Holmium Laser Enucleation of the Prostate: Initial Report of the First 230 Egyptian Cases Performed in a Single Center

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.

Two-year follow-up after holmium laser enucleation of the prostate and bipolar transurethral resection of the prostate: a prospective randomized study

Background

Different treatment options are available for the management of BPH. Our study aimed to compare the surgical outcomes of a holmium laser enucleation of the prostate (HoLEP) and a bipolar transurethral resection of the prostate (Bipolar-TURP) after 2 years.

Methods

Our prospective randomized study included 114 patients: 55 patients underwent HoLEP procedure and 59 patients underwent bipolar TURP procedure. All patients underwent a complete preoperative assessment and a physical examination. The postoperative follow-up data included Q max and IPSS recordings at 1, 3, 6, 12, and 24 months and PVR urinary volume recordings at 6 and 12 months. Any postoperative complications were also recorded.

Results

There were no statistically significant differences between both groups regarding IPSS and Q max scores at one and 24 months postoperative. Also, there were no statistically significant differences between both groups regarding postoperative PVR at 6 and 12 months. One patient in the HoLEP group developed total incontinence after surgery.

Conclusion

Our study did not show a significant difference between HoLEP and bipolar TURP regarding postoperative Q max and IPSS scores at 24 months of follow-up.

Bipolar Plasmakinetic Enucleoresection of the Prostate: Our Experience with 245 Patients for 3 Years of Follow-Up

OBJECTIVE

The aim of this study was to evaluate the safety, feasibility, and effectiveness of bipolar transurethral plasmakinetic enucleation of the prostate (PKEP).

PATIENTS AND METHODS

Between January 2010 and October 2013, 245 patients with lower urinary tract symptoms due to benign prostatic hyperplasia underwent transurethral enucleation of prostate using bipolar plasma vaporization energy. Patients were evaluated preoperatively by full detailed history, routine preoperative investigation digital rectal examination, serum prostate-specific antigen, abdominal and transrectal ultrasonography, and maximum flow rates (Q_max).

RESULTS

Patients' ages ranged from 50 to 81 (65.5 ± 6) years with transrectal ultrasound-measured prostate volume of 97.1 ± 36.7 mL resulting in an operating time of 76.9 ± 27.9 minutes, and postoperative irrigation and catheterization times were 3.5 ± 3.2 and 12.7 ± 6.1 hours, respectively. No significant complication occurred intra- or postoperatively. Q_max increased from 7.1 ± 3.2 mL/second preoperative to 18.4 ± 4.2 mL/second (p < 0.001). The International Prostate Symptom Score decreased from 25 ± 6 to 7.9 ± 2.4 (p < 0.01).

CONCLUSION

This study confirmed that PKEP is a safe, easy to learn, and durable technique suitable for any prostate sizes.

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.

A comparative study between holmium laser enucleation of the prostate and transurethral resection of the prostate: 12-month follow-up

Background

This was a prospective randomized clinical trial to compare the safety and efficacy of holmium laser enucleation of the prostate and transurethral resection of the prostate for surgical treatment of patients with bladder outlet obstruction due to benign prostatic hyperplasia (BPH).

Patients and methods

From December 2009 to October 2010, 60 consecutive patients with lower urinary tract obstruction (LUTs) due to BPH were randomized to either surgical treatment with HOLEP (group 1, n = 30) or standard TURP (group 2, n = 30). Preoperative assessments included American Urological Association (AUA) symptom score, serum prostate-specific antigen, (SPSA), post-void residual urine volume (PVR), transrectal ultrasound (TRUS) and uroflowmetry. Perioperative parameters included total operating time, resected tissue weight, hemoglobin loss, presence or absence of blood transfusion, time of catheter removal and duration of hospital stay. Postoperative evaluations were conducted at one, three, six and 12 months.

Results

Patients in the HOLEP group had shorter catheterization time and hospital stay, but longer operating time. Mean hemoglobin loss was lower in the HOLEP group (0.900 ± 0.419 g/dl vs 1.157 ± 0.918 g/dl). The follow-up results up to 12 months regarding AUA symptom score, PVR urine volume and Qmax showed that both groups were comparable.

Complications

Complications were similar between the two procedures with no significant difference.

Conclusion

HOLEP proved to be a safe and highly effective technique for surgical treatment of bladder outlet obstruction due to BPH.

Prostate tissue retrieval after holmium laser enucleation of the prostate; assessment of non-morcellation approaches

Objectives

To review non-morcellation approaches for tissue retrieval after holmium laser enucleation of the prostate (HoLEP) and whether these approaches demolish the advantages of the HoLEP procedure.

Patients and methods

We reviewed our prospectively maintained laser prostate database for HoLEP procedures where non-morcellation approaches were used for retrieval of the enucleated adenoma. Non-morcellation approaches were adopted in cases of morcellator malfunction or whenever concomitant pathology indicated laparotomy. Patients were stratified into the laparotomy group (Group I) or the transurethral resection (TUR) group (Group II). Safety and efficacy of each approach were assessed and compared.

Results

Between August 2012 and July 2015, of 392 HoLEP procedures non-morcellation approaches were used for tissue retrieval in 37 (9.4%). In 19 procedures a laparotomy approach was adopted (17 mini-laparotomies and two conventional laparotomies for concomitant diverticulectomy). TUR of the enucleated adenoma was adopted in 18 patients. Baseline demographic data and indications for surgery were comparable between the groups. However, significantly larger prostates were treated in Group I. There were no significant differences between the groups for tissue retrieval time, histopathological findings of retrieved tissue, and peri-procedure biochemical changes. However, significantly more tissue was retrieved (median tissue weight 115 vs 38 g) and at a faster rate (4.6 vs 1.09 g/min) in Group I. The median hospital stay was similar in both groups, but the median time to catheter removal was longer in Group I (5 vs 2 days). Minimal and similar peri-procedure complications were reported in both groups and in both groups there was a significant and comparable improvement in all urinary outcome measures.

Conclusion

In the absence or malfunction of a tissue morcellator, or whenever concomitant pathology indicates laparotomy, non-morcellation tissue retrieval approaches are feasible options for endourologists practicing transurethral enucleation of prostate adenoma. These approaches are valid alternatives retaining most of the advantages of the transurethral prostate enucleation procedure.

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.

'Minimum-incision' endoscopically assisted transvesical prostatectomy: Surgical technique and early outcomes

Objective

To describe the surgical technique and report the early outcomes of a ‘minimum-incision’ endoscopically assisted transvesical prostatectomy (MEATP) for managing benign prostatic obstruction secondary to a large (>80 g) prostate.

Patients and methods

In a prospective feasibility trial, 60 men with large benign prostates underwent MEATP. The baseline and postoperative evaluation included the International Prostate Symptom Score (IPSS), a measurement of maximum urinary flow rate (Q_max), and the postvoid residual (PVR) urine volume. The adenoma was enucleated digitally through a 3-cm suprapubic skin incision, and haemostasis was completed with endoscopic coagulation of the prostatic fossa. Perioperative complications were recorded and stratified according to the modified Clavien–Dindo score.

Results

The mean (SD, range) prostate weight estimated by ultrasonography was 102.9 (15.4, 80–160) g, the operative duration was 52 (8, 40–65) min, the haemoglobin loss was 2.1 (1, 0.4–5) g/dL, the catheterisation time was 5.2 (1.3, 4–9) days, and the hospital stay was 6.2 (1.4, 5–10) days. There were 21 complications recorded in 16 (27%) patients, and most (86%) were of grades 1 and 2. The most frequent complications were bleeding requiring a blood transfusion (8%), and prolonged drainage (5%). There was a significant improvement at 3 months after surgery in the IPSS (8.6 vs. 21.6, P < 0.001), Q_max (19.5 vs. 7.7, P < 0.001), and PVR (15.8 vs. 83.9 mL, P < 0.001).

Conclusion

MEATP is feasible, safe and effective. Comparative studies and long-term data are required to determine its role in the surgical treatment of large-volume BPH.

180-W XPS GreenLight laser vaporization for benign prostate hyperplasia: 12-month safety and efficacy results for glands larger than 80 mL

The purpose of the current study was to evaluate the efficacy and safety of laser prostatectomy by using the latest 180-W XPS GreenLight laser with the new MoXy fiber in the surgical treatment of glands larger than 80 mL in a prospective study. From December 2011 to May 2013, 68 consecutive patients with a mean age of 71.1 ± 9.8 years (range 49 to 85) underwent 180-W XPS laser prostatectomy at our institution. The baseline characteristics, perioperative data, and complications were recorded. Evaluation of outcomes was assessed at 3, 6, and 12 months postoperatively comparing subjective (International Prostate Symptom Score [IPSS], International Index of Erectile Function-5 [IIEF-5]) and objective (Maximal flow rate [Qmax], postvoid residual urine [PVR], transrectal ultrasound [TRUS] volume) parameters to the preoperative data. Mean preoperative prostate volume was 104.3 ± 29.7 mL (range 81 to 185). Mean operation time was 65.5 ± 29.6 min (range 38 to 124), with a mean energy delivery of 398 ± 169 kJ (range 39 to 523). The catheterization time was 20.8 ± 1.9 h (range 6 to 92) and the hospital stay was 27.3 ± 8.7 h (range 12 to 80). No major intraoperative complications were observed. Improvement in IPSS, Qmax, and PVR was statistically significant (p < 0.001) at 3, 6, and 12 months. Urethral strictures were observed in two patients (2.9%). No patients required reintervention due to residual adenoma. The average volume reduction was 40.5% at 12 months. Photoselective vaporization of the prostate (PVP) using the new 180-W XPS GreenLight laser system seems to be a safe and effective procedure and could play an important role in the surgical treatment of symptomatic benign prostatic hyperplasia (BPH) patients with larger prostate volumes.

Mid-term Results of Holmium Laser Enucleation of the Prostate (HoLEP) for the Treatment of Benign Prostatic Hyperplasia (BPH) by a Single Surgeon

ObjectivesHere the author report the mid-term clinical outcomes analysis with efficacy and safety of HoLEP. MethodsFrom May 2010 to September 2012, 270 consecutive patients treated with HoLEP were enrolled in this study. All patients was evaluated by digital rectal examination (DRE), transrectal ultrasonography (TRUS), serum PSA preoperatively. International Prostate Symptom Score (IPSS), peak urinary flow rate (Qmax), and postvoid residual urine (PVR) were documented preoperatively and 1, 3, 6, 12, 24 months postoperatively. The perioperative data and complications were analyzed. All procedures of HoLEP was done by a single surgeon. ResultsThe mean patient age at the surgery was 67.5 years (45-82), and the mean PSA was 3.7 ng/mL (0.4-19.4). Mean operation time was 73.6 minutes (30-150). Mean prostate volume was 64.3 mL (20-150) and mean resected tisssue weight was 9.3 g (2-63). Mean catheter indwelling time was 2.7 day (1-6), and mean hospital stay was 3.2 day (1-7). The blood loss was minimal, so transfusion was not needed. The baseline data were IPSS; 23.0 (7-35), QoL score; 5.4 (4-6), Qmax (mL/s); 12.5 (1.2-16.5), PVR (mL); 59 (20-250). Postoperatively, IPSS and QoL scores and PVR decreased, and Qmax increased significantly. Intraoperative complication was minor capsular perforation (n = 5). Postoperative complications were acute urinary retention (n = 9), transient incontinence (n = 17), urinary tract infection (n=4), urethral stricture (n=4) and bladder neck contracture (n = 12). ConclusionsHoLEP showed statistical improvement of clinical parameters after 1 month operation and these results sustained for 24 months regardless of prostatic size.

Holmium laser enucleation of the prostate: a modified enucleation technique and initial results

PURPOSE

Although holmium laser enucleation of the prostate has been proven to be an excellent technique for the treatment of benign prostatic hyperplasia, it has not been widely applied due to technical difficulties and longer operative time. We modified the current technique of enucleation and present our initial experience.

MATERIALS AND METHODS

A total of 189 patients with benign prostatic hyperplasia underwent prostatectomy with our modified technique for holmium laser enucleation of the prostate. Intraoperative and postoperative data were prospectively collected. For followup International Prostate Symptom Score, quality of life, maximal flow rate and post-void residual urine were recorded.

RESULTS

Mean±SD preoperative prostate volume was 78.1±24.3 cc and 60.9±39.2 gm tissue were enucleated. Mean operative and enucleation times were 54.7±21.1 and 36.5±16.3 minutes, respectively. Mean serum hemoglobin decrease was 0.98±0.72 gm/dl. Mean catheter time was 1.2±0.5 days and mean postoperative hospital stay was 4.9±3.4 days. Serious complications were not observed. Three patients complained of transient stress incontinence which resolved within 3 months. Significant improvement occurred in International Prostate Symptom Score, quality of life, maximal flow rate and post-void residual urine volume at 3 and 6-month followup compared with the preoperative baseline.

CONCLUSIONS

The modified holmium laser enucleation of the prostate technique is effective and safe when treating benign prostatic hyperplasia.