Let’s not forget about TUIP: A highly underutilized, minimally invasive and durable technique for men with <30 g prostates

Abstract

Benefits of TUIP include a low risk of perioperative morbidity, low incidence of retrograde ejaculation, shortened operative time, reduced postoperative bleeding -all coupled with the benefits of demonstrated short-term outcomes similar to transurethral resection of the prostate (TURP) for wellselected patients. A meta-analysis of short-and long-term data from 10 randomized controlled trials comparing TUIP with TURP found similar LUTS improvements and lower, but not significant, improvements in maximum flow rates for TUIP patients with small prostates, without enlarged prostate median lobes.5 There is also published data to support significantly lower bladder neck contracture rate for men undergoing TUIP when compared to TURP. 6 Despite these merits, TUIP remains underutilized in the urological community, possibly because of the concerns of the prostate size limitations, lack of transrectal ultrasonography to evaluate prostate volume prior to BOO surgery, reimbursement factors favouring TURP, and the question of long-term durability of success. Holmium TUIP (Ho-TUIP) has been previously described and used safely and effectively for small prostates even in high-risk anticoagulated patients. 7,8 In the current retrospective study of 80 patients, Elkoushy and colleagues demonstrate a durability of benefits with long-term 5-year follow-up in prostate volumes <30 cc. Interestingly, re-operated patients (11%) after Ho-TUIP had significantly larger prostate volume (36.8 ± 8.9 vs. 27.6 ± 5.1 cc, p < 0.001). Furthermore, the authors showed in a multivariate regression model that only prostate size independently predicted re-operation (adjusted odds ratio 95% confidence interval 7.12 [2.92-9.14], p = 0.01). Moreover, in a randomized study comparing TUIP and TURP in prostates <30 cc, the re-treatment rate was 7.5 % for both TURP and TUIP with slightly better IPSS and maximum flow rate, in favour of the TURP group. However, TUIP had a significantly lower rate of retrograde ejaculation (22.5%) and erectile dysfunction (7.5%) compared to TURP (52.5% and 20%, respectively).10 Despite its retrospective nature, this study is noteworthy as it confirms the beneficial use of Ho-TUIP for selected patients with small prostates. The authors should be congratulated for this clever study and acknowledged for reminding us of this overlooked technique, which is also attractive, by its cost-effectiveness due to its shorter hospitalization stay and the use of reusable Holmium laser fibres. Finally their findings also highlight the importance of using preoperative imaging, notably TRUS, to accurately assess prostate size before planning BPH surgery to select the most appropriate procedure. 11In concluding this editorial comment, we, the urological community, should ask the basic question: do men with small <30 cc volume prostates biologically have BPH? Or does their BOO stem from high, tight bladder necks? Not all prostates fit into the same "BPH bucket."

Comparison of transurethral incision of the prostate and silodosin in patients having benign prostatic obstruction in terms of retrograde ejaculation

“…Prostate volume < 40 cc was the inclusion criteria in contrast to the majority of previous reports suggesting that prostate volume should be taken < 30 cc in order to obtain successful results. However, there is little evidence on long-term effectiveness and there is no clear cutoff prostate size that achieves long-term favourable outcomes after TUIP (13). In our series, the improvement in IPSS, Q max and IIEF was significantly higher in TUIP group compared to silodosin group whereas RE rate was significantly lower in TUIP group compared to silodosin group.…”

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“…Long-term stability of symptom relief following TUIP has been documented by previous authors [34,35]. The TUIP failure in controlling symptoms with the need for re-operation was seen in patients with the preoperative prostate size of > 30 gram [21]. In a previous study, the ejaculation rate dysfunction in patients undergoing TUIP was significantly lesser than that of patients undergoing TURP, provided that those patients had preoperative size of prostate of less than 30 g [25].…”

“…The technique of "transurethral incision of the prostate (TUIP)" involves splitting the bladder outlet to relieve lower urinary tract symptoms associated with BPH with no need to remove tissues. This technique was initially described by Orandi in 1969 [21]. According to the American, European, and Canadian guidelines, this technique is reserved for small size prostate (less than 30 ml) and with no middle lobes [22][23][24].…”

“…Advantages of this type operation included less frequent retrograde ejaculation, negligible risk of morbidity perioperatively, less postoperative hemorrhage, and shorter duration of operation [25]. Despite these advantages, TUIP is still less favorable by urologic surgeons and this may be due to questionable long term symptomatic relief, limitations due to the size of prostate, the lack of transrectal ultrasound for exact size estimation, and the subjective preference of the widely accepted TURP [21]. The primary objective of the current study is to assess and compare the results of each of these procedures (TUIP and TURP) in a case reference study using a sample of Iraqi patients who had surgery to treat BPH.…”

Risk factors for bladder neck contracture after transurethral resection of the prostate

“…However, TUIP has not been reported to lead to a higher rate of postoperative BNC formation than TURP. 15,16 But, as TUIP is still a not widely used procedure, 16,17 this association might therefore not have reached significance yet.…”