Una nuova tecnica tecnica chirurgica di enucleazione transvescicale della prostata nel trattamento della IPB ostruttiva: la F-STEP
JOURNAL OF ENDOUROLOGYVolume 25, Number 3, March 2011ª Mary Ann Liebert, Inc.Pp. 459–464DOI: 10.1089=end.2010.0453 Novel Surgical Technique for Obstructive Benign Prostatic Hyperplasia: Finger-Assisted, Single-Port Transvesical Enucleation of the Prostate Jong Jin Oh, M.D., and Dong Soo Park, M.D., Ph.D.AbstractPurpose: To report our experience with ﬁnger-assisted, single-port transvesical enucleation of the prostate (F-STEP) compared with transurethral resection of the prostate (TURP) for benign prostatic hyperplasia.Patients and Methods: From January 2009 to April 2010, perioperative data on the 32 patients in the F-STEPgroup were collected and compared with the 67 patients in the TURP group. Intravesical prostatic protrusion(IPP) grade 3 was included in the F-STEP group. In the F-STEP group, a homemade, single-port device using anAlexis wound retractor was introduced transvesically through a small incision. After establishing a pneumo-vesicum, the adenoma was enucleated laparoscopically with ﬁnger dissection. A conventional method wasperformed in the TURP group.Results: There was no signiﬁcant preoperative difference in age, prostate size, maximum uroﬂow rate (Qmax),dysuria, international prostate symptom score (IPSS), and quality of life score (QoLs) between the two groups.The postoperative IPSS (4.00 vs 8.77, P ¼ 0.03), Qmax (36.19 vs 22.03 mL=min, P ¼ 0.04), dysuria (visual analoguescore 1.73 vs 3.14, P ¼ 0.04), and IPSS recovery period (5.54 vs 10.88 weeks, P ¼ 0.01) were signiﬁcantly improvedin the F-STEP group compared with the TURP group. The mean operative time (109.42 vs 68.03 min, P ¼ 0.02)and catheterization time (5.31 vs 2.09 days, P ¼ 0.03) were signiﬁcantly longer. Weight of the extracted specimen(48.35 vs 29.85 gm, P ¼ 0.03) were greater in the F-STEP than in the TURP group. In the F-STEP group, nourethral stricture developed.Conclusions: F-STEP is an effective technique modiﬁcation without urethral complications that is indicated formoderate-to-large prostates with intraveiscal protruding adenoma.Introduction Recently, there has been increased interest in minimally invasive techniques, such as single-port transvesical enucle- ation of the prostate (STEP) for obstructive BPH.8 The initialB enign prostatic hyperplasia (BPH) is one of the most common diseases affecting the aging male. About 60% ofmen over 60 years are affected.1,2 Currently, transurethral reports of STEP were encouraging, but the indication for STEP is large prostates (>90 cm3). Because a moderate-sized pros-resection of the prostate (TURP) is recognized as the gold tate with a protruding adenoma is at risk of prostatic tissuestandard method of treatment for men with BPH. Never- regrowth because of difﬁculty in completely resecting thetheless, the incidence of complications (bleeding, urethral adenoma,9 we have included moderate-sized prostates withstricture, and adenoma recurrence) is signiﬁcant, despite im- protruding adenomas as an indication for STEP. In an attemptprovements in surgical technique. A larger caliber resecto- to prevent urethral strictures after the STEP procedure, wescope for transurethral surgery will inevitably cause ischemia report our experience with ﬁnger-assisted, single-port trans-and result in urethral strictures.3 Indeed, in most Asian pa- vesical enucleation of the prostate (F-STEP) as a modiﬁcationtients who have a narrow urethra, there is a greater chance of of STEP.urethral strictures.4 Open simple prostatectomy remains theprocedure of choice for prostate adenomas too large for safe Materials and Methodsendoscopic resection.5,6 This procedure, however, is associ- Study populationated with considerable morbidity, including blood transfu-sion, prolonged convalescence and catheterization, and even After obtaining Institutional Review Board approval, allmortality.7 patients were included in this study between January 2009 Department of Urology, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea. 459
460 OH AND PARKand April 2010. Ninety-nine patients received a diagnosis oflower urinary tract symptoms secondary to BPH and hadresponded poorly to medical treatment. A digital rectal ex-amination was performed, and the serum prostate-speciﬁcantigen (PSA) level was determined. A prostate biopsy wasperformed if prostate cancer was suspected. The results wereevaluated using the following parameters preoperatively andpostoperatively (1 and 3 months): International ProstateSymptom Score (IPSS), maximum uroﬂow rate (Qmax),prostate volume, postvoid residual (PVR) urine volume,quality-of-life score (QoLs), visual analogue scale (VAS) ofdysuria, and PSA level, analyzed by Student t test. The in-clusion criterion for the patients was urinary symptoms ofmoderate-to-severe intensity, as indicated by a Qmax 15mL=s and an IPSS !10. Urodynamic studies, including pres-sure-ﬂow studies, were only performed in cases in which aneurogenic bladder was suspected. Informed consent wasobtained from all patients. Patients were assigned to one of the following two groups:Group 1 (n ¼ 32) underwent F-STEP and group 2 (n ¼ 67)underwent standard TURP. Assignment to the F-STEP groupwas based on an intravesical prostatic protrusion (IPP) grade3, regardless of the total prostate size. The methodology of IPPmeasurement and its classiﬁcation (three grades) was de-scribed previously.10 Measurement of IPP was from the tip ofthe protruding prostate to the base of the bladder. Grade 1 IPPis intravesical protrusion 5 mm, grade 2 is >5 to 10 mm, andgrade 3 is >10 mm on transrectal ultrasonography (Fig. 1). FIG. 1. The measurement of intravesical prostatic protru- sion (IPP). Transrectal ultrasonographic sagittal view ofPostoperative urethral stricture was diagnosed by bladder and prostate: Measurement of IPP from the tip of thecystourethroscopy Æ retrograde urethrography after present- protruding prostate to the base of the bladder. IPP grade 1,ing symptoms recurrence. The SPSS software package version 5 mm or less; grade 2, more than 5 to 10 mm; grade 3, more15.0 (Statistical Package for Social Sciences,TM Chicago, IL) than 10 mm. D ¼ distance of IPP.was used for statistical analysis.Surgical technique performed to reach the capsular plane (Fig. 2B). After sufﬁ- cient dissection under direct vision, the surgical glove was F-STEP. Thirty-one patients were administered general detached, and an index ﬁnger was introduced through theanesthesia and 1 patient received spinal anesthesia. The pa- Alexis wound retractor. The index ﬁnger was inserted into thetients were in the supine position with mild ﬂexion at the hip dissection plane, the tip of the ﬁnger was forced around usinglevel. After the bladder was ﬁlled with physiologic saline, a the ﬁngernail as a wedge, and the prostatic adenoma was2.5 cm low-vertical skin incision was made at the level of the completely enucleated and extracted through the Alexisbladder, 3 to 4 ﬁngerbreadths above the symphysis pubis. The wound retractor. Concomitant with ﬁnger dissection, a re-anterior rectus sheath and rectus muscle were divided and traction suture to the adenoma facilitated the enucleationmobilized laterally. The bladder wall was identiﬁed and en- (Fig. 2C).tered with a small vertical incision. Figure-of-eight sutures (2-0 polyglactin) were placed at the An extra-small AlexisÒ wound retractor (Applied Medical, 4- and 8-o’clock positions, avoiding the ureteral oriﬁces. He-Rancho Santa Margarita, CA) and a surgical glove were mostasis was conﬁrmed under laparoscopic camera visionfashioned and used as a homemade, single-port device11,12 without a pneumovesicum, an 18F three-way Foley catheter(Fig. 2A). Speciﬁcally, the Alexis wound retractor was in- was inserted via the urethra, and the balloon was inﬂated toserted in the incised bladder, and over the outer ring of the 35 cc. Continuous irrigation was maintained until near clearwound retractor, a size 6 1=2 surgical glove was attached. urine color was emitted.Three or four ﬁngers of the glove were cut, and one 10-mm TURP. A 24F continuous ﬂow resectoscope (Karl Storz,trocar and two or three 5-mm trocars were placed. A home- Tuttlingen, Germany) with a 30 degree lens was used.made, single-port device was constructed by securing the UrosolÒ (CJ, Seoul, Korea) was used as an irrigation ﬂuidﬁngers of the glove to the end of the three trocars with a throughout the procedure. All procedures followed the con-rubber band and ﬁxed to the outer ring of the wound retrac- ventional method.tor, followed by insufﬂation of the bladder with CO2 to 12 to14 mm Hg to establish a pneumovesicum. Results Using articulating laparoscopic instruments (AutonomyÔLaparo-Angle,Ô Cambridge Endo, Framingham, MA), a cir- There was no signiﬁcant difference in patient age, preop-cular incision was made over the bladder mucosa around the erative prostate size, Qmax, PVR, dysuria (VAS) score, IPSS,adenoma. Careful blunt and electrocautery dissection were or QoLs between the two groups (Table 1). The median
SINGLE-PORT TRANSVESICAL ENUCLEATION OF THE PROSTATE 461FIG. 2. Surgical technique of F-STEP. (A) Homemade single-port device used in pneumovesicum. (B) Adenoma wasenucleated under direct vision using a hook electrode, drawing opposite direction with grasper. (C) Finger dissectionthroughout the Alexis wound retractor. Retraction sutures from the adenoma facilitated the enucleation. F-STEP ¼ ﬁnger-assisted, single-port transvesical enucleation of the prostate.follow-up period was 10 months(range 3–14 mos). The mean 76.7% in the F-STEP group, both of which were signiﬁcantlysize and range of transrectal ultrasonography (TRUS) were higher in the F-STEP group than in the TURP group (specimenlarger in the F-STEP group than in the TURP group. All of the weight, 29.85 g; P ¼ 0.03; specimen-to-TRUS size: 48.87%;F-STEP group were included in grade 3 IPP. Table 2 details the P ¼ 0.02).perioperative data. Signiﬁcant improvement was observed in both groups in The catheterization time (5.31 vs 2.09 days, P ¼ 0.03) and terms of Qmax, dysuria VAS score, and IPSS values. A sig-operative time (109.42 vs 68.03 min, P ¼ 0.02) were signiﬁ- niﬁcant statistical difference in subjective (IPSS, QoLs, andcantly increased in the F-STEP group compared with the dysuria VAS score) and objective (Qmax) postoperative out-TURP group. In the F-STEP group, the urethral catheter re- comes was observed between the F-STEP and TURP groupsmained approximately 4 to 8 days (average 5.31 d) in most (Table 1). QoLs was improved, but not signiﬁcant. Post-patients who underwent the transvesical approach. In the F- operative mean IPSS, QoLs, and dysuria VAS score in theSTEP group, the average operative time was 109.42 Æ 44.48 F-STEP group (4.00, 1.08, and 1.73, respectively) were signif-minutes (range 70–235 min), longer than in the TURP group, icantly lower than in the TURP group. In this study, we divided68.03 Æ 25.02 minutes (range 30–120 min) for more technical the IPSS into two categories (storage symptom score [numbercomplexity and difﬁculty. 2, 4, and 7] and voiding symptom score [number 1, 3, 5, and 6]). Estimated blood loss was 176.54 mL and 126.54 mL for While improvement was observed in both groups in terms ofF-STEP and TURP groups, respectively, without statistical the two symptom categories, a signiﬁcant statistical differencedifference. Blood transfusions were necessary in two (6.3%) in the storage symptom category outcomes was observed be-patients—only for the F-STEP not the TURP group. There tween the F-STEP and TURP groups in favor of the F-STEPwere no intraoperative or postoperative complications. Post- postoperatively (P ¼ 0.03). In the F-STEP group, storageoperative urethral stricture occurred in one paient in the symptoms were controlled. The overall symptom recoveryTURP group, diagnosed at 11 months after surgery. No ure- period was signiﬁcantly shorter in the F-STEP group than in thethral complication developed for the others of the TURP and TURP group (5.54 vs 10.88 weeks, P ¼ 0.01). There were noall of the F-STEP group. surgical complications, persistent bleeding, anesthetic compli- The mean weight of the enucleated tissue was 48.35 g, and cations, or CO2 emboli. The transurethral resection syndromethe average ratio of extracted specimen-to-TRUS size was did not occur in any patient in the TURP group.
462 OH AND PARK Table 1. Comparison of Preoperative Parameters Discussion and Postoperative Parameters in Finger-Assisted,Single-Port Transvesical Enucleation of the Prostate TURP is the most commonly performed procedure in theand Transurethral Resection of the Prostate Groups surgical management of BPH, with a focus on the physical F-STEP TURP removal of hyperplastic growth.13 Because treatment and (N ¼ 32) (N ¼ 67) P value early recurrence of symptoms are associated with residual tissue, the optimal goal of therapy is the complete removal ofAge, years 70.19 Æ 6.78 69.17 Æ 7.97 0.23 hyperplastic tissue. A TURP can achieve near-complete re-PSA level, ng=ml 3.88 Æ 1.84 4.89 Æ 1.64 0.33 section of the adenoma; a TURP is typically performed onProstate volume, ml 73.04 Æ 20.40 61.08 Æ 21.36 0.08 prostate glands 75 g. A TURP has increased operative(Range) (48.29–102.60) (27.13–73.13) morbidity in procedures lasting >90 minutes and in elderlyQmax, mL=s patients.14,15 For larger glands, suprapubic prostatectomy has Preoperative 5.84 Æ 1.57 7.82 Æ 4.48 0.36 been used as an alternative to TURP1,7; however, the disad- Postoperative 36.19 Æ 6.62 22.03 Æ 12.03 0.04 vantage is a larger incision, severe pain, and greater inva-PVR, mL 66.27 Æ 24.99 89.79 Æ 101.99 0.07 siveness.Dysuria (VAS score) Recently, a novel method, single-port transvesical simple Preoperative 4.69 Æ 1.85 4.85 Æ 1.71 0.29 prostatectomy using a pneumovesicum and standard or Postoperative 1.73 Æ 2.03 3.14 Æ 1.32 0.04 articulating laparoscopic instrumentation, has been intro-IPSS duced. 8,16 The F-STEP has the beneﬁts of laparoscopic mini- Preoperative 27.12 Æ 7.27 27.27 Æ 7.01 0.90 mal invasiveness and effective removal using an open Postoperative 4.00 Æ 1.13 8.77 Æ 3.15 0.03 surgical technique. In our study, the postoperative subjectiveStorage Sx score symptoms in the F-STEP group were much improved com- Preoperative 10.35 Æ 3.37 11.67 Æ 3.24 0.25 pared with the TURP group. Unlike the STEP study,8 the Postoperative 1.27 Æ 0.60 4.33 Æ 1.48 0.03 F-STEP method was very effective, not only with large- butVoiding Sx score also moderate-sized prostates. In particular, intravesical, pro- Preoperative 16.77 Æ 4.65 15.60 Æ 4.29 0.16 Postoperative 2.73 Æ 0.87 4.44 Æ 2.53 0.07 truding adenomas were highly indicated for surgical conve- nience. Other objective outcomes were signiﬁcantly improvedQoLs Preoperative 4.73 Æ 0.72 5.02 Æ 0.49 0.26 in the F-STEP group compared with the TURP group. Postoperative 1.08 Æ 0.39 2.40 Æ 1.43 0.11 Minimally invasive and effective procedures, such as hol-IPP grade mium laser enucleation of the prostate and potassium-titanyl- 1 0 13 (19.4%) phosphate laser prostatectomy17,18 are effective, but bring a 2 0 54 (80.6%) concern about urethral strictures. Signiﬁcantly late compli- 3 32 (100%) cations involving urethral strictures have been reported to occur in approximately 15% of patients who undergo TURP F-STEP ¼ ﬁnger-assisted single-port enucleation of the prostate; and other transurethral surgeries.4,14,19–21 A signiﬁcant num-TURP ¼ transurethral resection of the prostate; PSA ¼ prostate-speciﬁc antigen; Qmax ¼ maximum uroﬂow rate; PVR ¼ postvoid ber of such patients need a second intervention within 10residual; VAS ¼ visual analogue scale; IPSS ¼ International Prostate years. In the F-STEP method, urethral instrumentation isSymptom Score; Sx ¼ symptom; QoLs ¼ quality-of-life score; IPP ¼ minimal (only for urethral Foley catheterization); thereby,intravesical prostatic protrusion. there is little risk of a urethral stricture. Although there was a limitation of a short follow-up period, no urethral stricture developed in this study. Also, the sphincter could be pre- served under direct laparoscopic vision for more accurate dissection. No incontinence was observed in this study,Table 2. Operative Parameters in the Finger-Assisted, although the follow-up period may not have been long Single-Port Transvesical Enucleation of the Prostate and Transurethral Resection enough. Occasionally after surgery for BPH via the transur- of the Prostate Groups ethral route, persistent residual symptoms (dysuria and frequency) exist because of urethral problems. Therefore, F-STEP TURP P F-STEP will also be suitable for patients for whom concerns (N ¼ 32) (N ¼ 67) value exist for urethral problems and urethral strictures. All procedures were performed without any irrigationHospital stay (days) 3.02 Æ 4.56 1.90 Æ 3.82 0.14 ﬂuids, thereby eliminating the transurethral resection syn-Catheterization 5.31 Æ 0.76 2.09 Æ 1.74 0.03 time (days) drome. Bleeding was effectively controlled with pneumove-IPSS recovery 5.54 Æ 2.85 10.88 Æ 20.94 0.01 sicum formation and enucleation under direct vision, period (week) achieving adequate hemostasis.Blood loss (mL) 176.54 Æ 14.11 126.54 Æ 14.60 0.07 Although minimally invasive, prostatic adenomas can beOperative time (min) 109.42 Æ 44.48 68.03 Æ 25.02 0.02 completely enucleated via F-STEP as via open surgery. In thisSpecimen weight (g) 48.35 Æ 21.12 29.85 Æ 13.41 0.03 study, the average extracted specimen weight wasSpecimen=TRUS 76.70 48.87 0.02 48.35 Æ 21.12 g, and the specimen=TRUS size was 76.70%, size (%) which was signiﬁcantly greater than the TURP group. As F-STEP ¼ ﬁnger-assisted single-port enucleation of the prostate; mentioned in the STEP study,8 ﬁnger dissection was highlyTURP ¼ transurethral resection of the prostate; IPSS ¼ International effective in dissecting adenomas. The ﬁnger-assisted proce-Prostate Symptom Score; TRUS ¼ transrectal ultrasonography. dure was similar to the open technique, easily adapted, and
SINGLE-PORT TRANSVESICAL ENUCLEATION OF THE PROSTATE 463the learning curve was steep. A recent study by Desai and 5. Servadio C. Is open prostatectomy really obsolete? Urologyassociates22 addressed outcomes after STEP; ﬁnger assistance 1992;40:419–421.was effectively used to expedite enucleation of the distal 6. Baumert H, Ballaro A, Dugardin F, Kaisary AV. Laparo-apical portion in some cases. Fingertip dissection was not only scopic versus open simple prostatectomy: A comparativesensitive in identifying the surgical plane, but ﬁnger dissec- study. J Urol 2006;175:1691–1694.tion effectively extracted the prostate and reduced the oper- 7. Serretta V, Morgia G, Fondacaro L, et al. Open prostatec-ative time to within 2 hours. We applied this technique in all tomy for benign prostatic enlargement in southern Europe incases (F-STEP). the late 1990s: A contemporary series of 1800 interventions. Grade 3 IPP was a clinical predictor of higher symptoms Urology 2002;60:623–627. 8. Desai MM, Aron M, Canes D, et al. Single-port transvesicaland need for surgery.23 Lee and colleagues24 reviewed grade 3 simple prostatectomy: Initial clinical report. Urology 2008;IPP 10.4 odds ratio for BPH progression. Therefore, complete 72:960–965.resection of intravesical protruding adenoma was important 9. Sandhu JS, Ng C, Vanderbrink BA, et al. High-powerfor BPH surgery. The rate of reoperation after TURP, how- potassium-titanyl-phosphate photoselective laser vaporiza-ever, has been reported to be nearly 2% each year to remove tion of prostate for treatment of benign prostatic hyperplasiarecurrent adenomas.25 Our concept for complete resection in men with large prostates. Urology 2004;64:1155–1159.with capsular margin would be ideal for grade 3 IPP BPH; in 10. Yuen JS, Ngiap JT, Cheng CW, Foo KT. Effects of bladderour study, the reoperative rate was zero, but long-term ob- volume on transabdominal ultrasound measurements ofservation is needed for veriﬁcation of this ﬁnding. intravesical prostatic protrusion and volume. Int J Urol 2002; The average hospital stay was 3.02 days for F-STEP and 9:225–229.1.90 days for TURP. Hospital stays are relatively longer in 11. Park YH, Kang MY, Jeong MS, et al. LaparoendoscopicF-STEP without statistical signiﬁcance, because most patients single-site nephrectomy using a homemade single-port de-requested discharge after catheter removal. In Korea, insur- vice for single-system ectopic ureter in a child: Initial caseance covers hospitalization for the most part, and relatively report. J Endourol 2009;23:833–835.longer hospital stays result from pressure by the patients. 12. Han WK, Park YH, Jeon HG, et al. The feasibility of lapar- oendoscopic single-site nephrectomy: Initial experience usingConclusion home-made single-port device. Urology 2010;76:862–865. 13. Dawkins GP, Miller RA. Sorbitol-mannitol solution for F-STEP is a very effective, safe, straightforward, modiﬁca- urological electrosurgical resection—a safer ﬂuid than gly-tion of STEP. In addition, F-STEP is suitable for prostate cine 1.5%. Eur Urol 1999;36:99–102.glands that are moderate to large with protruding adenoma. 14. Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Trans-Intraoperative bleeding during F-STEP is minimal because of urethral prostatectomy: Immediate and postoperative com-the reduced venous bleeding controlled by the CO2 pneu- plications. Cooperative study of 13 participating institutionsmovesicum and more accurate dissection under direct vision. evaluating 3,885 patients. 1989. J Urol 2002;167:5–9.The ﬁnger-assisted procedure is more convenient and reduces 15. de la Rosette JJ, Alivizatos G, Madersbacher S, et al. EAUthe operative time. Most of all, there were no urethral prob- Guidelines on benign prostatic hyperplasia (BPH). Eur Urollems during BPH surgery. The current study, however, is 2001;40:256-264.limited by its nonrandomized nature. Also, the follow-up 16. Sotelo RJ, Astigueta JC, Desai MM, et al. Laparoendoscopicperiod is short in our analysis. Therefore, further studies with single-site surgery simple prostatectomy: Initial report. Ur-a randomized large number of patients and longer follow-up ology 2009;74:626–630.are warranted to assess the use of this procedure in the sur- 17. Rehman J, Khan SA, Sukkarieh T, et al. Extraperitonealgical management of BPH. laparoscopic prostatectomy (adenomectomy) for obstructing benign prostatic hyperplasia: Transvesical and transcapsular (Millin) techniques. J Endourol 2005;19:491–496.Disclosure Statement 18. Tan AH, Gilling PJ. Holmium laser prostatectomy: Current techniques. Urology 2002;60:152–156. No competing ﬁnancial interests exist. 19. Tan A, Liao C, Mo Z, Cao Y. 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464 OH AND PARK largement in patients receiving medical treatment. Int J Urol 2010;17:69–74. Abbreviations Used25. Jung P, Mattelaer P, Wolff JM, et al. Visual laser ablation of BPH ¼ benign prostatic hyperplasia the prostate: Efﬁcacy evaluated by urodynamics and com- F-STEP ¼ ﬁnger-assisted, single-port transvesical pared to TURP. Eur Urol 1996;30:418–423. enucleation of the prostate IPP ¼ intravesical prostatic protrusion IPSS ¼ International Prostate Symptom Score Address correspondence to: Qmax ¼ maximum uroﬂow rate Dong Soo Park, M.D., Ph.D. QoLs ¼ quality-of-life score Department of Urology PSA ¼ prostate-speciﬁc antigen CHA Bundang Medical Center PVR ¼ postvoid residual CHA University STEP ¼ single-port transvesical encucleation 351 Yatap-dong, Bundang-gu of the prostate Seongnam-si, 463-712 TRUS ¼ transrectal ultrasonography Korea TURP ¼ transurethral resection of the prostate VAS ¼ visual analogue scale E-mail: email@example.com