Safety and Feasibility of Outpatient Surgery in Benign Prostatic Hyperplasia: A Systematic Review and Meta-Analysis - Beyond the Abstract

Over the last 10 years, advances in technology and efforts to improve cost-effectiveness have allowed many endourological procedures to no longer require hospital admission. The benefits of outpatient surgery include cost savings for the health care system and reduced morbidity for the patient.1 The endoscopic management of ureteral and kidney stones on an outpatient basis is well established and widely practiced worldwide.2-4 In the field of benign prostatic hyperplasia (BPH) surgery, technological advances have resulted in many surgical procedures available so that the choice of the device is often linked to surgeon preference. These differences may in part explain the low quality of evidence exploring the safety of surgical procedures for BPH in the outpatient setting and therefore the lack of specific recommendations from urological societies.


In this systematic review, we analyzed the feasibility and safety of outpatient surgery for BPH showing that BPH surgery in an outpatient setting is safe and feasible with a pooled failure rate (FR) of 7.8%.3 Moreover, subgroup analysis according to type of surgical technique revealed the presence of a statistical difference among the three different approaches: Pooled FR was 3%, 7.1%, and 11.8% for transurethral resection of the prostate (TURP), Green-light, and Holmium laser enucleation of the prostate (HoLEP) respectively. The results for HoLEP in our opinion are not a surprise since the surgical technique is more complex as well as the fact that both photo vaporization and enucleoresection are often performed for larger prostate volumes.

Our analysis did not capture differences in surgeon or facility volume or experience. An additional question that remains unanswered is whether patient characteristics suggest eligibility for outpatient BPH surgery. In the subgroup analysis according to prostate volume, ASA score showed no significant differences suggesting that surgical procedures for BPH on an outpatient basis are safe both in healthy patients and in patients with comorbidities including patients taking anticoagulants. Prostate volume can affect the failure rate (4.1% for prostate volume <40 Vs 10.7% for prostate volume >40).  Another important question is whether the protocol of discharge can affect the rate of hospital readmission. Interestingly in our analysis, pooled FR was higher in patients discharged with urethral catheter 10.2% (95%CI: 6.3%-14.1%) when compared with those who were catheter free (4.4%, 95%CI: 0.8%-8%).

As secondary outcomes, we analyzed event rate (ER) for early outpatient visits or emergency room visits without readmission observing. Our analysis showed that the pooled ER using a random-effect model was 7.7% (95%CI: 4.3%-11%). Despite no significant difference in predicted risk of complications or outpatient/ER visits, we noticed a slight but interesting rising trend in these events from the studies using TURP to Green-Light. For the Green-light the high percentage of unexpected visits was mainly due to irritative lower urinary tract symptoms and we believe this finding could be in part mitigated by improvements in perioperative patient counseling.

Written by: Stefano Salciccia,1 Francesco Del Giudice,2 Simon L Conti3

  1. Associate Professor in Urology-Department of Urology, Sapienza University of Rome, Italy
  2. MD in Urology-Department of Urology, Sapienza University of Rome, Italy
  3. Clinical Assistant Professor in Urology, Department of Urology, Stanford University, School of Medicine, Stanford, CA, USA
References

  1. Nguyen DD, Marchese M, Ozambela M, Bhojani N, Ortega G, Trinh QD, Friedlander DF. Ambulatory-Based Bladder Outlet Procedures Offer Significant Cost Savings and Comparable 30-Day Outcomes Relative to Inpatient Surgery. J Endourol. 2020 Apr 7. doi: 10.1089/end.2019.0684
  2. Salciccia S, Sciarra A, Pierella F, Leoncini PP, Vitullo P, Polese M, Maggi M, Perugia G, Di Marco P, Ricciuti GP. Predictors of Hospitalization After Ureteroscopy Plus Elective Double-J Stent as an Outpatient Procedure. Urol Int. 2019;102(2):167-174.
  3. Busetto GM, Del Giudice F, Maggi M, Antonini G, D'Agostino D, Romagnoli D, Del Rosso A, Giampaoli M, Corsi P, Palmer K, Ferro M, Lucarelli G, Terracciano D, De Cobelli O, Sciarra A, De Berardinis E, Porreca A. Surgical blood loss during holmium laser enucleation of the prostate (HoLEP) is not affected by short-term pretreatment with dutasteride: a double-blind placebo-controlled trial on prostate vascularity. Aging (Albany NY). 2020 Mar 11;12(5):4337-4347. doi: 10.18632/aging.102883.
  4. Busetto GM, Giovannone R, Antonini G, Rossi A, Del Giudice F, Tricarico S, Ragonesi G, Gentile V, De Berardinis E. Short-term pretreatment with a dual 5α-reductase inhibitor before bipolar transurethral resection of the prostate (B-TURP): evaluation of prostate vascularity and decreased surgical blood loss in large prostates. BJU Int. 2015 Jul;116(1):117-23. doi: 10.1111/bju.12917.
  5. Salciccia S, Del Giudice F, Maggi M, Eisenberg M, Chung BI, Conti SL, Kasman A, Vilson FL, Ferro M, Lucarelli G, Viscuso P, Di Pierro G, Busetto GM, Luzi M, Sperduti I, Ricciuti GP, De Berardinis E, Sciarra A. Safety and Feasibility of Outpatient Surgery in Benign Prostatic Hyperplasia: a Systematic Review and Meta-analysis. J Endourol. 2020 Oct 21.
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