Modified plasmakinetic enucleation and resection of the prostate by three glands: proposal of a novel anatomical treatment for benign prostatic hyperplasia

Transurethral resection of the prostate (TURP) cannot completely resect hyperplastic tissues and is often associated with high recurrence rate and short recurrence interval. Western and Chinese scholars have reported higher incidences of stress urinary incontinence (SUI) with traditional enucleations. This study investigated the potential applicability of Modified Plasmakinetic Enucleation and Resection of the Prostate by three glands (MPKERP) in treating benign prostatic hyperplasia (BPH). Between April 2020 and June 2021, 28 patients underwent MPKERP for BPH. The surgical procedures included (1) surgical capsule exploration; (2) moderate range enucleation; (3) middle gland enucleation; (4) sector resection at 12 o’clock in the lithotomy position; (5) cut residual distal urethral mucosa; (6) lateral hyperplastic glands enucleation. All 28 patients recovered well after the surgery, and the curative effect was satisfactory. The average operation time was 68.9 ± 21.8 min, the average weight of excised glands was 62.5 ± 19.1 g, the average indwelling catheter time was 4.6 ± 0.6 d, and the average bladder washing time was 28.6 ± 9.5 h. The average postoperative 1-day hemoglobin decrease was 10.2 ± 9.8 g/L. Only one severe hyperplasia patient had transient SUI (incidence rate: 3.6%). No complications, such as urethral stricture, dysuria, urinary incontinence and urinary retention, were reported during follow-up. International Prostate Symptoms Score (IPSS), quality of life (QOL), maximum urinary flow rate (Qmax) and post-void residual volume (PVR) significantly improved three months after surgery (p < 0.0001). The MPKERP can enucleate and resect the hyperplastic glands anatomically in an orderly manner and pay attention to expanding space, reducing resistance, reducing the damage of pushing and pulling, protecting the urethral sphincter complex (USC), and reducing the incidence of urinary incontinence. Altogether, our findings support MPKERP as an improved surgical technique worthy of promotion, and it is more suitable for grass-roots hospitals that lack hardware equipment.

Benign prostatic hyperplasia (BPH); Modified plasmakinetic enucleation and resection of prostate by three glands (MPKERP); Stress urinary incontinence (SUI); Urethral sphincter complex (USC); Space; Resistance; Push and pull injury

[1] Strebel RT, Kaplan SA. The state of TURP through a historical lens. World Journal of Urology. 2021; 39: 2255–2262.

[2] Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP)—incidence, management, and prevention. European Urology. 2006; 50: 969–980.

[3] Miernik A, Gratzke C. Current Treatment for Benign Prostatic Hyperpla-sia. Deutsches Ärzteblatt International. 2020; 117: 843–854.

[4] Xu P, Xu A, Chen B, Zheng S, Xu Y, Li H, et al. Bipolar transurethral enucleation and resection of the prostate: whether it is ready to supersede TURP? Asian Journal of Urology. 2018; 5: 48–54.

[5] Zhu L, Chen S, Yang S, Wu M, Ge R, Wu W, et al. Electrosurgical enucleation versus bipolar transurethral resection for prostates larger than 70 mL: a prospective, randomized trial with 5-year followup. The Journal of Urology. 2013; 189: 1427–31.

[6] Luo YH, Shen JH, Guan RY, Li H, Wang J. Plasmakinetic enucleation of the prostate vs plasmakinetic resection of the prostate for benign prostatic hyperplasia: comparison of outcomes according to prostate size in 310 patients. Urology. 2014; 84: 904–10.

[7] Bebi C, Turetti M, Lievore E, Ripa F, Rocchini L, Spinelli MG, et al. Bipolar transurethral enucleation of the prostate: is it a size-independent endoscopic treatment option for symptomatic benign prostatic hyperplasia? PLoS One. 2021; 16: e0253083.

[8] Buckley BS, Lapitan MCM, Glazener CM. The effect of urinary incontinence on health utility and health-related quality of life in men following prostate surgery. Neurourology and Urodynamics. 2012; 31: 465–469.

[9] McNeal JE. The zonal anatomy of the prostate. The Prostate. 1981; 2: 35–49.

[10] Koraitim MM. The male urethral sphincter complex revisited: an anatomical concept and its physiological correlate. Journal of Urology. 2008; 179: 1683–1689.

[11] Sinha S, Sinha U, Malis V, Bhargava V, Sakamoto K, Rajasekaran M. Exploration of male urethral sphincter complex using diffusion tensor imaging (DTI)-based fiber-tracking. Journal of Magnetic Resonance Imaging. 2018; 48: 1002–1011.

[12] Li X, He F, Huang C, Zhang L, Liu Q, Song J. Development and validation of a nomogram for predicting early stress urinary incontinence following endoscopic enucleation of the prostate. World Journal of Urology. 2021; 39: 3447–3453.

[13] Walz J, Burnett AL, Costello AJ, Eastham JA, Graefen M, Guillonneau B, et al. A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy. European Urology. 2010; 57: 179–92.

[14] Endo F, Shiga Y, Minagawa S, Iwabuchi T, Fujisaki A, Yashi M, et al. Anteroposterior dissection HoLEP: a modification to prevent transient stress urinary incontinence. Urology. 2010; 76: 1451–5.