Holmium laser enucleation of the prostate using Moses 2.0 vs non-Moses: a randomised controlled trial

To Hold or Continue Blood Thinners? A Retrospective Analysis on Outcomes of Holmium Laser Enucleation of the Prostate in Patients Who Either Held or Continued Antiplatelet/Anticoagulation Therapy

OBJECTIVE

To compare the outcomes between those who held or continued antiplatelet or anticoagulation therapy (APAC) for holmium laser enucleation of the prostate (HoLEP).

METHODS

We retrospectively reviewed patients on APAC who underwent HoLEP between January 2021 and August 2023 by a single surgeon at a high-volume center. APAC was further categorized to the specific medication: clopidogrel, apixaban, warfarin, rivaroxaban. Preoperative, intraoperative, and postoperative characteristics and outcomes were then compared. SPSS was used for statistical analysis with significance defined as P <.05.

RESULTS

One hundred thirty-nine patients were on APAC, of which 82 held and 57 continued APAC: 38 on clopidogrel (21 held), 20 on warfarin (11 held), 57 on apixaban (34 held), 24 on rivaroxaban (16 held). Overall, there were no significant differences between those who held versus those who continued APAC. On sub-analysis, controlling for age and prostate size, patients who held clopidogrel had shorter length of stays (11.3 hours vs 27.3 hours, P = .016), higher likelihood for same-day catheter removal (90.5% vs 47.1%, P = .002) and same-day discharge (90.5% vs 35.3%, P = .002). Patients who held warfarin had shorter procedure (61.3 minutes vs 92.2 minutes, P = .025) and morcellation time (7.36 minutes vs 18 minutes, P = .048).

CONCLUSION

HoLEP is safe and efficacious in patients whether APAC is held or continued through surgery. Holding APAC in those on clopidogrel may decrease length of stay and improve rates of same-day Foley removal and discharge. Patients who held warfarin had shorter morcellation and procedure times.

Is Pulse Modulation the Future of Laser Technology in Endourology: Evidence from a Literature Review - Section of EAU Endourology

BACKGROUND AND OBJECTIVE

The aim of our review was to comprehensively evaluate the impact of pulse modulation technology in the field of endourology, with a focus on laser lithotripsy and prostate enucleation.

METHODS

A systematic search was conducted in the PubMed, MEDLINE, and Scopus databases for articles published during the past 20 yr (January 2004-July 2024). Article selection adhered to the Population, Intervention, Comparator, Outcome (PICO) framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In vivo, ex vivo, in vitro, and clinical studies that reported on the impact of pulse modulation technologies in laser lithotripsy or prostate enucleation in comparison to a standard references or as a standalone report, with a focus on stone ablation efficiency, safety, tissue ablation, and hemostasis, were eligible. A total of 29 articles were included.

KEY FINDINGS

Pulse modulation is a feature mostly implemented for Ho:YAG laser generators. Preclinical studies on pulse modulation have demonstrated promising results for both stone fragmentation and laser-tissue interaction. Clinical studies that investigated technologies such as the Vapor Tunnel, Virtual Basket, and Moses have revealed better efficiency in comparison to the short-pulse modality. While there have been modest improvements in hemostasis and operating time, there has been no obvious improvement in outcomes after prostate surgery.

CONCLUSIONS AND CLINICAL IMPLICATIONS

While in vitro studies have shown that pulse modulation improves stone fragmentation, reduces retropulsion, and maintains thermal safety, clinical outcomes are more variable. For prostate enucleation, the benefits are less consistent. Pulse modulation may improve efficiency, primarily by reducing operating times, but key outcomes such as stone-free and complication rates remain comparable to those with standard modalities.

PATIENT SUMMARY

Our review shows that pulse modulation technology improves the effectiveness and safety of laser treatments for kidney stones. However, the benefits of this technology for prostate surgery are still uncertain, highlighting the need for more research.

Second-generation MOSES 2.0 versus MOSES 1.0 pulse-modulation technologies for holmium laser enucleation of the prostate (HoLEP)

INTRODUCTION AND OBJECTIVE

To report our initial experience with enhanced MOSES 2.0 technology in patients who underwent holmium laser enucleation of the prostate (HoLEP) for the treatment of benign prostatic hyperplasia (BPH), in comparison to those who underwent HoLEP with MOSES 1.0 technology at our institution.

METHODS

We retrospectively reviewed data of patients who underwent HoLEP using MOSES 1.0 or MOSES 2.0 pulse-modulation technology from December 2020 to September 2023. Preoperative and intraoperative parameters, postoperative outcomes, as well as perioperative complications were collected and analyzed.

RESULTS

A total of 196 patients were included in the study. Among them, 146 patients underwent MOSES 1.0 HoLEP, while 50 had MOSES 2.0 HoLEP. No statistically significant differences in preoperative characteristics were observed between the two groups. The median prostate volume for the MOSES 1.0 and MOSES 2.0 HoLEP groups was 109 cc and 117.5 cc, respectively. Patients in the MOSES 2.0 group had a shorter median enucleation time (52.5 vs. 42.5 min, p < 0.001) and hemostasis time (8 vs. 6 min, p = 0.002), along with lower laser energy usage (101 vs. 86.4 kJ, p = 0.012), when compared to those in the MOSES 1.0 cohort. Postoperative outcomes, including IPSS, QoL, Qmax, and PVR, were comparable between the two groups at 1, 3, and 6 months postoperative. The incidence of hospital readmission (p = 0.42), as well as one-month postoperative urge urinary incontinence (p = 0.2) and stress urinary incontinence (p = 0.13) were also comparable between the cohorts.

CONCLUSIONS

HoLEP with second-generation MOSES 2.0 technology is a safe and effective treatment option for BPH. It offers notable improvements, including reduced enucleation and hemostasis times, while using less energy when compared to MOSES 1.0.

Future aspects of plant derived bioactive metabolites as therapeutics to combat benign prostatic hyperplasia

ETHNOPHARMACOLOGICAL RELEVANCE

Benign prostatic hyperplasia (BPH), characterized by prostate enlargement due to cell proliferation, is a common urinary disorder in men over 50, manifesting as lower urinary tract symptoms (LUTS). Currently, several therapeutic options are accessible for treating BPH, including medication therapy, surgery and watchful waiting. Conventional drugs such as finasteride and dutasteride are used as 5α-reductase inhibitors for the treatment of BPH. However long-term use of these drugs is restricted due to their unpleasant side effects. Despite the range of available medical therapies, the effective treatment against BPH is still inadequate. Certain therapeutic plants and their phytochemicals have the aforementioned goals and work by regulating this enzyme.

AIM OF THE STUDY

This review aims to provide a comprehensive insight to advancements in diagnosis of BPH, modern treatment methods and the significance of ethnobotanically relevant medicinal plants as alternative therapeutics for managing BPH.

MATERIAL AND METHODS

A thorough and systematic literature search was performed using electronic databases and search engines such as PubMed, Web of Science, NCBI and SciFinder till October 2023. Specific keywords such as "benign prostatic hyperplasia", "medicinal plants", "phytochemicals", "pharmacology", "synergy", "ethnobotany", "5-alpha reductase", "alpha blocker" and "toxicology". By include these keywords, a thorough investigation of pertinent papers was assured, and important data about the many facets of BPH could be retrieved.

RESULTS

After conducting the above investigation, 104 herbal remedies were found to inhibit Phosphodiesterase-5 (PDE-5) inhibition, alpha-blockers, or 5α -reductase inhibition effects which are supported by in vitro, in vivo and clinical trial studies evidence. Of these, 89 plants have ethnobotanical significance as alpha-blockers, alpha-reductase inhibition, or PDE-5 inhibition, and the other fifteen plants were chosen based on their ability to reduce BPH risk factors. Several phytocompounds, including, rutaecarpine, vaccarin, rutin, kaempferol, β-sitosterol, quercetin, dicaffeoylquinic acid, rutaevin, and phytosterol-F have been reported to be useful for the management of BPH. The use of combination therapy offers a strong approach to treating long-term conditions compare to single plant extract drugs. Furthermore, several botanical combinations such as lycopene and curcumin, pumpkin seed oil and saw palmetto oil, combinations of extracts from Funtumia africana (Benth.) Stapf and Abutilon mauritianum (Jacq.) Medik., and Hypselodelphys poggeana (K.Schum.) Milne-Redh. and Spermacoce radiata (DC.) Sieber ex Hiern are also supported through in vitro and in vivo studies for managing BPH through recuperation in patients with chronic long-term illnesses, as measured by the International Prostate Symptom Score.

CONCLUSION

The review proposes and endorses careful utilization of conventional medications that may be investigated further to discover possible PDE-5, 5 alpha-reductase, an alpha-blocker inhibitor for managing BPH. Even though most conventional formulations, such as 5 alpha-reductase, are readily available, systemic assessment of the effectiveness and mechanism of action of the herbal constituents is still necessary to identify novel chemical moieties that can be further developed for maximum efficacy. However, there exist abundant botanicals and medicinal plants across several regions of Africa, Asia, and the Americas, which can be further studied and developed for utilization as a potential phytotherapeutic for the management of BPH.

Evaluation of safety and efficacy of insulated-gate bipolar transistor holmium laser technology for prostate enucleation in canine model: a preliminary study

The evolution of laser medical devices for benign prostatic hyperplasia (BPH) treatment aims to enhance vaporization, coagulation, or tissue removal. In this study, we aim to evaluate the effectiveness and safety of the innovative application of insulated-gate bipolar transistor (IGBT) xenon lamp-pulsed drive technology holmium laser in endoscopic prostate enucleation operations using canine models. Six canines were used as an experimental unit, the breed of the canine unit used was beagle. Each canine served as its own control to minimize the number of experimental units. Endoscopic enucleation, performed by a single surgeon, involved enucleating the left hemi-prostate, leaving the right hem-prostate untouched to serve as the control. Throughout the study period, all canines maintained good health. No adverse events were observed in all six canines. Postoperatively, there were no indications of redness, swelling, or other adverse effects at the surgical sites. No abnormalities were observed in the appearance and morphology of major organs. The prostate and bladder, removed for further pathological evaluation, exhibited no abnormalities in size, color, or texture. No abnormalities or inflammation were observed, and the tissues were free of adhesions, indicating successful healing. In conclusion, our comparison of preoperative and postoperative parameters in canines suggests that the IGBT pulsed laser, at a power setting of 100 W, demonstrates characteristics of safety, efficacy, minimal tissue damage, and no major postoperative complications. This study establishes a theoretical foundation for future applications in human settings, encouraging further exploration of the IGBT holmium laser's potential in clinical practice.

MOSES™ Technology vs Non-Moses Holmium Laser Enucleation of the Prostate: A Randomized Controlled Trial From a High-Volume Center

OBJECTIVE

Benign prostatic hyperplasia (BPH) management has evolved from transurethral resection of the prostate (TURP) to holmium laser enucleation of the prostate (HoLEP). Recent innovation introduces Moses™ technology in holmium lasers, with the Lumenis Pulse™ system.

METHODS

To compare Moses-augmented HoLEP (MoLEP) to non-Moses HoLEP in terms of enucleation efficiency, hemostasis, and applicability in day surgery settings. A single-blind, prospective, parallel randomized controlled trial was conducted in Shanghai, China, from March to December 2022. Ethical approval (SK2020-038) was obtained, and 100 consenting men over 50 with BPH indications were randomized (1:1) into MoLEP and HoLEP groups. Surgical procedures were standardized, and outcomes were assessed by blinded analysts.

RESULTS

Data from 80 participants (38 MoLEP, 42 HoLEP) were analyzed. Baseline characteristics were comparable. MoLEP demonstrated superior enucleation efficiency (3.5±0.8 g/min) and shorter enucleation time (22.5±7.6 minutes) compared to HoLEP, although not statistically significant. MoLEP achieved hemostasis in less time (6.6±4.2 minutes) than HoLEP (11.2±5.1 minutes). Postoperative care demands varied, with MoLEP requiring less bladder irrigation. MoLEP exhibited a shorter average catheterization time (1.3±0.1 days) and reduced hospitalization compared to HoLEP. Both groups showed significant postoperative improvements in functional outcomes.

CONCLUSION

While statistical significance was not achieved in certain outcome measures, MoLEP exhibited potential advantages in postoperative care demands, shorter catheterization time, and reduced hospitalization, suggesting its feasibility and safety in day surgery settings. Postoperative functional outcomes improved significantly in both groups.

Construction of lncRNA- and circRNA-associated ceRNA networks in the prostatic urethra of rats after simulating transurethral laser prostatectomy (TULP)

Non-coding RNA appears to be involved in wound repair. Competing endogenous RNA (ceRNA) appears to be an important post-transcriptional mechanism, it means that long noncoding RNA (lncRNA) or circular RNA (circRNA) acts as a microRNA (miRNA) sponge to further regulate mRNA. However, ceRNA network related to wound repair after prostatectomy has yet been constructed. TULP is the main surgical method of prostatectomy, but there have been no reports of TULP rat models in the past. We simulated TULP on rats, and observed the whole process of wound injury and repair after operation through pathological examination of wound tissue. Next, we discovered 732 differentially expressed lncRNAs (DElncRNAs), 47 differentially expressed circRNAs (DEcircRNAs), 17 differentially expressed miRNAs (DEmiRNAs), and 1892 differentially expressed mRNAs (DEmRNAs) related to wound repair after TULP through full transcriptome microarray and bioinformatics methods, and confirmed the reliability of transcriptome data by quantitative Reverse Transcription PCR (qRT-PCR), and immunohistochemistry. Then, we constructed the lncRNA- and circRNA-associated ceRNA regulatory networks related to wound repair after TULP in rats. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses showed that molecules in these networks were mainly involved in inflammatory infiltration, cell differentiation, and intercellular interactions and involved signal pathways such as the PI3K-Akt signaling pathway. Thus, this study successfully established the TULP model in rats, revealed potentially important biomarkers and ceRNA networks after prostatectomy in rats, and provided theoretical support for the repair of post-prostatectomy wound.

Adult onset urinary retention caused by a prolapsing ureterocele

Preoperative cystoscopy is imperative in anticipation of a bladder outlet procedure. This case highlights a now catheter dependent middle aged gentleman who was referred for treatment of urinary retention. He was found to have a prolapsing ureterocele causing obstruction. This was managed with a transurethral ureterocelectomy utilizing the Moses laser which resulted in a precise and bloodless resection. He is now voiding with out issue.

Laser Technology Advancements in the Treatment of Benign Prostatic Hypertrophy

PURPOSE OF REVIEW

Lasers have had a significant impact on the treatment of benign prostatic hypertrophy. This article attempts to distill the advancements in laser technology for the treatment of benign prostatic hypertrophy (BPH) into key and understandable points to help make this topic more accessible to urologists.

RECENT FINDINGS

The holmium:yttrium-aluminum-garnet (YAG) laser, one of the most significant lasers in the field of urology, has recently been improved with pulse modulating technology (Moses™ technology). New thulium:YAG technology allows both pulsed and continuous wave modes. The thulium fiber laser is one of the newer lasers to come to market and has been shown to have effective and safe outcomes. GreenLight™ lasers are predominantly used in photovaporization procedures and have also been studied extensively, although less in recent years. The modern urologist is fortunate to have many high-quality lasers and a wide variety of surgical techniques to choose from when treating BPH. Understanding the basic laser principles and applications will help urologists to select the best treatment options for their patients with BPH.

Experts' recommendations in laser use for the endoscopic treatment of prostate hypertrophy: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group

PURPOSE

To identify expert laser settings for BPH treatment and evaluate the application of preventive measures to reduce complications.

METHODS

A survey was conducted after narrative literature research to identify relevant questions regarding laser use for BPH treatment (59 questions). Experts were asked for laser settings during specific clinical scenarios. Settings were compared for the reported laser types, and common settings and preventive measures were identified.

RESULTS

Twenty-two experts completed the survey with a mean filling time of 12.9 min. Ho:YAG, Thulium fiber laser (TFL), continuous wave (cw) Tm:YAG, pulsed Tm:YAG and Greenlight™ lasers are used by 73% (16/22), 50% (11/22), 23% (5/22), 13.6% (3/22) and 9.1% (2/22) of experts, respectively. All experts use anatomical enucleation of the prostate (EEP), preferentially in one- or two-lobe technique. Laser settings differ significantly between laser types, with median laser power for apical/main gland EEP of 75/94 W, 60/60 W, 100/100 W, 100/100 W, and 80/80 W for Ho:YAG, TFL, cwTm:YAG, pulsed Tm:YAG and Greenlight™ lasers, respectively (p = 0.02 and p = 0.005). However, power settings within the same laser source are similar. Pulse shapes for main gland EEP significantly differ between lasers with long and pulse shape modified (e.g., Moses, Virtual Basket) modes preferred for Ho:YAG and short pulse modes for TFL (p = 0.031).

CONCLUSION

Ho:YAG lasers no longer seem to be the mainstay of EEP. TFL lasers are generally used in pulsed mode though clinical applicability for quasi-continuous settings has recently been demonstrated. One and two-lobe techniques are beneficial regarding operative time and are used by most experts.

Histopathological assessment of depth of coagulation necrosis with Holmium, Moses, and Thulium fiber lasers in human prostate tissue

PURPOSE

To evaluate coagulation necrosis depth (CND) of Holmium (HL), Moses (ML), and Thulium fiber laser (TFL) in ex vivo human prostate tissue at various energy settings.

METHODS

After endoscopic HL enucleation, small prostate tissue fragments were removed from the bladder with graspers and used for study. Immediately after surgery, a single incision was made on the surface of the tissue kept under normal saline at room temperature using a hand-held 550-µm laser fiber. Variable energy settings were tested for all three lasers. Two pathologists measured the CND with light microscopy using ocular micrometer. Impact of various laser settings on CND was analyzed. The differences in CND of all three lasers at similar laser power were compared.

RESULTS

Mean CND was 0.56 ± 0.53 mm for long-pulse HL, 0.54 ± 0.53 mm for ML, 0.67 ± 0.67 mm for low-pulse TFL, and 0.81 ± 0.78 mm for high-pulse TFL. There was no significant difference between mean CND of HL and ML at various laser settings ranging from 10 to 120 W and CND with long- and short-pulse settings of TFL at settings from 10 to 60 W. There was a trend of increasing CND in HL and ML with increasing laser power; however, it was not statistically significant. TFL had similar tissue effects as HL and ML.

CONCLUSION

There is no significant difference in CND of HL, ML, and TFL in ex vivo human prostate tissue. Other factors besides laser type and settings need to be studied to explain clinical differences among various lasers used for prostate enucleation.

The outcomes of same-day discharge following holmium laser enucleation of the prostate (HoLEP) surgeries: our experience during the COVID-19 pandemic

OBJECTIVE

To describe the outcomes of Same-Day Discharge (SDD) following Holmium Laser Enucleation of the Prostate (HoLEP) in patients during the COVID-19 pandemic.

METHODS

A retrospective review of HoLEP surgeries at a single institution between January 2021 and March 2022 was performed. Patient demographic and operative data were collected, and postoperative outcomes were evaluated in terms of safety and efficacy and compared in both groups using a t-test and chi-square test. Logistic regression was also performed to identify factors that correlate with the failure of SDD.

RESULTS

A total of 155 patients were identified; 135 patients were successfully discharged on the same day and 20 were admitted (87% SDD rate). Admitted HoLEP patients had a significantly higher median prostate-specific antigen (5.7 vs 3.9 ng/dL, P < 0.001), prostate volume (152.3 vs 100.6 mL, P < 0.001), and enucleated tissue weight (90.3 vs 56.9 g, P = 0.04) compared to the SDD group. The SDD group had a 2.9% (n = 4) readmission rate and a 5.2% (n = 7) Emergency Department (ED) visit rate. There was no significant difference in the rate of postoperative ED visits (P = 0.64), readmissions (P = 0.98), complications, and catheterization time (P = 0.98) between both groups. Preoperative predictors of SDD failure included prostate gland volume > 150 mL (OR = 7.17; CI 2.01-25.67; P < 0.01) and history of antiplatelet/anticoagulation use (OR = 6.59; CI 2.00-21.67; P < 0.01).

CONCLUSION

Same-day discharge following HoLEP is a safe and effective approach that can be performed in most patients using a liberal discharge criteria and relying on postoperative findings only.

Peri- and post-operative outcomes, complications, and functional results amongst different modifications of endoscopic enucleation of the prostate (EEP): a systematic review and meta-analysis

PURPOSE

To investigate and assess outcomes, complications, and functional results amongst different modifications of endoscopic enucleation of the prostate (EEP).

METHODS

We conducted a systematic review and meta-analysis according to the PRISMA checklist. We searched the Medline, Cochrane, and Embase databases. We included only randomised-controlled trials (RCT) comparing modifications of EEPs and assessed the risk of bias (RoB).

RESULTS

Seven RCTs were included in the study. Overall, 1266 patients were treated with Holmium laser enucleation of the prostate (HoLEP) and 80 patients with thulium laser vapo-enucleation of the prostate (ThuVEP). The operative time during pulse shape-modified HoLEP was shorter when compared to standard pulse HoLEP (MD 18.08 min, 95% CI 8.11-28.05 min, p = 0.0004). The decrease in haemoglobin was significantly lower for two-lobe HoLEP when compared to three-lobe HoLEP (MD 0.16 g/dl, 95% CI 0.22-0.1 g/dl, p < 0.00001). Virtual Basket (VB) HoLEP showed a smaller haemoglobin decrease when compared to standard pulse HoLEP (1.12 ± 1.78 vs. 2.54 ± 1.23 g/dl, p = 0.03). When directly comparing one- vs. two- vs. three-lobe HoLEP, surgical time (p < 0.001) and enucleation efficiency (p = 0.006) were significantly different and favouring one- and two-lobe HoLEP in the study with the largest patient population included. No significant differences for complications were observed; however, Clavien-Dindo IVa events were reported for two patients.

CONCLUSION

All variations of EEP improve symptoms and functional parameters with a low incidence of high-grade complications. One- and two-lobe approaches and pulse shape-modified HoLEP seem to be beneficial in terms of operative time and blood loss.

Efficiency and clinical outcomes of Moses technology for holmium laser enucleation of the prostate: An evidence-based analysis

BACKGROUND

To compare the safety and clinical efficacy of Moses laser enucleation of the prostate (MoLEP) with those of holmium laser enucleation of the prostate (HoLEP) for treating benign prostatic hyperplasia (BPH).

METHODS

We systematically searched PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang databases, and SinoMed databases. The retrieval period was from the establishment of the database to March 2022. Stata17.0 was used for calculations and statistical analyses.

RESULTS

This study included 12 articles comprising 1160 patients for meta-analysis. Compared with those of the HoLEP group, the hemostasis time (weighted mean difference [WMD] = -4.66, 95% confidence interval [CI] [-6.47, -2.84], p < 0.001), enucleation time (WMD = -7.23, 95% CI [-10.67, -3.79], p < 0.001), operative time (WMD = -15.02, 95% CI [-20.50, -9.53], p< 0.001), length of hospital stay (WMD = -15.02, 95% CI [-20.50, -9.53], p< 0.001), intraoperative blood loss (WMD = -11.19, 95% CI [-12.94, -9.44], p< 0.001), and total postoperative complications rate (OR = 0.51, 95% CI [0.32, 0.81], p = 0.004) were shorter in the MoLEP group. Postoperative quality of life (WMD = 0.30, 95% CI [0.00, 0.59], p = 0.047) was lower in the HoLEP group, and there were no statistically significant differences in the International Prostate Symptom Score, postoperative maximum urinary flow rate, and postoperative residual urine (p > 0.05).

CONCLUSION

MoLEP has more advantages than HoLEP in terms of safety, shorter operation time and hospital stay, and fewer complications. However, this conclusion needs to be verified with a larger sample size, longer follow-up time, and multicenter randomized controlled trial data.

Comparative efficacy and safety of holmium laser enucleation of the prostate (HoLEP) using moses technology and standard HoLEP: A systematic review, meta-analysis, and meta-regression

Purpose

The use of HoLEP was associated with steep learning curve thus prolonging operative procedure. The problem of learning curve could be solved with the invention of Moses HoLEP. This study aimed to evaluate the comparison of efficacy and safety between Moses HoLEP and standard HoLEP in BPH patient.

Materials and methods

Systematic search was carried out using PRISMA guideline. Pubmed, Scopus and Embase were searched to collect randomized controlled trials and observational studies. Quantitative analysis was performed to evaluate the comparison in intraoperative, postoperative and complications characteristics. RevMan 5.4 and STATA were used in data analysis.

Results

Total of 7 studies (1226 patients) were included. Regarding intraoperative characteristics, Moses HoLEP provided significantly shorter enucleation time (MD: 3.00, 95% CI: 5.57 to -0.43, p = 0.02), shorter hemostasis time (MD: 3.79, 95% CI: 5.23 to -2.34, p < 0.00001), and shorter laser use time (MD: 2.79, 95% CI: 5.03 to -0.55, p = 0.01). For postoperative characteristics, Moses HoLEP possessed significantly lower PVR (MD -34.57, 95% CI -56.85 to -12.30, p = 0.002). Overall complication was higher in standard HoLEP although the result was not significant (MD 0.68, 95%CI: 0.38 to 1.21, p = 0.19). Moses HoLEP possessed more superiority over standard HoLEP regarding shorter hemostasis time with the increasing of prostate size (coefficient -0.894, p = 0.044).

Conclusion

Moses HoLEP demonstrated shorter enucleation time, shorter hemostasis time and shorter laser use time. Moses HoLEP also possessed lower PVR. There were no safety issues in Moses HoLEP compared with standard HoLEP.

Does MOSES Technology Enhance the Efficiency and Outcomes of Standard Holmium Laser Enucleation of the Prostate? Results of a Systematic Review and Meta-analysis of Comparative Studies

CONTEXT

Holmium laser enucleation of the prostate (HoLEP) is currently the size-independent gold standard for surgical treatment of benign prostate enlargement (BPE).

OBJECTIVE

To systematically review the current literature and compare perioperative parameters, early outcomes, and complications after HoLEP with MOSES technology LEP (MoLEP) for BPE.

EVIDENCE ACQUISITION

This study was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework using the PICOS (Patient, Intervention Comparison, Outcome, Study) model to frame the clinical question. The population was adults undergoing LEP for BPE, with standard HoLEP as the intervention and MoLEP as the comparison. The outcomes were enucleation time, surgical time, haemostasis time, energy used, hospital length of stay (LOS), recatheterisation, urethral stricture rate, and functional outcomes. The study type included randomised, prospective nonrandomised, and retrospective studies.

EVIDENCE SYNTHESIS

Seven studies were included for meta-analysis after screening. Mean enucleation time was significantly shorter for MoLEP (mean difference [MD] -7.27 min, 95% confidence interval [CI] -11.26 to -3.28; p = 0.0004). Postoperative LOS was significantly longer in the HoLEP group (MD 0.3 d, 95% CI -0.24-0.85,p<0.0001). Although not statistically significant, there was a trend for higher incidence of recatheterisation (odds ratio [OR] 1.39, 95% CI 0.47-4.09; p = 0.55) and urethral stricture (OR 1.81, 95% CI 0.45-7.37; p = 0.41) in the HoLEP group. The mean maximum peak flow favoured HoLEP (MD 0.95 ml/s, 95% CI -1.66 to 3.57; p = 0.47) and a lower mean postvoid residual volume was noted in the MoLEP group (MD -10.08 ml, 95% CI -53.54 to 33.37; p = 0.65).

CONCLUSIONS

MoLEP performed better in terms of intraoperative outcomes compared to standard HoLEP, resulting in shorter enucleation, haemostasis, and total surgical times for similar energy delivered. In addition, postoperative LOS with an early trial of catheter favours MoLEP, making it appealing as a day surgery procedure.

PATIENT SUMMARY

We reviewed the literature for early outcomes of laser treatment of the prostate for tissue removal using a MOSES system in comparison to standard treatment with a holmium laser for BPE. We found that the MOSES laser system can improve intraoperative performance, making prostate treatment a same-day discharge surgery.

Lasers for benign prostatic hyperplasia (hybrid, blue diode, TFL, Moses). Which one to choose?

PURPOSE OF REVIEW

To present the evidence of latest developments of lasers for the surgical treatment of benign prostatic hyperplasia (BPH). We focused on recent advancements in Ho:YAG laser such as Moses technology, the Thulium Fiber Laser (TFL), the blue diode laser, and hybrid laser.

RECENT FINDINGS

Laser enucleation of prostate techniques using either Ho:YAG laser with the Moses technology and Moses 2.0, or TFL seem efficient and safe compared with the standard enucleation using Ho:YAG laser. Only in vitro studies evaluated the blue diode laser and hybrid laser (combination of a continuous wave TFL and blue diode laser). Blue diode laser showed intermediate incision depth and minimal coagulation depth compared with Ho:YAG laser and Super Pulse TFL. Hybrid laser showed deep incision depth and small coagulation area compared with Ho:YAG laser and continuous wave TFL.

SUMMARY

Surgical treatment of BPH using Moses technology, Moses 2.0, and TFL shows encouraging results comparable to the standard enucleation using Ho:YAG laser. Only in vitro data are currently available for blue diode laser and hybrid laser. Future well-designed studies comparing these technologies and evaluating them on specific risk groups of patients as well as the long-term durability of outcomes are needed.

Comparative analysis of MOSESTM technology versus novel thulium fiber laser (TFL) for transurethral enucleation of the prostate: A single-institutional study

INTRODUCTION

Novel laser technologies have been developed for the minimally invasive surgical management of benign prostatic hyperplasia (BPH). The objective of this study was to assess the safety and efficacy of MOSESTM technology versus the thulium fiber laser (TFL) in patients with BPH undergoing transurethral enucleation of the prostate.

METHODS

We conducted a retrospective review of prospectively collected data of eighty-two patients who underwent transurethral enucleation of the prostate using MOSESTM or TFL technologies from August 2020 to September 2021. Preoperative and intraoperative parameters, in addition to postoperative outcomes, were collected and analyzed.

RESULTS

Twenty patients underwent transurethral enucleation of the prostate with TFL, while 62 had MOSESTM HoLEP. No statistically significant difference in preoperative characteristics was observed between the groups. Patients in the TFL group had longer median enucleation, hemostasis, and morcellation times (p < 0.001) than those in the MOSESTM cohort. The longer morcellation time of TFL is mostly related to less visibility. The postoperative outcomes IPSS, QoL, Qmax, and post void residual (PVR), were comparable between the groups at 1, 3 and 6 months. The incidence of urge urinary incontinence (p = 0.79), stress urinary incontinence (p = 0.97), and hospital readmission rates (p = 0.1) were comparable between the two groups.

CONCLUSIONS

A satisfactory safety and efficacy profile with comparable postoperative outcomes was demonstrated for both techniques; though, MOSESTM technology was superior to TFL in terms of shorter overall operative time.

Randomized prospective trial of the severity of irritative symptoms after HoLEP vs ThuFLEP

PURPOSE

To compare the short-term postoperative functional outcomes and severity of irritative symptoms following holmium and thulium fiber laser enucleation (HoLEP and ThuFLEP).

METHODS

This prospective randomized single-blinded study was performed in accordance with CONSORT. The inclusion criteria were IPSS > 20 or Qmax < 10 ml/s. Patients were randomized between HoLEP and ThuFLEP. Demographics, objective data (PSA, prostate volume, etc.), data on urinary and sexual function (IPSS, IIEF, QoL, QUID, Qmax, ICIQ-MLUTS) were collected. Detailed perioperative information and postoperative data on functional outcomes at 1, 2, 3, 4, 6, 8, 10, 12 weeks and 6 months were collected.

RESULTS

Data on 163 participants were included (77-HoLEP, 86-ThuFLEP). No differences were found in surgery duration; number of postoperative complications (Clavien-Dindo I-III), catheterization time and hospital stay. Functional outcomes up to 6 months didn't differ between the groups (IPPS, IIEF, QoL, QUID, ICIQ-MLUTS, Qmax, p > 0.05). Total ICIQ-MLUTS, bother and voiding scores at 1 and 3 months significantly increased compared with the baseline in both groups (p < 0.05). No difference between the groups were observed. In HoLEP the SUI series rate was 1.3% and 1.3% after 3 and 6 months following the procedure; in ThuFLEP: it was 3.5% and 2.3% respectively (p = 0.35 and p = 0.54).

CONCLUSION

The preliminary results of the study showed no apparent differences in functional outcomes (IPSS, Qmax), rate of SUI or irritative symptoms. Both ThuFLEP and HoLEP are efficient ways of treating benign prostatic obstruction. Both surgeries are comparable in terms of duration and postoperative complication rates.

Holmium: yttrium-aluminum-garnet laser with Moses: does it make a difference?

PURPOSE OF REVIEW

Moses effect is an inherent physical principle of Ho:YAG laser functioning. Moses Technology is a pulse modulation modality of Ho:YAG laser, which became commercially available for the treatment of two urological conditions: urinary stones and benign prostatic obstruction. The purpose of this narrative review is to distinguish between Moses effect and Moses Technology, as well as to summarize the latest evidence on Moses Technology and its main application in the urological field.

RECENT FINDINGS

During laboratory lithotripsy, Moses Technology seems to reduce stone retropulsion and determine higher ablation volume compared with regular lithotripsy. However, this technology presents similar characteristics to long pulse Ho:YAG laser, and several studies showed no significant difference between Moses Technology and standard lasers. When used in prostate enucleation, Moses Technology promises to reduce operating time by increasing the efficiency of prostate resection and improve the hemostasis. Moreover, some studies state that it is possible to reduce the HoLEP morbidity. Despite this, the clinical impact of the time reduction remains uncertain and different studies either present relevant limitations or are burdened by significant bias.

SUMMARY

Although Moses effect has been extensively described and characterized, and several studies have been published on the usage of Moses Technology for both laser lithotripsy and laser enucleation of the prostate with Holmium YAG, solid clinical evidence on the real improvement of surgical outcomes is still missing.

Laser fiber degradation following holmium laser enucleation of the prostate utilizing Moses technology versus regular mode

PURPOSE

We sought to objectively compare laser fiber degradation for holmium laser enucleation of the prostate (HoLEP) cases performed with 550 μm standard fibers versus 550 μm Moses 2.0 fiber in BPH mode on a macroscopic and microscopic level.

METHODS

We prospectively collected outcomes for 50 standardized HoLEP cases using 550 μm Moses fiber with 2.0 BPH mode compared to our historical cohort of 50 patients using 550 μm standard fibers on regular mode. Macroscopic degradation length was the difference in length of exposed fiber at the start and end of each case. Five consecutive 550 μm standard fibers, five 550 μm Moses fibers and their respective controls underwent novel utilization of three objective corroborating imaging techniques: Brightfield high resolution microscopy, high resolution 3-D microCT and Confocal Reflection Surface Analysis. Mann-Whitney U, 2-tailed T tests and Chi-squared tests were used.

RESULTS

Standard fibers demonstrated greater degradation than the Moses fibers with 2.0 BPH mode [2.9 cm (IQR 1.7-4.3 cm) vs 0.2 cm (IQR 0.1-0.4 cm), p < 0.01]. This difference remained significant when comparing degradation per energy used, per minute enucleation and per gram enucleated (all p < 0.05). None of the cases with Moses fiber and 2.0 BPH mode required intraoperative interruption to re-strip the fiber. Objective fiber degradation by three microscopic techniques confirmed more damage to the standard fibers with regular mode.

CONCLUSION

Overall, use of the 550 μm Moses fiber with 2.0 BPH mode resulted in less fiber degradation compared to a standard 550 μm fiber with regular mode as confirmed using 4 corroborating macroscopic and microscopic techniques.

Laser endoscopic procedures on the prostate: it is the small details that count

PURPOSE OF REVIEW

This review aims to highlight the pros and cons of each laser device and to consider additional possible milestones for the development of laser technologies in the surgical treatment of benign prostate hyperplasia.

RECENT FINDINGS

Over the last three decades, lasers' role in endourology has gone from strength to strength. Specifically, the primary techniques where laser surgery for BPO relief is concerned are vaporization and enucleation. The idea behind vaporization is that lasers are able to vaporize substantial amounts of tissue due to deep ablation depth and increased power. The most efficient devices for vaporization are those affecting hemoglobin as primary chromophore and/or using a continuous firing mode (KTP/LBO:YAG, diode lasers, Tm:YAG). As for enucleation, multiple devices have been suggested for the adequate anatomical enucleation of the prostate (EEP). As it is a skill-dependent technique, the EEP is effective irrespective of which device the surgeon uses. However, some devices have shown significant advances where enucleation is concerned.

SUMMARY

The choice of device should be based primarily on the technique the surgeon prefers. Although the most suitable lasers for vaporization are hemoglobin-targeting and/or continuous wave devices, the EEP may be done with any enough powered laser, yet some provides specific effects which you should be aware before the surgery.

The constant search for the greater good: evolving from TURP to anatomic enucleation of the prostate is a safe bet

PURPOSE

In a troubling moment in history with an ongoing world pandemic and the impending economic crises, there is today a plethora of commercially available options for the minimally invasive treatment of BPH. New industry-driven evaluation criteria of these treatments, the logical marketing hype, a short follow-up for many of them, make challenging to interpret the role they will finally adopt in the armamentarium to treat BPH.

METHOD

The author comments on recently published literature based in own experience and insight.

RESULTS AND CONCLUSIONS

In this situation, choosing to evolve from TURP to the next step of endoscopic treatment, the size-independent anatomic endoscopic enucleation of the prostate is a safe bet. It is now exceedingly feasible when the paradigm of AEEP has changed, due to better learning opportunities and technological and surgical technique modifications that have refined this procedure significantly since its inception.