Benign prostatic enlargement (BPE) and urinary stone disease are some of the most common urological diseases across the world and are major contributors of morbidity, health care use, and reduced quality of life (1,2). The common reason of bladder outlet obstruction and lower urinary tract symptoms (LUTS) is progressive prostatic enlargement, whereas urolithiasis can cause recurring colic, infection, obstruction, and renal dysfunction (2,3). When medical management fails, complications arise or when the obstruction proved to be rather anatomical, the surgical intervention is necessary.

Previously, open prostatectomy and open stone surgery were considered as the ultimate cure especially where the volume of prostate is large or the stones are complex (4). Open procedures offer good visualization and tissue or stone clearance, but are linked with higher incisions, increased blood loss, extended catheterization, and extended hospital stay (5,6). As optical systems, laser technology, and miniaturized instrumentation developed, endourological methods have increasingly been used to substitute open surgery in most clinical cases (7,8).

In the case of BPE, the surgical standard has always been transurethral resection of the prostate (TURP),(9,10). Modern systematic reviews and guideline revisions show that there are no functional differences between minimally invasive methods and open simple prostatectomy, and perioperative morbidity is much lower in minimally invasive methods (1,11). It has been reported to have a lower rate of transfusion, reduced bleeding risk and reduced hospitalization (8,12). These merits were supported by the better visualization as well as accurate tissue dissection and hemostasis by using energy-based technologies.

Likewise, percutaneous nephrolithotomy (PCNL), ureteroscopy (URS), have replaced the open stone surgery to a substantial degree in urinary stone disease currently (2,13). The open procedures have become mostly confined to extremely selected cases that involve complicated anatomy or those that have undergone failed treatment with minimal invasions. There is evidence of comparative analysis that suggests that endourological stone management has high clearance rates that are associated with low postoperative pain, ambulation and short hospital stay compared to open surgery (14,15).

Although there is robust international guideline support of minimally invasive procedures (13), resources and expertise of surgeons regarding endourology may not be equally available to all institutions, especially in the low resource environment. Even in these conditions, open surgery can be carried out in cases of large prostates or heavy stone load. Therefore, the comparisons in localized hospital systems are critical to examine the actual outcomes, measure the benefits of the perioperative advantages, and make sure that it complies with the modern standards.

Clinically meaningful indicators of early recovery, such as postoperative pain, time to ambulation, duration of catheterization, length of hospital stay, are metrics that are clinically meaningful indicators of surgical invasiveness and perioperative physiological stress (16,17). Theoretical advantages of endourology include reduced tissue trauma, decreased incisions, and enhanced hemostasis, which lead to reduced inflammatory response, reduced analgesic need, and faster functional recovery (18). Additionally, a shorter duration of hospitalization lowers patient care expenses and nosocomial danger and reinforces the health-system repercussions of procedural decision-making (19).

Multiple retrospective and meta-analytic studies indicate that the currently used minimal invasive procedures are superior to full-scale surgery in terms of perioperative outcomes, but the fact that many studies are heterogeneous in terms of patient selection, prostate volume, stone burden, and institutional guidelines makes it difficult to generalize them (8,14). Although benign prostatic enlargement and urinary stone disease are distinct clinical entities, they were evaluated within a shared perioperative framework because the primary objective of this study was to compare surgical approach-related recovery and morbidity. To address potential heterogeneity, disease-specific outcomes were also analyzed separately for each cohort.

This study aimed to compare perioperative outcomes, early recovery, and complication profiles between endourological and open surgical procedures in patients undergoing surgery for benign prostatic enlargement and upper urinary tract stone disease. Early postoperative recovery with focus on pain, ambulation time and length of stay, were the primary ones. Intraoperative blood loss, transfusion need, complication rate and patient-reported satisfaction were the secondary outcomes. This study  aim was to provide clinically relevant information regarding the present role of minimally invasive urological surgery in comparison with the open procedures with the addition of institutional data and available evidence.

Due to ethical, logistical, and resource constraints in real-world surgical settings. This study was based on previously recorded clinical data reflecting routine clinical practice. Treatment decisions were made by the managing clinicians, and no intervention or allocation was performed as part of the study.

Since the allocation of treatment was based on standard clinical practice, there was no experimental intervention. Even though benign prostatic enlargement and urinary stone disease are two different clinical entities, they were discussed in a single context since the main aim of conducting this study was to compare the perioperative outcome based on surgical approach and not disease-specific pathology. The internal validity and interpretability of results were dealt with by conducting disease-specific subgroup analyses in each cohort to capture the heterogeneity that may exist.

Study Design and Setting This retrospective cohort study was conducted at Gomal University using previously recorded patient data. Study Population Medical records of patients diagnosed with prostatic enlargement and urinary stone disease were reviewed. Patients who had undergone either endourological or open surgical procedures as part of routine clinical care were included. Grouping of Patients Patients were categorized into two groups based on the type of procedure they had received: endourological procedures and open surgical procedures. This grouping was made to compare them. Data Collection Hospital records were reviewed to obtain relevant data, such as patient characteristics, clinical, procedural, and postoperative outcomes. All the data were gathered in written form without affecting the management of patients. Outcome Measures The study aimed to compare outcomes between the two groups based on recorded clinical and postoperative parameters. Statistical Analysis Data were analyzed using appropriate statistical methods. Continuous variables were expressed as means and standard deviations, while categorical variables were presented as frequencies and percentages. Comparative analysis was performed to assess differences between groups. Ethical Considerations Patient confidentiality was maintained by using anonymized data.

Study Population

The number of patients who were evaluated on the basis of eligibility in the course of the study was 248. The exclusion criteria were the incomplete records or loss to follow-up (16). Patients were equally distributed between the endourology group (n=116) and the open surgery group (n=116). The total number of patients who were operated on was equal to 128 (55.2) because of benign enlargement of the prostate and 104 (44.8) because of urinary stone disease. Baseline demographic and clinical characteristics were comparable between groups. Disease-specific variables, including prostate volume in the BPE cohort and stone size in the stone disease cohort, were also comparable between corresponding groups. Both disease cohorts were equally distributed between the two treatment groups, with 64 patients per group in the BPE cohort and 52 patients per group in the stone disease cohort.

Figure 1. Flow Chart

Baseline Characteristics

Table 5: Baseline Demographic and Clinical Characteristics

*BPE cohort only
*Stone cohort only
*There is no meaningful difference between the two groups for that variable

There were no statistically significant differences in baseline variables between groups, suggesting comparable baseline characteristics. However, due to the non-randomized design, multivariable regression analysis including clinically relevant variables was performed to adjust for potential confounding (confounding by indication).

2. Primary Outcome Measures

The mean 24-hour VAS pain score was significantly lower in the endourology group (3.2 ± 1.1 vs 6.1 ± 1.4; p<0.001).

Time to ambulation was significantly shorter in the endourology group (10.4 ± 3.2 vs 22.8 ± 5.6 hours; p<0.001).

Mean hospital stay was also reduced (2.3 ± 0.9 vs 5.6 ± 1.8 days; p<0.001).

In addition, mean blood loss was significantly lower (138 ± 52 vs 412 ± 105 mL; p<0.001), and catheter duration was shorter (2.1 ± 0.8 vs 5.2 ± 1.5 days; p<0.001).

Figure 2

Figure 2. Comparison of mean hospital stay between Endourology (2.3 ± 0.9 days) and Open Surgery (5.6 ± 1.8 days) groups. Error bars represent standard deviation.

Table 6: Primary Early Recovery Outcomes

 Secondary Outcome Measures

In endourology group, 3 patients (2.6%) and 18 patients (15.5%) in open surgery group required blood transfusion (p=0.001).

The final postoperative complications were in 14 patients (12.1%) in the endourology group and 31 patients (26.7%) in the open surgery group, indicating a high complication rate among the open surgery group (p=0.005).

Table 7: Secondary Perioperative Outcomes

Disease-Specific Outcomes
In the BPE subgroup, improvement in IPSS at 4 weeks was comparable between the two groups (17.2 ± 4.0 vs 16.5 ± 4.0; p=0.324). However, perioperative outcomes remained significantly better in the endourology group, with reduced hospital stay and blood loss (p<0.001 for both).

In the stone disease subgroup, stone clearance rates were comparable between the two groups (94.2% vs 96.1%; p=1.00, Fisher’s exact test), while perioperative recovery parameters continued to favor the endourology group.

Table 8: BPE Subgroup Outcomes

Table 9: Stone Disease Subgroup Outcomes

Patient Satisfaction Survey.

A structured survey with a 5-point Likert scale was performed at discharge to identify perceived recovery and satisfaction.

Table 10: Patient Satisfaction Survey Results

Patients who had endourological surgeries had a much greater level of satisfaction in all areas.

Table 11: Multivariate Logistic Regression Model of Postoperative Complications.

In a multivariate logistic regression analysis, endourological approach was found to be independently connected to decreased risk of postoperative complications (OR 0.23; p=0.005). The remaining variables, e.g. age, diabetes mellitus and hypertension were not reported as independent predictors.

This retrospective cohort study compared the results between endourological and open surgery in patients with benign prostatic enlargement and urinary stone disease. Endourological procedures are becoming more popular because they are minimally invasive and are related to better perioperative results. In the present study, patients who underwent endourological surgeries had reduced hospital stay and postoperative complications. These results can be explained by the decreased surgical trauma, minimized incision or natural orifice access, and faster postoperative recovery. Endourological techniques are especially appropriate in patients in which fast recovery and less morbidity are of concern. On the contrary, open surgery procedures continue to play a significant role in surgery, especially in situations where the disease or the anatomy is more extensive. In this research, the patients undergoing open operation experienced relatively longer hospitalization and increased postoperative complications. This may be partly associated with the invasive nature of open procedures but also with the choice of more complicated or advanced cases to be done in this manner. Thus, the differences between the two groups are to be viewed in the context of underlying clinical decision-making instead of procedural superiority, as such. The results of this research are consistent with the overall clinical knowledge that minimally invasive procedures are beneficial regarding recovery and perioperative results, and open surgery remains of paramount importance in a few specific situations. Surgical option is usually determined by various factors such as disease severity, the weight of the stones, the size of the prostate, comorbidities of the patient, and the expertise of the surgeon. Thus, both of these methods are still applicable, and their application is to be adjusted to the needs of each patient. A crucial factor that should be taken into account when interpreting these findings is that the study is retrospective. As the data was gained through the existing medical records, the decisions of the treatment were not made by the study but through the common clinical judgment. This presents the risk of selection bias, with patients who have open surgery possibly having a more severe disease at baseline. Also, it is not randomized, which restricts the possibility to control confounding factors that can affect the results. Regardless of these shortcomings, the research is a good source of information on clinical practice in the field. In contrast to controlled experimental studies, retrospective analyses capture real-life treatment patterns and outcomes in such a way that they are applicable to practice. The regularity of the trends observed justifies the use of endourological procedures as a desirable method in the appropriate patients, as well as the further relevance of open surgical methods in complicated situations. Future studies with larger sample sizes and more detailed stratification of patient characteristics may further clarify the comparative effectiveness of these approaches. Prospective studies may also help in better controlling confounding factors and providing more definitive conclusions. Limitations Lack of randomization may lead to selection bias and unadjusted residual confounding even after statistical adjustment. Nevertheless, its design is realistic in terms of clinical decision-making, which leads to increased external validity. There were a number of limitations in this study. It was conducted in the DHQ, Department of Urology, Dera Ismail Khan, a peripheral teaching hospital currently working with medium to limited resources Advanced endourological technologies (HoLEP and RIRS) were not available at the study center and thus they were not analyzed. Although this design improves internal validity, the findings may not be easily extrapolated to highly specialized tertiary centers which have complete laser and flexible endoscopic platforms. Furthermore, follow-up was restricted to early postoperative results and short-term functional evaluation and a longer follow-up would give a more insight into long-term stability of results and late complications. Future Implications Further research with more rigorous endourological procedures, longer follow-ups, and cost-effectiveness evaluations is necessary to further confirm these results and inform surgery practice in resource-poor areas.

Compared to open surgery, endourological surgery was linked with improved perioperative outcomes such as less postoperative pain, less blood loss, less hospitalization, and less complication, but was equally effective in the short term. The implications of these findings were that minimally invasive methods may be preferred in appropriately selected patients especially in resource constrained situations.

Funding

No funding was received for this study.

Conflict of Interest

The authors declare no conflict of interest.

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