A randomized trial comparing thulium laser resection to standard transurethral resection of the prostate for symptomatic benign prostatic hyperplasia: four-year follow-up results

Reoperation after surgical treatment for benign prostatic hyperplasia: a systematic review

Context

Surgical treatment is important for male lower urinary tract symptom (LUTS) management, but there are few reviews of the risks of reoperation.

Objective

To systematically evaluate the current evidence regarding the reoperation rates of surgical treatment for LUTS in accordance with current recommendations and guidelines.

Evidence acquisition

Eligible studies published up to July 2023, were searched for in the PubMed® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), and Web of Science™ (Clarivate™, Philadelphia, PA, USA) databases. STATA® (StataCorp LP, College Station, TX, USA) software was used to conduct the meta-analysis. Random-effects models were used to calculate the pooled incidences (PIs) of reoperation and the 95% confidence intervals (CIs).

Evidence synthesis

A total of 119 studies with 130,106 patients were included. The reoperation rate of transurethral resection of the prostate (TURP) at 1, 2, 3, and 5 years was 4.0%, 5.0%, 6.0%, and 7.7%, respectively. The reoperation rate of plasma kinetic loop resection of the prostate (PKRP) at 1, 2, 3, and 5 years was 3.5%, 3.6%, 5.7%, and 6.6%, respectively. The reoperation rate of holmium laser enucleation of the prostate (HoLEP) at 1, 2, 3, and 5 years was 2.4%, 3.3%, 5.4%, and 6.6%, respectively. The reoperation rate of photoselective vaporization of the prostate (PVP) at 1, 2, 3, and 5 years was 3.3%, 4.1%, 6.7%, and 7.1%, respectively. The reoperation rate of surgery with AquaBeam® at 1, 2, 3, and 5 years was 2.6%, 3.1%, 3.0%, and 4.1%, respectively. The reoperation rate of prostatic artery embolization (PAE) at 1, 2, 3, and 5 years was 12.2%, 20.0%, 26.4%, and 23.8%, respectively. The reoperation rate of transurethral microwave thermotherapy (TUMT) at 1, 2, 3, and 5 years was 9.9%, 19.9%, 23.3%, and 31.2%, respectively. The reoperation rate of transurethral incision of the prostate (TUIP) at 5 years was 13.4%. The reoperation rate of open prostatectomy (OP) at 1 and 5 years was 1.3% and 4.4%, respectively. The reoperation rate of thulium laser enucleation of the prostate (ThuLEP) at 1, 2, and 5 years was 3.7%, 7.7%, and 8.4%, respectively.

Conclusion

Our results summarized the reoperation rates of 10 surgical procedures over follow-up durations of 1, 2, 3, and 5 years, which could provide reference for urologists and LUTS patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023445780.

Outcomes of thulium prostatectomy with "Oyster technique" versus transurethral prostatectomy (TURP): a randomized control trial

PURPOSE

To compare the perioperative and postoperative outcomes between Oyster prostate vaporesection using Tm-YAG laser and the conventional transurethral prostatectomy using monopolar energy.

METHODS

Patients with LUTS with an accumulative size of at least 60 ml were randomly assigned to one of two parallel groups to undergo Tm-YAG laser vaporesection (Group 1) or conventional monopolar transurethral prostatectomy (Group 2). The primary endpoints were the reduction in IPSS and the increase in Qmax postoperatively. Secondary endpoints included the Hemoglobin drop, the complication rate, the changes in urodynamic parameters, the duration of hospitalization and catheterization and the changes in IIEF during the 24-month follow-up.

RESULTS

In total 32 and 30 patients were enrolled in Groups 1 and 2, respectively. Patient age (p = 0.422) and prostate volume were similar among the groups (p = 0.51). The outcomes in terms of IPSS decrease and Qmax amelioration were comparable (p = 0.449 and p = 0.237, respectively). Operative and hospitalization times were lower in Group 1 (p = 0.002 and p = 0.004, respectively). Hemoglobin drop, changes in urodynamic parameters and improvement in IIEF and QoL scores did not differ among the two Groups. The average time with the catheter was 2.06 ± 0.35 and 2.5 ± 0.82 (p = 0.003) days for Group 1 and Group 2, respectively. The overall complication rate was 6.2% for Group 1 and 13.3% for Group 2.

CONCLUSIONS

The Oyster technique leads to similar postoperative outcomes compared to the standard monopolar transurethral prostatectomy. The shorter catheterization, hospitalization and operation time should be considered advantages of the Oyster technique.

The effectiveness and safety of three surgical procedures for the treatment for benign prostatic hyperplasia: A network meta-analysis

Objective

To evaluate the effectiveness and safety of transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP) and thulium laser enucleation of the prostate (ThuLEP) in the treatment of benign prostatic hyperplasia using a network Meta-analysis.

Methods

Randomized controlled trials of TURP, HoLEP and ThuLEP for benign prostatic hyperplasia were collected by computerized searches of databases including CNKI, WANFANG, VIP, PubMed, The Cochrane Library, the Web of Science and Embase, with a search time frame of build to January 2022. The literature was screened and data was extracted by two investigators separately, while the risk of bias of the included studies was evaluated before systematic evaluation and network meta-analysis using ADDIS 1.16.8 software and RevMan 5.3 software.

Results

A total of 27 RCTs with a total of 3335 patients were involved. The results of the network meta-analysis showed that ThuLEP was better than the remaining two procedures in terms of enhancing patients' subjective perception and improving objective indicators, and the incidence of adverse events such as postoperative urethral stricture and urinary incontinence was lower compared with that of conventional TURP in both short- and long-term postoperative follow-ups.

Conclusion

As ThuLEP is effective, safe, and featured with few postoperative complications, it can be the preferred surgical procedure for prostate enlargement. Nevertheless, because of the limited number of studies included, more-sample, multicenter, double-blind clinical randomized controlled trials are required in the future to further verify the findings of the present study.

Long-term Reinterventions after Thulium Laser Enucleation of the Prostate: 12-Year Experience with more than 1000 Patients

BACKGROUND

Thulium laser enucleation of the prostate (ThuLEP) is an established treatment option for benign prostatic enlargement (BPE), but long-term outcomes have not yet been reported.

OBJECTIVE

To prove the durability of ThuLEP by investigating its long-term efficacy and morbidity.

DESIGN, SETTING, AND PARTICIPANTS

All patients who underwent ThuLEP at a German tertiary referral center between 2009 and 2021 were retrospectively followed up for reinterventions for persistence or regrowth of prostate adenoma (ReIP) or long-term complications (ReIC).

INTERVENTION

ThuLEP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We calculated the cumulative incidence for ReIP and ReIC at 10 yr. Univariate and multivariate Cox regression models were constructed to identify predictors of ReIP and ReIC.

RESULTS AND LIMITATIONS

Overall, 1097 patients underwent ThuLEP. The median overall follow-up was 6.0 yr (interquartile range [IQR] 2.4-9.2). For one-third of patients (n = 369), median follow-up of 10 yr (IQR 9.1-11.2) was available. A total of 42 patients (3.8%) underwent ReIP after a median of 2 yr (IQR 0.3-4.9). The rate of long-term ReIC was 2.6% (n = 29) and the median time to ReIC was 0.5 yr (IQR 0.3-1.7). The most frequent ReIC was urethrotomy (n = 16, 1.5%). The cumulative incidence of ReIP and ReIC at 10 yr was estimated at 5.6% and 3.4%, respectively. Enucleation weight ≥60 g was a significant predictor of ReIP (hazard ratio 1.2, p = 0.014). The retrospective study design and the lack of functional outcomes are the main limitations.

CONCLUSIONS

ThuLEP is a durably effective and safe procedure with low reintervention rates within 12 yr.

PATIENT SUMMARY

This study investigated long-term outcomes of thulium laser enucleation of the prostate for benign enlargement of the prostate (BPE). Low rates of repeat treatment for BPE recurrence or for other complications were observed. Our results show the safety and efficacy of this treatment over a period of 12 years.

Assessment of Sexual Outcomes in Patients Undergoing Thulium Laser Prostate Surgery for Management of Benign Prostate Hyperplasia: A Systematic Review and Meta-analysis

Background

Thulium laser (Tm:YAG) prostate surgery is a safe and effective procedure with low morbidity and comparable clinical outcomes to those of transurethral resection of the prostate (TURP). However, the sexual function outcomes (erectile and ejaculatory function) have been scarcely studied.

Aim

We aimed to assess the impact of Tm:YAG prostate surgery on sexual outcomes (erectile and ejaculatory function) and compare them with those patients undergoing TURP.

Material and Methods

We searched digital databases like PUBMED, SCOPUS, CENTRAL and EMBASE using relevant keywords to identify comparative studies on TURP and non-comparative studies on Tm:YAG prostate surgery that assessed sexual outcomes. We performed qualitative and quantitative analyses with the extracted data. We carried out a meta-analysis to compare postoperative International Index of Erectile Function (IIEF-5) scores and incidences of retrograde ejaculation (RE) in patients undergoing either Tm:YAG or TURP. The pre-operative and post-operative IIEF-5 scores were pooled to estimate overall scores.

Results

We included 5 comparative and 8 non-comparative studies in this review. We found the postoperative IIEF-5 score improvements to be significantly higher in the Tm:YAG prostate surgery group than in the TURP group with a significant mean difference (MD) of 0.45 (95% CI, 0.18 to 0.72; P = .001). We found no significant associations between the procedures. The pooled OR for the association of RE was estimated at 0.90 (95% CI, 0.50 to 1.60; P = .71; I² = 0%).

Conclusion

Tm:YAG prostate surgery improves erectile function more than TURP, according to our findings. Tm:YAG prostate aided surgery also outperforms TURP in terms of preserving sexual function following surgery.However, We found similar or no difference in incidence of RE between Tm:YAG prostate surgery and TURP.

Bibo L, Hao L, Pang K, et al. Assessment of Sexual Outcomes in Patients Undergoing Thulium Laser Prostate Surgery for Management of Benign Prostate Hyperplasia: A Systematic Review and Meta-analysis. Sex Med 2022;10:100483.

ROS-NLRP3 signaling pathway induces sterile inflammation after thulium laser resection of the prostate

The sterile inflammation (SI) of the urinary tract is a common problem requiring serious consideration after prostatectomy. This study mainly focuses on the role of the reactive oxygen species-NLR family, pyrin domain-containing 3 (ROS-NLRP3) signaling pathway in SI after thulium laser resection of the prostate (TmLRP). Urinary cytokines were determined in patients who received TmLRP, and heat shock protein 70 (HSP70) was detected in the resected tissues. The involvement of ROS signaling in HSP70-induced inflammation was explored in THP-1 cells with or without N-acetyl- l-cysteine (NAC) pretreatment. The function of NLRP3 and Caspase-1 was determined by Western blot analysis, enzyme-linked immunosorbent assay (ELISA), and polymerase chain reaction. These phenomena and mechanisms were verified by the beagle models that received TmLRP. Clinical urine samples after TmLRP showed high expression of inflammatory factors and peaked 3-5 days after surgery. The high expression of HSP70 in the resected tissues was observed. After HSP70 stimulation, the expression of ROS, NLRP3, Caspase-1, and interleukin-18 (IL-18) increased significantly and could be reduced by ROS inhibitor NAC. The expression of IL-1β and IL-18 could be inhibited by NLRP3 or Caspase-1 inhibitors. In beagle models that received TmLRP, HSP70, NLRP3, Caspase-1, IL-1β, and IL-18 were highly expressed in the wound tissue or urine, and could also be reduced by NAC pretreatment. Activation of the ROS-NLRP3 signaling pathway induces SI in the wound after prostatectomy. Inhibition of this pathway may be effective for clinical prevention and treatment of SI and related complications after prostatectomy.

Holmium laser enucleation and water vapor thermal therapy for the treatment of symptomatic benign prostatic hyperplasia: A cost analysis

PURPOSE

To perform a cost analysis of the current gold standard operation of Holmium Laser Enucleation of the prostate (HoLEP) compared to the new technique of water vapor thermal therapy with the Rezum™ system for the treatment of symptomatic benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Between October 2017 and January 2020, consecutive patients with invalidating lower urinary tract symptoms due to BPH who underwent Rezūm™ and HoLEP procedures from the Aix regional hospital were identified. The outcome of each technique was assessed in terms of cost from the institutional perspective. Detailed expense reports based were provided by the accounts department of the hospital. These were used to compare in-hospital costs for each procedure.

RESULTS

A total of 53 and 94 consecutive patients underwent respectively water vapor thermal therapy and HoLEP. The median costs for the surgical procedure were €1344 (IQR 1331-1361) and €669 (IQR 584-824), respectively for Rezūm™ and HoLEP (median difference €675; P<0.001). The median costs of the hospital stay were €869 (IQR 869-869) for Rezūm™ and €1295 (IQR 1295-1330) for HoLEP (median difference €426; P<0.001). Finally, the median total costs per patient were lower for HoLEP (€2005 [IQR 1902-2150]) than for Rezūm™ (€2228 [IQR 2209-2243]) procedure, and the median difference of €233 was significant (P<0.001).

CONCLUSIONS

One of the anticipated benefits of Rezūm™, reduced length of hospital stay with an associated reduction in cost, did not materialize within this study. The patient's clinical condition and expectations should also be taken into account when deciding between Rezum™ and standard therapies.

LEVEL OF PROOF

3.

Nomenclature in thulium laser treatment of benign prostatic hyperplasia: it's time to pull the rabbit out of the hat

We performed a narrative review with the focus on laser settings and surgical procedure with thulium laser. Our primary goal was to define the most valid settings of each surgical procedure to overcome the inconsistency about nomenclature of thulium surgery and to ensure comparability of future publications. A literature search of articles on thulium laser treatment of benign prostatic hyperplasia (BPH) was conducted between 2009 and 2019. We proposed a new classification standard for laser settings and associated surgical procedure. Each article was analyzed and categorized as concordant or discordant referring to the new classification. In total, 74 papers were included in this narrative review. Overall, 43% and 42% of included studies reported discordant laser parameters and surgical description, respectively. Most of the studies on vaporization were categorized as discordant because they reported a medium/low laser setting instead of high power. Conversely, 93.3% of studies on enucleation were deemed as discordant for laser setting because they reported high power parameters instead of medium-low power setting. Most of the studies on laser enucleation and vapo/enucleation were considered discordant for surgical procedure since authors did not mention the use of mechanical vs. laser method for enucleation. The current literature lacks a uniform definition and standardization of the terminology of thulium laser settings and surgical techniques to guarantee comparability between different approaches. We found a huge heterogeneity in 10 years of surgery with thulium laser. We proposed a new classification of laser setting and procedural description for categorization of thulium laser surgery for BPH.

Thulium laser transurethral vaporesection versus transurethral resection of the prostate for benign prostatic obstruction: the UNBLOCS RCT

BACKGROUND

Transurethral resection of the prostate (TURP) is the standard operation for benign prostatic obstruction (BPO). Thulium laser transurethral vaporesection of the prostate (ThuVARP) vaporises and resects the prostate using a technique similar to TURP. The small amount of existing literature suggests that there may be potential advantages of ThuVARP over TURP.

OBJECTIVE

To determine whether or not the outcomes from ThuVARP are equivalent to the outcomes from TURP in men with BPO treated in the NHS.

DESIGN

A multicentre, pragmatic, randomised controlled parallel-group trial, with an embedded qualitative study and economic evaluation.

SETTING

Seven UK centres - four university teaching hospitals and three district general hospitals.

PARTICIPANTS

Men aged ≥ 18 years who were suitable to undergo TURP, presenting with bothersome lower urinary tract symptoms (LUTS) or urinary retention secondary to BPO.

INTERVENTIONS

Patients were randomised 1 : 1 to receive TURP or ThuVARP and remained blinded.

MAIN OUTCOME MEASURES

Two co-primary outcomes - patient-reported International Prostate Symptom Score (IPSS) and clinical measure of maximum urine flow rate (Qmax) at 12 months post surgery.

RESULTS

In total, 410 men were randomised, 205 to each arm. The two procedures were equivalent in terms of IPSS [adjusted mean difference 0.28 points higher for ThuVARP (favouring TURP), 95% confidence interval (CI) -0.92 to 1.49 points]. The two procedures were not equivalent in terms of Qmax (adjusted mean difference 3.12 ml/second in favour of TURP, 95% CI 0.45 to 5.79 ml/second), with TURP deemed superior. Surgical outcomes, such as complications and blood transfusion rates, and hospital stay were similar for both procedures. Patient-reported urinary and sexual symptoms were also similar between the arms. Qualitative interviews indicated similar patient experiences with both procedures. However, 25% of participants in the ThuVARP arm did not undergo their randomised allocation, compared with 2% of participants in the TURP arm. Prostate cancer was also detected less frequently from routine histology after ThuVARP (65% lower odds of detection) in an exploratory analysis. The adjusted mean differences between the arms were similar for secondary care NHS costs (£9 higher for ThuVARP, 95% CI -£359 to £376) and quality-adjusted life-years (0.01 favouring TURP, 95% CI -0.04 to 0.01).

LIMITATIONS

Complications were recorded in prespecified categories; those not prespecified were excluded owing to variable reporting. Preoperative Qmax and IPSS data could not be collected for participants with indwelling catheters, making adjustment for baseline status difficult.

CONCLUSIONS

TURP was superior to ThuVARP in terms of Qmax, although both operations resulted in a Qmax considered clinically successful. ThuVARP also potentially resulted in lower detection rates of prostate cancer as a result of the smaller volume of tissue available for histology. Length of hospital stay after ThuVARP, anticipated to be a key benefit, was equal to that after TURP in this trial. Overall, both ThuVARP and TURP were effective procedures for BPO, with minor benefits in favour of TURP. Therefore, the results suggest that it may be appropriate that new treatment alternatives continue to be compared with TURP.

FUTURE WORK

Longer-term follow-up to assess reoperation rates over time, and research into the comparative effectiveness of ThuVARP and TURP in large prostates.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN00788389.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 41. See the NIHR Journals Library website for further project information.

The New American Urological Association Benign Prostatic Hyperplasia Clinical Guidelines: 2019 Update

PURPOSE OF REVIEW

The goal of this paper was to analyze the efficacy of the current modalities available to surgically treat lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH).

RECENT FINDINGS

There have been significant surgical advancements for the treatment of BPH, including an increasing development and utilization of minimally invasive surgical techniques (MISTs). These procedures have varying outcomes that are critical to understand. In addition, MISTs have important adverse effects, though have minimized effects on sexual function when compared to more invasive surgical techniques. It is important for all urologists to be familiar with the surgical techniques available to treat BPH and the updated American Urological Association (AUA) Guidelines. Further studies evaluating efficacy, safety, and sexual functioning will help guide care in the future and evolve practice.

Transurethral anatomical enucleation of the prostate with Tm:YAG support (ThuLEP): Evolution and variations of the technique. The inventors' perspective

After its introduction, transurethral anatomical enucleation of the prostate with Tm:YAG support (ThuLEP) has evolved as one of the standard techniques of transurethral anatomical endoscopic enucleations of the prostate. Growing evidence has proven ThuLEP as an alternative for the treatment of bladder outlet obstruction caused by benign prostatic enlargement and has been acknowledged by the EAU Guidelines on Management of Non-Neurogenic Male Lower Urinary Tract Symptoms, incl. Benign Prostatic Obstruction. The uniqueness of ThuLEP as a concept made it a blueprint for other laser and nonlaser enucleating techniques based on the emphasis on two principles: widely blunt anatomical dissection and demystification of energy sources as being secondary for transurethral enucleation. The original technique has been technically refined by the inventor and other working groups in the field. The evolutionary modifications followed the academic discourse on anatomical enucleation for measures to prevent early postoperative stress urinary incontinence and preservation of antegrade ejaculation. Variations of the original three-lobe dissection technique were introduced with two-lobe approach or en bloc dissection. The manuscript is accompanied by an instructional video and surgical atlas on the currently most commonly applied two-lobe technique.

Outcome of simultaneous thulium laser enucleation of bladder tumor and prostate in patients with non-muscle invasive bladder tumor and benign prostatic hyperplasia: a matched-pair comparison with a long-term follow-up

OBJECTIVE

To access the surgical and oncological outcomes of simultaneous thulium laser enucleation of bladder tumor (ThuLEBT) and thulium laser enucleation of prostate (ThuLEP) in patients with non-muscle invasive bladder tumor (NMIBC) and benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Between June 2009 and June 2017, 118 men with NMIBC who underwent simultaneous ThuLEBT and ThuLEP and fulfilled the inclusion criteria were matched with 118 patients who received ThuLEBT alone. Clinicopathological parameters, surgical outcome data and oncological outcomes were retrospectively analyzed and compared.

RESULTS

The patients who underwent simultaneous ThuLEBT and ThuLEP experienced a longer length of operation time (70.4 vs. 25.5 min; p < 0.001), but there were no statistically significant differences in catheterization period, hospital stay and complication between the two groups. At a mean follow-up of 58.7 and 55.8 months in ThuLEBT/ThuLEP group and ThuLEBT group, no significant differences in overall recurrence rates, progression rates, recurrence in the bladder neck/prostatic fossa and mean elapsed time to recurrence were detected. The 5-year recurrence-free probability was 73.2% for ThuLEBT/ThuLEP and 69.2% for ThuLEBT (p = 0.361).

CONCLUSIONS

Our results indicate that simultaneous ThuLEBT and ThuLEP can be safely performed without increasing the surgical risk and the risk of tumor recurrence and progression in patients with NMIBC and BPH, and it may be preferred alternative for select patients.

Development of Research Agenda in Prostate Artery Embolization: Summary of Society of Interventional Radiology Consensus Panel

PURPOSE

To summarize the Society of Interventional Radiology Foundation's Research Consensus Panel development of a research agenda on prostate artery embolization (PAE).

MATERIALS AND METHODS

PAE for the treatment of lower urinary tract symptoms has been shown to be safe and effective in decreasing symptoms and prostate size. Lack of randomized controlled trials (RCTs) on PAE in the United States has prevented inclusion in American Urologic Association guideline recommendations for treatment of lower urinary tract symptoms resulting from benign prostatic hyperplasia. Recognizing the need for well-designed trials, the SIR Foundation funded a Research Consensus Panel to prioritize a research agenda. The panel included interventional radiologists, urologists, SIR Foundation leadership, and industry representatives. The goal of the meeting was to discuss weaknesses with current data and study design for development of US trials to report long-term outcomes data.

RESULTS

Final consensus on a research design could not be made because the group was split on 3 research designs: (i) RCT of PAE versus sham with crossover of the sham group. (ii) RCT of PAE versus simple prostatectomy. (iii) RCT of PAE versus holmium laser enucleation of the prostate/thulium laser enucleation of the prostate. The panel recommended a nonindustry-funded registry to obtain real-world data.

CONCLUSIONS

Level 1 data are required to be included in the American Urologic Association guidelines for treatment of benign prostatic hyperplasia. Because of concerns with all 3 study designs, the panel did not reach a consensus. Further meetings are planned with the panel to select among these research designs.

A review of surgery and new technology procedures for the management of benign prostatic obstruction

Level of evidence: Not applicable for this review article.

Porous Se@SiO2 nanosphere-coated catheter accelerates prostatic urethra wound healing by modulating macrophage polarization through reactive oxygen species-NF-κB pathway inhibition

Benign prostatic hyperplasia (BPH) patients experience complications after surgery. We studied oxidative stress scavenging by porous Se@SiO₂ nanospheres in prostatic urethra wound healing after transurethral resection of the prostate (TURP). Beagle dogs were randomly distributed into two groups after establishing TURP models. Wound recovery and oxidative stress levels were evaluated. Re-epithelialization and the macrophage distribution at the wound site were assessed by histology. The mechanism by which porous Se@SiO₂ nanospheres regulated macrophage polarization was investigated by qRT-PCR, western blotting, flow cytometry, immunofluorescence and dual luciferase reporter gene assays. Our results demonstrated that Porous Se@SiO₂ nanosphere-coated catheters advance re-epithelization of the prostatic urethra, accelerating wound healing in beagle dogs after TURP, and improve the antioxidant capacity to inhibit oxidative stress and induced an M2 phenotype transition of macrophages at the wound. By restraining the function of reactive oxygen species (ROS), porous Se@SiO₂ nanospheres downregulated Ikk, IκB and p65 phosphorylation to block the downstream NF-κB pathway in macrophages in vitro. Since activation of NF-κB signaling cascades drives macrophage polarization, porous Se@SiO₂ nanospheres promoted macrophage phenotype conversion from M1 to M2. Our findings suggest that porous Se@SiO₂ nanosphere-coated catheters promote postoperative wound recovery in the prostatic urethra by promoting macrophage polarization toward the M2 phenotype through suppression of the ROS-NF-κB pathway, attenuating the inflammatory response. STATEMENT OF SIGNIFICANCE: The inability to effectively control post-operative inflammatory responses after surgical treatment of benign prostatic hyperplasia (BPH) remains a challenge to researchers and surgeons, as it can lead to indirect cell death and ultimately delay wound healing. Macrophages at the wound site work as pivotal regulators of local inflammatory response. Here, we designed and produced a new type of catheter with a coating of porous Se@SiO₂ nanosphere and demonstrated its role in promoting prostatic urethra wound repair by shifting macrophage polarization toward the anti-inflammatory M2 phenotype via suppressing ROS-NF-κB pathway. These results indicate that the use of porous Se@SiO₂ nanosphere-coated catheter may provide a therapeutic strategy for postoperative complications during prostatic urethra wound healing to improve patient quality of life.

1470 nm Diode Laser Enucleation vs Plasmakinetic Resection of the Prostate for Benign Prostatic Hyperplasia: A Randomized Study

Objective: The purpose of the current work was to comparatively assess 1470 nm diode laser enucleation of the prostate (DiLEP) and plasmakinetic resection of the prostate (PKRP) for treating benign prostatic hyperplasia (BPH).

Patients and Methods: From January 2016 to March 2017, 157 individuals with bladder outflow obstruction caused by BPH were randomized to DiLEP and PKRP groups, for prospective analysis. Of these, 152 cases were evaluated before operation and at 3, 6, and 12 months postsurgery. Patient baseline properties, presurgery data, and postsurgical outcomes were comparatively assessed, as well as complications.

Results: There were no significant preoperative differences between surgical groups. DiLEP-treated cases showed remarkable reduced operative time, postsurgical bladder irrigation time, catheterization duration, and hospital stay compared with the PKRP group (P < 0.001). Hemoglobin amount decrease was markedly less pronounced after DiLEP (P = 0.004). However, no patients needed blood transfusion in either group. The decrease in sodium level showed no marked differences between the DiLEP and PKRP groups (P = 0.380). In addition, complications were comparable and no significant differences in both groups. At 3, 6, and 12 months, International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and postvoid residual (PVR) were similar in both groups (P > 0.05).

Conclusions: DiLEP and PKRP are similar in efficacy and safety for relieving obstruction and low urinary tract symptoms. Compared with PKRP, DiLEP has decreased risk of hemorrhage, operative time, bladder irrigation time, catheterization duration, and hospital stay. However, IPSS, QoL, Qmax, and PVR were similar for both procedures within 12 postoperative months.

Comparison of vaporization using 120-W GreenLight laser versus 2-micrometer continuous laser for treating benign prostatic hyperplasia: A 24-month follow-up study of a single center

OBJECTIVE

To evaluate safety, efficacy, and long-term outcomes of photoselective vaporization of prostate using 120-W HPS GreenLight KTP laser and compare the results with those obtained with 2-micrometer continuous-wave (2 um CW) laser for treatment of patients with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

One group of 216 patients diagnosed with BPH underwent 120-W KTP laser vaporization of the prostate, while another group of 198 BPH patients underwent 2 um CW laser vaporization. The relevant pre-, peri-, and post-operative parameters were compared between the two therapy groups. Functional results in terms of improvement of International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and post-void residual (PVR) urine were assessed at 3, 6, 12, and 24 months.

RESULTS

BPH was successfully treated with 120-W HPS KTP laser and 2 um CW laser in all patients. There were no significant difference between two patient groups in the baseline characteristics (such as PSA, IPSS, QoL, and Qmax). No major complications occurred intraoperatively (capsule perforation and TUR syndrome) or postoperatively (electric unbalance), and no blood transfusions were required in both groups. Average catheterization time was 1.9±1.3 days for the 120-W PVP and 2.2±1.9 days for the 2 um CW laser treatment. In addition, the hospitalization times were 3.8±1.2days (120-W PVP) and 4.8±1.5 days (2 um CW laser), respectively. The incidence of dysuria and urge incontinence was higher in the 2 um CW laser group (35/198, 24/198) than in the 120 W PVP group (15/216, 10/216). Dramatic improvement was observed in Qmax, IPSS, Qol, and PVR as compared with the respective pre-operative values. The degree of improvement during the follow-up period was comparable in both groups. No significant differences were observed in terms of re-operation rates, bladder neck stricture, and urethral stricture.

CONCLUSIONS

Both 120-W HPS laser and 2 um CW laser vaporization present effective treatment options in patients with BPH, but 120-W PVP provides safer therapy with less post-operative complications within the 2-year follow-up period.

Transurethral procedures in the treatment of benign prostatic hyperplasia: A systematic review and meta-analysis of effectiveness and complications

BACKGROUND

With the progress of surgical techniques and instruments, various minimally invasive surgical therapies were developed to treat benign prostatic hyperplasisa (BPH). However, the efficacy and safety of different transurethral procedures for the treatment of BPH are still undefined.

METHOD

A systematic search was performed for all randomized controlled trials (RCTs), which compared the transurethral procedures for BPH from 1995 to 2016. The clinical baseline characteristics, International Prostate Symptom Score (IPSS), quality of life (QoL), postvoid residual (PVR), maximum flow rate (Qmax), short-term and long-term complications were analyzed using RevMan and ADDIS software.

RESULT

Eighty-eight randomly controlled trials and fifteen procedures were included in the network meta-analysis. HoLEP greatly inproved PVR. TmLRP had the best efficacy in improving QoL score. Diode laser vaporization of prostate was superior in improving IPSS and Qmax. Diode laser through vaporization required the shortest time in catheterization, while Nd:YAG was the longest procedure. For the hospitalization time, TUR was the longest and HoLEP was the shortest. TmLRP was related to the lowest postoperative hemoglobin decrease. TmLEP had the least rates of occurrence of hematuria, reoperation and erectile dysfunction. HoLEP was the best choice to reduce the incidence of recatheterization, urinary retention, urinary tract infection, stress urinary incontinence and retrograde ejaculation. The complications such as blood transfusion, urethral stricture, bladder neck contracture were relatively rare in the patients who underwent diode laser vaporization of prostate.

CONCLUSION

Compared with other transurethral procedures, thulium, holmium and diode lasers were associated with better efficacy and fewer complications.

Transurethral thulium laser enucleation versus resection of the prostate for treating benign prostatic hyperplasia: a retrospective study

This study aimed to compare the clinical outcomes between transurethral thulium laser enucleation of the prostate (ThuLEP) and transurethral thulium laser resection of the prostate (ThuLRP) for treating benign prostatic hyperplasia (BPH). From May 2014 to August 2015, 212 patients underwent ThuLRP and 188 patients underwent ThuLEP. The ThuLEP group was further divided into two subgroups according to the ways the prostate was taken out. The perioperative parameters were recorded and analyzed. The international prostate symptom score (IPSS), quality-of-life (QoL) score, maximum flow rate (Qmax), and postvoid residual urine volume (PVR) in both groups were estimated and compared 3, 6, and 12 months after surgery. No significant difference was observed between the groups in terms of irrigated time, irrigated volume, catheterization time, and hospital stay. However, the significantly lower hemoglobin drop was observed in the ThuLRP group compared with the ThuLEP group. The ThuLEP group with a morcellator required a shorter operation time for patients with large prostate volume (> 60 mL) compared with the ThuLRP and ThuLEP groups without a morcellator. During 12 months of follow-up, IPSS, Qmax, QoL, and PVR improved significantly without significant differences between the groups. No severe complications were reported; however, the occurrence of transient urge incontinence was higher after ThuLEP compared with ThuLRP, and the proportion of urinary tract infection after surgery was higher in ThuLRP than in ThuLEP. ThuLRP and ThuLEP are safe and efficient for treating patients with symptomatic BPH. ThuLRP offers advantages in terms of minimal blood loss.

Safety and feasibility of thullium laser transurethral resection of prostate for the treatment of benign prostatic enlargement in overweight patients

Objective

We aimed to determine safety and feasibility of thulium laser transurethral vapoenucleation of prostate (ThuVEP) for treatment of obese patients affected by benign prostatic hyperplasia (BPH).

Methods

We retrospectively analysed data of 452 patients with BPH who underwent ThuVEP from February 2012 to March 2016 in a single center. Patients were divided into three groups according to body mass index (BMI, kg/m²): Normal weight (18.5 ≤ BMI < 25; Group A), overweight (25 ≤ BMI < 30; Group B) and obese (BMI ≥ 30; Group C), for a total of 412 patients evaluable for this study. Preoperative total serum prostate-specific antigen (PSA), digital rectal examination of the prostate, transrectal ultrasound (TRUS), renal ultrasound, urine culture, uroflowmetry, International Prostate Symptoms Score (IPSS), and Quality of Life (QoL) score were analyzed. Post-operative complications, hospital stay and days of catheterization, questionnaires and uroflowmetry at 1 and 3 months after surgery were evaluated. Preoperative data, surgical outcomes, complication rate and clinical outcomes were compared between groups.

Results

The median age of patients was 69 years (Interquartile Range [IQR 10]). The preoperative median IPSS among groups was 19 (IQR 8.75), 20 (IQR 10), and 18 (IQR 10) respectively. At 1 and 3 months of follow-up, this value was 8 (IQR 7), 8 (IQR 4), 7 (IQR 5) and 5 (IQR 6.25), 5 (IQR 6), 6 (IQR 5), respectively (all p between groups > 0.05). There was no statistically significant difference among three groups as for hospital stay and days of catheterization (p > 0.05).

Conclusion

Our results showed that ThuVEP was safe and feasible even in overweight patients with substantially enlarged prostate.

Absorption of Irrigation Fluid During Thulium Laser Vaporization of the Prostate

PURPOSE

To assess the prevalence and extent of irrigation fluid absorption during thulium laser vaporization of the prostate.

MATERIAL AND METHODS

Fifty-four patients undergoing thulium laser vaporization of the prostate were prospectively included into the trial at a tertiary referral center. Isotonic saline containing 1% ethanol was used for intraoperative irrigation. Absorption of irrigation fluid was measured periodically during the operation using the expired breath ethanol technique. Among others, intra- and postoperative changes in biochemical and hematological laboratory findings were assessed.

RESULTS

Absorption of irrigation fluid was detected in 7 out of 54 (13%) patients with a median absorption volume of 265 mL (227-615). No significant differences of intra- and postoperative blood parameters were observed between absorbers and nonabsorbers. No risk factor (i.e., age, prostate size, surgery duration, applied energy, and amount of irrigation fluid) for the occurrence of fluid absorption could be identified.

CONCLUSION

Absorption of irrigation fluid also occurs during thulium laser vaporization of the prostate and should be kept in mind, especially in patients at a high cardiovascular risk. However, compared with previously assessed resection and vaporization techniques, thulium vaporization might have a favorable safety profile regarding fluid absorption.

Two-micrometer thulium laser resection of the prostate-tangerine technique in benign prostatic hyperplasia patients with previously negative transrectal prostate biopsy

The 2-μm thulium laser resection of the prostate-tangerine technique (TmLRP-TT) has been introduced as a minimally invasive treatment for benign prostatic hyperplasia (BPH). This study was undertaken to assess the clinical efficacy and safety of TmLRP-TT for the treatment of BPH patients with previously negative transrectal prostate biopsy. A prospective analysis of 51 patients with previously negative transrectal prostate biopsy who underwent surgical treatment using TmLRP-TT was performed from December 2011 to December 2013. Preoperative status, surgical details, and perioperative complications were recorded. The follow-up outcome was evaluated with subjective and objective tests at 1 and 6 months. TmLRP-TT was successfully completed in all patients. Mean prostate volume, operative duration, and catheterization time were 93.3 ± 37.9 ml, 69.5 ± 39.5 min, and 6.5 ± 1.3 days, respectively. The mean International Prostate Symptom Score, quality of life score, maximum urinary flow rate, and post-void residual urine volume changed notably at 6-month follow-up (22.5 ± 6.9 vs 6.1 ± 3.2, 4.8 ± 1.3 vs 1.1 ± 0.9, 7.3 ± 4.5 vs 18.9 ± 7.1 ml s⁻¹, and 148.7 ± 168.7 vs 28.4 ± 17.9 ml). Two (3.9%) patients required blood transfusion perioperatively, while 3 (5.9%) patients experienced transient hematuria postoperatively, and 2 (3.9%) patients received 3 days recatheterization due to clot retention. TmLRP-TT is a safe and effective minimally invasive technique for patients with previously negative transrectal prostate biopsy during the 6-month follow-up. This promising technology may be a feasible surgical method for previously negative transrectal prostate biopsy in the future.

The efficacy and safety of 2-μm continuous laser in the treatment of high-risk patients with benign prostatic hyperplasia

Two-micrometer laser resection of prostate-tangerine technique dissects whole prostatic lobes off the surgical capsular, similar to peeling a tangerine. The present study aimed to evaluate the safety and efficacy of 2-μm continuous laser vaporization in the treatment of high-risk patients with benign prostatic hyperplasia (BPH) during the 24-month follow-up. The study included 248 patients with moderate to severe lower urinary tract symptoms who underwent 2-μm continuous laser vaporization of the prostate. All patients were accompanied with different degree comorbidities and 94 patients were taking oral anticoagulants. BPH was successfully treated with 2-μm continuous laser vaporization in all patients. Mean pre-operative prostate volume was 76 ± 25.3 ml and mean operative time was 49.8 ± 16.5 min. There were no major complications intra-operatively or postoperatively, and no blood transfusions were needed. About 20 patients (8.1%) needed bladder irrigation postoperatively. Average catheterization time was 2.0 ± 1.8 days (range 1-5 days). Four patients required reoperation due to enlarged prostates from residual adenoma. At 3-, 6-, 12-, and 24-month follow-ups, maximum urinary flow rates (Qmax) increased from 6.9 ± 1.7 to 19.1 ± 4.2, 19.5 ± 4.6, 19.4 ± 4.6, and 19.5 ± 4.1 ml/s, respectively. Mean International Prostate Symptom Scores (IPSS) decreased from 27.6 ± 5.1 (pre-operation) to 9.2 ± 2.6, 7.12 ± 1.42, 6.18 ± 1.32, and 6.25 ± 1.30 at 3-, 6-, 12-, and 24-month post-operation, respectively. Two-micrometer continuous laser vaporization is a safe and effective surgical endoscopic technique associated with low complication rate in BPH patients at high risk and those on anticoagulation therapy who have severe LUTS caused by BPH.

Tissue damage by laser radiation: an in vitro comparison between Tm:YAG and Ho:YAG laser on a porcine kidney model

The understanding of tissue damage by laser radiation is very important for the safety in the application of surgical lasers. The objective of this study is to evaluate cutting, vaporization and coagulation properties of the 2 µm Tm:YAG laser (LISA Laser Products OHG, GER) in comparison to the 2.1 µm Ho:YAG laser (Coherent Medical Group, USA) at different laser power settings in an in vitro model of freshly harvested porcine kidneys. Laser radiation of both laser generators was delivered by using a laser fiber with an optical core diameter of 550 µm (RigiFib, LISA Laser GER). Freshly harvested porcine kidneys were used as tissue model. Experiments were either performed in ambient air or in aqueous saline. The Tm:YAG laser was adjusted to 5 W for low and 120 W for the high power setting. The Ho:YAG laser was adjusted to 0.5 J and 10 Hz (5 W average power) for low power setting and to 2.0 J and 40 Hz (80 W average power) for high power setting, accordingly. The specimens of the cutting experiments were fixed in 4 % formalin, embedded in paraffin and stained with Toluidin blue. The laser damage zone was measured under microscope as the main evaluation criteria. Laser damage zone consists of an outer coagulation zone plus a further necrotic zone. In the ambient air experiments the laser damage zone for the low power setting was 745 ± 119 µm for the Tm:YAG and 614 ± 187 µm for the Ho:YAG laser. On the high power setting, the damage zone was 760 ± 167 µm for Tm:YAG and 715 ± 142 µm for Ho:YAG. The incision depth in ambient air on the low power setting was 346 ± 199 µm for Tm:YAG, 118 ± 119 µm for Ho:YAG. On the high power setting incision depth was 5083 ± 144 µm (Tm:YAG) and 1126 ± 383 µm (Ho:YAG) respectively. In the saline solution experiments, the laser damage zone was 550 ± 137 µm (Tm:YAG) versus 447 ± 65 µm (Ho:YAG), on the low power setting and 653 ± 137 µm (Tm:YAG) versus 677 ± 134 µm (Ho:YAG) on the high power setting. Incision depth was 1214 ± 888 µm for Ho:YAG whereas Tm:YAG did not cut tissue at 5 W in saline solution. On the high power setting, the incision depth was 4050 ± 1058 µm for Tm:YAG and 4083 ± 520 µm for Ho:YAG. Both lasers create similar laser damage zones of <1 mm in ambient air and in saline solution. These in vitro experiments correspond well with in vivo experiments. Thereby, Tm:YAG offers a cutting performance, coagulation and safety profile similar to the standard Ho:YAG lasers in urological surgery.

Evidence of the efficacy and safety of the thulium laser in the treatment of men with benign prostatic obstruction

In 2005, the high power thulium laser was introduced for the surgical treatment of benign prostatic obstruction. It has several properties that confer theoretical advantages over other lasers used for the same indication, such as technical versatility and a relatively small zone of thermal damage. Studies using the 70-150 W thulium laser systems demonstrate good efficacy of these procedures with low morbidity and few complications even in higher risk patients. Different techniques have been employed to treat the prostate with this technology, including enucleation, vapoenucleation, vaporization and resection. Comparative studies have been published comparing thulium laser prostatectomy to monopolar transurethral resection of prostate (TURP), bipolar TURP and holmium laser enucleation of prostate (HoLEP). In this review we discuss the current literature on the safety and efficacy of various thulium techniques for the treatment of benign prostatic hyperplasia and examine comparative studies.

Comparison between thulium laser resection of prostate and transurethral plasmakinetic resection of prostate or transurethral resection of prostate

Benign prostatic hyperplasia (BPH) is one of the most common diseases in middle-aged and elderly men. In the present study, we aimed to compare the efficacy and safety of thulium laser resection of the prostate (TMLRP) with either transurethral plasmakinetic resection of the prostate (TUPKP) or transurethral resection of the prostate (TURP). A literature search was performed, eventually, 14 studies involving 1587 patients were included. Forest plots were produced by using Revman 5.2.0 software. Our meta-analysis showed that operation time, decrease in hemoglobin level, length of hospital stay, catheterization time, and development of urethral stricture significantly differed, whereas the transitory urge incontinence rate, urinary tract infection rate, and recatheterization rate did not significantly differ between TMLRP and either TURP or TUPKP. The blood transfusion rate was significantly different between TMLRP and TURP, but not between TMLRP and TUPKP. In addition, the retrograde ejaculation rate between TMLRP and TURP did not significantly differ. At 1, 3, 6, and 12 months of postoperative follow-up, the maximum flow rate, post-void residual, quality of life, and International Prostate Symptom Score did not significantly differ among the procedures. Thus, the findings of this study indicate that TMLRP may be a safe and feasible alternative.

Thulium laser versus standard transurethral resection of the prostate for benign prostatic obstruction: a systematic review and meta-analysis

PURPOSE

To assess the efficacy and safety of thulium laser versus standard transurethral resection of the prostate (TURP) for treating patients with benign prostatic obstruction.

METHODS

A systematic search of the electronic databases, including Medline, Embase, Web of Science, and The Cochrane Library, was performed up to February 1, 2014. The pooled estimates of demographic and clinical baseline characteristics, perioperative variables, complications, and postoperative efficacy including International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and postvoid residual (PVR) were calculated.

RESULTS

Seven trials assessing thulium laser versus standard TURP were considered suitable for meta-analysis including four randomized controlled trials (RCTs) and three non-RCTs. Compared with TURP, although thulium laser prostatectomy (TmLRP) needed a longer operative time [weighted mean difference (WMD) 8.18 min; 95 % confidence interval (CI) 1.60-14.75; P = 0.01], patients having TmLRP might benefit from significantly less serum sodium decreased (-3.73 mmol/L; 95 % CI -4.41 to -3.05; P < 0.001), shorter time of catheterization (WMD -1.29 days; 95 % CI -1.95 to -0.63; P < 0.001), shorter length of hospital stay (WMD -1.83 days; 95 % CI -3.10 to -0.57; P = 0.005), and less transfusion (odds ratio 0.09; 95 % CI 0.02-0.41; P = 0.002). During the 1, 3, and, 12 months of postoperative follow-up, the procedures did not demonstrate a significant difference in IPSS, QoL, Qmax, and PVR.

CONCLUSIONS

TmLRP had a similar efficacy to standard TURP in terms of IPSS, QoL, Qmax, and PVR, and offered several advantages over TURP in terms of blood transfusion, serum sodium decreased, catheterization time, and hospital stay, while TURP was superior in terms of operation duration. Well-designed multicentric/international RCTs with long-term follow-up are still needed.

Two-micron (Thulium) Laser Prostatectomy: An Effective Method for BPH Treatment

The two-micron (thulium) laser is the newest laser technique for treatment of bladder outlet obstruction resulting from benign prostatic hyperplasia (BPH). It takes less operative time than standard techniques, provides clear vision and lower blood loss as well as shorter catheterization times and hospitalization times. It has been identified to be a safe and efficient method for BPH treatment regardless of the prostate size.