Enucleation of the prostate for benign prostatic hyperplasia thulium laser versus holmium laser: a systematic review and meta-analysis

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.

The thermal effect of lasers in urology: a review article

Lasers as a technology have a leading role in the modern urological treatment armamentarium. In this article, the application of lasers in different areas of urology is described. The major uses are in urolithiasis, benign prostatic enlargement (BPE), and management of many urological malignancies and other benign pathologies. Lasers have become an established treatment modality in urolithiasis, an acceptable alternative with the least side effect profile in BPE patients, and a novel and promising therapy in many other fields of Urology.

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.

Thulium: YAG vs continuous-wave thulium fiber laser enucleation of the prostate: do potential advantages of thulium fiber lasers translate into relevant clinical differences?

PURPOSE

To compare endoscopic enucleation of the prostate using a thulium: yttrium-aluminum-garnet (Tm:YAG) laser and a super-pulsed thulium fiber laser set in continuous-wave (CW) mode, and to evaluate whether theoretical advantages of thulium fiber lasers, related to their shorter wavelength, translate into relevant clinical differences.

METHODS

In total, 110 patients suffering from lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia were randomized to undergo either thulium:YAG laser enucleation of the prostate (ThuLEP) or CW thulium fiber laser enucleation of the prostate (CW-ThuFLEP). Intraoperative and postoperative variables and complications were compared. Micturition improvement was assessed at 3-month follow-up using the International Prostate Symptom Score (IPSS), post-void residual urine (PVR) and maximum flow rate (Qmax). Erectile function was evaluated using the International Index of Erectile Function-5 (IIEF-5).

RESULTS

No significant differences between the ThuLEP and CW-ThuFLEP groups were found in terms of operative time (70.69 vs 72.41 min), enucleation time (50.23 vs 53.33 min), enucleated tissue weight (40.2 vs 41.9 g), enucleation efficiency (0.80 vs 0.79 g/min), catheterization time (2.45 vs 2.57 days), hospital stay (2.82 vs 2.95 days) and hemoglobin drop (1.05 vs 1.27 g/dl). At 3-month follow-up, no significant differences were found in IPSS (5.09 vs 5.81), Qmax (26.51 vs 27.13 ml/s), PVR (25.22 vs 23.81 ml) and IIEF-5 (14.01 vs 14.54).

CONCLUSION

ThuLEP and CW-ThuFLEP were equivalent in relieving patients from LUTS and improving micturition. Theoretical advantages of the TFL, such as shallower penetration depth and improved vaporization capacity, did not translate into relevant perioperative outcomes or clinical differences.

Application of En Bloc and Urethral Mucosal Flap Sparing Techniques Improve the Functional Outcomes in Holmium Laser Enucleation of Prostate: A Retrospective Case Control Study

The purpose of the study was to study the feasibility of holmium laser enucleation of prostate (HoLEP) with en bloc and urethral mucosal flap sparing technique in treating benign prostatic hyperplasia (BPH) patients and to evaluate the influence of this modified technique on urinary function. A cohort of 188 BPH patients underwent HoLEP from June 2017 to October 2019. Among them, 92 patients underwent conventional en bloc HoLEP and the other 96 patients underwent HoLEP with en bloc and urethral mucosal flap sparing techniques. The basic characteristics, the volume of the prostate, urodynamic data, and perioperative parameters were recorded for comparison. The outcome parameters include international prostate symptom score (IPSS), maximum urinary flow rate (Qmax), post-voiding residual (PVR), quality of life score (QoL), and incidence of de novo stress urinary incontinence (SUI). The basic characteristics were equivalent in both groups. All HoLEP procedures were smoothly carried out. The perioperative complications were low and did not show a significant difference. The follow-up period was 12 months or longer. IPSS, Qmax, QoL, and PVR were improved postoperation in both groups. There was no statistical difference in the parameters between the two groups. When considering a postoperative SUI, the occurrence of short-term and long-term SUI in the modified HoLEP group was significantly less than those in the conventional HoLEP group (p < 0.05). In summary, HoLEP by using en bloc and urethral mucosal flap sparing technique is a safe and effective treatment for BPH patients, especially in preventing postoperative SUI.

Contemporary surgical management of benign prostatic obstruction: does there remain a place in the toolbox for TURP?

Level of evidence: 5

Safety and Efficacy of Laser Enucleation of the Prostate in Elderly Patients - A Narrative Review

Benign prostatic hyperplasia (BPH) is a common health condition in aging men resulting in lower urinary tract symptoms (LUTS) and low quality of life (QoL). We aimed to review studies on laser enucleation of the prostate (LEP) due to LUTS in elderly patients (>65 years) comparing different age groups, particularly considering functional outcomes, safety, and perioperative complications. A comprehensive search was conducted using the PubMed-MEDLINE, Web of Science, Wiley Online Library and Cochrane Library databases over the last 10 years until 7 October 2021 with the following search terms solely or in combination: “laser enucleation”, “prostate”, “laser prostatectomy”, “aging”, “elderly patients”, “older patients” and “age”. We identified 12 articles for inclusion in our analysis. Five studies focussed mainly on holmium laser enucleation of the prostate (HoLEP), one compared HoLEP to other laser prostatectomy procedures, two studies examined thulium laser enucleation of the prostate (ThuLEP), and two studies focused on GreenLight laser, one study focussed on potassium-titanyl-phosphate (KTP) laser, and another study compared laser prostatectomy to transurethral resection of the prostate (TURP). These studies showed that LEP improved IPSS, Qmax and QoL compared to baseline regardless of age; no significant difference was reported among age groups. Although ASA scores and anticoagulation/antiplatelet therapy rates are higher in elderly patients, studies revealed no significant difference in perioperative complication rates between age groups. Laser enucleation of the prostate is an effective and safe procedure in elderly patients, resulting in good functional outcomes, low morbidity, and few perioperative complications.

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.

Enucleation vs vaporization of benign prostatic hyperplasia: a head-to-head comparison of the various outcomes and complications. A systematic review and meta-analysis

INTRODUCTION

Vaporization of the prostate (VP) and endoscopic enucleation of the prostate (EEP) are reliable and frequently used methods for BPO relief. Both surgeries utilize lasers and EAU recommends them in similar patient cohorts. Our objective was to compare intra- and perioperative results of patients who had undergone VP and EEP.

EVIDENCE ACQUISITION

A systematic literature search was performed in three databases (MEDLINE, Web of Science and Scopus). The detailed search strategy is available at Prospero, CRD42020204739. Primary outcomes were functional results (IPSS, QoL, PVR, Qmax), and secondary outcomes were intraoperative results, postoperative PSA and prostate volume, complications, and recurrence rate.

EVIDENCE SYNTHESIS

VP required less operative time compared to EEP, mean difference=-5.51 (95%CI -7.52; -3.50). IPSS and Qmax for VP were worse after 12-month follow-up, mean difference=0.89 (95%CI 0.52; 1.27) and -3.7 (95%CI -4.56; -2.85), respectively, while QoL did not differ significantly. Postoperative PSA level was higher in the VP group, mean difference=2.28 (95%CI 2.00; 2.55). VP was associated with reduced Clavien-Dindo grade I (OR=4.16; 95%CI 2.96; 5.84) and grade II (OR=3.79; 95%CI 2.25; 6.39) complication rate, especially in terms of the percentage of blood transfusion and transient urinary incontinence. The rate of complications grade IIIa and higher was similar (3 - 6%). Reoperation rate was only estimated in one study and was significantly higher in the PVP group at 60 months of follow-up, 2.7% vs 0%, p<0.05.

CONCLUSIONS

EEP and VP share the efficacy and safety in BPH management. Our meta-analysis shows comparable complication rate in Clavien-Dindo III, VP superiority in operation time, and EEP superiority in long-term functional outcomes and PSA reduction.

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.

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.

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.

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.

[Surgical treatment of benign prostatic obstruction (BPO) in patients under anticoagulation: a review of the bleeding risks of established techniques]

BACKGROUND

In an aging society an increase of benign prostatic obstruction (BPO) requiring treatment is to be expected and the proportion of patients with cardiovascular comorbidities under anticoagulation is also increasing. As the operative treatment of BPO can be problematic, the hemostatic effect of the techniques is of particular importance.

OBJECTIVE

This review article discusses the data situation on the bleeding risk of established surgical techniques and the statement of the European Association of Urology (EAU) guidelines "EAU guidelines on management of non-neurogenic male lower urinary tract symptoms (LUTS), incl. benign prostatic obstruction (BPO)" on this topic.

MATERIAL AND METHODS

Data analysis from PubMed.

RESULTS

The EAU guidelines favor transurethral laser vaporization of the prostate using "greenlight", thulium or diode laser and laser enucleation using a holmium or thulium laser in this patient collective. The bipolar is superior to monopolar transurethral resection (TUR-P) in hemostasis. In the future bipolar enucleation of the prostate (BipoLEP) can be an alternative under good hemostasis. Bleeding is a rare complication after recently established minimally invasive techniques, such as Urolift®, I‑TIND© and Rezum™, the same applies to prostate artery embolization. Aqua-ablation/AquaBeam® seems to be unsuitable due to frequent hematuria. Surgical adenomectomy can be associated with a high risk of bleeding.

CONCLUSION

According to current data, transurethral laser vaporization and enucleation of the prostate are the treatment of choice for patients under anticoagulation; however, other transurethral techniques, such as BipoLEP have an acceptable risk of bleeding and can be an alternative depending on local resources. Newer minimally invasive approaches could become more important in the future.

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.

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

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