Is Holmium Laser Enucleation of the Prostate a Good Surgical Alternative in Benign Prostatic Hyperplasia Management? A Review Article

Patient reported outcome and quality of life measured by a simple questionnaire in patients with symptomatic benign prostate hyperplasia treated by holmium laser enucleation of the prostate (HoLEP)

Introduction

Holmium Laser Enucleation of the Prostate (HoLEP) is established as an effective transurethral treatment option for LUTS due to BPH with improved postoperative outcome. The aim of this study was to evaluate the medium-term results by patient reported outcome measurement and to detect potential risk factors for postoperative complications or impaired outcome.

Methods

We performed a retrospective single-center cohort study including all patients undergoing HoLEP in the study center between April 2019 and December 2021. Therefore, perioperative parameters and postoperative outcome was documented and all patients were asked for their outcome (PROM), complications, IPSS, QoL and changes in sexual and continence function by a questionnaire at a single time point.

Results

In the study period, a total of 541 patients with a mean age of 72.5 ± 8.4 years were treated by HoLEP in the study center. 71.7% of the questionnaires were returned after a mean observation period of 14.9 ± 6.3 month. 91% of the patients reported to the single-timepoint questionnaire reporting a good satisfaction with the procedure and a low postoperative complication rate. The international prostate symptom score could be reduced significantly to 6.2 ± 5.7 (preoperative 19.0 ± 7.2; p < 0.001). Patients with an ASA score ≥ 3, prostate volume > 80 ml, medication with platelet inhibitors or DOAK or preoperative need of an indwelling catheter didn't show an increased complication rate.

Conclusion

The overall satisfaction with the procedure and its results are high. We could not identify any independent risk factors for postoperative complications after HoLEP. The used questionnaire is a simple tool for postoperative patient reported outcome measurement with a good correlation to clinical parameters.

The Efficacy and Safety of 'Inverted Omega En-bloc' Holmium Laser Enucleation of the Prostate (HoLEP) for Benign Prostatic Hyperplasia: A Size-Independent Technique for the Surgical Treatment of LUTS

PURPOSE

To evaluate the safety, efficiency, and size-dependency of the 'Inverted omega En-bloc (Ʊ)' holmium laser enucleation of the prostate (HoLEP) in benign prostate hyperplasia (BPH) with lower urinary tract symptoms.

MATERIALS AND METHODS

A retrospective analysis of 716 consecutive patients who underwent HoLEP under the care of a single surgeon from 2014-2021. These patients were treated using the 'Inverted omega En-bloc' HoLEP technique for BPH. The patients were divided into 3 groups: Group 1 (<40 mL, n=328), Group 2 (40-60 mL, n=221), and Group 3 (≤60 mL, n=167). Perioperative parameters, safety, and functional outcomes were assessed and analyzed.

RESULTS

The perioperative parameters, like enucleation time (45.8±26.9 min), morcellation time (13.2±47.5 min), and catheterization duration (1.6±1.2 d) significantly differed to favor smaller prostate sizes (p<0.01). Significant improvements in the IPSS (total, voiding, storage, and quality of life), post-void residual urine, and maximum flow rate were observed 3 months post-HoLEP and continued during the 1-year follow-up period in all groups (p<0.01). The postoperative complications included urethral stricture in 11 patients (1.5%), bladder neck contracture in 12 (1.7%), urinary incontinence in 14 (2.0%), and bladder injuries in 4 (0.6%). Bladder neck contractures occurred only in Group 1. The postoperative surgical management for complications included urethral sounding (n=9, 1.3%), endoscopic internal urethrotomy (n=2, 0.3%), and re-HoLEP for bladder neck contractures in (n=12, 1.7%). The rate of re-HoLEP for regrowing adenomas was 15 (2.1%). Postoperative medications exceeding 6 months were α-blocker (n=22, 3.1%), cholinergics (n=16, 2.2%), anticholinergics (n=58, 8.1%), antidiuretics (n=18, 2.5%), and daily PDE5 inhibitor (n=38, 5.3%). Thirty-four patients (4.7%) had postoperative incidental prostate cancer.

CONCLUSIONS

The inverted omega En-bloc HoLEP technique is safe and effective for the treatment of BPH. Moreover, 'Inverted omega En-bloc' HoLEP is a size-independent and effective method for all prostate sizes.

Robot-assisted radical prostatectomy following holmium laser enucleation of the prostate: perioperative, functional, and oncological outcomes

Robot-assisted radical prostatectomy with previous holmium laser enucleation of the prostate is challenging, and few studies have analyzed its perioperative, functional, and oncological outcomes. Here we retrospectively evaluated 298 robot-assisted radical prostatectomies, including 25 with and 273 without previous holmium laser enucleation of the prostate, performed in 2015-2022. Regarding perioperative outcomes, operative and console times were significantly longer in the previous holmium laser enucleation of the prostate group. In contrast, the estimated blood loss was similar between groups, and there were no transfusions or intraoperative complications. Multivariable Cox hazard regression analysis of the functional outcomes of postoperative urinary continence showed that body mass index, intraoperative bladder neck repair, and nerve sparing were independently associated factors, whereas a history of holmium laser enucleation of the prostate was not. Similarly, a history of holmium laser enucleation of the prostate was not associated with biochemical recurrence; however, positive surgical margins and seminal vesicle invasion were independent risk factors of biochemical recurrence. Our findings revealed that robot-assisted radical prostatectomy after holmium laser enucleation of the prostate was safe and raised no concerns of postoperative urinary incontinence or biochemical recurrence. Therefore, robot-assisted radical prostatectomy may be a treatment option for patients with prostate cancer after holmium laser enucleation of the prostate.

Surgical outcomes of low-power thulium laser enucleation of prostates >80 g. One-year of follow-up

Introduction

The aim of this study was to assess the effectiveness of low-power thulium (30 W) and the duration necessary to eliminate adenomas at the level of the surgical capsule, as well as its impact on postoperative urinary and sexual function.

Material and methods

Patients with symptomatic benign prostatic hyperplasia (BPH), who had ThuLEP between December 2019 and March 2022 and had a prostate size >80 mL and had not responded to the medication therapy, were included. The prostate size, prostate-specific antigen (PSA), enucleation and morcellation times, postoperative International Prostate Symptom Score (IPSS), and International Index of Erectile Function-5 (IEFF-5) records at 1, 3, 6, and 12 months were among the information gathered.

Results

The average age of the 80 patients who received ThuLEP was 66.7 ±6.4 years, with a mean prostate volume of 112.65 ±19.3 mL. The mean duration for enucleation was 71 ±11 min. At the initial follow-up after one month, the mean IPSS was 8.012 ±1.78 mL and the mean Qmax enhancement was 30.16 ±4 mL s-1. In contrast to baseline, our findings demonstrated a substantial improvement in postoperative urgency and urgency urinary incontinence (UUI) (p = 0.005) but no meaningful variation in IIEF-5 score at the 12-month follow-up.

Conclusions

Low-power ThuLEP is worthwhile for therapeutic use because it effectively treats patients with large prostates with satisfactory urinary and sexual effects.Clinical trials .gov ID: NCT05494944.

Detection rate and variables associated with incidental prostate cancer by holmium laser enucleation of the prostate

OBJECTIVES

Holmium laser enucleation of the prostate is well-established and effective for bladder outlet obstruction due to benign prostatic hyperplasia. The objective of this study was to examine the detection rate of incidental prostate cancer by holmium laser enucleation of the prostate and variables associated with them.

METHODS

A total of 612 patients were enrolled. We retrospectively examined the detection rate of incidental prostate cancer and perioperative variables associated with them.

RESULTS

Forty-nine of 612 patients were diagnosed with incidental prostate cancer. Univariate logistic regression analysis showed that higher prostate-specific antigen density (odds ratio 3.34, 95% confidence interval 1.02-10.94, P = 0.05), higher prostate-specific antigen density of the transition zone (odds ratio 2.28, 95% confidence interval 1.02-5.09, P = 0.04), and findings of the prostate cancer on magnetic resonance imaging (peripheral zone: odds ratio 4.71, 95% confidence interval 1.70-13.1, P = 0.003; transition zone: odds ratio 3.46, 95% confidence interval 1.74-6.86, P < 0.001; peripheral and transition zones: odds ratio 6.00, 95% confidence interval 1.51-23.8, P = 0.01) were significantly associated with incidental prostate cancer. Multivariate logistic regression analysis showed that findings of the prostate cancer on magnetic resonance imaging (peripheral zone: odds ratio 4.36, 95% confidence interval 1.49-12.8, P = 0.001; transition zone: odds ratio 3.54, 95% confidence interval 1.75-7.16, P < 0.001; peripheral and transition zones: odds ratio 6.14, 95% confidence interval 1.53-24.5, P = 0.01) was an independent risk factor for incidental prostate cancer.

CONCLUSION

The detection rate of incidental prostate cancer was 8.0%, and findings of the prostate cancer on magnetic resonance imaging were an independent predictive factor for incidental prostate cancer.

Robotic-assisted simple prostatectomy versus holmium laser enucleation of the prostate for large benign prostatic hyperplasia: a single-center preliminary study in Korea

Background

Holmium laser enucleation of the prostate (HoLEP) and robotic-assisted simple prostatectomy (RASP) are the two most important therapeutic modalities for large benign prostatic hyperplasia. However, there are currently no studies comparing these two treatments in a Korean setting. In this study, the authors seek to compare the safety and efficacy associated with these procedures.

Methods

The authors retrospectively analyzed 59 male patients who underwent HoLEP (n = 26) or RASP (n = 33) at single center. The following preoperative data were compared: age, the International Prostatic Symptom Score (IPSS), transrectal ultrasonography, uroflowmetry, and hemoglobin. Intraoperative data included operation time and specimen weight. Postoperative data included change in IPSS, uroflowmetry, and hemoglobin. Length of stay, catheterization time, and complications were also reviewed.

Results

No significant differences between the two groups were found in terms of age, total prostate, and transitional volume. Postoperatively, both groups showed similar improvement in the maximum flow rate, post-void residual urine, IPSS, and quality of life. Intraoperatively, there were no differences regarding operation time and resected prostate volume. Catheter removal time and length of stay were significantly shorter in the HoLEP group than the RASP group. In addition, postoperative hemoglobin changes were significantly lower in the HoLEP group. However, incontinence rates at 1 month and 2 months postoperative in the RASP group were lower than the HoLEP group.

Conclusions

Both HoLEP and RASP can produce excellent postoperative outcomes. However, catheter removal time, length of stay, and hemoglobin changes were more favorable in the HoLEP group. On the other hand, postoperative incontinence was more favorable in the RASP group. These factors must be heavily considered when deciding surgical the method for large benign prostatic hyperplasia.

“Fenestration and Tunnel Method” a Modification for the Holmium Laser Transurethral Prostatectomy of Large-Volume Prostates >80 ml: A Retrospective Study Based on 1-Year Follow-Up

The purpose of this study was to promote the holmium laser enucleation of the prostate (HoLEP) technology for large-volume prostates (>80 ml) and compare it with the traditional method, we modified the technique and applied this technology to clinical practice. A retrospective study comprising 118 patients who underwent HoLEP surgery from February 2018 to December 2019 was conducted in our center. Group A consisted of 57 patients with large-volume prostate (>80 ml) who received modified “fenestration and tunnel method” from February 2019 till December 2019, while group B consisted of 61 patients who received the traditional trivalvular operation method from February 2018 to December 2018 for comparison. Control subjects are selected such that they match the cases concerning certain characteristics, and perioperative data, voiding outcomes, and complications were evaluated at 1- and 12-month follow-up. The international prostatic symptomatic score (IPSS), quality of life (QoL), and maximum flow rate (Qmax) at 1 month and 12 months were both significantly improved compared with the preoperative baseline, and no significant differences were found between Groups A and B. The mean enucleation time, operation time, catheter indwelling duration, and hemoglobin decrease during the operation of Group A showed superiority compared with Group B (p<.05). The modified “fenestration and tunnel method” of HoLEP was statistically superior to the traditional trivalvular method in terms of the operation time, enucleation time, catheter indwelling duration, and hemoglobin decrease. For large-volume prostates (>80 ml), modified HoLEP was suggested to be a better treatment option.

Surgical Complications in the Management of Benign Prostatic Hyperplasia Treatment

PURPOSE OF REVIEW

There are a variety of treatment options for men with symptomatic benign prostatic hyperplasia (BPH); transurethral resection of the prostate (TURP) remains the gold standard surgical treatment. The field continues to evolve with the introduction of new energy and laser technologies, increasing adoption of enucleation techniques, in addition to the advent of minimally invasive surgical technologies (MIST) that enable office-based treatments. The choice in surgical management has become very nuanced depending on a variety of patient and anatomic factors. There continues to be high success rates for surgical treatment of BPH; however, the risk profiles vary across the various surgical treatments. We sought to evaluate contemporary series and summarize the experience of complications associated with BPH treatment and management of these complications.

RECENT FINDINGS

A comprehensive literature review was performed, and identified 79 manuscripts, published between 2005 and 2021 characterizing the diagnosis and management of complications following BPH surgery. Commonly cited issues included bleeding, ureteral orifice injury, bladder neck injury, rectal injury, TURP syndrome, bladder neck contractures, urethral stricture disease, refractory OAB symptoms, and complications unique to new modalities of treatment. The practicing urologist has multiple surgical options to choose from in treating patients with symptomatic BPH. The surgical management of BPH is generally well tolerated with high objective success rates that allow for significant improvement in urinary quality of life. It is critical to understand the potential complications associated with these various treatment options, which will enable trainees and practicing urologists to better counsel patients and manage these potential complications.

Economic Evaluation of 1470 nm Diode Laser Enucleation vs Bipolar Transurethral Resection of the Prostate

Purpose: Large meta-analyses demonstrate the noninferiority of laser enucleation to transurethral resection of the prostate (TURP) with regard to long-term efficacy and reoperation rate. Although the 1470 nm diode laser enucleation of the prostate (DiLEP) is superior in hemostasis and surgical visibility, its complexity and associated longer operative time limit its widespread usage. The objective of this study was to generate long-term cost estimates for bipolar TURP and DiLEP, taking into account perioperative and adverse event costs. Materials and Methods: This is a retrospective review of patients who underwent DiLEP (n = 114; November 2016 to February 2020) or TURP (n = 194; January 2016 to December 2018). A decision analysis model was constructed to compare costs of the primary procedure and subsequent complications taking into account disposable costs, operating room time, length of stay, reoperation rates, and readmissions. Costs were estimated from internal data, published literature and Medicare procedure costs. Markov modeling was used to create cost projections up to 10 years. Results: DiLEP was associated with shorter length of stay and fewer total complications, but longer operative times and greater initial costs. Cost were recuperated at 8 years postoperatively. At 10 years postoperatively, DiLEP represented approximately $664 cost savings per patient over TURP. Conclusions: DiLEP is a cost-effective alternative to TURP for the treatment of benign prostatic hyperplasia in the properly selected patient. DiLEP has greater initial costs due to longer operative times. Costs are recuperated by 10 years postoperatively due to higher rate of same-day discharges, and lower complication and reoperation rates, incurring a $664 cost savings per patient treated by DiLEP relative to TURP.

The Learning Curves for Laser Application in Urology Procedures: Review of the Literature

Introduction: Currently, a laser is a popular technology in urological surgeries. The important laserrelated issue is the time when a surgeon reaches an acceptable level of safety and efficacy using laser technology. Methods: In this review, we aimed to assess the learning curves of three types of surgeries in urology, including photoselective vaporization of the prostate (PVP), holmium laser enucleation of the prostate (HoLEP) and retrograde intra-renal surgeries (RIRSs). Here, we searched Medline, Web of Science, Google Scholar, EMBASE, and Scopus for such keywords as Urology, laser, laser vaporization, prostate, nephrolithiasis, benign prostatic hyperplasia (BPH), and learning curve. Results: We evaluated 14 studies about PVP, 17 about RIRS, and 29 studies about HoLEP. Also, we separately discussed the learning curves of these three kinds of surgeries in detail. Conclusion: All the urologists, even expert surgeons, should attend a formal training course and have a skilled tutor present at their first cases.

Clinical Safety and Cost-Effectiveness of Follow-up Virtual Clinic for Bladder Outflow Obstruction Surgery

Introduction: Bladder outflow obstruction (BOO) surgery is among the most commonly performed urologic procedures. Postoperative assessment consists of physical measurement of uroflowmetry and post-void residual volume, but health systems worldwide have experienced pressures in demand, leading to exploration of greater efficiency in organizing clinic protocols. International Prostate Symptom Score (IPSS) questionnaire measurement has been identified as a tool to predict change in postoperative management. Our institution established a nurse-led follow-up virtual clinic (VC) for patients undergoing BOO surgery based on IPSS measurement. We present the clinical and economic outcomes of this new service. Materials and Methods: Patients with a successful postoperative trial without catheter were contacted by telephone via VC and discharged by a Urology Clinical Nurse Specialist (UCNS) if IPSS was <8. Data were analyzed for IPSS, arrangement of subsequent clinic visits, and numbers discharged. Primary outcome was the proportion of patients discharged after VC consultation. Secondary outcomes were overall discharge rate following subsequent face-to-face (FTF) appointment; and the proportion of patients re-referred from Primary Care within 3 months of discharge from VC. Cost savings were calculated based on tariffs of £135 for first attendance with UCNS, £199 for uroflowmetry, and £47.84 for VC appointment. Results: The first 50 patients to be recipients of the new VC were included. The median IPSS and quality-of-life score were 13 (interquartile range [IQR] 5) and 3 (IQR 1), respectively. Thirty-nine (78%) patients were discharged from VC; 36 (72%) had IPSS <8. Overall discharge rate following subsequent FTF appointment was 88%. Two patients discharged from VC (5.1%) were subsequently re-referred, neither of whom required additional treatment. Total cost savings with VC amounted to £10,634. Conclusion: Telephone follow-up for BOO surgery based on IPSS is clinically safe and cost-effective, providing greater efficiency for clinic protocols.