Holmium laser enucleation of the prostate for very large benign prostatic hyperplasia (≥ 200 cc)

Future aspects of plant derived bioactive metabolites as therapeutics to combat benign prostatic hyperplasia

ETHNOPHARMACOLOGICAL RELEVANCE

Benign prostatic hyperplasia (BPH), characterized by prostate enlargement due to cell proliferation, is a common urinary disorder in men over 50, manifesting as lower urinary tract symptoms (LUTS). Currently, several therapeutic options are accessible for treating BPH, including medication therapy, surgery and watchful waiting. Conventional drugs such as finasteride and dutasteride are used as 5α-reductase inhibitors for the treatment of BPH. However long-term use of these drugs is restricted due to their unpleasant side effects. Despite the range of available medical therapies, the effective treatment against BPH is still inadequate. Certain therapeutic plants and their phytochemicals have the aforementioned goals and work by regulating this enzyme.

AIM OF THE STUDY

This review aims to provide a comprehensive insight to advancements in diagnosis of BPH, modern treatment methods and the significance of ethnobotanically relevant medicinal plants as alternative therapeutics for managing BPH.

MATERIAL AND METHODS

A thorough and systematic literature search was performed using electronic databases and search engines such as PubMed, Web of Science, NCBI and SciFinder till October 2023. Specific keywords such as "benign prostatic hyperplasia", "medicinal plants", "phytochemicals", "pharmacology", "synergy", "ethnobotany", "5-alpha reductase", "alpha blocker" and "toxicology". By include these keywords, a thorough investigation of pertinent papers was assured, and important data about the many facets of BPH could be retrieved.

RESULTS

After conducting the above investigation, 104 herbal remedies were found to inhibit Phosphodiesterase-5 (PDE-5) inhibition, alpha-blockers, or 5α -reductase inhibition effects which are supported by in vitro, in vivo and clinical trial studies evidence. Of these, 89 plants have ethnobotanical significance as alpha-blockers, alpha-reductase inhibition, or PDE-5 inhibition, and the other fifteen plants were chosen based on their ability to reduce BPH risk factors. Several phytocompounds, including, rutaecarpine, vaccarin, rutin, kaempferol, β-sitosterol, quercetin, dicaffeoylquinic acid, rutaevin, and phytosterol-F have been reported to be useful for the management of BPH. The use of combination therapy offers a strong approach to treating long-term conditions compare to single plant extract drugs. Furthermore, several botanical combinations such as lycopene and curcumin, pumpkin seed oil and saw palmetto oil, combinations of extracts from Funtumia africana (Benth.) Stapf and Abutilon mauritianum (Jacq.) Medik., and Hypselodelphys poggeana (K.Schum.) Milne-Redh. and Spermacoce radiata (DC.) Sieber ex Hiern are also supported through in vitro and in vivo studies for managing BPH through recuperation in patients with chronic long-term illnesses, as measured by the International Prostate Symptom Score.

CONCLUSION

The review proposes and endorses careful utilization of conventional medications that may be investigated further to discover possible PDE-5, 5 alpha-reductase, an alpha-blocker inhibitor for managing BPH. Even though most conventional formulations, such as 5 alpha-reductase, are readily available, systemic assessment of the effectiveness and mechanism of action of the herbal constituents is still necessary to identify novel chemical moieties that can be further developed for maximum efficacy. However, there exist abundant botanicals and medicinal plants across several regions of Africa, Asia, and the Americas, which can be further studied and developed for utilization as a potential phytotherapeutic for the management of BPH.

Prostate Artery Embolization (PAE) with Small Beads for the Treatment of Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH) is the most frequent cause of Lower Urinary Tract Symptoms (LUTSs) in elderly populations. Minimally invasive treatments of BPH are safe and effective and are gaining popularity among both professionals and patients. Prostate Artery Embolization (PAE) has proven to be effective in Trans-Urethral Resection of the Prostate (TURP) in terms of prostate volume reduction and LUTS relief. PAE entails the selective catheterization of the prostatic artery and later embolization of distal vessels with beads of various calibers. Universal consensus regarding the ideal particle size is yet to be defined. We retrospectively evaluated 24 consecutive patients (median age: 75 years; range: 59-86 years) treated with PAE at our institution from October 2015 to November 2022. Particles of different sizes were employed; 12 patients were treated with 40-120 µm particles, 5 with 100 µm, 5 with 100-300 µm and 2 with 250 µm. Technical success, defined as selective prostate artery catheterization and controlled release of embolizing beads, was achieved in all patients. Removal vs. retention of the urinary catheter at the first post-procedural urological visit was the main clinical objective. No major peri-procedural complications were recorded, with 56% of patients successfully removing the urinary catheter.

[Prostate Surgery for Benign Prostatic Syndrome >200 ml: Endoscopic, Robotic, or Open Approach]

Surgical approaches for benign prostatic hyperplasia have evolved and diversified over the past decades. While numerous studies document the efficacy of surgical procedures for moderate prostate sizes, there remains insufficient data for large prostate volumes >200 ml, leaving important questions unanswered regarding their effectiveness and safety. Consequently, selecting and adapting suitable therapeutic options for this specific patient group often poses a significant challenge. In this context, this review comprehensively summarizes and discusses current insights into surgical treatment options for large prostate volumes (>200 ml) following an extensive literature review.In summary, the surgical treatment of prostate volumes >200 ml is a challenge regardless of the chosen surgical method. Minimally invasive approaches should be considered standard practice today. Anatomical endoscopic enucleation of the prostate is a size-independent method and has the lowest morbidity. As it may be performed in spinal anaesthesia, endoscopic enucleation is feasible in patients with an increased anaesthetic risk. In extremely large prostate glands, the procedure poses challenges even for highly experienced surgeons. Especially in obese patients, the surgeon should be familiar with different exit strategies. Robot-assisted simple prostatectomy provides a minimally invasive alternative that may also treat pathologies such as diverticula or large bladder stones in the same surgical session. Due to its transabdominal approach, the morbidity and anaesthetic risk is comparatively higher. Each centre and surgeon should individually decide in which method they have the greatest expertise and which option is best suited for the specific case. In cases of limited expertise, it is advisable to refer patients to a centre with appropriate specialization.

Urethral-sparing laparoscopic simple prostatectomy for the treatment of benign prostatic hyperplasia with asymptomatic urethral stricture after urethral stricture surgery

OBJECTIVE

To evaluate the efficacy of urethral-sparing laparoscopic simple prostatectomy (US-LSP) for the treatment of large-volume (>80 ml) benign prostatic hyperplasia (BPH) with asymptomatic urethral stricture (urethral lumen > 16 Fr) after urethral stricture surgery.

METHODS

We retrospectively analyzed clinical data of 39 large-volume BPH patients with asymptomatic urethral stricture after urethral stricture surgery who underwent US-LSP from January 2016 to October 2021. Postoperative follow-ups were scheduled at 1, 3, and 6 months.

RESULTS

All patients affected by significant BPH-related lower urinary tract symptoms (LUTS) including 22 cases with asymptomatic anterior urethral stricture and 17 cases with asymptomatic posterior urethral stricture. Median operative time was 118 min (interquartile range [IQR]100-145). Median estimated blood loss was 224 ml (IQR: 190-255). 33 patients(84.6%) avoided continuous bladder irrigation. Postoperative complications occurred in 5 patients (12.8%), including 4 cases with Clavien-Dindo grade 1 and grade 2 and 1 case with grade 3a. During follow-up, US-LSP presented statistically significant improvements in LUTS compared to baseline (P < 0.05). A total of 25 patients had normal ejaculation preoperatively and 3 patients (12%) complained retrograde ejaculation postoperatively. Two patients (5.1%) reported stress urinary incontinence (SUI) and no patient reported aggravated urethral stricture during follow-up.

CONCLUSIONS

US-LSP was safe and effective in treating large-volume BPH with asymptomatic urethral stricture after urethral stricture surgery. Meanwhile, US-LSP could reduce the risk of SUI in patients with asymptomatic posterior urethral stricture and maintain ejaculatory function in a high percentage of patients.

Early experience of "En bloc" holmium laser enucleation of the prostate in Saudi Arabia

Purpose

Holmium laser enucleation of the prostate (HoLEP) showed higher efficacy than transurethral resection for treating benign prostatic hyperplasia (BPH). The present study aims to report the outcome of BPH treatment by HoLEP in a tertiary center.

Patients and Methods

An observational prospectively collected data for consecutive symptomatic BPH patients undergoing HoLEP between January 2020 and December 2021. Demographic and perioperative data were collected with the International Prostate Symptom Score (IPSS), quality of life, peak flow rate (Qmax), residual urine postvoid residual (PVR), and prostate-specific antigen (PSA) changes, in addition to perioperative and late adverse events.

Results

One hundred patients were included with a median age of 73 years (range 65-80). The IPSS improved by 80% postoperatively (25 vs. 5, P < 0.001). Similarly, Qmax significantly improved. Seven patients were found to have incidental prostate cancer. No patient needed a perioperative blood transfusion. Compared to its preoperative values, follow-up PSA has been reduced by 75% (P < 0.001). Urethral stricture and bladder neck contracture were noted in < 2% of the patients.

Conclusions

HoLEP is feasible for all prostate sizes and a safe and effective treatment for BPH patients; our results are consistent with the reported data in the literature regarding functional outcomes, complication rates, and urinary incontinence rates.

Transurethral bipolar enucleation using a TUEB loop for large benign prostatic hyperplasia: a retrospective cohort study

PURPOSE

We aimed to assess the efficacy and safety of transurethral enucleation with bipolar system (TUEB) regardless of the prostate size using a specially developed TUEB loop.

METHODS

A total of 251 patients who underwent TUEB were categorized into two groups depending on the prostate volume (PV): small-PV (≤ 80 mL) group, 133 patients; large-PV (> 80 mL) group, 118 patients. Comparisons of background information and treatment outcomes were performed between the groups.

RESULTS

Operation (113.5 vs 166.4 min), enucleation (49.4 vs 68.1 min), and morcellation (11.4 vs 26.4 min) times were longer and hemoglobin decreased significantly (0.84 vs 1.30 g/dL) in the large PV group. However, the enucleation efficiency (enucleated weight per enucleation time; 0.71 vs 0.97 g/min) and prostate-specific antigen reduction rate (24.6% vs 16.1%) were significantly better in the large-PV group, with similar enucleation rates (enucleated weight per transitional zone volume; 82% vs 81%). The International Prostate Symptom Score, uroflowmetry maximum flow rate, and post-void residual urine in both groups improved at 3, 6, and 12 months compared with baseline. No patient underwent blood transfusion. There were no differences in the frequency of postoperative clot retention, urethral stricture, or stress incontinence at 3, 6, and 12 months.

CONCLUSION

TUEB using a TUEB loop resulted in high levels of satisfaction regarding the enucleation efficiency, efficacy, and safety for BPH surgery regardless of the prostate size. TUEB should be considered one of the best treatment options for large BPH that is uncontrollable with medication.

Advances in lasers for the minimally invasive treatment of upper and lower urinary tract conditions: a systematic review

PURPOSE

Technological advancements in laser lithotripsy are expanding into numerous fields of urology, like ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and benign and malignant soft-tissue treatments. Since the amount of research regarding lasers in urology has grown exponentially, we present a systematic review of the most recent and relevant advances encompassing all lasers used in urological endoscopic treatment.

METHODS

We performed a literature search using PubMed (May 2023) to obtain information about lasers for urological purposes. We included only recent data from published articles between 2021 and 2023 or articles ahead of print.

RESULTS

Lasers are widely used in lithotripsy for ureteric, renal, and bladder stones, benign prostate surgery, and bladder and upper tract tumor ablation. While the holmium (Ho:YAG) laser is still predominant, there seems to be more emphasis on pulse modulation and newer lasers such as thulium fiber laser (TFL) and pulsed Tm:YAG laser.

CONCLUSION

The use of lasers and related technological innovations have shown increasing versatility, and over time have proven to be invaluable in the management of stone lithotripsy, treatment of benign and malignant prostate diseases, and urothelial tumors. Laser endoscopic treatment is heavily based on technological nuances, and it is essential to know at least the basics of these technologies. Ultimately the choice of laser used depends on its availability, cost, surgeon experience and expertise.

Is Holmium Laser Enucleation of the Prostate Truly Size-Independent? A Critical Evaluation at the Extreme Ends of the Spectrum

OBJECTIVE

To assess the outcomes of holmium laser enucleation of the prostate (HoLEP) at the extremes of the size spectrum, comparing whether the results are consistent for very large and small prostates.

METHODS

A retrospective review of 402 patient charts was conducted to compare the outcomes of HoLEP in patients with prostate size ≤40 g (group 1), 41-200 g (group 2), and >200 g (group 3). Various preoperative, perioperative, and postoperative variables were collected.

RESULTS

HoLEP showed comparable voiding outcomes among all 3 groups, although patients with small prostates had a higher International Prostate Symptom Score during follow-up (P = .022). We noted a higher rate of perioperative blood transfusion in patients with very large prostates (P = .019) and a higher rate of transient acute urinary retention (AUR) in group 1 when compared to group 3 (P = .048). Patients with smaller prostates had a higher rate of bladder neck stenosis and urethral strictures, but the differences were not found to be statistically significant. The incidence of other complications, length of hospital stay, and catheterization duration did not differ significantly among the groups.

CONCLUSION

HoLEP has consistent and safe outcomes across a wide range of prostate sizes. Although, the risk of blood transfusion is higher in patients with very large prostates and the risk of transient AUR is greater in patients with small glands, the overall efficacy and safety of HoLEP are not significantly influenced by prostate size.

Robotic assisted simple prostatectomy versus other treatment modalities for large benign prostatic hyperplasia: a systematic review and meta-analysis of over 6500 cases

BACKGROUND

Current guidelines recommend simple prostatectomy or endoscopic enucleation of the prostate (EEP) as treatment of choice for bladder prostatic obstruction (BPO) caused by large prostate glands. We aimed to provide a wide-ranging analysis of the currently available evidence, comparing safety and effectiveness of robot-assisted simple prostatectomy (RASP) versus open simple prostatectomy (OSP), laparoscopic simple prostatectomy (LSP), and laser EEP.

METHODS

A systematic search was performed across MEDLINE, EMBASE, and Web of Science databases for retrospective and prospective studies comparing RASP to OSP or LSP or laser EEP (HoLEP/ThuLEP). Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) recommendations were followed to design the search strategies, selection criteria, and evidence report. A meta-analysis evaluated perioperative safety and effectiveness outcomes. The weighted mean difference and risk ratio were used to compare continuous and dichotomous variables, respectively. Quality was assessed using the Newcastle-Ottawa scale and the Cochrane Collaboration's tool for RCT article assessing risk of bias.

RESULTS

15 studies, including 6659 patients, were selected for meta-analysis: 13 observational studies, 1 non-randomized prospective study, and 1 randomized controlled trial. RASP was associated with statistically significant longer operative time (OT) and lower postoperative complication rate, length of stay (LOS), estimated blood loss (EBL), and transfusion rate (TR) compared to OSP. LSP showed longer LOS and lower postoperative SHIM score, with no difference in OT, EBL, and complications. Compared to laser EEP, RASP presented longer LOS and catheterization time and higher TR. ThuLEP presented shorter OT than RASP. No difference were found in functional outcomes between groups both subjectively (IPSS, QoL) and objectively (Qmax, PVR).

CONCLUSION

RASP has become a size-independent treatment for the management of BPO caused by a large prostate gland. It can duplicate the functional outcomes of OSP while offering a better safety profile. When compared to LSP, the latter still stands as a valid lower-cost option, but it requires solid laparoscopic skill sets and therefore it is unlikely to spread on larger scale. When compared to laser EEP, RASP offers a shorter learning curve, but it still suffers from longer catheterization time and LOS.

Outcomes of holmium laser enucleation of the prostate (HoLEP) for very large-sized benign prostatic hyperplasia (over 150 mL): open simple prostatectomy is dead

INTRODUCTION

Our study aimed to describe the outcomes of transurethral enucleation of the prostate (HoLEP) for large-sized benign prostatic hyperplasia over 150 mL (bBPH).

METHODS

We conducted a retrospective, descriptive, and analytical study of patients undergoing HoLEP for bBPH. The primary endpoint was the success of the procedure, defined by a mixed criteria: complete endoscopic enucleation of the prostate, absence of blood transfusion or reoperation for bleeding, post-operative improvement of quality of life (assessed by a ≥ 2 points increase at in the 8th question of the IPSS test) and post-operative continence (no pads use) at 3 months.

RESULTS

Eighty-one patients were included with a mean age of 73.9 ± 7.3 and a mean measured prostate volume of 183.3 ± 34.5 cc. The mean operative time was 57.5 ± 29.7 min and the average wet weight of resected tissue removed was 151.8 ± 44.7 g. Mean hospitalization stay was 1.3 ± 0.7 days with a mean post-operative catheterization period of 1.9 ± 0.9 days. The success of the surgery was achieved in 77 patients (95%). Functional improvements were found at 1 and 6 months for Qmax, post-void residual, IPSS and QoL-IPSS. The 30-day complication rate was 9.9%. The average PSA level dropped from 14.8 ± 11.6 ng/mL at baseline to 0.8 ± 0.5 ng/mL at 6 months.

CONCLUSION

HoLEP for bBPH is both safe and efficient. Regarding the benefit/risk balance, it should be highlighted as the gold standard for the management of big BPH.

Predictive factors affecting morcellation efficiency in holmium laser enucleation of the prostate

PURPOSE

To determine the factors affecting morcellation efficiency in holmium laser enucleation of the prostate (HoLEP) surgery.

MATERIALS AND METHODS

Patients who underwent HoLEP surgery by a single surgeon between 2018 and 2022 were included in the study. Our primary outcome of interest in this study was morcellation efficiency. The effect of preoperative and perioperative variables on morcellation efficiency was evaluated with linear regression analysis.

RESULTS

A total of 410 patients were included in the study. The mean morcellation efficiency was 6.95±1.70 g/min. Univariable and multivariable linear regression analysis was performed to identify factors affecting morcellation efficiency. Presence of the "beach ball" effect (small, round prostatic tissue fragments that are fibrotic and difficult to morcellate), the learning curve, resectoscope sheath type, prostate-specific antigen (PSA) density, morcellated tissue weight, and the presence of prostate calcification were found to be independent predictive factors (β=-1.107, 95% CI: -1.59 to -0.55, p<0.001; β=-0.514, 95% CI: -0.85 to -0.17, p=0.003; β=-0.394, 95% CI: -0.65 to -0.13, p=0.003; β=-0.302, 95% CI: -0.59 to -0.09, p=0.043; β=0.062, 95% CI: 0.05 to 0.06, p<0.001; β=-0.329, 95% CI: -0.55 to -0.10, p=0.004; respectively).

CONCLUSIONS

This study reports that presence of the beach ball effect, the learning curve, small resectoscope sheath, PSA density, and presence of prostate calcification negatively affect morcellation efficiency. On the contrary, morcellated tissue weight has a linear relationship with morcellation efficiency.

Predictors of readmission and impact of same-day discharge in holmium laser enucleation of the prostate

Background

Holmium enucleation of the prostate (HoLEP) is becoming the gold standard for the treatment of benign prostatic hyperplasia (BPH). Our objective was to identify predictors of 30-day readmission and the impact of same-day discharge after HoLEP.

Methods

Using NSQIP data from 2011 to 2019, we identified men who underwent HoLEP for the treatment of BPH. We compared patients based on time of discharge and readmission status. We used multivariable logistic regression analysis (MLRA) to identify independent factors associated with 30-day readmission.

Results

A total of 3,489 patients met inclusion criteria with 833 (23.88%) being discharged within 24 hours and 2,656 (76.12%) discharged after 24 hours. There were 158 (4.53%) 30-day readmissions, mostly due to hematuria and urinary tract infection. Patients being readmitted were older (72 vs. 70 years old, P = 0.001), were more likely to have preoperative anemia (36.7% vs. 23.1%; P < 0.001), chronic kidney disease (29.7% vs. 19.7%; P < 0.001), bleeding disorder (10.8% vs. 2.8%; P < 0.001), higher American Society of Anesthesiologists (ASA) scores (≥3: 70.3% vs. 46.7%; P < 0.001) and a higher frailty burden (5-item modified frailty index [5i-mFI] ≥ 2: 36.1% vs. 19.1%; P < 0.001) compared to their counterparts. Factors independently associated with 30-day readmission were bleeding disorder (OR 2.89; 95% CI 1.63-5.11; P < 0.001), 5i-mFI ≥ 2 (OR 1.67; 95% CI 1.03-2.71; P = 0.038) and an ASA score ≥3 (OR 1.80; 95% CI 1.21-2.70; P = 0.004); however, same-day discharge was not found to be a significant predictor of 30-day readmissions.

Conclusion

The overall readmission rate after HoLEP is low. Patients discharged within 24 hours have similar rates of readmission compared to patients discharged after 24 hours. We found bleeding disorder, frailty burden, and ASA score to be independent predictors of 30-day readmission.

Incidence and risk factors for postoperative urinary incontinence after various prostate enucleation procedures: systemic review and meta-analysis of PubMed literature from 2000 to 2021

PURPOSE

To evaluate the risk of urinary incontinence (UI) after various prostate enucleation procedures (PEP).

METHODS

PubMed was searched from January 2000 to July 2021 for studies investigating UI after PEP. The articles were divided into 5 subgroups: holmium, thulium, greenlight laser, electrocautery, and simple prostatectomy. Meta-analysis was performed to examine rate of stress (SUI), urge (UUI) or unspecified UI at short (< 3 months), intermediate (3-6 months), and long-term (> 6 months). The impact of age, prostate size, surgery time, laser time, postoperative nadir PSA level and technical modifications on UI was analyzed.

RESULTS

Most (69.4%) of 49 articles included employed holmium laser. There was no significant difference in incidence of short-, intermediate-, and long-term UI, SUI and UUI between five sub-groups and within different technical modifications. Although not statistically significant, the incidence of UI was higher (15%) at short-term with green-light and simple prostatectomy (95% CI 9-23 and 1-84), and higher (4%) at intermediate-term with holmium laser (95% CI 2-8). SUI was more prevalent at short-term with holmium laser (4%; 95% CI 2-5%), and at intermediate term with simple prostatectomy (3%; 95% CI 1-14). UUI was higher in the thulium group (10%, 95% CI 7-16). Increased age, surgery time, laser time and prostate size up to 80 cc were associated with higher UI. There was no correlation between postoperative PSA and UI.

CONCLUSIONS

There is no significant difference in incidence of UI, SUI and UUI after various PEP. Patients age, prostate size, surgery and laser time are linearly associated with UI.

Improving Prostatic Preoperative Volume Estimation and Planning before Laser Enucleation

We aimed to validate a formula for improving the estimation of prostatic volume by abdominal ultrasound (AUS) prior to transurethral laser enucleation. A total of 293 patients treated for benign prostate hyperplasia (BPH) by laser enucleation from 2019−2022 were included. The preoperative AUS volume was adjusted by the formula 1.082 × Age + 0.523 × AUS − 53.845, which was based on specimens retrieved by suprapubic prostatectomy. The results were compared to the weight of the tissue removed by laser enucleation as determined by the intraclass correlation coefficient test (ICC). The potential impact of preoperative planning on operating time was calculated. The ICC between the adjusted volumes and the enucleated tissue weights was 0.86 (p < 0.001). The adjusted volume was more accurate than the AUS volume (weight-to-volume ratio of 0.84 vs. 0.7, p < 0.001) and even more precise for prostates weighing >80 g. The median operating time was 90 min. The adjusted volume estimation resulted in an overall shorter expected preoperative operating time by a median of 21 min (24%) and by a median of 40 min in prostates weighing >80 g. The adjustment formula accurately predicts prostate volume before laser enucleation procedures and may significantly improve preoperative planning, the matching of a surgeon’s level of expertise, and the management of patients’ expectations.

Laser enucleation of the prostate in men with very large glands ≥175 ml: A systematic review

Background

Surgical treatment options for lower urinary tract symptoms can differ according to prostate size. There are few studies on the efficacy and safety of endoscopic enucleation of prostate (EEP) in patients with very large prostates focusing on laser as energy source. In this systematic review, we aimed to examine the efficacy and safety of laser-based EEP on prostate glands ≥150 ml.

Methods

A systematic search was conducted using Web of Science, PubMed-MEDLINE, Wiley Online Library and Cochrane Library databases with the following search terms solely or in combination: "large prostate", "laser enucleation", "laser prostatectomy"by combining PICO (population, intervention, comparison, and outcome) terms. Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed.

Results

We retrieved 6 studies included 375 patients with prostate sizes ≥175 ml treated with laser-based EEP for symptomatic benign prostatic obstruction. Three studies examined Holmium laser enucleation of prostate (HoLEP) outcomes with a prostate volume (PV) >200 ml, one evaluated HoLEP outcomes with a PV of 200–299 and ≥ 300 ml, two studies evaluated HoLEP outcomes with a PV > 175 ml. We observed improvement in postoperative functional outcomes in patients with a PV > 175, >200 and >300 ml. The retreatment rate was 0–1.3% in all studies involving prostate size ≥175 ml. Most of the complications were Clavien-Dindo I (%0–9) and II (%12.7–16.6).

Conclusions

Laser-based EEP is an efficient, safe and feasible procedure even in very large prostates with good functional outcomes, low perioperative complication and retreatment rates.

•

We observed better postoperative functional outcomes in prostates with a volume of ≥175, >200 and >300 ml in the present study.

•

The retreatment rate was 0–1.3% in all studies involving prostate size ≥175 ml.

•

Laser-based- endoscopic enucleation of the prostate is an efficient, safe and feasible procedure even in very large glands.

Toxicity and outcomes after external beam irradiation for prostate cancer in patients with prior holmium laser enucleation of the prostate: Early experience

PURPOSE/OBJECTIVES

Holmium laser enucleation of the prostate (HoLEP) is commonly performed in patients with significant bladder outlet obstruction. However, there are few reports on the toxicity of external beam irradiation (RT) for prostate cancer in patients after prior HoLEP. In this study, we evaluate the side effects and treatment outcomes of RT after HoLEP.

MATERIALS/METHODS

Eighteen patients who had HoLEP and subsequently received RT for prostate cancer were included. Data collected included patient and disease characteristics, urinary function, and radiation dose. Acute and late urinary (GU) and gastrointestinal (GI) side effects were evaluated. Disease control and survival rates were calculated using Kaplan-Meier method.

RESULTS

Median follow-up was 18 months (range: 4-46 months). Median prostate volume was 107 ml before HoLEP and 24 ml after HoLEP. Median International Prostate Symptom Score (IPSS) was 17 (range: 5-32) before HoLEP. Median decline in IPSS score after HoLEP was 7 (range: -2-21). On uroflow study, peak flow rate, and post-void residual were significantly improved after HoLEP. After radiation, peak flow rate and average flow rate showed a decline but remained significantly improved compared to pre-HoLEP measurements. Maximum acute Common Terminology Criteria for Adverse Events (CTCAE) adverse events were 12 grade 1 and 3 grade 2 for GU, and 3 grade 1 for GI, respectively. Maximum late adverse events were 13 grade 1 and 2 grade 2 for GU, and all grade 0 for GI, respectively. At last follow-up, there were 8 grade 1 and 1 grade 2 late GU, and 3 grade 1 late GI adverse events, respectively. There was no significant increase in urinary incontinence after RT compared to before RT. The 18-month biochemical control, local control, distant control rates were 78%, 94%, and 80%, respectively.

CONCLUSIONS

Patients who received RT as definitive treatment for prostate cancer after prior HoLEP had low risk of serious acute and late side effects. HoLEP can be safely performed and should be considered in patients with significant bladder outlet obstruction and large prostate volume before RT.

Japanese giant benign prostatic hyperplasia: Sibling cases

Introduction

The pathophysiology of benign prostatic hyperplasia (BPH) remains incompletely understood but is likely multifactorial. Inflammation and metabolic factors may increase the risk of BPH. Several studies have evaluated the possible roles played by genetic factors. Here, we describe two cases of suspected familial BPH.

Case presentations

We report the cases of two brothers, aged 77 and 69 years, with giant BPH. As both exhibited urinary retention, we performed Holmium Laser Enucleation of the Prostate (HoLEP) and obtained tissue samples weighing 276 g and 153 g, respectively. The postoperative courses were good.

Conclusion

We experienced two cases of sibling BPH with volumes exceeding 200 mL and successfully treated them with HoLEP.

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.

Conversion of Holmium Laser Enucleation of Prostate to Open Prostatectomy

OBJECTIVES

To determine the incidence and predictive factors for conversion to an open procedure during Holmium Laser Enucleation of Prostate (HoLEP).

METHODS

A retrospective review was performed on files of all patients that underwent HoLEP at our institution between 2013 and 2020. Data collected included demographics, pre-operative estimated prostate size, intraoperative data, pathologic data, and functional baseline. A univariate and multivariate comparison between the pre-operative data of converted and un-converted cases was conducted.

RESULTS

Among a total of 807 HoLEP procedure performed during the above period, 20 cases were converted to open procedures (2.4%). Median pre-operative estimated prostate size in cases of conversion was 228ml compared to 95ml for unconverted cases (p<0.001). The reasons for conversion were anatomical in 8 cases (40%), bleeding that was difficult to control endoscopically in 4 cases (20%), expected procedure to be too long due to large prostate size in 6 cases (30%), one case of morcellation technical malfunction, and one case with very large bladder stones not suitable for endoscopic treatment. Prostate size was the only factor that was found to be associated with conversion in univariate and multivariate analysis.

CONCLUSIONS

The risk of conversion of HoLEP to open procedures is size-dependent. The risk for conversion to open prostatectomy/cystotomy must be communicated to patients who choose HoLEP to improve the informed consent process and provide the highest quality of patient care and transparency. Open prostatectomy/cystotomy should be a part of the armamentarium of every HoLEP surgeon operating on large prostates.

Holmium Laser Enucleation of the Prostate Efficiency by Prostate Gland Size: Is There a Sweet Spot?

Holmium laser enucleation of the prostate (HoLEP) is one of only two AUA guideline-recommended prostate size-independent surgeries for benign prostate hyperplasia (BPH). The significant variation in gland size treated results in a wide range of enucleation and morcellation times. We sought to understand the effect of prostate size on HoLEP efficiency to better educate patients and improve operative room utilization. After IRB approval, we identified patients from 1 July 2016 to 1 January 2020 who underwent HoLEP by two endourologists. Our primary objectives were to assess the effects of increasing increments (25 g) of mean enucleated prostate tissue weight on enucleation and morcellation efficiency (g/min). One-way Kruskal–Wallis ANOVA with Dunn’s post hoc test was used, with significant p < 0.05. We included 675 HoLEPs with all comers mean tissue weight resected of 72.1 g (Range 1–448 g), energy used 110.00 kJ (10.73–340 kJ), enucleation time 48.6 min (5–151 min), and morcellation time 10.1 min (0.5–113 min). Average enucleation efficiency increased with increasing prostate size categories (e.g., <25 g–0.48 g/min, >325 g–3.91 g/min) (K-W ANOVA p = 0.004, Dunn’s post hoc p = 0.004). The combined average enucleation and morcellation efficiency was ≥5 g/min between 55 and 271 g. Inefficiency for cases <55 g was driven by enucleation, while >271 g case inefficiency was driven by morcellation. Increasing tissue weight at the time of HoLEP is associated with a linear relationship of increasing enucleation and decreasing morcellation efficiencies.

Prostatic Artery Embolization: An Alternative Treatment for Benign Prostatic Hyperplasia

Purpose Prostatic artery embolization (PAE) has emerged as a minimally invasive alternative for patients with prostates >80 mL and has demonstrated lower morbidity rates. We sought to evaluate PAE at a single tertiary medical center. Methods A retrospective review of all patients who underwent PAE was completed. Demographic, clinicopathologic, procedure, and outcome data were collected to include international prostatic symptom score (IPSS) and quality of life (QoL) assessments. Results The pre-PAE mean prostate-specific antigen (PSA) was 8.4 ng/mL, mean prostate volume was 146.9 mL (9% >200 mL), and mean postvoid residual (PVR) was 208.2 mL (21.9% 200–300 mL). IPSS mean was 19.8 and QoL was “mostly dissatisfied.” Following PAE, mean PSA was reduced by 3.2 ng/mL (38.1%, p = 0.3014), the mean prostate volume reduction was 59.2 mL (40.3%, n = 19, p < 0.0001), and the average PVR reduction was 150.3 mL (72.2%, n = 27, p = 0.0002). Average IPSS score was also lower (11.9; 60.1%, n = 25, p < 0.0001) and QoL was reduced to “mostly satisfied” (p < 0.0001). Technical success was 100% with 24% minor morbidities. Conclusion PAE is a successful treatment for patients with BPH resulting in large prostates that are not good candidates for simple prostatectomy, providing optimal care with less operative and postoperative complications.

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.

A call for HoLEP: AEEP for mega-prostates (≥ 200 cc)

PURPOSE

To evaluate the efficiency and efficacy of HoLEP, and methods of tissue retrieval, in patients with prostate volume (PV) ≥ 200 cc (Group 1) and to compare these to patients with PV 80-199 cc (Group 2).

METHODS

A database of all cases performed under the care of two surgeons at a tertiary HoLEP centre was reviewed.

RESULTS

157 patients with PV ≥ 200 cc were compared to 157 of the most recent consecutive cases with PV 80-199 cc. Median (IQR) enucleation efficiency was greater in Group 1 [2.8 g/min (2.2-3.5)] than Group 2 [2.1 g/min (1.6-2.5), p < 0.001]. Morcellation efficiency did not differ significantly. Cystotomy was required for tissue retrieval in Group 1 only (5.7%). Decrease in serum haemoglobin (Hb) was greater in Group 1 (19 g/l (30-8) vs 12 (18-3.5), p < 0.001) with a transfusion rate of 4.5% vs 1.3%, respectively (p = 0.104). Length of stay was longer in Group 1 than Group 2 (1 day (1-2) vs 1 (1-1), p < 0.001). There were no significant differences between groups in: time to and success of first trial without catheter, pre- and post-operative IPSS, Qmax and PVR, and 3 month catheter-free and urinary incontinence rates.

CONCLUSION

HoLEP outcomes are largely PV-independent even when PV is ≥ 200 cc, although length of stay and reduction in Hb are greater in this group. Alternatives to pure morcellation, such as cystotomy and resection of nodules, are more likely to be necessary with PV ≥ 200 cc.

Morcellation After Endoscopic Enucleation of the Prostate: Efficiency and Safety of Currently Available Devices

CONTEXT

Although several studies have compared different morcellators and enucleation techniques for the management of benign prostatic hyperplasia (BPH), there is sparse literature on morcellation, so further experimental and clinical research is required for its optimization.

OBJECTIVE

To critically appraise the contemporary literature on prostate morcellation and to evaluate the safety and efficiency of currently available morcellators for endoscopic enucleation of the prostate (EEP) in the context of BPH.

EVIDENCE ACQUISITION

A comprehensive review of the English and French literature relevant to prostate morcellation was performed using the PubMed-MEDLINE, Cochrane Library, Web of Science, and Wiley Online Library database from 1998 to 2020 using PICOS (patient population, intervention, comparison, outcome, and study design) criteria.

EVIDENCE SYNTHESIS

We retrieved 26 studies involving 5652 patients treated with a morcellator that were eligible for data extraction and analysis. The mean patient age was 67.4 (range 61.4-72.8) yr. The weighted mean efficiency of Piranha, VersaCut, and DrillCut morcellators was 5.29, 3.95, and 5.3 g/min, respectively. Several approaches, such as en bloc, two-lobe, inverse, and improved techniques, may increase morcellation efficiency and safety. The lowest weighted mean rate of bladder wall injury was 1.24% for Piranha, followed by 1.98% for DrillCut, and 5.23% for VersaCut, while the VersaCut morcellator had the lowest weighted mean rate of device malfunction at 0.74%, compared to 2.07% for Piranha and 7.86% for DrillCut.

CONCLUSIONS

All three morcellators are efficient and safe for prostatic morcellation after EEP. Further development of devices and techniques may improve the efficiency and safety profile of morcellation. To increase safety, surgeon expertise, technical equipment, and patient characteristics should be considered. Therefore, interdisciplinary exchange of knowledge and further technological innovations are strongly encouraged.

PATIENT SUMMARY

We reviewed the safety and efficacy of devices called morcellators. These devices cut tissue into small pieces that are easier to remove from the body, and are used during laser surgery for benign enlargement of the prostate. Three morcellators are currently available on the market and are comparable in safety and efficacy.

Efficacy of holmium laser enucleation in patients with a small (less than 30 mL) prostate volume

Purpose

To evaluate the efficacy of holmium laser enucleation of the prostate (HoLEP) in patients with a small prostate volume (≤30 mL).

Materials and Methods

We retrospectively evaluated 1,135 patients who underwent HoLEP at two institutions between July 2007 and March 2020. Patients who were not evaluated for the International Prostate Symptom Score (IPSS) before or after HoLEP were excluded. We divided patients into two groups according to estimated prostate volume (ePV): ≤30 (n=198) and >30 mL (n=539). The patient characteristics, IPSS, peak urinary flow rate (Qmax), postvoid residual urine volume (PVR), and other data were compared before and after surgery in each group and between the two groups. Multivariate analysis was performed to identify the factors associated with the efficacy of HoLEP in the group with ePV ≤30 mL.

Results

A total of 737 patients were included in this retrospective study. ePV (23.4 mL vs. 50 mL; p<0.001) and PVR differed significantly between the two groups. The IPSS, IPSS-quality of life, PVR, and Qmax significantly improved after HoLEP in both groups. Improvements in the IPSS, IPSS-quality of life, Qmax, and PVR were greater in the >30 mL group (p<0.001), whereas operation time and morcellation time were significantly shorter in the ≤30 mL group. In the multivariate analysis, age <70 years was independently associated with improvement by HoLEP.

Conclusions

HoLEP is an effective treatment for patients with a small prostate, even though the extent of improvement after HoLEP was greater in those with a larger prostate.

Holmium laser enucleation of the prostate using Moses 2.0 vs non-Moses: a randomised controlled trial

OBJECTIVES

To compare the enucleation efficiency of Moses 2.0 with non-Moses technology in patients undergoing holmium laser enucleation of the prostate (HoLEP).

PATIENTS AND METHODS

A double-blinded, randomised study of patients undergoing HoLEP at the Mayo Clinic in Arizona, using the Lumenis Pulse™ 120H laser system. Patients were randomised to either right lobe enucleation using Moses 2.0 and left lobe enucleation using non-Moses, or the opposite. The primary outcome was individual lobe enucleation efficiency. Secondary outcomes included individual lobe laser time, laser energy, individual enucleation and haemostasis laser energies, and fibre burn back. Two independent reviewers watched videos of the procedures and provided a subjective evaluation of the technologies.

RESULTS

A total of 27 patients were included in the study. For the entire cohort, Moses 2.0 had less fibre degradation (3.5 vs 16.8 mm, P < 0.01) compared to non-Moses. When HoLEP procedures were performed by an expert, Moses 2.0 resulted in shorter enucleation time (21 vs 36.7 min, P = 0.016) and higher enucleation efficiency (1.75 vs 1.05 g/min, P = 0.05) compared to non-Moses. When HoLEP was performed by trainees, the Moses 2.0 cohort had a shorter haemostasis laser time (4.1 vs 9 min, P = 0.035) compared to the non-Moses. Fibre degradation was lower with Moses 2.0 compared to non-Moses for both experts and trainees. Moses 2.0 received a higher score than the standard technology for the incision sharpness, fibre control, tissue separation, tissue damage, haemostasis, visibility, and charring. The overall inter-observer correlation coefficient was 0.63.

CONCLUSION

Moses 2.0 has higher enucleation efficiency compared to non-Moses when used by experts. The subjective evaluation favoured Moses 2.0.

Efficacy, safety, and perioperative outcomes of holmium laser enucleation of the prostate-a comparison of patients with lower urinary tract symptoms and urinary retention

Holmium laser enucleation of the prostate (HoLEP) is a valid treatment option to relieve bladder outlet obstruction in patients with large prostate volumes (PV). Its efficacy, tolerability, and safety are comparable to the ones of other laser treatments of the prostate and resection techniques. However, safety and efficacy of HoLEP have not been compared between patients with and without preoperative urinary retention. We included 350 patients (mean age 71.2 years) who had undergone HoLEP due to lower urinary tract symptoms (LUTS) or urinary retention caused by prostatic hyperplasia. We evaluated the differences in peri- and postoperative outcomes and complications between patients with and patients without preoperative urinary retention. The mean PV was 115 cm³. PV was > 100 cm³ in 61.9% and < 100 cm³ in 38.1% of the patients. Perioperative complications occurred in 23 patients (6.6%), 15 of which (4.3%) required operative revision. We found no significant differences in terms of complication rates between patients with PV > 100 cm³ and patients with PV < 100 cm³. Mean catheterization-duration was 3.3 days. Preoperatively, 140 patients (40%) had a suprapubic or transurethral indwelling catheter; they did not differ from patients without preoperative catheter regarding postoperative catheter removal success rate, early postoperative complications, and functional outcomes. Prostate cancer was diagnosed in 43 patients (12.3%). Median postoperative PSA-decline was 6.1 ug/l (89.8% drop). HoLEP is a safe and effective treatment for patients with LUTS or urinary retention and large PV. PV > 100 cm³ was not associated with higher complication rates or successful catheter-removal. Furthermore, functional outcomes were independent of preoperative catheterization.