Transition in Type of Surgery for Benign Prostatic Hyperplasia: A Multi-institutional Study in Japan

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1 LUTS (211) 3, ORIGINAL ARTICLE Transition in Type of Surgery for Benign Prostatic Hyperplasia: A Multi-institutional Study in Japan Kimihiko MASUI, 1 Koji YOSHIMURA, 2 Hiroyuki NISHIYAMA, 2 Hiroshi OKUNO, 1 and Osamu OGAWA 2 1 Department of Urology, Kyoto Medical Center, Kyoto, Japan and 2 Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan Objectives: This study compared the numbers and types of benign prostatic hyperplasia (BPH) surgeries performed in 28 with those performed in 23 to investigate changes in surgical procedures in Japan with the introduction of transurethral enucleation procedures. Methods: Forty-three hospitals in Japan participated in this study. We examined the numbers of patients undergoing BPH surgery in 23 and 28. Types of BPH surgery were divided into five categories: R (resection); E (enucleation); S (urethral stent); O (open surgery); and A (ablation or others). The participating hospitals were divided into two groups, those performing E surgery (E hospitals) and those which did not (Non-E hospitals). Results: The total numbers of BPH surgeries performed in all hospitals were 161 in 23 and 172 in 28. Of these, 1391 (86%) in 23 and 1129 (66%) in 28 were R-type, and 1 (<%) in 23 and 428 (25%) in 28 were E-type. There were 17 E hospitals and 26 Non-E hospitals, and other characteristics of the hospitals were similar. In the E hospitals, the total number of BPH surgeries increased from 552 in 23 to 776 in 28. Conversely, that in Non-E hospitals decreased from 158 in 23 to 944 in 28. The rate of R-type surgery was significantly lower in E hospitals than in Non-E hospitals, even in 23 (73 vs 94%, P <.1). Conclusion: E-type surgery increased considerably in the 5 years examined, but even in E hospitals, R-type surgery remained the main type of BPH surgery performed in 28. Key words benign prostatic hyperplasia, male urological surgical procedures, surgery 1. INTRODUCTION Since development of the Stern-McCarthy resectoscope, 1 transurethral resection of the prostate (TURP) has been the gold standard of surgery for benign prostatic hyperplasia (BPH) for 7 years. Although this procedure provides excellent improvement in lower urinary tract symptoms, there are several potential adverse effects, including excessive bleeding and electrolyte imbalance. To reduce these problems, several minimally invasive techniques, such as transurethral needle ablation (TUNA), transurethral microwave thermotherapy (TUMT) and interstitial laser coagulation of the prostate (ILCP), were developed during the 199s. However, these techniques were not as effective as TURP for symptom relief, and none of these have currently achieved popularity. More recently, a novel surgical technique has been introduced, which involves transurethral enucleation of the inner gland of the prostate. Gilling et al. reported their initial experience of holmium laser enucleation of the prostate (HOLEP) in As the holmium laser works via physiological saline, the risk of dilutional hyponatremia, known as transurethral resection syndrome, can be ignored. Bipolar plasmakinetic energy has also been used as a transurethral enucleation technique. 3 The ablation procedure has become more sophisticated with the use of new types of energy that have been introduced into surgery, such as the potassium-titanylphosphate laser. It has been reported that photoselective vaporization of the prostate (PVP), which uses the potassium-titanyl-phosphate laser, is easy to learn and is safe and effective. 4 Thus, the surgical procedures for BPH chosen by urologists have dramatically changed during the past decade. In this study, we aimed to investigate the changes in surgical procedures for BPH in Japan between 23 and METHODS A total of 43 hospitals in Japan participated in this study (Appendix 1). We retrospectively collected data Correspondence: Koji Yoshimura, MD, Department of Urology, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto , Japan. Tel: ; Fax: ky7527@kuhp.kyoto-u.ac.jp Received 25 November 21; revised 5 February 211; accepted 16 February 211 DOI: /j x

2 Benign Prostatic Hyperplasia Surgery 15 regarding these institutions and the surgical procedures performed for BPH in 23 and in 28, without personal patient information. Data obtained included the total numbers of beds, numbers of urologic beds and numbers of urological staff members. Total numbers of urologic operations, numbers of BPH surgeries and types of BPH surgeries performed in 23 and in 28 were also examined. The types of BPH surgeries were divided into five categories: R (resection, such as TURP and TURP using plasma kinetics); E (enucleation; such as HOLEP, transurethral enucleation of the prostate using plasma kinetics); A (ablation, vaporization, coagulation and thermotherapy; such as transurethral vaporization of the prostate [TVP], TUMT, TUNA, ILCP, HOLAP and PVP); S (urethral stent); O (open surgery; such as retropubic open prostatectomy). Participating hospitals were divided into two groups: hospitals actively performing E-type surgery in 28 (E hospital group), and those not actively performing E-type surgery in 28 (Non-E hospital group), as reported by the hospital. We compared the differences in BPH surgery type from 23 to 28 between E and Non-E groups. While the comparison was carried out overall using the five categories of surgery, individual surgical methods in E- and A-type surgery were also compared (n=161) 29(2%) 65(4%) 124(8%) 1(%) 1391(86%) (n=172) (3%) 94(5%) 22(1%) 428(25%) 1129(66%) Fig. 1 Proportions of benign prostatic hyperplasia surgeries in 23 and 28 in all participant hospitals. A, ablation or other; E, enucleation; O, open surgery; R, resection; S, urethral stent (4%) 16(3%) 113(2%) (%) 32(4%) 28(4%) 2(3%) 417(54%) 2.1. Statistics The Mann Whitney s U-test and chi-squared test were used for statistical analyses. P <.5 were considered to indicate statistical significance. 43(73%) (n=552) (n=776) (36%) 3. RESULTS 3.1. Characteristics of participant hospitals Of 43 participating hospitals, 12 (28%) were university hospitals, 2 (5%) private clinics and the remaining 29 (68%) general hospitals. Seventeen hospitals (4%) were classified into the E group and 26 (6%) into the Non-E group. The number of urologic surgeries performed in 28, total beds, urologic department beds and urologic staff members were not significantly different between E and Non-E groups (Table 1). Fig. 2 Changes in benign prostatic hyperplasia surgery from 23 to 28 in the E hospital group. A, ablation or other; E, enucleation; O, open surgery; R, resection; S, urethral stent Change in types of BPH surgery A total of 161 and 172 operations were performed for BPH in 23 and in 28, respectively (Figs 1 3, Table 2). The total number of BPH surgeries increased in the E hospital group from 552 to 776, whereas it decreased in the Non-E group from 158 to 944. TABLE 1. Characteristics of participant hospitals All (n = 43) E hospitals (n = 17) Non-E hospitals (n = 26) P-values Types of hospital University hospital 12 (28%) 6 (35%) 6 (23%).39 General hospital 29 (67%) 11 (65%) 18 (69%) Private clinics 2 (5%) (%) 2 (8%) Annual urologic surgery 3 15 (35%) 7 (42%) 8 (3%) (47%) 5 (29%) 15 (58%) 51 8 (18%) 5 (29%) 3 (12%) Total beds (mean ± SD) ± ( ) ± ( ) 54.5 ± (13 1).16 Urologic beds (mean ± SD) 23.5 ± 9.8 (8 47) 23.3 ± 9.7 (8 47) 23.6 ± 9.9 (1 45).91 Urologic staff members (mean ± SD) 5.9 ± 3.7 (2 14) 6.2 ± 3.6 (2 13) 5.7 ± 3.7 (2 14).67 Chi-squared test. Mann-WhitneyU-test. E hospital, performing enucleation surgery; Non-E hospital, not performing enucleation.

3 16 Kimihiko Masui et al (n=158) 23 9(1%) 49(5%) 11(1%) 1(%) 988(94%) (n=944) 28 15(2%) 66(7%) 2(%) 11(1%) 85(9%) Fig. 3 Changes in benign prostatic hyperplasia surgery from 23 to 28 in the Non-E hospital group. A, ablation or other; E, enucleation; O, open surgery; R, resection; S, urethral stent. The total number of E-type surgeries from all the participating hospital significantly increased from 1 (<%) to 428 (25%). This increase was mainly accounted for by an increase in E-type surgery performed in E hospitals. On the other hand, the number of R- and A-type surgeries decreased from 1391 (86%) to 1129 (66%), and from 124 (8%) to 22 (1%), respectively. Although the decrease in R-type surgery was marked in the E group (from 43 to 279), a slight decrease was also observed in the Non-E group (from 988 to 85). If we further divided the hospitals into university and community hospitals, the decrease in R-type surgery was more marked in university hospitals (from 156 [88%] to 93 [37%]) than in community hospitals (from 247 [66%] to 186 [41%]) in the E group. However, there were no differences observed between general hospitals and university hospitals in the non-e group regarding R-type surgery (data not shown). Despite these changes, the total number of R-type surgeries performed in 28 presented the highest proportion among the five categories of BPH surgery. TURP using plasma kinetics was more frequently performed in E than in Non-E hospitals in 28 (23 vs 3%, respectively). Although the main method of E-type surgery performed in 28 was HOLEP (6%), other methods including plasmakinetic enucleation were also frequently performed. A-type surgery, such as TVP, TUMT, TUNA and ILCP was occasionally performed in 23. However, these types of A-type surgery were nearly abandoned by 28, and the remaining A-type surgery was HOLAP (2 performed in E hospitals in 28). Non-E hospitals performed only two operations of the A-type in 28. None of 43 participant hospitals adopted PVP. The number of O-type surgeries was small and increased slightly between 23 and 28, and this increase was similar in the E group (16 to 28, Fig. 2) and Non-E group (49 to 66, Fig. 3). The number of S-type surgeries was also small and slightly increased in both groups. 4. DISCUSSION Various treatment modalities for BPH, not only surgery but also medical treatment, have been introduced recently. The advent of alpha-adrenergic blockers and fivealpha reductase inhibitors has markedly changed the treatment strategy. 5 However, as Takeuchi et al. pointed out, alpha-blockers could not reduce surgical intervention for BPH; however, they did prolonged the periods of non-surgical intervention. 6 They also reported that the size of the prostate requiring surgery had become larger and that the number of BPH operations had increased in the recent decades. In this study, we revealed that BPH surgery did slightly increase in number between 23 and 28, which was compatible with their report over previous years. Thus, it is possible that the need for BPH operations will further increase in the near future despite the introduction of novel treatment modalities, although the advent of five-alpha reductase inhibitors can reduce the number of BPH operations. 5 The dramatic change in type of BPH surgeries was mainly associated with the increase in E-type surgery performed in E hospitals. The BPH surgery performed most TABLE 2. Comparison of R-, E- and A-type surgeries in 23 and 28 All E hospitals Non-E hospitals R-type surgery Total (n) TURP conventional 1391 (1%) 135 (91%) 43 (1%) 214 (77%) 988 (1%) 821 (97%) TURP using plasma kinetics (%) 94 (9%) (%) 65 (23%) (%) 29 (3%) E-type surgery Total (n) HOLEP 1 (1%) 257 (6%) ( ) 25 (6%) 1 (1%) 7 (64%) Others (%) 171 (4%) ( ) 167 (4%) (%) 4 (36%) A-type surgery Total (n) TVP 52 (43%) 2 (9%) 52 (46%) (%) (%) 2 (1%) TUMT 5 (4%) (%) (%) (%) 5 (46%) (%) TUNA 3 (2%) (%) 3 (3%) (%) (%) (%) ILCP 63 (5%) (%) 57 (5%) (%) 6 (54%) (%) HOLAP 1 (1%) 2 (91%) 1 (1%) 2 (1%) (%) (%) A, ablation or other; E, enucleation; E hospital, performing enucleation surgery; HOLEP, holmium laser enucleation of the prostate; ILCP, interstitial laser coagulation of the prostate; Non-E hospital, not performing enucleation; R, resection; TUMT, transurethral microwave thermotherapy; TUNA, transurethral needle ablation of the prostate; TURP, transurethral resection of the prostate; TVP, transurethral vaporization of the prostate.

4 Benign Prostatic Hyperplasia Surgery 17 frequently by this hospital group in 28 was E-type surgery, most of which consisted of HOLEP. However, R-type was still the dominant surgery over all the hospitals examined. Recently, HOLEP was considered the new gold standard for symptomatic BPH, because the size of the prostate is rarely considered in the choice of surgery. 7 Ahyai et al. reviewed the functional outcomes and complications following transurethral procedures for BPH to determine the contemporary status of TURP, TURP using plasma kinetics, TVP using plasma kinetics, HOLEP and PVP. They reported that a reduction in International Prostate Symptom Score and an increase in maximum flow rate were significantly more pronounced only after HOLEP compared with TURP. 8 They showed no statistically significant differences in overall morbidity, though it tended to be smaller after HOLEP than after TURP. However, the initial cost for equipment would be too expensive for relatively small-size hospitals, and the learning curve is long. 9 The fact that TURP using plasma kinetics was more frequently performed in E hospitals than in Non-E hospitals would also reflect this cost issue. Our results suggest that R-type surgery is likely be a gold standard therapy for some time. A-type surgery, such as PVP, is another promising type of surgery. Ruszat et al. reported that PVP is characterized by excellent hemostatic properties and a very low intraoperative complication rate even in patients on oral anticoagulation. 1 Ahyai et al. reviewed and concluded that in small to midsize prostates, PVP shows promising results with comparable efficacy to TURP. 8 However, for larger prostates, the efficacy of PVP was less than that of TURP or open surgery. 11,12 Because PVP has not yet been approved and is not so prevalent in Japan, none of the hospitals examined in this study introduced PVP. Older types of A-type surgery, such as TUMT, TUNA and ILCP, were no longer performed in 28. The presumable reason of this observation was that the long-term effectiveness of these treatment modalities was found to be less than that of TURP. 13 Another interesting observation of this study was that O-type surgery increased in number despite the introduction of E-type surgery. This observation may suggest that not all urologists were able to master enucleation techniques even in E-type hospitals, although the learning curves of the techniques were generally steep. Furthermore, this observation may also suggest that the prostates have been larger in patients with symptomatic BPH in recent years, as reported by Takeuchi et al. 6 However, we cannot explain the exact reason of this observation. Our study had several limitations. These results may not represent all urologic hospitals in our country. As mentioned above, PVP has not yet been approved for treatment of BPH in Japan. However, several hospitals did introduce PVP and reported the good clinical outcomes. This study examined the number of surgeries during only 2 years. Furthermore, detailed study would be more informative in predicting the future changes in BPH surgery. Despite these limitations, our observations were of value to determine the current trend in BPH surgery performed in Japan and may reflect the changes worldwide. Acknowledgments We greatly thank Drs. Yasuharu Kunishima, Akito Terai, Isao Araki, Masayuki Takeda, Atsuro Sawada, Kazuhiro Okumura, Akio Hoshi, Toshiro Terachi, Yoshikatsu Nojiri, Kikuo Okamura, Takuya Okada, Masanori Nishimura, Yasunori Nishio, Takuma Kato, Norihito Yamamoto, Shingo Yamamoto, Masakazu Nakashima, Yasumasa Shichiri, Sachiyo Nishida, Taiji Tsukamoto, Hidefumi Kinoshita, Tadashi Matsuda, Motohiko Sugi, Takashi Murota, Hiroya Oka, Teruyoshi Aoyama, Takayuki Hashimura, Yasuki Hori, Kazuo Nishimura, Nobuyoshi Yamaoka, Yuji Uetsuki, Yoshiyuki Kakehi,TakahitoSoma, Ryo Iguchi, Noriyuki Ito, Takashi Obara, Tomonori Habuchi, Mutsushi Kawakita, Shigeki Fukuzawa, Seiji Moroi, Masaaki Ito, Keiji Ogura, Tetsuya Yoshida, Yusaku Okada, Hiroyuki Onishi, Hironobu Wakeda, Toshiyuki Kamoto, Toru Yoshida, Tomohiro Ueda, Akihiro Ito, Yoichi Arai, Yosuke Shimizu, Tadashi Hayashi, Kanji Nagahama, Hiroshi Kanamaru, Mitsuo Nonomura, Hitoshi Yamada, Hideki Tsukazaki, Toshiaki Shirahase, Tetsuya Noguchi, Miharu Sasaki, Noriyasu Takao, Yoji Taki, and Shuichi Hida for their cooperation. 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5 18 Kimihiko Masui et al. laser vaporization versus transurethral resection of the prostate for prostates larger than 7 ml: a short-term prospective randomized trial. Urology 28; 72: Alivizatos G, Skolarikos A, Chalikopoulos D et al. Transurethral photoselective vaporization versus transvesical open enucleation for prostatic adenomas >8ml: 12-mo results of a randomized prospective study. Eur Urol 27; 54: Lourenco T, Armstrong N, N Dow J et al. Systematic review and economic modeling of effectiveness and cost utility of surgical treatments for men with benign prostatic enlargement. Health Technol Assess 28; 12: APPENDIX 1 Participating hospitals (in alphabetical order): Akita University, Hamamatsu Rosai Hospital, Hida Clinic, Himeji Medical Center, Hyogo Medical University, Ijinkai Takeda General Hospital, Kagawa University, Kansai Electronic Power Hospital, Kansai Medical University Hirakata Hospital, Kansai Medical University Takii Hospital, Kitano Hospital, KKR Takamatsu Hospital, Kobe City Medical Center General Hospital, Koseikai Takeda Hospital, Kurashiki Central Hospital, Kyoto City Hospital, Kyoto Katsura Hospital, Kyoto Medical Center, Kyoto University, Nara Social Insurance Hospital, National Center for Geriatrics and Gerontology, Nishi- Kobe Medical Center, Obihiro Kyokai Hospital, Osaka Red Cross Hospital, Otsu Municipal Hospital, Otsu Red Cross Hospital, Rakuwakai Otowa Hospital, Saiseikai Noe Hospital, Sakaide City Hospital, Sapporo Medical University, Shiga Medical Center for Adults, Shiga University of Medical Science, Shimada Municipal Hospital, Shizuoka City Hospital, Shizuoka General Hospital, Soma Hospital, Tenri Hospital, Tohoku University, Tokai University, Toyooka Hospital, University of Miyazaki, University of Yamanashi, Wakayama Red Cross Medical Center.