Introduction & Objectives
Anatomical endoscopic enucleation of the prostate (AEEP) is a guideline-recommended surgical treatment for benign prostate hyperplasia (BPH). The Refinement in Endoscopic Anatomical enucleation of Prostate (REAP) database was established to analyse outcomes and complications of AEEP using real-world data from centres across the world.
Materials & Methods
The REAP registry consists of 6193 patients who underwent AEEP for BPH in 8 centres between January 2020 and January 2022. Procedures were performed by 12 experienced surgeons with >200 cases of enucleation experience each. Patients with previous prostate/urethral surgery, prostate cancer, and pelvic radiotherapy were excluded. Patients who underwent concomitant lower urinary tract surgery (internal urethrotomy, cystolithotripsy, or transurethral resection of bladder tumor) were also excluded. Patients were assessed post-surgery according to the local standard of care; follow-up time intervals were either 3, 6, 12, 24 months, or a combination of the above time points. Complication rates and postoperative urinary incontinence were analyzed.
Results
The median age was 68, with 8% of the cohort being aged >80 years. 22% of patients were on a preoperative indwelling catheter for urinary retention. 38% of patients had large prostates (>80cc). Thulium fiber laser was the commonest modality (37%), followed by high-power Holmium laser (32%), and propensity score-matched comparisons found no difference in most postoperative outcomes between the two. 2-lobe enucleation technique was the commonest (49%) followed by en-bloc enucleation (39%). 86% of procedures were performed under spinal anesthesia. The median operation time was 67 min (IQR 50-95). Median postoperative catheter time was 2 days (IQR 1-3). For early complications (<30 days), acute urinary retention occurred in 4.1%, urinary tract infection in 4.7%, and sepsis requiring intensive care unit admission in 0.1%. Postoperative incontinence occurred in 15%, of which most were <3 months in duration; this was commoner in patients with prostate volume >100cc. Late complications included bulbar urethral stricture requiring intervention in 1.3% and bladder neck sclerosis requiring transurethral incision in 0.7%.
Conclusions
The REAP registry is, to our knowledge, the largest multicenter global registry of AEEP for BPH by highly experienced surgeons. Analysis of complications from this database show that AEEP is a safe procedure with a low incidence of serious complications. Urinary incontinence and urethra/bladder neck injury are the two main concerns with AEEP, which may be more prevalent when dealing with large prostates. Patients must be appropriately counselled as these can negatively impact quality of life in the immediate postoperative period.
