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

Surgical outcomes of endoscopic enucleation of the prostate in community aging males with or without preoperative urinary retention

OBJECTIVES

This study aims to investigate the surgical outcomes of endoscopic enucleation of the prostate in older males with or without preoperative urinary retention (UR).

MATERIAL AND METHODS

We conducted a study on selected patients with symptomatic benign prostatic hyperplasia (BPH) who underwent either thulium:YAG laser (vela XL) prostate enucleation (ThuLEP) or bipolar plasma enucleation of the prostate (B-TUEP) at the geriatric urology department of our institution. The studied patients were categorized into two groups, namely the UR group and the non-UR group, on the basis of whether they experienced UR in the 1 month preceding their surgery. Their clinical outcomes following prostate endoscopic surgery were evaluated and analyzed.

RESULTS

Our results revealed comparable outcomes for operation time, length of hospital stay, percentage of tissue removed, re-catheterization rate, and urinary tract infection rate within the 1 month between the B-TUEP and ThuLEP surgery groups, regardless of UR history. However, the non-UR B-TUEP group experienced more blood loss relative to the non-UR ThuLEP group (P = .004). Notably, patients with UR exhibited significantly greater changes in IPSS total, IPSS voiding, and prostate-specific antigen values relative to those without UR.

CONCLUSIONS

Both ThuLEP and B-TUEP were effective in treating BPH-related bladder outlet obstruction. Our study identified more pronounced changes in IPSS total, IPSS voiding, and prostate-specific antigens within the UR group. Moreover, the rate of postoperative UR in this group was not higher than that observed in the non-UR group. Our study also revealed that the presumed benefits of laser surgery in reducing blood loss were less pronounced for patients with UR.

Procedural Intervention for Benign Prostatic Hyperplasia in Men ≥ Age 70 Years - A Review of Published Literature

Objective

We set out to review studies reporting on the use of surgical intervention to treat Benign Prostatic Hyperplasia in elderly men ≥70 years of age.

Methods

A systematic literature search was conducted using Scopus, PubMed-MEDLINE, Cochrane, and Wiley Online Library databases including studies published between January 2012 through December 2022. This 10-year interval was chosen given the recent plethora of new modalities that have entered the BPH armamentarium, many of which have been marketed as appropriate for older and high-risk patients. The following database search words were used either individually or in conjunction: "BPH", "elderly", "surgical", "ablation", "resection", "embolization", and "aging".

Results

We identified 28 studies for inclusion in this review. The pros and cons of these modalities are presented, specifically as applicable to an older and higher risk population.

Conclusion

There are a wide variety of surgical procedures available for surgically treating BPH in elderly men with varying states of health. Each of these comes with different risks and benefits, supporting that individualized approaches are important. Long-term data and further studies comparing modalities, specifically as regards the elderly and frail, would enhance our approaches to BPH treatment in this patient population.

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.

Thulium: YAG vs continuous-wave thulium fiber laser enucleation of the prostate: do potential advantages of thulium fiber lasers translate into relevant clinical differences?

PURPOSE

To compare endoscopic enucleation of the prostate using a thulium: yttrium-aluminum-garnet (Tm:YAG) laser and a super-pulsed thulium fiber laser set in continuous-wave (CW) mode, and to evaluate whether theoretical advantages of thulium fiber lasers, related to their shorter wavelength, translate into relevant clinical differences.

METHODS

In total, 110 patients suffering from lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia were randomized to undergo either thulium:YAG laser enucleation of the prostate (ThuLEP) or CW thulium fiber laser enucleation of the prostate (CW-ThuFLEP). Intraoperative and postoperative variables and complications were compared. Micturition improvement was assessed at 3-month follow-up using the International Prostate Symptom Score (IPSS), post-void residual urine (PVR) and maximum flow rate (Qmax). Erectile function was evaluated using the International Index of Erectile Function-5 (IIEF-5).

RESULTS

No significant differences between the ThuLEP and CW-ThuFLEP groups were found in terms of operative time (70.69 vs 72.41 min), enucleation time (50.23 vs 53.33 min), enucleated tissue weight (40.2 vs 41.9 g), enucleation efficiency (0.80 vs 0.79 g/min), catheterization time (2.45 vs 2.57 days), hospital stay (2.82 vs 2.95 days) and hemoglobin drop (1.05 vs 1.27 g/dl). At 3-month follow-up, no significant differences were found in IPSS (5.09 vs 5.81), Qmax (26.51 vs 27.13 ml/s), PVR (25.22 vs 23.81 ml) and IIEF-5 (14.01 vs 14.54).

CONCLUSION

ThuLEP and CW-ThuFLEP were equivalent in relieving patients from LUTS and improving micturition. Theoretical advantages of the TFL, such as shallower penetration depth and improved vaporization capacity, did not translate into relevant perioperative outcomes or clinical differences.

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.

Assessment of Sexual Outcomes in Patients Undergoing Thulium Laser Prostate Surgery for Management of Benign Prostate Hyperplasia: A Systematic Review and Meta-analysis

Background

Thulium laser (Tm:YAG) prostate surgery is a safe and effective procedure with low morbidity and comparable clinical outcomes to those of transurethral resection of the prostate (TURP). However, the sexual function outcomes (erectile and ejaculatory function) have been scarcely studied.

Aim

We aimed to assess the impact of Tm:YAG prostate surgery on sexual outcomes (erectile and ejaculatory function) and compare them with those patients undergoing TURP.

Material and Methods

We searched digital databases like PUBMED, SCOPUS, CENTRAL and EMBASE using relevant keywords to identify comparative studies on TURP and non-comparative studies on Tm:YAG prostate surgery that assessed sexual outcomes. We performed qualitative and quantitative analyses with the extracted data. We carried out a meta-analysis to compare postoperative International Index of Erectile Function (IIEF-5) scores and incidences of retrograde ejaculation (RE) in patients undergoing either Tm:YAG or TURP. The pre-operative and post-operative IIEF-5 scores were pooled to estimate overall scores.

Results

We included 5 comparative and 8 non-comparative studies in this review. We found the postoperative IIEF-5 score improvements to be significantly higher in the Tm:YAG prostate surgery group than in the TURP group with a significant mean difference (MD) of 0.45 (95% CI, 0.18 to 0.72; P = .001). We found no significant associations between the procedures. The pooled OR for the association of RE was estimated at 0.90 (95% CI, 0.50 to 1.60; P = .71; I² = 0%).

Conclusion

Tm:YAG prostate surgery improves erectile function more than TURP, according to our findings. Tm:YAG prostate aided surgery also outperforms TURP in terms of preserving sexual function following surgery.However, We found similar or no difference in incidence of RE between Tm:YAG prostate surgery and TURP.

Bibo L, Hao L, Pang K, et al. Assessment of Sexual Outcomes in Patients Undergoing Thulium Laser Prostate Surgery for Management of Benign Prostate Hyperplasia: A Systematic Review and Meta-analysis. Sex Med 2022;10:100483.

Is thulium laser vapoenucleation of the prostate equally safe and effective in elderly patients? A propensity score matched analysis of early perioperative and functional outcomes

PURPOSE

To evaluate if thulium laser vapoenucleation of the prostate (ThuVEP) is equally safe and effective in a selected cohort of elderly patients when compared to "younger" patients.

MATERIALS AND METHODS

We performed a retrospective analysis of consecutive patients who underwent ThuVEP between September 2018 and February 2020. After application of the inclusion/exclusion criteria, patients were stratified according to the 75 years-old cut-off point suggested by the WHO. Group A included patients ≤75 years-old; Group B included patients >75 years-old. Preoperative assessment included urological consultation, prostate specific antigen (PSA), International Prostate Symptom Score (IPSS) and quality of life index, transrectal ultrasound to estimate prostate volume (PVol), and uroflowmetry to assess preoperative Qmax, Qave and post-void residual volume (PVR). Perioperative and postoperative data were analyzed during 3-month follow-up.

RESULTS

After propensity-score analysis, 51 versus 51 patients were 1:1 matched according to PVol, PSA, Qmax, IPSS and QoL. Patients were comparable at baseline excluding age (65 (IQR 59-70) versus 79 (IQR 77-82) years, Group A versus B, respectively, P-value <.001). No differences were found in terms of hemoglobin drop, complications rate, catheterization time and length of hospital stay. Group A (younger) patients had more significant improvement in 30-days absolute Qmax, Qave and ΔQmax. At 90-days follow-up, the differences between the groups disappeared. Within the 90-days follow-up, no significant differences were found in the readmission rate, with no need of reinterventions.

CONCLUSIONS

In our hands, even in elderly patients affected by BPH, ThuVEP appears to be a safe and effective treatment option.

Clinical Outcome of Endoscopic Enucleation of the Prostate Compared With Robotic-Assisted Simple Prostatectomy for Prostates Larger Than 80 cm3 in Aging Male

This study investigated and compared the surgical outcomes of using endoscopic enucleation (thulium: YAG laser and bipolar plasma; ThuLEP) with robotic-assisted simple prostatectomy (RASP) in the treatment of prostates larger than 80 cm3. Records were obtained for the period from January 2014 to December 2020 for selected patients with BPO who underwent RASP, ThuLEP, or bipolar transurethral enucleation of the prostate (B-TUEP). Patients were excluded if they had active malignant disease, neurogenic bladder, lower urinary tract syndrome for reasons other than BPO, and a history of prostate surgery. Data of 396 patients who underwent B-TUEP, ThuLEP, and RASP were examined. A total of 112 patients met the including criteria, 85 of whom (B-TUEP: 29; ThuLEP: 41; RASP: 15) completed the final visit. The mean operation time and duration of postoperative hospital stays in the RASP group were significantly longer than those of the B-TUEP and ThuLEP groups. Only 1 patient in the RASP group required blood transfusion. The RASP group was superior to the other groups in voiding improvement including Qmax and IPSS voiding score. The pain score of the ThuLEP group after surgery was significantly lower than that of the other two groups during hospitalization, whereas the QoL scores were identical between the three groups at 2 weeks, 3 months, and 6 months post operation. The rates of returning to ER within the first postoperative month did not differ significantly between the three groups, and all the reasons for return involved minor complications that required no additional invasive treatment. These three surgical methods (B-TUEP, ThuLEP, and RASP) are all effective and safe for treating prostates larger than 80 cm3, with each having its particular advantages. B-TUEP requires the shortest operation time, ThuLEP causes the lowest postoperative pain, and RASP results in superior voiding function improvement.

Is thulium laser vapoenucleation of the prostate equally safe and effective in elderly patients? A propensity score matched analysis of early perioperative and functional outcomes

PURPOSE

To evaluate if thulium laser vapoenucleation of the prostate (ThuVEP) is equally safe and effective in a selected cohort of elderly patients when compared to "younger" patients.

MATERIALS AND METHODS

We performed a retrospective analysis of consecutive patients who underwent ThuVEP between September 2018 and February 2020. After application of the inclusion/exclusion criteria, patients were stratified according to the 75 years-old cut-off point suggested by the WHO. Group A included patients < 75 years-old; Group B included patients > 75 years-old. Preoperative assessment included urological consultation, prostate specific antigen (PSA), International Prostate Symptom Score (IPSS) and quality of life index, transrectal ultrasound to estimate prostate volume (PVol), and uroflowmetry to assess preoperative Qmax, Qave and post-void residual volume (PVR). Perioperative and postoperative data were analyzed during 3-month follow-up.

RESULTS

After propensity-score analysis, 51 versus 51 patients were 1:1 matched according to PVol, PSA, Qmax, IPSS and QoL. Patients were comparable at baseline excluding age (65 (IQR 59-70) versus 79 (IQR 77-82) years, Group A versus B, respectively, p-value < 0.001). No differences were found in terms of hemoglobin drop, complications rate, catheterization time and length of hospital stay. Group A (younger) patients had more significant improvement in 30-days absolute Qmax, Qave and ΔQmax. At 90-days follow-up, the differences between the groups disappeared. Within the 90-days follow-up, no significant differences were found in the readmission rate, with no need of reinterventions.

CONCLUSIONS

In our hands, even in elderly patients affected by BPH, ThuVEP appears to be a safe and effective treatment option.

Reasons to go for thulium-based anatomical endoscopic enucleation of the prostate

PURPOSE

To summarize the current evidence and the reasons to go for thulium-based anatomical endoscopic enucleation of the prostate (AEEP).

METHODS

This review discusses the available literature on thulium-based AEEP.

RESULTS

Thulium lasers operate at a wavelength between 1940 and 2013 nm. This wavelength, which has a low penetration depth in water, allows to perform smooth cuts in the prostatic tissue and allows urologists to perform various procedures: resection, vaporization, enucleation, or vapoenucleation of the prostate. Depending on the type of thulium laser, it can be used either in a continuous, or pulsed mode.

CONCLUSION

In recent years, an increasing amount of evidence has described the thulium laser as a minimally invasive and size-independent treatment option for benign prostatic enlargement with excellent long-term results.

Retrospective analysis of the changes in the surgical treatment of benign prostatic hyperplasia during an 11-year period: a single-center experience

The present study aimed to determine whether the number of patients with symptomatic benign prostatic hyperplasia (BPH) who preferred surgery decreased during the past 11 years at our center (West China Hospital, Chengdu, China), and whether this change affected the timing of surgery and the physical condition of surgical patients. This retrospective study included 57 557 patients with BPH treated from January 2008 to December 2018. Of these, 5427 patients were treated surgically. Surgical patients were divided into two groups based on the time of treatment (groups 8–13 and groups 13–18). The collected data comprised the percentage of all patients with BPH who underwent surgery, baseline characteristics of surgical patients, rehabilitation time, adverse events, and hospitalization costs. The surgery rates in groups 8–13 and groups 13–18 were 10.5% and 8.5% (P < 0.001), respectively. The two groups did not clinically differ regarding patient age and prostate volume. The rates of acute urinary retention and renal failure decreased from 15.0% to 10.6% (P < 0.001) and from 5.2% to 3.1% (P < 0.001), respectively. In groups 8–13 and groups 13–18, the mean catheterization times were 4.0 ± 1.7 days and 3.3 ± 1.6 days (P < 0.001), respectively, and the mean postoperative hospitalization times were 5.1 ± 2.4 days and 4.2 ± 1.8 days (P < 0.001), respectively. The incidences of unplanned second surgery and death reduced during the study period. The surgery rate decreased over time, which suggests that medication was chosen over surgery. However, the percentage of late complications of BPH also decreased over time, which indicates that the timing of surgery was not delayed.

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.