Holmium laser enucleation (HoLEP) and photoselective vaporisation of the prostate (PVP) for patients with benign prostatic hyperplasia (BPH) and chronic urinary retention

Peripheral zone thickness in preoperative MRI is predictive of Trifecta achievement after Holmium laser enucleation of the prostate (HoLEP)

PURPOSE

To investigate various anatomical features of the prostate using preoperative MRI and patients' clinical factors to identify predictors of successful Holmium:YAG laser enucleation of the prostate (HoLEP).

METHODS

71 patients who had received HoLEP and undergone a 3.0-T prostate MRI scan within 6 months before surgery were retrospectively enrolled. MRI features (e.g., total prostate and transitional zone volume, peripheral zone thickness [PZT], BPH patterns, prostatic urethral angle, intravesical prostatic protrusion, etc.) and clinical data (e.g., age, body mass index, surgical technique, etc.) were analyzed using univariable and multivariable logistic regression to identify predictors of successful HoLEP. Successful HoLEP was defined as achieving the Trifecta, characterized by the contemporary absence of postoperative complications within 3 months, a 3-month postoperative maximum flow rate (Qmax) > 15 mL/s, and no urinary incontinence at 3 months postoperatively.

RESULTS

Trifecta achievement at 3 months post-surgery was observed in 37 (52%) patients. Patients with Trifecta achievement exhibited a lower preoperative IPSS-quality of life score (QoL) (4.1 vs. 4.5, P = 0.016) and a thinner preoperative peripheral zone thickness (PZT) on MRI (7.9 vs.10.3 mm, P < 0.001). In the multivariable regression analysis, a preoperative IPSS-QoL score < 5 (OR 3.98; 95% CI, 1.21-13.07; P = 0.017) and PZT < 9 mm (OR 11.51; 95% CI, 3.51-37.74; P < 0.001) were significant predictors of Trifecta achievement after HoLEP.

CONCLUSIONS

Alongside the preoperative QoL score, PZT measurement in prostate MRI can serve as an objective predictor of successful HoLEP. Our results underscore an additional utility of prostate MRI beyond its role in excluding concurrent prostate cancer.

Sacral neuromodulation in the management of non-obstructive urinary retention: Test phase and predictive factors

AIM

The aim of this study is to evaluate the success of the test phase of sacral neuromodulation in management of chronic non-obstructive urinary retention and the factors predictive of good response.

MATERIALS AND METHODS

This is a retrospective study carried out on a cohort of patients followed up in a tertiary University Hospital in France. Fifty-two patients with chronic non-obstructive urinary retention were included in this study. These patients were seen over the past 20 years, from the year 2000 to 2020. The initial evaluation of patients included a summary of medical and surgical history, age, BMI, history of pelvic floor disorders, initial voiding pattern, physical examination, voiding diary, initial uroflowmetry and a urodynamic study. Postoperative follow-up and analysis of complications were also carried out.

RESULTS

A total of 52 patients were included in this study, 13 males and 39 females. Out of these patients, 17 patients (32.7%) with a median age of 47.3 years±18.1 benefited from definitive implantation of the sacral neuromodulation. The univariate analysis showed that age was the only significant variable in this study and the optimal age threshold was<58.5 years.

CONCLUSION

SNM is a therapy with significant clinical benefits and low morbidity for patients with chronic non-obstructive urinary retention. The results obtained need to be confirmed with a prospective study with a larger number of patients.

LEVEL OF EVIDENCE: 4

Patterns and Predictors of Optimal Surgical and Functional Outcomes after Holmium Laser Enucleation of the Prostate (HoLEP): Introducing the Concept of "Trifecta"

PURPOSE

The present study sought to provide reproducible and patient-oriented metrics to assess the rate of "successful" outcomes (Trifecta) following holmium laser enucleation of the prostate (HoLEP). Clinical and surgical predictors of failure to achieve Trifecta were investigated.

MATERIALS AND METHODS

We queried our prospectively collected database of all patients treated with HoLEP between March 2017 and January 2021. Trifecta was defined as the contemporary presence of: (1) no postoperative complication within 3 months; (2) no urinary incontinence at 3-months follow-up; and (3) 3-month postoperative max flow-rate >15 mL/s. Cases were grouped according to Trifecta achievement. All surgical procedures were carried out by a single surgeon. Surgical experience was divided into two different eras according to the number of procedures conducted (surgical era). Multivariate logistic regression analysis was performed to assess predictors of Trifecta failure.

RESULTS

Overall 305 patients were included. Of these, 192 patients (63.0%) achieved Trifecta. Preoperative patient-related features were comparable between the two groups, except for a higher post-void residual (PVR) in non-Trifecta patients (median 180 vs. 130 mL, p=0.003). A significant proportion of Trifecta patients (88.5%) were treated in the second surgical era and in 126 (65.6%) cases an en-bloc enucleation was performed. Multivariate analysis confirmed PVR ≥250 mL, first surgical era and standard three-lobes enucleation technique as independent predictors of Trifecta failure.

CONCLUSIONS

In our experience the rate of "successful" HoLEP, defined according to our newly introduced Trifecta metric, was 63.0%. We demonstrated that surgical strategy together with rising experience and baseline PVR are key elements to forecast the outcomes.

Efficacy of Holmium laser enucleation of the prostate in men with impaired bladder contractility: A review

Introduction:

Since Holmium laser enucleation of the prostate (HoLEP) was introduced in the 1990s as an endoscopic deobstructing modality for benign prostatic hyperplasia (BPH), several reports have concluded that HoLEP has compared favourably to transurethral resection of prostate (TURP) in relieving Bladder Outlet Obstruction (BOO). However, there has been no consensus regarding the efficacy of surgical management of men with Detrusor Underactivity (DU) and BOO.

Methods:

We performed a literature search of PubMed, Google Scholar, Scopus, and Web of Science databases. All studies that provided data on the effectiveness of HoLEP in men with BOO and DU were assessed. Data collected included the number of patients, median follow-up, International Prostate Symptom Score (IPSS), Qmax, post-void residual (PVR) and catheter dependency pre- and post-intervention.

Results:

Nine studies were identified in the literature with a follow-up range between 6 and 60 months. Only one prospective study was identified where investigators performed urodynamic studies (UDSs) before and after the intervention. In addition to a significant improvement of voiding parameters, they reported partial recovery of detrusor muscle contractility in approximately 80% of patients. Furthermore, all other studies reported an improvement in all outcome parameters and proved the efficacy of HoLEP in patients with DU and BOO.

Conclusion:

The current literature underpins the efficacy of HoLEP in patients with impaired bladder contractility. However, current research is limited and the majority of the published data are retrospective in nature. Therefore, more well-conducted prospective randomised studies are needed to reinforce high-level evidence for this hypothesis.

Level of evidence:

Not applicable.

Enucleation vs vaporization of benign prostatic hyperplasia: a head-to-head comparison of the various outcomes and complications. A systematic review and meta-analysis

INTRODUCTION

Vaporization of the prostate (VP) and endoscopic enucleation of the prostate (EEP) are reliable and frequently used methods for BPO relief. Both surgeries utilize lasers and EAU recommends them in similar patient cohorts. Our objective was to compare intra- and perioperative results of patients who had undergone VP and EEP.

EVIDENCE ACQUISITION

A systematic literature search was performed in three databases (MEDLINE, Web of Science and Scopus). The detailed search strategy is available at Prospero, CRD42020204739. Primary outcomes were functional results (IPSS, QoL, PVR, Qmax), and secondary outcomes were intraoperative results, postoperative PSA and prostate volume, complications, and recurrence rate.

EVIDENCE SYNTHESIS

VP required less operative time compared to EEP, mean difference=-5.51 (95%CI -7.52; -3.50). IPSS and Qmax for VP were worse after 12-month follow-up, mean difference=0.89 (95%CI 0.52; 1.27) and -3.7 (95%CI -4.56; -2.85), respectively, while QoL did not differ significantly. Postoperative PSA level was higher in the VP group, mean difference=2.28 (95%CI 2.00; 2.55). VP was associated with reduced Clavien-Dindo grade I (OR=4.16; 95%CI 2.96; 5.84) and grade II (OR=3.79; 95%CI 2.25; 6.39) complication rate, especially in terms of the percentage of blood transfusion and transient urinary incontinence. The rate of complications grade IIIa and higher was similar (3 - 6%). Reoperation rate was only estimated in one study and was significantly higher in the PVP group at 60 months of follow-up, 2.7% vs 0%, p<0.05.

CONCLUSIONS

EEP and VP share the efficacy and safety in BPH management. Our meta-analysis shows comparable complication rate in Clavien-Dindo III, VP superiority in operation time, and EEP superiority in long-term functional outcomes and PSA reduction.

Anatomical endoscopic enucleation of bladder outlet obstruction

Anatomical endoscopic enucleation of the prostate (AEEP) differs from other endoscopic modalities for bladder outlet obstruction (BOO) because it extracts the whole benign prostatic hyperplasia component. AEEP has been launched for almost 40 years as a first-line treatment method for BOO regardless of prostate size according to several guidelines. However, it remains underperformed worldwide. In this review article, we elaborate on the advantages and disadvantages of AEEP compared to other surgical modalities for BOO to investigate its efficacy and safety as a gold standard surgical management option for males with BOO.

Perioperative Outcomes of Holmium Laser Enucleation of the Prostate: A Systematic Review

INTRODUCTION

The aim of the study was to systematically review the literature and describe perioperative complications of holmium laser enucleation of the prostate (HoLEP), including the Clavien-Dindo classification of surgical complications.

METHODS

All English language publications on HoLEP were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines to evaluate PubMed®, Scopus®, and Web of Science™ databases from January 1, 1998, to June 1, 2020.

RESULTS

Fifty-seven studies were included, for a total of 10,371 procedures. We distinguished between intra-, peri-, and postoperative complications. Overall, the rate of complications is 0-7%. Intraoperative complications include incomplete morcellation (2.3%), capsular perforation (2.2%), bladder (2.4%), and ureteric orifice (0.4%) injuries. Perioperative complications include postoperative urinary retention (0.2%), hematuria and clot retention (2.6%), and cystoscopy for clot evacuation (0.7%). Postoperative complications include dysuria (7.5%), stress (4.0%), urge (1.8%), transient (7%) and permanent (1.3%) urinary incontinence, urethral stricture (2%) and bladder neck contracture (1%).

CONCLUSIONS

HoLEP is a safe procedure, with a satisfactory low complication rate. The most common reported perioperative complications are not severe (Clavien-Dindo classification grades 1-2). Further randomized studies are certainly warranted to fully determine the predictor of surgical complications in order to prevent them and improve this technique.

Efficacy of holmium laser enucleation of the prostate in patients with detrusor underactivity: systematic review and meta-analysis

Background

Benign prostatic hyperplasia (BPH) is commonly found in the aging male. Treatment of BPH can be in form of conservative or surgical intervention. Transurethral resection of the prostate (TURP) is the gold-standard treatment for BPH according to the guideline. However, there is no evidence that there is a benefit for TURP in patients with detrusor underactivity (DUA). Holmium laser enucleation (HoLEP) is theorized to have a better outcome due to its property of complete prostate enucleation. Therefore, this meta-analysis aims to determine the benefit of HoLEP for BPH patients with DUA.

Main body

We performed systematic literature searching from five databases including PubMed, Scopus, Embase, Science Direct, and Web of Science for articles up to 31 December 2020 for relevant studies. A total of five articles are eligible for this meta-analysis. A total of 2.180 subjects participated in all of the studies included. Two studies comparing patients with and without DUA that was treated with HoLEP, two studies comparing HoLEP with other surgical approaches for BPH, and one study comparing both parameters. IPSS score reduction is significantly higher in the patients with DUA (Mean Difference = 3.28, 95% CI 1.91 to 4.64, p < 0.01). Qmax and PVR are not significantly different between both groups. HoLEP also showed better improvement in IPSS and Qmax compared to TURP (IPSS: Mean Difference = -4.80, 95% CI − 7.83 to − 1.77, p = 0.002; Qmax: Mean Difference = 4.20, 95% CI 0.58 to 7.82, p = 0.02) and PVP (IPSS: Mean Difference = − 2.47, 95% CI − 4.47 to − 0.47, p = 0.02; Qmax: Mean Difference = 2.31, 95% CI 0.34 to 4.28, p = 0.02).

Conclusion

HoLEP showed better improvement in IPSS scores in patients with DUA. HoLEP can be considered to be performed in the BPH patients with DUA for better outcomes for the patients.

Thulium laser vapo-enucleation treatment for prostates >100 cc following urinary retention

INTRODUCTION

Practical advantages of Thulium in the endoscopic treatment of BPH include its technical versatility, precision and safety, offering reduced need for haemostasis and risk of injury. Evidence has shown Holmium laser to be effective in the treatment of chronic retention, however no studies address the use of Thulium laser for larger prostates after urinary retention.

OBJECTIVES

We have selected this group in our retrospective analysis on the efficacy of Thulium laser vapo-enucleation for men with both urinary retention and large prostate volumes greater than 100 cc.

METHODS

We analysed a 10-year single centre operation database of 740 Thulium vapo-enucleation of prostates. An inclusion of 47 living patients with prostates over 100 cc who have undergone the procedure following urinary retention secondary to bladder outflow obstruction (BOO) from benign prostatic hyperplasia (BPH). Patients were sub grouped into Group 1: 100-149 cc and Group 2: >150 cc.

RESULTS

Number of patients in sub groups 1 (n = 27) and 2 (n = 20) had mean prostate volumes of 116 and 173 cc respectively, with the largest measuring 234 cc. Mean resected volumes were 26 g (range 15-50.5 g) and 28 g (range 2-57 g). The overall trial without catheter (TWOC) pass rate for all patients in our series was 96% with comparable results between the two groups. Overall known early and late complication rates for all patients was 17% (UTI 13%, urosepsis 2%, AUR 2%) and 12.5% (failure 5%, OAB symptoms 5%, significant haematuria requiring surgical intervention 2.5%) respectively. Success of surgery was 96%, with an average follow-up of 5 months and no re-referrals for lower urinary tract symptoms following discharge.

CONCLUSION

We show the use of Thulium laser vapo-enucleation to be safe and effective in the treatment of retention for large prostates. Results have demonstrated signs of long-term efficacy with a low failure rate.

A call for HoLEP: AEEP for mega-prostates (≥ 200 cc)

PURPOSE

To evaluate the efficiency and efficacy of HoLEP, and methods of tissue retrieval, in patients with prostate volume (PV) ≥ 200 cc (Group 1) and to compare these to patients with PV 80-199 cc (Group 2).

METHODS

A database of all cases performed under the care of two surgeons at a tertiary HoLEP centre was reviewed.

RESULTS

157 patients with PV ≥ 200 cc were compared to 157 of the most recent consecutive cases with PV 80-199 cc. Median (IQR) enucleation efficiency was greater in Group 1 [2.8 g/min (2.2-3.5)] than Group 2 [2.1 g/min (1.6-2.5), p < 0.001]. Morcellation efficiency did not differ significantly. Cystotomy was required for tissue retrieval in Group 1 only (5.7%). Decrease in serum haemoglobin (Hb) was greater in Group 1 (19 g/l (30-8) vs 12 (18-3.5), p < 0.001) with a transfusion rate of 4.5% vs 1.3%, respectively (p = 0.104). Length of stay was longer in Group 1 than Group 2 (1 day (1-2) vs 1 (1-1), p < 0.001). There were no significant differences between groups in: time to and success of first trial without catheter, pre- and post-operative IPSS, Qmax and PVR, and 3 month catheter-free and urinary incontinence rates.

CONCLUSION

HoLEP outcomes are largely PV-independent even when PV is ≥ 200 cc, although length of stay and reduction in Hb are greater in this group. Alternatives to pure morcellation, such as cystotomy and resection of nodules, are more likely to be necessary with PV ≥ 200 cc.

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.

HoLEP for acute and non-neurogenic chronic urinary retention: how effective is it?

PURPOSE

To determine catheter status within 3 months of holmium laser enucleation of the prostate (HoLEP) for acute and non-neurogenic chronic urinary retention (AUR and NNCUR), to compare short-term outcomes of HoLEP for urinary retention (UR) versus lower urinary tract symptoms (LUTS), and to report long-term serum creatinine (SC) after HoLEP for high-pressure chronic urinary retention (HPCUR).

METHODS

A prospectively maintained database of the first 500 consecutive HoLEP cases performed under the care of a single surgeon was analysed retrospectively. Urodynamic studies (UDS) did not play a role in the decision making process for those with UR. NNCUR was defined as painless, with post-void residual volume (PVR) greater than 300 ml in men able to void and initial catheter drainage > 1000 ml in men unable to void.

RESULTS

280/500 (56%) were in UR: AUR (195), and NNCUR (85) including 22 with HPCUR. The UR cohort were older with higher enucleated tissue weight [median (IQR); 72 years (66-79 year) and 56 g (29.8-86.3 g)], than the LUTS cohort [70 years (64-75 year) and 38 g (18-67 g)] (p < 0.001). 98.9% with AUR and 98.8% with NNCUR were catheter-free 3 months after HoLEP. There were no significant differences in transfusion rates, hospital stay, or time to first trial without catheter (TWOC) between the LUTS and UR cohorts, nor in international prostate symptom score and quality of life scores, maximum urinary flow rate, post void residual volume or urinary incontinence at 3 months. Patients with NNCUR were less likely to pass their first TWOC (58.8%) than those with AUR (84.6%) or LUTS (87.7%), p < 0.001. None with HPCUR had a clinically significant deterioration in SC at a median of 60 months (IQR 36-82 months).

CONCLUSION

HoLEP has 3-month catheter-free rates in excess of 98.5% for AUR and NNCUR in patients not pre-selected by UDS. First TWOC is significantly more likely to fail after HoLEP for NNCUR than AUR or LUTS. HoLEP is a durable treatment for HPCUR and there is no need to monitor renal function to detect recurrence.

Propensity-score analysis comparing perioperative and functional outcomes between XPS 180 W-photovaporization and GreenLight laser enucleation of the prostate: reasons to discard vaporization and move to enucleation

PURPOSE

To compare the perioperative and functional outcomes between 180_W XPS GreenLight photoselective vaporization (PVP) and 532-nm GreenLight laser enucleation of the prostate (GreenLEP) in the surgical management of benign prostatic obstruction (BPO).

METHODS

Retrospective review of a prospectively maintained international database of patients managed with GreenLight laser surgery (PVP or GreenLEP) was performed. To adjust for potential baseline confounders, propensity-score matching (PSM) was applied at a ratio of 1:1 to compare the perioperative and functional outcomes between the groups.

RESULTS

A total of 2,420 patients were included. 1,491 (61.6%) underwent PVP and 929 (38.4%) underwent GreenLEP. Before PSM analysis, patients in the vaporization group were older (p < 0.001), had a lower PSA and prostate volume at baseline (p < 0.001). Using estimated propensity scores, 78 patients in the PVP group were matched 1:1 to the patients in the GreenLEP group. The incidence of overall postoperative complications was comparable between the two groups (19 vs. 16%, p = 0.06). However, after PSM, PVP was found to be associated with a higher rate of overall complications (33 vs. 11%, p = 0.001). At 3 months and at last follow-up the I-PSS, Qmax and PSA had similarly decreased in the two groups with a greater improvement in the GreenLEP group (all p < 0.05).

CONCLUSIONS

PVP and GreenLEP are two efficient and safe techniques for treating BPO. However, PVP was associated with longer operative time and higher risk of reoperation on a midterm follow-up compared to GreenLEP.

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.

Endoscopic enucleation vs endoscopic vaporization procedures for benign prostatic hyperplasia: how should we choose: A protocol for systematic review and meta-analysis

OBJECTIVE

To assess the safety and efficacy of different endoscopic procedures of the prostate techniques, by comparing endoscopic enucleation (EEP) and endoscopic vaporization procedures (EVP) of the prostate; and laser enucleation procedures (L-EEP) vs laser vaporization procedures (L-EVP) surgeries for benign prostatic hyperplasia.

METHODS

A systematic literature review was performed in December 2019 using PubMed, Embase and the Cochrane Library to identify relevant studies. Two analyses were carried out: (1) EEP vs EVP; and (2) L-EEP vs L-EVP. Efficacy and safety were evaluated using perioperative data, functional outcomes, including maximum urinary flow rate (Qmax), quality of life (QoL), international prostate symptom score (IPSS), postvoiding residual urine volume (PRV), and rate of complications. Meta-analyses were conducted using RevMan5.3.

RESULTS

Sixteen studies (4907 patients) evaluated EEP vs EVP, and 12 of them (4392 patients) evaluated L-EEP vs L-EVP. EEP showed improved functional outcomes compared with EVP. EEP was always presented a better Qmax at various follow-up times. EEP also associated with a reduced PRV and IPSS at 12 months postsurgery, an increased Qmax, and reduced IPSS and QoL score at both 24 and 36 months postsurgery. In addition, EEP was associated with less total energy utilized and retreatment for residual adenoma, but a longer catheterization time. Among other outcomes, there was no significant difference. L-EEP favors total energy used, retreatment for residual adenoma, and functional outcomes. L-EEP was associated with reduced PRV at 1, 6, and 12 months postsurgery, a greater Qmax at 6 and 12 months postsurgery, a lower IPSS at 12 months postsurgery, and higher Qmax and lower IPSS and QoL scores at 24 and 36 months postsurgery. However, there was no difference at 3 months postsurgery. No significant differences were observed for other perioperative data and complications.

CONCLUSIONS

Both EEP and EVP displayed sufficient efficacy and safety for treating benign prostatic hyperplasia. EEP and L-EEP were favored in perioperative data, rate of complications, and functional outcomes. However, the clinical significance of those statistical differences was unclear. Hence, higher-quality randomized controlled trials may be needed to provide a clear algorithm.

Anatomical endoscopic enucleation of the prostate: The next gold standard? Yes!

Anatomical endoscopic enucleation of the prostate (AEEP) differs from other surgical techniques for benign prostatic obstruction (BPO) in that it removes the entire benign prostatic hyperplasia (BPH) component of the prostate. We summarise the main advantages of AEEP compared to other surgical techniques for BPO. These include better urodynamic relief of bladder outlet obstruction, superior outcomes for urinary retention even in the presence of impaired detrusor contractility, safe and effective for any size prostate, and superior durability compared to vaporisation and resection techniques. We summarise evidence that suggests AEEP offers outcomes that are independent of patient age and prostate volume. We conclude that AEEP is the gold standard surgical treatment for men with either lower urinary tract symptoms (LUTS) or urinary retention, regardless of prostate volume, detrusor contractility and age. It offers the ability to safely and effectively treat a wider range of patients than any other BPO procedure. More widespread use of mentorship programmes, that take advantage of the growing number of experienced mentors, is recommended to train more urologists in AEEP.

Holmium laser technologies versus photoselective greenlight vaporization for patients with benign prostatichyperplasia: a meta-analysis

This study aims to compare the efficacy and safety of holmium laser technologies (HoL-Ts) and photoselective greenlight vaporization (PVP) for the treatment of benign prostatic hyperplasia (BPH), and to perform a meta-analysis according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines on PubMed, EMBASE, ClinicalTrial.gov, and the Cochrane Central Register of Controlled Trials up to August 2019. Functional outcomes, perioperative parameters, and complications were included and analyzed. Review Manager 5.3 (Cochrane Collaboration, Oxford, UK) was used to perform all analyses. A total of six articles composed of 2014 patients were included in this review. In comparison with PVP, HoL-Ts had a better performance in 1-, 3-, and 6-month Qmax (P = 0.02, but I² = 81%), with less postvoid residual urine volume (PVR) (MD = -33.85, 95% CI -52.13 to -15.57, P = 0.0003) and less total energy used (MD = -31.66, 95% CI -58.99 to -4.33, P = 0.02). Moreover, HoL-Ts had a relatively lower risk of conversion rate (OR = 0.08, 95% CI 0.01 to 0.60, P = 0.01) associated with enough enucleation and less intraoperative bleeding. Subgroup analysis of holmium laser enucleation of prostate (HoLEP) versus PVP suggested that HoLEP presented better results in 1-, 3-, 6-month and 1-year Qmax with less PVR, less energy consumption, and lower conversion rate. Compared with PVP, HoL-Ts had higher 1-, 3-, and 6-month Qmax, less PVR, and less total energy consumption with a relatively lower risk of conversion rate. In subgroup analyses, HoLEP had shown better results in accordance with all HoL-Ts. Nevertheless, well-designed RCTs including overall functional indicators are required to confirm our findings.

A novel vaporization-enucleation technique for benign prostate hyperplasia using 120-W HPS GreenLight™ laser: Seoul technique II in comparison with vaporization and previously reported modified vaporization-resection technique

PURPOSE

We developed a novel vaporization-enucleation technique (Seoul II), which consists of vaporization-enucleation of the prostate using 120-W HPS GreenLight laser, and enucleated prostate resection using bipolar devices for tissue removal. We compared the outcomes of the Seoul II with vaporization and a previously reported modified vaporization-resection technique (Seoul I).

METHODS

Among patients with benign prostate hyperplasia who underwent transurethral surgery using GreenLight laser at our institute, 347 patients with prostate volume ≥ 40 ml were included. The impact of surgical techniques on efficacy and postoperative functional outcomes was compared.

RESULTS

No difference was found in baseline characteristics, although the prostate volume was marginally greater in Seoul II (p = 0.051). Prostate volume reduction per operation time (p < 0.001) and lasing time (p = 0.016) were greater in Seoul II. At postoperative 12 months, the International Prostate Symptom Score (I-PSS) was lower (p = 0.011), and the decrement in I-PSS was greater in Seoul II (p = 0.001) than other techniques. In multivariate analysis, postoperative 12-month I-PSS for Seoul II was significantly superior to vaporization (p < 0.001), although it was similar to Seoul I. The maintenance of immediate postoperative I-PSS decrement, until postoperative 12 months was superior in Seoul II compared with vaporization (p = 0.014) and Seoul I (p = 0.048).

CONCLUSIONS

Seoul II showed improved efficacy and voiding functional maintenance over postoperative 12 months in patients with prostate volume ≥ 40 ml compared with vaporization and Seoul I. This technique could be easily accepted by clinicians who are familiar with GreenLight lasers and add flexibility to surgery without additional equipment.

Long-term Efficacy of Holmium Laser Enucleation of the Prostate in Patients With Detrusor Underactivity or Acontractility

OBJECTIVE

To evaluate long-term outcomes for men with benign prostatic obstruction (BPO) and concurrent detrusor underactivity (DUA) or acontractility following holmium laser enucleation of the prostate (HoLEP).

METHODS

A retrospective chart review was performed on all patients with BPO and urodynamic evidence of DUA or acontractility secondary to a nonneurogenic etiology that underwent HoLEP at our institution over a 4-year period. Patients were included if they had at least 24 months of follow-up.

RESULTS

We identified 9 patients with DUA and 8 patients with acontractility who met inclusion criteria with median ages of 76 and 75 years, respectively. Preoperatively, 7 (77.8%) men with DUA and 8 (100%) men with acontractility had catheter-dependent urinary retention for a median of 2 and 5 months, respectively. Postoperatively, 8 (88.9%) men with DUA and 5 (62.5%) men with acontractility were catheter free, with a median follow-up of 50.9 and 38.6 months, respectively. All the men requiring catheterization were voiding spontaneously, but used intermittent catheterization for elevated postvoid residuals.

CONCLUSION

HoLEP appears to be an effective surgical option for patients with BPO and detrusor hypocontractility or acontractility, with durable results at follow-up greater than 24 months. However, patients with acontractile bladders should be counseled on possible need to for intermittent catheterization that may be needed for high postvoid residuals.

Acupuncture for Chronic Urinary Retention due to Spinal Cord Injury: A Systematic Review

No systematic review has been published on the use of acupuncture for the treatment of chronic urinary retention (CUR) due to spinal cord injury (SCI). The aim of this review was to assess the effectiveness and safety of acupuncture for CUR due to SCI. Three randomized controlled trials (RCTs) including 334 patients with CUR due to SCI were included. Meta-analysis showed that acupuncture plus rehabilitation training was much better than rehabilitation training alone in decreasing postvoid residual (PVR) urine volume (MD -109.44, 95% CI -156.53 to -62.35). Likewise, a combination of acupuncture and aseptic intermittent catheterization was better than aseptic intermittent catheterization alone in improving response rates (RR 1.23, 95% CI 1.10 to 1.38). No severe adverse events were reported. In conclusion, acupuncture as a complementary therapy may have a potential effect in CUR due to SCI in decreasing PVR and improving bladder voiding. Additionally, acupuncture may be safe in treating CUR caused by SCI. However, due to the lack of high quality RCTs, we could not draw any definitive conclusions. More well-designed RCTs are needed to provide strong evidence.