Authors (including presenting author) :
Lo KL (1), Wu I (1), Siu WH (1), Kwok H (1), Lau S (1), Lai TH (1), Wong CT (1), Leung KW (1), Wong SK (1), Liu A (1), Wong HM (1), Tang E (1), Ko CH (1), Yuen KK (1), Wong HF (1), Wong F (1), Tam HM (1), Chan W (1), Yee CH (1), Teoh YC (1), Chiu KF (1), Chan CK (1), Ng CF (1)
Affiliation :
(1) S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
Introduction :
Traditionally, transurethral resection of prostate is the gold standard surgical treatment of benign prostatic hyperplasia. It is performed under the general or spinal anesthesia in the operation theatre. On average, it takes at least one to two hours for the whole procedure. After the surgery, urethral catheterization and bladder irrigation are required. So, these patients need to stay as in-patient care for at least 2 days after surgery. Possible complications include infection, bleeding, urinary tract injury, urinary incontinence, retrograde ejaculation, erectile dysfunction, etc.
Due to the aging population, the waiting time for surgery increases with time. Currently, these patients need to wait for at least one year before they can have this surgery. Moreover, high-risk urinary retention patients who do not fit for general or spinal anesthesia require long-term urethral catheterization. This results in frequent in-patient readmission due to urinary tract infection or bleeding from the urethral catheter.
Apart from the surgical issue, the waiting time for out-patient benign prostatic hyperplasia clinic is also getting longer with time. It is due to the accumulation of patients who require medication to relieve their lower urinary tract symptoms. They include storage and voiding symptoms such as urgency, frequency, nocturia, weak stream, etc. Some patients even develop complications including acute retention of urine, urinary bladder stone, recurrent haematuria, obstructive nephropathy, etc. Early surgery is required for those who want to stop the current medication or prevent all the possible complications.
Because of the above practical concern and future challenge, a new surgical service model is necessary to tackle the problem. It should be safe, efficient and cost-effective.
Objectives :
In October 2022, we launched the new office-based service model of minimally invasive surgical therapies of benign prostatic hyperplasia under local anesthesia in the Alice Ho Miu Ling Nethersole Hospital. It's the first hospital to introduce this service model in Hong Kong.
The latest international evidence has proven the safety, efficiency and cost-effectiveness of the minimally invasive surgical therapies in benign prostatic hyperplasia. They include transurethral prostatic urethral lift and water vapour thermal therapy of the prostate which are now under the support of the Medical Device Program.
With this new service model, we aim to shorten the waiting time for surgery and out-patient clinic, reduce the burden of in-patient care and readmission rate, decrease the surgical-related complication and improve the quality of life of patients.
Methodology :
For patients who are arranged for either transurethral prostatic urethral lift or water vapour thermal therapy of the prostate, they are admitted to our Prostatic Minimally Invasive Day Surgical Therapies Centre on the same day of the surgery.
During the procedure, we implant small metal pins to compress on the prostate tissue and open up the urethral channel. Alternatively, we use water vapour to heat up the prostate tissue and shrink the prostate size. In the past, we did all these procedures under the general or spinal anesthesia in the operation theatre. It took at least 1 hour for the whole procedure. After introduction of this new service model, we can manage to finish it within 30 minutes under local anesthesia in our procedure room which is 2 times faster than before.
After the surgery, these patients are observed for few hours and can be discharged home directly. At three months after surgery, they have follow-up in our nurse-led clinic for post-operative assessment and can stop the medication for their lower urinary tract symptoms. At one year after surgery, they have the last follow-up in our out-patient clinic. If they are satisfied with their voiding condition, they will be discharged from the clinic.
Result & Outcome :
From October 2022 to December 2024, this new surgical service model treated more than 300 patients with minimally invasive surgical therapies outside the operation theatre. So, it has saved significant operation theatre sessions for other urological diseases, including urinary tract cancer, stone diseases, etc. These surgeries must be performed in the operation theatre.
As it takes within 30 minutes to finish one minimally invasive surgical therapy, it is 4 times faster than the traditional transurethral resection of prostate. After implement of this new service model, the waiting time for surgery has been shortened from 12 to 4 months. In the past, only 39% of urinary retention patients with urethral catheter could have the traditional surgery within two months. Currently, 65% of this group of patients can have this new surgery within two months. We planned to increase this service scope in 2025 so as to further shorten the waiting time for surgery.
In the past, patients needed to stay as in-patient care for at least two days after traditional surgery, but this was unnecessary with this new surgical service model. From now on, these patients can be discharged few hours after new surgery, not occupying any in-patient bed. Moreover, new surgical method has less complications than the traditional surgery with reduced rate of urinary incontinence, retrograde ejaculation, sexual dysfunction, etc. Clinical research of this new surgery service model was published in the Hong Kong Medical Journal on 10th May, 2024.
In October 2024, a press conference was organized in the Alice Ho Miu Ling Nethersole Hospital with more than 10 media reporting this new service model. Extensive and positive coverage was generated. Apart from that, it was accredited as the first Asia Preceptorship Program of transurethral prostatic urethral lift and water vapour thermal therapy of the prostate. Not only local Urologists from different hospitals, but also Urologists from China, Indonesia, Macau, Singapore, Taiwan, Thailand, etc. have visited our hospital and learned to introduce this new service model into their home countries.
To conclude, this surgical service model is safe, efficient and cost-effective. It can effectively improve lower urinary tract symptoms of our patients with minimal hospital stay and less complication. Moreover, it can serve as an educational platform to bring the best treatment modality to our patients.
