To evaluate whether suprapubic cystostomy (SPC) improves operative efficiency and perioperative safety during monopolar transurethral enucleation of the prostate (M-TUEP) in patients with large benign prostatic hyperplasia (prostate volume ≥80 cc). We hypothesized that SPC-assisted M-TUEP would shorten operative time, increase resection efficiency, and reduce perioperative physiological disturbances without increasing complications.

This prospective randomized controlled trial included 160 patients with symptomatic benign prostatic hyperplasia and prostate volume ≥80 cc. Patients were randomized 1:1 to undergo monopolar transurethral enucleation of the prostate (M-TUEP) without suprapubic cystostomy (Group A, n=80) or with suprapubic cystostomy (Group B, n=80). Allocation was performed using a computer-generated randomization sequence with sealed opaque envelopes. All procedures were performed by experienced endourologists using a monopolar system with water irrigation. In the SPC group, suprapubic drainage was established at the start of surgery to allow continuous bladder decompression throughout the procedure. Primary outcomes were operative time and resection efficiency (resected tissue weight/operative time). Secondary outcomes included perioperative hemoglobin drop, serum sodium drop, catheterization time, hospital stay, complications, and functional outcomes assessed by International Prostate Symptom Score (IPSS) and maximum urinary flow rate (Qmax) at 1, 6, and 12 months.

Baseline characteristics were comparable between groups. SPC significantly reduced operative time compared with no SPC (85.6 vs 102.4 minutes, p<0.001) and improved resection efficiency (0.56 vs 0.39 g/min, p<0.001). Postoperative hemoglobin decline was lower in the SPC group (1.0 vs 1.3 g/dL, p=0.001), as was serum sodium decline (0.8 vs 3.1 mmol/L, p=0.001). Functional outcomes favored SPC throughout follow-up: Qmax was significantly higher at 1 month (20.2 vs 18.6 mL/s, p<0.001), 6 months (21.4 vs 19.5 mL/s, p=0.001), and 12 months (21.6 vs 19.6 mL/s, p=0.001). IPSS was significantly lower in the SPC group at 1 month (6.0 vs 7.1, p<0.001), 6 months (4.1 vs 5.9, p<0.001), and 12 months (4.2 vs 5.9, p<0.001). Overall complication rates were comparable. Early urinary incontinence at 1 month was less frequent with SPC (26.3% vs 45.0%, p=0.020). One case of TUR syndrome occurred in the non-SPC group, while no case occurred in the SPC group.

Suprapubic cystostomy appears to improve the operative environment during M-TUEP, likely by maintaining bladder decompression, reducing intravesical pressure, and limiting irrigation fluid absorption. This was associated with shorter operative time, greater resection efficiency, lower perioperative physiological disturbance, and better early and mid-term functional outcomes without increasing overall morbidity.

SPC-assisted M-TUEP significantly improves operative efficiency and perioperative safety in large benign prostatic hyperplasia without increasing complications. SPC may represent a useful adjunct during monopolar enucleation, particularly when prolonged surgery is anticipated.

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