In the domain of AEEP, short-term functional outcomes such as incontinence are also correlated with preoperatively measured prostate volume, especially for larger prostates.2
In the domain of AEEP, what remained to be elucidated was whether enucleated prostate weight is also a predictor of better functional outcomes. If this was indeed so, enucleating surgeons should then aim to enucleate more prostate tissue regardless of the baseline prostate volume.
We set out to shed some light on this question via an analysis of 692 patients in the REAP database, a retrospective multicenter AEEP database spanning several countries.3 Although REAP contained 6193 patients, only 692 had data on both preoperatively measured prostate volume and postoperatively measured prostate weight.
For statistical analysis, the relationship between preoperatively measured prostate volume and enucleated specimen weight was first visualized using a scatter plot. Linear regression was utilized to derive a relationship between the two variables (volume-weight concordance) and to plot a regression line. Using the regression line, 3 groups were defined, corresponding respectively to:
- Less-than-expected enucleated specimen weight
- Appropriate concordance between prostate volume and enucleated specimen
- More-than-expected enucleated specimen weight. These 3 groups hence represent different tiers of prostate weight corresponding to the same preoperatively measured prostate volume, and hence serve to compare the ‘before’ (volume) and ‘after’ (weight) surgery outcomes.
- More-than-expected specimen weight is associated with longer enucleation time and total operation time, but better Qmax improvement within 3 months
- Acute urinary retention is commoner in less-than-expected prostate weight, possibly suggesting incomplete enucleation
- Volume-weight concordance may be associated with the above outcomes, but stratification by absolute prostate volume does not produce significant correlations.
Although these findings are purely hypothesis-generating due to the inexact nature of volume and weight measurements, some thought-provoking suggestions can be derived. On one hand, this would suggest that all surgeons performing enucleation should aim for enucleated adenoma weight to be on the regression line or above, in order to achieve better Qmax improvement and lower the rate of acute urinary retention. On the other hand, subjective and objective improvements in the group with less-than-expected enucleated weight were still more than acceptable. Among the 3 regression-stratified groups, the median improvement in IPSS was 15.5 to 19; that of QoL, 4 to 5; and that of Qmax, 6.6 to 10.5 – as seen in the table below.
Considering both of these suggestions in equipoise, our study heralds the paradigm shift in endourological BPH management with enucleation as a size-independent procedure; and the very concept of enucleation transcends its components such as laser energy (“enucleation is enucleation is enucleation is enucleation”).4 Overall, absolute enucleated weight is likely to prove of less clinical relevance to the outcomes of AEEP than to its predecessor of TURP – instead, the focus would move towards the correct enucleation technique. Nonetheless, from an academic standpoint, preoperative ultrasound-measured prostate volume and actual enucleated specimen weight should be interpreted in the context of each other and not as standalone measures.
Written by: Khi Yung Fong,1 Vineet Gauhar,2 Daniele Castellani,3 Ee Jean Lim,4 Mario Sofer,5 Dmitry Enikeev,6 Fernando Gómez Sancha,7 Jeremy Teoh,8 Bhaskar Somani,9 Thomas Herrmann10 – for the Refinement in Endoscopic Anatomical Enucleation of Prostate (REAP) registry
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Urology, Ng Teng Fong General Hospital, Singapore
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy
- Department of Urology, Singapore General Hospital, Singapore
- Department of Urology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russian Federation
- Department of Urology and Robotic Surgery, ICUA-Clínica CEMTRO, Madrid, Spain
- S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, United Kingdom
- Department of Urology, Kantonspital Frauenfeld, Spital Thurgau AG, Frauenfeld, Switzerland
- Chen SS, Hong JG, Hsiao YJ, Chang LS. The correlation between clinical outcome and residual prostatic weight ratio after transurethral resection of the prostate for benign prostatic hyperplasia. BJU International. 2000;85(1):79-82.
- Gauhar V, Castellani D, Herrmann TRW, et al. Incidence of complications and urinary incontinence following endoscopic enucleation of the prostate in men with a prostate volume of 80 ml and above: results from a multicenter, real-world experience of 2512 patients. World Journal of Urology. 2024;42(1):180.
- Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients to refine endoscopic anatomical enucleation of the prostate (REAP) by evaluating trends and outcomes and nuances of prostate enucleation in a real-world setting. World J Urol. 2023;41(11):3033-3040.
- Herrmann TRW. Enucleation is enucleation is enucleation is enucleation. World Journal of Urology. 2016;34(10):1353-1355.