-A injections for obstructive benign prostatic enlargement

I.O. Abdel Hafeez, H.M. El Shawaf, K. Mokhtar

Department of Urology, Ain Shams University and Saudi German Hospital, Egypt and Saudi Arabia

Objectives: Obstructive BPE patients are managed medically or surgically. While some fail medical treatment, others refuse surgical intervention due to subsequent ejaculatory dysfunction, and others are poor surgical candidates. In men, studies following BTX-A injection showed significant improvement of IPSS and flow rate, decreased prostate volume and PSA. This is a preliminary report evaluating the effectiveness of prostate injection with BTX-A toxin in obstructive BPE.

Material and Methods: 5 patients with obstructive BPE were selected: two aged 52 and 56 years, sexually active, failing medical treatment, refusing the risk of retrograde ejaculation post TURP; and 3 patients with impaired bleeding profile. Selected patients had an IPSS >18, prostate volume <50 ml, PSA <4 ng/dl and obstructed P-Q plot. Each prostate lobe was injected endoscopically with BTX-A 100 u. All received a 2 weeks course of alpha blocker tamsulosin 0.4mg and phytotherapy post injection. IPSS and urodynamic parameters at baseline, 4 weeks and 12 weeks after treatment were compared.

Results: Improvement in IPSS, flow rate were evident and progressive over the 12 weeks follow up. Prostate volume at 12 weeks by TRUS did not alter. Serum PSA was not evaluated due to post-traumatic expected rise after injection. No adverse events were confronted.

Conclusions: Prostate injection with BTX-A might prove to be an effective alternative treatment for selected patients with obstructive BPE. Regression in prostate volume and serum PSA level need at least 24 weeks follow up. Further cases and follow up are necessary.

Presented at the: 18th Saudi Urological Conference

King Abdulaziz University Hospital

20–23 February 2006 (21–24 Muharram 1427)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Lower urinary tract symptoms: How to approach

M. Sherif Mourad

Department of Urology, and President of Pan Arab Continence Society Ain Shams University, Egypt

BPH is one of the most common diseases to affect men. Histological disease is present in >60% of men in their 60s. Over 40% of men beyond 60s have symptoms, about half of whom have an impaired Qol. The prevalence increases with age (patients affected are rising worldwide).

Storage symptoms are more bothersome and significantly affect Qol as measured by appropriate questionnaires. Detrusor overactivity is considered a significant cause of storage symptoms. A substantial proportion of men with "LUTS" have a combination of both "storage" and "voiding" symptoms, suggesting possible coexisting B)) and OAB.

Bladder overactivity is traditionally treated with anticholinergic drugs. However, guidelines from the European Association of Urologists make no mention of the possible therapeutic role of anticholinergic drugs for treating storage symptoms in such patients (with BPH). Efficacy and safety studies of anticholinergic medication in men with LUTS/BPH are few and far between.

Preliminary data suggests they are not associated with a substantial risk of urinary retention nor with a substantial increase in residual urine volume. Recent data suggest that for BPH/bladder outlet obstruction and concomitant detrusor overactivity the combination of an α1-adrenoceptor blocker with an anticholinergic agent significantly improves storage symptoms without compromising urine outflow.

Presented at the: 18th Saudi Urological Conference

King Abdulaziz University Hospital

20–23 February 2006 (21–24 Muharram 1427)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Holmium laser for transurethral resection of benign prostatic hyperplasia

Faris M. Ayyat

Dhahran Health Center, Dhahran, Aramco

TURP is the treatment modality for symptomatic BPH and it is well known in the urology specialty as the gold standard for surgical treatment of BPH. Different modalities of laser devices for treatment of BPH were introduced in the last two decades and most of those are no longer in use. Recently, the Holmium Laser (HL) has been in use for enucleation of the prostate. Some advantages over TURP are less blood loss, a shorter hospital stay, and no TURP syndrome. This ten minute videotape will illustrate HL procedure. A power of 60–100 watts is used with normal saline and with the continuous irrigation 26F resectoscope and special laser-working element. A laser fiber of 500–1000 is used. HL surgery resects the median lobe between the 5 and 7 o'clock positions with a transverse incision just proximal to the verumontanum. Enucleation of the median lobe proceeds distally towards the bladder neck proximally in the surgical plane of the prosthetic capsule. Both lateral lobes are enucleated in the same fashion between the 1 and 5 o'clock positions and also between the 7 and 11 o'clock positions. Prosthetic tissues are morcellated and sent for pathology.

Conclusion: HL prostatectomy for symptomatic BPH is still evolving and requires hands-on training. It has a higher incidence of extravasation than TURP. It is not replacing TURP presently because it is not the ideal treatment currently.

Presented at the: 16th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2–4 March 2004 (11–13 Muharram 1425)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Holmium laser enucleation of the prostate initial experience in Kuwait

Ahmed Mohammed Al Kandari

Department of Surgery, Faculty of Medicine, Kuwait University, Kuwait

Objectives: To evaluate the efficiency of Holmium laser for enucleation of the benign prostatic adenoma (HOLEP) and present our initial experience in Kuwait as the only Center so far using this technique.

Methods: Twenty four patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with a mean age of 61 years (range 52–71 years) were included in this study. The mean volume of the prostatic adenoma was 46 gm (range 38–115). All patients were treated with HOLEP. The treatment outcome was evaluated at 3 and 6 months post operatively by "American Urological Association (AUA) symptom score, Qmax, post void residual urine estimation."

Results: All 24 patients demonstrated immediate improvement within the first week after HOLEP. There was minimal intraoperative bleeding and none of the patients required blood transfusion. Mean catheterization time and postoperative hospital stay were 1.5 day and 1.8 day respectively. Mean AUA symptom score urine flow rate and post void residual urine showed significant improvement at one month post operatively. This improvement was maintained at 3 and 6 months. There was one intraoperative complication including minor capsular perforation managed with catheter for three days. Only long term complication included one patient who developed bulbar urethral stricture at one month follow up.

Conclusion: The initial good result for HOLEP and “low complication rate indicates that HOLEP is a viable option for the treatment of BPH and can be readily adapted with a reasonable learning curve.”

Presented at the: 18th Saudi Urological Conference

King Abdulaziz University Hospital

20–23 February 2006 (21–24 Muharram 1427)

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

The clinical response of obstructive benign prostatic enlargement to botolinum A toxin locally: A preliminary report

Hisham El Shawaf, Khaled Mokhtar, Ismail O. Abdelhafeez

Department of Urology, Saudi German Hospital, Riyadh, Saudi Arabia, Department of Urology, Neurology Unit, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Introduction and Objectives: Obstructive BPE patients are managed medically and surgically. However, some do fail medical treatment, others refuse surgical intervention due to subsequent ejaculatory dysfunction, while others are poor surgical candidates. BTX-A has been used to decrease in size following BTX-A injection with resultant denervation atrophy of its glandular epithelium. In men, studies following BTX-A injection showed significant improvement of IPSS and flow rate, decreased prostate volume and PSA. The objective is to demonstrate the effectiveness of prostate injection with BTX-A toxin in patients with obstructive BPE.

Materials and Methods: 15 patients with obstructive BPE were selected, their age range from 52–65 years. All patients included were either sexually active, failing medical treatment, refusing the risk of retrograde ejaculation post TUR-P; or high risk patients with impaired (bleeding profile and/or cardiovascular conditions). All patients had an IPSS >18, prostate volume < 50 ml, PSA <4 ng/dl and obstructive P-Q plot. Each prostate lobe was injected endoscopically with lidocaine reconstituted BTX-A 100 units. All received a 2 weeks course of alpha-blocker Tamsulosin 0.4 mg and phytotherapy post injection. IPSS, prostate volumes, PSA levels and urodynamic parameters at baseline, 4 weeks, 12 weeks and 12 months after treatment were compared. Follow up extended to minimum of 1 year in all patients.

Results: Subjective and objective improvements in (IPSS, flow rate, QOL) were evident and progressive over the 12 weeks follow up and sustained throughout the whole follow up period. Prostate volume at 12 weeks by TRUS did not alter while, serum PSA was not evaluated due to post-traumatic expected rise after intraprostatic injection. Changes of both Prostate Volumes (TRUS) by

Presented at the: 19th Saudi Urological Conference

King Khalid University Hospital, Riyadh

26 February to 01 March 2007

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Comparative study of transurethral resection versus transurethral vapour resection and holmium laser enucleation of the prostate

Hamza Alsisi

Division of Urology, King Fahd Hospital, Madinah Al Monawara, Saudi Arabia

Objectives: Transurethral resection of the prostate (TURP) is the gold standard treatment for benign prostatic hyperplasia (BPH). Recently, less invasive. Transurethral vapor resection of the prostate (TUVRP) and holmium laser enucleation of the prostate (HOLEP), have been developed. Herein, we investigated the safety and efficacy of TUVRP and HOLEP compared to TURP, the standard surgical therapy, as treating large prostate is associated with greater morbidity.

Patients and Methods: We prospectively randomized 80 patients with BPH and glands of >60g were treated: 20 patients by HOLEP, 30 patients by TURVP and 30 patients by TURP. The criteria for surgery were determined by a preoperative International Prostate Symptom Score (IPSS), a prior tech failure of medical therapy, and urinary retention. The operative duration, blood loss, duration of catheterization and complications were noted. All patients were followed up for 12 months after their operations. Treatment outcomes were evaluated by four different criteria: (i) the International Prostatic Symptom Score (I-PSS), (ii) the maximum flow rate (Qmax), (iii) postvoided residual urine volume (PVR) before treatment and after treatment, and (iv) prostatic volume before operation and postoperatively.

Results: The patients in all three groups had comparable characteristics before surgery. The mean operating duration and intraoperative irrigant used for TUVRP was less than for HOLEP or TURP, and blood loss with HOLEP and TUVRP was less than with TURP (all P < 0.001). Postoperative irrigation, nursing contact time and catheter duration were significantly less for HOLEP than TURP or TUVRP, and for TUVRP than TURP. At follow up, patients in all groups had a significant improvement from baseline in IPSS, Q (max) and PVR, but the differences between the groups were not significant at 1 year.

Conclusions: HOLEP and TUVRP are both acceptable alternatives to TURP for treating large prostate glands but these techniques need long learning curve, with less perioperative morbidity and comparable efficacy at 1 year. HOLEP is a safe and effective procedure for treatment of symptomatic BPH, regardless of prostate size, with low morbidity and short hospital stay. HOLEP appears to be modern alternative to transurethral resection of the prostate and open prostatectomy, and it may be considered a size-independent new gold standard.

Presented at the: 19th Saudi Urological Conference

King Khalid University Hospital, Riyadh

26 February to 01 March 2007

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Involuntary detrusor contractions following prostatectomy

M. Elqadhi

Departments of Urology, National Institute of Urology and Nephrology, Cairo, Egypt, and Al-Manaa General Hospital, Saudi Arabia

Aim of the Work: To evaluate the prostatectomy outcome on over activity symptoms associated with BPH.

Patients and Methods: A group of 64 men with a median age of 65.7 ± 6.82 years, diagnosed as having BPH with irritative urinary symptoms were included in this study between November 2003 and June 2007. Eleven patients did not complete the study. Patients included when they are ≥50 years, suffering from irritative LUTS and peak flow rate ≤15 ml/sec. The exclusions criteria include previous surgeries on bladder, prostate or urethra, as well as pathological, neurological or malignant diseases. The pre-operative evaluation includes measurement of serum creatinine, PSA, KUB x-ray, renal ultrasonography and transrectal ultrasound (TRUS) scanning and pressure/flow study. The decision to do surgery (TURP) was based on clinical and urodynamic assessment. Post-operative follow up for 53 patients was done by re-assessment of the burden of the disease.

Results: The incidence of preoperative UDCs was 94%. Cystometric studies of all 53 patients revealed persistence of UDC s in 47% and 30% at early and late postoperative visits respectively. Patients over 70 years showed 50% persistence of UDCs compared to complete resolution for those below 60 years. Forty percent of the patients with urge incontinence showed persistence UDCs, whereas only 20% of patients with urgency revealed unresolved contractions.

Conclusions: Age, severity of symptoms are significant variables and could be considered for prediction of prostatectomy outcome for BPH associated detrusor over activity. Further evaluation with longer follow up period for the surgical outcome is still needed.

Presented at the: 20th Saudi Urological Conference

King Fahad Hospital of the University, Tabuk

18–20 March 2008

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Continuous versus intermittent tamsulosin treatment in men with symptomatic benign prostatic hyperplasia

S. Elmikkawy, H. Abouzeid

Department of Urology, Al-Azhar Faculty of Medicine, Cairo, Egypt

Aim of the Work: To compare the outcomes of continuous (once daily) versus intermittent use of Tamsulosin (every other day) in the treatment of cases presented by lower urinary tract symptoms (LUTS) compatible with benign prostatic hyperplasia (BPH).

Patients and Methods: In this study 258 patients presented by LUTS were evaluated. Inclusion criteria included male ambulatory patients 250 years of age with a diagnosis of BPH confirmed by digital rectal examination (DRE) and ultrasound, patients with International Prostate Symptom Score (IPSS) ≥8, peak flow rate (Qmax) of 5–15 ml/second with voided volume of >150 ml, post voiding residual urine (PVR) <200 ml and patients able to receive oral treatment with α1-adrenoceptor antagonists. In the first phase, all patients received one Tamsulosin capsule 0.4 mg daily for 12 weeks and then reevaluated by IPSS, uroflowmetry, sonographic estimation of PVR. Significant improvement occurred in 164 patients in the form of 40% decrease in IPSS, 30% increase in Qmax and 25% reduction in PVR. Responders were enrolled into the second phase of this study and randomized into three groups: Group 1 (n = 57) continued receiving Tamsulosin capsule 0.4 mg daily. Group 2 (n = 59) continued receiving one Tamsulosin capsule 0.4 mg every other day. In the third group (48 cases) Tamsulosin intake was discontinued. All groups were followed up at 4, 12 and 24 weeks. Non-responders to Tamsulosin, those who did not tolerate side effects and those who did not complete follow up were excluded from the study. The three groups were compared statistically regarding IPSS, Qmax, average flow rate (wave) and PVR.

Results: The mean IPSS for the groups 1 to 3 before randomization was 7.6 ± 2.1, 7.3 ± 2.6 and 7.4 ± 2.7 respectively. After 24 weeks, those values were 7.2 ± 1.5, 7.1 ± 1.1 and 12 ± 2.6 respectively. Mean Qmax was 10.8 ± 3.9, 11.0 ± 3.6 and 11.2 ± 1.3 ml/sec respectively. After 24 weeks, the values were 11.3 ± 2.9, 11.5 ± 4.8 and 8.3 ± 2.5 ml/sec respectively. Mean residual volume was 72.6 ± 23.5, 73.2 ± 17.8 and 73.4 ± 22.3 ml respectively. After 24 weeks the values were 75.6 ± 24.6, 64.6 ± 11.5 and 90.0 ± 21.8 respectively. The differences between patients in group 1 and 2 were of no statistical significance at 24 weeks while differences between patients in group 1 and 3 and those between group 2 and 3 were statistically significant for IPSS, Qmax, Q wave and PVR.

Conclusions: The results of this study suggested that intermittent use of Tamsulosin was as effective and safe as continuous daily use of the drug.

Presented at the: 20th Saudi Urological Conference

King Fahad Hospital of the University, Tabuk

18–20 March 2008

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Holmium laser enucleation of the prostate compared to transurethral resection of the prostate: Initial experience in Kuwait

A. Al-Kandari, H. Ibrahim, Y. El-Shebini, M. El-Hilali

Department of Surgery, Urology Division, Adnan Hospital, Kuwait

Aim of the Work: To compare our initial experience with Holmium laser for the enucleation of benign prostatic adenoma (HOLEP) with the standard TURP technique.

Patients and Methods: 80 patients were included in this study. Patients were randomly divided into; group A treated by TURP and group B treated by HOLEP. Treatment outcome was evaluated at 1, 3 and 6 months postoperatively by the AUA symptom score, Qmax, estimation of post voiding residual urine (PVR) volume and TRUS.

Results: There was immediate improvement within the first week in both groups. Adenoma size ranged from 30 to 100 cc in patients who underwent TURP and from 60 to 200 cc in patients who underwent HOLEP. Three patients in group A needed blood transfusion, while none of group B needed transfusion. There was significant drop of serum sodium in one patient from group A, but not in group B. Operative time was longer with HOLEP ranging from 110 to 240 minutes. In 4 cases a small 4cm suprapubic incision was made to remove the adenoma to reduce the operative time in group A and 22 hours in group B, while the mean postoperative hospital stay was 3.7 days and 1.3 days respectively. The AUA symptom score, Qmax, PVR volume and TRUS showed marked improvement at 1.3 and 6 months postoperatively in both groups.

Conclusions: HOLEP compares well with standard TURP in terms of outcome. HOLEP has the advantage of better hemostasis and no risk of TURP syndrome. Mean times of postoperative catheterization and hospital stay are shorted in HOLEP than TURP. HOLEP requires relatively special skills and longer learning time.

Presented at the: 20th Saudi Urological Conference

King Fahad Hospital of the University, Tabuk

18–20 March 2008

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Short term outcome of green light laser prostatectomy using 120 W

K. Al Othman, R. Seyam, S. Al Shehri

King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Aim of Work: Green light laser prostatectomy with 120W is a relatively new procedure. Clinical outcome of this procedure needs to be examined.

Patients and Methods: We did a prospective study for patients with symptomatic benign prostatic hyperplasia (BPH) who have clinical indication for Transurethral Resection of Prostate (TURP). Patients were evaluated pre and post operatively by using International Prostate Symptoms Score questionnaire, uroflowmetry, bladder ultrasound, transrectal ultrasound, PSA measurement, duration of catheterization after surgery and hospital staying.

Results: 25 patients underwent green light laser prostatectomy. Mean age, mean volume of prostate, mean operative time were 56 yr, 57 ml, 62 min, respectively. The bladder catheter was removed usually on the first post operative day; the average hospital staying is one day post operative. 5 patients have the procedure as day surgery. The most common complication is irritative voiding symptoms which was seen in 8 patients (30%) followed by delayed hematuria which was seen in 3 patients (12%).

Conclusion: Green light laser prostatectomy with 120 W is safe and effective procedure for the treatment of BPH. Long term study is needed.

Presented at the: 20th Saudi Urological Conference

King Fahad Hospital of the University, Tabuk

18–20 March 2008

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

HPS green light laser prostatectomy: Outcome in patients with urinary retention

M. Abdulwahab, H. Mosli, A. Tayib, T. Abdel-Meguid, H. Farsi, A. Sayyad, M. Risk

Department of Urology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Objective: To study the efficacy and safety of HPS 120 W green light laser prostatectomy in patients with urinary retention due to BPH with or without risk factors.

Patients and Methods: Patients with urinary retention due to BPH with or without risk factors were enrolled in the study. Patients were assessed preoperatively, then at 2 and 12 weeks postoperatively. Work up included complete history and examination, PSA, CBC, serum Na+, CMG (in selected patients) and Q-max (postoperatively). Patients on oral anticoagulant medications were switched to heparin infusion pump 5 days before surgery. The HPS 120 W green light laser was utilized in all patients to create an immediate TURP-like prostatic cavity.

Results: Out of 55 BPH patients who underwent green light laser prostatectomy, 14 patients (25.5%) with urinary retention were included in the study. Their age ranged from 56 to 80 years. Duration of catheterization ranged from 3 to 18 months. The majority were high risk patients with cardiac problems (6), CVA (2), PE (1) and oral anticoagulant medications (9). Preoperative prostate volume (range 35–80 cc and average 49.7) was reduced at 2 weeks post treatment to a range of 10–28 cc and average of 15.8 cc (68.2% reduction ratio). The volume further decreased at 12 weeks by additional 16%. Average PSA was 5.1, 6.1 and 2.4 ng/mL preoperatively, 2 and 12 weeks postoperatively, respectively. All patients were able to void freely postoperatively, with Q-max ranging between 7.7–18.5 and 11.2–15.4 mL/sec at 2 and 12 weeks, respectively. I-PSS score was ranging between 22 and 32 prior to retention. At 2 weeks postoperatively, the score showed 25% improvement ratio (range 14–20). An additional 25% improvement was obtained at 12 weeks. Blood loss was minimal with the 11.9 g/dL average of preoperative hemoglobin decreased to 11.4 g/dL (4.7% reduction ratio). The average of sodium before surgery was 139.3 mEq/L which decreased to 136.4 after surgery, with reduction ratio of 2.1%.

Conclusion: This study provides some evidence on the efficacy and safety of HPS green light technology in management of BPH patients with urinary retention, including high risk patients.

Presented at the: 21st Saudi Urological Conference

North West Armed Forces Hospital, Tabuk

14–16 April 2009

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Green light laser prostatectomy in high risk patients

A. Nassir, M. El-Azab, A. Tayib

International Medical Center, Jeddah, Saudi Arabia

Objectives: To evaluate the outcome and safety of the high power green light laser (KTP) prostatectomy in high risk patient with symptomatic BPH.

Patients and Methods: Only patients with high risk for anesthesia were included in this study. All patient underwent preoperative and postoperative cardiac and anesthesia evaluation, ultrasound of the urinary tract, routine preoperative laboratory investigation, international prostate score system (IPSS), and clinical presentations. A 120 watt green light photo-vaporization system was used for all patients. Intra-operative and postoperative complications as well as follow up were recorded.

Results: Fourteen Saudi male patients were included in the study with an average age 75.5 years (range: 65–87). Nine patients presented with refractory urinary retention and 5 with severe LUTS. The mean prostate volume was 60 cc. Twelve patients had an uneventful intra and postoperative course. Two patients required postoperative admission to the ICU. The average blood loss was insignificant. One patient required post operative blood transfusion. The Foley catheter was removed at the 1st postoperative day in 11 patients, 2nd day in 2, and 1 patient had a suprapubic catheter for 4 days. All patients voided satisfactory after removal of the catheter, and 10 patients complained of urgency.

Conclusion: Higher power green laser prostatectomy is a safe and effective method of treating symptomatic BPH in high risk patients for anesthesia.

Presented at the: 21st Saudi Urological Conference

North West Armed Forces Hospital, Tabuk

14–16 April 2009

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

King Abdulaziz University Hospital experience in the treatment of the first 55 patients with benign prostatic hyperplasia using green-light laser technology

M. Abdulwahab, H. Mosli

Department of Urology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Objective: To present the early experience at King Abdulaziz University in Jeddah in the surgical treatment of BPH using the green-light laser technology.

Patients and Methods: Until date we treated 55 patients presented with symptomatic or complicated BPH. The symptom severity was documented pre-operatively using the I-PSS score system. The sexual function of the patients was also documented using the IIEF-5 Questionnaire. The clinical workup for all patients enrolled included complete medical history, past history and urological examination including DRE and investigations including routine urine and blood work, PSA, flow-rate, abdominal ultrasound, and TRUS in selected patients for determination of the prostate size. The green light laser according to the photo selective vaporization of the prostatic adenoma with the high power system utilizing KTP at 120 W was used in the surgical treatment of those patients.

Results: The age range was from 55 to 83 years, prostate volume from 33 to 85 cc (estimation using DRE, abdominal US and TRUS in selected patients). The final results regarding age, presentation, size of the prostate of those patients, Q-max values pre and postoperative and changes in I-PSS and IIEF-5 score will be analyzed, tabulated and presented.

Conclusion: Our preliminary results indicate that the treatment using the green light laser at 120 W for surgical treatment of BPH is safe, efficient especially for high risk patients, need short learning curve with minimal complications on the short and long run.

Presented at the: 21st Saudi Urological Conference

North West Armed Forces Hospital, Tabuk

14–16 April 2009

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Complete bladder neck obliteration after open prostatectomy. A safe stepwise technique for bladder neck incision

M. Gomha, H. Al-Ali, M. Aggamy, A. Al-Dayel

Department of Urology, King Fahd Specialist Hospital, Damam, Saudi Arabia

Objective: To describe and show a video of an endoscopic safe technique for bladder neck incision for management of complete bladder neck obliteration after open prostatectomy.

Materials and Methods: A 73 years old male patient presented to us with an indwelling suprapubic catheter of 6 month duration. He had past history of open prostatectomy since 6 months followed by two endoscopic trials to relieve obstruction, the last one was associated with marked extravasation. Urethrogram in our hospital showed complete arrest of contrast medium at bladder neck. Combined cystourethrogram showed complete obliteration at bladder neck with 1 cm defect. Urethroscopy combined with suprapubic cystoscopy confirm the complete obstruction at bladder neck with a significant retro-trigonal pouch. We describe a safe technique for establishing a channel between the urethra and bladder followed by bladder neck incision. This involves passing a stiff wire through the obliterated tissue under suprapubic cystoscopic guidance, followed by serial coaxial dilation, followed by hot-knife bladder neck incision.

Results: Patient voided very well after catheter removal, and he is continent as well.

Conclusion: Complete bladder neck obliteration after open prostatectomy is rare. Endoscopic incision of the bladder neck can be successful and safe using our stepwise technique.

Presented at the: 21st Saudi Urological Conference

North West Armed Forces Hospital, Tabuk

14–16 April 2009

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Chemodenervation of the rhabdosphincter alone versus combined injection of external urethral sphincter and prostate in patients with prostatitis and chronic pelvic pain syndrome Type III: Prospective randomized controlled trial

Hisham Mohamed El Shawaf

Department of Urology, Saudi German Hospital, Riyadh, Shams University, Egypt

Hypothesis/Aims of Study: Pelvic floor dysfunction has been suggested in many patients with chronic prostatitis and chronic pelvic pain syndrome type III. Our aim is to elucidate whether there will be an additional benefits of intra-prostatic Botulinum A Toxin (BTA) over injection of external urethral sphincter (EUS) alone in those patients with urodynamically proven detrusor external sphincter dyssynergia (DESD) and monitored by improvement of chronic prostatitis symptoms index (CPSI).

Methods: Fifty two (52) male patients with chronically proven chronic prostatitis and chronic pelvic pain syndrome type III after failure of several courses of medical therapy were selected from patients referred to the neurourology unit of the urology department for voiding dysfunction evaluation and management. All patients were selected according to the classification of NIDDR/NIH (type III) and underwent detailed medical history, clinical laboratory, TRUS, and full urodynamic evaluation including EMG to EUS. All patients had urodynamically proven DESD. All patients were randomly allocated into two groups. GI included another 26 patients (n = 26) who received 100 units of BTA into EUS endoscopically. GII included another 26 patients who received combined injection of EUS and prostate with 100 units for each. All patients were followed up by NIH-CPSI that includes scoring for pain, urinary symptoms and quality of life impact at 12 weeks, 6 months, and 12 months were compared to baseline assessment. Urodynamic and TRUS evaluation were done at 12 week and at 12 moth follow up.

Results: All patients showed different degrees of both subjective and objective improvements in QOL and LUTS, flow rates and PVR. UDS-EMG evidenced regression in DESD in all patients of both groups. GII patients showed more significant improvement in NIH-CPSI scores compared to GI patients and could be explained by the ultrasonically proven reduction of prostate volumes at 12 month follow up in the former group of patients GII. Only two patients (7.7%) among GI needed 2nd cycle of BTX after 12 months to maintain the obtained result compared to none of GI patients and the difference was found to be statistically significant (p < 0.05). No adverse effects were encountered in both groups of patients.

Summary and Conclusion: The presence of pelvic floor dysfunction and DESD among patients with chronic pelvic pain syndrome is an important factor responsible for the symptomatology of those patients with long standing history of chronic prostatitis type III not responding to all the known treatment regimen. Chemodernervation of the EUS and/or combined injection of EUS and prostate using Botulinum Toxin is a safe, cost effective with an additional benefits among GII patients intraprostatic injection of BTX-A who showed significant improvement in prostate volumes compared to GI confirming its role in controlling the whole scenario of the disease entity while further larger scale trials in different centers is warranted.

Presented at the: 22nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15–18 March 2010

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Photo selective vaporization of prostate by green light KTP laser: A retrospective review from King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Muhammad Aslam, Khalid Al Othman, Said Kattan, Hassan Al Zahrani, Ali Bin Mahfooz, Mohammed Al Otaibi, Waleed Al Taweel, Waleed Al-Khudair

King Faisal Specialist Hospital and Research Centre, Saudi Arabia

Introduction: PVP is an emergent technology in the surgical management of enlarged prostate. Green Light Laser Prostatectomy was pioneered by Malek and colleagues in Mayo Clinic USA demonstrating excellent improvements in flow rates and symptoms as well as reduction in catheterization time, hospital stay and complication rates. We report the retrospective review to assess the functional outcome of green light laser prostatectomy.

Methods: Medical Records of patients who underwent Green Light Laser Prostatectomy from 2007 to 2009 were reviewed retrospectively. The parameters included age, follow up, prostate volume, energy delivered, catheter duration, hospital stay, post surgery Qmax and post void residual as well as complications.

Results: There were 42 patients; out of them four (4) were high risk and on anticoagulants. Mean follow up 14 months mean prostate volume 42 cc, mean energy delivered 206KJ, and mean laser time 37 minutes. Thirty eight (38) patients' catheters removed on first post operative day, in 2 removed on the same day and in 2 removed after 2 days. Thirty six (85%) discharged on next day of surgery, 6 (15%) stayed for 2–3 days. Mean post surgery Qmax and post void residual were 19 cc and 26 cc, respectively.

Complications: Two (2) were found to have bulbar stricture and two (2) developed bladder neck contracture. Two (2) were re-operated (residual prostate was resected).

Conclusions: Photo selective vaporization of prostate to treat bladder outflow obstruction by green light laser was found effective and durable and the technique enabled us to treat high risk patients on anticoagulants. However, treatment modality was underutilized; meticulous technique as well as improved learning curve can reduce the complications to minimum.

Presented at the: 22nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15–18 March 2010

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Plasma vaporization of the prostate

Alaa Elshennawy

Department of Urology, King Fahad Hospital, Al Baha, Saudi Arabia

Introduction/Objectives: To evaluate the bipolar plasma vaporization of the prostate in patients with lower urinary tract symptoms (LUTS) due to Benign Prostatic Obstruction (BPO).

Materials and Methods/Patients and Methods: Eighteen patients presented with LUTS due to BPO. Two of them had acute urinary retention (AUR). International Prostate Symptom Score (IPSS), maximum flow rate (Qmax) and post-void residues (PVR) were evaluated in the other sixteen cases preoperatively. Prostate volume (by transrectal ultrasound (TRUS) and PSA were estimated in all cases before the procedure. All patients underwent plasma vaporization of the prostate by the same surgeon. IPSS and Qmax were evaluated for all patients at 1 and 6 months post-operatively.

Results: Mean pre-operative prostate volume was 48 ± 28 gm (30–110). Mean operating time was 68 ± 18 min (40–120). Catheter time averaged 52 ± 20 h (36–120). Qmax improved from pre-operative average of 7.2 ± 2.8 ml/sec to 14.1 ± 3.8 and 19.2 ± 4.1 at 1 and 6 months respectively. Mean IPSS improved from 19.5 ± 4.6 to 12 ± 2.2 and 10.1 ± 2.1 at 1 and 6 months respectively.

Conclusion: This is an initial evaluation for a small non-randomized prospective study of a new modality "plasma vaporization of the prostate" with a short follow up. Bipolar plasma vaporization of the prostate demonstrated a safe and effective treatment option for patients with LUTS due to BPO. This novel technique needs further evaluation with randomized prospective studies with longer follow up.

Presented at the: 23rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21–24 February 2011

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

KTP green-light laser photo-selective vaporization of prostate: King Abdulaziz University Hospital in Jeddah experience with 62 consecutive cases

Mohamed Hani Abdulwahab, Hisham Mosli, Abdulmalik Tayib, Ahmed Al-Sayyad, Hasan Farsi, and Taha Abolmagd

Department of Urology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

We further report the efficacy, safety, learning curve and perioperative complications of photo-selective vaporization of the prostate (PVP) used for patients complaining of symptomatic obstructive benign prostatic hyperplasia (BPH).

A total of 62 patients over two years were included in the study. Preoperative data include: age, international symptom score (IPSS), Transrectal ultrasound (prostate size estimation), uroflowmetry (Qmax), prostatic specific antigen (PSA), hemoglobin and serum sodium levels. All patients included were not in urinary retention since this condition affects the above mentioned parameters, an additional 30 patients who presented in retention of urine are reported separately. Intraoperative data were collected also, lasing time, amount of power delivered to prostate, number of fibers used and intraoperative complications. We followed up our patients for 24 weeks using same preoperative parameters. Our preoperative date revealed that the mean age was 68.9 ± years (52–78), IPSS was 24.5 ± (19–31), prostate volume was 44.2 ± cc (24–48), mean PSA was 3.8 ± ng/ml (24–0.3), mean Qmax was 7.8 ± ml/sec (2.8–13) and mean hemoglobin was 13.3 ± g/dl (9.8–16.2).

Assessment over the follow up period revealed that:

The mean IPSS was 16.9 9 ± (12–23), 12.9 ± (11–15), 12.4 ± (10–14) at 2, 12 and 24 weeks respectively.

The mean prostate volume showed significant reduction through0out the follow up period, it was 26.6 ± cc (12–47), 19.8 ± cc (10–35), 18.1 ± cc (10–28) at 2, 12 and 24 weeks respectively.

The mean PSA level showed significant decrease on follow up, it was 4.02 ± ng/ml (0.9–23), 1.07 ± ng/ml (0.3–3.9), 0.46 ± ng/ml (0.01–0.96) at 2, 12 and 24 weeks respectively.

The Qmax shows improvement at 24 weeks to be 20.4 ± ml/sec (12–48).

The hemoglobin showed drop 12.7 ± g/dl (7.3–15.9), 12.3 ± g/dl (9.8–12.5) at 24 hours, 12 weeks respectively.

PVP is a unique, safe and effective modality that provides immediate symptomatic and urodynamic relief of bladder outlet obstruction secondary to BPH.

Although the learning curve is short, yet it needs persistence and paying attention to operative details to get a good vaporization effect in a bloodless clear field.

Long-term follow up is needed to validate further the maintenance of clinical efficacy of such procedure and to prove advantage of it over other modalities.

Presented at the: 23rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21–24 February 2011

Urol Ann. 2015 Oct;7(Suppl 3):S232–S258.

Laser vaporization of benign prostatic hyperplasia versus transurethral resection of prostate

Hamza Alsisi, Abdelrahman Alqahtani, Khaled Mokri and Mohamad Alhalawany

Department of Urology, King Fahad Hospital, Al Madinah, Al Monawarah, Saudi Arabia

Introduction: The gold standard for intra vesical obstruction due to BPH is transurethral prostate resection (TURP). This method proved to be effective and efficient but cardiac insufficiency is a relative contraindication because of the risk of a TUR syndrome. Also the prophylactic intake of thrombocyte aggregation inhibitors causes prolonged hospitalization due to bleeding. The morbidity of TURP is low but still patients demand for shorter hospital stays. Laser vaporization of the prostate is promising to fulfill those demands. To evaluate the outcome and morbidity rate of laser ablation of the prostate in comparison with TURP.

Materials and Methods: For five years back, 82 patients with symptomatic BPH treated with laser vaporization of the prostate (LVP) in King Fahad Hospital, Almadinah Almonawarah, Saudi Arabia were compared with 90 patients treated with TURP in the same period. Holmium laser was used in the laser vaporization of the prostate. All patients were assessed preoperatively by urodynamic studies. Perioperative date, as well as symptom scores, Quality of Life (QoL) scores, and maximum urinary flow rates (Qmax) were obtained at one, three, and six months. Post-void residual volumes symptom scores, Qualify of Life (QoL) scores, and maximum urinary flow rates, obtained six months postoperatively. Mean PSA: 2.5 ng/ml (0.5–6) vs. 2.6 ng/ml (0.7–5.9), mean preoperative TRUS volume 68.3f 5.2 (40–110) vs. 76.0f 4.0 mL (44–152), mean AUA symptom score: 20 vs. 19, mean peak uro-flow rate: 7.0 mLis vs. 6.8 mLis. The procedure was performed using a standard cystoscope under general intravenous anaesthesia.

Results: At 6 months, the mean AUA symptom score had decreased to 9 (55%) for the laser group and to 7 (63.1%) for the TURP group. The mean peak uroflow rate increased to 14.7 mLis for the laser group and to 17.0 mLis for the TURP group. In the laser prostatectomy group duration of operation (38,4f8,5) min vs. 49,6f7,5 min), amount of fluid used during the operation (10,691f1,8 L vs. 12,36f2,5) and duration of bed rest were less than those of the TURP group. Patients in the LVP group had shorter catheter times and hospital stays.

Conclusion: Laser prostate vaporization decrease the operative time, duration of bed rest, providing excellent haemostasis and lower morbidity. Laser vaporization of the prostate is a minimally invasive alternative to TURP for patients who are medically high risk or need faster return to previous activities.

Presented at the: 23rd Saudi Urological Conference

King Fahd Specialist Hospital, Dammam

21–24 February 2011

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