31Archivio Italiano di Urologia e Andrologia 2017; 89, 1 ORIGINAL PAPER Comparison of transurethral incision of the prostate and silodosin in patients having benign prostatic obstruction in terms of retrograde ejaculation Basri Cakiroglu 1, Aydin Ismet Hazar 2, Orhun Sinanoglu 3, Ersan Arda 1, Sinan Ekici 1 1 Hisar Intercontinental Hospital, Department of Urology, Istanbul, Turkey; 2 Gaziosmanpaşa Taksim Eğitim Araştırma Hastanesi, Department of Urology Istanbul, Turkey; 3 Maltepe University, Medical School Department of Urology, Istanbul, Turkey. Background: To compare the functional outcomes and retrograde ejaculation (RE) after transurethral incision of the prostate (TUIP) or silodosin in bladder outlet obstruction (BOO) secondary to a small prostate. Methods: Prospectively collected data from December 2011 through December 2014 of 192 LUTS patients having fertility concerns with prostate volume smaller than 40 ml receiving either TUIP or silodosin treatment were prospectively reviewed. The treatment outcomes were evaluated and compared. Results: TUIP was performed in 96 cases and silodosin 8 mg was prescribed in 96 cases. At 12th months after TUIP or con- tinuous silodosin treatment, the decrease in mean International Prostate Symptom Score (IPSS) and postvoiding residual urine (PVR) and the improvement of mean maximal flow rate (Qmax) were significant (p = 0.000). The improvement in IPPS and Qmax was significantly higher in TUIP group compared to silodosin group (p = 0.005, p = 0.000) with a lower rate of retrograde ejaculation (RE) in TUIP group. (11/96 vs 33/96) (p = 0.000) Conclusions: Both TUIP and silodosin ensures comparable improvement in PVR, IPSS and Qmax with a lower rate of RE on the TUIP group in prostates weighing less than 40 grams suggesting that TUIP is a better choice in younger patiens seeking preservation of ejaculation with fertility concerns. KEY WORDS: Prostate; Retrograde ejaculation; Silodosin; Transurethral incision prostate. Submitted 26 May 2016; Accepted 19 July 2016 Summary No conflict of interest declared. matic BPH; one blocks the α1-adrenoreceptors, the other inhibits the enzyme 5α-reductase. The former cat- egory is expected to provide relatively rapid symptom relief starting within 2-6 weeks (3). Silodosin, is an adrenergic blocker considered to be high- ly selective for α1a receptor subtype and confirmed to be highly effective in patients with BPH. However, almost 70% of patients report either anejaculation or hyposper- mia, with a concomitant orgasmic function (OF) impair- ment in 17% of the patients. Younger patients claimed higher rates of ejaculatory dysfunction (4). Transurethral resection of the prostate (TURP) is the gold standard for surgical treatment of BPH. Like many inva- sive modalities, this procedure is associated with with sig- nificant morbidity such as bleeding requiring blood trans- fusion (3%), and hyponatremia (TUR syndrome, 1%) as well as long-term complications such as stricture (7%), surgical revision (6%), significant urinary tract infection (4%), bleeding incontinence (3%), erectile dysfunction (10%), and ejaculatory dysfunction (65%) (5, 6). Furthermore, it may be an over-treatment for small size prostate in younger patients seeking protection of ejacu- latory function. In this context, transurethral incision of the prostate (TUIP) became a an established treatment for BOO secondary to small-size BPH (7). TUIP has been reported to be an equivalent symptomatic improvement for men with prostate volume < 30 mL, with the advan- tages of less hemorrhage and less sexual dysfunction such as ED or RE than TURP (7, 8). In the present study, our objective is to compare the out- comes of TUIP and silodosin treatment in men with LUTS due to BPH seeking protection of fertility in terms of antegrade ejaculation. MATERIALS AND METHODS A review of prospectively collected data of patients having LUTS due to BPH with ejaculatory concerns receiving silo- dosin 8 mg or undergoing TUIP. Inclusion criteria were patients with mild-moderate LUTS, seeking preservation of fertility, age ≤ 60 years prostate volume ≤ 40 cc and pre- operative cystoscopic evaluation. All patients signed an informed consent agreeing to supply their own anonymous DOI: 10.4081/aiua.2017.1.31 INTRODUCTION Lower urinary tract symptoms (LUTS) due to bladder outlet obstruction (BOO) are a common problem in aging males. Benign prostatic hyperplasia (BPH) is the most common cause of LUTS (1). The treatment of symptomatic BPH is to relieve the BOO due to enlarged portion of the prostate. This can be ensured with surgery definitively or with medications providing symptomatic relief. However, the invasive treatment modalities are not free of complications, including permanent urinary incontinence, retrograde ejaculation (RE) as well as erectile dysfunction (ED) (2). Therefore, to avoid invasive methods, two main cate- gories of drugs are used for the treatment of sympto- Cakiroglu_Stesura Seveso 04/04/17 09:12 Pagina 31 Archivio Italiano di Urologia e Andrologia 2017; 89, 1 B. Cakiroglu, A.I. Hazar, O. Sinanoglu, E. Arda, S. Ekici 32 information for the study. Patients included in the alpha blocker treatment arm were prescribed to receive daily dos- ing silodosin 8 mg for a 12-months course. For TUIP pro- cedure and silodosin treatment, prostate volume > 40 cc, the presence of middle lobe, a history of prostate surgery or history of concomitant urethral stricture and hypersensitiv- ity to alpha blockers, orthostatic hypertension, other drug interaction were exclusion criteria, respectively. All TUIP procedures were performed or supervised by a single sur- geon with a continuous flow 26 Ch resectoscope and a video camera. The bladder neck was deeply incised at 5 and 7 o’clock positions just distal to each ureteral orifice to create a groove down to the true capsule to both side of the verumontanum. A 3-way 20Ch Foley catheter was insert- ed and connected to drainage and minimal saline irriga- tion. The patient was discharged once the urine was clear and the patient was able to void without a catheter. The fol- low-up visits were at 1, 6, and 12 months and then annu- ally. Baseline and follow-up data were compared both sub- jectively and objectively in terms of the International Prostate Symptoms Score (IPSS), International Index of Erectile Function (IIEF), post-void residual urine volume (PVR) (mL), peak flow rate (Qmax). Only baseline and post treatment 12th month data were then collected and ana- lyzed. Statistics The SPSS 16.0 (Statistical Package for Social Sciences, Chicago, USA) software was used for all statistical evalua- tions. Changes from baseline data for the same group were compared using the paired t-test while between groups comparison was done by the Fisher exact test for categorical variables and Mann Whitney-U test for continuous variables. P value of less than 0.05 was con- sidered statistically significant. RESULTS Ninety six patients underwent TUIP and 96 patients received silodosin 8 mg. The differences in baseline parameters of treatment groups were not statistically significant; mean age, IPSS, prostate volume, IIEF, PVR, Qmax and PSA were 48.8 ± 7.6 vs 48.3 ± 6.8, 12.9 ± 4.0 vs 11.9 ± 3.9, 30.1 ± 6.2 vs 31.5 ± 4.6, 24.9 ± 3.2 vs 25 ± 3.2, 68.2 ± 29.6 vs 68.0 ± 26.2, 12 ± 3.5 vs 12 ± 2.4 and, 1.3 ± 0.8 vs 1.4 ± 0.7 in TUIP and silodosin groups, respectively (Table 1). Both groups were comparable in subjective and objective voiding parameters within follow up period at 3th, 6th and 9th month. At 12th months after TUIP and contin- uous silodosin 8 mg treatment, the decrease in mean IPSS, and PVR and the improvement of mean maximal flow rate (Qmax) were significant in both groups (p = 0.000). No significant change occured in IIEF scores of either groups. The improvement in IPSS and Qmax was significantly higher in TUIP group compared to silodosin group (4.7 ± 2.0 vs 5.7 ± 2.6 and 20.8 ± 23.2 vs 26.5 ± 26.8) (p = 0.005, p = 0.000) (Table 2) with a lower rate of RE in TUIP group (11/96 vs 33/96) (p = 0.000) (Table 3). IIEF scores in TUIP and silodosin groups at 12th month were 24.9 ± 3.1 vs 25.3 ± 3.2 (p = 0.389). DISCUSSION The management of BOO in BPH patients is divided into medical and surgical treatment modalities. Medical ther- apy for the common condition of BPH consists of alpha blockers and/or 5-alpha-reductase inhibitors, which can both lead to sexual dysfunction and declines in ejacula- tory function (9). According to clinical experience, the younger patients are more likely to encounter ejaculatory and orgasmic problems when using alpha blockers, so the physicians should be more careful when prescribing medicines. Additionally, medical treatment options including alpha blokers for BPH are only for relieving or palliating symp- toms of LUTS, on the other hand the surgery is the defin- itive method to eliminate BOO due to prostatic enlarge- ment. Among surgical treatment modalities open prostate- ctomy and TURP are the leading entities. With the pres- ence of gold standard TURP, the minimally invasive pro- cedure, TUIP, in patients with small prostates has not gained enough popularity. In fact, the risk of blood trans- fusion and retrograde ejaculation are significantly lower with TUIP when compared to TURP. The reintervention rate is lower for TURP, but this is compensated with decreased morbidity of TUIP (10). TUIP is comparable to TURP in terms of functional outcomes within the first 12 Table 1. Preoperative parameters of patients in treatment groups. Age IPSS Volume IIEF PVR Qmax PSA TUIP (#96) 48.8 ± 7.6 12.9 ± 4.0 30.1 ± 6.2 24.9 ± 3.2 68.2 ± 29.6 12 ± 3.5 1.3 ± 0.8 Silodosin (#96) 48.3 ± 6.8 11.9 ± 3.9 31.5 ± 4.6 25.0 ± 3.2 68.0 ± 26.2 12 ± 2.4 1.4 ± 0.7 P value 0.66 0.97 0.07 0.74 0.96 0.98 0.44 TUIP: Transurethral incision of the prostate, IPSS: International prostate symptom score, IIEF: International index of erectile function, PVR: Post voiding residue, Qmax: Maximum flow rate, PSA: Prostate specific antigen. Student T test Table 2. Postperative parameters of patients in treatment groups. IPSS IIEF PVR Qmax TUIP (#96) 4.7 ± 2.0 24.9 ± 3.1 20.8 ± 23.24 19.6 ± 3.9 Silodosin (#96) 5.7 ± 2.6 25.3 ± 3.2 26.5 ± 26.8 15.0 ± 4.7 P value 0.005 0.389 0.123 0.000 TUIP: Transurethral incision of the prostate, IPSS: International prostate symptom score, IIEF: International index of erectile function, PVR: Post voiding residue, Qmax: Maximum flow rate. Student T test Table 3. Retrograde ejaculation (RE) status according to treatment modality. RE (-) RE (+) Total TUIP 85 (88.5%) 11 (11.5%) 96 (100%) Silodosin 63 (65.6%) 33 (34.4%) 96 (100%) Total 148 (77.1%) 44 (22.9%) 192 (100%) TUIP: Transurethral incision of the prostate, p = 0.000. Chi square test Cakiroglu_Stesura Seveso 04/04/17 09:12 Pagina 32 months postoperatively, except Qmax that was more sig- nificantly improved with TURP (11). The operative time and hospital stay is shorter in the TUIP procedure (12). In the present study, we compared silo- dosin with the invasive procedure, TUIP. Prostate volume < 40 cc was the inclusion criteria in contrast to the major- ity 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, Qmax and IIEF was significantly higher in TUIP group compared to silo- dosin group whereas RE rate was significantly lower in TUIP group compared to silodosin group. To our knowl- edge, this is the first study comparing RE status in terms of alpha bloker treatment and TUIP procedure. There are comparative reports only among different surgical meth- ods in this regard. In the present study, RE rates in silo- dosin vs TUIP were 34.4% and 11.5%, respectively. A systematic review comparing TURP and TUIP proce- dures reported that RE rates were 65.4% and 18.2% respectively (14). The major adverse events of silodosin are ejaculatory dysfunction, dizziness, diarrhea or loose stools, skin rash, nasal congestion, abnormal liver func- tion and thrombocytopenia. Patients underwnt TUIP avoid all these adverse events additionally (15). Lastly, in terms of TUIP complications in our series, there were not any short term complication such as bleeding and long term complication such as urethral stricture or bladder neck contracture. Of interest, re- operation after TUIP for the management of LUTS sec- ondary to BPH was needed after 12 months in 1 patient. There were limitations to our study. First, it was prospec- tive in nature, and second, only the 12 month follow up data after initial treatment were compared. Lack of urody- namic studies may be considered as another limitation. CONCLUSIONS Young patients with LUTS due to BPH using highly uros- elective alpha blokers experience quite often anejacula- tion, aspermia and reduced orgasm feeling. Therefore, TUIP remains as an alternative, safe and efficient proce- dure to treat BOO secondary to a small-sized prostate in young BPH patients seeking preservation of ejaculatory and orgasmic function with both infertility and sexual dissatisfaction concerns. 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Six-year follow up of silodosin monotherapy for the treatment of lower urinary tract symptoms sug- gestive of benign prostatic hyperplasia: What are the factors for con- tinuation or withdrawal? International J Urol. 2015; 22:1143-48. 33Archivio Italiano di Urologia e Andrologia 2017; 89, 1 Retrograde ejaculation Correspondence Cakiroglu Basri, MD (Corresponding Author) drbasri@gmail.com Arda Ersan, MD Ekici Sinan, MD Hisar Intercontinental Hospital, Department of Urology, Saray Mh.Siteyolu Cad. No.7 34768 Umraniye, Istanbul, Turkey Hazar Aydin Ismet, MD Gaziosmanpaşa Taksim Eğitim Araştırma Hastanesi, Department of Urology Istanbul, Turkey Sinanoglu Orhun, MD Maltepe University, Medical School Department of Urology, Istanbul, Turkey Cakiroglu_Stesura Seveso 04/04/17 09:12 Pagina 33