Holmium Laser Enucleation Versus Transurethral Resection of the Prostate: Results From a 2-Center Prospective Randomized Trial in Patients With Obstructive Benign Prostatic Hyperplasia

Thirty versus 60-Watt thulium laser enucleation of prostate: Toward the development of low-power anatomical enucleation of the prostate

Introduction

We aimed to study whether using 30 W versus 60 W thulium enucleation of the prostate (ThuLEP) would affect postoperative outcomes in patients with benign prostatic hyperplasia (BPH).

Materials and Methods

We prospectively identified male patients with moderate or severe lower urinary tract symptoms due to BPH. We randomized patients into 30 W (Group 1) or 60 W (Group 2) thulium yag laser with a 550 μm laser fiber and a 26 Fr continuous flow resectoscope. We collected data related to prostate size, enucleation time, morcellation time, laser time, perioperative complications, and 1-year functional outcomes.

Results

A total of 120 patients were included, with a mean age of 67 years and a mean prostate size of 105 g. The preoperative characteristics were similar across both groups. The mean operative time was shorter in the 60 W group, 74 ± 27 vs. 91 ± 33 min in the 30 W group (P = 0.001), and the mean laser time was 55 ± 20 in 60 W versus 71 ± 25 in 30 W (P = 0.0001). The mean hospital stay was 1 day in both groups and at 1-year follow-up; there was a similar improvement in mean Qmax and International Prostate Symptom Score symptom scores.

Discussion/Conclusion

Both 30 and 60 W ThuLEP provided a safe and comparable outcome with a relatively shorter operative time for the 60 W groups. Perhaps using a 30-W setting would be beneficial in the early learning curve or cases with more bleeding capsular perforators; besides, the financial benefit of manufacturing low-cost low-power devices that may help in the widespread of AEEP.

Incidence and predictors of urinary incontinence rates post-holmium laser enucleation of prostate

INTRODUCTION

One of the main adverse outcomes following Holmium laser enucleation of the prostate (HoLEP) is the development of transient de novo urinary incontinence (UI). We aimed to evaluate the correlation of multiple risk factors to UI rates post-HoLEP.

METHODS

A review of prospectively maintained 7 year database for HoLEP patients in a single center was performed. UI data at 6 week, 3 month, and 1 year follow-up intervals were assessed with bivariate and multivariate analysis of multiple potential risk factors.

RESULTS

The study included 666 patients with median (IQR) age of 72 (66-78) years old and median (IQR) preoperative prostate volume of 89 (68-126) gm. UI was seen in 287 (43%), 100 (15%) and 26 (5.8%) at 6 week, 3 month, and 1 year follow up occasions respectively. At 6 weeks follow up, UI type was stress, urge and mixed in 121 (18.16%), 118 (17.72) and 48 (7.21%) patients respectively. Using a multivariate regression analysis, obesity and pre-operative UI were associated with postoperative UI rate at both 6 week (p = .0065, .031) and 3 month (p = .0261, .044) follow up encounters respectively. Also, larger specimen weight was another predictor for 6 week UI (p = .0399) while higher frailty score was a predictor for UI at 3 month occasion (p = .041).

CONCLUSION

Patients with preoperative UI, obesity, frailty, and large prostate volume are at higher risk of short-term UI post-HoLEP up to 3 months. Patients with one or more of these risk factors should be counseled regarding the higher risk of UI.

Thulium laser vaporesection of prostates with volume exceeding 100 cm3 as an alternative to HoLEP and ThuLEP

The aim of this study is to evaluate the outcomes of thulium laser vaporesection of prostates with volume exceeding 100 cm³. In the present prospective study, patients with infra-vesical urinary obstruction due to a prostate with volume exceeding 100 cm³ underwent endoscopic vaporesection using thulium laser. In this procedure, prostate chips were resected without morcellation. The technical aspects of surgery, admission time, post-operative catheter time and post-operative complications were analyzed. Flowmetry was performed combined with prostatic ultrasound in the follow-up. Between March 2010 and November 2018, 156 cases with benign prostatic hyperplasia (BPH; volume >100 cm³) were treated. The mean patient age was 67.8 years (48.4-86.6 years), and the mean prostatic volume was 137 cm³ (100-436 cm³). The mean length of hospitalization was 1.48 days (1-8 days), and the mean post-operative catheter time was 5.1 (1-17). Three cases (1.9%) required readmission due to hematuria. The mean follow-up time was 31.2 months (standard deviation = 27.7). Urethral stricture was observed in 14 cases (9%), with bulbar urethra being the most frequent finding. Urinary tract infection was observed in 11 cases (7.1%), and urinary incontinence was observed in 5 cases. The mean peak urinary flow at 12 and 24 months was 26.9 ± 12.5 and 23.9 ± 11.7 ml/s, respectively, and the mean urinary flow during the final follow-up at 41 months was 21.6 ml/s. Thulium laser vaporesection is a valid alternative to open prostatectomy, HoLEP and ThuLEP in patients with large BPH. Urinary flow remained elevated throughout the follow-up.

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.

Influence of holmium laser enucleation of the prostate on erectile function: results of a multicentric analysis of 235 patients

PURPOSE

Preserved sexual function is one of the endpoints of the surgical management of lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Our aim was to investigate the evolution of erectile function (EF) at 3 and 12 months after holmium laser enucleation of the prostate (HoLEP).

METHODS

A multicentric retrospective study was performed including 235 sexually active patients who underwent HoLEP between January 2016 and June 2017. Evaluation of EF was carried out with the five-item version of the International Index of Erectile Function (IIEF-5) completed before surgery and at 3 and 12 months after surgery. A change of more than five points in either direction in the IIEF-5 score compared to baseline was considered as an improvement or impairment of EF.

RESULTS

No significant differences were found between median pre-operative IIEF-5 and median scores at 3 and 12 months (p  =  0.15 and p  =  0.45). At 3 and 12 post-operative months, respectively, 10% and 13% of patients reported an improvement, whereas 15% and 16% reported an impairment. The reduction in IIEF-5 score was only statistically significant within the sub-group of patients with normal pre-operative EF (p < 0.001). In this sub-group, 15% of patients reported a decrease of more than five points in total IIEF-5 score.

CONCLUSION

This multicentric evaluation confirmed that median IIEF-5 score was not significantly impaired after HoLEP. However, for patients with normal pre-operative EF, a significant decrease in EF after HoLEP was observed. These results may be taken into account when counselling patients before HoLEP.

Does Holmium laser enucleation of the prostate (HoLEP) still have a steep learning curve? Our experience of 100 consecutive cases from Turkey

AIM

The aim of our study is to examine the learning curve of HoLEP and to discuss our results in the light of the literature.

METHODS

100 patients who had LUTS resistant to medical treatment and complicated BPH to whom HoLEP procedure had been administered regardless of the size of the prostate in the last 1 year were analysed retrospectively. To evaluate the learning curve, the patients were classified into 4 main groups of 25 consecutively operated patients beginning from the first case. The 4 main groups were divided into 2 subgroups including patients who had prostate volume below or above 80 grams.

RESULTS

The mean age of the 100 patients who had HoLEP was 64.5 years. The mean prostate volume was 99.1 cc (45-281 cc). When those with prostate smaller than 80 g are examined, Enucleation efficiency was 0.76 g/min (0.46-0.97 g/min) and Morcellation efficiency was 3.07 g/min (3.34-4 g/min). When those with prostates larger than 80 g are examined, Enucleation efficiency was 0.89 g/min (0.66-1.04 g/min) and Morcellation efficiency was 4.01 g/min (3.93-4.25 g/min). These two parameters were statistically and significantly different in all the 4 groups (p < 0.05).

CONCLUSIONS

HoLEP still has a steep learning curve. It is necessary to reach the number of cases of 25-50 to reach fundamental experience.

Safety and efficacy of holmium laser enucleation of prostate as salvage procedure for persistent or recurrent lower urinary tract symptoms secondary to bladder outlet obstruction after prior prostate artery embolization: a match analysis

PURPOSE

To evaluate safety and efficacy of Holmium laser enucleation of Prostate (HoLEP) for management of persistent or recurrent lower urinary tract symptoms after prior prostate artery embolization (PAE). We also evaluated histopathological changes in prostate after PAE.

METHODS

Ten patients who underwent HoLEP after prior PAE were matched according to age, weight of resected prostate tissue, and anticoagulation status in 1:2 ratio with patients who underwent HoLEP without prior PAE by a researcher who was blinded to patient's outcome at the time of matching. Histopathological examination of prostate tissue was performed to look for changes related to prior PAE. Patient's demographics, perioperative parameters, and follow-up data were retrospectively compared.

RESULTS

The median interval between PAE and HoLEP was 25 months [IQR 14.5-37.5]. Patients demographic were comparable in both groups. Intra-operatively plane of enucleation were well-maintained in spite of prior PAE. The differences in duration of surgery, enucleation efficiency, hemoglobin drop, duration of catheterization and hospital stay, and complications were statistically insignificant. Incidental prostate cancer was identified in 10% specimens from both groups. Post-PAE prostate specimens demonstrated evidence of remote-healed infarction represented by dense hyalinized paucicellur connective tissue with surrounding squamous metaplasia. There were no statistically significant differences in AUA symptom scores, maximum urine flow rate, post-void residual urine volume, and PSA at 3- and 6-month follow-up between both groups.

CONCLUSIONS

Plane of enucleation is well-maintained after prior PAE. Salvage HoLEP is safe and effective after previous PAE and provide outcome comparable with HoLEP as a primary procedure.

The combination of waterjet ablation (Aquabeam®) and holmium laser power for treatment of symptomatic benign prostatic hyperplasia: early functional results

Introduction

The aim of this study was to assess the short-term functional outcomes and the efficacy of hemostasis performed with holmium laser performed following prostatic hydroablation with the Aquabeam^® system.

Material and methods

Between June 2019 and July 2020, 53 consecutive patients underwent Aquabeam^® with our modified hemostasis approach with holmium laser. The following standard preoperative assessments were retrospectively recorded: prostate volume; International Prostate Symptom Score (IPSS) and Quality of Life (IPSS-QoL); uroflowmetry including Qmax and post void residual volume (PVR).

Results

Fifty-three patients consecutively underwent aquablation and holmium laser hemostasis. Median age at surgery, median prostate-specific antigen (PSA) and median prostate volume were 62 years (IQR: 57-66), 2.95 ng/ml (IQR: 1.6-4.8) and 55 ml (IQR: 43-65), respectively.Median operative time was 60 minutes (IQR: 40-80). Median catheterization time and length of hospital stay were 2 days (IQR: 1-3) for both parameters. The median hemoglobin decrease between the preoperative values and those assessed on the second day was equal to 1.25 g/dl (IQR: 0.7-1.85).Continence rate was 100% at catheter removal. Thirty-six patients (72%) reported anterograde ejaculation preservation. IPSS (6, 3-21) and Qmax (19, 9-26) changed dramatically between baseline and 3 months follow-up.

Conclusions

The combination of Aquabeam^® and holmium laser energy for hemostasis is a safe, reproducible technique to relieve moderate lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH) while preserving ejaculation in younger and sexually active individuals. The short-term results showed a lower rate of complications; the encouraging functional results confirm that this can be a valid surgical approach for treatment of BPH.

Endoscopic enucleation of the prostate (EEP). The same but different-a systematic review

Purpose

Various techniques for EEP exist. They differ by surgical steps and the source of energy. It is assumed that the latter is of minor importance, whereas adherence to the anatomical enucleation template determines the postoperative result. So far, no systematic review highlights the differences between the energy sources in use for anatomical EEP. This study will address selfsame topic.

Methods

A systematic review of the literature was completed on September 1st, 2020. Studies comparing HoLEP, ThuLEP, DiLEP, or BipolEP with TUR-P providing 12 months of postoperative follow-up were included. Two frequentist network meta-analyses were created to compare the techniques of EEP indirectly.

Results

31 studies, including 4466 patients, were found eligible for our meta-analysis. Indirect pairwise comparison showed differences in surgery time between BipolEP and HolEP (MD − 16.72 min., 95% CI − 27.75 to − 5.69) and DiLEP and HoLEP (MD − 22.41 min., 95% CI − 39.43 to − 5.39). No differences in the amount of resected prostatic tissue, major and minor complications and postoperative catheterization time were found. The odds for blood transfusions were threefold higher for BipolEP than for HoLEP (OR 3.27, 95% CI 1.02–10.5). The difference was not statistically significant when comparing prospective trials and matched-pair analysis only (OR 3.25, 95% CI 0.94–11.18). The Qmax 12 months after surgery was 2 ml/sec. higher for BipolEP than for DiLEP (MD  2.00, 95% CI 0.17–3.84) and 1.94 ml/sec. lower for DiLEP than for HoLEP (MD − 1.94, 95% CI − 3.65 to − 0.22).

Conclusion

The energy source used for EEP has an impact on the intervention itself. BipolEP promotes surgical efficiency; laser techniques lower the risk of bleeding.

Registry

This meta-analysis is registered in the PROSPERO international prospective register registry with the registration number CRD42020205836.

Comparison of Efficacy of Different Surgical Techniques for Benign Prostatic Obstruction

Purpose

We compared success rates of 3 surgical techniques (holmium laser enucleation of the prostate [HoLEP], transurethral resection of the prostate [TURP], and photoselective laser vaporization prostatectomy [PVP]) for treatment of benign prostatic obstruction (BPO). We aimed to identify preoperative clinical variables and urodynamic parameters that predict surgical success.

Methods

A total of 483 patients who underwent surgical treatment for BPO at Samsung Medical Center between 2006 and 2017 were retrospectively analyzed; of these 361, 81, and 41 patients underwent HoLEP, TURP, and PVP, respectively. Prostate-specific antigen, prostate volume, urodynamic parameters, and International Prostate Symptom Score (IPSS)/quality of life (QoL) index were evaluated preoperatively; uroflowmetry, postvoid residual urine, and IPSS/QoL index were measured 6 months postoperatively. Surgical success was defined based on IPSS, maximum flow rate, and QoL index and predictive factors were identified using multiple logistic regression analyses.

Results

Success rates of HoLEP, TURP, and PVP were 67.6%, 65.4%, and 34.1%, respectively, and the HoLEP and TURP groups were not significantly different. Regression analysis revealed prostate volume ≥50 mL and bladder outlet obstruction index (BOOI) ≥40 to be independent factors predicting HoLEP success. Only high preoperative QoL could predict the success of TURP, whereas other urodynamic parameters remained unrelated.

Conclusions

Patients treated with HoLEP and TURP displayed equivalent efficacies, but PVP was relatively less efficient than both. Preoperative variables of prostate volume ≥50 mL and BOOI ≥40 were independent predictive factors for the success of HoLEP but not of TURP.

Comparison of Long-term Effect and Complications Between Holmium Laser Enucleation and Transurethral Resection of Prostate: Nations-Wide Health Insurance Study

OBJECTIVE

To investigate and compare the postoperative efficacy and complications of the transurethral resection of prostate (TURP) and holmium laser enucleation (HoLEP) using the nationwide insurance database of Korea.

METHODS

We created a cohort of benign prostatic hyperplasia (BPH) patients treated with TURP and HoLEP between 2011 and 2017 from the nationwide database of reimbursement. We compared the postoperative effects between the two surgical groups.

RESULTS

We retrieved a total of 58,346 patients (TURP 38,308 and HoLEP 20,038 patients). The mean follow-up duration was 51.6 and 47.6 months, respectively. The rate of reoperation was significantly higher in the TURP group (4.50%) than in the HoLEP group (1.27%) (P < .01). The postoperative use of alpha-blockers and dutasteride/finasteride was significantly higher in the TURP group until 24 months postoperatively. The rate of the postoperative use of medications for symptoms of overactive bladder was lower in the TURP group than in the HoLEP group until 12 months postoperatively, but it did not differ after 12 months postoperatively. Overall, urethral surgeries were less frequently performed in the TURP group than in the HoLEP group (P < .05); however, more severe cases required surgeries under general anesthesia in the TURP group (P < .05). Postoperative surgery for stress incontinence was performed in 0.10% and 0.31% of patients after TURP and HoLEP, respectively (P < .01).

CONCLUSION

This study showed the superiority of HoLEP compared to TURP in terms of postoperative efficacy and its inferiority in terms of complications of stress incontinence in real life practice.

Rates and predictors of postoperative complications after Holmium laser enucleation of the prostate (HoLEP) at a high-volume center

BACKGROUND

Holmium laser enucleation of the prostate (HoLEP) is considered a challenging procedure with a non-negligible risk of complications limiting its widespread adoption. We investigated rates and pre-operative predictors of complications in a high volume center with long-time experience.

METHODS

Data from 284 patients treated with HoLEP between 2015 and 2017 were analysed. Postoperative complications occurring up to 12 months after surgery were collected following the EAU guidelines recommendations. Procedure-specific complications were defined and graded by using the Clavien-Dindo (CD) system. Logistic regression analysis tested preoperative risk factors for postoperative complications.

RESULTS

Baseline prostate volume was (median, IQR) 87 (60, 120) ml. As a whole, in-hospital and after discharge complications were 19% and 11.6%, respectively, with a 28.6% overall rate at 12 months from surgery. Complications were graded as CD 1 [8% (22)], 2 [18.2% (52)] and 3 [1.8% (5)], respectively. Fever was the most frequently reported (11% of cases), followed by acute urinary retention (8%). At logistic regression analysis, older age (OR: 1.07; 95%CI: 1.01-1.12; p=0.01) and having an indwelling catheter before surgery (OR: 4.03; 95%CI 1.64-9.9; p=0.002) emerged as significant risk factors for post-HoLEP complications, after accounting for surgeon experience and baseline parameters.

CONCLUSIONS

HoLEP is a safe procedure in a high volume center with less than 2% high-grade complications. Older patients with indwelling catheter deserve to be carefully managed due to a higher risk of postoperative complications.

En-Bloc Holmium Laser Enucleation of the Prostate with Early Apical Release: Are We Ready for a New Paradigm?

Background: Holmium laser enucleation of the prostate (HoLEP) is considered a safe and effective treatment in case of bladder outlet obstruction (BOO). Despite technical execution has evolved over time, from the standard three-lobes to the more recent en-bloc approaches, data comparing these two techniques are missing. The aim of the present study was to describe our en-bloc HoLEP with early apical release technique and compare peri- and postoperative results with the classical three-lobe approach in a single referral center. Materials and Methods: We prospectively analyzed all consecutive cases between 2017 and 2019 divided according to the type of approach. Patients were preoperatively studied through instrumental assessment and clinical evaluation, using validated questionnaires and then postoperatively at specific time frames. Linear regression analysis was performed to evaluate possible predictor of continuous variables. All the procedures were carried out by one single expert surgeon. Results: Overall, 168 patients were included, of which 81 were treated with classical three-lobes and 87 with en-bloc with early apical release technique. The two cohorts were comparable related to preoperative features and postoperative complication rate. Mean enucleation time (ET), lasing time, amount of energy delivered, and overall operative time were significantly lower in en-bloc procedures (p < 0.05). Stepwise multivariable linear regression showed that en-bloc strategy can significantly predict shorter ET and lower energy delivered. Stress incontinence rate at 1-month follow-up was found to be significantly reduced in the en-bloc group, compared with the counterpart. Conclusions: Both techniques are effective and safe treatment options for BOO, since peri- and postoperative surgical and functional outcomes were favorable. En-bloc strategy may significantly decrease ET and the amount of energy delivered leading to a reduced early stress incontinence rate compared with the standard approach.

Pharmacological and interventional treatment of benign prostatic obstruction: An evidence‐based comparative review

Introduction

The recommended treatment for bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) after the failure of behavioral therapy and fluid modification includes pharmacological, minimally invasive interventional, and surgical approaches. Each option has different risk and benefit profiles, and the urologist must be aware of the unique characteristics of each option in order to be able to accurately counsel the patients based on their individual values and preferences. We provide a comparative review of the commonest pharmacological and most widely performed interventional/surgical treatments for BPO, discussing the evidence for the treatment characteristics that are most useful for the practicing urologist.

Methods

A search of the PubMed database was performed for articles reporting on the following treatments for LUTS due to BPO: α‐blockers, 5α‐reductase inhibitors, phosphpdiesterase‐5 inhibitors, prostatic urethral lift (Urolift), convective radiofrequency water vapor thermal therapy (Rezum), Temporary implantable Nitinol Device (iTIND), prostate artery embolization (PAE), transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), Aquablation, and anatomical endoscopic enucleation of the prostate (AEEP). We performed a narrative review focussing on the following outcomes: efficacy, safety, durability, duration of catheterization, length of stay, re‐treatment rate, efficacy in special situations (enlarged median lobe, prostate size, urinary retention, and anticoagulant use), and sexual adverse events.

Results

AEEP offers the greatest long‐term improvement in maximum flow rate, IPSS, and prostate volume reduction, with lowest re‐treatment rate, followed by PVP, TURP, and Aquablation. Urolift, Rezum, and PAE have similar efficacy for prostate volume up to 80cc, and all are more effective than the pharmacological treatment. Urolift offers the lowest rate of sexual dysfunction, followed by Rezum, and both can be performed as a day case under local anesthesia.

Conclusion

Several treatment options exist to treat voiding LUTS due to BPO. Newer minimally invasive treatments reduce the hospital stay and postoperative complications, whereas AEEP provides the greatest long‐term symptom improvement at the expense of higher morbidity and sexual dysfunction. Men should be counseled regarding all suitable treatment options as some may favor reduced efficacy in association with reduced side effects.

[Surgical and interventional management of benign prostatic obstruction: Guidelines from the Committee for Male Voiding Disorders of the French Urology Association]

OBJECTIVE

The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO).

METHODS

All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions.

RESULTS/GUIDELINES

Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm³, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm³. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm³. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm³ without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols.

CONCLUSION

Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.

Combined top-down approach with low-power thulium laser enucleation of prostate: evaluation of one-year functional outcomes

OBJECTIVES

To evaluate the safety and efficacy of combined top and down low power thulium laser enucleation of the prostate (ThuLEP).

PATIENTS AND METHODS

Between May 2017 and May 2019, after institutional board review approval, successfully consented patients underwent combined top and down low power ThuLEP. We used a 30 -W Thulium laser with a 550 μm laser fiber and a 26 Fr continuous flow resectoscope. We collected data related to prostate size, enucleation time, morcellation time, perioperative complications, and early outcomes.

RESULTS

Sixty patients underwent combined Top and down low power ThuLEP with mean age 67 ± 8. Acute urine retention was the main indication for surgery in 22% of patients, while the remaining had mean IPPS score 26 ± 3. The mean prostate volume was 102 ± 25 ml and the mean Qmax was 6 ± 2 ml/sec. Mean operative time was 103 ± 25 min, while; mean enucleation time was 80 ± 12 min, and mean morcellation time was 17 ± 6 min. The mean enucleated prostate volume was 73 ± 16 g and the mean hemoglobin drop was 1 ± 0.2 mg/dl. There was no need for blood transfusion and the mean hospital stay was 18 ± 4 h and catheters were removed on discharge. The 1st visit was at one month, and we observed significant mean Qmax improvement18 ± 5 ml/s. Our results showed no significant change of IIEF-5 score at 12-month follow-up compared to baseline.

CONCLUSION

Low-power Thulium enucleation with a combined top and down technique provided a safe and efficacious outcome, that may reduce strenuous wrist flexion and eliminate the need for high-power Thulium laser device.

Comparison Study of Learning Curve Using Cumulative Sum Analysis Between Holmium Laser Enucleation of the Prostate and Transurethral Resection of the Prostate: Is Holmium Laser Enucleation of the Prostate a Difficult Procedure for Beginner Urologists?

Objectives: Although there is no comparison study about the learning curves for holmium laser enucleation and other surgical modalities to treat benign prostatic hyperplasia (BPH), beginner urologists are hesitant to perform holmium laser enucleation because of its steep learning curve. Therefore, we investigated the degree of surgical difficulty of holmium laser enucleation by comparing its learning curve with that of transurethral resection. Patients and Methods: Two beginner urologists performed surgery for BPH: H.J.Y. performed holmium laser enucleation and K.H.K. performed transurethral resection. Of 141 patients, 72 were enrolled in the holmium laser enucleation group and 69 in the transurethral prostate resection group. After retrospectively reviewing medical records, we performed a cumulative sum analysis of resection speed (RS) and resected ratio (RR) to compare the learning curves of holmium laser enucleation and transurethral resection. Results: Both surgeons achieved RS competency with a speed <0.13 g/min. The surgeon who performed holmium laser enucleation achieved RR competency with a ratio <0.40, whereas the surgeon who performed transurethral resection achieved competency with a ratio <0.35. To achieve RS competency of 0.13 g/mL, the holmium laser enucleation and transurethral resection groups required 12 and 23 cases, respectively. To achieve RR competency of 0.35, the holmium laser enucleation and transurethral resection groups required 12 and 5 cases, respectively. Conclusions: Holmium laser enucleation is not a difficult procedure compared with transurethral resection in beginner urologists. Therefore, it is unnecessary to avoid holmium laser enucleation because the concerns that it may be difficult are unfounded.

'Top-Down' holmium laser enucleation of the prostate. Report of initial cases performed by a single surgeon

Objectives

To present the 12-month outcomes of ‘Top-Down’ holmium laser enucleation of the prostate (HoLEP).

Patients and methods

We retrospectively reviewed the charts of prospectively collected patients who underwent Top-Down HoLEP between 2017 and 2018. All cases were operated upon by a single urologist (H.E), using a 100-W holmium:YAG laser with a 550-μm laser fibre. We recorded the enucleation time, morcellation time, intraoperative, and postoperative complications. All patients had postoperative follow-up visits at 1, 3, 6 and 12 months. The evaluation included the International Prostate Symptom Score (IPSS), quality-of-life (QoL) assessment, measurement of maximum urinary flow rate (Q_max) and the post-void residual urine volume (PVR).

Results

A total of 60 consecutive patients were recruited. The median (range) prostatic volume, resected prostatic weight, and percentage of resected prostatic tissue were 124 (70–266) mL, 90 (44–242) g and 76 (46–97)%, respectively. The median (range) enucleation and morcellation times were 80 (25–200) and 14.5 (4–58) min, respectively. One patient had a simple bladder mucosal injury and another developed clot retention. At 3 months, three patients (5%) had stress urinary incontinence (SUI) and eight patients (13.3%) presented with urge UI (UUI). At the last follow-up visit, one patient (1.7%) presented with persistent SUI, while three patients (5%) presented with UUI. The IPSS and QoL significantly improved during the follow-up period (P = 0.045 and P = 0.04, respectively).

Conclusion

The results of the Top-Down technique are comparable to those of traditional HoLEP. However, the Top-Down technique may reduce the complexity, operating time, and SUI rates.

Abbreviations

BN: bladder neck; HoLEP: holmium laser enucleation of the prostate; PVR: post-void residual urine volume; Q_max: maximum urinary flow rate; QoL: quality of life; TOV: trial of voiding; (S)(U)UI: (stress) (urge) urinary incontinence

Endoscopic enucleation for prostate larger than 60 mL: comparison between holmium laser enucleation and plasmakinetic enucleation

PURPOSE

To compare perioperative and functional outcomes of two different energy sources, holmium laser and bipolar current for endoscopic enucleation of prostate larger than 60 mL.

METHODS

A prospective, monocentric, comparative, non-randomized study was conducted including all patients treated for prostate larger than 60 mL, measured by transrectal ultrasound. Patients were assigned to each group based on the surgeons' practice. Perioperative data were collected (preoperative characteristics, operating, catheterization and hospitalization times, hemoglobin loss, complications) and functional outcomes (IPSS, IPSS Quality of Life (QoL), PSA) at 3 months and 1 year.

RESULTS

100 patients were included in each group from October 2015 to March 2018. No differences between HoLEP and plasma groups were observed at baseline, except for mean IPSS score, IPSS QoL score and preoperative PVR that were significantly higher in the HoLEP group. Operating time (142.1 vs 122.4 min; p = 0.01), catheterization time (59.6 vs 44.4 h; p = 0.01) and hospitalization time (2.5 vs 1.8 days; p = 0.02) were significantly shorter in the plasma group. Complication and transfusion rate were no significantly different between HoLEP and plasma. No significant differences were observed concerning functional outcomes at 3 months and 1 year. The urinary incontinence rate was higher 21.1% vs 6.4% (p < 0.01) at 3 months in HoLEP group, but no difference was observed at 1 year.

CONCLUSION

Holmium and plasma are both safe and effective for endoscopic treatment for prostate larger than 60 mL. Operating, catheterization and hospitalization times were significantly shorter in the plasma group. The complication rate and functional outcomes were not significantly different.

Ten-year Follow-up Results After Holmium Laser Enucleation of the Prostate

BACKGROUND

Scarce data are available about long-term follow-up (FU) in men undergoing holmium laser enucleation of the prostate (HoLEP).

OBJECTIVE

To investigate the risk of being symptomatic at 10-yr FU after HoLEP.

DESIGN, SETTING, AND PARTICIPANTS

Perioperative data from 125 patients submitted to HoLEP in 2007-2010 by a single, highly experienced surgeon were analyzed. Patients were assessed by International Prostate Symptoms Score (IPSS), prostate-specific antigen (PSA), and uroflowmetry at 6-mo and 10-yr FU.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Logistic regression models tested the association between clinically significant predictors and the risk of being symptomatic at long-term FU (defined as IPSS≥8 and/or peak flow rate [PFR]<15ml/s and/or postvoid residual volume [PVR]>20ml, need for symptomatic medical treatment, or redo surgery).

RESULTS AND LIMITATIONS

At surgery, median (interquartile range) age was 66 years (61, 69), prostate volume was 78ml (56, 105), and PFR was 9ml/s (7, 12). All patients showed favorable outcomes (ie, IPSS and uroflowmetry parameters) 6 months after surgery. At median 126-month FU, PFR was 16ml/s (13, 23), PVR was 10ml (5, 15), total IPSS was 5 (1-7), and PSA was 0.7 ng/ml (0.4, 1.3). Of all, 32 patients (26%) were symptomatic at long-term FU, seven (5.7%) reported urinary incontinence, and six (4.7%) underwent redo surgery throughout the FU period due to either bladder neck contracture or urethral stricture. Older patients at surgery (odds ratio [OR]: 1.12; 95% confidence interval [CI]: 1.03-1.22; p=0.006) and patients who never recovered full continence postoperatively (OR: 0.49; 95% CI: 0.01-0.27; p=0.001) were at a higher risk of being symptomatic at very long-term FU, after adjusting for baseline clinical characteristics.

CONCLUSIONS

HoLEP ensures a durable relief of urinary symptoms in almost 75% of patients up to 10 years after surgery. Older patients and those who do not recover from incontinence after surgery should be counseled carefully regarding a higher risk of symptom recurrence at long-term assessment.

PATIENT SUMMARY

Consistent symptom relief is preserved even 10 years after holmium laser enucleation of the prostate in almost 75% of patients. Older age and incomplete continence recovery after surgery were the two most relevant risk factors for being symptomatic at long-term follow-up. Postoperative functional outcomes are kept in three out of four patients at 10-yr follow-up after holmium laser enucleation of the prostate. Conversely, the older the patient at surgery and the presence of incomplete continence recovery throughout the postoperative period, the greater the probability of being symptomatic at long-term follow-up.

Is Holmium Laser Enucleation of the Prostate a Good Surgical Alternative in Benign Prostatic Hyperplasia Management? A Review Article

Several therapeutic approaches such as holmium laser enucleation of the prostate (HoLEP) have been introduced to relieve bladder outlet obstruction caused by benign prostatic hyperplasia (BPH). Compared with other techniques including the transurethral resection of the prostate (TURP) and simple open prostatectomy, HoLEP results in a shorter hospital stay and catheterization time and fewer blood loss and transfusions. HoLEP is a size-independent treatment option for BPH with average gland size from 36 g to 170 g. HoLEP is a safe procedure in patients receiving an anticoagulant and has no significant influence on the hemoglobin level. Also, HoLEP is an easy and safe technique in patients with a prior history of prostate surgery and a need for retreatment because of adenoma regrowth. The postoperative erectile dysfunction rate of patients treated with HoLEP is similar to TURP or open prostatectomy and about 77% of these patients experience loss of ejaculation. Patients with transitional zone volume less than 30 mL may suffer from persistent stress urinary incontinence following HoLEP so other surgical techniques like bipolar TURP are a good choice for these patients. In young patients, considering HoLEP with high prostate-specific antigen density and a negative standard template prostate biopsy, multiparametric MRI needs to be considered to exclude prostate cancer.

Complications of anatomical endoscopic enucleation of the prostate

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

Super early detailed assessment of lower urinary tract symptoms after holmium laser enucleation of the prostate (HoLEP): a prospective study

PURPOSE

To prospectively investigate early and consecutive changes of lower urinary tract symptoms (LUTS), specifically storage symptoms after holmium laser enucleation of the prostate (HoLEP).

METHODS

Patients referred for HoLEP completed the International Prostatic Symptom Score (IPSS) the day before, at discharge, and 1, 2, 3, 4, 6, 8, 12, 16, 20, 24, and 52 weeks after HoLEP. Total IPSS was stratified into mild (score 0-7), moderate (8-19), and severe (20-35) LUTS. Storage symptoms were sub-stratified into storage "negative" and "positive". IPSS changes served as the main postoperative outcome. Mixed linear models identified risk factors affecting postoperative recovery of LUTS.

RESULTS

Between December 2010 and 2012, 144 consecutive HoLEP patients were prospectively included in the study. Preoperatively 57.6% of the cohort reported severe storage symptoms (mean total IPSS: 22.6 ± 5.0). Total IPSS decreased significantly immediately after surgery (p < 0.001). Patients with severe LUTS, storage-positive sub-score, and high maximum urinary flow rate were affected by a rebound of mainly storage symptoms 6-8 weeks after HoLEP and prolonged recovery from LUTS. Of these, about 7.4% presented persisting urge complaints. Finally, 12 weeks following HoLEP, the vast majority of patients were symptom-free. Limitations of this study include missing urodynamic workup and a comparative patient cohort.

CONCLUSION

Immediately after HoLEP, patients experience a significant decrease of LUTS. Continuous symptom recovery seems to be hampered in patients with severe and storage-positive baseline symptoms. (De-novo) storage symptoms slightly affect postoperative recovery. Quality of life is restored to a stable and significantly improved status 3 months after surgery.

En-bloc endoscopic enucleation of the prostate: a systematic review of the literature

INTRODUCTION

Transurethral resection of the prostate (TURP) remains the gold standard for treatment of benign prostatic hyperplasia (BPH). Yet, the introduction of lasers for the treatment of LUTS due to BPO has dramatically changed the surgical landscape of benign prostatic obstruction (BPO) treatment. Recently, "en-bloc" techniques have shown to prove advantageous in terms of better visualization, more prompt identification of the surgical capsule and the correct plane to dissect. Herein we provide a comprehensive overview of available series of en-bloc enucleation of the prostate, focusing on surgical techniques, perioperative and functional outcomes.

EVIDENCE ACQUISITION

A systematic review of the literature was performed according to PRISMA recommendations and was conducted on surgical techniques and perioperative outcomes of minimally invasive en-bloc surgery for prostate adenoma detachment.

EVIDENCE SYNTHESIS

Overall, 16 studies with 2750 patients between 2003 and 2019 were included. Specific technical nuances have been described to maximize perioperative outcomes of en-bloc prostatic enucleation, including early apical release, horse-shape incisions, inverted U-shape tractions and low power. Overall, regardless of the energy employed, en-bloc prostatic enucleation achieved favorable outcomes including low risk of major complications and quality of life improvement. However, a great heterogeneity of study design, patients' inclusion criteria, prostate volume and en-bloc surgical strategy was found.

CONCLUSIONS

En-bloc endoscopic enucleation of the prostate has been shown to be technically feasible and safe, with potential technical advantages over the classic three-lobe technique. Larger comparative studies are needed to evaluate the ultimate impact of the en-bloc approach on postoperative outcomes, in light of the surgeon's learning curve.

Preoperative pelvic floor muscle exercise for early continence after holmium laser enucleation of the prostate: a randomized controlled study

Background

Transient postoperative urinary incontinence is a bothersome complication of holmium laser enucleation of the prostate (HoLEP). The effects of preoperative pelvic floor muscle exercise (PFME) for early recovery of continence after HoLEP have never been elucidated. The aim of this study was to determine the benefit of preoperatively started PFME for early recovery of continence after HoLEP.

Methods

We randomly assigned patients to start PFME preoperatively and continue postoperatively (group A) or start PFME no earlier than the postoperative period (group B). The primary outcome was time to complete urinary control, defined as no pad usage. The secondary outcome was measured using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score. Univariate and multivariate analyses were performed to identify parameters associated with recovery of continence after HoLEP.

Results

Seventy patients were randomized across groups A (n = 35) and B (n = 35). Patients’ characteristics were not different between groups A and B. The postoperative urinary incontinence rate significantly decreased in group A compared with that in group B at 3 months postoperatively [3% vs. 26% (P = 0.01)]. However, there were no significant differences between groups A and B at 3 days [40% vs. 54% (P = 0.34)], 1 month [37% vs. 51% (P = 0.34)], and 6 months [0% vs. 3% (P = 1.00)] postoperatively, respectively. The postoperative ICIQ-SF score was not significantly different between groups A and B at any time point postoperatively. In univariate analysis, patients who performed preoperative PFME had a 0.56-fold lower risk of urinary incontinence 1 month after HoLEP and a 0.08-fold lower risk of urinary incontinence 3 months after HoLEP.

Conclusions

Preoperatively started PFME appears to facilitate improvement of early urinary continence after HoLEP.

Trial registration

The study was registered with the University Hospital Medical Information Network Clinical Trials Registry in Japan (UMIN000034713); registration date: 31 October 2018. Retrospectively registered.

Our clinic's first experience with HoLEP

OBJECTIVE:

The present study reports a retrospective evaluation of the first Holmium laser prostate enucleation (HoLEP) cases and their results in our clinic.

METHODS:

Twenty four patients who underwent HoLEP surgery between April 2017 and November 2017 were evaluated for demographic characteristics, duration of operation, amount of hemorrhage, amount of energy used, tissue weight removed, catheterization time and complications. IPSS and uroflowmetry results were compared before and after the surgery.

RESULTS:

Patients with hemoglobin, IPSS, uroflowmetry, and voiding speeds (Qmean, Qmax) were compared before and after the surgery. There was a significant difference in IPSS, Qmean and hemoglobin values but not in Qmax, statistically. Our complications rates were correlated with the literature.

CONCLUSION:

HoLEP stands out as a surgical method that can be applied with high confidence in the treatment of benign prostatic hyperplasia and it has similar functional results to gold standard surgeries, causes fewer complications, improves patient comfort due to short catheterization and hospitalization and is more advantageous regarding cost.

Evidence-based outcomes of holmium laser enucleation of the prostate

PURPOSE OF REVIEW

Holmium laser enucleation of the prostate (HoLEP) has been a mainstay therapy for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostate hyperplasia (BPH) for nearly 20 years. We briefly review current and sentinel publications that provide outcomes data after HoLEP.

RECENT FINDINGS

Current literature continues to support HoLEP as a versatile and durable surgical option for men with LUTS secondary to BPH. Despite evidence supporting durable symptom relief beyond 10 years even in large prostate glands, HoLEP is still not widely available to all patients. Concerns surrounding the learning curve of the procedure, high rates of retrograde ejaculation, and transient urinary incontinence seem to persist and limit the adoption of HoLEP by established urologists and residency training programs.

SUMMARY

Recent publications continue to show excellent short-term and long-term outcomes after HoLEP, in the categories of voiding function and patient satisfaction. Continued attempts to demonstrate equivalent outcomes of alternate-BPH surgical techniques are being met with renewed efforts by those performing HoLEP to demonstrate equivalent outcomes and patient safety during the learning phase of HoLEP for both mentored and self-directed surgical training.

A Systematic Review and Meta-analysis of Efficacy and Safety Following Holmium Laser Enucleation of Prostate and Transurethral Resection of Prostate for Benign Prostatic Hyperplasia

Transurethral resection of prostate (TURP) still remains the "gold standard" surgical treatment for benign prostatic hyperplasia (BPH). In recent years, holmium laser enucleation of prostate (HoLEP) gets more and more popularity in the world. Our objective is to compare the efficacy and safety of HoLEP and TURP for BPH. Eleven studies met our eligibility criteria including 1339 patients. The prostate sizes of the all included studies were smaller than 100 g. Overall, in patients with small to mid-sized prostates, HoLEP offers safer clinical outcomes with less blood drop and potentially better long-term relief of bladder outlet obstruction.

The effect of prostatic tissue density on the perioperative outcomes of Holmium laser enucleation of prostate (HoLEP): a pilot study

PURPOSE

To evaluate the effect of prostate tissue density (PTD) on perioperative Holmium laser enucleation of prostate (HoLEP) outcomes.

METHODS

Two hundred fourteen patients underwent HoLEP between December 2016 and August 2018 (group 1: PTD < 1 g/mL and group 2: PTD ≥ 1 g/mL). Enucleation time (ET), morcellation time (MT), total operation time (TOT), total laser energy (TLE), efficiency of laser (EL), efficiency of enucleation (EE), efficiency of morcellation (EM), enucleation rate (ER), and enucleated tissue weight (ETW) were recorded.

RESULTS

The mean ages of the groups 1, 2 were 61.36±5.92 and 63.1±7.52 years, respectively. TOT (76.4 vs 86.21 min), ET (69.18 vs 79.94 min), EE (0.80 vs 0.91 g/min), and ETW (55.8 vs 70.23 g) were not significantly different between the two groups. However, the MT was longer in group 2 (11.27 ± 8.57 min and 7.22 ± 5.46 min, p = 0.0001). Furthermore, EM was higher in group 1 (9.81 ± 5.61 g/min and 7.45 ± 4.14 g/min, p = 0.0003). The EL and TLE were similar in both groups. PTD positively correlated with MT (ρ = 0.272, p = 0.0005) and negatively correlated with EM (ρ = - 0.315, p = 0.0001). No correlations were identified between the PTD and EL or EE.

CONCLUSIONS

PTD is a factor that influences the HoLEP on perioperative outcomes. The PTD particularly affects the morcellation phase of the surgery. Patients with higher PTD will have a longer duration of MT and lesser EM. Future studies with the use of different imaging methods will give insight into the duration and difficulty of the HoLEP.

Effect of preoperative urethral dilatation on preventing urethral stricture after holmium laser enucleation of the prostate: A randomized controlled study

INTRODUCTION

We aimed to evaluate the effect of preoperative urethral dilatation during holmium laser enucleation of the prostate (HoLEP) on the prevention of urethral stricture.

METHODS

A total of 72 patients without urethral stricture underwent HoLEP for benign prostatic hyperplasia (BPH). Recruited patients were randomly divided into two groups (groups A and B). Patients in group A (36 patients, experimental group) received preoperative urethral dilatation and patients in group B (36 patients, control group) did not. Each patient was evaluated at four weeks, 12 weeks, and 24 weeks after surgery. The effectiveness of preoperative urethral dilatation was evaluated based on the International Prostate Symptom Score (IPSS), peak urine flow rate (Qmax), voided volume, and post-void residual (PVR) volume. To diagnose urethral stricture, Qmax <10 mL/s, as assessed using uroflowmetry and findings of visualization through retrograde urethrography and urethroscopy, were used.

RESULTS

Among 72 initial participants, 33 patients in group A and 31 patients in group B completed the experiment. Preoperative characteristics were well-balanced between groups. At each postoperative visit, there was no significant difference in voiding symptoms between groups. Two patients (6.06%) in group A and five patients (15.15%) in group B showed a Qmax <10 mL/s on uroflowmetry (p=0.013). On urethroscopy, no patient in group A (0%) and two patients in group B (6.45%) (p=0.021) showed urethral stricture after HoLEP.

CONCLUSIONS

Preoperative urethral dilatation during HoLEP decreased the incidence of urethral stricture. This procedure could be useful to reduce the risk of urethral stricture after transurethral prostate surgery. One limitation of the current study is the single-centre design. Also, we sought to determine the efficacy of preoperative urethral dilatation for the prevention of urethral stricture after transurethral prostate surgery within a short time period, which could be another limitation of the study. Despite these limitations, to the best of our knowledge, the present study is the first reported prospective, randomized trial analyzing the safety and efficacy of preoperative urethral dilatation for the prevention of urethral stricture after transurethral prostate surgery.

[Surgical treatment of BPO: Standard and innovations]

INTRODUCTION AND OBJECTIVE

Surgical management of benign prostatic hyperplasia has dramatically changed in the recent years towards higher proportion of endoscopic treatment and fewer perioperative complications. Nevertheless the question of urinary and sexual quality of life after surgical treatment remains partially unresolved with a high proportion of retrograde ejaculation after conventional surgical treatments. Therefore mini-invasive alternatives to conventional surgery have been proposed. The objective of this literature review was to provide an overview of the alternatives to monopolar TURP currently available in France.

MATERIAL AND METHOD

A non-systematic review of the scientific literature was conducted from the PubMed database to retrieve the most relevant scientific publications. A first research was cross-referenced with the results of literature reviews already published and enriched by the authors of this review. A synthesis is proposed for each alternative technique mentioning its level of clinical development, but also its potential advantages and disadvantages compared to conventional surgical techniques.

RESULTS

The quality of life of patients after surgical or interventional management has become the main priority of urologists since the risks of perioperative complication have been reduced by the use of laser or bipolar endoscopic techniques. Thanks to the development of minimally invasive alternatives that are better and better evaluated by randomized trials versus interventional simulation and conventional surgical treatment, more personalized care is possible. Patients' expectations and their individual risk factors can thus be placed at the center of the therapeutic decision and the preoperative information.

CONCLUSION

The surgical and interventional management of LUTS due to BPH has evolved to lower perioperative morbidity with the help of numerous technological developments. Mini-invasive alternatives to standard treatment have also been proposed in order to improve the quality of postoperative sexual life. These alternatives provide significant improvement in LUTS that remains lower than after conventional treatments. Somme of these alternative are also not fully supported by clinical trials, which should urge urologists to act with caution when proposing these alternatives in daily clinical practice.

[Endoscopic enucleation of the prostate: Indication, technique and results]

INTRODUCTION

Laser prostatic enucleation is an increasingly popular technique among surgical urology. It is now gradually becoming a contender for gold standard surgical treatments, trans-urethral resection of the prostate (TURP) and open prostatectomy (OP).

MATERIALS AND METHODS

This study is based on data collected from sources published between June 1995 and June 2017. Medline and Embase database have been used to research the following keywords: Holmium; Thulium; Greenlight; Laser; Prostate; Enucleation; Benign prostatic obstruction; Surgical technique.

RESULTS

With HoLEP process, catheterization time varies from 17,7hrs to 46,4hrs with 2 to 2.5 hospitalization days. With ThuLEP process, catheterization time varies from 2 to 2.5 days with 2.15 to 6.5 hospitalization days. With GreenLEP process, catheterization and hospitalization times are both 2 days. IPSS score after a year varies from 12.7 to 19.1 points in different publications.

CONCLUSION

Convincing results of Laser prostatic enucleation make it a valid alternative to existing treatments.

Patient satisfaction after holmium laser enucleation of the prostate (HoLEP): A prospective cohort study

Objective

To investigate patient satisfaction after holmium laser enucleation of the prostate (HoLEP) in a prospective study.

Subjects and methods

From May 2012 to December 2014, 397 patients underwent HoLEP by a single surgeon and enrolled in our prospective registry. Baseline data included age, PSA, transrectal ultrasonography, the international prostate symptom score (IPSS), and overactive bladder symptom score (OABSS). Subjective assessment of surgical outcomes was performed at 6 months postoperatively using self-administered questionnaires consisting of ‘satisfaction with treatment question’ (STQ), ‘overall response assessment’ (ORA), and ‘willingness to undergo surgery question’ (WSQ).

Results

A total of 331 patients (mean age 69.6±7.0 years) were included in the analysis. Mean total prostate volume was 69.5 (±42.2) ml. Mean preoperative IPSS score was 18.5 (±7.8). The STQ showed that most patients (91.8%) were satisfied after the surgery. Only 11 (3.3%) patients responded with ‘dissatisfied’, and no patients replied with ‘very dissatisfied’. The WSQ showed that 311 (94.0%) patients were willing to undergo the surgery again if they had to reconsider the surgical decision. The ORA showed that all patients (99.4%) experienced an improvement. When compared with satisfied patients, neutral/dissatisfied patients had lower IPSS quality of life scores (2.7 vs. 0.9, p<0.001), higher IPSS voiding symptom scores (7.0 vs. 1.4, p<0.001), and more frequent episodes of urgency urinary incontinence in OABSS (1.0 vs. 0.3, p = 0.017) at 6 months postoperatively.

Conclusions

The overall level of satisfaction after HoLEP was high. The most common reason for dissatisfaction was the occurrence of urgency urinary incontinence after the surgery.

Monopolar Transurethral Enucleation of Prostatic Adenoma: Preliminary Report

OBJECTIVE

To describe preliminary results of our monopolar transurethral enucleation of prostatic adenoma (mTUEPA).

MATERIALS AND METHODS

A consecutive series of male patients treated with mTUEPA, a retrograde enucleation of the prostatic adenoma performed by means of a standard monopolar resectoscope, were prospectively enrolled. Symptoms, uroflowmetry parameters, and post-voiding residual were assessed at baseline and at 1, 6, and 12 months postoperatively. Prostate volume was evaluated at baseline by means of transrectal ultrasound. Antiplatelet and anticoagulant drugs were stopped at least 1 week before the operation.

RESULTS

Forty-seven patients were enrolled. Mean preoperative prostate volume was 64.9 ± 28.5 g. When assessed at baseline, the mean total International Prostatic Symptoms Score was 15.2 ± 3.9, peak flow rate (Qmax) was 8.4 ± 2.9 mL/s and the post-voiding residual was 103.2 ± 90.6 mL. Four weeks after surgery, patients reported a mean International Prostatic Symptoms Score of 5.3 ± 3. This lower urinary tract symptoms relief was further maintained at 6 and 12 months after surgery. A significant postoperative improvement in uroflowmetry parameters was described, being the 6 and 12 months mean Qmax of 23.4 ± 10.6 mL/s and 18.8 ± 9.2 mL/s, respectively (P < .001). Overall, 14 postoperative complications were reported by 13 of 47 (27.6%) patients: most of them were minor complications (Clavien-Dindo Grade I-II), whereas 1 patient reported capsule perforation during surgery, requiring interruption of the procedure and its further completion (Clavien-Dindo IIIb).

CONCLUSION

mTUEPA is a safe and effective technique, merging the principles of laser enucleation and the advantages of mechanical enucleation with standard monopolar transurethral resection of the prostate equipment.

Predictors of urgency improvement after Holmium laser enucleation of the prostate in men with benign prostatic hyperplasia

Purpose

To investigate the change in urinary urgency and predictors of urgency improvement after holmium laser enucleation of the prostate (HoLEP) in men with benign prostatic hyperplasia (BPH).

Materials and Methods

We retrospectively analyzed the medical records of patients who were treated with HoLEP for BPH and had preoperative urgency measuring ≥3 on a 5-point urinary sensation scale. Those with prostate cancer diagnosed prior to or after HoLEP, a history of other prostatic and/or urethral surgery, moderate to severe postoperative complications, and neurogenic causes were excluded. Patients who had improved urgency with antimuscarinic medication after HoLEP were excluded. We divided the patients into 2 groups based on urgency symptoms 3 months after HoLEP: improved and unimproved urgency. Improved urgency was defined as a reduction of 2 or more points on the 5-point urinary sensation scale. Preoperative clinical and urodynamic factors as well as perioperative factors were compared between groups.

Results

In total, 139 patients were included in this study. Voiding parameters in all patients improved significantly after HoLEP. Seventy-one patients (51.1%) had improved urgency, while 68 (48.9%) did not show any improvement. A history of acute urinary retention (AUR) and postvoid residual were associated with postoperative urgency improvement in univariate analysis. In multivariate analysis, a history of AUR was an independent factor affecting urgency improvement.

Conclusions

A preoperative history of AUR could influence the change in urgency after HoLEP surgery in patients with BPH.

Long-term sexual outcomes after holmium laser enucleation of the prostate: which patients could benefit the most?

Assess rate and predictors of erectile function (EF) outcomes at long-term follow-up (FU) after holmium laser enucleation of the prostate (HoLEP). Cross-sectional analyses were performed on 135 patients with a mean FU of 12 years post HoLEP. Patients completed both a baseline and a FU International Index of Erectile Function (IIEF)-EF domain and the International Prostatic Symptoms Score (IPSS). Postoperative EF outcomes, including rate and predictors of EF improvement considering minimal clinically important differences (MCIDs) criteria, were assessed. Logistic regression models tested the association between predictors and EF. At a mean (median) FU of 152.1 (163) months, patients showed a significant decrease in the IIEF-EF score P<0.01) and significant IPSS improvement (P<0.01). Overall, 50 (37%) patients worsened by at least one IIEF-EF category. Conversel, 23 (17%) patients reported an improvement in postoperative IIEF-EF score; 75 (55.6%) and 10 (7.4%) patients maintained and eventually improved their IIEF-EF category, respectively. Patients reporting a decrease in the postoperative IIEF-EF score were significantly older (P=0.03) and showed a significantly longer mean FU (P<0.01) than those reporting postoperative improvements of IIEF-EF. Nine (6.7%) patients showed significant EF improvement according to MCIDs criteria. Both higher IPSS scores (odds ratio (OR): 1.12; P=0.02) and lower IIEF-EF (OR: 0.88; P<0.01) at baseline, emerged as independent predictors of postoperative EF improvement. HoLEP was associated with a decrease in EF and a persistent amelioration of BPH-related urinary symptoms at long-term FU. Almost one third of patients worsened by at least one IIEF-EF category. However, a clinically meaningful EF improvement was observed in roughly 7% of the individuals. Patients with more severe preoperative urinary symptoms and ED benefited more from HoLEP in terms of EF.

Postoperative infectious complications in patients undergoing holmium laser enucleation of the prostate: Risk factors and microbiological analysis

OBJECTIVES

To examine the incidence of postoperative bacteriuria and febrile complications, and to investigate bacterial strains in the urine of patients undergoing holmium laser enucleation of the prostate.

METHODS

We retrospectively analyzed 190 evaluable patients treated with holmium laser enucleation of the prostate at the Gifu University Hospital, Gifu, Japan, between September 2005 and May 2014. All patients presented with lower urinary tract symptoms as a result of benign prostatic hyperplasia. We also evaluated the causative bacteria and compared the findings with the results of preoperative urine cultures. We analyzed the relationship between the emergence of postoperative febrile complications, antibiotic prophylaxis, patient background and surgical procedure.

RESULTS

The frequency of bacterial isolation in preoperative and postoperative urine cultures was 41% and 23%, respectively. Preoperatively, Enterococcus faecalis was the most frequently cultured bacteria, second was methicillin-resistant Staphylococcus epidermidis, and third was Escherichia coli. Postoperatively, Enterococcus faecalis was still the most frequently cultured bacteria, whereas the second was Escherichia coli. Risk factors for postoperative bacteriuria were evaluated. Multivariate analysis showed that the rate of postoperative bacteriuria in patients who had taken dutasteride preoperatively was significantly lower than that in the other patients. Risk factors for febrile complications could not be identified.

CONCLUSIONS

The use of perioperative prophylactic antibacterial agents for holmium laser enucleation of the prostate keeps the rate of postoperative infectious complications low. Dutasteride treatment administered before surgery might reduce the risk of postoperative bacteriuria.

Efficacy and safety of holmium laser enucleation of the prostate for extremely large prostatic adenoma in patients with benign prostatic hyperplasia

Purpose

To evaluate the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) for extremely large prostates.

Materials and Methods

Patients undergoing HoLEP between July 2008 and December 2013 from the Seoul National University Hospital Benign Prostatic Hyperplasia Database Registry were retrospectively analyzed. The patients were divided into three groups according to their total prostate volume (TPV): group A (TPV<100 mL), group B (100 mL≤TPV<200 mL), and group C (TPV≥200 mL); the clinical data of the three groups were compared. All patients were followed up 2 weeks, 3 months, and 6 months after surgery.

Results

A total of 502 patients (group A, 426; group B, 70; group C, 6) with a mean age of 69.0 (standard deviation, ±7.3) years were included in our analysis. The mean prostate volume and prostate-specific antigen level were 68.7±36.9 mL and 4.15±4.24 ng/mL, respectively. The enucleation and morcellation times were longer in group C (p<0.001), and the enucleation efficacy was higher in this group (p<0.001, R²=0.399). Moreover, the mean postoperative catheterization and hospitalization periods were significantly longer in group C (p=0.004 and p=0.011, respectively). However, there were no significant differences between the groups in any other postoperative events, including recatheterization, reoperation, urinary tract infection, clot retention, and bladder neck contracture (p range, 0.516-0.913). One patient in group C experienced recurrence of the urethral stricture.

Conclusions

HoLEP in patients with an extremely large prostate can be performed efficiently and safely.

A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update

CONTEXT

A number of transurethral ablative techniques based on the use of innovative medical devices have been introduced in the recent past for the surgical treatment of benign prostatic obstruction (BPO).

OBJECTIVE

To conduct a systematic review of the literature and a meta-analysis of available randomized controlled trials (RCTs), and to evaluate the efficacy and safety of transurethral ablative procedures for BPO.

EVIDENCE ACQUISITION

A systematic literature search was performed for all RCTs comparing any transurethral surgical technique for BPO to another between 1992 and 2013. Efficacy was evaluated after a minimum follow-up of 1 yr based on International Prostate Symptom Score, maximum flow rate, and postvoid residual volume. Efficacy at midterm follow-up, prostate volume, perioperative data, and short-term and long-term complications were also assessed. Data were analyzed using RevMan software.

EVIDENCE SYNTHESIS

A total of 69 RCTs (8517 enrolled patients) were included. No significant difference was found in terms of short-term efficacy between bipolar transurethral resection of the prostate (B-TURP) and monopolar transurethral resection of the prostate (M-TURP). However, B-TURP was associated with a lower rate of perioperative complications. Better short-term efficacy outcomes, fewer immediate complications, and a shorter hospital stay were found after holmium laser enucleation of the prostate (HoLEP) compared with M-TURP. Compared with M-TURP, GreenLight photoselective vaporization of the prostate (PVP) was associated with a shorter hospital stay and fewer complications but no different short-term efficacy outcomes.

CONCLUSIONS

This meta-analysis shows that HoLEP is associated with more favorable outcomes than M-TURP in published RCTs. B-TURP and PVP have resulted in better perioperative outcomes without significant differences regarding efficacy parameters after short-term follow-up compared with M-TURP. Further studies are needed to provide long-term comparative data and head-to head comparisons of emerging techniques.

PATIENT SUMMARY

Bipolar transurethral resection of the prostate, photovaporization of the prostate, and holmium laser enucleation of the prostate have shown efficacy outcomes comparable with conventional techniques yet reduce the complication rate. The respective role of these new options in the surgical armamentarium needs to be refined to propose tailored surgical treatment for benign prostatic obstruction relief.

Comparison between complication rates of laser prostatectomy electrocautery transurethral resection of the prostate: A population-based study

INTRODUCTION

We compare the complication rates and length of stay (LOS) of laser transurethral resection of the prostate (L-TURP) versus electrocautery transurethral resection of the prostate (E-TURP) in a population-based cohort. L-TURP has shown enhanced intraoperative safety and equivalent efficacy relative to E-TURP in several high volume centres.

METHODS

Relying on the Florida Datafile as part of the Healthcare Cost and Utilization Project State Inpatient Databases (SID) between 2006 and 2008, we identified 8066 men with benign prostate hyperplasia who underwent L-TURP or E-TURP. Chi-square and Mann-Whitney tests were used to compare baseline characteristics. A multivariable linear regression model was used to analyze the effect of L-TURP versus E-TURP on complication rates and LOS.

RESULTS

Overall complication rates did not differ significantly for L-TURP compared to E-TURP in univariable (8.8 vs. 7.4%, p = 0.1) and multivariable analyses (odds ratio [OR]: 1.06, confidence interval [CI]: 0.85-1.32, p = 0.6). Individuals undergoing E-TURP were less likely to experience a LOS in excess of 1 day (46.2 vs. 59.7%, p < 0.001). A lower risk to experience a LOS in excess of 1 day was confirmed for patients undergoing L-TURP after a multivariable linear regression model (OR: 0.37, CI: 0.23-0.58, p < 0.001), but not for a LOS in excess of 2 days (OR: 0.96, CI: 0.83-1.10, p = 0.2).

CONCLUSIONS

Patient characteristics and perioperative safety were similar for L-TURP and E-TURP patients. However, LOS patterns demonstrated a modest benefit for L-TURP compared to E-TURP patients.

Tissue effects resulting from eraser laser enucleation of the prostate: in vivo investigation

BACKGROUND/AIMS/OBJECTIVES: To describe the depth of the laser coagulation zone in vivo based on histological examinations and the functional outcome of a 1,318-nm diode laser for enucleation in benign prostatic enlargement (BPE).

METHODS

A total of 20 patients with BPE were treated by laser Eraser® enucleation of the prostate (ELEP). Prostatic tissue wedges were evaluated to assess the depth of the ELEP coagulation zones. Additionally, patients were assessed preoperatively and 12 months postoperatively.

RESULTS

The coagulation zones were 0.36 ± 0.17 mm in epithelial tissue, 0.28 ± 0.15 mm in stromal tissue, and 0.25 ± 0.12 mm in mixed tissue. The coagulation area at the cutting edge completely sealed capillary vessels, reaching a depth of 0.35 ± 0.15 mm. The diameter of the coagulated vessels measured 1.75 ± 0.83 mm. Mean blood loss was 115.54 ± 93.12 ml, catheter time 1.35 ± 0.33 days, and hospital stay 1.89 ± 0.52 days. The International Prostate Symptom Score, maximal flow rate, and quality of life significantly improved 12 months after the procedure.

CONCLUSIONS

ELEP is safe and effective for BPE treatment and yields good results at a follow-up of 1 year. Because of the limited penetration depth, damage to the urinary sphincter is not expected.