Available Options of Surgery for Treating LUTS

    Over the past 6 to 7 decades, a long list of procedures have been designed, tried, and used to testify their glorying
    ups and frowning downs reflecting their related safety, easiness, and durability.

    The list includes - does not limit -  the following:
    - TURP (transurethral resection of prostate),
    - TUIP (transurethral incision of prostate or bladder neck),
    - balloon dilation of prostate urethra,
    - stent of prostate urethra,
    - open prostatectomy (to remove the obstructing part of the prostate),
    - TUNA (transurethral needle ablation),
    - TUMT (transurethral microwavetherapy),
    - laser enucleation of obstructing part of the prostate,
    - PVP  (photoselective vaporization of the prostate) with laser,
    - vaporization with electrocautery,
    - Internal tucking and compressing prostate tissue with Urolift,...

    Among these, TURP has led the pack and still remains as the gold standard of procedures for LUTS, and PVP
    follows.

    Which procedure will be used among urologists? The decision reflects equipment availability and support of
    institutions and professional proficiency and confidence in performing the procedures.

    In my hands, nowadays, I have exclusively used PVP. Over the past 8 years, I have performed PVP in >750
    patients with laser usage up to 1,300,000 joules usually under 180 watts, and with >90% of patients discharged
    home the same day of procedure with indwelling catheter and its self-pulling-out as instructed in 2-5 days, and
    with return visit in 3-4 months. There has been no concern or issue for blood loss and water over-absorption. In
    fact, no one needs blood transfusion or develop fluid overload despite vaporizing prostate tissue up to 250-300 cc.

    Yet, not every urologist would feel comfortable in performing a procedure like PVP. For instance, I have introduced
    my favorable PVP to three urologists over the past 7 years, but no one did well and stuck with it; they simply
    abandoned it in 6 months.

    Of note, please do not think PVP is a magic procedure. Although it lacks intraoperative and immediate
    postoperative complication, it still has its own delayed complications from my experience such as: delayed
    bleeding which is usually inconsequential; bladder neck contracture, which may occasionally occur few months
    or even 1-2 years after PVP; some encrustation (stone formation attached to the rugged tissues after laser
    vaporization leading in some 0.35% of cases).  

    Finally, I would like to remind that surgery like PVP is always considered as the last resort of care after failing to
    all available conservative options including expectation adjustment, behavioral modification, and use of related
    drugs, so would give no guaranty to return normal urination, which is highly related with bladder function before
    procedure.

    A Case in Point:
    In 1990s, I saw a 83-y-o man, who presented himself with urinary frequency to a local emergency room where he
    was evaluated and confirmed renal failure with serum creatinine up to 12.5 mg/dl resulting from post-renal
    urinary obstruction by slowly developed urinary retention up to >3,500 cc. This man was taught to do clean
    intermittent self-catheterization (CISC) for >11 months before I performed TURP (transurethral resection of the
    prostate) for him when he began self voiding with some postvoid residual urine. After TURP, he has been happy
    in how he voids despite still having some residual urine of 150-200 cc with creatinine at 1.5-1.75 mg/dl.

    This case illustrates the importance on when and how to decide and act at reasonable time in reasonable way to
    reasonable patient as discussed before.


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