Eraser Laser Enucleation of the Prostate: Technique and Results

Recent evidence for anatomic endoscopic enucleation of the prostate (AEEP) in patients with benign prostatic obstruction on antiplatelet or anticoagulant therapy

INTRODUCTION

Due to demographic changes in today's society, the number of patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) is increasing. Similarly, the proportion of patients with cardiovascular risk factors undergoing antiplatelet (AP) or anticoagulation (AC) therapy is growing as well.

METHODS

This review discusses the current literature on various techniques used for anatomic endoscopic enucleation of the prostate (AEEP) in patients on AC/AP therapy.

RESULTS

The large number of energy sources used for AEEP makes it difficult to compare them. Overall, fewer bleeding-associated complications arise in patients under AP compared to AC or bridging therapy with low molecular weight heparin. However, perioperatively both AP and AC therapy lead to a higher risk of bleeding complications compared to patients not taking anticoagulants.

CONCLUSIONS

The literature shows that AEEP is possible and efficacious in patients under AC/AP therapy, with only slight differences compared to patients not taking AC/AP drugs, on a short and long-term basis. Nevertheless, the sparse data, the retrospective nature of many studies and the inclusion of prostate sizes between 50 and 110 ml only, make it difficult to come to strong conclusions.

Minimally invasive simple prostatectomy in the era of laser enucleation for high-volume prostates: A systematic review and meta-analysis

Objective

To perform a systematic review and meta-analysis of available prospective and retrospective studies comparing the minimally invasive (laparoscopic or robot-assisted) simple prostatectomy (MISP) and laser enucleation of the prostate for treating male lower urinary tract symptoms in high-volume prostates, as laser enucleation of the prostate is the new trend for treating high-volume prostates (>80 mL) but many urologists now prefer MISP.

Methods

A systematic search was done using the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cochrane databases in June 2019, with research terms including: ‘laser’, ‘laparoscopy’, ‘enucleation’, ‘BPH’, ‘simple prostatectomy’, ‘Millins’, and ‘adenomectomy’. The meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Of 38 screened articles, six were analysed and a total of 975 men were included. The average operative time, length of stay and catheterisation time were significantly shorter in the laser enucleation group (P = 0.006, P < 0.001 and P < 0.001, respectively). The amount of prostatic tissue removed during surgery was comparable between both the laser enucleation and MISP groups (P = 0.39). The International Prostate Symptom Score, prostate-specific antigen level, maximum urinary flow rate and post-void residual urine volume were also comparable at 3 months. Finally, similar transfusion rates and Clavien–Dindo complication rates were observed (P = 0.08 and P = 0.41, respectively).

Conclusion

This systematic review of the literature and meta-analysis provide a further demonstration of the safety and effectiveness of both laser enucleation and MISP. While laser enucleation had a shorter catheterisation time and hospital stay than MISP, the latter still had unique and specific indications.

Abbreviations: ELEP: eraser laser enucleation of the prostate; HoLEP: holmium laser enucleation of the prostate; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PVR: post-void residual urine volume; Q_max: maximum urinary flow rate; (L)(MI)(RA)SP: (laparoscopic) (minimally-invasive) (robot-assisted) simple prostatectomy

[Endoscopic enucleation of the prostate]

The spectrum of surgical procedures for the minimally invasive treatment of benign prostatic hyperplasia (BPH) has significantly increased over the last two decades. The simple suprapubic prostatectomy (subtotal prostatectomy, SP) has largely lost relevance in current practice. On the other hand, transurethral resection of the prostate (TURP) has been further standardized and potentially made safer by the introduction of the bipolar technique and low-pressure systems.Transurethral (endoscopic) enucleation techniques (endoscopic enucleation of the prostate, EEP) are increasingly competing with the current gold standard TURP and are replacing SP for treatment of larger adenomas. This approach is especially related to the rapid development of laser technology, which has sustainably changed the face of modern BPH treatment in a similar way to stone therapy. This has been incorporated in the clinical patient management, clinical studies and standardization of numerous surgical techniques that are systematically described in this article. Additionally, efforts have also been made to use other energy sources, such as bipolar current in EEP. With respect to scientific objectivity, high-quality clinical trials are regularly published which further strengthen the position of EEP.

Towards optimizing prostate tissue retrieval following holmium laser enucleation of the prostate (HoLEP): Assessment of two morcellators and review of literature

INTRODUCTION

We assess different approaches to retrieve the enucleated adenoma after transurethral enucleation of the prostate, particularly using the holmium laser.

METHODS

A retrospective review through our prospectively maintained database was performed looking for safety and efficacy of two morcellators. The enucleation phase of the holmium laser enucleation of the prostate (HoLEP) was classically performed followed by retrieval of the intravesical adenoma using either the Piranha (Wolf Inc., Knittlingen, Germany) or VersaCut (Lumenis) morcellator. A PubMed-MEDLINE search was conducted for all transurethral enucleation procedures and relevant data regarding methods of prostate tissue retrieval were extracted.

RESULTS

Strictly limiting the study to 3 reusable blades with each morcellator, we performed 67 and 55 consecutive procedures with Piranha and VersaCut, respectively. There was no significant difference between the two morcellators regarding perioperative complications, apart from 5 bladder mucosal injuries with the VersaCut (9%). Furthermore, there were similar retrieved tissue weight, mechanical problems-rate, catheter-time and hospital-stay in both morcellators. However, the Piranha morcellator needed significantly less morcellation-time, needed to use cold loop to remove non-morcellated pieces and to score the adenoma by laser for better bite of the adenoma, and had a higher median morcellation-rate 6.2 (rate: 2.8-12) g/min. Despite little reporting on morcellation, we had data on the tissue retrieval rate (2.6 to 6.5 g/min with Piranha and 1.9 to 11 g/min with VersaCut. Furthermore, bladder mucosal injury was reported in 1.4% and 0.7 to 5.7% with Piranha and VersaCut, respectively; bladder perforation with VersaCut was experienced in about 0.1 to 1.5% of patients. Our study is limited by its non-randomization.

CONCLUSION

The Piranha morcellator was the most efficient and safe way to retrieve tissue after a transurethral enucleation of a prostate adenoma.

Laparoscopic adenomectomy versus Eraser laser enucleation of the prostate

PURPOSE

To evaluate functional outcomes and morbidity rates after laparoscopic adenomectomy (LA) and Eraser laser enucleation of the prostate (ELEP).

MATERIALS AND METHODS

Forty patients with lower urinary tract symptoms suggesting bladder outlet obstruction, with a prostate heavier than 70 g on transrectal ultrasound, were selected to undergo laparoscopic adenomectomy or Eraser laser enucleation of the prostate. All patients were consecutively enrolled without randomization and assessed preoperatively, 3 and 6 months postoperatively. Baseline characteristics, perioperative data, and postoperative outcomes were compared.

RESULTS

The total operating time was significantly longer in the LA group (138.8 ± 11.4 vs. 78.4 ± 10.0 min, p < 0.000001). Catheter removal was performed earlier (61.2 ± 21.3 vs. 174.0 ± 13.2 h, p < 0.000001) and the hospital stay was significantly shorter (62.4 ± 21.2 vs. 187.2 ± 12.6 h, p < 0.000001) in the ELEP group. The latter group experienced significantly less perioperative hemoglobin (Hb) loss (0.71 ± 0.25 vs. 2.15 ± 1.08 g/dl, p < 0.000001), and their postoperative Hb levels (14.1 ± 1.21 vs. 11.7 ± 1.31 g/dl, p < 0.000001) were significantly higher. The resected tissue was significantly greater in the LA group (58.5 ± 23.3 vs. 87.9 ± 22.4 g, p = 0.0002). Significant improvements in Qmax, Qol, and symptom scores from baseline to each follow-up time point were noted in both groups. No statistically significant difference in symptom scores or Qmax was registered between the LA and the ELEP group throughout the follow-up period.

CONCLUSION

Laparoscopic adenomectomy and ELEP were equally effective for relieving bladder outflow obstruction and lower urinary tract symptoms. The advantages of ELEP include less blood loss, shorter catheterization times, and shorter hospital stays.

Enucleation techniques for benign prostate obstruction: which one and why?

PURPOSE OF REVIEW

Endoscopic enucleation of the prostate is the most advanced form of surgical management of benign prostate hyperplasia. The purpose of this review is to update the reader on various modalities currently in use, and in trial, for endoscopic enucleation.

RECENT FINDINGS

A recent paradigm shift has occurred for the proponents of electrosurgery technology to utilizes the advantages offered by laser enucleation with interest in bipolar enucleation. Holmium laser enucleation still has the greatest randomized evidence with the longest follow-up among all the various lasers used to perform enucleation.

SUMMARY

Randomized trials with longer follow-up are required to demonstrate whether nonholmium types of energy really have advantages in enucleation (speed, ease of use and hemostasis) and durability (decade plus) as compared to the holmium laser.

Common trend: move to enucleation-Is there a case for GreenLight enucleation? Development and description of the technique

BACKGROUND

Transurethral laser prostatectomy has evolved as a viable alternative for the management of benign prostate enlargement. Since the renaissance of laser prostatectomy with the advent of the holmium:yttrium-aluminum-garnet laser in the 1990s, various lasers and subsequent procedures have been introduced. These techniques can be categorized as vaporizing, resecting, and enucleating approaches. Photoselective vaporization of the prostate (PVP) is dominated by high-power lithium triborate (LBO) crystal lasers (GreenLight XPS). The mainstay of this technique is for the treatment of small to medium prostate volumes whereas enucleating techniques, such as holmium laser enucleation of the prostate and thulium enucleation of the prostate, focus on large-volume glands. In order to perspectively "delimit" LBO into the field of large-volume prostates, we developed LBO en bloc enucleation to render it as a competing transurethral enucleating approach.

MATERIALS AND METHODS

We present a detailed stepwise progressive technique developed in Madrid, Spain, for the complete removal of the transitional zone by vapoenucleation. The steps include exposition of the prostatic capsule by PVP toward the peripheral zone, thereby identifying the anatomical limits of enucleation. Subsequently, the transitional zone is excised in a single bloc and morcellated after its placement into the bladder.

CONCLUSION

This new GreenLight en bloc enucleation technique allows to treat larger prostates than those previously treated with the PVP technique.

EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction

OBJECTIVE

To present a summary of the 2013 version of the European Association of Urology guidelines on the treatment and follow-up of male lower urinary tract symptoms (LUTS).

EVIDENCE ACQUISITION

We conducted a literature search in computer databases for relevant articles published between 1966 and 31 October 2012. The Oxford classification system (2001) was used to determine the level of evidence for each article and to assign the grade of recommendation for each treatment modality.

EVIDENCE SYNTHESIS

Men with mild symptoms are suitable for watchful waiting. All men with bothersome LUTS should be offered lifestyle advice prior to or concurrent with any treatment. Men with bothersome moderate-to-severe LUTS quickly benefit from α1-blockers. Men with enlarged prostates, especially those >40ml, profit from 5α-reductase inhibitors (5-ARIs) that slowly reduce LUTS and the probability of urinary retention or the need for surgery. Antimuscarinics might be considered for patients who have predominant bladder storage symptoms. The phosphodiesterase type 5 inhibitor tadalafil can quickly reduce LUTS to a similar extent as α1-blockers, and it also improves erectile dysfunction. Desmopressin can be used in men with nocturia due to nocturnal polyuria. Treatment with an α1-blocker and 5-ARI (in men with enlarged prostates) or antimuscarinics (with persistent storage symptoms) combines the positive effects of either drug class to achieve greater efficacy. Prostate surgery is indicated in men with absolute indications or drug treatment-resistant LUTS due to benign prostatic obstruction. Transurethral resection of the prostate (TURP) is the current standard operation for men with prostates 30-80ml, whereas open surgery or transurethral holmium laser enucleation is appropriate for men with prostates >80ml. Alternatives for monopolar TURP include bipolar TURP and transurethral incision of the prostate (for glands <30ml) and laser treatments. Transurethral microwave therapy and transurethral needle ablation are effective minimally invasive treatments with higher retreatment rates compared with TURP. Prostate stents are an alternative to catheterisation for men unfit for surgery. Ethanol or botulinum toxin injections into the prostate are still experimental.

CONCLUSIONS

These symptom-oriented guidelines provide practical guidance for the management of men experiencing LUTS. The full version is available online (www.uroweb.org/gls/pdf/12_Male_LUTS.pdf).