Holmium Laser Enucleation of the Prostate versus Robotic Assisted Simple Prostatectomy for lower urinary tract symptoms in patients with extremely large prostates ≧200 ml: A comparative analysis

Safety and feasibility of En-bloc holmium laser enucleation for very large prostates (> 200 cc) with trainee involvement

Objectives

To evaluate the safety and feasibility of "en-bloc" Holmium Laser Enucleation of the Prostate (HoLEP) with trainee involvement in patients with prostates larger than 200 cc.

Patients and Methods

A retrospective analysis was conducted on patients undergoing HoLEP using the "en-bloc" technique for prostate sizes > 200 cc between July-2017 and December-2023 at an academic teaching hospital. Perioperative data was collected, including patient demographics, clinical parameters, operative details and functional outcomes. Patients who continued to experience incontinence at 1 year were further followed up at 2 years to update their continence status. Sub-group analysis was performed to compare outcomes between patients with preoperative prostate size of 200-300 cc and > 300 cc.

Results

The analysis included 89 patients with a mean age of 73.12 ± 8.10 years. Preoperative prostate weight ranged from 200 to 401 cc with a median of 245 cc, and median PSA was 7.71 ng/ml. Median operative time was 218.5 minutes, and median enucleated prostate volume was 164.2 cc. Median postoperative PSA was 0.4 [0.21-0.78] ng/ml. At 1-year follow-up, mean IPSS was 1 ± 2.4, Qmax was 27.03 ± 11.57 ml/s and PVR was 21.6 ± 28.6 ml. Postoperative complications included blood transfusion (5.6%), acute renal injury (4.5%), urinary tract infection (2.2%), postoperative urinary retention (2.2%) and urethral stricture (5%). Although transient urinary incontinence was noted in 41.6% at 1-3-months, complete continence was achieved in 83.3% and 96.3% at 1 and 2 years postoperatively, respectively. Subgroup analysis showed significant differences in operative time and enucleated weight between prostates 200-300 cc and > 300 cc, but no significant differences in postoperative IPSS, PVR or Qmax at 3-months.

Conclusion

"En-bloc" HoLEP is a feasible and safe procedure for prostates larger than 200 cc, demonstrating favourable perioperative and functional outcomes despite the extended operative times and involvement of trainees.

Predictive Factors of Transient Urinary Incontinence Following Holmium Laser Enucleation of the Prostate (HoLEP): Single-Center Experience

Background and Objectives: The aim of this study was to assess the predictive factors associated with transient urine incontinence (TUI) following holmium laser enucleation of the prostate (HoLEP). Materials and Methods: A retrospective analysis was conducted on a prospectively maintained database containing the first 149 consecutive HoLEP cases between June 2022 and December 2023. The study recorded several patient characteristics, and preoperative data such as IPSS score, total gland volume, preoperative catheterization, Qmax, and PVR volume were collected. During the operation, data on total operating time, enucleation time, morcellation time, and weight of enucleated tissue were recorded. Finally, postoperative data were also documented. TUI refers to a patient's complaint of urine leakage, irrespective of type. Univariate and multivariate logistic regression analyses were performed to determine factors that predict TUI. Results: The study included 119 patients with BPH. Nineteen (15.96%) of them experienced postoperative TUI. Of those 19 patients, 15 (78.94%) recovered within three months from the date of the surgery. In the multivariate regression analysis, increased age (odds ratio [OR], 3.47; 95% confidence interval [CI], 1.56~7.78; p = 0.002), prostate volume ≥ 100 mL (OR 1.86; 95% CI 1.54-2.13; p = 0.001), preoperative PVR volume ≥ 250 mL (OR 1.22; 95% CI 1.10-1.32; p = 0.02), preoperative catheterization (OR, 0.56; 95% CI 0.34-0.78; p = 0.003), increased operation time (OR, 3.87; 95% CI 1.62-4.19; p = 0.002), and resected tissue weight ≥ 40 g (OR, 1.032; 95% CI, 1.015-1.048; p = 0.002) were found to be independent predictors of TUI. Conclusions: The incidence of TUI following HoLEP was found to be 15.96% in patients, with a recovery rate of 78.94% within three months post-surgery. Predictive factors for TUI included age at surgery, prostatic volume, preoperative catheterization, high PVR, longer operative time, and resected tissue weight.

Incidence of complications and urinary incontinence following endoscopic enucleation of the prostate in men with a prostate volume of 80 ml and above: results from a multicenter, real-world experience of 2512 patients

PURPOSE

To evaluate complications and urinary incontinence (UI) after endoscopic enucleation of the prostate (EEP) stratified by prostate volume (PV).

METHODS

We retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with different energy sources in 14 centers (January 2019-January 2023).

INCLUSION CRITERIA

prostate volume ≥ 80 ml.

EXCLUSION CRITERIA

prostate cancer, previous prostate/urethral surgery, pelvic radiotherapy.

PRIMARY OUTCOME

complication rate.

SECONDARY OUTCOMES

incidence of and factors affecting postoperative UI. Patients were divided into 3 groups. Group 1: PV = 80-100 ml; Group 2 PV = 101-200 ml; Group 3 PV > 200 ml. Multivariable logistic regression analysis was performed to evaluate independent predictors of overall incontinence.

RESULTS

There were 486 patients in Group 1, 1830 in Group 2, and 196 in Group 3. The most commonly used energy was high-power Holmium laser followed by Thulium fiber laser in all groups. Enucleation, morcellation, and total surgical time were significantly longer in Group 2. There was no significant difference in overall 30-day complications and readmission rates. Incontinence incidence was similar (12.1% in Group 1 vs. 13.2% in Group 2 vs. 11.7% in Group 3, p = 0.72). The rate of stress and mixed incontinence was higher in Group 1. Multivariable regression analysis showed that age (OR 1.019 95% CI 1.003-1.035) was the only factor significantly associated with higher odds of incontinence.

CONCLUSIONS

PV has no influence on complication and UI rates following EEP. Age is risk factor of postoperative UI.

High-power holmium laser versus thulium fiber laser for endoscopic enucleation of the prostate in patients with glands larger than 80 ml: Results from the Prostate Endoscopic EnucLeation study group

Background

Endoscopic enucleation of the prostate (EEP) has gained acceptance as an equitable alternative to transurethral resection of the prostate for benign prostate hyperplasia (BPH). Our primary aim is to compare peri-operative outcomes of EEP using thulium fiber laser (TFL) against high-power holmium laser (HPHL) in hands of experienced surgeons for large prostates (≥80 ml in volume). Secondary outcomes were assess complications within 1 year of follow up.

Materials and Methods

We retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with TFL or HPHL in 13 centers (January 2019-January 2023). Patients with prostate volume ≥80 ml were included, while those with concomitant prostate cancer, previous prostate/urethral surgery, and pelvic radiotherapy were excluded.

Results

Of 1,929 included patients, HPHL was utilized in 1,459 and TFL in 470. After propensity score matching (PSM) for baseline characteristics, 247 patients from each group were analyzed. Overall operative time (90 [70, 120] vs. 52.5 [39, 93] min, P < 0.001) and enucleation time (90 [70, 105] vs. 38 [25, 70] min, P < 0.001) were longer in the TFL group, with comparable morcellation time (13 [10, 19.5] vs. 13 [10, 16.5] min, P = 0.914). In terms of postoperative outcomes, there were no differences in 30-day complications such as acute urinary retention, urinary tract infection or sepsis. In the PSM cohort, univariable analyses showed that higher age, lower preoperative Qmax, higher preoperative PVRU, and longer operation time were associated with higher odds of postoperative incontinence, while 2-lobe enucleation had lower odds of incontinence compared to 3-lobe enucleation.

Conclusions

This real-world study reaffirms that HPHL and TFL in large prostates are equally efficacious in terms of 30-day complications. TFL with the en-bloc technique has a shorter operative time which significantly improves short- and medium-term functional outcomes.

Efficacy and safety of transurethral thulium laser enucleation versus robot-assisted prostatectomy for large-volume benign prostatic hyperplasia: a systematic review and meta-analysis

To compare perioperative outcomes between Holmium laser enucleation of the prostate (HoLEP) and robotic-assisted simple pasta-ectomy (RASP)for large-volume benign prostatic hyperplasia(> 80 ml). In August 2023, we undertook a comprehensive search of major global databases including PubMed, Embase, and Google Scholar, focusing solely on articles written in English. Studies that were merely reviews or protocols without any specific published data were omitted. Furthermore, articles that comprised conference abstracts or content not pertinent to our subject of study were also disregarded. To calculate the inverse variances and 95% confidence intervals (CIs) for categorical variables' mean differences, we employed the Cochran-Mantel-Haenszel approach along with random-effects models. The findings were denoted in the form of odds ratios (ORs) and 95% CIs. A p-value less than 0.05 was deemed to indicate statistical significance. Our finalized meta-analysis incorporated six articles, including one randomized controlled trial (RCT) and five cohort studies. These studies accounted for a total of 1218 patients, 944 of whom underwent Holmium Laser Enucleation of the Prostate (HoLEP) and 274 who underwent Robotic-Assisted Simple Prostatectomy (RASP). The pooled analysis from these six papers demonstrated that compared to RASP, HoLEP had a shorter hospital stay, shorter catheterization duration, and a lower blood transfusion rate. Moreover, HoLEP patients exhibited a smaller reduction in postoperative hemoglobin levels. Statistically, there were no significant differences between the two procedures regarding operative time, postoperative PSA, the weight of prostate specimens, IPSS, Qmax, PVR, QoL, and postoperative complications. (HoLEP) and (RASP) are both effective and safe procedures for treating large-volume benign prostatic hyperplasia. HoLEP, with its benefits of shorter catheterization and hospitalization duration, lesser decline in postoperative hemoglobin, and reduced blood transfusion needs, stands as a preferred choice for treating extensive prostate enlargement. However, further validation through more high-quality clinical randomized trials is required.