Enucleation is enucleation is enucleation is enucleation

The long-term learning curve of holmium laser enucleation of the prostate (HoLEP) in the en-bloc technique: a single surgeon series of 500 consecutive cases

PURPOSE

To evaluate perioperative parameters, clinical outcomes, and the learning curve of holmium laser enucleation of the prostate (HoLEP) of a single surgeon in 500 consecutive cases.

METHODS

Demographic parameters, outcomes, and adverse events were evaluated. The learning curve for HoLEP in en-bloc technique of the first 500 consecutive patients was analyzed in clusters of 100 (clusters 1-5) using the Wilcoxen rank test, Chi² test and Kruskal Wallis test.

RESULTS

Enucleation weight was similar in the clusters 1,2,3, and 5 (62 g, 63 g, 61 g, 61 g), in cluster 4 it was slightly higher at 73 g. There was a significant reduction in operating time from 67 min (cluster 1) to 57 min (cluster 2), 46 min (cluster 3), 53 min (cluster 4), and 43 min (cluster 5), p < 0.001. Enucleation efficiency (g/min) showed a steady increase (1.72, 2.24, 2.79, 2.92 vs. 2.99, p < 0.001). Laser energy efficiency also improved (2.17 vs. 2.12 vs. 1.71 vs. 1.65 vs. 1.55; p < 0.001). There was no measurable learning curve regarding the length of hospital stay (mean 2.5 days), catheterization time (1.9 days), hemoglobin drop (approx. 1 g/dl) or complications (p > 0.1).

CONCLUSIONS

HoLEP using the en-bloc technique is a safe and highly effective method. Over time, a slight but steady learning curve and improvement in operation time, enucleation efficiency and laser energy efficiency were shown even for an experienced surgeon - after 500 cases, still no plateau was reached. There was no measurable learning curve regarding blood loss, complications, length of hospital stay, and catheterization time.

Refining surgical strategies in ThuLEP for BPH: a propensity score matched comparison of En-bloc, three lobes, and two lobes techniques

PURPOSE

This study compares the peri-operative and functional outcomes of three distinct surgical techniques in Thulium Laser Enucleation of the Prostate (ThuLEP) for benign prostatic hyperplasia (BPH). The main aim is to assess whether the En-bloc, Three-lobe, and Two-lobe techniques have differential effects on surgical efficacy and patient outcomes.

METHODS

A retrospective analysis was conducted on patients undergoing ThuLEP for BPH between January 2019 and January 2024 at two tertiary centers. Propensity score matching was utilized to balance baseline characteristics among patients undergoing the different techniques. Surgical parameters, including operative time, enucleation time, morcellation time, energy consumption, and postoperative outcomes, were compared among the groups.

RESULTS

Following propensity score matching, 213 patients were included in the analysis. Intraoperative analysis revealed significantly shorter enucleation, laser enucleation, morcellation and operative times and total energy delivered in the En-bloc and Two-lobe groups compared to the Three-lobe group. No significant differences were observed among the groups in terms of intraoperative and postoperative complications. There were no significant differences in functional outcomes at the 3-month follow-up among the groups.

CONCLUSION

The findings of this study suggest that while the En-bloc and Two-lobe techniques may offer efficiency benefits and could be considered safe alternatives in ThuLEP procedures, the reduction in laser enucleation time and energy delivered did not necessarily translate into improvements in post operative storage symptoms or other functional outcomes for the patients. Surgeon preference and proficiency may play a crucial role in selecting the most suitable technique for individual patients. Future research should focus on larger-scale prospective studies to further validate these findings and explore potential factors influencing surgical outcomes.

[Thulium or holmium laser or both: where will the journey take us?]

The Holmium:YAG laser has been the gold standard for laser lithotripsy over the past three decades and, since the late 1990s, also for prostate enucleation. Pulsed thulium fibre lasers (TFL) demonstrated their efficacy in in-vitro experiments and were introduced to the market a few years ago. Initial clinical results for TFL in lithotripsy and enucleation are very promising. In addition to TFL, a pulsed Thulium:YAG solid-state laser has been introduced, but clinical data for this laser are currently limited. This article aims to review the key technological differences between Ho:YAG lasers and pulsed thulium lasers and compare/discuss the initial clinical results for stone lithotripsy and laser enucleation.In-vitro studies have demonstrated the technical superiority of TFL compared with Ho:YAG lasers. However, as TFL is still a new technology, only limited studies are available to date, and optimal settings for lithotripsy have not been established. For enucleation, the differences of TFL compared with a high-power Ho:YAG laser seem to be clinically irrelevant. Initial studies on pulsed Tm:YAG lasers show good results, but there continues to be a lack of comparative studies.Based on the current literature, pulsed thulium lasers have the potential of being an alternative to Ho:YAG lasers. However, further studies are necessary to determine the optimal laser technology for enucleation and lithotripsy of urinary stones, considering all parameters, including efficacy, safety, and cost.

Incidence of urinary incontinence following endoscopic laser enucleation of the prostate by en-bloc and non- en-bloc techniques: a multicenter, real-world experience of 5068 patients

We aim to evaluate the incidence of incontinence following laser endoscopic enucleation of the prostate (EEP) comparing en-bloc (Group 1) versus 2-lobe/3-lobe techniques (Group 2). We performed a retrospective review of patients undergoing EEP for benign prostatic enlargement in 12 centers between January 2020 and January 2022. Data were presented as median and interquartile range (IQR). Univariable and multivariable logistic regression analysis was performed to evaluate factors associated with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI). There were 1711 patients in Group 1 and 3357 patients in Group 2. Patients in Group 2 were significantly younger (68 [62-73] years vs 69 [63-74] years, P = 0.002). Median (interquartile range) prostate volume (PV) was similar between the groups (70 [52-92] ml in Group 1 vs 70 [54-90] ml in Group 2, P = 0.774). There was no difference in preoperative International Prostate Symptom Score, quality of life, or maximum flow rate. Enucleation, morcellation, and total surgical time were significantly shorter in Group 1. Within 1 month, overall incontinence rate was 6.3% in Group 1 versus 5.3% in Group 2 ( P = 0.12), and urge incontinence was significantly higher in Group 1 (55.1% vs 37.3% in Group 2, P < 0.001). After 3 months, the overall rate of incontinence was 1.7% in Group 1 versus 2.3% in Group 2 ( P = 0.06), and SUI was significantly higher in Group 2 (55.6% vs 24.1% in Group 1, P = 0.002). At multivariable analysis, PV and IPSS were factors significantly associated with higher odds of transient SUI/MUI. PV, surgical time, and no early apical release technique were factors associated with higher odds of persistent SUI/MUI.

Monopolar Transurethral Enucleoresection of Prostate: Feasibility of Modified Nesbit's Enucleoresection with Apical Release

Background: Transurethral resection of the prostate (TURP) has been the standard surgical treatment for Benign Hyperplasia of the Prostate (BPH) for decades. Our objective was to evaluate the outcome of our new technique: Monopolar Transurethral Enucleoresection of the Prostate (TUERP) with apical release (bring it all to centre). Methods: A prospective study of all cases undergoing TUERP at a tertiary centre from January 2020 to October 2022 was performed. Patient demographics, intraoperative variables and postoperative results along with follow-up data were collected. Data of all the cases who had completed a one-year follow-up post-surgery were included and analysed. Results: A total of 240 patients with complete data including a one-year follow-up were included. Mean prostatic volume was 55.3 ± 11.6 gm, and 28 (11.67%) cases were >100 gm. The mean operative time was 31.7 ± 7.6, and mean haemoglobin drop at 24 h was 0.73 ± 1.21 gm/dL. The overall complication rate was 16.67%, with only two (0.83%) Clavien-Dindo III complications (haematuria and clots needing evacuation) and the other complications being Clavien-Dindo I/II complications. Sustained improvement at 1 year of follow-up was noted: Qmax: 25.2 ± 5.6 mL/s, IPSS: 4.7 ± 2.5 and PVR: 22.5 ± 9.6 mL. Conclusions: Monopolar TUERP with a modified Nesbit's enucleoresection with apical release can be considered a promising technique, which needs further studies to be validated with appropriate comparisons.

Propensity score-matched analysis comparing perioperative, functional, and safety outcomes between thulium fiber laser and bipolar enucleation of the prostate performed by a single surgeon with two years of follow-up

PURPOSE

To compare perioperative, functional, and safety outcomes between thulium fiber laser enucleation of the prostate (ThuFLEP) and bipolar enucleation of the prostate performed by a single surgeon with use of propensity score (PS)-matched analysis.

MATERIALS AND METHODS

Data were from 675 patients, 422 of whom underwent ThuFLEP and bipolar enucleation by a single highly experienced surgeon. ThuFLEP was performed with Fiberlase U1 (IRE Polus Ltd.). Perioperative parameters, safety, and functional outcomes, such as International Prostate Symptom Score (IPSS), quality of life (QoL), postvoid residual volume (PVR), and maximum urinary flow rate (Qmax) were assessed. To control for selection bias, a 1:1 PS-matched analysis was carried out using the following variables as covariates: total prostate volume, preoperative IPSS and early sphincter release.

RESULTS

Of 422 patients, 370 (87.7%) underwent ThuFLEP and 52 (12.3%) underwent bipolar enucleation. Operation, enucleation, and morcellation time were comparable between groups before and after PS-matched analysis (p=0.954, p=0.474, p=0.362, respectively). Functional parameters (IPSS, QoL, PVR, Qmax) were also comparable between groups at every time point before and after PS matching. Significant improvements in IPSS, QoL score, Qmax, and PVR were observed during the 24-month follow-up period for both ThuFLEP and bipolar enucleation without any significant differences between groups. Early and late postoperative complications before and after PS-matched analysis were similar.

CONCLUSIONS

ThuFLEP was comparable to bipolar enucleation in perioperative characteristics, improvement in voiding parameters, and complication rates. Both procedures were shown to be effective and safe in the management of benign prostatic hyperplasia.

Minimally invasive surgical therapies (MISTs) for lower urinary tract symptoms (LUTS): promise or panacea?

ABSTRACT

The increasing importance of treatment of lower urinary tract symptoms (LUTS), while avoiding side effects and maintaining sexual function, has allowed for the development of minimally invasive surgical therapies (MISTs). Recently, the European Association of Urology guidelines reported a paradigm shift from the management of benign prostatic hyperplasia (BPH) to the management of nonneurogenic male LUTS. The aim of the present review was to evaluate the efficacy and safety of the most commonly used MISTs: ablative techniques such as aquablation, prostatic artery embolization, water vapor energy, and transperineal prostate laser ablation, and nonablative techniques such as prostatic urethral lift and temporarily implanted nitinol device (iTIND). MISTs are becoming a new promise, even if clinical trials with longer follow-up are still lacking. Most of them are still under investigation and, to date, only a few options have been given as a recommendation for use. They cannot be considered as standard of care and are not suitable for all patients. Advantages and disadvantages should be underlined, without forgetting our objective: treatment of LUTS and re-treatment avoidance.

One-year outcomes after prostate artery embolization versus laser enucleation: A network meta-analysis

Background

Although holmium laser enucleation (HoLEP) is considered a size-independent procedure for treatment of an enlarged prostate, prostate artery embolization (PAE) is emerging as an alternative modality to treat moderate and large benign prostatic hyperplasia. This study aims to compare the early post-operative and short-term efficacy of PAE and HoLEP.

Methods

PubMed, Cochrane Library and EMBASE databases were searched. Network meta-analysis was performed following PRISMA-N-guidelines. Post-operative parameters analysed include international prostate symptom score (IPSS), quality of life (QOL), post-void residual urine (PVR), maximal uroflow rate (Qmax) and serious adverse events (SAE). Random effects model calculated weighted mean differences (WMD). If 95%CI crossed the line of no effect (WMD = 0), evidence indicated no statistically significant difference between treatments compared.

Results

Qualitative and quantitative syntheses included 20 and 18 studies with 1991 and 1606 patients, respectively. At 3 months, there was no statistically significant difference between PAE and HoLEP in IPSS score improvement [WMD: -2.21: 95%CI: (-10.20, 5.78), favouring PAE], QoL score improvement [WMD: -0.22:95%CI: (-1.75, 1.32), favouring PAE] and PVR improvement [WMD: 26.97: 95%CI: (-59.53, 113.48), favouring HoLEP]. However, PAE was found inferior to HoLEP for Qmax improvement [WMD: 8.47, 95%CI: (2.89, 14.05), favouring HoLEP]. At 1-year follow-up, there was no statistically significant was found between PAE and HoLEP for IPSS score improvement [WMD:6.03, 95%CI: (-1.30, 13.35)], QoL score improvement [WMD: 0.03, 95%CI: (-1.19, 1.25)], PVR improvement [WMD:4.11, 95%CI: (-32.31, 40.53)] and Qmax improvement [WMD:2.60, 95%CI: (-2.20, 7.41)] with all differences favouring HoLEP. PAE was superior to HoLEP for SAE [PAE vs. HoLEP-OR: 0.68, 95%CI: (0.25, 1.37)].

Conclusion

HoLEP was superior to PAE at 3 months for Qmax improvement. There was no significant difference in IPSS, QoL, PVR and Qmax improvement at 1 year between PAE and HoLEP. PAE was also associated with lesser SAE compared to HoLEP. Studies on the long-term outcome of PAE are needed to establish the durability of early outcomes after PAE.

Holmium laser with MOSES technology (MoLEP) vs Thulium fiber laser enucleation of the prostate (ThuFLEP) in a real-world setting. Mid-term outcomes from a multicenter propensity score analysis

PURPOSE

To compare Holmium laser with MOSES technology (MoLEP) and Thulium fiber laser enucleation of the prostate (ThuFLEP) in terms of surgical and functional outcomes.

METHODS

We performed a retrospective analysis of all patients who underwent either procedure in five centers (January 2020-January 2022).

EXCLUSION CRITERIA

previous urethral/prostatic surgery, radiotherapy, concomitant surgery. Propensity score matching (PSM) analysis was performed to adjust for the bias inherent to the different characteristics at baseline. Differences between procedures were estimated using Firth Penalized Likelihood regression for International prostate symptom score (IPSS), quality of life (QL), maximum flow rate (Qmax).

RESULTS

PSM retrieved 118 patients in each group. Baseline characteristics were similar except for PSA and number of men on indwelling catheter (higher in MoLEP group). Median surgical time was significantly longer in the MoLEP group despite the enucleation and morcellation times being similar. Median catheter dwelling time and postoperative length of stay were similar. Most of the early complications were Clavien ≤ 2 grade. There were only two Clavien grade 3 complications (one for each group), one grade 4 in MoLEP group. Rate and type of early and persistent incontinence (> 3 months) were similar. At 12-month, proportion of patients reaching a decrease (Δ) of IPSS ≥ 18 from baseline was significantly larger in MoLEP group, with no significant difference in ΔQmax > 12 ml/sec and ΔQL ≥ -3.

CONCLUSION

MoLEP and ThuFLEP were safe and efficacious procedures with similar short-term operative and functional outcomes. At 1-year, MoLEP patients had a sustained reduction of IPPS score.

Results from a global multicenter registry of 6193 patients to refine endoscopic anatomical enucleation of the prostate (REAP) by evaluating trends and outcomes and nuances of prostate enucleation in a real-world setting

PURPOSE

To collect a multicentric, global database to assess current preferences and outcomes for endoscopic enucleation of the prostate (EEP).

METHODS

Endourologists experienced in EEP from across the globe were invited to participate in the creation of this retrospective registry. Surgical procedures were performed between January 2020 and August 2022.

INCLUSION CRITERIA

lower urinary tract symptoms not responding to or worsening despite medical therapy and absolute indication for surgery.

EXCLUSION CRITERIA

prostate cancer, concomitant lower urinary tract surgery, previous prostate/urethral surgery, pelvic radiotherapy.

RESULTS

Ten centers from 7 countries, involving 13 surgeons enrolled 6193 patients. Median age was 68 [62-74] years. 2326 (37.8%) patients had large prostates (> 80 cc). The most popular energy modality was the Holmium laser. The most common technique used for enucleation was the 2-lobe (48.8%). 86.2% of the procedures were performed under spinal anesthesia. Median operation time was 67 [50-95] minutes. Median postoperative catheter time was 2 [1, 3] days. Urinary tract infections were the most reported complications (4.7%) followed by acute urinary retention (4.1%). Post-operative bleeding needing additional intervention was reported in 0.9% of cases. 3 and 12-month follow-up visits showed improvement in symptoms and micturition parameters. Only 8 patients (1.4%) required redo surgery for residual adenoma. Stress urinary incontinence was reported in 53.9% of patients and after 3 months was found to persist in 16.2% of the cohort.

CONCLUSION

Our database contributes real-world data to support EEP as a truly well-established global, safe minimally invasive intervention and provides insights for further research.

En bloc resection of bladder tumors (ERBT) revisited 12 years after reintroduction: too good to be further ignored

En bloc resection of bladder tumors (ERBT) orginally described in 1980 and adopted by few centers in the late 1990s has regained attention in the 2010s as a renaissance of a technique with high potential. The advent of new lasers indirectly lead to a better understanding of anatomical dissection from the experience in anatomical dissection in endoscopic enucleation of the prostate. 12 years after the reintroduction of ERBT evidence mounts that it is not only equivalent but better in some regards. However, ERBT still falls short with regard to wide adoption despite the striking technique inherent and reproducible features of accurate staging and specimen quality as requested by pathologist, as well and despite the high intraoperative safety and fast adoption of this technique even in early phase of training. The editorial walks the reader through the timeline of the renaissance speculating why there is a blockage between cognitive understanding and dissonance in surgical practice. The special issues presents the meta-analysis of surgical and oncological data on one hand and the level of understanding and power of this surgical technique in fields offsite oncological results in training achieving results almost right from the start after adoptation. Unlike in earlier years reviewing the literature of ERBT in 2023, ERBT seems not only to be a viable alternative, but something one should turn towards no to underperform with regards to the endpoints achievable by ERBT in a critical disease like bladder cancer.

The use of statins is related to a lower PSA level after endoscopic enucleation of the prostate with holmium laser (HoLEP) for the treatment of BPH

OBJECTIVE

To determine the factors that may be associated with a 2-month high baseline level of Total Prostatic Specific Antigen (PSA) after endoscopic enucleation of the prostate with Holmium Laser (HoLEP).

MATERIALS AND METHODS

Retrospective study of a prospectively collected database of adult males undergoing HoLEP at a single tertiary institution from September 2015 to February 2021. Pre-operative epidemiological, clinical characteristics and post-operative factors were analyzed and a multivariate analysis was performed to determine factors independently related to PSA decline.

RESULTS

A total of 175 men aged 49-92 years with a prostate size ranging from 25 to 450 cc underwent HoLEP, and after excluding data from patients due to loss of follow-up or incomplete data, 126 patients were included in the final analysis. The patients were divided into group A (n = 84), which included patients with postoperative PSA nadir lower than 1 ng/ml, and group B(n = 42), with postoperative PSA levels greater than 1 ng/ml. In the univariate analysis there was a correlation between the variation of the PSA value and the percentage of resected tissue (p = 0.028), for each 1 g of resected prostate there was a reduction of 0.104 ng/mL, furthermore there was a difference between the means of age of group A (71.56 years) and group B (68.17 years) (p = 0.042). In the multivariate analysis, the use of statins and lower postoperative PSA levels (p = 0.024; HR = 3.71) were correlated.

CONCLUSIONS

Our results indicate that PSA after HoLEP is correlated with patient's age, the presence of incidental prostate cancer, and the use of statins.

En Bloc enucleation with early apical release technique using MOSES (En Bloc MoLEP) vs. classic En Bloc HoLEP: a single arm study comparing intra- and postoperative outcomes

BACKGROUND AND PURPOSE

We aimed to describe the technique and outcomes of En-Bloc MOSES laser enucleation of the prostate (En-Bloc MoLEP) with early apical release comparing it to En-Bloc HoLEP (non-MOSES).

PATIENTS AND METHODS

This is a single-arm prospective study, using a historical control. n = 80 patients were enrolled to the En Bloc MoLEP group and compared to a retrospective group of n = 137 patients treated by En Bloc HoLEP (non-MOSES), in total n = 217 patients.

RESULTS

En-Bloc MoLEP, showed to significantly improve the surgical time by 32% compared to non-MOSES HoLEP (32.16 ± 14.46 min, 47.58 ± 21.32, respectively; P = 0.003). Enucleation time, ablation rate and hemostasis time were also significantly improved (P < 0.001, for all three parameters). Enucleation time was 22.10 ± 9.27 min and 31.46 ± 14.85 min (P < 0.001), ablation rate 4.11 ± 2.41 and 2.54 ± 1.31 gr/min (P < 0.001), Hemostasis time 3.01 ± 2.50 and 8.35 ± 5.38 min (P < 0.001), for En Bloc MoLEP and En Bloc HoLEP, respectively. Q-max, PVR, PSA and IPSS showed significant improvement, however, at 12 months no significant differences were observed comparing both groups.

CONCLUSIONS

En-Bloc MoLEP was significantly better than En-Bloc HoLEP in terms of surgical time, enucleation time, ablation rate and hemostasis time. However, large comparative RCT with long-term follow-up are needed.

Transperineal laser ablation as a new minimally invasive surgical therapy for benign prostatic hyperplasia: a systematic review of existing literature

Introduction

Transperineal laser ablation (TPLA) of the prostate is a new, minimally invasive technique for benign prostatic hyperplasia (BPH) with promising effectiveness and safety outcomes. This systematic review aims to provide an update of existing literature.

Methods

A literature review was performed in Pubmed/MEDLINE, Embase, Cochrane Library, and clinicaltrials.gov from January 2000 up to April 2023. Data extraction and risk of bias were performed independently by three authors.

Results

A total of 11 studies were included, among which 9 were observational, 1 randomized controlled trial, 1 animal study, while 2 of them were comparative (1 with prostatic artery embolization and 1 with transurethral resection of the prostate). Functional outcomes were improved in the majority of studies both for objective (maximum flow rate and post-void residual) and subjective outcomes (improvement of International Prostate Symptom Score and quality of life). Complication rates ranged between 1.9% and 2.3% for hematuria, 3.7% and 36.3% for dysuria, 1.9% and 19% for acute urinary retention, 0.6% and 9.1% for orchitis/urinary tract infections, and 0.6% and 4.8% for prostatic abscess formation. Regarding sexual function, >95% of patients retained their ejaculation while erectile function was maintained or improved.

Conclusion

TPLA of the prostate is an innovative, minimally invasive technique for managing patients with BPH. Existing studies indicate an effective technique in reducing International Prostate Symptom Score and quality of life scores, post-void residual reduction, and increase in Qmax, albeit the measured improvements in terms of Qmax are not equal to transurethral resection of the prostate. Although sexual function is maintained, the mean catheterization time is 7 days, and no long-term data are available for most patients.

Switching lasers: learning curve of HoLEP in surgeons experienced in ThuLEP

OBJECTIVE

To evaluate perioperative parameters, clinical outcomes, and the learning curve of holmium laser enucleation of the prostate (HoLEP) in surgeons with experience in thulium laser enucleation of the prostate (ThuLEP).

MATERIALS AND METHODS

The learning curves for HoLEP of the first 50 consecutive patients of two surgeons experienced in ThuLEP were analyzed. In addition, demographic parameters, clini¬cal outcomes and adverse events were evaluated.

RESULTS

Mean operation time was 70.9 + 29.7 min (SD) (Surgeon 1) and 74.4 + 35.4 min (Surgeon 2), the mean enucleation efficiency was 1.5 + 0.6 g/min (Surgeon 1) and 1.5 + 0.7 g/min (Surgeon 2). The hemoglobin loss was 0.9 + 0.8 g/dl and 0.8 + 0.8 g/dl. For both surgeons, there was a significant learning curve in enucleation efficiency within the first 50 cases (Surgeon 1: p = .034, Surgeon 2: p = .006, both: p = .0003, Spearman's ρ = .351). Both surgeons started with an enucleation efficiency of around 1g/min in their first 10 cases. No significant correlation between hemoglobin loss and experience could be found (p = .823, ρ = .025). While there was no significant learning curve for morcellation efficiency (p = .785, ρ = .028), a significant progress was found for one of the two surgeons regarding laser energy efficiency (p = .014). The overall incidence of all grade treatment-related adverse events was very low at 10.0%, and extremely low for significant complications with Clavien-Dindo Grade > II at 1%.

CONCLUSIONS

In our analysis, switching to HoLEP is uncomplicated and safe for experienced ThuLEP surgeons. The enucleation efficiency was high from the beginning, but a learning curve was present for both surgeons. No learning curve was noticeable in hemoglobin loss and the incidence of complications, both of which were very low throughout the study.

Comparative analysis of MOSESTM technology versus novel thulium fiber laser (TFL) for transurethral enucleation of the prostate: A single-institutional study

INTRODUCTION

Novel laser technologies have been developed for the minimally invasive surgical management of benign prostatic hyperplasia (BPH). The objective of this study was to assess the safety and efficacy of MOSESTM technology versus the thulium fiber laser (TFL) in patients with BPH undergoing transurethral enucleation of the prostate.

METHODS

We conducted a retrospective review of prospectively collected data of eighty-two patients who underwent transurethral enucleation of the prostate using MOSESTM or TFL technologies from August 2020 to September 2021. Preoperative and intraoperative parameters, in addition to postoperative outcomes, were collected and analyzed.

RESULTS

Twenty patients underwent transurethral enucleation of the prostate with TFL, while 62 had MOSESTM HoLEP. No statistically significant difference in preoperative characteristics was observed between the groups. Patients in the TFL group had longer median enucleation, hemostasis, and morcellation times (p < 0.001) than those in the MOSESTM cohort. The longer morcellation time of TFL is mostly related to less visibility. The postoperative outcomes IPSS, QoL, Qmax, and post void residual (PVR), were comparable between the groups at 1, 3 and 6 months. The incidence of urge urinary incontinence (p = 0.79), stress urinary incontinence (p = 0.97), and hospital readmission rates (p = 0.1) were comparable between the two groups.

CONCLUSIONS

A satisfactory safety and efficacy profile with comparable postoperative outcomes was demonstrated for both techniques; though, MOSESTM technology was superior to TFL in terms of shorter overall operative time.

Randomized prospective trial of the severity of irritative symptoms after HoLEP vs ThuFLEP

PURPOSE

To compare the short-term postoperative functional outcomes and severity of irritative symptoms following holmium and thulium fiber laser enucleation (HoLEP and ThuFLEP).

METHODS

This prospective randomized single-blinded study was performed in accordance with CONSORT. The inclusion criteria were IPSS > 20 or Qmax < 10 ml/s. Patients were randomized between HoLEP and ThuFLEP. Demographics, objective data (PSA, prostate volume, etc.), data on urinary and sexual function (IPSS, IIEF, QoL, QUID, Qmax, ICIQ-MLUTS) were collected. Detailed perioperative information and postoperative data on functional outcomes at 1, 2, 3, 4, 6, 8, 10, 12 weeks and 6 months were collected.

RESULTS

Data on 163 participants were included (77-HoLEP, 86-ThuFLEP). No differences were found in surgery duration; number of postoperative complications (Clavien-Dindo I-III), catheterization time and hospital stay. Functional outcomes up to 6 months didn't differ between the groups (IPPS, IIEF, QoL, QUID, ICIQ-MLUTS, Qmax, p > 0.05). Total ICIQ-MLUTS, bother and voiding scores at 1 and 3 months significantly increased compared with the baseline in both groups (p < 0.05). No difference between the groups were observed. In HoLEP the SUI series rate was 1.3% and 1.3% after 3 and 6 months following the procedure; in ThuFLEP: it was 3.5% and 2.3% respectively (p = 0.35 and p = 0.54).

CONCLUSION

The preliminary results of the study showed no apparent differences in functional outcomes (IPSS, Qmax), rate of SUI or irritative symptoms. Both ThuFLEP and HoLEP are efficient ways of treating benign prostatic obstruction. Both surgeries are comparable in terms of duration and postoperative complication rates.

Endoscopic Enucleation of the Prostate Is Better than Robot-assisted Simple Prostatectomy

In 2022, endoscopic enucleation of the prostate (EEP) is the treatment of choice for benign prostatic obstruction (BPO) for glands >80 ml and is a valid alternative for patients with bleeding disorders. Unlike robot-assisted radical prostatectomy, EEP has no additional access-related trauma and can be performed using the same instruments as for bipolar enucleoresection. With favorable costs, EEP can serve as a global solution for BPO treatment.

Thulium laser enucleation of prostate versus laparoscopic trans-vesical simple prostatectomy in the treatment of large benign prostatic hyperplasia: head-to-head comparison

Objectives:

To compare thulium laser enucleation of prostate (ThuLEP) versus laparoscopic trans-vesical simple prostatectomy (LSP) in the treatment of benign prostatic hyperplasia (BPH).

Materials and Methods:

Data of patients who underwent surgery for “large” BPH (>80mL) at three Institutions were collected and analyzed. Two institutions performed ThuLEP only; the third institution performed LSP only. Preoperative (indwelling catheter status, prostate volume (PVol), hemoglobin (Hb), Q_max, post-voiding residual volume (PVR), IPSS, QoL, IIEF-5) and perioperative data (operative time, enucleated adenoma, catheterization time, length of stay, Hb-drop, complications) were compared. Functional (Q_max, PVR, %ΔQ_max) and patient-reported outcomes (IPSS, QoL, IIEF-5, %ΔIPSS, %ΔQoL) were compared at last follow-up.

Results:

80 and 115 patients underwent LSP and ThuLEP, respectively. At baseline, median PVol was 130 versus 120mL, p <0.001; Q_max 9.6 vs. 7.1mL/s, p=0.005; IPSS 21 versus 25, p <0.001. Groups were comparable in terms of intraoperative complications (1 during LSP vs. 3 during ThuLEP) and transfusions (1 per group). Differences in terms of operative time (156 vs. 92 minutes, p <0.001), Hb-drop (-2.5 vs. −0.9g/dL, p <0.001), catheterization time (5 vs. 2 days, p <0.001) and postoperative complications (13.8% vs. 0, p <0.001) favored ThuLEP. At median follow-up of 40 months after LSP versus 30 after ThuLEP (p <0.001), Q_max improved by 226% vs. 205% (p=0.5), IPSS decreased by 88% versus 85% (p=0.9), QoL decreased by 80% with IIEF-5 remaining almost unmodified for both the approaches.

Conclusions:

Our analysis showed that LSP and ThuLEP are comparable in relieving from BPO and improving the patient-reported outcomes. Invasiveness of LSP is more significant.

The efficacy of a suppository based on Phenolmicin P3 and Bosexil (Mictalase®) in control of irritative symptoms in patients undergoing thulium laser enucleation of prostate: a single-center, randomized, controlled, open label, phase III study

Background

Several studies described post-operative irritative symptoms after laser enucleation of prostate, sometimes associated with urge incontinence, probably linked to laser-induced prostatic capsule irritation, and potential for lower urinary tract infections We aimed to evaluate the efficacy of a suppository based on Phenolmicin P3 and Bosexil (Mictalase®) in control of irritative symptoms in patients undergoing thulium laser enucleation of prostate (ThuLEP).

Methods

In this single-center, prospective, randomized, open label, phase-III study, patients with indication to ThuLEP were enrolled (Dec2019–Feb2021—Institutional ethics committee STS CE Lazio approval no.1/N-726—ClinicalTrials.gov NCT05130918). The report conformed to CONSORT 2010 guidelines. Eligible patients were 1:1 randomized. Randomization defined Group A: patients who were administered Mictalase® suppositories twice a day for 5 days, then once a day for other 10 days; Group B: patients who did not receive Mictalase® (“controls”). Study endpoints were evaluated at 15 and 30 days postoperation. Primary endpoint included evaluation of effects of the suppository on irritative symptoms by administering IPSS + QoL questionnaire. Secondary endpoint included evaluation of effects on urinary tract infections by performance of urinalysis with urine culture.

Results

111 patients were randomized: 56 in Group A received Mictalase®. Baseline and perioperative data were comparable. At 15-days, no significant differences were found in terms of IPSS + QoL scores and urinalysis parameters. A significant difference in the rate of positive urine cultures favored Group A (p = 0.04). At 30-days follow-up, significant differences were found in median IPSS score (6 [IQR 3–11] versus 10 [5–13], Group A vs B, respectively, p = 0.02). Urinalysis parameters and rate of positive urine cultures were not significantly different.

Conclusions

The present randomized trial investigated the efficacy of Mictalase® in control of irritative symptoms and prevention of lower urinary tract infections in patients undergoing ThuLEP. IPSS improvement 30-days postoperation was more pronounced in patients who received Mictalase®. Lower rate of positive urine culture favored Mictalase® group 15-days postoperatively.

Trial registration

The clinical trial has been registered on ClinicalTrials.gov on November 23rd, 2021—Registration number NCT05130918.

Robot assisted simple prostatectomy versus endoscopic enucleation of the prostate: A systematic review and meta-analysis of comparative trials

Robot assisted simple prostatectomy (RASP) and endoscopic enucleation of the prostate (EEP) are two minimally invasive alternatives to simple prostatectomy, which is considered the standard treatment in large prostate glands. It remains unclear which of the two is superior in terms of outcome and complications. To compare perioperative and functional outcomes of robot assisted simple prostatectomy (RASP) versus endoscopic enucleation of the prostate (EEP) systematic review and meta-analysis was conducted according to the recommendations of the Cochrane Collaboration and in line with the PRISMA criteria. The database search included clinicaltrials.gov, Medline (via PubMed), CINAHL and Web of Science and was using the PICO criteria. All comparative trials were considered. Risk of bias was assessed with the revised ROBINS-I tool. 760 studies were identified, four of which were eligible for qualitative and quantitative analysis, reporting on a total of 901 patients with follow-up up to 24 months. Hemoglobin drop (MD[CI]: 0.34 g/dl [0.09; 0.58]), the rate of blood transfusions (OR[CI]: 5.01 [1.60; 15.61]) catheterization time (MD[CI]: 3.26 d [1.30; 5.23]) and length of hospital stay (LoS) (MD[CI]: 1.94 d [1.11; 2.76]) were significantly lower in EEP. No significant differences were seen in operating time and enucleation weight. No significant differences were observed in the incidence of postoperative urinary retention, postoperative transient incontinence and complications graded according to the Clavien-Dindo Classification. Functional results were similar, with no significant differences in International Prostate Symptom Score and maximum urinary flow rate at follow-up. Conclusion: Both EEP and RASP offer excellent improvement of symptoms due to prostatic hyperplasia. EEP has lower blood loss, shorter catheterization time and LoS and should be the first choice if available. RASP remains an attractive alternative for extremely large glands, in concomitant diseases or whenever EEP is not available.

Laser endoscopic procedures on the prostate: it is the small details that count

PURPOSE OF REVIEW

This review aims to highlight the pros and cons of each laser device and to consider additional possible milestones for the development of laser technologies in the surgical treatment of benign prostate hyperplasia.

RECENT FINDINGS

Over the last three decades, lasers' role in endourology has gone from strength to strength. Specifically, the primary techniques where laser surgery for BPO relief is concerned are vaporization and enucleation. The idea behind vaporization is that lasers are able to vaporize substantial amounts of tissue due to deep ablation depth and increased power. The most efficient devices for vaporization are those affecting hemoglobin as primary chromophore and/or using a continuous firing mode (KTP/LBO:YAG, diode lasers, Tm:YAG). As for enucleation, multiple devices have been suggested for the adequate anatomical enucleation of the prostate (EEP). As it is a skill-dependent technique, the EEP is effective irrespective of which device the surgeon uses. However, some devices have shown significant advances where enucleation is concerned.

SUMMARY

The choice of device should be based primarily on the technique the surgeon prefers. Although the most suitable lasers for vaporization are hemoglobin-targeting and/or continuous wave devices, the EEP may be done with any enough powered laser, yet some provides specific effects which you should be aware before the surgery.

Are all procedures for benign prostatic hyperplasia created equal? A systematic review on post-procedural PSA dynamics and its correlation with relief of bladder outlet obstruction

PURPOSE

To evaluate and provide a comprehensive literature review of Prostate specific antigen (PSA) dynamics after various surgical procedures for benign prostatic hyperplasia (BPH).

METHODS

A thorough PubMed database search was performed over last 30 years including terms "PSA" and various surgical procedures for BPH. PSA nadir after various procedure was evaluated. The post-operative improvement in International Prostate Symptom Score, maximum void rates and post-void residue after surgeries were recorded. An indirect correlation was made between PSA nadir and outcome of various BPH surgical procedures.

RESULTS

Enucleation procedures like simple prostatectomy and endoscopic enucleation of prostate (EEP) produced maximum drop in PSA level after surgery and were associated with the highest improvement in post-operative parameters. The PSA nadir following resection techniques like transurethral resection of prostate and Holmium laser resection of prostate and vaporization technique was variable and less robust when compared to EEP. Newer techniques like Aquablation, Rezum, Urolift, Prostate artery embolization and Temporary implantable nitinol devices (iTIND) produce relatively less reduction in PSA and lesser percentile improvement in post-operative parameters.

CONCLUSIONS

Various surgical procedures for BPH result in varying PSA nadirs level. Enucleation procedures and simple prostatectomy produce the most drastic and sustained decrease in PSA. There is a possible indirect evidence suggesting that the level of PSA nadir corresponds closely with the degree of post-operative improvement and durability of the procedure. Establishing the new PSA nadir at 3-6 months after the procedure is recommended as a part of routine surveillance for prostate cancer in eligible patients.

Endoscopic enucleation of the prostate (EEP). The same but different-a systematic review

Purpose

Various techniques for EEP exist. They differ by surgical steps and the source of energy. It is assumed that the latter is of minor importance, whereas adherence to the anatomical enucleation template determines the postoperative result. So far, no systematic review highlights the differences between the energy sources in use for anatomical EEP. This study will address selfsame topic.

Methods

A systematic review of the literature was completed on September 1st, 2020. Studies comparing HoLEP, ThuLEP, DiLEP, or BipolEP with TUR-P providing 12 months of postoperative follow-up were included. Two frequentist network meta-analyses were created to compare the techniques of EEP indirectly.

Results

31 studies, including 4466 patients, were found eligible for our meta-analysis. Indirect pairwise comparison showed differences in surgery time between BipolEP and HolEP (MD − 16.72 min., 95% CI − 27.75 to − 5.69) and DiLEP and HoLEP (MD − 22.41 min., 95% CI − 39.43 to − 5.39). No differences in the amount of resected prostatic tissue, major and minor complications and postoperative catheterization time were found. The odds for blood transfusions were threefold higher for BipolEP than for HoLEP (OR 3.27, 95% CI 1.02–10.5). The difference was not statistically significant when comparing prospective trials and matched-pair analysis only (OR 3.25, 95% CI 0.94–11.18). The Qmax 12 months after surgery was 2 ml/sec. higher for BipolEP than for DiLEP (MD  2.00, 95% CI 0.17–3.84) and 1.94 ml/sec. lower for DiLEP than for HoLEP (MD − 1.94, 95% CI − 3.65 to − 0.22).

Conclusion

The energy source used for EEP has an impact on the intervention itself. BipolEP promotes surgical efficiency; laser techniques lower the risk of bleeding.

Registry

This meta-analysis is registered in the PROSPERO international prospective register registry with the registration number CRD42020205836.

Reasons to go for thulium-based anatomical endoscopic enucleation of the prostate

PURPOSE

To summarize the current evidence and the reasons to go for thulium-based anatomical endoscopic enucleation of the prostate (AEEP).

METHODS

This review discusses the available literature on thulium-based AEEP.

RESULTS

Thulium lasers operate at a wavelength between 1940 and 2013 nm. This wavelength, which has a low penetration depth in water, allows to perform smooth cuts in the prostatic tissue and allows urologists to perform various procedures: resection, vaporization, enucleation, or vapoenucleation of the prostate. Depending on the type of thulium laser, it can be used either in a continuous, or pulsed mode.

CONCLUSION

In recent years, an increasing amount of evidence has described the thulium laser as a minimally invasive and size-independent treatment option for benign prostatic enlargement with excellent long-term results.

Green Light laser enucleation of the prostate with early apical release is safe and effective: single center experience and revision of the literature

BACKGROUND

Green Light laser enucleation of the prostate (GreenLEP) is an endoscopic treatment to treat bladder outlet obstruction in men with large prostate (>100 cc). Herein, we describe our GreenLEP series and describe its safety and efficacy.

METHODS

Between February 2014 and April 2019, 120 patients from a single center underwent en-bloc GreenLEP with early apical release. All procedures were performed with the AMS XPS laser generator (set: 120 W for vaporization and 20 W for coagulation). Morcellation was carried out with the Wolf Piranha morcellator. Data concerning the pre-, intra- and postoperative outcomes were prospectively collected. The follow-up data at 6, 12 months and at the last control were collected.

RESULTS

The median age was 66.0 (IQR: 61.0-71.0) years; 37.5% of the patients were under antiplatelet/anticoagulant therapy, 15.0% had indwelling catheter history. The median prostate volume and the baseline PSA value were 98.5ml (IQR 83.0-130.0) and 4.2ng/ml (IQR: 3.2-6.8), respectively. The median operative and lasing time were 65.0 (IQR: 51.0-83.5) and 6.0 (IQR: 6.0-10.0) minutes, respectively. In the post-operative period 1 patient was transfused. The median follow-up was 18.0 (IQR: 12.0-39.5) months. All patients had significant improvement in terms of improvement of uroflowmetry [median from 9ml/sec (IQR 7.8, 11.0) to 20.0 (IQR 18.0, 22.0), p <0.001] and symptoms control [IPSS median score from 26.0ml/sec (IQR 22.0, 28.0) to 7.0 (IQR 6.0, 8.0), p <0.001]) over time. After 12 months 1 patient complained of stress incontinence (1 pad/day) and 1 of "de novo" wet urgency.

CONCLUSIONS

En-bloc GreenLEP with early apical release is a safe and effective procedure even for large volume prostates. It allows us to limit the use of laser energy and shorten the operating times with stable and satisfactory long-term outcomes.

How many procedures are needed to achieve learning curve of Millin simple laparoscopic prostatectomy

BACKGROUND

Aim of our study was to evaluate learning curve of the Millin simple prostatectomy analysing three expert laparoscopic surgeons.

METHODS

Learning curve of 3 expert laparoscopic surgeons with excellent radical prostatectomy training was evaluated. Surgeon 1 had more than 20 years of experience, while other surgeons had 10 years of experience. The first 45 procedures of the surgeons were considered for analysis. The cumulative sum (CUSUM) technique, one of the methods developed to monitor the performance and quality of the industrial sector, was adopted to analyse learning curves. The variables included to evaluate learning curve of the surgeons were: operative time (OT), hospitalisation (HO) and complication rate.

RESULTS

Overall 135 patients were included in the analysis. Median age was 68 (64/74), median prostate volume was 83 (75/97), median Qmax 9 ml/s (6/11) and median IPSS 20 (18/22). Complications included: 9/135 (7%) transfusion, 4/135 (3%) Urinary retention, 3/135 (2%) fever, 1/35 (<1%) reintervention and 1/135 (<1%) conversion. Surgeon 1 presented a lower median operative time when compared to surgeon 2 and 3. No significant differences were recorded in terms of hospitalisation, blood loss and transfusion rate as well as postoperative outcomes. According to the CUSUM analysis the number of procedures needed to achieve a plateau in surgical time is 10/15 procedures (fig 1).

CONCLUSIONS

In conclusion, according to our results 15 procedures are needed to reach a plateau in surgical time for trained laparoscopic surgeons.

The constant search for the greater good: evolving from TURP to anatomic enucleation of the prostate is a safe bet

PURPOSE

In a troubling moment in history with an ongoing world pandemic and the impending economic crises, there is today a plethora of commercially available options for the minimally invasive treatment of BPH. New industry-driven evaluation criteria of these treatments, the logical marketing hype, a short follow-up for many of them, make challenging to interpret the role they will finally adopt in the armamentarium to treat BPH.

METHOD

The author comments on recently published literature based in own experience and insight.

RESULTS AND CONCLUSIONS

In this situation, choosing to evolve from TURP to the next step of endoscopic treatment, the size-independent anatomic endoscopic enucleation of the prostate is a safe bet. It is now exceedingly feasible when the paradigm of AEEP has changed, due to better learning opportunities and technological and surgical technique modifications that have refined this procedure significantly since its inception.

Pharmacological and interventional treatment of benign prostatic obstruction: An evidence‐based comparative review

Introduction

The recommended treatment for bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) after the failure of behavioral therapy and fluid modification includes pharmacological, minimally invasive interventional, and surgical approaches. Each option has different risk and benefit profiles, and the urologist must be aware of the unique characteristics of each option in order to be able to accurately counsel the patients based on their individual values and preferences. We provide a comparative review of the commonest pharmacological and most widely performed interventional/surgical treatments for BPO, discussing the evidence for the treatment characteristics that are most useful for the practicing urologist.

Methods

A search of the PubMed database was performed for articles reporting on the following treatments for LUTS due to BPO: α‐blockers, 5α‐reductase inhibitors, phosphpdiesterase‐5 inhibitors, prostatic urethral lift (Urolift), convective radiofrequency water vapor thermal therapy (Rezum), Temporary implantable Nitinol Device (iTIND), prostate artery embolization (PAE), transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), Aquablation, and anatomical endoscopic enucleation of the prostate (AEEP). We performed a narrative review focussing on the following outcomes: efficacy, safety, durability, duration of catheterization, length of stay, re‐treatment rate, efficacy in special situations (enlarged median lobe, prostate size, urinary retention, and anticoagulant use), and sexual adverse events.

Results

AEEP offers the greatest long‐term improvement in maximum flow rate, IPSS, and prostate volume reduction, with lowest re‐treatment rate, followed by PVP, TURP, and Aquablation. Urolift, Rezum, and PAE have similar efficacy for prostate volume up to 80cc, and all are more effective than the pharmacological treatment. Urolift offers the lowest rate of sexual dysfunction, followed by Rezum, and both can be performed as a day case under local anesthesia.

Conclusion

Several treatment options exist to treat voiding LUTS due to BPO. Newer minimally invasive treatments reduce the hospital stay and postoperative complications, whereas AEEP provides the greatest long‐term symptom improvement at the expense of higher morbidity and sexual dysfunction. Men should be counseled regarding all suitable treatment options as some may favor reduced efficacy in association with reduced side effects.

Comparison of 532-nm GreenLight HPS laser with 980-nm diode laser vaporization of the prostate in treating patients with lower urinary tract symptom secondary to benign prostatic hyperplasia: a meta-analysis

To evaluate the efficacy and safety of 532-nm GreenLight HPS laser (PVP) vs 980-nm diode laser vaporization of the prostate (DVP) in treating patients with lower urinary tract symptom (LUTS) secondary to benign prostatic hyperplasia (BPH). PubMed, Cochrane Library databases, EMBASE (until Jun 2020), and original references of the included articles were searched. PRISMA checklist was followed. A total of four articles including 521 patients were studied. There was no significant difference in total operating time and lasering time of the two laser surgeries; however, a higher amount of total applied laser energy was delivered with DVP (P < 0.00001). The catheterization time after surgery in the PVP group was significantly longer than that in the DVP group (P = 0.0008), whereas the hospitalization time was significantly shorter than that in the DVP group (P = 0.02). Compared with baseline, there were significant improvements in the voiding variables over the observation period after surgery in both groups. PVP had a significant improvement in total international prostate symptom score (IPSS) (P = 0.0002) and quality of life (QoL) index (P = 0.003) compared with DVP after ≥12 months of postoperative follow-up. For complications after surgery, PVP had a larger number in needing for electrocautery to control bleeding (P = 0.02). Besides, the application of DVP resulted in a higher incidence of bladder neck contracture (P = 0.0007), dysuria (≥1 month) (P = 0.002), transient incontinence (P = 0.003), postoperative recatheterization (P = 0.02), and reoperation (P < 0.0001). The voiding parameters and micturition symptoms of patients with BPH after two kinds of laser surgery were significantly improved. However, PVP was more beneficial than DVP in terms of total IPSS, QoL index, and hospitalization time. Moreover, PVP showed a lower incidence of postoperative adverse events, but a higher risk of postoperative bleeding. PROSPERO registration number: CRD42020203222.

Photoselective sharp enucleation of the prostate with a front-firing 532-nm laser: an innovative surgical technique for benign prostatic hyperplasia-a single-center study of 475 cases

PURPOSE

To describe the novel technique of photoselective sharp enucleation of the prostate (PSEP) with a front-firing 532-nm laser and evaluate its efficacy and safety.

METHODS

A seven-step standardized surgical procedure was established, and PSEP was performed in an en bloc or lobulate manner according to the size of the middle lobe of the prostate. The following clinical data of 583 patients who underwent PSEP in our center from November 2016 to May 2018 were retrospectively reviewed: maximum flow rate (Q_max), International Prostate Symptom Score (IPSS), quality of life score (Q_ols), post-void residual volume (PVR), prostate volume, operation time, serum prostate-specific antigen (PSA) concentration, and complications at 1, 6, and 12 months postoperatively.

RESULTS

Of the 583 patients, 475 had complete clinical information and were included in the study. The median operation time was 39 min. There were significant improvements in the Q_max, IPSS, Q_ols, PVR and PSA concentration at each follow-up time point postoperatively. Postoperative hemorrhage occurred in 22 patients (4.6%), urinary retention in 29 (6.1%), urinary tract infection in 55 (11.6%), bladder neck contracture in 8 (1.7%), urethral strictures in 11 (2.3%), and stress urinary incontinence in 9 (1.9%).

CONCLUSIONS

PSEP is effective and safe for the treatment of benign prostatic hyperplasia. The innovative technique integrates the excellent hemostatic property of the 532-nm laser and the high efficiency of enucleation. It decreases the occurrence of postoperative incontinence associated with "blunt" enucleation of 532-nm laser and eliminates the lack of tissue samples problem associated with photoselective vaporization of the prostate.

Holmium laser enucleation of the prostate versus bipolar transurethral enucleation of the prostate in management of benign prostatic hyperplasia: A randomized controlled trial

OBJECTIVE

To evaluate the safety, efficacy and cost-effectiveness of holmium enucleation of the prostate and bipolar transurethral enucleation of the prostate.

METHODS

In our randomized controlled trial, 120 patients were allocated into two equal groups representing holmium enucleation of the prostate and bipolar enucleation of the prostate. Operative parameters were recorded according to operative, enucleation and resection time in addition to the intraoperative complications. Patients were followed up at 1, 3 and 12 months postoperative to assess the prostate size, post-voiding residual urine, International Prostate Symptom Score, peak urine flow rate and quality of life, and compared with the preoperative parameters. Cost analysis was evaluated for both procedures.

RESULTS

We evaluated 107 patients who finished our follow up and their data were analyzed. The prostate size was 135.2 ± 34.8 mL and 125 ± 26.9 mL for holmium enucleation of the prostate and bipolar enucleation of the prostate, respectively. Holmium enucleation of the prostate was associated with a shorter operative time of 83.43 ± 6.92 min compared with 94.7 ± 12.2 min in bipolar enucleation of the prostate groups. Holmium enucleation of the prostate was associated with an earlier catheter removal time and shorter hospital stay compared with bipolar enucleation of the prostate. Postoperative International Prostate Symptom Score, quality of life, post-voiding residual urine, peak urine flow rate, prostate-specific antigen and prostate volume reduction were comparable between both groups, and they both showed statistically significant improvement compared with their preoperative parameters. In the cost analysis, holmium enucleation of the prostate was more cost-effective than bipolar enucleation of the prostate.

CONCLUSION

Both holmium enucleation of the prostate and bipolar enucleation of the prostate are safe and effective in the surgical management of large prostatic adenomas. Holmium enucleation of the prostate has a shorter operative time and hospital stay with earlier catheter removal time, and is more cost-effective than bipolar enucleation of the prostate.

Systematic review of the endoscopic enucleation of the prostate learning curve

INTRODUCTION

It has been shown that endoscopic enucleation of the prostate (EEP) allows for similar efficacy and safety, no matter what energy and type of instruments we use, but the length of learning may differ greatly. The aim of this systematic review is to verify if there is any significant difference between EEP methods in learning.

EVIDENCE ACQUISITION

We performed a systematic literature search in three databases and included only the articles containing their own data on the EEP learning curve assessment during the last 10 years. The primary endpoint was to determine the necessary experience needed to achieve a plateau. The secondary endpoints were to review methods used to evaluate a learning curve.

EVIDENCE SYNTHESIS

The final sample included 17 articles, containing a total of 4615 EEPs performed by 76 surgeons, the most common method was HoLEP (9/17). The majority of articles studying HoLEP report a learning curve of experience level achievement in roughly 30-40 (min 20; max 60) cases. The studies of GreenLight laser showed high heterogeneity in the results with minimum of 20 cases and maximum of 150-200 cases. TUEB required roughly 40-50 cases to reach the plateau.

CONCLUSION

Although EEP is considered challenging, it shows a steep learning curve with a plateau after 30-50 cases. Proper criteria are critical for accurate assessment of the learning curve. The Trifecta and Pentafecta criteria are currently the most appropriate method to evaluate EEP learning.

Ejaculation-sparing thulium laser enucleation of the prostate (ES-ThuLEP): outcomes on a large cohort

PURPOSE

To assess the effects of a new ejaculation-sparing thulium laser enucleation of the prostate (ES-ThuLEP) technique on sexual functions and micturition, in patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH) and to evaluate how the surgical technique of ES-ThuLEP can lead to ejaculation preservation.

METHODS

A prospective study was carried out between January 2015 and January 2018 on patients with surgical indication for BPH, who wished to preserve ejaculation. The patients were treated with ES-ThuLEP and were evaluated before and 3 and 6 months after surgery. Three validated questionnaires (ICIQ-MLUTSsex, IIEF-5 and IPSS) were used to assess changes in ejaculation, erectile function and urinary symptoms. Uroflowmetry (Qmax and Qavg), post-void residual volume and voided volume were also evaluated, to assess micturition improvement. Patients with moderate to severe erectile dysfunction were excluded. Statistical analysis was performed with the Student's t test, Chi-square test and logistic regression analysis.

RESULTS

Two hundred and eighty three patients were enrolled. Ejaculation was spared in 203 and 219 patients at 3 and 6 months after surgery. No significant differences were observed between erectile function before and after surgery: baseline IIEF-5 = 16.2 ± 4.47 vs 16.7 ± 2.9 (p = 0.419) and 17.7 ± 3.2 (p = 0.410) at 3 and 6 months. Significant improvement in urinary symptoms was achieved: baseline IPSS = 19.4 ± 7.24 vs 5.8 ± 4.3 (p = 0.032) and 3.9 ± 4.1 (p = 0.029) at 3 and 6 months.

CONCLUSION

ES-ThuLEP effectively preserved ejaculation in over two thirds of the patients without compromising micturition improvement or erectile function. ES-ThuLEP could be a valid treatment option for BPH in young and sexually active men.

Endoscopic enucleation for prostate larger than 60 mL: comparison between holmium laser enucleation and plasmakinetic enucleation

PURPOSE

To compare perioperative and functional outcomes of two different energy sources, holmium laser and bipolar current for endoscopic enucleation of prostate larger than 60 mL.

METHODS

A prospective, monocentric, comparative, non-randomized study was conducted including all patients treated for prostate larger than 60 mL, measured by transrectal ultrasound. Patients were assigned to each group based on the surgeons' practice. Perioperative data were collected (preoperative characteristics, operating, catheterization and hospitalization times, hemoglobin loss, complications) and functional outcomes (IPSS, IPSS Quality of Life (QoL), PSA) at 3 months and 1 year.

RESULTS

100 patients were included in each group from October 2015 to March 2018. No differences between HoLEP and plasma groups were observed at baseline, except for mean IPSS score, IPSS QoL score and preoperative PVR that were significantly higher in the HoLEP group. Operating time (142.1 vs 122.4 min; p = 0.01), catheterization time (59.6 vs 44.4 h; p = 0.01) and hospitalization time (2.5 vs 1.8 days; p = 0.02) were significantly shorter in the plasma group. Complication and transfusion rate were no significantly different between HoLEP and plasma. No significant differences were observed concerning functional outcomes at 3 months and 1 year. The urinary incontinence rate was higher 21.1% vs 6.4% (p < 0.01) at 3 months in HoLEP group, but no difference was observed at 1 year.

CONCLUSION

Holmium and plasma are both safe and effective for endoscopic treatment for prostate larger than 60 mL. Operating, catheterization and hospitalization times were significantly shorter in the plasma group. The complication rate and functional outcomes were not significantly different.

Sexual outcomes of endoscopic enucleation of prostate

The emergence of various endoscopic enucleation techniques in the past decade has provided surgeons with more options and opportunities in performing enucleation. With the same surgical principle as holmium laser enucleation of prostate, the early results of different techniques were comparable. However, sexual outcomes of endoscopic enucleation of the prostate (EEP) were less commonly reported than the voiding and urodynamic outcomes. In this review, the sexual outcomes including erectile function, ejaculatory and orgasmic function of various endoscopic enucleation technique would be studied. The overall sexual outcomes were heterogeneous and inconclusive. Outcomes measurement, sample size calculation, hypothesis generation and selection criteria were not specifically designed for sexual outcomes or even available. There were also limitations in the individual sexual assessment tools. Nonetheless, most studies showed no significant deterioration of erectile function after EEP, and ejaculation dysfunction was common. Looking forward in the field of benign prostatic enlargement surgery, the 'one size fits all' notion should be abandoned. Treatment should be tailor-made according to the prostate size, co-morbidities and sexual needs. The sexual outcomes of enucleation have to be better studied and defined. More prospective controlled studies focusing primarily on sexual functions are needed. For enucleation surgeons, exploring different ejaculatory-sparing technique could be the golden opportunities in further consolidating the role and expanding the indication of enucleation surgery.

Lasers in Transurethral Enucleation of the Prostate-Do We Really Need Them

The acronym EEP, coding for transurethral Endoscopic Enucleation of the Prostate, was introduced in 2016 by the European Association of Urology (EAU) guidelines panel on management of non-neurogenic male lower urinary tract symptoms (LUTS) and benign prostatic obstruction (BPO). Since then, a laser-based treatment, Holmium Laser Enucleation of the Prostate (HoLEP), and the current-based treatment of bipolar enucleation of the prostate (BipoLEP) are equally appreciated as valuable options for the management of benign prostatic obstruction (BPO). This was mainly inspired by the results of two meta-analyses on randomized controlled trials, comparing open prostatectomy with either Holmium Laser Enucleation of the Prostate (HoLEP) or bipolar enucleation of the prostate (BipoLEP). Prior to that, HoLEP was embraced as the only valid option for transurethral enucleation, although evidence for equivalence existed as early as 2006, but was not recognized due to a plethora of acronyms for bipolar energy-based treatments and practiced HoLEP-centrism. On the other hand, the academic discourse focused on different (other) laser approaches that came up, led by Thulium:Yttrium-Aluminum-Garnet (Tm:YAG) Vapoenucleation (ThuVEP) in 2009 and, finally, transurethral anatomical enucleation with Tm:YAG support (thulium laser enucleation of the prostate, ThuLEP) in 2010. Initially, the discourse on lasers focused on the different properties of lasers rather than technique or surgical anatomy, respectively. In and after 2016, the discussion ultimately moved towards surgical technique and accepting anatomical preparation as the common of all EEP techniques (AEEP). Since then, the unspoken question has been raised, whether lasers are still necessary to perform EEP in light of existing evidence, given the total cost of ownership (TCO) for these generators. This article weighs the current evidence and comes to the conclusion that no evidence of superiority of one modality over another exists with regard to any endpoint. Therefore, in the sense of critical importance, AEEP can be safely and effectively performed without laser technologies and without compromise.