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

Lasers for Benign Prostatic Obstruction: And the Winner Is …

The past three decades have witnessed continuing evolution and diversification of laser technologies used for the surgical treatment of benign prostatic obstruction (BPO). These advances resulted from a better understanding of laser-tissue interactions, technical refinements, and increasing clinical experience. To date, holmium and thulium lasers are most commonly used in BPO surgery owing to their intrinsic characteristics, such as strong absorption in water and minimal tissue penetration. These laser types have also been widely assessed in clinical studies that provided strong evidence for their efficiency. This mini review describes current trends for laser applications in the treatment of BPO. PATIENT SUMMARY: Our mini review describes the different types of lasers used to remove prostate tissue in patients with a benign enlarged prostate gland that is obstructing urine flow. We highlight the advantages and disadvantages of the different techniques.

Holmium: YAG laser enucleation of the prostate using the new cyber Ho generator with magneto technology: does it provide any advantages compared to thulium: YAG prostate enucleation?

PURPOSE

To assess differences in efficacy and safety between Thulium:YAG laser enucleation of the prostate (ThuLEP) and enucleation performed with the Holmium:YAG Cyber Ho laser generator (HoLEP) with Magneto technology (Quanta System®).

METHODS

Patients with surgical indication for benign prostatic hyperplasia underwent ThuLEP using Cyber TM generator (Group A) versus HoLEP using Cyber Ho generator with Magneto technology (Group B). In Group A settings were 100W for enucleation and 35W for coagulation. In Group B early apical detachment and coagulation were performed with energy 1 J and frequency 30 Hz by applying Magneto technology. Enucleation was performed with energy 2 J and frequency 40 Hz by applying Virtual Basket pulse modulation.

RESULTS

200 patients were enrolled (100 patients per group). Preoperative features were comparable. Mean prostate size was 78.9 vs. 80.5 ml in Group A vs. B (p = 0.09). Mean operative time was 70.6 vs. 64.3 min (p = 0.13) with mean enucleation time 48.8 vs. 43.7 min (p = 0.21) and morcellation time 21.2 vs. 14.6 min (p = 0.03) in ThuLEP vs. HoLEP group. Micturition improvements were comparable. Postoperative gross haematuria was significantly more frequent after ThuLEP and clots-induced urinary retention occurred in 5.0% of cases, compared to no cases after HoLEP (p = 0.02).

CONCLUSIONS

HoLEP using the Cyber Ho generator with the application of Magneto technology for coagulation seems to provide an haemostatic advantage compared to ThuLEP, suggested by the significantly shorter morcellation time, higher morcellation efficiency and lower rate of postoperative gross haematuria and clots-induced urinary retention. Functional outcomes are comparable.

Application trends and research hotspots of endoscopic enucleation of the prostate: a bibliometric and visualization analysis

PURPOSE

Endoscopic enucleation of the prostate (EEP) is a preferred treatment for benign prostatic hyperplasia (BPH). This bibliometric analysis aims to analyze the application trends and research hotspots of EEP.

METHODS

We conducted a bibliometric analysis of publications indexed in the Web of Science Core Collection from 1989 to 2023. The techniques examined include holmium laser enucleation (HoLEP), thulium laser enucleation (ThuLEP/ThuFLEP), bipolar/monopolar transurethral enucleation (b-TUEP/m-TUEP), GreenLight laser enucleation (GreenLEP), and diode laser enucleation (DiLEP). We utilized VOSviewer, CiteSpace, and the R package 'bibliometrix' for the analysis.

RESULTS

A total of 739 English-language studies were analyzed, revealing a steady increase in EEP-related publications. HoLEP was the most extensively studied technique, followed by ThuLEP and b-TUEP, while ThuFLEP gaining emerging interest. There has been a notable lack of high-quality randomized controlled trials (RCTs) for GreenLEP, DiLEP and m-TUEP. China, the United States, and Germany led in publication volume and collaboration networks. Key contributors in the field were identified, with recent research focusing on topics like postoperative transient urinary incontinence (TUI) and the role of robot-assisted simple prostatectomy (RASP) in comparison to EEP.

CONCLUSIONS

EEP is gaining widespread clinical acceptance for BPH treatment. Future research should focus on addressing the gap in high-quality RCTs, especially for underexplored techniques like GreenLEP, DiLEP and m-TUEP, and explore strategies to reduce postoperative TUI. Prospective comparisons between RASP and EEP will be crucial for optimizing surgical approaches in BPH management.

Pulsed Thulium: YAG laser for the management of Urolothiasis: a systematic review from the EAU section of endourology

INTRODUCTION

In an effort to address the limitations of current lasers, pulsed-waved Thulium: YAG laser devices were released. The purpose of this systematic review is to present all existing data, arising exclusively from human studies and clinical practice, regarding the endourological applications of the new pulsed-waved Thulium: YAG laser technology in stone disease management.

PATIENTS AND METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, three databases (PubMed, Scopus and Cochrane) were thoroughly investigated from inception to 30 December 2024. The following search string was utilized: (pulsed OR hybrid) AND (thulium: YAG OR Tm: YAG).

RESULTS

In total eight studies satisfied all inclusion criteria and were finally included in the qualitative analysis. Six studies reported the use of the pulsed-waved Thulium: YAG laser during ureteroscopic lithotripsy (URSL) or retrograde intrarenal surgery (RIRS) and two studies reported its use during percutaneous nephrolithotomy (PCNL). In included studies, the lasing time ranged from 6.7 (2.7-13.9) to 36 (11-52) minutes. Stone-free rates (SFRs) ranged from 82 to 95%, while the Grade I-II and III-IV complications, based on the Clavien-Dindo Classification System, ranged from 3.3 to 30% and from 0 to 2%, respectively.

CONCLUSION

The purely pulsed Thulio® and hybrid RevoLix® Thulium: YAG lasers demonstrate promising safety and efficacy for RIRS and PCNL, with high peak power enabling efficient stone disintegration and effective dusting. However, the evidence is limited by small sample sizes, heterogeneity, and a lack of high-quality comparative trials. Further robust studies are needed to confirm these findings and draw reliable conclusions.

Ejaculation-sparing enucleation of the prostate with Thulium: Yag laser (ES-ThuLEP) versus Thulium Fiber laser (ES-ThuFLEP): outcomes on sexual function

PURPOSE

To compare the effect on sexual function of ejaculation-sparing enucleation of the prostate using Thulium: YAG laser (ES-ThuLEP) versus continuous-wave Thulium Fiber Laser (ES-ThuFLEP).

METHODS

112 patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia who wished to preserve ejaculation were treated. 58 patients underwent ES-ThuLEP (Group A) using the Cyber TM generator. 54 patients underwent ES-ThuFLEP (Group B) using the Fiber Dust generator. Sexual function was evaluated through the International Index of Erectile Function 5 (IIEF-5) score, the four-item Male Sexual Health Questionnaire (MSHQ-EjD), personal satisfaction and the occurrence of haemospermia and painful ejaculation 3 and 6 months after surgery.

RESULTS

Mean age of patients was 65.8 years in Group A and 66.7 years in Group B. Groups were comparable according to preoperative features. Mean preoperative IIEF-5 score was 18.8 in Group A and 17.9 in Group B (p = 0.14). In all cases an ejaculation-sparing procedure was performed sparing the tissue around the veru montanum and near the prostate apex. Three months after surgery mean IIEF-5 score was 19.3 in Group A and 18.0 in Group B (p = 0.12). Six months after surgery mean IIEF-5 score was 17.8 in Group A and 18.1 in Group B (p = 0.09). No significant differences were observed according to anterograde ejaculation (81.0% vs. 81.5%, p = 0.07), subjective satisfaction (72.4% vs. 74.1%, p = 0.10), painful ejaculation (10.3% vs. 11.1%, p = 0.14) and haemosparmia rate (12.1% vs. 14.8%, p = 0.08). Ejaculation and satisfaction rate were significantly higher with prostates ≥ 80 ml in both groups.

CONCLUSION

Ejaculation-sparing enucleation of the prostate effectively preserved sexual function in the majority of patients, with high rate of anterograde ejaculation and subjective satisfaction, low rates of painful ejaculation and haemospermia and no significant differences between Thulium: YAG and Thulium Fiber Laser. Preservation of ejaculation and personal satisfaction were significantly higher with prostates ≥ 80 ml compared to smaller ones.

Transurethral resection of the prostate across continents: a meta-analysis evaluating quality of gold standard in the twenty-first century

PURPOSE

To compare outcomes of transurethral resection of the prostate (TURP) across different regions worldwide over the past two decades.

METHODS

A systematic review and meta-analysis of randomized clinical trials indexed to PubMed that assessed TURP. A total of 102 studies with 8,454 patients were included and grouped by continents: Europe, Asia, Africa, and Others (North America, South America, and Australia). International Prostate Symptom Score (IPSS), peak flow (Qmax), postvoid residual urine (PVR), PSA levels, prostate volume, and Sexual Health Inventory for Men scores (at 3, 12, and 36 months) were assessed, along with postoperative complications. Heterogeneity across studies was classified as low (I2 < 25%), moderate (I2 = 25-75%), or high (I2 > 75%).

RESULTS

TURP consistently exhibited significant enhancements in IPSS, Qmax, and PVR across various regions. Notably, PVR demonstrated high heterogeneity (I²=100%). TURP presented low complication rates with TURP syndrome (2%), bleeding (8%), and blood transfusion (6%). However, significant heterogeneity was observed, particularly for clot evacuation (I2 = 87%), irritative symptoms (I2 = 96%), and incontinence (I2 = 84%). The retreatment rates at 1 and 3 years were 5% and 7%, respectively, with significant differences across regions.

CONCLUSION

Global outcomes of TURP lack a discernible trend. The substantial heterogeneity observed among continents suggests a lack of standardization. Nevertheless, uniform symptomatic improvements among patients still support TURP as the gold-standard surgical treatment for benign prostatic hyperplasia, despite variations in its results worldwide.

Real-world experience with the new pulsed solid-state Thulium: YAG laser (Thulio) for endoscopic enucleation of the prostate

PURPOSE

The solid-state Thulium laser (Tm: YAG) is a novel alternative to the widely used Holmium laser for endoscopic enucleation of the prostate (EEP) due to its relatively high peak power. The aim of this study was to examine the efficacy and safety of a new pulsed Tm: YAG laser in its first application in humans.

METHODS

Data were retrospectively collected for the first 103 patients who underwent EEP with a new pulsed solid-state Tm: YAG laser (Thulio®, Dornier MedTech Systems GmbH, Weßling, Germany). Peri- and postoperative data were assessed. Procedure-specific complications were graded using Clavien-Dindo Classifications (CDC). Patients were interviewed 15 months after the surgery to evaluate functional and long-term outcomes. Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS®).

RESULTS

The mean preoperative prostate volume was 105.6 ± 55.0 ml. Median enucleation speed was 4.1 g per minute (range 1.1-9.7). Short-term postoperative complications occurred in 21 patients (20.4%), but no high-grade complications (CDC ≥ IV) were observed. Five patients suffered gross haematuria and required reintervention (CDC IIIb; 4.9%). After 15 months, 76 patients (73.8%) participated in the follow-up interview, where seven patients (9.2%) reported complications, including two reinterventions for urethral strictures (CDC IIIb; 2.6%). Most patients reported an improvement in continence (54.0%) and urine stream (93.4%), but no difference in erectile function (81.6%). No persistent dysuria was reported. Patient satisfaction with the surgery results was very high (96.1%).

CONCLUSION

Endoscopic enucleation of the prostate with the new pulsed solid-state Tm: YAG laser is a safe and effective option for surgical BPH treatment.

TRIAL REGISTRATION

German Clinical Trials Register number: DRKS00031676. Registration date: 10 May 2023, retrospectively registered.

Prospective randomized multicenter study to evaluate holmium vs. new thulium fiber laser for prostate enucleation

BACKGROUND

Benign prostatic hyperplasia (BPH) commonly causes lower urinary tract symptoms (LUTS) in men. Holmium (HoLEP) and thulium (ThuLEP) laser enucleation are established techniques for BPH treatment. Thulium fiber laser (TFL) for prostate enucleation (ThuFLEP) shows promising outcomes.

METHODS

A prospective randomized multicenter study was conducted. Patients with BPH and LUTS unresponsive to medical therapy were enrolled. Preoperative, surgical, perioperative and postoperative data were recorded with follow-up at 3 and 6 months. The primary outcome was functional improvement, and the secondary outcome was safety in terms of complications.

RESULTS

Two hundred patients were included (HoLEP 100, ThuFLEP 100). No significant baseline difference was found between groups. At 3 and 6 months we found statistically significant improvements from baseline for both HoLEP and ThuFLEP in efficacy: International Prostatic Symptoms Score (IPSS), IPSS-Quality of Life (QoL), maximum urinary flow rate (Qmax), and post-void residual volume (PVR; P<0.05). At 6 months, mean±SD IPSS, IPSS-QoL, Qmax, and PVR for HoLEP vs. ThuFLEP were 5.8±4.9 vs. 4.8±5.0 points (P=0.57), 1.6±1.4 vs. 0.7±1.1 points (P=0.09), 29.9±12.5 vs. 29.6±8.0 mL/s (P=0.8), and 16.3±17.7 vs. 15.5±13.4 mL (P=0.92), respectively. No intraoperative complication was recorded. No Clavien-Dindo ≥III complications occurred during hospitalization. After 6 months, 8 (8%) and 6 (6%) patients reported mild stress urinary incontinence in HoLEP and ThuFLEP groups, respectively (P=0.24). Urethral stenosis was observed in 3 men (3%) in the HoLEP group and 1 subject (1%) in the ThuFLEP group (P=0.72).

CONCLUSIONS

HoLEP and ThuFLEP are effective and safe for BPH treatment, with comparable functional outcomes and complication rates at 6 months. Further research is needed to confirm these findings.

Evaluation of the learning curve for Thulium fiber laser enucleation of prostate (ThuFLEP): retrospective study of a single-surgeon experience in real-world settings

PURPOSE

To assess the learning curve of Thulium Fiber Laser Enucleation of prostate (ThuFLEP) of a single surgeon inexperienced in laser endoscopic enucleation of prostate (EEP).

METHODS

We retrospectively analyzed all patients with benign prostate hyperplasia undergoing ThuFLEP at our center between January 2022 and August 2023 by one surgeon. Inclusion criteria were International Prostate Symptom Score > 7, prostate volume < 200 g, and maximal urinary flow rate < 15 mL/s. The surgeon was inexperienced in laser EEP and trained by watching educational videos of ThuFLEP before starting to perform the procedure under mentoring during the first 4 cases. Procedural data (enucleation and morcellation efficiency, complications) and functional results up to 3 months were evaluated. Patients were divided into 4 cohorts of 20 consecutive cases to evaluate outcomes evolution throughout time.

RESULTS

The mean age of the patients was 69.9 years (SD 7.8) and mean prostate volume was 89.9 g (SD 25.8). Preoperative functional parameters were comparable between the groups. Mean enucleation efficiency (EE) ratio and morcellation efficiency (ME) ratio reached respectively 0.78 g/min (SD 0.55) and 2.49 g/min (SD 1.03) and both variables significantly increased from group 1 to group 3 (p < 0,001). Perioperative complications remained low throughout the caseload with similar significant 3-month functional improvements between all groups.

CONCLUSION

This is the first study to evaluate ThuFLEP learning curve for a single surgeon inexperienced in laser EEP with limited mentoring. Under these real-world conditions, nearly 60 cases were needed to complete the learning curve with a complications rate remaining low throughout the training process.

The safety and efficacy of five surgical treatments in prostate enucleation: a network meta-analysis

PURPOSE

The aim of our study was to investigate the comparative outcomes of five different energy types on surgical efficacy and postoperative recovery in patients with benign prostate hyperplasia.

METHODS

The literature was systematically reviewed on December 1st, 2023, encompassing studies retrieved from PubMed, Embase, Web of Science, and The Cochrane Library databases that incorporated clinical studies of holmium laser enucleation of the prostate (HoLEP), Thulium:YAG laser enucleation of the prostate (ThuLEP), transurethral plasmakinetic enucleation of prostate (PKEP), diode laser enucleation of the prostate (DiLEP) and thulium fiber laser enucleation of the prostate (ThuFLEP) in the treatment of prostatic hyperplasia. Two independent reviewers extracted study data and conducted quality assessments using the Cochrane Collaboration's Risk of Bias tool and Newcastle-Ottawa Scale (NOS). Network meta-analysis (NMA) was employed to indirectly analyze the outcomes of endoscopic enucleation of the prostate (EEP) techniques.

RESULTS

The study included a total of 38 studies, comprising 21 non-randomized controlled trials (nRCTs) and 17 randomized controlled trials (RCTs), incorporating five distinct techniques: holmium laser, Thulium:YAG laser, bipolar plasma, diode laser and thulium fiber laser. In comparing treatment durations, ThuLEP and HoLEP had shorter overall hospital stays than PKEP, while the enucleation time of ThuLEP and HoLEP was shorter than that of ThuFLEP. Moreover, the enucleation tissue weight of both thulium fiber laser and holmium laser was heavier than bipolar plasma. However, the analysis did not reveal any statistically significant variation in complications among the various types of enucleation. In postoperative follow-up, the IPSS at 3 months post-operation was superior in the Thulium:YAG laser group compared to the holmium laser group. The thulium fiber laser technique demonstrated significant advantages over other enucleation methods in terms of QoL and PVR at 12 months after surgery.

CONCLUSION

Theoretical properties may vary among different energy sources; however, there are no discernible clinical differences in operation-related parameters, postoperative complications, and postoperative follow-up. Therefore, the choice of laser does not significantly impact the outcome. However, due to the limited number of included studies, future research should focus on larger sample sizes and multicenter investigations to further validate the findings of this study.

Initial experience with thulium fiber laser for prostate enucleation: Analysis of the intraoperative and short-term outcomes in a prospective, multicenter cohort

INTRODUCTION

Holmium laser enucleation of the prostate has rapidly become the gold standard for the surgical treatment of benign prostate hyperplasia, although thulium fiber laser (TFL) has also been postulated as an effective and safe alternative for prostate enucleation. The aim of this study is to describe our initial experience with the TFL for endoscopic enucleation of the prostate.

MATERIAL AND METHODS

All patients proposed to TFL prostate enucleation were included in the analysis, regardless their prostate volume, catheter status and severity of symptoms, in 3 centers. Preoperative characteristics, intraoperative times and functional 3-months follow-up variables were collected, along with complications.

RESULTS

Fifty-six patients were available, with a mean age of 68.7 years. Enucleation and morcellation efficiencies were 2.04 and 7.47 g/min, respectively. Median hospital stay was one day. Comparable functional data, pre and 3-month post-surgery was: mean prostate volume 88.9 vs 21.3 g, maximum urinary flow 13.2 vs 27.3 ml/s, post-void residual volume 149 vs 7.8 ml, prostatic specific antigen level 11.2 vs 1 ng/ml, and International Prostate Symptom Score 20.75 vs 3.96. Fourteen out of 56 (25%) patients presented with complications grade ≤2, according to the Clavien-Dindo classification.

DISCUSSION

With wider evidence for other urological indications, very recent evidence about the suitability of TFL for prostate enucleation has arisen, since the first case described in 2021. Our results seem to back up these previous successful experiences as long as we obtained good intraoperative and short term follow-up functional results. However, there is still a need of longer follow-up data.

CONCLUSIONS

TFL represents a novel technology for prostate enucleation, with a good intraoperative and short follow-up functional results, and a safety profile similar to the observed for those techniques that have been wider used for this indication. Further studies with longer follow-up periods and comparative with these other techniques are necessary.

A prospective analysis of thulium laser enucleation in benign prostatic hyperplasia comparing low- and high-power approaches for prostates exceeding 80 g

INTRODUCTION AND OBJECTIVES

To compare the perioperative and functional outcomes of low-power and high-power thulium:YAG VapoEnucleation (ThuVEP) of the prostate for the treatment of large-volume benign prostatic hyperplasia (BPH) (> 80 ml).

PATIENTS AND METHODS

A prospective analysis of 80 patients with symptomatic BPO and prostatic enlargement (more than 80 ml) was conducted. They were divided randomly into two groups (40 patients in each group). One group was treated with low-power ThuVEP, and the other group was treated with high-power ThuVEP. All patients were assessed preoperatively and early postoperatively, and 12-month follow-up data were analyzed. The complications were noted and classified according to the modified Clavien classification system.

RESULTS

The mean age at surgery was 68 (± 6.1) years, and the mean prostate volume was 112 (± 20.1) cc, and there were no differences between the groups (p = 0.457). The mean operative time was 88.4 ± 11.79 min for group A and 93.4 ± 16.34 min for group B, while the mean enucleation time was 59.68 ± 7.24 min for group A and 63.13 ± 10.75 min for group B. There were no significant differences between the groups regarding catheterization time and postoperative stay. The quality of life (QoL), International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), postvoiding residual urine (PVR), and prostate volume improved significantly after treatment and were not significantly different between those treated with the different energies. The incidence of complications was low and did not differ between both the groups.

CONCLUSION

Low-power ThuVEP is feasible, safe, and effective with comparable results with high-power ThuVEP in the treatment of BPO.

Thulium fiber laser enucleation of the prostate: a systematic review of the current outcomes

INTRODUCTION

One recent addition to different lasers used for endoscopic enucleation of the prostate is the thulium fiber laser (TFL). The purpose of this systematic review is to present the feasibility, safety and efficacy of TFL Enucleation of the Prostate (ThuFLEP).

EVIDENCE ACQUISITION

PubMed®, Scopus® and Cochrane® primary databases were systematically screened. The search strategy used the PICO (Patients, Intervention, Comparison, Outcome) criteria. Patients should be adults with benign prostatic obstruction (BPO) undergoing ThuFLEP. While comparative studies reporting comparison of ThuFLEP to other BPO treatments were included, cohort studies with no comparison group were also accepted. Outcomes including enucleation time and complication rates were reported.

EVIDENCE SYNTHESIS

Twelve studies met all the predefined criteria and were included in the final qualitative synthesis. Mean operative time and enucleation time ranged from 46.6±10.2 to 104.5±33.6 and from 38.8±17.9 to 66.0±24.9 minutes, respectively. Most of the complications were Grade I or Grade II ones. Although TFL was found to present some advantages over older BPO treatments, its outcomes were comparable with other endoscopic enucleation approaches.

CONCLUSIONS

ThuFLEP seems to be a feasible, safe and efficient approach for BPO symptoms management. Limited evidence showed that although ThuFLEP was associated with a reduced total operative time, it was also associated with worse IPSS improvement at 1-year follow-up, when compared with MOSESTM Holmium Laser Enucleation of the Prostate (HoLEP). These findings confirm the well-established opinion that the enucleation technique itself is more important than the technology which is used.

Propensity score-matched analysis comparing perioperative, functional, and safety outcomes between thulium fiber laser and bipolar enucleation of the prostate performed by a single surgeon with two years of follow-up

PURPOSE

To compare perioperative, functional, and safety outcomes between thulium fiber laser enucleation of the prostate (ThuFLEP) and bipolar enucleation of the prostate performed by a single surgeon with use of propensity score (PS)-matched analysis.

MATERIALS AND METHODS

Data were from 675 patients, 422 of whom underwent ThuFLEP and bipolar enucleation by a single highly experienced surgeon. ThuFLEP was performed with Fiberlase U1 (IRE Polus Ltd.). Perioperative parameters, safety, and functional outcomes, such as International Prostate Symptom Score (IPSS), quality of life (QoL), postvoid residual volume (PVR), and maximum urinary flow rate (Qmax) were assessed. To control for selection bias, a 1:1 PS-matched analysis was carried out using the following variables as covariates: total prostate volume, preoperative IPSS and early sphincter release.

RESULTS

Of 422 patients, 370 (87.7%) underwent ThuFLEP and 52 (12.3%) underwent bipolar enucleation. Operation, enucleation, and morcellation time were comparable between groups before and after PS-matched analysis (p=0.954, p=0.474, p=0.362, respectively). Functional parameters (IPSS, QoL, PVR, Qmax) were also comparable between groups at every time point before and after PS matching. Significant improvements in IPSS, QoL score, Qmax, and PVR were observed during the 24-month follow-up period for both ThuFLEP and bipolar enucleation without any significant differences between groups. Early and late postoperative complications before and after PS-matched analysis were similar.

CONCLUSIONS

ThuFLEP was comparable to bipolar enucleation in perioperative characteristics, improvement in voiding parameters, and complication rates. Both procedures were shown to be effective and safe in the management of benign prostatic hyperplasia.

Advances in lasers for the minimally invasive treatment of upper and lower urinary tract conditions: a systematic review

PURPOSE

Technological advancements in laser lithotripsy are expanding into numerous fields of urology, like ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and benign and malignant soft-tissue treatments. Since the amount of research regarding lasers in urology has grown exponentially, we present a systematic review of the most recent and relevant advances encompassing all lasers used in urological endoscopic treatment.

METHODS

We performed a literature search using PubMed (May 2023) to obtain information about lasers for urological purposes. We included only recent data from published articles between 2021 and 2023 or articles ahead of print.

RESULTS

Lasers are widely used in lithotripsy for ureteric, renal, and bladder stones, benign prostate surgery, and bladder and upper tract tumor ablation. While the holmium (Ho:YAG) laser is still predominant, there seems to be more emphasis on pulse modulation and newer lasers such as thulium fiber laser (TFL) and pulsed Tm:YAG laser.

CONCLUSION

The use of lasers and related technological innovations have shown increasing versatility, and over time have proven to be invaluable in the management of stone lithotripsy, treatment of benign and malignant prostate diseases, and urothelial tumors. Laser endoscopic treatment is heavily based on technological nuances, and it is essential to know at least the basics of these technologies. Ultimately the choice of laser used depends on its availability, cost, surgeon experience and expertise.

Pulsed-wave vs Continuous-wave Thulium Fiber Laser Enucleation of the Prostate (ThuFLEP): A Comparison of Perioperative Outcomes

OBJECTIVE

To compare intra and early postoperative outcomes between pulsed-wave and continuous-wave Thulium Fiber Laser Enucleation of the Prostate (PW-ThuFLEP vs CW-ThuFLEP) for the treatment of benign prostatic hyperplasia.

METHODS

238 patients with lower urinary tract symptoms due to benign prostatic hyperplasia underwent PW-ThuFLEP (118 patients) vs CW-ThuFLEP (120 patients). Preoperative prostate volume, adenoma volume, prostate-specific antigen (PSA), and hemoglobin values were recorded. International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), post-void residual volume, and International Index of Erectile Function-5 score (IIEF-5) were assessed. Operative time, enucleation time, enucleation efficiency, catheterization time, irrigation volume, hospital stay, hemoglobin drop, and postoperative complications were recorded. Micturition improvements and sexual outcomes were evaluated 3months after surgery.

RESULTS

CW-ThuFLEP showed shorter operative time (61.5 vs 67.4 minutes, P = .04). Enucleation time (50.2 vs 53.3 minutes, P = .12), enucleation efficiency (0.8 vs 0.7 g/min, P = .38), catheterization time (2.2 vs 2.1days, P = .29), irrigation volume (32.9 vs 32.8L, P = .71), hospital stay (2.8 vs 2.6days, P = .29) and hemoglobin drop (0.38 vs 0.39 g/dL, P = .53) were comparable. No significant difference in complication rate was observed. At 3-month follow-up, the procedures did not show any significant difference in IPSS, Qmax, post-void residual volume, IIEF-5, and PSA value.

CONCLUSION

PW-ThuFLEP and CW-ThuFLEP both relieve lower urinary tract symptoms equally, with high efficacy and safety. Operative time was significantly shorter with CW-ThuFLEP, but with a small difference with low clinical impact. Enucleation time, enucleation efficiency, catheterization time, irrigation volume, hospital stay, hemoglobin and PSA drop, complication rate, and sexual outcomes showed no differences.

A systematic review and meta-analysis of efficacy and safety comparing greenlight laser vaporization with transurethral resection of the prostate for benign prostatic hyperplasia with prostate volume less than 80 ml

We conducted a meta-analysis to evaluate the efficacy and safety of photo selective vaporisation of the prostate (PVP) with the GreenLight Laser versus transurethral resection of the prostate (TURP) for the treatment of small-volume benign prostatic hyperplasia (BPH). As of July 2022, relevant literature in online databases such as Cochrane Library, PubMed, and Embase was searched, including studies published on or before that date, and there were 9 studies in total, including 5 RCTs and 4 non-RCTs. In total 1525 patients were included to compare the efficacy of PVP and TURP in treating BPH. The Cochrane Collaboration criteria were used to evaluate the risk of bias. The software was used for random effect meta-analysis with RevMan 5.3. Data extraction included: clinical baseline characteristics, perioperative parameters, complication rates, International Prostate Symptom Score (IPSS), prostate specific antigen (PSA), post-void residual urine (PVR), maximum flow rate (Qmax), and quality of life (QoL). The pooled analysis showed that PVP was associated with reduced blood loss, blood transfusion, clot retention, catheterization time, definitive catheter removal, and hospital stay, but was associated with longer operative time and more severe dysuria (all p < 0.05). The results of this meta-analysis show that PVP as a technique for the treatment of benign prostatic hyperplasia with a volume of less than 80 cc has similar efficacy to standard TURP in IPSS, PSA, PVR, Qmax and QoL, and is an effective alternative. It outperformed TURP in terms of blood transfusion, catheterization time and hospital stay, while TURP is superior to PVP in terms of operation time.