2019 American Urological Association assessment of BPH surgical procedures

Men's health
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If you cut and paste the following into google it shows the current status of American Urological Association recommendations. The paper also states when surgery should be considered.

Benign Prostatic Hyperplasia: Surgical Management of Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms (2018, amended 2019)

The different surgeries get either a B or C “evidence level” recommendation. PAE is not recommended, probably because the urologists can’t do it.

We can only hope that someday there will be an “A” rating.

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No report is shown.

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https://www.auanet.org/guidelines/benign-prostatic-hyperplasia-(bph)-guideline

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I put the link in the above reply.

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Here is the link I used Bing not Google…

https://www.auanet.org/guidelines/benign-prostatic-hyperplasia-(bph)-guideline

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Hey Doug

It is a very good Report. I did not have to cut and paste. I just did a search I put in “” American Urological Association Recommendations for 2019 “” It was the first on the page.

I did go over it but I have to read it again. I really did not see any of Grade A. Then do talk about it some Did see a lot of Grade B & C and some with no grades when it came to surgery’s.

Boy do they sure love the Turp. It is all in this article. To me they are pushing it because it is the gold standard. That is a matter of opinion. I would never do that with all the other procedures out there.

Another thing that I do not like is they have a way of saying no matter what the side effects you have you should still have the procedure so you can pee better. Everything else does not matter.

I feel this way because of what I read about Sexual Function and the Surgical Therapy. This is from the report.

Data on sexual side effects of BPH surgery’s can be difficult to ascertain as many studies are not primarily designed to answer these questions. As such many studies evaluate sexual side effects by looking at reported adverse events only, rather then specifically assessing sexual functions.

This is why we have to do as much research we can before we have a procedure. Doctor are suppose to tell you everything about the procedures but there are some that just tell you enough to have the procedure. They also say that this because most doctor’s feel that after 50 we should not be that interested in sex.

But after our kids are gone and you and you wife or partner are alone. This is when you can let your hair down and have fun and enjoy life together.

Well this is all I have to say for now. I get carried away with some of this.

All the best…Ken

Thanks again Doug. All men should read this article…

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Hi Ken,
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I downloaded and read the report too. You did not see any A’s because there is probably not a BPH procedure that can get an A due to the morbidity and complications associated with any prostate surgery.
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Yes it looks like they still love TURP which they gave a B rating and has been around forever but still has the highest morbidity, highest percentage of complications, longest hospital stay, and longest recovery time when compared to newer and less invasive procedures.
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The report gives the newer procedures a C rating but that is because there is a lot less data (i.e evidence level) on the newer procedures than TURP. Many urologists stopped doing TURP 10 to 15 years ago when laser technologies came out but many are still doing TURP.
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You and I chose 2 new but different procedures because we were concerned about the negative complications of TURP. When looking for a urologist, I recommend choosing one who is concerned about our concerns about the negative complications of any BPH surgery.
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The moral of the story is to careful choose your urologist before considering any BPH surgery.
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Steve
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PS: Ken, in the last 2 weeks, my PVR’s have dropped below 100 several times, so my bladder is showing signs of slowly recovering.

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PS: It is interesting that the report did not recommend Prostate Artery Embolization (PAE), which is a procedure that is not done by urologists.

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Hey Steve

In a few days I’m going to print it up not enough ink Maybe I will save it on a file on the computer for now. Yes did go through it but I want to sit and read it slowly.

Yes I did see that PAE was not given a grade and is not recommended maybe it is because there is data but not enough.

Like you and I try to tell the men to make sure you do your research and research the doctor. Read his reviews and if he rushes you through just move on and find another.

All the best to everyone…Ken

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I dont think moderator allows.posting report. if you could summarize the report for everyone who does not have access to the report, it would be grateful.

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Ken,
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Written like a true wize man “do your research and research the doctor. Read his reviews and if he rushes you through just move on and find another.” Note that the urologist that I finally chose to do my Rezum was a 'her". She was concerned about my guy concerns and took precautions accordingly.
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Steve

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The problem is in posting links. The solution is to post what is necessary to search for the report, i.e. the name of the report. It would be a lot of work for any of us to post a summary of this report as it reviews several BPH procedures and lists their pros and cons.
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S

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Steven

Yes we do all have to do that to get the best results from a doctor. They need to listen to our concerns to.

Yes I know that you had a women Urologist and a few of the other guys. That is all I have to say on that subject.

Ken

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Good evening All

I sent a PM to him the way I found it. Yes that would be a lot to post. 33 pages

Ken

15

As a satisfied TURP recipient, I did not need to read much. I did find the discussion on monopolar vs bipolar TURP pretty interesting and am pasting it here for anyone who might be considering a TURP.

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A large body of literature has been published in recent years regarding certain modifications of the standard TURP using monopolar energy, most notably the use of bipolar energy transmission.

Contrary to monopolar TURP, the energy does not travel through the body to reach a skin pad in bipolar TURP systems. The energy is confined between an active (resection loop) and a passive pole situated on the resectoscope tip. While monopolar TURP requires the use of either iso-osmolar solutions of sorbitol, mannitol, or glycine, bipolar TURP may be performed in 0.9% NaCl solution. This reduces (if not eliminates) the risk for acute dilutional hyponatremia during prolonged resection, which may lead to the so-called TUR syndrome.

Regarding the comparative efficacy, effectiveness, and safety of monopolar versus bipolar TURP, there are five systematic reviews and meta-analyses published between 2009 and 2015 that compared bipolar TURP to monopolar TURP.34-38 None of the authors found significant differences in terms of I-PSS improvement at 12 months or improvements in peak urinary flow rates, the main efficacy parameters of interest.

However, there were differences regarding safety parameters. Time to catheter removal or catheterization time was evaluated in four pooled analyses. All four favored bipolar TURP; however, the differences in the effect estimate were highly variable as was the degree of heterogeneity. Length of stay and dilution hyponatremia both favored bipolar TURP; however, there was close to 98% heterogeneity in each of the meta-analyses that evaluated these outcomes. Pooled data from Mamoulakis (2009), Burke (2010), Tang (2014), and Omar (2014) all supported that TUR syndrome occurred less frequently in the group that received bipolar TURP.35-38

Risk reduction for clot retention favored bipolar TURP in general. Bleeding and drops in hemoglobin seem to favor bipolar TURP but with a relatively high degree of heterogeneity in both meta-analyses. Need for blood transfusion post-operatively seems to favor bipolar TURP, although two out of six meta-analyses revealed no statistical significance.

The findings of the meta-analyses and systematic reviews allow the following conclusions:

Since there are no differences in efficacy, it is reasonable to compare surgical interventions in this guideline document with either monopolar or bipolar TURP series regarding efficacy measures.
Since the main difference between monopolar and bipolar TURP is regarding TUR syndrome, which is unique to TURP and no other treatment, safety parameters other than TUR syndrome can also be compared between surgical interventions and monopolar and bipolar TURP.
The reduced risk of hyponatremia and TUR syndrome allows for longer resection times; therefore, bipolar TURP may be used in larger glands compared to monopolar TURP.
Since not all hospitals have bipolar TURP equipment available, it is left to the surgeon’s discretion and level of experience as to which type of TURP energy she/he may use.
For the remainder of this document the reader should assume that all efficacy comparisons between surgical interventions and TURP make no difference as to what type of energy was used for the TURP comparator arm(s).

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A quick summary is that the URA gives the following grades:

TURP, TUIP, TUVP (an upgraded TURP procedure) , PVP (another TURP upgrade?), Laser Enuc leation (HoLEP): B
Simple Prostatectomy, PUL (UroLift), TUMT, Water Vapor Thermal Energy (Rezum?), Aquablation: C

TUNA and PAE are not recommended.

Looks like TURP and TURP variants, except for HoLEP get a B and some of the newer techniques like UroLift and Rezum get a C.

There are many caveats in the article related to prostate size and co-existing medical conditions.

I’m thinking there is a huge human factor which could only be ascertained by researching the surgeon. I.e. someone who is really good with a Grade C procedure might produce a better result than a novice using a Grade B procedure.

Also, as someone else mentioned, the article tends to minimize sexual side effects, except they do say for PUL (UroLift):

"15. PUL may be offered to eligible patients concerned with erectile and ejaculatory function for the treatment of with LUTS attributed to BPH. "

I imagine that pertains to a lot of people!

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It is important for everyone to understand that the grade rating as written in the Methodology section is as follows:
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“the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low)”.
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This has nothing to do with the morbidity (the medical problems caused by a treatment) and the complications (such as RE and ED) of the procedure, but instead is about how much data is available on the procedure.
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Newer procedures or procedures that are not widely used will have a lower grade, while TURP which has been around forever will have a higher grade, despite the fact that it has the highest morbidity, highest incident of complications, longest hospital stay, and longest recovery time.
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So the grading system avoids the question that we are all asking, “if I have a certain procedure, then what will be my sexual functioning afterwards”. The report does give recommendations for some procedure as follows:
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“…may be offered to eligible patients who desire preservation of erectile and ejaculatory function.”
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The first urologist that I saw, was very much like this report. He only gave a high score to TURP because that is what he had done forever and totally avoided answering my very direct question on the morbidity and complications of TURP. I decided to find another urologist.
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While this report does provide some useful information, the grade rating in the report is avoiding answering our question of “if I have a certain procedure, then what will be my sexual functioning afterwards”.
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Steve

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This info just reminds we have to educate ourselves on all the ins & outs of this medical issues as others, as it appears the medical profs (some not all) miss the mark in so many ways. Would like to find info on Urologists that have gone thru these proceedures that had BPH.!!