Enucleation of the prostate: An anatomical perspective

Clinical outcomes of holmium laser enucleation of the prostate: A large prospective registry-based patient cohort study under regular follow-up protocol

PURPOSE

To evaluate the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) in a large prospective cohort of patients with benign prostatic hyperplasia (BPH) through systematic follow-up at a single institution.

MATERIALS AND METHODS

Clinical outcomes were analyzed between August 2008 and June 2022. Patients were followed-up at 2 weeks, 3 months and 6 months postoperatively.

RESULTS

A total of 3,000 patients (mean age, 69.6±7.7 years) underwent HoLEP. Baseline total International Prostate Symptom Score (IPSS) was 19.3±7.7 and maximum flow rate (Qmax) was 9.4±4.8 mL/s. Mean total prostate volume was 67.7±3.4 mL. Total operation time was 60.7±31.5 minutes, and catheterization time was 1.0 days (range, 1.0-1.0 days). At 6 months postoperatively, the total IPSS decreased to 6.6±5.8 and Qmax increased to 22.2±11.3 mL/s. Complications at 6 months postoperatively included stress urinary incontinence (SUI) in 36 patients (1.9%), urgency urinary incontinence (UUI) in 25 (1.3%), bladder neck contracture (BNC) requiring transurethral incision (TUI) in 16 (0.5%), and urethral stricture in 29 (1.0%). Eleven patients (0.4%) with prostatic fossa stones required stone removal. Sixty-one patients (2.0%) required secondary surgery (transurethral coagulation, 16 [0.5%]; TUI for BNC, 16 [0.5%]; stone removal for prostatic fossa stones, 11 [0.4%]; and endoscopic internal urethrotomy for urethral stricture, 18 [0.6%]).

CONCLUSIONS

Mid-term follow-up results after HoLEP in BPH patients showed excellent efficacy and low complication rates. Unlike previous reports, the incidence of SUI and UUI after HoLEP was low, but the occurrence of de novo stone formation in prostatic fossa was notable.

Effect of detrusor underactivity on surgical outcomes of holmium laser enucleation of the prostate

OBJECTIVE

To evaluate the effect of detrusor underactivity (DUA) on the postoperative outcomes of holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Patients with BPH who underwent HoLEP between January 2018 and December 2022 were enrolled in this prospective database study. Patients were divided into DUA (bladder contractility index [BCI] <100) and non-DUA (BCI ≥100) groups. Objective (maximum urinary flow rate [Qmax], post-void residual urine volume [PVR]) and subjective outcomes (International Prostate Symptom Score [IPSS], Overactive Bladder Symptom Score [OABSS], satisfaction with treatment question [STQ], overall response assessment [ORA], and willingness to undergo surgery question [WUSQ]) were compared between the two groups before surgery, and at 3 and 6 months after HoLEP.

RESULTS

A total of 689 patients, with a mean (standard deviation [SD]) age of 69.8 (7.1) years, were enrolled. The mean (SD) BCI in the non-DUA (325 [47.2%]) and DUA (364 [52.8%]) groups was 123.4 (21.4) and 78.6 (14.2), respectively. Both objective (Qmax and PVR) and subjective (IPSS, IPSS-quality of life, and OABSS) outcomes after surgery significantly improved in both groups. The Qmax was lower in the DUA than in the non-DUA group postoperatively. At 6 months postoperatively, the total IPSS was higher in the DUA than in the non-DUA group. There were no significant differences in surgical complications between the two groups. Responses to the STQ, ORA, and WUSQ at 6 months postoperatively demonstrated that the patients were satisfied with the surgery (90.5% in the DUA group; 95.2% in the non-DUA group), their symptoms improved with surgery (95.9% in the DUA group; 100.0% in the non-DUA group), and they were willing to undergo surgery again (95.9% in the DUA group; 97.9% in the non-DUA group). There were no significant differences in the responses to the STQ and WUSQ between the two groups.

CONCLUSION

Our midterm results demonstrated that patients with BPH and DUA showed minimal differences in clinical outcomes after HoLEP compared to those without DUA. The overall satisfaction was high in the DUA group.

Effect of Self-Training Using Virtual Reality Head-Mounted Display Simulator on the Acquisition of Holmium Laser Enucleation of the Prostate Surgical Skills

PURPOSE

We aimed to evaluate the effect of self-training using a virtual reality head-mounted display simulator on the acquisition of surgical skills for holmium laser enucleation surgery.

METHODS

Thirteen medical students without surgical skills for holmium laser enucleation of the prostate were trained using multimedia to learn the technique via simulator manipulation. Thereafter, participants performed the technique on a virtual benign prostatic hyperplasia model A (test A). After a 1-week wash-out period, they underwent self-training using a simulator and performed the technique on model B (test B). Subsequently, participants were asked to respond to Training Satisfaction Questions. Video footage of hand movements and endoscope view were recorded during tests A and B for later review by 2 expert surgeons. A 20-step Assessment Checklist, 6-domain Global Rating Scale, and a Pass Rating were used to compare performance on tests A and B.

RESULTS

Thirteen participants completed both tests A and B. The 20-step Assessment Checklist and 6-domain Global Rating Scale evaluation results showed significantly improved scores in test B than in test A (P<0.05). No evaluator rated participants as passed after test A, but 11 participants (84.6%) passed after test B. Ten participants (76.9%) indicated that the simulator was helpful in acquiring surgical skills for holmium laser enucleation of the prostate.

CONCLUSION

The virtual reality head-mounted display holmium laser enucleation of the prostate simulator was effective for surgical skill training. This simulator may help to shorten the learning curve of this technique in real clinical practice in the future.

Factors predicting indistinct plane of surgical capsule in patients underwent HoLEP procedures

PURPOSE

To evaluate factors that effectively predict indistinct plane (IP) in patients who underwent holmium laser enucleation of the prostate (HoLEP).

METHODS

Data of 208 consecutive patients from our HoLEP database were reviewed and analyzed. IP was defined in 107 cases, as the plane could be identified only depending on endoscopic beak dissection rather than laser dissection in the initial stage of HoLEP, whereas the control group consisted of 101 cases. Variables including age, body mass index, prostatic volume (PV), intravesical prostatic protrusion, prostate-specific antigen, prostate-specific antigen density, bladder stones, urinary tract infection, microscopic hematuria, prior biopsy (PB), diabetes, hypertension, history of acute urinary retention, 5-alpha reductase inhibitor treatment, catheter dependency, residual urine, region, smoking, and alcohol consumption were compared between the two groups. The risk factors for predicting the presence of IP were determined using a multivariable binary logistic regression model using a forward selection approach with a focus on improvement in the area under the receiver operating characteristic curve (AUC).

RESULTS

The incidence of IP was 51.4% (107/208). PV (OR = 0.977, p < 0.001) and PB (OR = 0.297, p = 0.028) were identified as the independent predictors of capsule plane status. PV with a cutoff of 54 ml had the best predictive effectiveness for IP based on AUC (0.727; 95% CI 0.659-0.795). The specificity and sensitivity of this cutoff were 82.2% and 53.3%, respectively.

CONCLUSION

PV is the most reliable factor to predict IP during HoLEP procedures. There is a high possibility of IP in patients with a PV less than 54 ml.

Comparison of EEP and TURP long-term outcomes: systematic review and meta-analysis

OBJECTIVE

To compare long-term reoperation rate and functional outcomes between EEP (endoscopic enucleation of the prostate) and TURP (transurethral resection of the prostate).

EVIDENCE ACQUISITION

A systematic literature review of Medline, Scopus, and Web of Science was conducted with primary outcome assessed being reoperation rate and secondary outcomes after a long term (> 3 years) being functional outcomes or related values (prostate volume, PSA level, etc.).

EVIDENCE SYNTHESIS

Five studies were found with long-term follow-up 4-7 years. EEP reoperation rate ranged from 0 to 1.27%, while from 1.7 to 17.6% for TURP. Meta-analysis showed significantly lower OR for EEP, 0.27 (95% CI 0.24-0.31), with notable homogeneity of the results, I2 = 0%. Long-term Qmax and IPSS were significantly better for EEP. Qmax pooled mean difference was 1.79 (95% CI 1.72-1.86) ml/s with a high concordance among the studies, I2 = 0%. IPSS mean difference -1.24 (95% CI - 1.28 to - 1.2) points, I2 = 57% but QoL did not differ, with mean difference being 0.01 (95% CI - 0.02 to 0.04), I2 = 0%. IIEF-5 score was also significantly better for EEP, mean difference 1.08 (95% CI 1.03-1.13), but heterogeneity was high, I2 = 70%. PSA level and prostate volume were only reported in one study and favored EEP slightly yet statistically significant.

CONCLUSION

EEP had a significantly lower reoperation rate and better functional outcomes (Qmax and IPSS) at long term compared with TURP. It may also be beneficial in terms of IIEF-5, PVR, and PSA level.

1470 nm laser is better for prostate hyperplasia treatment with different volume size via transurethral enucleation

INTRODUCTION

The large amount of intraoperative bleeding and the high incidence of postoperative hematuria are still common factors affecting the prostate surgery treatment effect. Our research aimed to observe the effect of prostatic enucleation using 1,470 nm semiconductor laser on the amount of bleeding in patients with different sizes of prostate hyperplasia.

METHODS

According to the size of the prostate, forty eligible patients with benign prostatic hyperplasia (BPH) were enrolled and divided into low and high volume group in this study. Hemoglobin decline, urinating condition, complications and erectile function were collected and compared before and after surgery.

RESULTS

Our data showed that hemoglobin decline was (10.0 ± 6.2) g/L and (12.1 ± 7.8) g/L, respectively for two group after surgery (P = 0.363). Urination was significantly improved following surgery in both groups of patients (P < 0.05), and no permanent urinary incontinence and sexual dysfunction and so no serious complications occurred.

CONCLUSION

The above results suggested that prostatic enucleation using 1,470 nm semiconductor laser can be safe and effective for prostatic hyperplasia, and this surgery produced no significant effect on the amount of bleeding in whatever size of the prostate.

The Efficacy and Safety of Holmium Laser Enucleation of Prostate Compared With Bipolar Technologies in Treating Benign Prostatic Hyperplasia: A Systematic Review and Meta-Analysis of 10 Randomized Controlled Trials

We performed a systematic review and meta-analysis on efficacy and safety of holmium laser enucleation of prostate compared with bipolar technologies in treating benign prostatic hyperplasia. We analyzed several databases such PubMed, Embase, and Web of Science. Two reviewers independently reviewed studies for consistent criteria and extracted relevant data. Reviewers independently assessed the risk of bias and strength of the evidence for the body of the literature. Ten randomized controlled trials including 1,157 participants were included in this meta-analysis. The holmium laser group had favorable perioperative outcomes in this study. The holmium laser group identified shorter catheterization duration and shorter hospital stay duration than the bipolar technologies group. Efficiency outcomes, such as International Prostate Symptom Score, peak urinary flow rate, quality of life, postvoid residual urine volume, and international index of erectile function reported no obvious differences between the holmium laser and bipolar technologies groups at the 6 to 12 months follow-up. Bipolar technologies and holmium laser groups shared equivalent effectiveness and safety in treatments for benign prostate hyperplasia. Holmium lasers identified lower catheter times, shorter hospital stays, and lesser risk of hemorrhage than bipolar technologies.

Application of En Bloc and Urethral Mucosal Flap Sparing Techniques Improve the Functional Outcomes in Holmium Laser Enucleation of Prostate: A Retrospective Case Control Study

The purpose of the study was to study the feasibility of holmium laser enucleation of prostate (HoLEP) with en bloc and urethral mucosal flap sparing technique in treating benign prostatic hyperplasia (BPH) patients and to evaluate the influence of this modified technique on urinary function. A cohort of 188 BPH patients underwent HoLEP from June 2017 to October 2019. Among them, 92 patients underwent conventional en bloc HoLEP and the other 96 patients underwent HoLEP with en bloc and urethral mucosal flap sparing techniques. The basic characteristics, the volume of the prostate, urodynamic data, and perioperative parameters were recorded for comparison. The outcome parameters include international prostate symptom score (IPSS), maximum urinary flow rate (Qmax), post-voiding residual (PVR), quality of life score (QoL), and incidence of de novo stress urinary incontinence (SUI). The basic characteristics were equivalent in both groups. All HoLEP procedures were smoothly carried out. The perioperative complications were low and did not show a significant difference. The follow-up period was 12 months or longer. IPSS, Qmax, QoL, and PVR were improved postoperation in both groups. There was no statistical difference in the parameters between the two groups. When considering a postoperative SUI, the occurrence of short-term and long-term SUI in the modified HoLEP group was significantly less than those in the conventional HoLEP group (p < 0.05). In summary, HoLEP by using en bloc and urethral mucosal flap sparing technique is a safe and effective treatment for BPH patients, especially in preventing postoperative SUI.

Impact of diabetes mellitus on urinary continence after holmium laser enucleation of the prostate due to lower urinary tract symptoms: a retrospective study

Introduction

Diabetes mellitus (DM) is known as a risk factor of stress urinary incontinence after Holmium laser enucleation of the prostate (HoLEP). We aimed to compare the postoperative continence status of patients with and without DM, after HoLEP surgery.

Material and methods

A total of 214 patients who underwent HoLEP between January 2017 and January 2020 were retrospectively assessed. Functional outcomes, perioperative total operation time (TOT)(min), enucleation time (ET)(min), enucleation efficiency (EE)(g/min), enucleated tissue weight (ETW)(g), morcellation efficiency (ME)(g/min), morcellation time (MT)(min), continence status, intraoperative and postoperative complications according to Clavien–Dindo classification were recorded.

Results

A total of 96 patients had DM additional to benign prostate hyperplasia (BPH) (Group 1), while 118 patients had only benign prostate hyperplasia without DM (Group 2). When comparing preoperative and postoperative functional outcomes, a statistically significant improvement was observed in both groups from baseline to the 1^st and 6^th month follow-up (p ≤0.001). There were no statistically significant differences between groups in postoperative stress urinary incontinence at postoperative months 1 and 6 (1.7% vs 2.1%, p = 1 and 0.8% vs 1%, p = 1; respectively). There was no significant difference between groups in intraoperative and postoperative complications (p >0.05).

Conclusions

HoLEP is safe to perform in patients with DM at low complication and urinary incontinence rates.

Determination of Face and Content Validity of Cadaveric Model for Holmium Anatomic Endoscopic Enucleation of the Prostate Training: An ESUT AEEP Group Study

Background

Bench and virtual reality nonbiological simulator models for anatomic endoscopic enucleation of the prostate (AEEP) surgery have been reported in the literature. These models are acceptable but have limited practical applications.

Objective

To validate a fresh-frozen human cadaver model for holmium AEEP training and assess its content validity.

Design, setting, and participants

Holmium AEEP operations on fresh-frozen cadavers performed by an experienced surgeon were recorded, and a video, including the main steps of the operation, was produced.

Outcome measurements and statistical analysis

The video and an accompanying questionnaire were subsequently distributed electronically to ESUT AEEP study group experts and associates (N = 32) for assessment of the AEEP training model. A ten-point Likert global rating scale was used to measure the content validity.

Results and limitations

A total of 26 answers were returned (81%). The experts agreed on the model’s suitability for AEEP training (mean Likert score: 8). According to the responses, “identifying anatomic structures and landmarks” was the most valuable aspect of the model in terms of AEEP training (median Likert score: 9). Conversely, the experts found the model’s ability, in terms of demonstrating laser and tissue reactions, to be weak (median Likert score: 6)

Conclusions

Based on the content validity assessment, the fresh-frozen cadaver-training model for laser AEEP seems to be a promising model for demonstrating and learning the correct prostate enucleation technique.

Patient summary

An increasing number of researchers have proposed that anatomic endoscopic enucleation of the prostate (AEEP) should replace transurethral resection of the prostate surgery and become the gold standard for treatment of bladder outlet obstruction due to benign prostatic hyperplasia. AEEP requires anatomic familiarity for enucleation, technical knowledge, and a solid training program before starting with the first cases. This is the first cadaver study to assess the content validity of a fresh-frozen human cadaver model for AEEP training.

Is 'Omega Sign' anatomical endoscopic enucleation of the prostate technique reproducible?

We aimed to evaluate the learning curve of the surgically standardised 'Omega Sign' anatomical endoscopic enucleation (AEEP) of the prostate surgery technique for junior surgeons. This study is a retrospective comparison of cases that underwent AEEP by a mentor surgeon and three junior surgeons who have completed their learning curve. A video-based laser enucleation of the prostate assessment tool (LEAT) composed of 8 steps of the technique was used to assess a senior surgeon and junior surgeons' surgical compatibility and consistency. The surgeon who defined Omega Sign technique was determined as group 1, and cases by three junior surgeons were identified as group 2. The end points were to assess the reproducibility and repeatability and operative post-operative outcomes of the technique. 55 patients' videos were rated by five experienced endourologists. There was no significant difference in LEAT scores between the groups among all steps. The most symmetry was found in the 1st and 3rd steps. Inter-rater consistency was also high for each step, with no statistically significant difference between the evaluators. The standardised anatomical 'Omega Sign' technique is reproducible for the junior surgeons. The operative steps can be performed with high consistency, and the functional and perioperative outcomes are comparable with the senior surgeon.