Holmium Laser Enucleation of the Prostate Is Associated with Complications and Sequelae Even in the Hands of an Experienced Surgeon Following Completion of the Learning Curve

Impact of age and anterior fibromuscular stroma preservation on post-enucleation voided volume

PURPOSE

This study is centered on the critical role of anterior fibromuscular stroma (AFS) preservation in prostate enucleation, an emerging strategy aimed at minimizing postoperative urinary incontinence-a common concern in benign prostatic hyperplasia (BPH) surgeries. By focusing on postoperative voiding volumes (VV), our research investigates the efficacy of AFS preservation. This approach, distinct in its methodology, is hypothesized to improve urinary function post-surgery, thereby offering a potentially significant advancement in BPH surgical treatments.

MATERIALS AND METHODS

A retrospective analysis was conducted, comparing patients who underwent prostate enucleation in 2017 without intentional AFS preservation to those in 2019 with this technique. We examined variables including age, BMI, diabetes, hypertension, and preoperative VV to assess their effect on post-catheter removal VV. The study's methodology includes a thorough review of the primary statistical analysis methods employed.

RESULTS

Our analysis indicates that while the 2017 and 2019 cohorts were similar in most preoperative parameters, the 2019 group that underwent AFS-preserved surgery showed a significant improvement in postoperative VVs. This was less pronounced in the patient group aged over 70, underscoring the importance of this demographic in our study.

CONCLUSIONS

The study concludes that intentional preservation of AFS during prostate enucleation positively impacts early postoperative VVs, with limited improvement in older patients. These findings highlight the potential of AFS preservation not only in enhancing urinary outcomes post-surgery but also in shaping future BPH surgical procedures and research directions.

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.

Incidence of urinary incontinence following endoscopic laser enucleation of the prostate by en-bloc and non-en-bloc techniques: a multicenter, real-world experience of 5068 patients

ABSTRACT

We aim to evaluate the incidence of incontinence following laser endoscopic enucleation of the prostate (EEP) comparing en-bloc (Group 1) versus 2-lobe/3-lobe techniques (Group 2). We performed a retrospective review of patients undergoing EEP for benign prostatic enlargement in 12 centers between January 2020 and January 2022. Data were presented as median and interquartile range (IQR). Univariable and multivariable logistic regression analysis was performed to evaluate factors associated with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI). There were 1711 patients in Group 1 and 3357 patients in Group 2. Patients in Group 2 were significantly younger (68 [62-73] years vs 69 [63-74] years, P = 0.002). Median (interquartile range) prostate volume (PV) was similar between the groups (70 [52-92] ml in Group 1 vs 70 [54-90] ml in Group 2, P = 0.774). There was no difference in preoperative International Prostate Symptom Score, quality of life, or maximum flow rate. Enucleation, morcellation, and total surgical time were significantly shorter in Group 1. Within 1 month, overall incontinence rate was 6.3% in Group 1 versus 5.3% in Group 2 (P = 0.12), and urge incontinence was significantly higher in Group 1 (55.1% vs 37.3% in Group 2, P < 0.001). After 3 months, the overall rate of incontinence was 1.7% in Group 1 versus 2.3% in Group 2 (P = 0.06), and SUI was significantly higher in Group 2 (55.6% vs 24.1% in Group 1, P = 0.002). At multivariable analysis, PV and IPSS were factors significantly associated with higher odds of transient SUI/MUI. PV, surgical time, and no early apical release technique were factors associated with higher odds of persistent SUI/MUI.

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.