Critical review of lasers in benign prostatic hyperplasia (BPH)

Prospective results of the minimally invasive laser enucleation of the prostate (MiLEP)

BACKGROUND

The objective of the present study is to prospectively analyze the prostate enucleation procedure with Holmium Laser using the minimally invasive technique (MiLEP), comparing the outcomes and their variables pre- and postoperatively.

METHODS

We studied men aged 40 years or over, with prostate volumes greater than or equal to 35 cm³ with lower urinary tract symptoms due to BPH. We performed flowmetry and administered the IPSS questionnaire before and 6 months after the MiLEP procedure. The patients were operated on with a 60 W Holmium Laser (Cyber-Ho Quanta System®) using 54 W of power (energy 1.8 J and frequency of 30 Hz). Enucleation was performed using the en bloc technique with early sphincter release. After enucleation, the tissue was morcellated using a 22 Fr morcescope (RZ-Medizintechnik GmbH, Tuttlingen, Germany) and Piranha (Richard Wolf) morcellator. The final Hemostasis after morcelation was made using laser with 30wW power, energy at 1,0 joules and frequency at 30 Hertz. Student's T test and Man-Whitney was used to statistical analysis (p < 0.05).

RESULTS

After selection we submitted 73 patients (mean age= 68.2 years) to MiLEP procedure with a follow up of 6 months. The prostate volume presented an average of 94.53 cm³ (65 to 112 cm³, SD = 5.363) preoperatively. The urinary continence rate after the procedure was greater than 95% after 1 week and 99% in the 1st month. All patients were continent after 6 months. The IPSS questionnaire before (mean = 21.18 points/SD = 6.557) and after (mean = 7.92 points/SD = 2.408) the MiLEP had statistical significance (p < 0.001). The flowmetry(ml/s) before (9.02/SD = 2.842) and after (21.07/SD = 6.228) the MiLEP had statistical significance (p < 0.001). The average time of the procedure was 78.5 min and the bladder catheter was removed after 18 h in mean. In 4 patients (5.8%) we observed hematuria and in 1 case (1.47%) the patient needs urinary catheterization.

CONCLUSION

MiLEP is a safe and effective procedure, with significant improvement in urinary flow and symptoms in the short term. Although the results of this study were satisfactory and the urinary incontinence rate was lower compared to HoLEP data found in the literature, multicenter studies with longer follow-up are needed to confirm these findings.

Early Hemorrhagic Complications after Holmium Laser Enucleation of the Prostate in Patients Undergoing Antithrombotic Therapy: A Retrospective Analysis from a High-Volume Centre

Objectives: This study intends to evaluate early hemorrhagic complications after holmium laser enucleation of the prostate (HoLEP) in patients undergoing antithrombotic therapy. Methods: The data of patients undergoing HoLEP between January 2020 and February 2023 were retrospectively analysed. Patients were clustered into three groups: (1) no antithrombotic therapy; (2) antiplatelet (AP) therapy; and (3) anticoagulant (AC) therapy. Pre-, intra-, and post-operative variables were compared. A logistic regression model was built to identify predictors of post-operative hemorrhagic complications. Results: A total of 338 patients underwent HoLEP, including 212 who received no antithrombotic therapy (62.7%), 76 who received AP (22.5%), and 50 who received AC (14.8%). Intra-operative outcomes did not show any significant difference. A significant difference was observed in terms of catheterisation time (p = 0.001) and length of hospital stay (p < 0.001), favouring patients who did not receive antithrombotic therapy. Early post-operative hemorrhagic complications (<30 days) included re-admissions for macrohematuria (3.5%), transfusions (2.4%), and endoscopic re-interventions for bleeding (1.2%). A comparison between the groups showed significant differences for both re-admission (p < 0.001) and transfusion rates (p = 0.01), favouring patients who did not receive antithrombotic therapy. The re-intervention rate did not show any significant difference between the groups (p = 0.1). In multivariate analysis, AC therapy was identified as an independent predictor of those complications (OR 4.9, p = 0.005). Conclusions: HoLEP is a safe and effective procedure for patients undergoing antithrombotic therapy. Both AP and AC therapies are associated with longer catheterisation and hospitalisation times. AC therapy is shown to be a predictor of minor post-operative hemorrhagic complications.

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.

Evaluation of the learning curve for Thulium laser enucleation of the prostate in a contemporary cohort

PURPOSE

To assess the learning curve of Thulium laser enucleation of the prostate (ThuLEP) of a single surgeon.

METHODS

Hundred patients suffering from benign prostatic hyperplasia were treated by the same surgeon. In all cases, a well-trained urologist was present in the operating room. Patients urinary function was assessed preoperatively using the International Prostate Symptoms Score (IPSS), maximum flow rate and Post-Void Residual volume. Preoperative prostate volume was recorded. Enucleation and morcellation efficiency and complication rate were evaluated. Patients were divided into 5 cohorts of 20 consecutive cases to assess changes in outcomes through time.

RESULTS

Mean age of patients was 73.1 years (SD 17.5) and mean prostate volume was 89.7 ml (SD 55.1). Overall, mean enucleation and morcellation efficiency were 1.7 (SD 2.9) and 5.1 (SD 2.7) g/min. A statistically significant increase in enucleation efficiency was observed when comparing cohort 1 vs 2 (0.9 vs 1.3 g/min, p = 0.03) and cohort 2 vs 3 (1.3 vs 1.7 g/min, p = 0.02). A statistically significant increase in morcellation efficiency was observed when comparing cohort 1 vs 2 (2.8 vs 3.7 g/min, p = 0.02) and cohort 2 vs 3 (3.7 vs 4.9 g/min, p = 0.03). In both cases, no significant differences were observed when comparing the following cohorts. Complication rate showed no significant differences throughout the caseload.

CONCLUSIONS

In our single-surgeon experience, we observed a learning curve of nearly 60 cases for the ThuLEP procedure in presence of a well-trained surgeon. Complication rate was low from the beginning of surgical experience.

Laser excision of urethral mesh erosion: a 10-year experience

PURPOSE

To review our 10-year experience with laser excision for urethral mesh erosion (UME) of mid-urethral slings (MUS).

METHODS

Following Institutional Review Board approval, the charts of female patients with endoscopic laser excision of UME were retrospectively reviewed. Demographics, clinical presentation, surgical history, pre- and post-operative Urinary Distress Inventory-6 scores and quality of life ratings, operative reports, and outcomes were obtained from electronic medical records. UME cure was defined as no residual mesh on office cystourethroscopy 5-6 months after the final laser excision procedure.

RESULTS

From 2011 to 2021, 23 patients met study criteria; median age was 56 (range 44-79) years. Twenty (87%) had multiple prior urogynecologic procedures. Median time from MUS placement to presentation with UME-related complaints was 5.3 [interquartile range (IQR) 2.3-7.6] years. The most common presenting symptom was recurrent urinary tract infection (rUTI) (n = 10). Median operating time was 49 (IQR 37-80) minutes. Median duration of follow-up was 24 (IQR 12-84) months. Fourteen (61%) required more than 1 laser excision procedure for UME. Although 5 were asymptomatic (22%), new (n = 5) or persistent (n = 8) urinary incontinence was the most common symptom on follow-up (57%).

CONCLUSION

UME presenting symptoms are highly variable, necessitating a high index of suspicion in patients with a history of MUS, especially in the case of rUTI. Endoscopic laser excision is a minimally invasive, brief, safe, outpatient procedure with a high UME cure rate.

Treatment Algorithm for Management of Benign Prostatic Obstruction: An Overview of Current Techniques

The management of benign prostatic obstruction (BPO) should involve a treatment algorithm that takes into account prostate size, and patient's symptoms and preference with the aim of helping with urinary symptoms and enhance quality of life. The diagnostic assessment for men with lower urinary tract symptoms (LUTS) should be comprehensive to help choose the best management strategy. Strategies from lifestyle modifications to medical treatment with alpha blockers and/or 5-alpha-reductase inhibitors to surgical procedures can all be used in the management algorithm. Surgical management ranges from transurethral resection of prostate (TURP) to minimally invasive surgical therapies (MIST) including laser therapies such as Holmium laser enucleation (HoLEP) and photoselective vaporisation (PVP), aquablation, Rezūm system, prostate artery embolisation (PAE), prostatic urethral lift (PUL), temporary implantable nitinol device (iTind) and Optilume BPH catheter system. BPO is a common urological condition that has a significant impact on quality of life and economic burden globally and is likely to become increasingly prevalent with an ageing population. Selecting the most appropriate treatment modality will depend on the individual patient preferences, availability of resources, cost, anatomical factors and the goals of treatment.

Predictors of early catheter replacement after HoLEP. Results from a high-volume laser center

INTRODUCTION

The aim of the study was to investigate clinical and surgical factors associated with early catheter replacement in patients treated with Holmium Laser Enucleation of the Prostate (HoLEP).

MATERIALS AND METHODS

Data of patients treated with HoLEP at our Institution by a single surgeon from March 2017 to January 2021 were collected. Preoperative variables, including non-invasive uroflowmetry and abdominal ultrasonography (US), were recorded. Bladder wall modifications (BWM) at preoperative US were defined as the presence of single or multiple bladder diverticula or bladder wall thickening 5 mm. Clinical symptoms were assessed using validated questionnaires. Only events occurred within the first week after catheter removal were considered.

RESULTS

Overall, 305 patients were included, of which 46 (15.1%) experienced early catheter replacement. Maintenance of anticoagulants/antiplatelets (AC/AP) therapy at surgery (p=0.001), indwelling urinary catheter (p=0.02) and the presence of BWM (p=0.001) were more frequently reported in patients needing postoperative re-catheterization. Intraoperative complications (p=0.02) and median lasing time (p=0.02) were significantly higher in this group. At univariate analysis, indwelling urinary catheter (p=0.02), BWM (p=0.01), ongoing AC/AP therapy (p=0.01) and intraoperative complications (p=0.01) were significantly associated with early catheter replacement. At multivariate analysis, indwelling urinary catheter (OR: 1.28; p=0.02), BWM (OR: 2.87; p=0.001), and AC/AP therapy (OR: 2.21; p=0.01) were confirmed as independent predictors of catheter replacement.

CONCLUSIONS

In our experience the presence of indwelling urinary catheter before surgery, BWM and the maintenance of AC/AP therapy were shown to be independent predictors of early catheter replacement after HoLEP.

Surgical reintervention requirements following GreenLight PVP: A single-center experience using three different laser device models

Objective

To assess the incidence, risk factors, and timing of specific causes of reoperations following PVP.

Material and Methods

A retrospective analysis of data on men who underwent GreenLight PVP between 2004 and 2019 in a single center and required surgical intervention for bladder neck contracture (BNC), urethral stricture (US), or persistent/recurrent prostate adenoma.

Results

The overall rate of reoperations was 13.8% during a 61-month median follow-up of 377 patients. Reoperations were due to BNC, US, and adenoma in 7.7%, 5.6%, and 4.8% of cases, respectively. The median interval until reoperation for US (11 months) was significantly shorter. None of the risk factors had any relevance to US. In patients who underwent reoperation for BNC, lasing time and energy were significantly lower, and the prostate volume was smaller; however, the multivariate analysis only identified shorter lasing time as a predictor. In patients who had reoperation for persistent/recurrent adenoma, the PSA was increased, while the prostate volume was non-significantly high, and performance by less-experienced surgeons was associated with a higher rate of reoperations (p < 0.05). A longer lasing time predicted an increased risk of reoperation for adenoma in multivariate analysis.

Conclusions

An unselective utilization of PVP may result in a relatively high rate of reoperations. The correlation of BNC with shorter lasing time may imply a higher risk after PVP of smaller prostates. A longer lasing time predicts an increased risk of reoperation due to persistent/recurrent adenoma, which may be related to higher prostate volumes and inefficient PVP by less-experienced surgeons.

Thulium laser vaporesection of prostates with volume exceeding 100 cm3 as an alternative to HoLEP and ThuLEP

The aim of this study is to evaluate the outcomes of thulium laser vaporesection of prostates with volume exceeding 100 cm³. In the present prospective study, patients with infra-vesical urinary obstruction due to a prostate with volume exceeding 100 cm³ underwent endoscopic vaporesection using thulium laser. In this procedure, prostate chips were resected without morcellation. The technical aspects of surgery, admission time, post-operative catheter time and post-operative complications were analyzed. Flowmetry was performed combined with prostatic ultrasound in the follow-up. Between March 2010 and November 2018, 156 cases with benign prostatic hyperplasia (BPH; volume >100 cm³) were treated. The mean patient age was 67.8 years (48.4-86.6 years), and the mean prostatic volume was 137 cm³ (100-436 cm³). The mean length of hospitalization was 1.48 days (1-8 days), and the mean post-operative catheter time was 5.1 (1-17). Three cases (1.9%) required readmission due to hematuria. The mean follow-up time was 31.2 months (standard deviation = 27.7). Urethral stricture was observed in 14 cases (9%), with bulbar urethra being the most frequent finding. Urinary tract infection was observed in 11 cases (7.1%), and urinary incontinence was observed in 5 cases. The mean peak urinary flow at 12 and 24 months was 26.9 ± 12.5 and 23.9 ± 11.7 ml/s, respectively, and the mean urinary flow during the final follow-up at 41 months was 21.6 ml/s. Thulium laser vaporesection is a valid alternative to open prostatectomy, HoLEP and ThuLEP in patients with large BPH. Urinary flow remained elevated throughout the follow-up.

Temperature change during laser upper-tract endourological procedures: current evidence and future perspective

PURPOSE OF REVIEW

To examine the most recent data on temperatures produced during laser lithotripsy and to provide several strategies for maintaining lower values and reducing the risk of complications during endourological treatment.

RECENT FINDINGS

Endourologists have access to a wide range of alternatives with the help of the holmium: yttrium-aluminum-garnet (Ho:YAG), thulium: yttrium-aluminum-garnet (TM:YAG), and thulium fiber laser (TFL) that compose a robust and adaptable laser lithotripsy armamentarium. Nevertheless, the threat of thermal damage increases as the local temperature rises with high total power. Most endourologists are not familiar with normal and pathological temperature ranges, how elevated temperatures affect perioperative problems, or how to avoid them.

SUMMARY

Increased temperatures experienced during laser lithotripsy may affect the course of the healing process. All lasers display a safe temperature profile at energies below 40 W. At equal power settings, Ho:YAG, Tm:YAG, and TFL lasers change the temperature comparably. Shorter on/off laser activation intervals, chilled irrigation, open irrigation systems, and UASs all aid in maintaining acceptable temperatures.

Simple and Convenient Method for Assessing the Severity of Bleeding during Endoscopic Prostate Surgery and the Relationships between Its Corresponding Surgical Outcomes

Bleeding during endoscopic prostate surgery is often overlooked, and appropriate measurement techniques are rarely applied. We proposed a simple and convenient method for assessing the severity of bleeding during endoscopic prostate surgery. We determined the factors affecting bleeding severity and whether they affected the surgical results and functional outcomes. Records from March 2019 to April 2022 were obtained for selected patients who underwent endoscopic prostate enucleation through either 120-W Vela XL Thulium:YAG laser or bipolar plasma enucleation of the prostate. The bleeding index was measured using the following equation: irrigant hemoglobin (Hb) concentration (g/dL) × irrigation fluid volume (mL)/preoperative blood Hb concentration (g/dL) × enucleated tissue (g). Our research revealed that patients who underwent surgery employing the thulium laser, those aged over 80 years, and those with a preoperative maximal flow rate (Qmax) of more than 10 cc/s experienced less surgical bleeding. The patients' treatment outcomes differed depending on the severity of the bleeding. Enucleating prostate tissue was easier in the patients with less severe bleeding, who also had a lower risk of developing urinary tract infections and an improved Qmax.

Functionalized Carbon Nanoparticles as Theranostic Agents and Their Future Clinical Utility in Oncology

Over the years, research of nanoparticle applications in pre-clinical and clinical applications has greatly advanced our therapeutic and imaging approaches to many diseases, most notably neoplastic disorders. In particular, the innate properties of inorganic nanomaterials, such as gold and iron oxide, as well as carbon-based nanoparticles, have provided the greatest opportunities in cancer theranostics. Carbon nanoparticles can be used as carriers of biological agents to enhance the therapeutic index at a tumor site. Alternatively, they can also be combined with external stimuli, such as light, to induce irreversible physical damaging effects on cells. In this review, the recent advances in carbon nanoparticles and their use in cancer theranostics will be discussed. In addition, the set of evaluations that will be required during their transition from laboratory investigations toward clinical trials will be addressed.

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.

Comparison of Emergency Room Visits and Rehospitalization for Bleeding Complications following Transurethral Procedures for the Treatment of Benign Prostatic Hyperplasia: A Population-Based Retrospective Cohort Study

Background: The postoperative bleeding complications associated with laser surgery of the prostate and transurethral resection of the prostate (TURP) were compared. Methods: We used the Taiwan National Health Insurance Research Database to conduct an observational population-based cohort study. All eligible patients who received transurethral procedures between January 2015 and September 2018 were enrolled. Patients who received laser surgery or TURP were matched at a ratio of 1:1 by using propensity score matching, and the association of these procedures with bleeding events was evaluated. Results: A total of 3302 patients who underwent elective transurethral procedures were included. The multivariable Cox regression analysis revealed that diode laser enucleation of the prostate (DiLEP) resulted in significantly higher emergency room risks within 90 days after surgery due to clot retention than the Monopolar transurethral resection of the prostate (M-TURP) (Hazard Ratio: 1.52; 95% Confidence Interval [CI], 1.06–2.16, p = 0.022). Moreover, GreenLight photovaporization of the prostate (PVP) (0.61; 95% CI, 0.38–1.00 p = 0.050) and thulium laser vaporesection of the prostate (ThuVARP) (0.67; 95% CI, 0.47–0.95, p = 0.024) resulted in significantly fewer rehospitalization due to clot retention than did M-TURP. No significant increase in blood clots were observed in patients using comedications and those with different demographic characteristics and comorbidities. Conclusions: Among the investigated six transurethral procedures for Benign prostatic hyperplasia, PVP and ThuVARP were safer than M-TURP because bleeding events and clot retention were less likely to occur, even in patients receiving anticoagulant or antiplatelet therapy. However, DiLEP and holmium laser enucleation of the prostate (HoLEP) did not result in fewer bleeding events than M-TURP.

Adaptive optics system for a short wavelength mid-IR laser based on a Shack-Hartmann wavefront sensor and analysis of thermal noise impacts

We present an adaptive optics (AO) system for a 1.94-µm laser source. Our system consists of a home-made Shack-Hartmann wavefront sensor and silver-coated bimorph deformable mirror operating in a closed-loop control scheme. The wavefront sensor used an uncooled vapor phase deposition PbSe focal-plane array for the actual light sensing. An effect of thermal afterimage was found to be reducing the centroid detection precision significantly. The effect was analyzed in detail and finally has been dealt with by updating the background calibration. System stability was increased by reduction of control modes. The system functionality and stability were demonstrated by improved focal spot quality. By replacing some of the used optics, the range of the demonstrated mid-IR AOS could be extended to cover the spectral range of 1-5 µm. To the best of our knowledge, it is the first AO system built specifically for mid-IR laser wavefront correction.

Intraoperative and postoperative outcomes of thulium laser enucleation versus bipolar resection in the transurethral treatment of benign prostatic hyperplasia: a meta-analysis

To compare the intraoperative and postoperative outcomes of thulium laser enucleation of the prostate (ThuLEP) vs bipolar transurethral resection of the prostate (B-TURP) in treating patients with benign prostatic hyperplasia (BPH). Clinical trials of ThuLEP and B-TURP in treating BPH were searched systematically by using PubMed, Cochrane Library databases, and EMBASE (until May 2021). The Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist was followed. The datum was calculated by Review Manager version 5.3.0. Four articles including 782 patients were studied in this analysis. The analysis discovered that there was no significant difference in operative time and percentage of tissue removed between ThuLEP and B-TURP. But the intraoperative irrigated volume and postoperative hemoglobin (Hb) decrease in the ThuLEP group was significantly less compared with the B-TURP group. The catheterization time and hospitalization duration in the B-TURP group was significantly longer than that in the ThuLEP group. Compared with those before treatment, the micturition indexes of the two groups improved significantly. But no significant difference was identified between ThuLEP and B-TURP for the variation of international prostate symptom score, quality of life, maximum flow rate, and post-void residual. By analyzing the postoperative complications, there were no significant discrepancies between ThuLEP and B-TURP in the incidence of blood transfusion, recatheterization, transient incontinence, bladder neck contracture, and urethral stricture. The micturition indexes and clinical symptoms were significantly improved after ThuLEP and B-TURP for patients with BPH. However, ThuLEP was more effective than B-TURP in terms of intraoperative irrigated volume, postoperative Hb decrease, catheterization time, and hospitalization duration.

Does Holmium laser enucleation of the prostate (HoLEP) still have a steep learning curve? Our experience of 100 consecutive cases from Turkey

AIM

The aim of our study is to examine the learning curve of HoLEP and to discuss our results in the light of the literature.

METHODS

100 patients who had LUTS resistant to medical treatment and complicated BPH to whom HoLEP procedure had been administered regardless of the size of the prostate in the last 1 year were analysed retrospectively. To evaluate the learning curve, the patients were classified into 4 main groups of 25 consecutively operated patients beginning from the first case. The 4 main groups were divided into 2 subgroups including patients who had prostate volume below or above 80 grams.

RESULTS

The mean age of the 100 patients who had HoLEP was 64.5 years. The mean prostate volume was 99.1 cc (45-281 cc). When those with prostate smaller than 80 g are examined, Enucleation efficiency was 0.76 g/min (0.46-0.97 g/min) and Morcellation efficiency was 3.07 g/min (3.34-4 g/min). When those with prostates larger than 80 g are examined, Enucleation efficiency was 0.89 g/min (0.66-1.04 g/min) and Morcellation efficiency was 4.01 g/min (3.93-4.25 g/min). These two parameters were statistically and significantly different in all the 4 groups (p < 0.05).

CONCLUSIONS

HoLEP still has a steep learning curve. It is necessary to reach the number of cases of 25-50 to reach fundamental experience.

A Modified Technique of Thulium Laser Enucleation for Benign Prostatic Hyperplasia With Non-morcellator Approach

Background: Until recently, most enucleation techniques of the prostate were performed with the application of morcellator. We introduce a modified enucleation technique of thulium laser with non-morcellator approach, which is about incising and vaporizing remaining prostate tissue instead of a morcellator.

Methods: A retrospective evaluation of 223 patients undergoing ThuLEP from January 2014 to December 2015 was performed in our institution. One hundred five of the patients used morcellator while the other 118 used non-morcellator approach. All patients were assessed with the International Prostate Symptom Score (IPSS), quality of life (Qol), ultrasonography, serum prostate-specific antigen (PSA), maximal urine flow rate (Qmax), and postvoid residual urine volume (PVR). We reassessed these parameters at 1-, 3-, 6-, and 12-months after operation. Operative time, perioperative, and postoperative complications were also recorded.

Results: Significant improvement was noted in the IPSS, QoL, Qmax, and PVR in both groups at the 12-month follow-up, and assessment showed no differences in these parameters between the two groups. Comparisons of the total operation time and enucleation time demonstrated no significant differences between the two groups. Our non-morcellator approach needed more time to incise and vaporize the enucleated tissue compared to morcellation when the prostate volume was about 40–80 ml (p < 0.05), while it showed a significant lower rate of superficial bladder injury than using morcellator (p < 0.05). There were no significant differences in other complications between the two groups (p > 0.05).

Conclusions: Our modified technique is a safe and effective procedure for the treatment of BPH avoiding the potential complications caused by morcellator.

Endoscopic enucleation of the prostate (EEP). The same but different-a systematic review

Purpose

Various techniques for EEP exist. They differ by surgical steps and the source of energy. It is assumed that the latter is of minor importance, whereas adherence to the anatomical enucleation template determines the postoperative result. So far, no systematic review highlights the differences between the energy sources in use for anatomical EEP. This study will address selfsame topic.

Methods

A systematic review of the literature was completed on September 1st, 2020. Studies comparing HoLEP, ThuLEP, DiLEP, or BipolEP with TUR-P providing 12 months of postoperative follow-up were included. Two frequentist network meta-analyses were created to compare the techniques of EEP indirectly.

Results

31 studies, including 4466 patients, were found eligible for our meta-analysis. Indirect pairwise comparison showed differences in surgery time between BipolEP and HolEP (MD − 16.72 min., 95% CI − 27.75 to − 5.69) and DiLEP and HoLEP (MD − 22.41 min., 95% CI − 39.43 to − 5.39). No differences in the amount of resected prostatic tissue, major and minor complications and postoperative catheterization time were found. The odds for blood transfusions were threefold higher for BipolEP than for HoLEP (OR 3.27, 95% CI 1.02–10.5). The difference was not statistically significant when comparing prospective trials and matched-pair analysis only (OR 3.25, 95% CI 0.94–11.18). The Qmax 12 months after surgery was 2 ml/sec. higher for BipolEP than for DiLEP (MD  2.00, 95% CI 0.17–3.84) and 1.94 ml/sec. lower for DiLEP than for HoLEP (MD − 1.94, 95% CI − 3.65 to − 0.22).

Conclusion

The energy source used for EEP has an impact on the intervention itself. BipolEP promotes surgical efficiency; laser techniques lower the risk of bleeding.

Registry

This meta-analysis is registered in the PROSPERO international prospective register registry with the registration number CRD42020205836.

Feasibility, safety, and efficacy of ultrasound-guided transperineal laser ablation for the treatment of benign prostatic hyperplasia: a single institutional experience

PURPOSE

To evaluate the feasibility, safety, and efficacy of ultrasound-guided transperineal laser ablation (TPLA) as a new minimally invasive surgical therapy (MIST) for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Under local anesthesia and conscious sedation up to two laser fibers for each prostatic lobe were inserted under US-guidance by a percutaneous approach. TPLA was performed using a continuous wave diode laser (SoracteLite-EchoLaserX4) able to generate a light-induced thermal heating and subsequent coagulative necrosis of the prostatic tissue. Patients were evaluated at 3, 6, and 12 months after TPLA.

RESULTS

Twenty-two consecutive patients were prospectively enrolled (median age 61.9 years). All procedures were well tolerated and no procedural complications were recorded. Median catheterization time was 7 days, while the median hospitalization time was 1 day. Three out of twenty-two patients (13.6%) experienced acute urinary retention and two (9.1%) of them urinary tract infection requiring major antibiotic treatment. At 3, 6, and 12 months, median prostate volume significantly decreased by a - 21.3%, - 29%, and - 41%, respectively. At the same time point, median IPSS was 8 (- 63.6%), 5 (- 74%), and 6 (- 75%), while median QoL score was 1 in all the scheduled timepoints of follow-up. The median postoperative Qmax at 3, 6, and 12 months improved by + 57.8%, + 98%, and + 115.8%, respectively. Ejaculatory function was preserved in 21 out of 22 patients (95.5%).

CONCLUSIONS

TPLA of the prostate appears to be a promising MIST for BPH. Long-term results and comparative studies against standard treatments are warranted before implementations of this technique in the urologist's armamentarium.

Tissue effects of a newly developed diode pumped pulsed Thulium:YAG laser compared to continuous wave Thulium:YAG and pulsed Holmium:YAG laser

Purpose

The objective of this study is to evaluate the laser-tissue effects of laser radiation emitted by a newly developed high frequency pulsed Tm:YAG laser in comparison to the continuous wave Tm:YAG laser and the pulsed Ho:YAG laser.

Methods

Ex-vivo experiments were performed on freshly slaughtered porcine kidneys in a physiological saline solution. Experiments were performed using two different laser devices in different settings: A Tm:YAG laser was operated in a pulsed mode up to 300 Hz and in a continuous wave (CW) mode. Results were compared with a 100 W standard pulsed Ho:YAG laser system. Comparative tissue experiments were performed at 5 W, 40 W and 80 W. The incision depth and the laser damage zone were measured under a microscope using a calibrated ocular scale.

Results

Increased laser power resulted in increased incision depth and increased laser damage zone for all investigated lasers in this set-up. The Ho:YAG created the largest combined tissue effect at the 5 W power setting and seems to be the least controllable laser at low power for soft tissue incisions. The CW Tm:YAG did not incise at all at 5 W, but created the largest laser damage zone. For the new pulsed Tm:YAG laser the tissue effect grew evenly with increasing power.

Conclusion

Among the investigated laser systems in this setting the pulsed Tm:YAG laser shows the most controllable behavior, insofar as both the incision depth and the laser damage zone increase evenly with increasing laser power.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03634-4.

Comparison of thermal injury depth of the prostate between plasma kinetic electrode, holmium laser, green light laser and Nd:YAG laser

OBJECTIVE

PlasmaKinetic electrode, holmium laser, green laser and Nd: YAG laser have been used for treating benign prostate hyperplasia (BPH). To compare the pathological changes of thermal injury by these different devices.

MATERIAL AND METHODS

Tissues donated by several male patients with prostate cancer who have written a consent. The tissues were diced them into small squares with 1 cm long on a side. Cutting experiments were performed in the normal temperature circulating water environment, the specimens of the prostate tissue were fixed in 4% formalin. The sections were then undergone HE and NADH-NBT staining.

RESULTS

The penetration depths and coagulation zone of tissue after treatment were ranked as Nd:YAG laser > plasma Kinetic electrode > green light laser > holmium laser respectively.

CONCLUSION

Holmium laser might have less thermal damage to tissue, although it still needs more research including clinical study. Our results will provide clinicians with some alternative basis for the application.

Is Thulium laser enucleation of prostate an alternative to Holmium and TURP surgeries - A systematic review?

To assess efficacy and safety of Thulium laser enucleation of prostate (ThuLEP) for benign prostatic hyperplasia. It is a systemic review based on a comprehensive search of PubMed, Cochrane, and Google scholar databases from inception to 31 March 2020. All studies in English evaluating ThuLEP as well as those comparing it with Transurethral resection of prostate (TURP) and Holmium Laser enucleation of prostate (HoLEP) were enrolled. The primary outcome was to evaluate operative, postoperative, and functional outcomes (IPSS, QoL, Qmax, PVR) in patients undergoing ThuLEP. Secondary outcome was to compare operative, postoperative, and functional outcomes with TURP and HoLEP in comparative studies. Fourteen studies with a total of 2,562 patients were included in this review. 2,034 underwent ThuLEP, 349 underwent TURP, and remaining 139 had HoLEP. We found that ThuLEP is safe as well as efficacious in all age groups as well as across all prostate sizes and with all four functional outcomes (IPSS, QoL, Qmax, PVR) revealing marked improvement at 3, 6, 12, and 24 months. Compared to TURP and HoLEP, Thulep is non-inferior in terms of operative and functional outcomes and, in fact, is associated with lesser catheterization duration as well as shorter hospital stay. Further, Thulium fiber laser (TFL) has advantages of being light weight, having high frequency, less fiber degradation, and less energy consumption, making it cost effective for operational and maintenance purpose. ThuLEP is a safe, efficacious, and cost-effective procedure for BPE.

A prospective multicenter randomized comparison between Holmium Laser Enucleation of the Prostate (HoLEP) and Thulium Laser Enucleation of the Prostate (ThuLEP)

PURPOSE

To compare intra and perioperative parameters between HoLEP and ThuLEP in the treatment of benign prostatic hyperplasia and to evaluate clinical and functional outcomes of the two procedures with a 12-month follow-up.

METHODS

A prospective randomized study was performed on 236 consecutive patients who underwent ThuLEP (n = 115), or HoLEP (n = 121) in three different centers. Intra and perioperative parameters were analyzed: operative time, enucleated tissue weight, irrigation volume, blood loss, catheterization time, hospital stay and complications. Patients were evaluated preoperatively and 3 and 12 months postoperatively with the international prostate symptom score (IPSS), the quality of life (QoL) score, post-void residual volume (PVR), PSA and maximum flow rate (Q_max).

RESULTS

Preoperative variables in each study arm did not show any significant difference. Compared to HoLEP, ThuLEP showed similar operative time (63.69 vs 71.66 min, p = 0.245), enucleated tissue weight (48.84 vs 51.13 g, p = 0.321), catheterization time (1.9 vs 2.0 days, p = 0.450) and hospital stay (2.2 vs 2.8 days, p = 0.216), but resulted in less haemoglobin decrease (0.45 vs 2.77 g/dL, p = 0.005). HoLEP presented a significantly higher number of patients with postoperative acute urinary retention and stress incontinence. No significant differences were found in PSA, Q_max, PVR, IPSS and QoL score during follow-up.

CONCLUSION

ThuLEP and HoLEP both relieved lower urinary tract symptoms equally, with high efficacy and safety. ThuLEP detemined reduced blood loss and early postoperative complications. Catheterization time, enucleated tissue, hospital stay, operative time and follow-up parameters did not show any significant difference.

Ejaculation-sparing thulium laser enucleation of the prostate (ES-ThuLEP): outcomes on a large cohort

PURPOSE

To assess the effects of a new ejaculation-sparing thulium laser enucleation of the prostate (ES-ThuLEP) technique on sexual functions and micturition, in patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH) and to evaluate how the surgical technique of ES-ThuLEP can lead to ejaculation preservation.

METHODS

A prospective study was carried out between January 2015 and January 2018 on patients with surgical indication for BPH, who wished to preserve ejaculation. The patients were treated with ES-ThuLEP and were evaluated before and 3 and 6 months after surgery. Three validated questionnaires (ICIQ-MLUTSsex, IIEF-5 and IPSS) were used to assess changes in ejaculation, erectile function and urinary symptoms. Uroflowmetry (Qmax and Qavg), post-void residual volume and voided volume were also evaluated, to assess micturition improvement. Patients with moderate to severe erectile dysfunction were excluded. Statistical analysis was performed with the Student's t test, Chi-square test and logistic regression analysis.

RESULTS

Two hundred and eighty three patients were enrolled. Ejaculation was spared in 203 and 219 patients at 3 and 6 months after surgery. No significant differences were observed between erectile function before and after surgery: baseline IIEF-5 = 16.2 ± 4.47 vs 16.7 ± 2.9 (p = 0.419) and 17.7 ± 3.2 (p = 0.410) at 3 and 6 months. Significant improvement in urinary symptoms was achieved: baseline IPSS = 19.4 ± 7.24 vs 5.8 ± 4.3 (p = 0.032) and 3.9 ± 4.1 (p = 0.029) at 3 and 6 months.

CONCLUSION

ES-ThuLEP effectively preserved ejaculation in over two thirds of the patients without compromising micturition improvement or erectile function. ES-ThuLEP could be a valid treatment option for BPH in young and sexually active men.

Introduction of a New Score to Assess Surgical Efficiency in Holmium Laser Enucleation of the Prostate

INTRODUCTION

While holmium laser enucleation of the prostate (HoLEP) is accepted as safe and efficient, a long learning curve is considered the main reason for its slow adoption in clinical practice. So far, no standardized and easy-to-use parameter has been implemented to measure surgical experience or efficiency which could be useful for training and quality control purposes. The aim of the present study was to evaluate the learning curves of 2 HoLEP beginners and to identify applicable efficiency outcome measures as well as potentially complicating factors in performing HoLEP.

PATIENTS AND METHODS

A total of 594 patients treated by HoLEP between September 2016 and May 2019 were enrolled. The procedures were initially performed by 1 HoLEP expert (reference surgeon); over time, 2 further surgeons were trained. Baseline characteristics, enucleation weight, morcellation and enucleation time, laser energy usage, and postoperative results were recorded prospectively. The learning curves of the 2 novices were analyzed and compared to the reference surgeon. Logistic regression analyses were performed to identify predictors for postoperative grade ≥2 complications.

RESULTS

Median enucleation ratio and complication rates did not significantly alter along the learning curves. Median enucleation speed and laser energy application of the 2 novices significantly improved with growing experience. Combining these variables, we introduced the "HoLEP efficiency score" (HES) which demonstrated the most appropriate value to reflect the surgical experience and efficiency. The median HES for the reference surgeon was 82.8 min kJ/g. For the 2 novices, a drop from 130 and 124.4 min kJ/g by -57 and -30%, respectively, was observed. Among several tested clinical parameters, the presence of prostate cancer (p = 0.047) and the surgical caseload (p < 0.001) influenced the HES. On multivariable logistic regression, American Society of Anesthesiologists score and prostate cancer were independent predictors for grade ≥2 complications (p = 0.002, odds ratio [OR] 2.042 and p = 0.038, OR 1.940).

CONCLUSION

We introduce the HES as an objective and measurable tool to quantify surgical efficiency. In clinical practice, the HES may find application in training and quality control purposes as well as in comparing surgical modifications and hardware. Patients with prostate cancer seem to be more challenging cases and have a higher risk for complications, and may preferably be treated by experienced surgeons.

Endoscopic enucleation for prostate larger than 60 mL: comparison between holmium laser enucleation and plasmakinetic enucleation

PURPOSE

To compare perioperative and functional outcomes of two different energy sources, holmium laser and bipolar current for endoscopic enucleation of prostate larger than 60 mL.

METHODS

A prospective, monocentric, comparative, non-randomized study was conducted including all patients treated for prostate larger than 60 mL, measured by transrectal ultrasound. Patients were assigned to each group based on the surgeons' practice. Perioperative data were collected (preoperative characteristics, operating, catheterization and hospitalization times, hemoglobin loss, complications) and functional outcomes (IPSS, IPSS Quality of Life (QoL), PSA) at 3 months and 1 year.

RESULTS

100 patients were included in each group from October 2015 to March 2018. No differences between HoLEP and plasma groups were observed at baseline, except for mean IPSS score, IPSS QoL score and preoperative PVR that were significantly higher in the HoLEP group. Operating time (142.1 vs 122.4 min; p = 0.01), catheterization time (59.6 vs 44.4 h; p = 0.01) and hospitalization time (2.5 vs 1.8 days; p = 0.02) were significantly shorter in the plasma group. Complication and transfusion rate were no significantly different between HoLEP and plasma. No significant differences were observed concerning functional outcomes at 3 months and 1 year. The urinary incontinence rate was higher 21.1% vs 6.4% (p < 0.01) at 3 months in HoLEP group, but no difference was observed at 1 year.

CONCLUSION

Holmium and plasma are both safe and effective for endoscopic treatment for prostate larger than 60 mL. Operating, catheterization and hospitalization times were significantly shorter in the plasma group. The complication rate and functional outcomes were not significantly different.

Clinical outcome of transurethral enucleation of the prostate using the 120-W thulium Laser (Vela™ XL) compared to bipolar transurethral resection of the prostate (TURP) in aging male

This study compared the surgical outcomes of the 120-W Thulium laser (Vela™ XL) enucleation of the prostate and bipolar transurethral resection of the prostate (TURP) in terms of efficacy, safety, and improvements of quality of life (QoL) in patients with benign prostate hyperplasia (BPH). Records were obtained from January 2014 to September 2018 for selected patients with symptomatic BPH who underwent 120-W Thulium laser (Vela™XL) prostate enucleation and bipolar TURP in our institution. All the patients selected met the surgical criteria for TURP and had received medical treatment for at least 3 months. Patients were excluded if their ECOG performance status was >1, if they had active malignant disease, of if they had a history of prostate surgery or reconstruction surgery of the urinary system. Patients decided which treatment option would be performed. Both the procedures were conducted by a single surgeon. Clinical outcomes such as changes in the International Prostate Symptom Score (IPSS) score, urodynamic parameters, drug consumption, pain scores, and QoL were evaluated. The rate of urinary tract infection, recatheterization, additional analgesic requirement, return to the emergency department for treatment, and other surgical complications was analyzed and compared between the two cohorts. A total of 276 patients met the inclusion criteria. Among them, 141 patients received bipolar TURP, where as 135 decided to receive laser vaporesection. No significant difference was observed in age, PSA level, prostate volume, and comorbidities between the two cohorts. Pre-operative (pre-op) urodynamic parameters were also identical, except that the laser surgery group had a higher rate of admission with a urinary catheter (24.4% vs. 14.2%, p=0.044). The operating time was longer in the laser surgery group (79.3 minutes vs. 62.4 minutes, p<0.001). However, enucleation using the Thulium laser was superior to bipolar TURP in terms of post-operative (post-op) pain status, including the numeric rating scale of pain, rate of additional narcotic use, and oral analgesic requirement. Compared with bipolar TURP, laser enucleation achieved a higher improvement in the QoL score at post-op follow-up at 2 weeks and 3 months. Nevertheless, the complication rate, changes in IPSS score, Qmax, and post-op medication-free survival were statistically identical in the two cohorts. Our data revealed that compared with bipolar TURP, 120-W Thulium laser (Vela™ XL) enucleation of the prostate achieved lower post-op pain and higher improvement in the short-term QoL of patients after surgery.

Efficacy and Safety of 1470-nm Diode Laser Enucleation of the Prostate in Individuals With Benign Prostatic Hyperplasia Continuously Administered Oral Anticoagulants or Antiplatelet Drugs

OBJECTIVE

To evaluate the efficacy and safety of 1470-nm Diode Laser Enucleation of the Prostate (DiLEP) in patients with benign prostatic hyperplasia continuously receiving oral anticoagulants or antiplatelet drugs.

METHODS

From January 2016 to June 2017, 144 patients were submitted to 1470-nm DiLEP, including 49 (34.0%) continuously administered anticoagulants or antiplatelet drugs per os due to cardiac and/or cerebrovascular diseases (group A), while 95 (66.0%) were not (group B). Evaluation was performed preoperatively, and at postoperative 3, 6, and 12 months, respectively. Patient baseline features, operative data, perioperative complications, and postsurgical outcomes were assessed.

RESULTS

Both groups had comparable preoperative parameters, except age (77.3 ± 7.5 vs 73.2 ± 8.8 years, P = .007). Meanwhile, surgical time, sodium decrease, catheterization duration, and hospital stay markedly differed between the 2 groups. In comparison with group B, group A patients had statistically higher blood loss (14.9 ± 7.3 g/L vs 10.2 ± 7.0 g/L, P < .001) and increased bladder irrigation time (21.1 ± 10.9 hours vs 16.1 ± 9.0 hours, P = .004). One case required blood transfusion in group A, because of moderate anemia preoperatively. Both groups showed similar blood transfusion and complication rates. International Prostate Symptom Score, quality of life score, maximum flow rate, and postvoid residual were markedly improved in both groups at 3-, 6-, and 12-month follow-up postoperatively compared with baseline values. However, no statistically significant differences were observed between the 2 groups in various assessment parameters at follow-up (P > .05).

CONCLUSION

These findings demonstrated that 1470-nm DiLEP is efficient and safe in benign prostatic hyperplasia cases receiving continuous oral anticoagulant or antiplatelet drugs. Anticoagulation therapy did not significantly influence the results and complication rates.

Effect of 5α-reductase inhibitors on the efficiency of thulium:yttrium-aluminium-garnet (RevoLix®) vaporesection for treating benign prostatic hyperplasia

Purpose

Preoperative use of 5α-reductase inhibitors (5ARIs) may cause fibrosis of the prostate tissue and reduce the efficiency of thulium laser surgery for treating benign prostate hyperplasia (BPH). Thus, we investigated the effects of preoperative 5ARI use in this setting.

Materials and Methods

This retrospective study examined 184 patients who underwent thulium laser surgery for BPH during 2012–2017. Patients were grouped according to their 5ARI use in order to compare their preoperative and intraoperative characteristics and subsequent outcomes. Surgical efficiency was assessed using vaporesection efficiency. The total operation time, vaporesection time and prostate volume change were measured.

Results

The 5ARI+ group included 83 patients (45.1%) and the 5ARI− group included 101 patients (54.9%). There were no significant differences in the two groups' preoperative characteristics, postoperative prostate size, thulium laser energy use, or prostate volume reduction rate. However, relative to the 5ARI− group, the 5ARI+ group had a significant shorter total operative time (65.0 min vs. 70.0 min, p=0.013) and a significantly shorter vaporesection time (48.0 min vs. 54.0 min, p=0.014), which resulted in significantly higher vaporesection efficiency in the 5ARI+ group (0.66 mL/min vs. 0.51 mL/min, p<0.001). Both groups exhibit significant improvements in their quality of life score and International Prostate Symptom Score during the 12-month follow-up.

Conclusions

In contrast with our expectations, the preoperative use of 5ARI increased the efficiency of thulium laser surgery for BPH. Thus, it may not be necessary to stop 5ARI treatment before performing thulium laser surgery in this setting.

The role of laparoscopic experience on the learning curve of HoLEP surgery: A questionnaire-based study

OBJECTIVE

Holmium laser enucleation of the prostate (HoLEP) is an established method for treating benign prostatic obstruction. Nonetheless, its steep learning curve limits its wide distribution. The purpose of the present study was to demonstrate the impact of laparoscopic experience on HoLEP learning curve by evaluating the association between learning curves of surgeons performing both laparoscopy and HoLEP surgery.

MATERIAL AND METHODS

A questionnaire was prepared to identify surgeon's experience on laparoscopy and HoLEP, as well as their learning curves. This questionnaire was then distributed via e-mail to 110 urologists who are actively involved in endourology/laparoscopy.

RESULTS

Of the 110 urologists, 80 (72.7%) responded and completed the questionnaire. Of the 80 surgeons, 47 (58.8%) reported that they had completed the HoLEP learning curve with <20 cases. Moreover, 33 (41.2%) reported that they were able to complete the learning curve by performing >20 cases. Completion of the HoLEP learning curve in <20 cases was reached at 1.3%, 13.8%, and 43.8% by beginner, moderate skilled, and experienced laparoscopists, respectively (p<0.001).

CONCLUSION

Laparoscopic experience appears to be beneficial for surgeons while learning HoLEP. Highly experienced laparoscopic surgeons have a shorter HoLEP learning curve.

A review of surgery and new technology procedures for the management of benign prostatic obstruction

Level of evidence: Not applicable for this review article.

Holmium laser enucleation of the prostate versus thulium laser enucleation of the prostate for the treatment of large-volume prostates > 80 ml: 18-month follow-up results

PURPOSE

To compare the perioperative and functional outcomes of holmium laser enucleation of the prostate (HoLEP) and thulium laser enucleation of the prostate (ThuLEP) for the treatment of large-volume benign prostatic hyperplasia (BPH) (> 80 ml).

METHODS

A total of 116 consecutive patients with BPH were randomized to be treated surgically with either HoLEP (n = 58) or ThuLEP (n = 58), following the classical three-lobe enucleation technique. Follow-up was assessed at 1, 3, 6, 12 and 18 months after surgery.

RESULTS

At 18 months, the lower urinary tract symptom index was improved significantly in both groups compared with the baseline values. The operative time (78.4 ± 8.0 vs. 71.4 ± 6.4 min) and enucleation time (61.2 ± 5.4 vs. 56.4 ± 8.4 min) were significantly shorter for ThuLEP compared to HoLEP (both p < 0.001). There were no significant differences between the two groups regarding morcellation time, resected weight, hemoglobin decrease, catheter time and hospital stay (p > 0.05). The HoLEP and ThuLEP groups had equivalent International Prostate Symptom Scores (3 [3-3] vs. 3 [3-3], p = 0.776), quality of life (1 [1-2] vs. 2 [1-2], p = 0.809), Qmax (25.3 ± 4.8 ml/s vs. 24.7 ± 4.4 ml/s, p = 0.470), postvoid residual urine (PVR) (6.1 [2.6-20.8] vs. 7.7 [3.1-22.8] ml, p = 0.449) and PSA (0.84 ± 0.32 vs. 0.90 ± 0.34 ml, p = 0.309) at 18 months postoperatively.

CONCLUSION

Both HoLEP and ThuLEP relieve lower urinary tract symptoms in a comparable way with high efficacy and safety. ThuLEP was statistically superior to HoLEP in operation time and enucleation time, although the differences were clinically negligible.

Effective treatment of post-intubation subglottic stenosis in children with holmium laser therapy and cryotherapy via flexible bronchoscopy

IMPORTANCE

Post-intubation subglottic stenosis (SGS) in children can be life threatening. Definitive treatment varies and lacks a universally accepted approach.

OBJECTIVE

We performed a prospective study to assess the safety and feasibility of holmium laser combined with cryotherapy delivered via flexible bronchoscopy for the treatment of post-intubation SGS in children.

METHODS

This study involved all patients with post-intubation SGS seen at the Interventional Pulmonology Department of Beijing Children's Hospital between July 2014 and December 2016. Holmium laser treatment and cryotherapy was then performed under flexible bronchoscopy, whose parents refused to accept the alternative standard treatment of tracheotomy and balloon dilation under direct laryngoscopy.

RESULTS

Sixteen patients with post-intubation SGS were included in this study. Ages ranged from 2 months to 12.25 years old. According to the Cotton-Myer grading system, three cases were Grade II, 12 cases were Grade III, and one case was Grade IV. According to the McCaffrey system, eight cases were Stage 1, two cases were Stage 2, and six cases were Stage 3. The average number of procedures was 4.88. Fifteen of the 16 patients achieved clinical cure. One patient achieved clinical improvement. The average treatment course duration was 55.31 days. No severe complications were seen. Post-treatment clinical symptoms, endoscopic findings and quality of life showed marked improvement.

INTERPRETATION

Our study supports the conclusion that holmium laser treatment combined with cryotherapy via flexible bronchoscopy appears to be a safe and feasible treatment for post-intubation SGS in children.

Comparison of bipolar plasmakinetic transurethral enucleation and resection of prostate gland in patients receiving anticoagulants and/or platelet aggregation inhibitors

BACKGROUND

The aim of this study was to evaluate the safety and efficacy of bipolar plasmakinetic enucleation of the prostate (BPEP) and bipolar plasmakinetic transurethral resection of prostate (B-TURP) for patients on oral anticoagulants (OA) and/or platelet aggregation inhibitors (PAI) with benign prostatic obstruction (BPO) and having a gland size of >60 g.

METHODS

Patient database of our hospital for the period of May 2012 to September 2017 was retrospectively reviewed for BPH patients with a gland size of >60 g who either underwent BPEP or B-TURP and were on OA and/or PAI. Patient demographic, perioperative, and follow-up data were analyzed.

RESULTS

There were no significant differences between the two surgical groups preoperatively. The mean operative time was lower in the BPEP group however, no statistical difference was found between them (P=0.77). There was significant difference in the mean resected tissue weight (52.11±17.92 vs. 77.19±17.78 g, P value ≤0.001), irrigation time and total hospital stay in favor of BPEP group. The blood loss observed in the B-TURP group and BPEP group was 2.57±0.36 and 1.45±0.44 g/dL, respectively, which was statistically significant (P<0.033). Eight and three patients of B-TURP and BPEP groups needed blood transfusion respectively. All patients were followed up for 12 months postoperatively. Both groups resulted in a significant improvement from baseline in terms of IPSS, QoL, Q-max, and PVRU volume values. No significant difference was found between them, however.

CONCLUSIONS

Both procedures are safe and effective options in patients who are on OA and/or PAI but BPEP is better in terms of low clot retention rate, less irrigation time and decreased hospital stay.

Transurethral thulium laser enucleation versus resection of the prostate for treating benign prostatic hyperplasia: a retrospective study

This study aimed to compare the clinical outcomes between transurethral thulium laser enucleation of the prostate (ThuLEP) and transurethral thulium laser resection of the prostate (ThuLRP) for treating benign prostatic hyperplasia (BPH). From May 2014 to August 2015, 212 patients underwent ThuLRP and 188 patients underwent ThuLEP. The ThuLEP group was further divided into two subgroups according to the ways the prostate was taken out. The perioperative parameters were recorded and analyzed. The international prostate symptom score (IPSS), quality-of-life (QoL) score, maximum flow rate (Qmax), and postvoid residual urine volume (PVR) in both groups were estimated and compared 3, 6, and 12 months after surgery. No significant difference was observed between the groups in terms of irrigated time, irrigated volume, catheterization time, and hospital stay. However, the significantly lower hemoglobin drop was observed in the ThuLRP group compared with the ThuLEP group. The ThuLEP group with a morcellator required a shorter operation time for patients with large prostate volume (> 60 mL) compared with the ThuLRP and ThuLEP groups without a morcellator. During 12 months of follow-up, IPSS, Qmax, QoL, and PVR improved significantly without significant differences between the groups. No severe complications were reported; however, the occurrence of transient urge incontinence was higher after ThuLEP compared with ThuLRP, and the proportion of urinary tract infection after surgery was higher in ThuLRP than in ThuLEP. ThuLRP and ThuLEP are safe and efficient for treating patients with symptomatic BPH. ThuLRP offers advantages in terms of minimal blood loss.

Holmium laser versus thulium laser enucleation of the prostate: a matched-pair analysis from two centers

Background

The aim of our study was to compare perioperative and functional outcomes of two different prostatic laser enucleation techniques performed in two high-volume centers: 100 W holmium laser enucleation of the prostate (HoLEP) (Lyon, France) and 110 W thulium laser enucleation of the prostate (ThuLEP) (Varese, Italy).

Materials and Methods

A nonrandomized, observational, retrospective and matched-pair analysis was performed on two homogeneous groups of 117 patients that underwent prostate laser enucleation in the HoLEP or ThuLEP centers between January 2015 and April 2017, following the classical 'three lobes' enucleation technique. The American Society of Anesthesiologists (ASA) score and prostate volume were the main parameters considered for matching the patients between the two groups. Patients on anticoagulant therapy, with documented detrusor hypoactivity or hyperactivity or with the finding of concurrent prostate cancer were excluded from the study. Follow up was assessed at 3, 6 and 12 months after surgery.

Results

Median enucleation and morcellation time was 75.5 and 11.5 min, respectively, in the HoLEP group versus 70.5 and 12 min, respectively, in the ThuLEP group (p = 0.001 and 0.49, respectively). Enucleated adenoma weight was comparable (44 g versus 45.6 g, p = 0.60). Energy index (3884.63 versus 4137.35 J/g, p = 0.30) and enucleation index (0.57 versus 0.6 g/min, p = 0.81) were similar in the two groups. Catheterization time was comparable (1 versus 1 day; p = 0.14). The International Prostate Symptom Score and Quality of Life score significantly decreased, as well as maximal urinary flow rate. Median prostate-specific antigen (PSA) drop 1 year after surgery was 2.1 ng/ml in the HoLEP group (-52.83%) versus 1.75 ng/ml in the ThuLEP group (-47.85%) (p = 0.013).

Conclusion

Both HoLEP (100 W) and ThuLEP (110 W) relieve lower urinary tract symptoms in a comparable way with high efficacy and safety, with negligible clinical differences.

Follow-up of Temporary Implantable Nitinol Device (TIND) Implantation for the Treatment of BPH: a Systematic Review

PURPOSE OF REVIEW

The purpose of the present systematic review is to offer a narrative synthesis of the available literature regarding the role of the temporary implantable nitinol device (TIND) (Medi-Tate®; Medi-Tate Ltd., Or Akiva, Israel) for the treatment of benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS), specifically focusing on the follow-up data.

RECENT FINDINGS

Current available evidences are limited in this topic. Sample size of patients available for analysis is small. Moreover, the duration of follow-up period is intermediate and longer follow-up is required. At the available 3 years follow-up, the TIND implantation is safe, effective, and well tolerated. The extended follow-up of the first and only available cohort of patients who underwent TIND for LUTS related to BPH corroborated previous literature findings. Further studies are required in order to assess the durability of TIND outcomes over a longer follow-up, to better define the indications of this approach, and to demonstrate the advantages of second-generation device over the first.

Dual-wavelength-assisted thermal hemostasis for treatment of benign prostate hyperplasia

Laser treatment on a large size of prostate gland often encounters significant bleeding that can prolong the entire procedure and cause urinary complications. The current study investigates the feasibility of dual-wavelength (532 and 980 nm) application to achieve rapid hemostasis for 532-nm laser prostatectomy. Porcine kidney and bleeding phantom models were tested to quantify the degree of the irreversible tissue coagulation and to estimate the time for the complete hemostasis, respectively. The ex vivo kidney testing verifies that the dual-wavelength created up to 40% deeper and 25% wider coagulation regions than a single wavelength does. The bleeding phantom testing demonstrates that due to the enhanced thermal effects, the simultaneous irradiation yields the complete photocoagulation (~11 seconds) whereas 532 or 980 nm hardly stops bleeders. Numerical simulations validate that the combined optical-thermal characteristics of both the wavelengths account for the augmented thermal coagulation. The dual-wavelength-assisted coagulation can be a feasible treatment to entail the rapid hemostasis and to facilitate the laser prostatectomy in an effective manner.

3-Year follow-up of temporary implantable nitinol device implantation for the treatment of benign prostatic obstruction

OBJECTIVES

To report 3-year follow-up results of the first implantations with a temporary implantable nitinol device (TIND^® ; Medi-Tate Ltd., Or Akiva, Israel) for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

In all, 32 patients with LUTS were enrolled in this prospective study. The study was approved by the local Ethics Committee. Inclusion criteria were: age >50 years, International Prostate Symptom Score (IPSS) ≥10, peak urinary flow (Q_max ) <12 mL/s, and prostate volume <60 mL. The TIND was implanted within the bladder neck and the prostatic urethra under light sedation, and removed 5 days later in an outpatient setting. Demographics, perioperative results, complications (according to Clavien-Dindo classification), functional results, and quality of life (QoL) were evaluated. Follow-up assessments were made at 3 and 6 weeks, and 3, 6, 12, 24 and 36 months after the implantation. The Student's t-test, one-way analysis of variance and Kruskal-Wallis tests were used for statistical analyses.

RESULTS

At baseline, the mean (standard deviation, sd) patient age was 69.4 (8.2) years, prostate volume was 29.5 (7.4) mL, and Q_max was 7.6 (2.2) mL/s. The median (interquartile range, IQR) IPSS was 19 (14-23) and the QoL score was 3 (3-4). All the implantations were successful, with a mean total operative time of 5.8 min. No intraoperative complications were recorded. The change from baseline in IPSS, QoL score and Q_max was significant at every follow-up time point. After 36 months of follow-up, a 41% rise in Q_max was achieved (mean 10.1 mL/s), the median (IQR) IPSS was 12 (6-24) and the IPSS QoL was 2 (1-4). Four early complications (12.5%) were recorded, including one case of urinary retention (3.1%), one case of transient incontinence due to device displacement (3.1%), and two cases of infection (6.2%). No further complications were recorded during the 36-month follow-up.

CONCLUSIONS

The extended follow-up period corroborated our previous findings and suggests that TIND implantation is safe, effective and well-tolerated, for at least 36 months after treatment.

Holmium Laser enucleation of the prostate (HoLEP) versus Transurethral Resection of the Prostate (TURP)

OBJECTIVE

to evaluate the effectiveness and applicability of Holmium laser enucleation of the prostate (HoLEP) - in the treatment of benign prostatic hyperplasia (BPH) - in comparison to transurethral resection of the prostate (TURP).

METHODS

patients with symptomatic prostatic hyperplasia and candidates for surgical treatment were selected. Both procedures were explained and they had choosen HoLEP or TURP. At the hospital were collected: age, date of birth, international prostate symptom score, urinary peak flow rate, prostate volume, post-voiding residual urine, globular volume and serum PSA. At the procedure operating time, morcellating time (HoLEP), bladder mucosal injury and intercurrences were collected. At the first postoperative day, globular volume and sodium. Besides that were observed the catheter indwelling time and hospital stay and after 90 days, urinary peak flow rate and international prostate symptom score. Statistical analisys have been done partially by Sinpe(r) and also by a professional team.

RESULTS

twenty patients in HoLEP group and 21 at TURP were operated. Baseline urinary peak flow rate was 8 ml/s in both groups and preoperative international prostate symptom score was 22 in HoLEP and 20 in TURP, very similar. Operative time was 85 minutes in HoLEP and 60 in TURP, p<0.05. Hospital stay was 47 hours for HoLEP and 48 hours to TURP, p<0.05. At 90 day the urinary peak flow rate was raised to 21.5 ml/s in HoLEP group and to 20 ml/s in TURP and the median of international prostate symptom score had been reduced to score 3 in both groups.

CONCLUSION

HoLEP is a feasible technique and is as effective as TURP on symptomatic prostatic hyperplasia surgical treatment.

Bipolar Plasma Enucleation of the Prostate (B-TUEP) in Benign Prostate Hypertrophy Treatment: 3-Year Results

OBJECTIVE

To investigate numerous endoscopic techniques that have been described for the treatment of benign prostate enlargement. Plasma-button enucleation of the prostate (B-TUEP) is a successful treatment option because the large surface creates a fast enucleation process, vaporization, and concomitant hemostasis. The aim of this study was to evaluate the efficacy of bipolar button electrode transurethral adenoma enucleation (B-TUEP) in saline solution. The second end point was to determine the change of International Prostate Symptom Score (IPSS), post-void residual urine, International Index of Erectile Function, transrectal ultrasound gland volume evaluation, and prostate-specific antigen.

MATERIALS AND METHODS

Between July 2011 and March 2012, 50 consecutive patients underwent B-TUEP in our facility, all performed by a single surgeon (R.G.). All patients were preoperatively assessed with maximum urinary flow rate, single-question quality of life assessment, IPSS and the International Index of Erectile Function questionnaires, transrectal ultrasound gland volume evaluation, prostate-specific antigen, and post-void residual urine.

RESULTS

We observed a significant improvement at 12, 24, and 36 months in terms of maximum urinary flow rate (22.3 ± 4.74 mL/s, 23.2 ± 0.30 mL/s, and 23.6 ± 1.26 mL/s, respectively, P <.01) and quality of life (5.28 ± 0.97, 5.69 ± 0.90, and 5.73 ± 0.87). IPSS and IEEF scores improved significantly (P <.05). Gland volume evaluation and post-void residue decreased (P <.001). The prostate-specific postoperative antigen levels were 0.76 ± 0.61 ng/mL, 0.7 ± 0.51 ng/mL, and 0.62 ± 0.18 ng/mL, at 12, 24, and 36 months, respectively. Two patients (4%) had persistent bladder outlet obstruction requiring reoperation.

CONCLUSION

After 3-year follow-up, B-TUEP represents an effective, durable, and safe form of surgical intervention. B-TUEP is an alternative treatment for symptomatic benign prostate enlargement.