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Photoselective Vaporization of the Prostate Is Similar to Transurethral Resection

Key findings

  • This claims-based study in New York state evaluated outcomes in 15,982 men up to seven years after they underwent primary ambulatory transurethral surgery for benign prostatic hyperplasia (BPH)
  • The primary outcome, treatment failure, was defined as any subsequent surgical reintervention or acute urinary retention
  • There were no significant differences between the two most common procedures, photoselective vaporization of the prostate and transurethral resection of the prostate (TURP), in the rates or adjusted hazards of treatment failure
  • Only 244 patients were treated with endoscopic enucleation of the prostate, but a sensitivity analysis showed such treatments were associated with significantly lower risk of long-term treatment failure compared with TURP (HR, 0.24; P=0.045)

Transurethral resection of the prostate (TURP) is the gold-standard treatment for lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH). In recent years, though, urologists have developed alternative transurethral procedures that are associated with shorter stays, shorter duration of catheterization and reduced bleeding risk.

Daniel M. Frendl, MD, PhD, chief resident in urology with the Department of Urology at Massachusetts General Hospital, Michelle M. Kim, MD, PhD, director of Prostate Health, and colleagues recently completed the first population-based assessment of long-term outcomes after common transurethral prostate surgeries in the U.S. In The Journal of Urology, they say the risk of treatment failure proved to be similar with photoselective vaporization of the prostate (PVP) and TURP—and, intriguingly, perhaps lower with procedures that involve endoscopic enucleation of the prostate (EEP).

Study Methods

The researchers used the Statewide Planning and Research Cooperative System all-payer claims database, which contains information on every ambulatory surgery visit in the state of New York. For the period January 1, 2010, to December 31, 2016, they identified 15,982 men who underwent a transurethral procedure in the ambulatory setting. Procedures include:

  • TURP: 5,708 (36%)
  • PVP: 9,807 (61%)
  • Various laser EEP procedures: 244 (1.5%)
  • Other (transurethral incision of the prostate, microwave ablation or radiofrequency ablation): 223 (1.5%)

Incidence of Treatment Failure

The primary outcome, treatment failure, was defined as any subsequent surgical reintervention or any emergency acute urinary retention event after the initial procedure. The median follow-up time was 2.8 years.

At seven years, the unadjusted cumulative failure rates were 15% for TURP, 14% for PVP, 7% for EEP and 18% for other procedures (P=0.04).

Multivariate Analysis

With TURP as the reference, the hazard ratio for treatment failure was:

  • PVP: 1.07 (P=0.35)
  • EEP: 0.67 (P=0.18)
  • Other: 1.68 (P=0.01)

Sensitivity Analysis

 The researchers conducted a sensitivity analysis designed to ensure thorough characterization of presurgical risk factors while maximizing the duration of follow-up. They included only patients who underwent their primary transurethral procedures in the years 2011 and 2012, which allowed at least four years of observation. For this subgroup the median follow-up was 4.8 years.

In general, the sensitivity analysis confirmed the same associations as the primary analysis did. However, the risk of treatment failure was significantly lower with EEP than with TURP (HR, 0.24; P=0.045).

Previous Trial Findings Seem Generalizable

These real-world findings are consistent with outcomes from randomized controlled trials, notably GOLIATH, which demonstrated equivalent surgical reintervention rates after PVP and TURP over two years of follow-up.

This study also supports the need to investigate real-world outcomes for EEP procedures, such as holmium laser enucleation, in a larger number of patients. 85% of patients who underwent EEP were discharged the same day, suggesting these procedures are feasible in the ambulatory setting.

76%
lower risk of treatment failure with laser enucleation of the prostate than with TURP in a sensitivity analysis

68%
greater risk of treatment failure with transurethral incision of the prostate, microwave ablation or radiofrequency ablation, compared with TURP

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