Take it away, Diana.
Diana Lopategui: Good afternoon and thanks for the opportunity to share this research. This was our paper published in the Gold Journal of Urology last January. And like you mentioned, just looking at if the severity of retention measured with PVR affected the outcomes of HoLEP. This was based on the concept that long-term bladder obstruction has been linked to failure to improve symptoms after bladder outlet procedures, thought to stem from a worsening of detrusor contractility with chronic worsening of retention and the classic teaching that in detrusor contractility a bladder outlet procedure might not be helpful to relieve symptoms from BPH.
So true assessment of detrusor function requires multichannel urodynamic testing, which can be time-consuming invasive. So elevated PVR can be determined non-invasively and quickly in the office. So we use this as a proxy for chronic retention and detrusor and their activity in this study. And we examined our outcomes after HoLEP based on elevated PVR comparing groups with baseline PVR less than 100 CCs, 100 to 300, 300 to 600 or more than 600.
So for that, we did keep prospectively maintained institutional database with all our patients undergoing HoLEP. And this was reviewed retrospectively for this study. We examined the patients getting surgery between 2017 and 2022. All the surgeries are done in blocked. The procedure is summarized in these pictures from different authors. Thus, essentially the same technique we utilized. Exclusion criteria was those patients that had acute painful retention, those missing data for baseline PVR and with comorbidities that could directly impact their function, namely strictures, neurogenic bladder conditions, and advanced prostate cancer undergoing channel procedures, those were excluded. We compared prostate size, PSA, perioperative complications, and time to cut theatheter removal and compare the groups. And in follow-up, we looked at PVR, PSA, International Prostate Symptom Score and uroflow results three months after surgery, six months and one year.
So these are the results, large table describing everything. But in summary, we did include 318 patients distributed amongst these different groups of PVR. And as you can see, we did not find any significant differences in terms of prostate size, preoperative PSA, surgery time or volume. Resect of prostate was fairly equivalent among the groups and there were no statistically significant differences in the outcomes. It is close to significance in the time for catheter removal. This is related to a difference in our protocol for those patients with PVR above 600. We did encourage those patients to have a period of what we call bladder rest, classically, or just trying to overcome thought of failure tof catheter removal immediately postoperatively. We suggest they start CIC or have a catheter placed two weeks before surgery or to keep the catheter for two weeks after surgery, as opposed to everyone else gets the catheter removed on post-op day one.
And in terms of functional outcomes during follow-up, these were our findings. All patients with no significant differences between groups had excellent improvement on their IPSS. There was a difference in the one-year AIPSS findings, the numbers are so low that I do think it's not a clinically significant difference. Flow as expressed as Q-max also greatly improved in all the groups pretty quickly after surgery, as did the PVR. That one that show significant difference at the three months as it seems like patients with very high PVR do take a little longer to improve that PVR. But it did go down to what we consider normality in all groups at three months thereafter.
So our conclusion was that severity of chronic retention does not impact the outcomes of HoLEP. It provides a greater relief of PBPH symptoms with no significant differences in all patients, regardless if their PVR was less than 100 or more than 600. And we think that they should reassure patients with large bladder capacity that HoLEP can still provide great functional outcomes and voiding improvement. That's essentially it. And thank you so much for the opportunity for sharing our findings.
And special thanks to all my co-authors and my mentors during fellowship, Dr. Shah, Dr. Marcovich, that was a full citation on everyone that was part of this project. Thanks.
Alan Wein: Terrific. So to me, I mean that brings up the question that if you have a patient show up in chronic retention, either on clean intermittent catheterization or with an indwelling tube, suprapubic or Foley catheter. I mean, should we even do urodynamics on these patients? Because it looks like even in other reports where they've had patients that they describe as having an acontractile bladder on urodynamic study, that the results have really been pretty good and as long as the patients aren't incontinent afterwards, you really haven't lost very much by doing it.
Diana Lopategui: Yeah, I would agree with that. And my answer would be that we don't think those are necessary. They were not done routinely in this patient cohort and how our group consult on HoLEP we did not routinely require that. In this particular cohort theyre were a total of 11 patients that had undergone urodynamic testing before they were referred for HoLEP. And this is detailed on the full text, but they were all in the group of more than 600 CCs for baseline PVR and they had different findings. It was specifically five of them had normal or increased detrusor contractility. Three wasere hypo contractile and the other two wasere acontractile detrusor. And they all had not significantly different outcomes in terms of recovery.
So we do think that it does not seem to impact significantly and that detrusor contractility did not follow the recovery of that in objective measures. But we do think there's a chance that it gets better. There is a chance that they also get better despite the lack of contractility. Some of the patients with very, very high bladder capacities, we've seen that they can void through Credé maneuvers occasionally, occasionally aiding with Valsalva, but that still provides relief and sufficient voiding to not require further CIC.
Alan Wein: Do you think this is peculiar to HoLEP? I mean is it transferable to other procedures where the amount of tissue removed is less and put in lay terms, the hole that you see afterwards is not as big.
Diana Lopategui: Reviewing the literature for that, it did seem that historically the most that's been looked at is TURP. It did not seem to be equivalent in terms of it does seem that HoLEP with the potential for further removal. I do think that there's an effect, as of what you're saying, a larger hole makes it easier for these patients who have difficulty contracting their bladders. So it seems to be more helpful. There's a little bit of conflicting literature, there's a significant trend towards HoLEP seemingly being a better indication in these cases would be my conclusion. It would be interesting to compare to other techniques. I wonder if Aquablation has been looked into. I'm not sure to my knowledge if that has been directly compared, but I'm sure that'd be.
Alan Wein: What about lack of sensation? Person that has a big residual and really no sensation does that make a difference or not? I mean, it sounds like in this group there must've been people that had really poor or almost no sensation, and yet they did as well.
Diana Lopategui: It does not change our management significantly. We do counsel them to do void timing. I do recommend they use the bathroom every two to three hours, do the double voiding, any other maneuvers that they find necessary that seems to provide sufficient emptying. And anecdotally, they often ask if the sensation will recover. I find that highly variable. I don't like to set that expectation. But I do find that anecdotally, some people think they can feel the urgency again, as recovery goes. It might take six months or a significant amount of time.
Alan Wein: Well, that was really terrific. I mean, I think a lot of people with increasing reports like this are going to change their views about what's really required in these patients before someone goes ahead with an outlet reducing procedure, like HoLEP, which I think of all the procedures that an Aquablation probably makes, in vernacular terms, the biggest hole.
Diana Lopategui: Right.
Alan Wein: But thank you so much and hope to see you again sometime soon.
Diana Lopategui: Thanks for the invitation and for your time. It was a pleasure.
Alan Wein: Thank you.