Gautier Müllhaupt

A 66-years old male patient presents with lower urinary tract symptoms, mostly due to obstructive symptoms, and an enlarged prostate with 80 cm³, with a broad-based median lobe, suggestive of benign prostatic obstruction (BPO). Trans-urethral resection of the prostate (TURP) was proposed. However, the patient desired to preserve ejaculatory function and was afraid of a potential negative impact on erectile function. Thus, the patient inquired about minimally invasive therapies (MITs) as alternatives to TURP. In this review, currently available MITs for BPO are described including prostatic artery embolization, water vapor thermal therapy (Rezum®), prostatic urethral lift, iTIND® (temporary implantable device) and aquablation (Aquabeam®). Focus is given on the description of the technique, level of evidence and advantages over conventional surgical options.

Introduction: A novel method for the surgical treatment of benign prostatic hyperplasia (BPH) called Aquablation has become commercially available. Previous studies have been able to show similar functional results when compared with transurethral resection of the prostate and a high efficacy has been demonstrated when this approach is applied to patients with a prostate size of 80–150 cm ³ . Holmium laser enucleation of the prostate (HoLEP) is a well-established procedure in the surgical treatment of BPH in prostate glands larger than 30 mL and a first-line therapy in glands over 80 mL. To date, no data are available whether Aquablation is non-inferior compared with HoLEP in the treatment of patients with medium-to-large-sized prostates regarding safety and efficacy. Methods and analysis: This is a prospective, randomised, open-label, non-inferiority clinical trial conducted at a Swiss centre of tertiary care. The primary outcome is assessment of non-inferiority of Aquablation compared with HoLEP in reducing lower urinary tract symptoms due to benign prostatic obstruction measured by the International Prostate Symptom Score (IPSS). Randomisation will be performed using secuTrial, stratifying on age (<70 years, 70+ years) and prostate volume (<100 mL, 100+ mL). Both interventions are performed in an inpatient setting and regular follow-up controls starting 8 weeks after intervention and continuing up to 5 years will be performed. The primary outcome (change in IPSS from baseline to 6 months) will be tested for non-inferiority with a one-sided t-test. Secondary outcomes, such as efficacy parameters, several patient-reported outcome measures, and periprocedural and safety parameters will be described by calculating means or relative frequencies for each treatment group and testing differences with two-sided standard superiority tests. Ethics and dissemination: The study was approved by the local ethics committee (EKOS 2020-02353). Results of the primary endpoint and each of the secondary endpoints will be published in an international peer-reviewed journal. Trial registration number: ClinicalTrials.gov Registry ( NCT04560907 ).

Purpose To determine the histological validity of the tissue acquired during aquablation of the prostate. Patients and methods Prostatic tissue of 12 patients that consecutively underwent aquablation for benign prostatic enlargement was systematically examined. Histological examination was performed by two experienced uropathologists using a digital slide scanner and slide viewer software (Pannoramic 250 and Case Viewer 2.3, 3D Histech, Hungary). The surface areas of the assessable glands were examined and set in relation to the total surface area of the material available for histology and to the patient’s total prostate volume. Examinations were performed analogously in ten consecutive patients undergoing transurethral resection of the prostate (TURP) to facilitate interpretation of the results. Data were analyzed using descriptive statistics. Results A median of 4.06% (range 1.43–7.5%) of the preoperative total prostate volume (median 64.5 ml (range 40–80 ml)) was obtained for histological examination by aquablation. Due to severe mechanical destruction and fragmentation, only a proportion of 0.43% (0.06–1.79%) of this tissue represented histologically assessable glands. Therefore, roughly 0.017% of the total prostatic volume was available for a reliable histological examination. In comparison, 32.5% (6.67–37.5%) of the total prostate volume was removed by TURP and 22.86% (7.45–40.57%) of this tissue represented informative prostatic glands, corresponding to 7.43% of the total prostate volume. Conclusion Histological significance of the tissue obtained by aquablation of the prostate is very limited. Costs and effort of the histological examination must, therefore, be weighed critically against the limited informative value.

Objectives To assess the quality of videos on surgical treatment on YouTube, since video sharing platforms are used very frequently as sources of patient information and the therapeutic landscape of lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) substantially evolved during the last years. Materials and Methods A systematic search for videos on YouTube addressing treatment options of LUTS/BPH was performed in May 2019. Assessed parameters included basic data (e.g., number of views), grade of misinformation and reporting of conflicts of interest. Quality of content was analyzed using the validated DISCERN questionnaire. Data were analyzed using descriptive statistics. Results A total of 159 videos with median 8’570 views (648 – 2’384’391) were included to the analysis. Only 21 videos (13.2%) were rated to contain no misinformation, 26 (16.4%) were free of commercial bias, and two (1.3%) disclosed potential conflicts of interest. According to DISCERN, the median overall quality of the videos was low (2 out of 5 points for question 16). Only four out of the 15 assessed categories (i.e., bipolar and Holmium laser enucleation, transurethral resection and patient based search terms) reached a moderate median overall quality (3 points). Conclusion Most videos about surgical treatment of LUTS/BPH on YouTube have a low quality of content, provide misinformation, are subject to commercial bias and do not report on conflicts of interest. These findings emphasize the importance of thorough doctor‐patient communication and active recommendation of unbiased patient education materials.

Purpose: This study aims to specify and explain the previous findings of unexpectedly high rates of ejaculatory disorders, i.e. 56%, found after prostatic artery embolization (PAE) in a randomized controlled trial comparing safety and efficacy of PAE and transurethral resection of the prostate (TURP). Patients and methods: Case report forms of the randomized controlled trial were analyzed to specify the grade of postoperative ejaculatory dysfunction 3 months postoperatively. In addition, study participants with assessable ejaculation were asked to complete the four-item Male Sexual Health Questionnaire-Ejaculation Dysfunction Short Form (MSHQ-EjD) referring to their ejaculatory function at present, as well as before treatment and 3 months after. Potential explanations for ejaculatory disorders after PAE were derived from histological examination of five radical prostatectomy specimens of patients that underwent PAE 6 weeks before radical prostatectomy within a proof-of-concept trial at the study site, St. Gallen Cantonal Hospital. An experienced uropathologist systematically examined the whole-gland embedded tissue with focus on structures that are involved into ejaculation. Results: While patients after TURP predominantly suffered from anejaculation (52%), diminished ejaculation was found more often after PAE (40%). Significantly higher MSHQ-EjD scores were found 3 months after PAE and at a median follow-up of 31 months. Histological examination showed marked changes of structures involved into ejaculation (e.g., prostatic glands, seminal vesicles, ejaculatory ducts) after PAE. Conclusion: Although anejaculation occurs less frequently after PAE (16%) compared to TURP (52%), patients have to be informed about the relevant risk of ejaculatory disorders, especially diminished ejaculation.