Sexual and ejaculatory function after holmium laser enucleation of the prostate and bipolar transurethral enucleation of the prostate: a single-center experience

The safety and efficacy of five surgical treatments in prostate enucleation: a network meta-analysis

PURPOSE

The aim of our study was to investigate the comparative outcomes of five different energy types on surgical efficacy and postoperative recovery in patients with benign prostate hyperplasia.

METHODS

The literature was systematically reviewed on December 1st, 2023, encompassing studies retrieved from PubMed, Embase, Web of Science, and The Cochrane Library databases that incorporated clinical studies of holmium laser enucleation of the prostate (HoLEP), Thulium:YAG laser enucleation of the prostate (ThuLEP), transurethral plasmakinetic enucleation of prostate (PKEP), diode laser enucleation of the prostate (DiLEP) and thulium fiber laser enucleation of the prostate (ThuFLEP) in the treatment of prostatic hyperplasia. Two independent reviewers extracted study data and conducted quality assessments using the Cochrane Collaboration's Risk of Bias tool and Newcastle-Ottawa Scale (NOS). Network meta-analysis (NMA) was employed to indirectly analyze the outcomes of endoscopic enucleation of the prostate (EEP) techniques.

RESULTS

The study included a total of 38 studies, comprising 21 non-randomized controlled trials (nRCTs) and 17 randomized controlled trials (RCTs), incorporating five distinct techniques: holmium laser, Thulium:YAG laser, bipolar plasma, diode laser and thulium fiber laser. In comparing treatment durations, ThuLEP and HoLEP had shorter overall hospital stays than PKEP, while the enucleation time of ThuLEP and HoLEP was shorter than that of ThuFLEP. Moreover, the enucleation tissue weight of both thulium fiber laser and holmium laser was heavier than bipolar plasma. However, the analysis did not reveal any statistically significant variation in complications among the various types of enucleation. In postoperative follow-up, the IPSS at 3 months post-operation was superior in the Thulium:YAG laser group compared to the holmium laser group. The thulium fiber laser technique demonstrated significant advantages over other enucleation methods in terms of QoL and PVR at 12 months after surgery.

CONCLUSION

Theoretical properties may vary among different energy sources; however, there are no discernible clinical differences in operation-related parameters, postoperative complications, and postoperative follow-up. Therefore, the choice of laser does not significantly impact the outcome. However, due to the limited number of included studies, future research should focus on larger sample sizes and multicenter investigations to further validate the findings of this study.

The prospective evaluation of learning curve of bipolar anatomic endoscopic prostate enucleation (AEEP) with Herrmann's vapoenucleation probe

PURPOSE

We aimed to evaluate the learning curve of Bipolar Endoscopic Prostate Enucleation (BIPOLEP) in benign prostate enlargement without a mentorship.

METHODS

The prospective data of 55 patients underwent BIPOLEP surgery by a single surgeon during 3 years were evaluated. The demographic, peri-operative and follow-up data were recorded. Trifecta was defined as a combination of complete enucleation and morcellation within < 90 min and without any conversion to standard TURP. Pentafecta was defined as a combination of Trifecta without postoperative complications or stress urinary incontinence at 3 months. The learning curve was considered to have been overcome when the surgeon obtained Trifecta/Pentafecta in four consecutive patients.

RESULTS

The mean age of the study group was 67.9 ± 6.8 years with mean prostate volume of 102.3 ± 56.4 ml. The mean operation time and enucleation time were 103.5 ± 41.1 and 65.78 ± 22.6 min, respectively. Trifecta and Pentafecta were achieved in 23rd (from 19th to 23rd) and 34th (from 30 to 34th) patients, respectively. Among the seven consecutive patients between Trifecta and Pentafecta, prostate capsule perforation was occurred during the surgery in four patients (26th, 27th and 29th patients). The mean follow-up duration was 16.7 ± 6.4 (3-24 months, range) months. Urethral stricture was observed in four (7. 2%) patients while bladder neck contracture was observed 1 (1.8%) patient. After the 3rd month, no patient reported stress incontinence.

CONCLUSION

Bipolar endoscopic enucleation of prostate is a safe surgical method and has similar and/or short learning curve compared to HOLEP even without a mentorship program.

What is the effect of laser anatomical endoscopic enucleation of the prostate on the ejaculatory functions? A systematic review

INTRODUCTION

Laser anatomical endoscopic enucleation of the prostate (LAEEP) has emerged as a promising new approach in endoscopic surgery for BPH. LAEEP could still result in ejaculatory dysfunction.

AIM

This systematic review aimed to examine the impact of LAEEP on male ejaculatory functions.

METHODS

The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, and 15 records were included. Outcomes of interest included ejaculatory dysfunction (retrograde ejaculation, painful ejaculation, etc.) and validated questionnaire scores. The quality of studies included in the systematic review was determined using QUADAS scoring.

RESULTS

We retrieved data for 1877 men in 15 clinical studies investigating LAEEP surgery and reporting EjD rates. While only three of the obtained studies were on thulium fiber (ThuLEP), the rest were on holmium (HoLEP). The definition of "Ejaculatory Dysfunction" was not standardized, but in most works, it is referred to as retrograde ejaculation (RE). There were no data on the relationship between other LAEEP techniques and ejaculation functions. The authors compared the outcomes of used standard laser enucleation techniques with the modified techniques. The RE rate in LAEEP was 62.1 ± 25.1%, 71.3 ± 16.1% in standard techniques, and 27.2 ± 18.1% in ejaculation-preserving modified techniques (p < 0.001).

CONCLUSION

This review demonstrated that ejaculation-preserving techniques, i.e., modified techniques are superior to standard techniques. Studies have also shown that ejaculatory dysfunction rates gradually decrease with long-term follow-ups. Future well-designed studies could further investigate the ejaculation-preserving modification of LAEEP techniques and how they impact EjD rates and other sexual function outcomes.

Impact of Surgery for Benign Prostatic Hyperplasia on Sexual Function: A Systematic Review and Meta-analysis of Erectile Function and Ejaculatory Function

CONTEXT

Several sexual side effects, including erectile, ejaculatory, and orgasmic dysfunction, were reported with the majority of surgical procedures for benign prostatic obstruction (BPO).

OBJECTIVE

To systematically review current evidence regarding the impact of benign prostatic hyperplasia (BPH) surgery on sexual function.

EVIDENCE ACQUISITION

A comprehensive bibliographic search on the MEDLINE, Cochrane Library, Embase, Web of Science, and Google Scholar databases was conducted in July 2021. The population, intervention, comparator, and outcome (PICO) model was used to define study eligibility. Studies were Included if they assessed patients with BPO and related lower urinary tract symptoms (P) undergoing BPH surgery (I) with or without a comparison between surgical treatments (C) evaluating the impact on sexual function (O). Retrospective and prospective primary studies were included. A pooled analysis was conducted on studies including the postoperative assessment of International Index of Erectile Function (IIEF)-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD; Function and/or Bother), or retrograde ejaculation (RE) rate (PROSPERO database ID: CRD42020177907).

EVIDENCE SYNTHESIS

A total of 151 studies investigating 20 531 patients were included. Forty-eight randomized controlled trials evaluating 5045 individuals were eligible for the meta-analysis. In most studies (122, 80.8%), only erectile and/or ejaculatory function was evaluated. A substantial number of articles (67, 44.4%) also used nonvalidated tools to evaluate erectile and/or ejaculatory function. The pooled analysis showed no statistically significant changes in IIEF-5 score compared with baseline for the transurethral resection of the prostate (TURP; weighted mean difference [WMD] 0.76 pts; 95% confidence interval [CI] -0.1, 1.62; p = 0.08), laser procedure (WMD 0.33 pts; 95% CI -0.1, 0.77; p = 0.13), and minimally invasive treatment (WMD -1.37 pts; 95% CI -3.19, 0.44; p = 0.14) groups. A statistically significantly higher rate of RE was found after TURP (risk ratio [RR] 13.31; 95% CI 8.37, 21.17; p < 0.00001), other electrosurgical procedures (RR 34.77; 95% CI 10.58, 127.82; p < 0.00001), and the entire laser group (RR 17.37; 95% CI 5.93, 50.81; p < 0.00001). No statistically significant increase in RE rate was described after most of the minimally invasive procedures (p > 0.05). The pooled analysis of MSHQ-EjD scores was possible only for prostatic urethral lift, showing no statistically significant difference between baseline and post-treatment MSHQ-EjD Function scores (WMD -0.80 pts; 95% CI -2.41, 0.81; p = 0.33), but postoperative MSHQ-EjD Bother scores were significantly higher (WMD 0.76 pts; 95% CI 0.22, 1.30; p = 0.006).

CONCLUSIONS

Erectile function appears to be unaffected by most surgical procedures for BPO. RE is a very common adverse event of BPH surgery, although emerging minimally invasive surgical procedures could be associated with a lower risk.

PATIENT SUMMARY

Benign prostatic hyperplasia surgery can have an impact on sexual function, mainly involving ejaculatory function.

Surgical Complications in the Management of Benign Prostatic Hyperplasia Treatment

PURPOSE OF REVIEW

There are a variety of treatment options for men with symptomatic benign prostatic hyperplasia (BPH); transurethral resection of the prostate (TURP) remains the gold standard surgical treatment. The field continues to evolve with the introduction of new energy and laser technologies, increasing adoption of enucleation techniques, in addition to the advent of minimally invasive surgical technologies (MIST) that enable office-based treatments. The choice in surgical management has become very nuanced depending on a variety of patient and anatomic factors. There continues to be high success rates for surgical treatment of BPH; however, the risk profiles vary across the various surgical treatments. We sought to evaluate contemporary series and summarize the experience of complications associated with BPH treatment and management of these complications.

RECENT FINDINGS

A comprehensive literature review was performed, and identified 79 manuscripts, published between 2005 and 2021 characterizing the diagnosis and management of complications following BPH surgery. Commonly cited issues included bleeding, ureteral orifice injury, bladder neck injury, rectal injury, TURP syndrome, bladder neck contractures, urethral stricture disease, refractory OAB symptoms, and complications unique to new modalities of treatment. The practicing urologist has multiple surgical options to choose from in treating patients with symptomatic BPH. The surgical management of BPH is generally well tolerated with high objective success rates that allow for significant improvement in urinary quality of life. It is critical to understand the potential complications associated with these various treatment options, which will enable trainees and practicing urologists to better counsel patients and manage these potential complications.

Is the Peripheral Zone Thickness an Indicator of a Learning Curve in Bipolar Transurethral Plasma Enucleation of the Prostate?—A Single Center Cohort Study

Background

We conducted this cohort study to assess the differences in the learning curve of bipolar transurethral plasma enucleation of the prostate (B-TUEP) associated with prostatic peripheral zone thickness (PZT) under MRI quantitative measurements.

Methods

For the study, 60 patients with benign prostatic hyperplasia (BPH) were involved. PZT are defined as “Thin” (<7 mm), “Thick” (>10 mm), and “Medium” (in between), with 20 patients in each group. Learning stages were defined as Group 1 (No. 1–20), Group 2 (No. 21–40), and Group 3 (No. 41–60). We measured parameters of the prostate, such as PZT and transitional zone thickness (TZT), with MRI. A learner with no experience in enucleation performed the operations. Statistical analyses were performed to compare the differences. Pearson correlation analysis and multiple linear regression analysis evaluated the relationship between characteristics of patients. P < 0.05 was deemed statistically significant.

Results

One-Way ANOVA revealed different enucleation efficiency (0.811 ± 0.18 vs. 0.748 ± 0.14 vs. 0.634 ± 0.16), prostate volume (58.9 ± 15.33 vs. 57.3 ± 15.58 vs. 46.6 ± 14.10), and thickness of transition zone (44.45 ± 7.60 vs. 42.45 ± 6.08 vs. 34.78 ± 6.04) among Thin, Medium, and Thick groups. The enucleation efficiency is different between groups divided by learning stages (Group 1 vs. Group 3, 0.658 vs. 0.783; Group 2 vs. Group 3, 0.751 vs. 0.783). Pearson correlation analysis reveals that PZT was negatively correlated with prostate volume (r = −0.427), resection weight (r = −0.35), enucleation efficiency (r = −0.445), and TZT (r = −0.533), and was positively correlated with Q-max (r = 0.301) and bladder outlet obstruction index (BOOI) (r = 0.388). The regression coefficients of PZT, TZT, prostate volume, and Q-max were −0.012, 0.008, 0.007, and 0.013, respectively (all P < 0.05).

Conclusion

Lower PZT is independent of higher enucleation efficiency, larger adenoma, and higher TZT. PZT may be an important factor on the learning curve of B-TUEP. Higher TZT, prostate volume. and Q-max may also relate to higher enucleation efficiency. For B-TUEP learners, it seems easier to perform the operation when the PZT is low, though more care should be taken with the capsule perforation. Further, the capsule plane should be maintained more attentively if the PZT is high.

Holmium laser enucleation versus bipolar transurethral enucleation for treating benign prostatic hyperplasia, which one is better?

OBJECTIVE

This study aims to evaluate the overall efficacy and safety between holmium laser enucleation of the prostate (HoLEP) and bipolar transurethral enucleation of the prostate (B-TUEP) for the treatment of benign prostatic hyperplasia (BPH).

METHOD

We systematically searched electronic databases (PubMed, Scopus, Web of Science, and Cochrane Library) to identify eligible comparative studies as of July 2021. The parameters including perioperative results, complications, and functional outcomes were evaluated. RevMan version 5.4 was used for the analysis.

RESULTS

A total of 10 studies involving 1725 patients were included. HoLEP had lower operative time (p = .03), shorter catheterization time (p = .007), lower bladder irrigation time (p = .01), and higher enucleation weight (p = .01) compared with B-TUEP. However, there were no significant differences between the techniques regarding the length of stay (LOS), hemoglobin drop, transfusion rates, and complications. Furthermore, no significant differences were also observed in postoperative functional outcomes at 1, 3, 6, 12, or 24 months.

CONCLUSIONS

HoLEP has more advantages in perioperative parameters compared with B-TUEP, but no significant differences are found regarding functional outcomes and complications. Large-scale studies with long-term follow-up are required to compare the outcomes of these two techniques.

Electrosurgery or laser for benign prostatic enlargement: trumpcard or pitfalls

PURPOSE OF REVIEW

To summarize and comment on publications of the last 2 years in the field of endoscopic surgery for benign prostatic enlargement, focusing on similarities and differences of laser and electrosurgery.

RECENT FINDINGS

Because of good hemostasis and safety, invasive endoscopic surgery has evolved to a choice of treatment for vulnerable patients with ongoing antithrombotic medication and in same-day surgery. Recent publications show a good perioperative course and no deterioration in the postoperative outcome. Furthermore, alterations to the original surgical techniques of resection, enucleation, and vaporization have increased the preservation rate for antegrade ejaculation, advancing them to an appealing choice of treatment for sexually active men. Favorable outcomes can be achieved in both laser and electrosurgery. Only the choice of the surgical technique determines the outcome.

SUMMARY

Various invasive endoscopic surgical techniques are available, offering different advantages and disadvantages for the patient. All of them can be performed with laser and electrosurgery. Therefore, focusing on the proper choice of surgical technique instead of the energy source will guarantee the patient to benefit most.

Bipolar Transurethral Enucleation of the Prostate: Is it a size-independent endoscopic treatment option for symptomatic benign prostatic hyperplasia?

Background

Bipolar Transurethral Enucleation of the Prostate (B-TUEP) is recommended as a first-choice treatment for benign prostatic obstruction in prostates >80 ml. Differently, B-TUEP is only considered as an alternative option after TURP for smaller prostates (30–80 ml). The aim of our study is to assess the relation between prostate size and surgical outcomes after B-TUEP.

Methods

We performed a retrospective analysis of data collected from 172 patients submitted to B-TUEP. Patients were segregated according to tertiles of prostate volume (PV) (≤60 ml, 61–110 ml, >110 ml). For each group we evaluated enucleation efficacy (enucleated weight/enucleation time), complication rates, urinary and sexual function parameters. Functional and sexual parameters were compared between groups at baseline, 1 and 3 months follow up. Descriptive statistics and linear and logistic regression models tested the association between PV and postoperative complications/outcomes.

Results

Operative time and weight of enucleated adenomas increased along with prostate volumes (all p≤0.01). Enucleation efficacy was higher in men with PV >110 ml compared to other groups (p≤0.001). Length of hospital stay, catheterization time and rates of postoperative complications, such as transfusion and clot evacuation rates and bladder neck/urethral strictures, were comparable between groups. Urinary symptoms improved at 1-and 3-months in each group as compared to baseline evaluation (all p<0.01) but they did not differ according to PV. In each group maximum urinary flow and post-void residual volume significantly improved at 3 months compared to baseline (all p≤0.01), without differences according to PV. Sexual symptoms were similar between groups at each follow up assessment. At multivariable linear and logistic regression analysis, prostate volume was not associated with postoperative functional outcomes and complications. Conversely, patient’s comorbid status and antiplatelet/anticoagulation use were independently associated with postoperative complications.

Conclusion

According to our findings, B-TUEP should be considered a “size independent procedure” as it can provide symptom relief in men with prostates of all sizes with the same efficacy and safety profile.