Comparison of thulium laser enucleation and plasmakinetic resection of the prostate in a randomized prospective trial with 5-year follow-up

Anatomic endoscopic enucleation of the prostate using a novel hybrid thulium:yttrium-aluminium-garnet laser generator: surgical technique and clinical outcomes

PURPOSE

We aim to report here the first clinical series of patients treated with AEEP using a novel hybrid thulium:yttrium-aluminium-garnet (Tm:YAG) laser generator (RevoLix HTL, LISA Laser Products, Germany), i.e. capable of emitting both in pulsated and continuous-wave.

METHODS

We included 39 consecutive patients who underwent hybrid Tm:YAG AEEP (hybrid ThuLEP) at a single center starting from July 2022 and were followed-up until 3 months after surgery. Complete baseline, intraoperative, and follow-up demographic and clinical data were collected. The International Prostatic Symptoms Score (IPSS) questionnaire was used to quantify urinary symptoms at baseline and during follow-up. Post-operative follow-up further included a PSA test, uroflowmetry with post-void residual volume (PVR) measurement. Clavien-Dindo classification was used to classify complications.

RESULTS

Median (IQR) age at surgery and prostate volume were 68 (IQR 63-74) years and 85 (60-105) cc. Both en-bloc or two-lobes technique enucleation were performed according to the intraoperative and endoscopic anatomy, with a median operative time of 85 (63-108) minutes. Bladder catheter was removed in all cases on postoperative day two. Intraoperative bleeding requiring conversion to bipolar enucleation was observed in two patients. After discharge, one patient developed arm phlebitis which was treated with anticoagulants leading to new onset haematuria requiring short term catheterisation (Clavien-Dindo grade II) and two more patients had a single episode of acute urinary retention (Clavien-Dindo grade I). Median pre- vs postoperative Qmax and IPSS were 8.0 (7.0-9.4) vs. 25.0 (22.5-32.5) ml/s and 22 (20-28) vs. 1 (0-2), whereas PVR decreased from 70 (50-115) to 0 (0-26) ml.

CONCLUSIONS

Hybrid ThuLEP is a feasible and effective surgical procedure for the management of benign prostatic obstruction.

Comparison of EEP and TURP long-term outcomes: systematic review and meta-analysis

OBJECTIVE

To compare long-term reoperation rate and functional outcomes between EEP (endoscopic enucleation of the prostate) and TURP (transurethral resection of the prostate).

EVIDENCE ACQUISITION

A systematic literature review of Medline, Scopus, and Web of Science was conducted with primary outcome assessed being reoperation rate and secondary outcomes after a long term (> 3 years) being functional outcomes or related values (prostate volume, PSA level, etc.).

EVIDENCE SYNTHESIS

Five studies were found with long-term follow-up 4-7 years. EEP reoperation rate ranged from 0 to 1.27%, while from 1.7 to 17.6% for TURP. Meta-analysis showed significantly lower OR for EEP, 0.27 (95% CI 0.24-0.31), with notable homogeneity of the results, I2 = 0%. Long-term Qmax and IPSS were significantly better for EEP. Qmax pooled mean difference was 1.79 (95% CI 1.72-1.86) ml/s with a high concordance among the studies, I2 = 0%. IPSS mean difference -1.24 (95% CI - 1.28 to - 1.2) points, I2 = 57% but QoL did not differ, with mean difference being 0.01 (95% CI - 0.02 to 0.04), I2 = 0%. IIEF-5 score was also significantly better for EEP, mean difference 1.08 (95% CI 1.03-1.13), but heterogeneity was high, I2 = 70%. PSA level and prostate volume were only reported in one study and favored EEP slightly yet statistically significant.

CONCLUSION

EEP had a significantly lower reoperation rate and better functional outcomes (Qmax and IPSS) at long term compared with TURP. It may also be beneficial in terms of IIEF-5, PVR, and PSA level.

Wound healing process in beagles after vaporization of the prostate with a novel 200W 450-nm laser

In comparison to other commercially used lasers, the coagulation layer of the novel 450-nm laser is thinner, and this coagulation layer's thickness is a key factor influencing wound healing. In this study, we investigated whether the novel 200W 450-nm laser system (BR6800, Blueray Medical Ltd., Shaanxi, China) is superior to classic transurethral resection of the prostate (TURP) for wound healing in beagles. Twenty-two 6-to 8-year-old male beagles were treated with TURP or blue laser vaporization of the prostate (BLVP). Prostate wounds were observed via cystoscopy at 3 h and at 1, 2, 3, and 5 weeks post-operation (two beagles per group). Additionally, two elderly beagles without surgery served as normal controls. After cystoscopy examination, prostate samples were collected and fixed for hematoxylin and eosin (H&E) and immunofluorescence staining to observe wound healing progression under microscopy. The urethras of prostates under cystoscopy in BLVP groups were healed three weeks after surgery, while in the TURP group, they were healed five weeks after surgery. H&E staining confirmed that the coagulation necrosis layer in the TURP group was thicker than that in the BLVP group and it took longer to remove coagulation necrosis after surgery. Macrophage polarity transformation was also earlier in the BLVP group. The new 200W 450-nm laser was superior to TURP for wound healing. The thinner coagulation layer of the 450-nm laser was the primary reason for this process.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intraoperative and postoperative outcomes of thulium laser enucleation versus bipolar resection in the transurethral treatment of benign prostatic hyperplasia: a meta-analysis

To compare the intraoperative and postoperative outcomes of thulium laser enucleation of the prostate (ThuLEP) vs bipolar transurethral resection of the prostate (B-TURP) in treating patients with benign prostatic hyperplasia (BPH). Clinical trials of ThuLEP and B-TURP in treating BPH were searched systematically by using PubMed, Cochrane Library databases, and EMBASE (until May 2021). The Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist was followed. The datum was calculated by Review Manager version 5.3.0. Four articles including 782 patients were studied in this analysis. The analysis discovered that there was no significant difference in operative time and percentage of tissue removed between ThuLEP and B-TURP. But the intraoperative irrigated volume and postoperative hemoglobin (Hb) decrease in the ThuLEP group was significantly less compared with the B-TURP group. The catheterization time and hospitalization duration in the B-TURP group was significantly longer than that in the ThuLEP group. Compared with those before treatment, the micturition indexes of the two groups improved significantly. But no significant difference was identified between ThuLEP and B-TURP for the variation of international prostate symptom score, quality of life, maximum flow rate, and post-void residual. By analyzing the postoperative complications, there were no significant discrepancies between ThuLEP and B-TURP in the incidence of blood transfusion, recatheterization, transient incontinence, bladder neck contracture, and urethral stricture. The micturition indexes and clinical symptoms were significantly improved after ThuLEP and B-TURP for patients with BPH. However, ThuLEP was more effective than B-TURP in terms of intraoperative irrigated volume, postoperative Hb decrease, catheterization time, and hospitalization duration.

Thermal effects of thulium: YAG laser treatment of the prostate-an in vitro study

PURPOSE

To objectively determine whether there is potential thermal tissue damage during Tm:YAG laser-based LUTS treatment.

METHODS

Our experimental model was comprised of a prostatic resection trainer placed in a 37 °C water bath. In a hollowed-out central area simulating the urethral lumen, we placed a RigiFib 800 fibre, irrigation inflow regulated with a digital pump, and a type K thermocouple. A second thermocouple was inserted 0.5/1 cm adjacently and protected with an aluminum barrier to prevent it from urethral fluid. We investigated continuous and intermittent 120 W and 80 W laser application with various irrigation rates in eight measurement sessions lasting up to 14 min. Thermal measurements were recorded continuously and in real-time using MatLab. All experiments were repeated five times to balance out variations.

RESULTS

Continuous laser application at 120 W and 125 ml/min caused a urethral ∆T of ~ 15 K and a parenchymal temperature increase of up to 7 K. With 50 ml/min irrigation, a urethral and parenchymal ∆T of 30 K and 15 K were reached, respectively. Subsequently and in absence of laser application, prostatic parenchyma needed over 16 min to reach baseline body temperature. At 80 W lower temperature increases were reached compared to similar irrigation but higher power.

CONCLUSIONS

We showed that potentially harming temperatures can be reached, especially during high laser power and low irrigation. The heat generation can also be conveyed to the prostate parenchyma and deeper structures, potentially affecting the neurovascular bundles. Further clinical studies with intracorporal temperature measurement are necessary to further investigate this potentially harming surgical adverse effect.

Thulium laser vapo-enucleation treatment for prostates >100 cc following urinary retention

INTRODUCTION

Practical advantages of Thulium in the endoscopic treatment of BPH include its technical versatility, precision and safety, offering reduced need for haemostasis and risk of injury. Evidence has shown Holmium laser to be effective in the treatment of chronic retention, however no studies address the use of Thulium laser for larger prostates after urinary retention.

OBJECTIVES

We have selected this group in our retrospective analysis on the efficacy of Thulium laser vapo-enucleation for men with both urinary retention and large prostate volumes greater than 100 cc.

METHODS

We analysed a 10-year single centre operation database of 740 Thulium vapo-enucleation of prostates. An inclusion of 47 living patients with prostates over 100 cc who have undergone the procedure following urinary retention secondary to bladder outflow obstruction (BOO) from benign prostatic hyperplasia (BPH). Patients were sub grouped into Group 1: 100-149 cc and Group 2: >150 cc.

RESULTS

Number of patients in sub groups 1 (n = 27) and 2 (n = 20) had mean prostate volumes of 116 and 173 cc respectively, with the largest measuring 234 cc. Mean resected volumes were 26 g (range 15-50.5 g) and 28 g (range 2-57 g). The overall trial without catheter (TWOC) pass rate for all patients in our series was 96% with comparable results between the two groups. Overall known early and late complication rates for all patients was 17% (UTI 13%, urosepsis 2%, AUR 2%) and 12.5% (failure 5%, OAB symptoms 5%, significant haematuria requiring surgical intervention 2.5%) respectively. Success of surgery was 96%, with an average follow-up of 5 months and no re-referrals for lower urinary tract symptoms following discharge.

CONCLUSION

We show the use of Thulium laser vapo-enucleation to be safe and effective in the treatment of retention for large prostates. Results have demonstrated signs of long-term efficacy with a low failure rate.

Comparison between thulium laser vapoenucleation and plasmakinetic resection of the prostate in men aged 75 years and older in a real-life setting: a propensity score analysis

BACKGROUND

Urologists may hesitate to offer transurethral resection of the prostate (TURP) because of increased morbidity in elderly patients.

AIMS

We aimed to compare data on postoperative outcomes of elderly men undergoing bipolar transurethral resection of the prostate (B-TURP) as compared to thulium laser vapoenucleation of the prostate (ThuVEP).

METHODS

We retrospectively reviewed data of all patients aged ≥ 75 years who underwent benign prostatic hyperplasia surgery. Differences between interventions were estimated using propensity scores (PS) to adjust for different patients characteristics.

RESULTS

Between 2017 and 2020, 275 men were included in the analysis. Propensity score retrieved 65 patients in each group. Median age was 78 (4) years in B-TURP group and 78 (6) in ThuVEP group. Median prostate volume was 63 (35) ml and 54 (24) ml in B-TURP group and ThuVEP group, respectively. Only American Society of Anesthesiologists score was significantly higher in ThuVEP group (p = 0.006). Median operation time, catheterization time, and hospital stay were similar in both groups (55 min, 2 and 3 days). Overall, 84.6% of men had no complications, with no significant differences between the groups (p = 0.234). Only one patient in B-TURP group experienced a Clavien grade IIIb complication. By 1 year, there were a statistically significant differences in International Prostate Symptom Score (p = 0.000) in favor of B-TURP group and in maximal urine flow rate (p = 0.000) in favor of ThuVEP group.

DISCUSSION AND CONCLUSIONS

Both procedures showed excellent functional improvements one year after surgery with a low rate of major complications in men aged ≥ 75 years with small-to-medium sized prostates.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

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

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

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Multivariate Analysis of the Failure of Removal of the Urinary Catheter within 48 Hours after Transurethral Enucleation and Resection of the Prostate

Objective

To assess the value of clinically relevant data for predicting the failure of removal of the urinary catheter within 48 hours after TUERP. Materials and Methods. We retrospectively analyzed the medical records of 357 patients who underwent TUERP between January 2015 and July 2018, all of whom stopped bladder irrigation and removed urinary catheter within 48 hours after the operation. According to whether the removal of the catheter was successful, the patients were classified into 2 groups: Group A was successful and group B was a failure. Univariate analysis was performed to determine the association between the failure of removal of the catheter and the patients' preoperative clinical characteristics. Logistic regression analysis and receiver operating characteristic analysis (ROC) were conducted to establish the prediction model. Then the area under the curve (AUC) and the cut-off value were calculated.

Results

357 patients were divided into group A (n = 305, 85.4%) and group B (n = 305, 85.4%) and group B (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (

Conclusion

This study demonstrated that IPSS, QoL, drug medication, history of AUR, TPV, and IPP are independent factors associated with the failure of removal of the urethral catheter within 48 hours after TUERP.

Clinical outcome of transurethral enucleation of the prostate using the 120-W thulium Laser (Vela™ XL) compared to bipolar transurethral resection of the prostate (TURP) in aging male

This study compared the surgical outcomes of the 120-W Thulium laser (Vela™ XL) enucleation of the prostate and bipolar transurethral resection of the prostate (TURP) in terms of efficacy, safety, and improvements of quality of life (QoL) in patients with benign prostate hyperplasia (BPH). Records were obtained from January 2014 to September 2018 for selected patients with symptomatic BPH who underwent 120-W Thulium laser (Vela™XL) prostate enucleation and bipolar TURP in our institution. All the patients selected met the surgical criteria for TURP and had received medical treatment for at least 3 months. Patients were excluded if their ECOG performance status was >1, if they had active malignant disease, of if they had a history of prostate surgery or reconstruction surgery of the urinary system. Patients decided which treatment option would be performed. Both the procedures were conducted by a single surgeon. Clinical outcomes such as changes in the International Prostate Symptom Score (IPSS) score, urodynamic parameters, drug consumption, pain scores, and QoL were evaluated. The rate of urinary tract infection, recatheterization, additional analgesic requirement, return to the emergency department for treatment, and other surgical complications was analyzed and compared between the two cohorts. A total of 276 patients met the inclusion criteria. Among them, 141 patients received bipolar TURP, where as 135 decided to receive laser vaporesection. No significant difference was observed in age, PSA level, prostate volume, and comorbidities between the two cohorts. Pre-operative (pre-op) urodynamic parameters were also identical, except that the laser surgery group had a higher rate of admission with a urinary catheter (24.4% vs. 14.2%, p=0.044). The operating time was longer in the laser surgery group (79.3 minutes vs. 62.4 minutes, p<0.001). However, enucleation using the Thulium laser was superior to bipolar TURP in terms of post-operative (post-op) pain status, including the numeric rating scale of pain, rate of additional narcotic use, and oral analgesic requirement. Compared with bipolar TURP, laser enucleation achieved a higher improvement in the QoL score at post-op follow-up at 2 weeks and 3 months. Nevertheless, the complication rate, changes in IPSS score, Qmax, and post-op medication-free survival were statistically identical in the two cohorts. Our data revealed that compared with bipolar TURP, 120-W Thulium laser (Vela™ XL) enucleation of the prostate achieved lower post-op pain and higher improvement in the short-term QoL of patients after surgery.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Level of evidence: Not applicable for this review article.

Lasers versus bipolar technology in the transurethral treatment of benign prostatic enlargement: a systematic review and meta-analysis of comparative studies

PURPOSE

To systematically review studies comparing the overall efficacy and safety of lasers and bipolar technology for the transurethral treatment of benign prostatic enlargement (BPE).

METHODS

A systematic review of the literature was completed in February 2018. Studies with comparative data between different lasers and bipolar technologies (enucleation or resection) were included in this review. A meta-analysis was performed using STATA 14.0, and subgroup analyses were also performed regarding the type of laser (holmium, thulium, green light and diode).

RESULTS

27 studies with 31 published articles (4382 patients) were selected for the meta-analysis. Compared with bipolar technology, lasers demonstrated shorter catheterization duration (standardized mean difference (SMD): 1.44; 95% CI 1.07-1.81; p < 0.001) and shorter hospital stay (SMD: 1.16; 95% CI 0.83-1.49; p < 0.001), and a smaller drop in hemoglobin (Hb) level (SMD: 0.86; 95% CI 0.47-1.26; p < 0.001). However, significant heterogeneity was detected in the studies and statistical significance was lost on sub-analyses. Furthermore, there were no significant differences between lasers and bipolar technology in the maximum flow rate (Qmax) and international prostate symptom score (IPSS) at a minimum of 3 months after treatment. Complications, including urethral stricture, urinary incontinence, urinary tract infection, re-catheterization and blood transfusion, did not significantly differ between lasers and bipolar technology.

CONCLUSION

Early efficacy and safety profiles were comparable between bipolar and laser treatments. Differences were observed in terms of smaller reduction in Hb, shorter catheterization duration and shorter hospital stay in favor of lasers. However, the smaller reduction in Hb, with lasers, did not translate into reduced transfusion requirements. Furthermore, there was significant heterogeneity in the studies and, in subgroup analyses, the differences were not statistically significant.

Influence of prostate size on the perioperative and postoperative outcome of transurethral plasmakinetic enucleation of the prostate: Results of 892 patients with 3 years of follow-up

To explore the influence of prostate size on the outcome of Plasmakinetic enucleation of the prostate (PkEP) for the treatment of benign prostate hyperplasia (BPH), The data of 892 patients with symptomatic BPH who underwent PkEP were retrospectively reviewed. Among them, 199 (22.31%) had the prostate size smaller than 40 g (Group 1), 409 (45.85%) between 40 and 79 g (Group 2), 197 (22.09%) between 80 and 120 g (Group 3), and 87 (9.75%) larger than 120 g (Group 4). Perioperative variables, perioperative and postoperative complications were recorded. Patients were followed up for 36 months postoperatively. The efficiency of the surgery increased as the prostate size increased. Greater decreases in hemoglobin were noted in groups with larger prostates, while the duration of catheterization after the operation was similar across all groups. During the 3-year follow-up, the postoperative improvement in International Prostate Symptom Score (IPSS), Quality of Life (QOL), maximal flow rate (Qmax) and post-void residual urine volume (PVR), as well as longterm complications including urethral stricture and bladder-neck contracture were comparable across the 4 groups. These findings revealed that PkEP is more efficient for large prostate and can treat all prostates regardless of the size with equivalent symptom relief and micturition improvement.