Changing patients' profile presenting for surgical management of benign prostatic hyperplasia over the past 16 years: a single-centre perspective.
Since its development in the early 1990s, alpha-adrenergic blockers have been widely accepted as the first-line choice for lower urinary tract symptoms (LUTS) secondary to non-complicated benign prostate hyperplasia (BPH). (1) Short- and long-term randomized clinical trials have demonstrated the efficacy of these medications, either alone or in combination with 5-alpha reductase inhibitors.
Combination therapy significantly decreases clinical progression, acute urinary retention and BPH-related surgery in men with moderate to severe LUTS; (2-4) improves bladder outlet obstruction; and protects against impaired detrusor contractility. (5) However, medical therapy has its own limitations and its failure results in worsening of symptoms and recurrent attacks of acute urinary retention and hydronephrosis which necessitate surgery. (6,7) About 8% of subjects receiving medical therapy required subsequent surgical therapy. (8)
Despite the 16% increase in the number of men at risk of BPH-related events, the advent of medical therapy for BPH has significantly delayed the time at which patients progress to BPH surgery. (9) As such, it has decreased the number of transurethral resection of the prostate (TURPs) dramatically. (7) In addition, significant comorbidities, including increased body mass index, hypertension and operative history, have increased in patients presenting with symptomatic BPH. (10)
Furthermore, as the population ages, more and more people will require medical care. (11) Any delay in surgical therapy, when indicated, can cause progression of BPH and worsen its symptoms. Late presenting elderly patients coming for surgery have larger prostates with more cardiovascular diseases mandating long-term use of blood thinners, frequent use of cardiac pacemakers, and are often catheter dependent. (11,12) Nevertheless, the surgical challenge associated with BPH treatment goes hand in hand with progressive evolution of techniques and refinement of the equipment.
The question is whether the evolution in surgical management techniques over the past 16 years has been able to maintain surgical outcomes despite significant changes in the target population. Furthermore, how does delay of surgery to relieve bladder outlet obstruction secondary to BPH affect recovery of the detrusor function?
We hypothesized that the widespread and prolonged medical treatment for symptomatic BPH delays surgical intervention, so that patients who eventually need surgery for BPH end up with more advanced disease. The intention of the present study was to assess the change in the profile of patients presenting for surgical management for LUTS secondary to BPH over the past 16 years and find out how much this change influenced their surgical outcomes.
Study design and patients enrollment
We reviewed a prospectively maintained laser prostate surgery database for patients presenting with symptomatic BPH since March 1998. Patients were divided into 3 consecutive time-based groups depending on their date of surgery: Group 1 for patients who were operated before April 2004; Group 2 for patients who were operated between April 2004 and March 2009; and Group 3 for patients who were operated thereafter until August 2014. All patients were evaluated, operated and supervised by a single surgeon (MME).
Data collection and preoperative workup
Demographic and preoperative data included age at surgery, presentation, presence of diabetes mellitus or coagulopathy, use of any prostatic medications for BPH, and history of previous prostatic surgery. After patients' interview, we conducted physical and clinical examinations, including digital rectal examination (DRE), international prostate symptoms score (IPSS) and quality of Life (QoL) index, measurement of peak flow rate (Qmax), post-void residual urine by ultra-sonography, prostate volume by transrectal ultrasound (TRUS), and prostate-specific antigen (PSA). Patients with abnormal DREs and/or high PSA (greater than the average for their age) underwent TRUS-guided prostate biopsy before surgery, where only patients with negative biopsy underwent surgery.
The American Society of Anesthesiologists (ASA) morbidity scores at the time of surgery were recorded and used as a surrogate measure for overall patient comorbidity. Moreover, the date and type of surgery and concomitant procedures were reviewed. In addition, we documented postoperative complications, including the need for any further surgical intervention to relieve bothersome LUTS after the primary procedure.
Urinary incontinence was defined as the accidental or involuntary leakage of urine immediately preceded by urgency or straining. In our study, urinary incontinence included all types of incontinence (urgency, stress, or mixed).
The primary outcome of the current study was to assess the change in the profile of patients presenting for surgical management for symptomatic BPH over the past 16 years. The secondary outcome was to compare the postoperative surgical outcome among the three consecutive study groups.
Descriptive statistics were reported in terms of number and percentages or means and standard deviations for categorical and continuous variables, respectively. The Fisher exact test was used for categorical variables, and one-way ANOVA or Kruskal-Wallis H test were used for normally and abnormally distributed continuous variables, respectively. Links between quantitative variables were measured by the Spearman rank correlation coefficient with a critical two-sided p value <0.05 used for statistically significant differences. A multivariate logistic regression model was used to assess predictors of postoperative urinary incontinence. Data were analyzed using the commercially available Statistical Package for Social Sciences for windows, version 20 (IBM SPSS, Armonk, NY).
A total of 1835 patients underwent surgery between March 1998 and August 2014, including 542 (29.5%), 614 (33.5%), and 679 (37%) patients in Group 1, Group 2, and Group 3, respectively (Table 1). The overall prostate size was 80.5 [+ or -] 49.5 mL and PSA was 5.97 [+ or -] 11 ng/mL. The overall mean (range) follow-up was 7.8 years (3 months-15 years); 12.8 [+ or -] 5.9 years for Group 1, 8.2 [+ or -] 4.7 years for Group 2, and 3.1 [+ or -] 9.3 years for Group 3.
All patients underwent laser prostate surgery, including holmium laser enucleation (HoLEP) in 1277 (69.6%), Holmium laser ablation (HOLAP) in 67 (3.7%), GreenLight photoselective vaporization procedures (PVP) in 406 (22.1%) and holmium transurethral incision of the prostate (Ho-TUIP) in 85 (4.6%) patients. Preoperative prostate volume was positively correlated with age at surgery (r = 0.62, p < 0.001), total energy used (r = 0.47, p < 0.001), and total operative time (r = 0.47, p < 0.001).
Patients in Group 3 were significantly older, for Group 3, Group 2 and Group 1, respectively (75.28 [+ or -] 8.47 vs. 71.11 [+ or -] 8.9 vs. 65.3 [+ or -] 9.04 years, p < 0.001), were more coagulopathic (18.7% vs. 12.3% vs. 5.9%, p < 0.001), and had significantly more morbidity (higher mean ASA score) (Table 2). The use of preoperative prostatic medications significantly increased over time (72.6% vs. 85.5%, vs. 87.4%, p < 0.001) in Group 1, Group 2 and Group 3, respectively (Table 2).
At the time of surgery, a significantly higher number of patients in Groups 3 and 2 had indwelling urethral catheters secondary to urinary retention (33.7% Group 3 vs. 34.4% Group 2 vs. 27.7 Group 1, p = 0.028). Moreover, patients in Group 3 had significantly larger prostate volume compared to patients in Group 1 and Group 2, respectively (87.96 [+ or -] 49.80 vs. 74.50 [+ or -] 46.53 vs. 78.44 [+ or -] 50.84, p < 0.001). Similarly, patients in Group 3 had significantly higher IPSS and QoL scores and lower Qmax than the other groups (p < 0.001) (Table 2).
We tallied perioperative parameters and types of laser prostatectomy among the three groups (Table 3). Enucleation-based procedures were significantly different among the 3 groups (33.5% Group 1 vs. 27.8% Group 2 vs. 38.7% Group 3, p < 0.001) (Table 3).
We also tallied perioperative and late postoperative complications among groups (Table 4). After a mean follow-up of 3 years for all groups, reoperation-free patients progressively increased over time: 94.1% vs. 96.1% vs. 98.3% for Group 1, Group 2, and Group 3, respectively. Late development of prostate cancer was detected in 35 (1.9%) patients who were primarily confirmed to have histological BPH. Late prostate cancer diagnosis was comparable among groups (0.60% Group 1 vs. 0.54% Group 2 vs. 0.76% Group 3, p = 0.13), respectively.
Of interest, failure of postoperative voiding trials and the development of early postoperative urinary incontinence were significantly lower in Group 1 (Table 4), despite the fact that surgeons had inherent learning curves with their techniques. Using the means of the whole cohort as cut-offs in a multivariate logistic regression model, age (>72 years), prostate volume (>80 cc), operative time (>95 minutes), and preoperative PSA (>6 ng/dL) were significantly associated with postoperative urinary incontinence. All patients who needed transfusion underwent a HoLEP procedure and despite the fact that consecutive time groups used blood thinners more frequently, the need for perioperative blood transfusion was significantly higher in Group 1 (Table 4).
BPH is one of the most common conditions associated with aging men and up to 25% of men in their eighth decade of life require treatment. (13) Bothersome symptoms are the most common reasons why men with BPH seek treatment. Therefore, therapeutic decision-making should be guided by the degree of bothersome symptoms and patient preference.
During the past decade, the introduction of highly effective combination drug therapies for BPH significantly delayed the time at which patients switched over to surgery. (9) Furthermore, the progressive increase of life expectancy in the general population, particularly in western countries, resulted in more and more elderly people requiring medical care. (11)
Patients with acute urinary retention tend to require a longer hospital stay, incur higher costs, and experience a higher risk of complications after TURP than those without retention. (14) Therefore, delay of surgical therapy, when indicated, can cause progression of BPH and worsen its outcome. In addition, significant comorbidities including increased body mass index, chronic medical diseases and operative history have increased in the last two decades for patients with symptomatic BPH. (10)
In the current study, we compared 3 consecutive time-based groups of BPH patients surgically treated with different modalities of Holmium and GreenLight lasers, including ablation, incision and enucleation procedures. We found that preoperative prostate volume significantly correlated with age at surgery, total energy used at surgery, and the total operative time. It would seem intuitive as patients get older for surgery, their prostates get larger and they may need higher energy for their laser surgeries and longer operative time. Moreover, we found that patient and prostate characteristics were significantly different among the 3 groups. Group 3 was different; patients had significantly larger prostates, were older, had a higher comorbidity score, failed medical therapy, and required surgery. However, despite the fact that predictors of complications under these circumstances following transurethral prostate procedures were different, the procedure-related complications in our study were comparable among study groups.
Reports have shown that longer operative time, (11) age, prostate size, (15) non-Caucasians, (12) and perioperative blood thinners use (16) independently predict surgical morbidity and mortality for patients with BPH. In addition, post-TURP morbidity was significantly higher in patients over 80 and in patients with prostates larger than 45 cc. (17)
In the current study, a higher proportion of patients in Group 3 were on preoperative combination drug therapy. Combination therapy has been shown to significantly improve LUTS more than monotherapy at 4 years and was superior to alpha-blocker-monotherapy in reducing the risk of acute urine retention or BPH-related surgery and risk of BPH clinical progression. (4,18) In our socialized medical environment, patients with BPH have to wait longer for surgery, which could contribute to longer medical therapy. Furthermore, a poorer preoperative flow rate was observed in patients in Group 3; there were more catheter-dependent patients for surgery in the Groups 2 and 3, compared to Group 1. This could be explained by the long-term outflow obstruction in older patients with larger prostates, which would impair bladder detrusor contractility especially when the response to treatment is unsatisfactory. Saito and colleagues previously found that the total bladder pressure observed with experimental long-standing outflow obstruction was significantly lower than in their control group. (19) Interestingly, there was no difference between the 3 time-groups in our study regarding the postoperative need of chronic clean intermittent catheterization--consistent with a report by Kojima and colleagues on the reversibility of detrusor muscle changes after relief of outflow obstruction. (20)
Longer medical treatment for BPH has been associated with a decreased number of patients undergoing BPH surgery resulting in increased prostate volume with potentially more patients needing open surgery. (21) The question is whether changes in laser surgery over the past 16 years have been able to sustain surgical outcome despite significant changes in the target population. Fortunately, the currently available new laser technology and equipment confer benefits to these patients and could overcome the challenge of increased prostate volume and patient comorbidities. (22) However, many clinical trials have shown higher reoperation rates after laser ablation of the prostate, (23,24) despite the fact that many of these laser techniques claim to be size independent. (25)
Short- and long-term functional outcomes of these different procedures have been previously published, including 3 randomized controlled trials comparing the 3 generations of the 532-nm laser with holmium laser ablation and enucleation. (26-32)
In our current study, all 3 successive groups were comparable regarding long-term adverse events and reoperation rates. However, there was a progressive decrease in the incidence of urethral stricture over time. This might be due to the lower incidence of previous prostate surgery in patients in Group 3 and the continuous refinement of instruments and quality of laser fibres over time. In addition, most patients in Group 3 underwent HoLEP, in which a new enucleation loop was used to help blunt the dissection of the adenoma, which could be a contributing factor.
Of interest, failed postoperative trial of voiding was significantly lower in Group 1, which could be the result of significantly higher enucleation procedures in Group 1 patients and/or the significantly increased prostate volume in the other 2 groups. Surprisingly, early postoperative transient de novo urinary incontinence was significantly lower in Group 1 patients despite the steep learning curve during that time. However, this finding was not surprising considering our multivariate analysis where postoperative urinary incontinence was likely in patients over 72, with prostates larger than 80 cc, a PSA over 6 ng/dL, and with operation times over 95 minutes. These parameters may explain the significantly lower incidence of early urinary incontinence in Group 1--with younger patients and smaller prostate volumes. In a previous study, the presence of diabetes mellitus, large prostate volume (>81 cc) and a greater reduction in postoperative PSA (>84%) predicted stress urinary incontinence after HoLEP. (33) These factors suggest a relationship between the novel urinary incontinence and the length of the procedure.
Finally, our data are consistent with the current growing trend in the urologic community--more BPH patients presenting late for surgery with larger glands and adopting more transurethral enucleation techniques. Good-quality data support the use of enucleation techniques on larger glands to minimize reoperation rates; regardless of the type of energy source used, transurethral enucleation or vapoe-nucleation is increasing. (34)
Our study has its limitations, including the duration of preoperative prostatic medications that were not recorded in our database. Another limitation is the study's retrospective nature. In addition, a selection bias could have been introduced with the patients referred to our tertiary centre--patients were older, had larger prostates and had an increase in comorbidity. Moreover, all patients were managed by a new laser technology, which may have reduced the impact of patient profile changes on surgical outcomes. Nevertheless, our study conclusions are validated in that it included a large series of patients over a considerable long follow-up.
We have found that over a 16-year period, patients presenting for surgery due to symptomatic BPH were older, more morbid, and had larger prostates and more abnormal voiding parameters. Also, over time, we found more and more patients using prostatic medications more frequently. Despite changes in patient profiles, perioperative safety and complications rates were comparable between groups. This may be a results of advances in laser technology and techniques. Age (>72 years), prostate volume (>80 cc), operative time (>95 minutes), and preoperative PSA (>6 ng/dL) were significantly associated with reversible postoperative urinary incontinence.
Published online December 14, 2015.
Competing interests: Dr. Mostafa Elhilali is a consultant for AMS, Pfizer, Astellas and Boston Scientific.
This paper has been peer-reviewed.
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Mohamed A Elkoushy, MD, MSc, PhD * ([dagger]) Ahmed M. Elshal, MD, FEBU, PhD; * ([section]) Mostafa M. Elhilali, MD, PhD, FRCSC *
* Department of Surgery, Division of Urology, McGill University Health Centre, Montreal, QC; ([dagger]) Department of Urology, Suez Canal University, Ismailia, Egypt; ([section]) Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
See related article on page 379.
Correspondence: Dr. Mostafa M. Elhilali, Professor of Urology, Royal Victoria Hospital, McGill University Health Centre, 1001 Boulevard Decarie, D05.5327, Montreal, QC, Canada H4A 3J1; email@example.com
Table 1. Demographic and overall preoperative voiding parameters Mean [+ or -] SD / Parameter No. (%) Age at surgery (years) 72.0 [+ or -] 8.8 Patients with DM 117 (6.4%) Medications for LUTS 1496 (81.5%) Patients presented with indwelling 590 (32.2%) urethral catheters ASA score 1.4 [+ or -] 0.67 IPSS 18.7 [+ or -] 7.7 Quality of life score 3.7 [+ or -] 1.5 Peak flow rate (mL/sec) 6.9 [+ or -] 5.1 Post-void residual urine volume /mL 255 [+ or -] 342 PSA (ng/dL) 5.97 [+ or -] 11 Preoperative prostate size by TRUS (cc) 80.5 [+ or -] 49.5 Preoperative hemoglobin (g/dL) 126.4 [+ or -] 41.4 Concomitant cystolitholapaxy 129 (7.0) Type of surgery Holmium laser enucleation 1277 (69.6) Holmium laser ablation 67 (3.7) Green light laser procedures 406 (22.1) Holmium transurethral incision 85 (4.6) of the prostate DM: diabetes mellitus; LUTS: lower urinary tract symptoms; ASA: American Society of Anesthesiologists; IPSS: International Prostate Symptoms Score; PSA: prostate-specific antigen; TRUS: transurethral ultrasound. Table 2. Demographic and baseline voiding parameters among groups Group I Variables n = 542 Age at time of 65.3 [+ or -] 9.04 surgery (years) ASA scores 1.33 [+ or -] 0.61 Patients with DM 37 (7.1) Coagulopathic 32 (5.9) patients Patients presented 150 (27.7) with indwelling urethral catheters Duration of dwelling 12.84 [+ or -] 8.13 catheter prior to surgery (weeks) Previous prostate 52 (9.59) surgery Preoperative None 148 (27.3) prostate Alpha blockers 320 (59.0) medications, 5ARIs [+ or -] 74 (13.7) no (%) alpha blockers Overall 394 (72.7) medications Preoperative PSA 6.13 [+ or -] 10.28 (mean [+ or -] SD, ng/dL) Preoperative 74.50 [+ or -] 46.53 prostate size by TRUS (Mean [+ or -] SD, cc) Preoperative 8.12 [+ or -] 6.95 Qmax (mL/sec) Preoperative 238 [+ or -] 216 PVR (mL) Preoperative IPSS 16.73 [+ or -] 7.44 Preoperative QoL 3.36 [+ or -] 1.46 Preoperative 135.74 [+ or -] 25.78 hemoglobin (g/dL) Group II Group III Variables n = 614 n = 679 Age at time of 71.11 [+ or -] 8.9 75.28 [+ or -] 8.47 surgery (years) ASA scores 1.21 [+ or -] 0.51 1.62 [+ or -] 0.78 Patients with DM 28 (4.6) 52 (7.7) Coagulopathic 76 (12.3) 127 (18.7) patients Patients presented 211 (34.4) 229 (33.7) with indwelling urethral catheters Duration of dwelling 11.98 [+ or -] 7.82 14.36 [+ or -] 8.39 catheter prior to surgery (weeks) Previous prostate 44 (7.17) 41 (6.03) surgery Preoperative 108 (17.6) 86 (12.7) prostate 354 (57.7) 299 (44.0) medications, 152 (24.7) 294 (43.3) no (%) 506 (82.4) 593 (87.3) Preoperative PSA 5.85 [+ or -] 10.69 5.93 [+ or -] 12.32 (mean [+ or -] SD, ng/dL) Preoperative 78.44 [+ or -] 50.84 87.96 [+ or -] 49.80 prostate size by TRUS (Mean [+ or -] SD, cc) Preoperative 7.19 [+ or -] 3.9 6.02 [+ or -] 4.4 Qmax (mL/sec) Preoperative 256 [+ or -] 253 278 [+ or -] 263 PVR (mL) Preoperative IPSS 19.60 [+ or -] 7.49 21.07 [+ or -] 7.68 Preoperative QoL 3.74 [+ or -] 1.49 4.52 [+ or -] 1.48 Preoperative 132.44 [+ or -] 35.85 104.74 [+ or -] 56.21 hemoglobin (g/dL) Variables p value Age at time of <0.001 surgery (years) ASA scores <0.001 Patients with DM 0.06 Coagulopathic <0.001 patients Patients presented 0.028 with indwelling urethral catheters Duration of dwelling 0.026 catheter prior to surgery (weeks) Previous prostate 0.06 surgery Preoperative prostate <0.001 medications, no (%) Preoperative PSA 0.92 (mean [+ or -] SD, ng/dL) Preoperative <0.001 prostate size by TRUS (Mean [+ or -] SD, cc) Preoperative <0.001 Qmax (mL/sec) Preoperative 0.27 PVR (mL) Preoperative IPSS <0.001 Preoperative QoL <0.001 Preoperative <0.001 hemoglobin (g/dL) Data are presented in means [+ or -] SD or No. (%) which appropriate. SD: standard deviation; DM: diabetes mellitus; ASA: American Society of Anesthesiologists; IPSS: International Prostate Symptoms Score; PSA: prostate-specific antigen; TRUS: transrectal ultrasound; 5ARIs: 5 alpha-reductase inhibitors; QoL: quality of life; Qmax: peak flow rate; PVR: post-void residual urine volume. Table 3. Perioperative parameters and types of laser prostatectomy among groups Variables Group I n = 542 (%) Operative time (min) 98.2 [+ or -] 51.3 Energy utilized (KJ) 188.3 [+ or -] 142.4 Length of hospital 1.47 [+ or -] 2.12 stay (days) Postoperative catheter 1.34 [+ or -] 1.68 duration (days) Enucleation-based 468 (33.5) procedures * HoLEP 468 (86.3) Type of laser procedure HOLAP 4 (0.7) Greenlight laser 5 (0.9) procedures Ho-TUIP 65 (12) Concomitant 34 (6.3) cystolitholapaxy Variables Group II Group III n = 614 (%) n = 679 (%) Operative time (min) 87.7 [+ or -] 46.9 103.3 [+ or -] 65.2 Energy utilized (KJ) 174.5 [+ or -] 85.5 197.9 [+ or -] 123.9 Length of hospital 1.06 [+ or -] 0.77 1.01 [+ or -] 0.60 stay (days) Postoperative catheter 1.51 [+ or -] 1.93 1.40 [+ or -] 2.12 duration (days) 388 (27.8) 537 (38.7) 388 (63.2) 421 (62.2) Type of laser procedure 62 (10.1) 1 (0.1) 153 (24.9) 248 (36.5) 11 (1.8) 9 (1.3) Concomitant 43 (7.0) 52 (7.7) cystolitholapaxy Variables p value Operative time (min) <0.001 Energy utilized (KJ) <0.001 Length of hospital <0.001 stay (days) Postoperative catheter 0.31 duration (days) <0.001 <0.001 Type of laser procedure <0.001 <0.001 <0.001 Concomitant 0.64 Cystolitholapaxy Data are presented in means [+ or -] SD or No (%) which appropriate. HoLEP: holmium laser enucleation of the prostate; HOLAP: holmium laser ablation of the prostate; PVP: photoselective vaporization of the prostate; Hol-TUIP: holmium laser transurethral incision of the prostate. * Enucleation-based procedures in Group 3 included HoLEPs and vapoenucleation of the prostate using Green light laser. Table 4. Perioperative and late postoperative complications among groups Time of Clavien- complications Dindo Grade Type of complication Prostate capsule violation Operative Grade I Bladder/urethral injury complications Bleeding Anaesthesia-related Grade I Postoperative hematuria Early postoperative Urinary incontinence complications Failed first TOV (within 30 days Grade II Thromboembolic postoperatively) Epididymo-orchitis Need for transfusion Grade I Persistent LUTS Late Complications Hematuria (conservative) Acute retention needs urethral catheter n=1626 Grade II Chronic retention (CIC) GI=533 GII=507 Recurrent UTI Persistent incontinence >12 months GIII=586 Bladder neck contracture Grade IIIb Urethral stricture Bladder stones Time of Group I Group II complications n = 542 No (%) n = 614 No (%) 1 (0.18) 0 (0) Operative 3 (0.55) 10 (1.63) complications 11 (2.03) 23 (3.74) 4 (0.74) 1 (0.16) 7 (1.29) 13 (2.12) Early postoperative 15 (2.77) 40 (6.51) complications 4 (0.74) 20 (3.26) (within 30 days 1 (0.18) 4 (0.65) postoperatively) 1 (0.18) 1 (0.16) 11 (2.13) 2 (0.32) 13 (2.44) 20 (3.94) Late Complications 3 (0.56) 2 (0.39) 2 (0.37) 5 (0.99) n=1626 2 (0.37) 6 (1.18) GI=533 GII=507 7 (1.31) 7 (1.38) 5 (0.99) 8 (1.58) GIII=586 13 (2.44) 12 (2.37) 19 (3.56) 15 (2.96) 5 (0.99) 3 (0.59) Time of Group III complications n = 679 No (%) p value 3 (0.44) 0.23 Operative 8 (1.18) 0.22 complications 27 (3.98) 0.13 0 (0) 0.04 13 (1.91) 0.07 Early postoperative 25 (3.68) 0.004 complications 19 (2.80) 0.01 (within 30 days 1 (0.15) 0.22 postoperatively) 2 (0.29) 0.86 2 (0.29) <0.001 13 (2.22) 0.18 Late Complications 1 (0.17) 0.55 1 (0.17) 0.13 n=1626 2 (0.34) 0.14 GI=533 GII=507 2 (0.34) 0.14 3 (0.51) 0.20 GIII=586 5 (0.85) 0.08 2 (0.34) <0.001 3 (0.51) 0.62 TOV: trial of void; LUTS: lower urinary tract symptoms; CIC: clean intermittent catheterization; UTI: urinary tract infection.
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|Title Annotation:||ORIGINAL RESEARCH|
|Author:||Elkoushy, Mohamed A.; Elshal, Ahmed M.; Elhilali, Mostafa M.|
|Publication:||Canadian Urological Association Journal (CUAJ)|
|Date:||Nov 1, 2015|
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