Holmium laser enucleation of the prostate versus thulium laser enucleation of the prostate for the treatment of large-volume prostates > 80 ml: 18-month follow-up results

Prospective randomized multicenter study to evaluate holmium vs. new thulium fiber laser for prostate enucleation

BACKGROUND

Benign prostatic hyperplasia (BPH) commonly causes lower urinary tract symptoms (LUTS) in men. Holmium (HoLEP) and thulium (ThuLEP) laser enucleation are established techniques for BPH treatment. Thulium fiber laser (TFL) for prostate enucleation (ThuFLEP) shows promising outcomes.

METHODS

A prospective randomized multicenter study was conducted. Patients with BPH and LUTS unresponsive to medical therapy were enrolled. Preoperative, surgical, perioperative and postoperative data were recorded with follow-up at 3 and 6 months. The primary outcome was functional improvement, and the secondary outcome was safety in terms of complications.

RESULTS

Two hundred patients were included (HoLEP 100, ThuFLEP 100). No significant baseline difference was found between groups. At 3 and 6 months we found statistically significant improvements from baseline for both HoLEP and ThuFLEP in efficacy: International Prostatic Symptoms Score (IPSS), IPSS-Quality of Life (QoL), maximum urinary flow rate (Qmax), and post-void residual volume (PVR; P<0.05). At 6 months, mean±SD IPSS, IPSS-QoL, Qmax, and PVR for HoLEP vs. ThuFLEP were 5.8±4.9 vs. 4.8±5.0 points (P=0.57), 1.6±1.4 vs. 0.7±1.1 points (P=0.09), 29.9±12.5 vs. 29.6±8.0 mL/s (P=0.8), and 16.3±17.7 vs. 15.5±13.4 mL (P=0.92), respectively. No intraoperative complication was recorded. No Clavien-Dindo ≥III complications occurred during hospitalization. After 6 months, 8 (8%) and 6 (6%) patients reported mild stress urinary incontinence in HoLEP and ThuFLEP groups, respectively (P=0.24). Urethral stenosis was observed in 3 men (3%) in the HoLEP group and 1 subject (1%) in the ThuFLEP group (P=0.72).

CONCLUSIONS

HoLEP and ThuFLEP are effective and safe for BPH treatment, with comparable functional outcomes and complication rates at 6 months. Further research is needed to confirm these findings.

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.

The safety and efficacy of five surgical treatments in prostate enucleation: a network meta-analysis

PURPOSE

The aim of our study was to investigate the comparative outcomes of five different energy types on surgical efficacy and postoperative recovery in patients with benign prostate hyperplasia.

METHODS

The literature was systematically reviewed on December 1st, 2023, encompassing studies retrieved from PubMed, Embase, Web of Science, and The Cochrane Library databases that incorporated clinical studies of holmium laser enucleation of the prostate (HoLEP), Thulium:YAG laser enucleation of the prostate (ThuLEP), transurethral plasmakinetic enucleation of prostate (PKEP), diode laser enucleation of the prostate (DiLEP) and thulium fiber laser enucleation of the prostate (ThuFLEP) in the treatment of prostatic hyperplasia. Two independent reviewers extracted study data and conducted quality assessments using the Cochrane Collaboration's Risk of Bias tool and Newcastle-Ottawa Scale (NOS). Network meta-analysis (NMA) was employed to indirectly analyze the outcomes of endoscopic enucleation of the prostate (EEP) techniques.

RESULTS

The study included a total of 38 studies, comprising 21 non-randomized controlled trials (nRCTs) and 17 randomized controlled trials (RCTs), incorporating five distinct techniques: holmium laser, Thulium:YAG laser, bipolar plasma, diode laser and thulium fiber laser. In comparing treatment durations, ThuLEP and HoLEP had shorter overall hospital stays than PKEP, while the enucleation time of ThuLEP and HoLEP was shorter than that of ThuFLEP. Moreover, the enucleation tissue weight of both thulium fiber laser and holmium laser was heavier than bipolar plasma. However, the analysis did not reveal any statistically significant variation in complications among the various types of enucleation. In postoperative follow-up, the IPSS at 3 months post-operation was superior in the Thulium:YAG laser group compared to the holmium laser group. The thulium fiber laser technique demonstrated significant advantages over other enucleation methods in terms of QoL and PVR at 12 months after surgery.

CONCLUSION

Theoretical properties may vary among different energy sources; however, there are no discernible clinical differences in operation-related parameters, postoperative complications, and postoperative follow-up. Therefore, the choice of laser does not significantly impact the outcome. However, due to the limited number of included studies, future research should focus on larger sample sizes and multicenter investigations to further validate the findings of this study.

Comparison of HoLEP, ThuLEP and ThuFLEP in the treatment of benign prostatic obstruction: a propensity score-matched analysis

PURPOSE

To compare the efficacy and safety of Holmium laser enucleation of the prostate (HoLEP), Thulium laser enucleation of prostate (ThuLEP) and Thulium fibre laser enucleation of prostate (ThuFLEP) by performing propensity score matched analysis (PSM).

METHODS

We retrospectively analysed the patients who underwent HoLEP (Group 1, n = 696), ThuLEP (Group 2, n = 146) and ThuFLEP (Group 3, n = 193) surgery because of benign prostatic obstruction (BPO). A 1:1:1 HoLEP: ThuLEP: ThuFLEP group matching was performed using PSM analysis. Perioperative, postoperative functional outcomes and complications were analysed and compared.

RESULTS

We observed significant improvement in functional parameters regarding IPSS, Qmax, PVR and quality of life in all groups compared to baseline values at the 1st, 6th and 12th postoperative months. There was no significant difference between different laser types in terms of urge (UUI) and stress urinary incontinence (SUI) at 1st postoperative month. In all three groups, no patient had postoperative SUI or UUI at 6th and 12th postoperative months. In addition, no significant difference was observed between laser types in terms of postoperative complications.

CONCLUSION

HoLEP, ThuLEP and ThuFLEP are safe and effective LEP methods with improvement in functional parameters and low complication rates. Similar results in terms of functional outcomes and complications clearly show that these surgeries are alternatives to each other for the patients with BPO. Experts' opinions, practices and enucleation techniques should also be taken into consideration when choosing a laser for BPO surgery.

[Development of endoscopic enucleation of the prostate]

This article deals with lasers from their initial description to the most advanced applications in the treatment of benign prostate enlargement.

A novel technique for thulium laser enucleation of the prostate: anterior releasing with ThuLEP (ARTh technique)

Thulium laser enucleation of the prostate (ThuLEP) is a highly effective approach to the treatment of benign prostatic hyperplasia. We present here a description of the "ARTh Technique" and the benefits it offers in terms of improved visualization, short operation times, and easy recognition of the dissection plane, describing specifically the anterior release (AR) technique using ThuLEP(Th). Included in this retrospective study were 32 consecutive patients operated on between January 2022-November 2022. Parameters were measured before and after the procedure: the International Prostate Symptom Score(IPSS), maximum flow rate(Qmax), post-void residual urine(PVR) prostate-specific antigen(PSA), prostate volume, operation-time, morcellation-time, catheterization-time and presence of transient urinary incontinence, and compared. The median age of patients undergoing enucleation of the prostate using the ARTh technique was 64 years (range: 44-83). The median prostate volume of the patients was 83.5 ml(50-128 ml), preoperative-IPSS was 24.8(15-33), postoperative-IPSS was 7(5-11), preoperative-Qmax was 8.1 ml/Sects. (5-11.5 ml/sec), postoperative-Qmax was 26.9 ml/Sect. (20.8-34 ml/sec), preoperative-PVR was 145 ml(75-258 ml), postoperative-PVR was 36.2 ml(0-66 ml), total operation time was 51.4 min(28-82 min), enucleation time was 36.9 min(19-51 min) and morcellation time was 15.3 min(8-27 min). The ARTh technique is a safe procedure that allows the surgeon to easily recognize and adhere to the defined dissection plane, thus decreasing operation times, significantly reducing the rate of postoperative transient urinary incontinence (TUI).

Value of serum free prostate-specific antigen density in the diagnosis of prostate cancer

PURPOSE

To investigate the value of serum free prostate-specific antigen density (fPSAD) in the diagnosis of prostate cancer (PCa).

METHODS

The data of 558 patients who underwent transrectal ultrasound-guided prostate biopsy were retrospectively analyzed. According to the pathological results, the patients were divided into a PCa group and a benign prostatic hyperplasia (BPH) group. Receiver operating characteristic curves were plotted, based on which the sensitivity, specificity, Youden index, concordance, and kappa values of free prostate-specific antigen (fPSA), the free-to-total f/tPSA, prostate-specific antigen density (PSAD), the free-to-total (f/t)/PSAD ratio, and fPSAD were compared. The patients were divided into three groups by PSA levels (PSA < 4 ng/mL, PSA = 4-10 ng/mL, and PSA > 10 ng/mL), into three groups by age (age < 60 year, age = 60-80y, and age > 80 years), and into two groups by prostate volume (PV) (PV ≤ 80 mL and PV > 80 mL) to compare the sensitivity, specificity, and concordance of indicators.

RESULTS

tPSA, PSAD, (f/t)/PSAD, and fPSAD had high accuracy in predicting PCa with AUC values of 0.820, 0.900, 0.846, and 0.867. fPSAD showed lower diagnostic sensitivity but significantly higher specificity and concordance for PCa than tPSA, f/tPSA, (f/t)/PSAD, or PSAD. Thus, fPSAD had the highest accuracy in the diagnosis of PCa. In the groups with different PSA, age, and PV stratification, the concordance of fPSAD was significantly higher (88.61%, 90.74%, and 90.38%) than that of other indicators.

CONCLUSION

With the optimal cutoff value of 0.062, fPSAD has a higher diagnostic value for PCa than tPSA, f/tPSA, (f/t)/PSAD, and PSAD, and can well predict the risk of PCa, significantly improve the clinical diagnostic rate of PCa, and reduce unnecessary biopsy.

A randomized trial of holmium laser vs thulium laser vs bipolar enucleation of large prostate glands

OBJECTIVE

To compare the outcome and morbidity of bipolar transurethral enucleation of the prostate (B-TUEP) and thulium laser enucleation of the prostate (ThuLEP) with those of holmium laser enucleation of the prostate (HoLEP) in the treatment of large symptomatic benign prostatic obstruction (BPO) through a non-inferiority randomized controlled trial (NCT03916536).

PATIENTS AND METHODS

A total of 155 patients were recruited from a single centre between February 2019 and August 2020. All had BPO, with a prostate volume ≥80 ml. Patients were randomly assigned to HoLEP, ThuLEP or B-TUEP using computer-generated random tables in a 1:1:1 ratio. Participants, investigators and surgeons were blinded to group assignment until the date of the operation. Thereafter, the patients were followed up at 1, 3, 6 and 12 months. The primary outcome was maximum urinary flow rate (Qmax ) at 6 months. Secondary outcomes included assessment of other functional urinary variables, peri-operative records, and adverse events.

RESULTS

There were 138 and 120 patients available for analysis at 6 and 12 months. There was no significant difference in Qmax between the groups at 6 and 12 months (P = 0.4 and P = 0.7, respectively), and no significant difference regarding International Prostate Symptom Score (IPSS), quality of life (QoL) or postvoid residual urine volume (PVR). The median (interquartile range) prostate-specific antigen (PSA) reductions (ng/ml) were similar in the three groups at last follow-up point (4.7 [2.2-7.1]; 5.6 [2.3-9.5] and 5 [3.4-10] after HoLEP, ThuLEP and B-TUEP, respectively). Differences in enucleation time, enucleation efficiencies and auxiliary manoeuvres were statistically insignificant (P = 0.1, 0.8 and 0.07, respectively). At 1 year, patients with prostate volumes >120 ml showed significant IPSS improvement in favour of HoLEP and ThuLEP (P = 0.01). Low- and high-grade adverse effects were recorded in 31 and five cases, respectively, with no statistically significant difference between the groups.

CONCLUSIONS

We conclude that ThuLEP and B-TUEP are as safe and effective as HoLEP for the treatment of large-sized BPO. Significant PSA reductions indicate that there was effective adenoma enucleation with all three approaches. The study provides objective evidence that endoscopic enucleation of the prostate is a technique rather than energy dependent procedure.

Surgical treatment of benign prostatic hyperplasia: Thulium enucleation versus single-port transvesical robotic simple prostatectomy

Objective

The objective of this work is to compare our outcomes using thulium laser enucleation of prostate (ThuLEP) to the single-port robot-assisted simple prostatectomy (SP RASP) in the surgical management of benign prostatic hyperplasia (BPH).

Methods

A retrospective cohort study was conducted from January 2017 through December 2021 of men who underwent SP RASP and ThuLEP performed by a single surgeon with an enucleation experience of >300 cases and extensive robotic experience. The primary outcome was changed in International Prostate Symptom Score (IPSS) postoperatively. Secondary outcomes were operative time, length of stay (LOS), change in post-void residuals (PVR), de novo stress- or urge-urinary incontinence (SUI, UUI), and rate of complications.

Results

One hundred two patients underwent surgery during the study period: 33 RASP and 69 ThuLEP. There was no difference in preoperative characteristics, including age and body mass index, between both groups. Changes in IPSS scores postoperatively were not significant between SP RASP versus ThuLEP (-17 vs. -14, p = 0.2956). SP RASP had a longer operative time (180 vs. 90 min, p < 0.0001). There was no difference in LOS (0 vs. 0 days, p = 0.2904). There was no difference in change in PVR (-96 vs. -91 mL, p = 0.8504). SP RASP patients had significantly less postoperative SUI than ThuLEP (0 vs. 13 patients, p = 0.0083), while there was no difference in UUI between both groups (4 vs. 2 patients, p = 0.0843). There was no difference in 30-day complication rate (21.2% vs. 21.7%, p = 0.9517), although there were three ThuLEP patients with Clavien-Dindo Class III or higher complication.

Conclusions

There was no difference in change in IPSS scores between the two groups. ThuLEP is associated with shorter postoperative catheter days and decreased operative times. Hospital LOS was equivalent. SP RASP demonstrates significantly improved continence rates. Though SP RASP is within the initial learning curve at our institution, early results demonstrate the role for this modality alongside ThuLEP in the treatment of large gland BPH.

Network Meta-Analysis of the Treatment Safety and Efficacy of Different Lasers in Prostate Enucleation

Purpose: This study aimed to compare different laser systems for the enucleation of benign prostate hyperplasia. Methods: Randomized controlled trials (RCTs) on different lasers for prostate enucleation were searched from PubMed, Embase, and CNKI databases. Pairwise and network meta-analyis (NMA) were performed to analyze the outcome regarding surgery time, complications, short-term postvoid residual (PVR), long-term PVR, and short-term international prostate symptom score (IPSS), long-term IPSS, short-term maximum urine flow rate (Qmax), and long-term Qmax. RevMan software was used for paired meta-analysis. Considering the variance uncertainty caused by the different source regions of RCTs and the different primary conditions of surgeons and patients, this study uses Bayesian NMA conducted with ADDIS software to compare different treatment methods indirectly. Node-splitting analysis was used to test inconsistency for closed-loop indirect comparison. Results: Nine studies were included in this study, involving four types of lasers: diode laser, holmium laser, thulium laser, and greenlight laser. In safety paired meta-analysis, holmium laser could bring more complication risk than thulium laser (odds ratio: 2.70, 95% confidential interval [CI]: 1.79-4.00, p < 0.001), and no other significant result was detected. In the efficacy comparisons, holmium laser could offer better postoperative long-term PVR (standardized mean difference [SMD]: -0.35, 95%CI: -0.62, -0.09, p = 0.011), better postoperative long-term IPSS (SMD: -0.30, 95%CI: -0.57, -0.04, p = 0.011), better postoperative short-term Qmax (SMD: 0.44, 95%CI: 0.17, 0.70, p = 0.001) compared with greenlight laser. According to the results of NMA, greenlight laser may bring more complication risks when applied to prostate enucleation than the other three lasers. Thulium laser may be the recommended laser system for prostate enucleation. Conclusion: Thulium laser may be the recommended laser system since it can bring less complication risk with comparable efficacy. More RCTs are still needed to validate this study.

Ejaculation Sparing Thulium Laser Enucleation of the Prostate: An Observational Prospective Study

Benign prostatic hypertrophy (BPH) is a condition that appears with advancing age and affects 1/3 of men over 50 years, resulting in filling and emptying symptoms. One of the main limitations of endoscopic techniques for BPH is the occurrence of retrograde ejaculation. The purpose of this prospective observational study is to evaluate the efficacy and feasibility of ejaculation-sparing thulium laser enucleation of the prostate (ES-ThuLEP) in the treatment of BPH-related LUTS and the preservation of ejaculation. Sexually active patients with BPH were enrolled and followed up with at 3, 6, and 12 months after surgery. Personal and pharmacological histories were collected, while three standardized questionnaires—the International Index of Erectile Function short form (IIEF-5), the International Consultation on Incontinence Questionnaire for Male Sexual Matters Associated with Lower Urinary Tract Symptoms Module (ICIQ—MLUTSsex), and the International Prostatic Symptom Score (IPSS)—were administered. In addition, all patients underwent uroflowmetry and an assessment of post-void residual volume (PVR). A total of 53 patients were enrolled. A statistically significant improvement in the IPSS score, maximum flow (Qmax), and post-void volume (PVR) at 3 months, 6 months, and 12 months after surgery was found (p < 0.05), while no statistically significant differences were reported between IIEF-5 scores before and after surgery. A total of 48 patients (88.6%) had preserved ejaculation at 3 months, while 92.4% and 94.3% of patients reported preserved ejaculation at 6 and 12 months, respectively. Nevertheless, some degree of hypoposia was referred, at 3, 6, and 12 months, by 43.7%, 30.6%, and 13.2% of patients, respectively. The ES-ThuLEP technique successfully preserved ejaculation in over 90% of patients, representing an ejaculation-sparing alternative in the treatment of BPH.

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.

Comparison of outcomes of holmium laser versus bipolar enucleation of prostates weighing >80 g with bladder outlet obstruction

Transurethral enucleation of the prostate has been increasingly recognized as an effective minimally invasive technique for management of enlarged prostates. We aimed to compare holmium laser enucleation (HoLEP) and bipolar transurethral enucleation (B-TUEP) of large-volume prostates. A prospectively maintained database in two tertiary referral centers was reviewed for patients with HoLEP and B-TUEP for prostates >80 g. Operative data, perioperative complications, and early postoperative outcomes were compared. The study included 101 patients, 70 who underwent HoLEP and 31 who underwent B-TUEP. The operative enucleation rate (weight of adenoma enucleated in g/min) was higher in HoLEP compared to B-TUEP (P < 0.0001). The operative complication rate, hemoglobin drop, and readmission rate were comparable in both groups (P = 0.13, 0.35, 0.29, 0.59, respectively). The HoLEP arm had a shorter hospital stay and shorter catheterization time (P = 0.001, 0.012). Follow-up data showed a lower International Prostate Symptom Score and serum prostate-specific antigen level in the HoLEP group. The incontinence rate was comparable in both groups. In conclusion, both techniques were effective in managing a high-volume prostate, although HoLEP had a shorter enucleation time, better symptom score, lower postoperative prostate-specific antigen level, shorter catheterization time, and shorter hospital stay compared to B-TUEP.

The Efficacy and Safety of HoLEP for Benign Prostatic Hyperplasia With Large Volume: A Systematic Review and Meta-Analysis

This meta-analysis was to evaluate the efficacy and safety of holmium laser enucleation of prostate (HoLEP) in the treatment of benign prostatic hyperplasia (BPH) with large volume. PubMed, Embase, and Cochrane Library databases (until March 2022) were used to search related randomized controlled trials. A total of 11 studies including 1,258 patients were involved. HoLEP could significantly decrease the length of hospital stay and accelerate recovery. In subanalysis, HoLEP had better perioperative outcomes than bipolar transurethral resection of the prostate (B-TURP) and bipolar transurethral enucleation of the prostate (BPEP). The improvement in operative time and enucleation time was better in thulium laser enucleation of the prostate (ThuLEP) than HoLEP. In the follow-up period, the HoLEP decreased post-void residual urine (PVR) in short-term intervals and improved patients’ maximum flow rate (Qmax) and prostate-specific antigen (PSA) in mid- and long-term intervals. In subanalysis, HoLEP presented significant improvements in Qmax, PSA, and quality of life (QoL) than B-TURP, and HoLEP could also improve Qmax than ThuLEP after 6 months of surgery. The HoLEP reduced the risk of postoperative bleeding compared with other surgeries in safety. In our study, we confirmed the advantages of HoLEP in treating BPH when the prostate size was larger than 80 mL, which indicated that HoLEP could be the best choice for treatment of large volume of prostate.

“Fenestration and Tunnel Method” a Modification for the Holmium Laser Transurethral Prostatectomy of Large-Volume Prostates >80 ml: A Retrospective Study Based on 1-Year Follow-Up

The purpose of this study was to promote the holmium laser enucleation of the prostate (HoLEP) technology for large-volume prostates (>80 ml) and compare it with the traditional method, we modified the technique and applied this technology to clinical practice. A retrospective study comprising 118 patients who underwent HoLEP surgery from February 2018 to December 2019 was conducted in our center. Group A consisted of 57 patients with large-volume prostate (>80 ml) who received modified “fenestration and tunnel method” from February 2019 till December 2019, while group B consisted of 61 patients who received the traditional trivalvular operation method from February 2018 to December 2018 for comparison. Control subjects are selected such that they match the cases concerning certain characteristics, and perioperative data, voiding outcomes, and complications were evaluated at 1- and 12-month follow-up. The international prostatic symptomatic score (IPSS), quality of life (QoL), and maximum flow rate (Qmax) at 1 month and 12 months were both significantly improved compared with the preoperative baseline, and no significant differences were found between Groups A and B. The mean enucleation time, operation time, catheter indwelling duration, and hemoglobin decrease during the operation of Group A showed superiority compared with Group B (p<.05). The modified “fenestration and tunnel method” of HoLEP was statistically superior to the traditional trivalvular method in terms of the operation time, enucleation time, catheter indwelling duration, and hemoglobin decrease. For large-volume prostates (>80 ml), modified HoLEP was suggested to be a better treatment option.

Ex Vivo Exposure to Soft Biological Tissues by the 2-μm All-Fiber Ultrafast Holmium Laser System

We present the results of ex vivo exposure by an ultrafast all-fiber Holmium laser system to porcine longissimus muscle tissues. A simple Ho-doped laser system generated ultrashort pulsed radiation with less than 1 ps pulse width and a repetition rate of 20 MHz at a central wavelength of 2.06 μm. Single-spot ex vivo experiments were performed at an average power of 0.3 W and different exposure times of 5, 30 and 60 s, varying the total applied energy in the range of 1.5–18 J. Evaluation of laser radiation exposure was performed according to the depth and diameter of coagulation zones, ablation craters and thermal damage zones during the morphological study. Exposure by ultrashort pulsed radiation with an average power of 0.3 W showed destructive changes in the muscle tissue after 5 s and nucleation of an ablative crater. The maximum ablation efficiency was about 28% at the ablation depth and diameter of 180 μm and 500 μm, respectively. The continuous-wave radiation impact at the same parameters resulted only in heating of the near-muscular tissue, without ablation and coagulation traces. Exposure to tissue with an average power at 0.3 W of ultrashort pulsed radiation led, within 30 and 60 s, to similar results as caused by 0.5 W of continuous-wave radiation, although with less carbonization formation.

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.

Surgical treatment options for benign prostatic obstruction: beyond prostate volume

PURPOSE OF REVIEW

Many surgical treatment options are available for patients who present with benign prostatic obstruction (BPO). This article reviews the current treatment options available and distinguishes them based on five clinical considerations: antithrombotic therapy, sexual function preservation, ambulatory procedures, anesthesia-related risks and duration of catheterization.

RECENT FINDINGS

A comprehensive review of the literature was performed on 10 BPO procedures. Laser enucleation of the prostate (LEP), bipolar plasma transurethral vaporization of the prostate and photoselective vaporization (PVP) of the prostate reduces the risk of bleeding, which is recommended for anticoagulated men. Ejaculatory function is more likely to be preserved following transurethral incision of the prostate, Rezūm, Aquablation, UroLift and iTind. Same-day discharge is possible for LEP, PVP and prostatic arterial embolization (PAE). For patients with high anesthesia-related risks, procedures compatible with local anesthesia (UroLift, Rezūm, iTind and PAE) should be favored. Catheterization duration is shorter with UroLift, PVP and LEP.

SUMMARY

BPO treatment options are growing rapidly. The optimal procedure for a given patient is based on factors such as associated risks, recovery and expected outcomes. Besides prostate volume, the clinical considerations in the present article can help elucidate the best surgical BPO treatment option for each patient based on their values, preferences, and risk tolerance.

Experimental ex-vivo performance study comparing a novel, pulsed thulium solid-state laser, chopped thulium fibre laser, low and high-power holmium:YAG laser for endoscopic enucleation of the prostate

Purpose

The aim of this study was to compare the enucleation performances of four different types of laser devices in an ex-vivo experiment: a novel, pulsed Tm:YAG solid-state laser evaluation model (p-Tm:YAG), chopped thulium fibre laser (TFL), low-power Ho:YAG laser (LP-Ho:YAG), and a high-power Ho:YAG laser (HP-Ho:YAG).

Methods

Our primary aim was to endoscopically separate the fascial layers of a porcine belly using laser fibres within a time period of 60 s. The size of a “tissue pocket” was assessed numerically. The enucleation characteristics reflecting the surgeon’s experience were evaluated via the NASA Task Load Index (TLX) questionnaire and a questionnaire based on Likert scale.

Results

HP-Ho:YAG achieved with the available laser settings the largest overall “tissue pocket” (31.5 cm²) followed by p-Tm:YAG (15 cm²), TFL (12 cm²), and LP-Ho:YAG (6 cm²). The coagulation performances of p-Tm:YAG and TFL were rated the best. In the performance evaluation by the Likert questionnaire, HP-Ho:YAG (average score of 4.06) was rated highest, followed by p-Tm:YAG (3.94), TFL (3.38), and LP-Ho:YAG (3.25). The evaluation of the NASA-TLX performance questionnaire revealed average scores for HP-Ho:YAG, LP-Ho:YAG, TFL and p-Tm:YAG of 4.38, 4.09, 3.92 and 3.90, respectively.

Conclusion

We are the first to compare different laser devices and settings in an ex-vivo study. We found that the surgeons were most satisfied with the HP-Ho:YAG laser device, followed by the p-Tm:YAG. These findings could be highly relevant for future research and for the practical utilisation of laser systems in endourology.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03825-z.

Comparison of enucleation between thulium laser and holmium laser for benign prostatic hyperplasia: A systematic review and meta-analysis

To compare the clinical efficacy and safety of Thulium laser enucleation of prostate (ThuLEP) and Holmium laser enucleation of prostate (HoLEP). We systematically searched PubMed, Embase, and Cochrane Library databases within a period from the date of database establishment to October 2020. RevMan 5.4. was used for calculation and statistical analyses. 8 studies of 2125 patients were included. ThuLEP provided less hemoglobin decrease (MD: -0.37, 95%CI -0.61 to -0.14, P = 0.002) and shorter length of hospital stay (MD: -0.41, 95%CI -0.72 to -0.10, P = 0.01). During the postoperative follow-ups, statistically significant differences only were found in IPSS (MD: -0.96; 95%CI -1.27 to -0.65; P < 0.00001) at the 3rd month. In conclusion, our study demonstrates that ThuLEP, compared with HoLEP, has better security, faster improvement of symptoms. However, our conclusions still require a larger sample size, multi-center, and longer follow-up randomized controlled trials to verify.

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.

WOLF® PIRANHA VERSUS STORZ® PROSTATE MORCELLATION DEVICES: A RETROSPECTIVE MULTI-INSTITUTIONAL STUDY

PURPOSE

Holmium laser enucleation of the prostate (HoLEP) entails both enucleation and morcellation. Only three popular prostate morcellation devices (PMDs) are available for this procedure. In this study, a retrospective review was done to compare the Wolf and Storz morcellators.

MATERIALS AND METHODS

After IRB approval, a multi-institutional retrospective chart review of prospectively collected data was performed at two institutions with a single surgeon at each center performing HoLEP. Thunder Bay Regional Health Sciences Centre employed the Storz morcellator while Baylor Scott and White Medical Center used the Wolf. Preoperative, perioperative, postoperative, and demographic data for both sets of patients were analyzed and compared retrospectively.

RESULTS

506 patients in the Wolf cohort and 60 patients in the Storz cohort were analyzed. Morcellated pathologic weight was 52.3 g in the Wolf Arm and 101.7 g on the Storz arm (p < 0.0001). Overall, average morcellation rates were faster in the Storz arm; morcellation rate was 5.8 g/min for Wolf and 6.7 g/min in the Storz (p=0.0015). Morcellator malfunction was significantly lower in Wolf cohort 0% vs. 6.6% in the Storz (p=0.0001), but this did not significantly slow morcellator efficiency times. The total number of mucosal bladder injuries was comparable with rates of 1.4% and 1.6% in the Wolf and Storz groups, respectively (p=0.59). Duration of hospital stay and catheterization were less than 24 hours in both groups.

CONCLUSIONS

In this retrospective study, the Storz Drillcut had higher efficacy in morcellation when compared to Wolf Piranha. However, it was associated with more malfunctions. Both morcellators have comparable rates of complications and perioperative outcomes.

Laser enucleation for prostates larger than 100 mL: Comparison of HoLEP and ThuLEP

Recently, with the advancements in laser technology, Holmium laser enucleation of the prostate (HoLEP) and Thulium laser enucleation of the prostate (ThuLEP) have come to the fore in the surgical treatment of benign prostatic hyperplasia (BPH). We aimed to evaluate and compare the outcomes of HoLEP and ThuLEP in patients with >100 ml prostate volume. Patients who underwent HoLEP and ThuLEP between July 2017 and March 2020 were reviewed retrospectively. The patients were divided into two groups as HoLEP (Group 1, n = 121) and ThuLEP (Group 2, n = 104). Perioperative parameters, functional outcomes, continence status, intra and post-operative complications were compared between groups in the post-operative 1st and 6th month. No significant difference was found in terms of total laser energy (TLE), morcellation efficiency (ME), enucleated tissue weight (ETW), complication rates (CR) and continence status of patients between both groups (p > .05). In favour of ThuLEP group, there were statistically significant differences regarding total operation time (TOT), laser efficiency (LE), enucleation time (ET) and enucleation efficiency (EE) between groups (p ≤ .05). HoLEP and ThuLEP can be used safely and effectively in prostates larger than 100 ml.

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.

Enucleation vs. Resection: A Matched-pair Analysis of TURP, HoLEP and Bipolar TUEP in Medium-sized Prostates

OBJECTIVE

To evaluate efficacy and safety of holmium laser enucleation of the prostate (HoLEP), bipolar enucleation of the prostate (bTUEP) and transurethral resection of the prostate (TURP) in medium-sized prostates (50cc).

METHODS

We present a retrospective analysis of 2230 patients treated for lower urinary tract symptoms. We analysed perioperative parameters, short-term clinical outcomes and adverse events in matched-pair cohorts.

RESULTS

Both HoLEP and bTUEP were superior in terms of efficacy compared to TURP (surgery time: 51min and 50min vs. 60min; P < 0.001; tissue retrieval percentage: 71.4% and 70% vs. 50%; P < 0.001) and showed stronger improvement of LUTS (change IPSS: -15 and -14 vs. -10; P = 0.008). Furthermore, urodynamic parameters (Qmax: +15 ml/s and +19 ml/s vs. +12 ml/s; P < 0.001; PVR: -100 ml and -95 ml vs. - 80ml; P < 0.008) were significantly more improved after enucleation than after TURP. All techniques showed an equally low complication rate (6.9% and 6.9% vs. 10.3%; P = 0.743). No relevant difference of clinical outcomes was identified between HoLEP and bTUEP.

CONCLUSION

Both resection and enucleation are efficient and safe procedures in patients with medium-sized prostates (50cc), but irrespective of the technical approach, transurethral enucleation is superior to TURP in terms of perioperative and functional outcomes.

Holmium Versus Thulium Laser Enucleation of the Prostate: A Systematic Review and Meta-analysis of Randomized Controlled Trials

CONTEXT

Holmium (HoLEP) and thulium laser enucleation of the prostate (ThuLEP) are the two methods most commonly applied for endoscopic enucleation of the prostate. It remains unclear which of the two is superior in terms of outcome and complications.

OBJECTIVE

To compare perioperative and functional outcomes between HoLEP and ThuLEP.

EVIDENCE ACQUISITION

A systematic review and meta-analysis were performed according to the recommendations of the Cochrane Collaboration and in line with the PRISMA criteria. A comprehensive database search including MEDLINE, Web of Science, CINAHL, ClinicalTrials.gov, and CENTRAL was conducted according to the PICO criteria. Only randomized controlled trials (RCTs) were considered. All review steps were conducted by two independent reviewers. Risk of bias was assessed using the revised Cochrane tool for RCTs.

EVIDENCE SYNTHESIS

The search identified 556 studies, of which four were eligible for qualitative and quantitative analysis, reporting on a total of 579 patients with follow-up of up to 18 months. No significant differences in operating time, enucleation weight, catheterization time, or hospital stay were observed between ThuLEP and HoLEP. The decrease in hemoglobin was significantly lower for ThuLEP (mean difference -0.54 g/dl, 95% confidence interval [CI] -0.93 to -0.15; p < 0.001), but with low certainty of evidence. Transient urinary incontinence was more common for HoLEP (odds ratio 0.56, 95% CI 0.32-0.99; p = 0.045), again with low certainty of evidence. Furthermore, no significant differences were observed for other complications or for functional measures and symptom scores.

CONCLUSIONS

ThuLEP and HoLEP offer comparable improvement in symptoms and postoperative voiding parameters. Both procedures are safe and major complications are rare. ThuLEP showed minor advantages for blood loss and the incidence of transient incontinence. This should be interpreted with caution owing to the low certainty of evidence. Therefore, treatment choice should be based on surgeon expertise and local conditions.

PATIENT SUMMARY

We reviewed four clinical trials that compared holmium and thulium lasers for treatment to reduce the size of the prostate gland. Our review assessed outcomes and complications. We found that both laser techniques are safe and suitable for reducing symptoms due to an enlarged prostate. Blood loss and short-lasting urinary incontinence were slightly lower after thulium compared to holmium laser treatment.

Watt matters: Safety and efficacy of using a 140-W high-powered holmium laser for enucleation of the prostate (HoLEP)

OBJECTIVE

This study aimed to assess the perioperative and the 12-month efficacy and safety of 140 W high-powered holmium laser for enucleation of the prostate (HP-HoLEP) for the treatment of benign prostatic obstruction.

MATERIAL AND METHODS

The data of 540 patients who underwent HoLEP by a single surgeon were analyzed retrospectively. Preoperative evaluation included a physical examination with a digital rectal examination, measurement of maximum urinary flow rate (Q_max), postvoid residual volume (PVR) and prostate volume by transabdominal ultrasonography, serum prostate-specific antigen (PSA), international prostate symptom score (I-PSS) and international index of erectile function-5 (IIEF-5) questionnaires, and urine analysis. Morcellation, enucleation, and operation efficiencies were calculated with the resected weight divided by morcellation, enucleation, and operative times, respectively. The patients were reassessed at 1, 3, 6, and 12 months after surgery by I-PSS, IIEF-5, Q_max, PSA, and the occurrence of complications.

RESULTS

The mean operative time was 65.2±20.9 minutes. The mean enucleation time and efficiency were 53±15.1 minutes and 1.72±0.4 g/min, respectively. The mean morcellation time and efficiency were 12.3±15.1 minutes and 7.4±3.2 g/min respectively. Clavien grade 1 complications were observed in 102 (18.9%) patients, Clavien grade 2 complications in 20 (3.7%) patients, and Clavien grade 3b complications in 23 (5.4%) patients. I-PSS, Q_max, and IIEF-5 at postoperative 1, 3, 6, and 12 months were significantly better than baseline results.

CONCLUSION

Our study demonstrated that 140 W HP-HoLEP can be performed with high enucleation efficiency, low perioperative and postoperative complication rates, and excellent functional results.

Comparison of outcomes of Holmium enucleation of the prostate for small- and moderate-sized prostates

There is an ongoing discussion in the literature on the surgical treatment option for small prostate size benign prostate hyperplasia (BPH) patients. This study aimed to evaluate the efficacy of Holmium laser enucleation of the prostate (HoLEP) surgery in small (<30 ml) and moderate (30-80 ml) prostate size as accepted in European Association of Urology guideline. We retrospectively analysed our database between May 2016 and May 2019 and patients who underwent HoLEP surgery. Patients who have prostate size <80 ml were included the study. These patients were divided into two group: group 1 with prostate size <30 ml (n: 64) and group 2 with prostate size 30-80 ml (n: 101). Enucleation time (ET), morcellation time (MT), total operation time (OT), enucleation efficiency (EE), morcellation efficiency (ME), intra- and post-operative complications were analysed. While EE and Hb drop were better in favour of group 2; PSA drop, ET, MT, OT and ME were superior in favour of group 1. In group 1, intra-operative complications were higher (6 vs. 2; p < .05) and post-operative complications did not differ statistically between groups (p = .14). No statistically significant finding was found between groups regarding incontinence. In conclusion, HoLEP is a reliable method in terms of its results in patients with small prostates.

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.

Holmium laser enucleation of prostate by using en-bloc and bladder neck preservation technique: technical consideration and influence on functional outcomes

Background

This study aimed to evaluate the efficacy and safety of holmium laser enucleation of prostate (HoLEP) by using en-bloc and bladder neck preservation technique on benign prostatic hyperplasia (BPH) and assess the influence of this procedure on urinary and sexual functional outcomes.

Methods

A total of 704 patients with BPH undergoing HoLEP were retrospectively analysed. Amongst them, 213 who met the sexual function assessment criteria were further assessed the influence of the technique on sexual functional outcomes.

Results

The mean operative time, resected prostate weight and mean estimated blood loss were 69.3±14.8 min, 53.4±17.6 g and 62.1±23.7 mL, respectively. The mean duration of catheterization after surgery and mean hospital stay were 2.1±1 and 5.4±3.6 days, respectively. The post-void residual volume, maximum urinary flow rate, international prostate symptom score and quality of life score were all significantly improved postoperation (P<0.05). Amongst the 213 patients with normal antegrade ejaculation before surgery, postoperative international index of erectile function scores slightly improved, although the difference was insignificant (P>0.05). The difference in the Erection Hardness Grading Scale before and after surgery was statistically insignificant (P>0.05). A total of 25 (11.7%) patients had retrograde ejaculation after surgery.

Conclusions

HoLEP by an en-bloc and bladder neck preservation technique can obtain good functional outcome with small injury and high efficiency, especially for patients who need to preserve normal sexual function and anterograde ejaculation.

A prospective multicenter randomized comparison between Holmium Laser Enucleation of the Prostate (HoLEP) and Thulium Laser Enucleation of the Prostate (ThuLEP)

PURPOSE

To compare intra and perioperative parameters between HoLEP and ThuLEP in the treatment of benign prostatic hyperplasia and to evaluate clinical and functional outcomes of the two procedures with a 12-month follow-up.

METHODS

A prospective randomized study was performed on 236 consecutive patients who underwent ThuLEP (n = 115), or HoLEP (n = 121) in three different centers. Intra and perioperative parameters were analyzed: operative time, enucleated tissue weight, irrigation volume, blood loss, catheterization time, hospital stay and complications. Patients were evaluated preoperatively and 3 and 12 months postoperatively with the international prostate symptom score (IPSS), the quality of life (QoL) score, post-void residual volume (PVR), PSA and maximum flow rate (Q_max).

RESULTS

Preoperative variables in each study arm did not show any significant difference. Compared to HoLEP, ThuLEP showed similar operative time (63.69 vs 71.66 min, p = 0.245), enucleated tissue weight (48.84 vs 51.13 g, p = 0.321), catheterization time (1.9 vs 2.0 days, p = 0.450) and hospital stay (2.2 vs 2.8 days, p = 0.216), but resulted in less haemoglobin decrease (0.45 vs 2.77 g/dL, p = 0.005). HoLEP presented a significantly higher number of patients with postoperative acute urinary retention and stress incontinence. No significant differences were found in PSA, Q_max, PVR, IPSS and QoL score during follow-up.

CONCLUSION

ThuLEP and HoLEP both relieved lower urinary tract symptoms equally, with high efficacy and safety. ThuLEP detemined reduced blood loss and early postoperative complications. Catheterization time, enucleated tissue, hospital stay, operative time and follow-up parameters did not show any significant difference.

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.

Animal models of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms are common clinical concerns that affect aging men all over the world. The underlying molecular and cellular mechanisms remain elusive. Over the past few years, a number of animal models of BPH, including spontaneous model, BPH-induction model, xenograft model, metabolic syndrome model, mechanical obstruction model, and transgenic model, have been established that may provide useful tools to fill these critical knowledge gaps. In this review, we therefore outlined the present status quo for animal models of BPH, comparing the pros and cons with respect to their ability to mimic the etiological, histological, and clinical hallmarks of BPH and discussed their applicability for future research.

The Evolution of Endoscopic Prostate Enucleation: A historical perspective

Here, we review the evolution of prostate enucleation in chronological order based on energy technology starting first with holmium laser, then bipolar electrocautery, followed by thulium laser and finally greenlight and diode laser enucleation of the prostate.

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.

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.

Complications of anatomical endoscopic enucleation of the prostate

Transurethral resection of the prostate (TURP) remains the 'gold standard' for surgical treatment of benign prostatic obstruction (BPO). Recently, anatomical endoscopic enucleation of the prostate (AEEP) using holmium laser, thulium laser and plasma, etc., is extensively applied in clinical practice. However, perioperative complications of AEEP are inevitable in spite of lower incidence compared with TURP. This study reviewed the literature related to the aetiology, prevention and treatment of common complications of AEEP, which would contribute to the diagnosis and treatment of BPO.

Holmium laser enucleation of the prostate for the treatment of size-independent BPH: A single-center experience of 600 cases

OBJECTIVE

Holmium laser enucleation of the prostate (HoLEP) is an endourologic minimal invasive intervention of benign prostate hyperplasia (BPH). The interest on HoLEP is increasing in the literature. The aim of the present study was to evaluate the learning curve and our preliminary results.

MATERIAL AND METHODS

A retrospective analysis on 600 patients with BPH who underwent HoLEP between July 2015 and April 2019 was performed. Perioperative measures including enucleation efficiency (EE), morcellation efficiency (ME), and percentage of resected tissue weight (PRW) were recorded. Hospitalization time (HT) and catheterization time (CT) were measured. Functional outcomes, Clavien-Dindo classification complications, and continence status were assessed at 1-, 3-, and 6-month follow-up.

RESULTS

The mean age, prostate size, and prostate-specific antigen levels of the patients were 64.54 years, 91 g, and 4.54 ng/mL, respectively. There were 38.3% of patients with ≥100 g prostate size. The measured EE, ME, and PRW were 1.12 g/min, 4 g/min, and 72%, respectively. The mean HT and CT were 24.53 h and 21.50 h, respectively. Functional outcomes showed significant improvement at 1-, 3-, and 6-month follow-up. Intraoperative and postoperative complications were comparable with the literature. The most common perioperative complication was superficial bladder mucosal injury (n=8, 1.33%). Only one patient had persistent stress urinary incontinence at 6-month follow-up.

CONCLUSION

As mentioned in the literature, HoLEP indications are independent from prostate size. Our results showed similarity with the literature on functional outcomes, complication rates, and continence status. With its superior results, our HoLEP series from Turkey supports that HoLEP will replace transurethral resection of the prostate as the known current gold standard.