“En-Bloc” Enucleation with Early Apical Release Compared to Standard Holmium Laser Enucleation of the Prostate: A Retrospective Pilot Study During the Initial Learning Curve of a Single Surgeon

Analysis of the top-down HoLEP learning curve: A single-center experience of two clinical fellows

INTRODUCTION

Holmium laser enucleation of the prostate (HoLEP) is known to have a steep learning curve. The top-down technique was introduced to lessen the number of procedures required to master HoLEP. We aimed to present the experiences of two successive clinical fellows with the top-down HoLEP learning curve and compare their performance with the supervisor.

METHODS

We conducted a prospective study of 40 patients who underwent top-down HoLEP performed by two successive fellows at our institution from September 2020 to November 2022. Before data collection, each learner observed three top-down HoLEP procedures and assisted with seven additional cases before independently performing top-down HoLEP under supervision. We collected data from each fellow's first 20 consecutive top-down HoLEP procedures. The learners' cases were grouped according to chronological order (Cases 1-10 and 11-20). The primary outcome was defined as the number of cases before the fellow could independently complete all steps of top-down HoLEP without any major intraoperative complications. The secondary outcomes included the intraoperative and postoperative outcomes of both groups. The fellows' 40 cumulative cases were then compared against retrospective data from 148 procedures conducted by their supervisor.

RESULTS

There were no significant differences in patient demographics for both clinical fellows. Each learner performed the first 20 cases independently without needing the supervisor to intervene. No major intraoperative complications were recorded, and there were no statistically significant differences in intraoperative and postoperative outcomes between fellows' cases. There was a statistically significant difference between the fellows and their supervisor in terms of operative efficiency and enucleation efficiency (p < 0.001). We did not find a significant difference between the fellows and the supervisor regarding intraoperative complications, major postoperative complications, or postoperative subjective and objective parameters.

CONCLUSIONS

Top-down HoLEP shows promising and reproducible results in shortening HoLEP's learning curve. Larger comparative and multi-institutional studies are warranted.

Postoperative urinary incontinence following BPH surgery: insights from a comprehensive national database analysis

BACKGROUND

Postoperative urinary incontinence (UI) is a feared complication of BPH surgery. Our study aims to investigate the incidence of UI among patients undergoing different procedures for BPH.

METHODS

A retrospective analysis was conducted using a large national database, containing patient records between 2011 and 2022. The most employed surgical procedures for BPH were considered, including TURP, Transurethral Incision of the Prostate (TUIP), Holmium/Thulium Laser Enucleation of the Prostate (HoLEP/ThuLEP), Open Simple Prostatectomy (OSP), minimally invasive simple prostatectomy (Lap/Rob SP), Photoselective Vaporization of the Prostate (PVP), Prostatic Urethral Lift (PUL), Robotic Waterjet Treatment (RWT - Aquablation®), Water Vapor Thermal Therapy (WVTT - Rezum®) and Prostatic Artery Embolization (PAE). Rates of any type of UI, including stress UI (SUI), urge UI (UUI) and mixed UI (MUI) were assessed. Multivariate regression analysis was used to identify predictors of "persistent" postoperative UI, defined as the presence of an active UI diagnosis at 12 months post-surgery.

RESULTS

Among 274,808 patients who underwent BPH surgery, 11,017 (4.01%) experienced persistent UI. UUI rates varied between 0.62% (PAE) and 2.71% (PVP), SUI ranged from 0.04% (PAE) and 2.75% (Lap/Rob SP), while MUI between 0.11% (PAE) and 1.17% (HoLEP/ThuLEP). On multivariable analysis, HoLEP/ThuLEP (OR 1.612; 95% CI: 1.508-1.721; P<0.001), PVP (OR 1.164; 95% CI:1.122-1.208; P<0.001), Open SP (OR 1.424; 95% CI:1.241- 1.624; P<0.001), and Lap/Rob SP (OR 1.667; 95% CI:1.119-2.384; P<0.01) showed significant higher likelihood of UI compared to TURP. PUL (OR 0.604; 95% CI:0.566-0.644; P<0.001), WVTT (OR 0.661; 95% CI:0.579-0.752; P<0.001), RWT (OR 0.434; 95% CI:0.216-0.767; P<0.01), and PAE (OR 0.178; 95% CI:0.111-0.269; P<0.001) were associated with lower likelihood of UI.

CONCLUSIONS

UI remains a concerning complication following BPH surgery, but it is an uncommon event affecting <5% of patients. Some differences in UI rates and risk might exist among various BPH procedures. These findings underscore the need for thorough patient selection and counseling.

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

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.

Experts' recommendations in laser use for the endoscopic treatment of prostate hypertrophy: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group

PURPOSE

To identify expert laser settings for BPH treatment and evaluate the application of preventive measures to reduce complications.

METHODS

A survey was conducted after narrative literature research to identify relevant questions regarding laser use for BPH treatment (59 questions). Experts were asked for laser settings during specific clinical scenarios. Settings were compared for the reported laser types, and common settings and preventive measures were identified.

RESULTS

Twenty-two experts completed the survey with a mean filling time of 12.9 min. Ho:YAG, Thulium fiber laser (TFL), continuous wave (cw) Tm:YAG, pulsed Tm:YAG and Greenlight™ lasers are used by 73% (16/22), 50% (11/22), 23% (5/22), 13.6% (3/22) and 9.1% (2/22) of experts, respectively. All experts use anatomical enucleation of the prostate (EEP), preferentially in one- or two-lobe technique. Laser settings differ significantly between laser types, with median laser power for apical/main gland EEP of 75/94 W, 60/60 W, 100/100 W, 100/100 W, and 80/80 W for Ho:YAG, TFL, cwTm:YAG, pulsed Tm:YAG and Greenlight™ lasers, respectively (p = 0.02 and p = 0.005). However, power settings within the same laser source are similar. Pulse shapes for main gland EEP significantly differ between lasers with long and pulse shape modified (e.g., Moses, Virtual Basket) modes preferred for Ho:YAG and short pulse modes for TFL (p = 0.031).

CONCLUSION

Ho:YAG lasers no longer seem to be the mainstay of EEP. TFL lasers are generally used in pulsed mode though clinical applicability for quasi-continuous settings has recently been demonstrated. One and two-lobe techniques are beneficial regarding operative time and are used by most experts.

Holmium laser with MOSES technology (MoLEP) vs Thulium fiber laser enucleation of the prostate (ThuFLEP) in a real-world setting. Mid-term outcomes from a multicenter propensity score analysis

PURPOSE

To compare Holmium laser with MOSES technology (MoLEP) and Thulium fiber laser enucleation of the prostate (ThuFLEP) in terms of surgical and functional outcomes.

METHODS

We performed a retrospective analysis of all patients who underwent either procedure in five centers (January 2020-January 2022).

EXCLUSION CRITERIA

previous urethral/prostatic surgery, radiotherapy, concomitant surgery. Propensity score matching (PSM) analysis was performed to adjust for the bias inherent to the different characteristics at baseline. Differences between procedures were estimated using Firth Penalized Likelihood regression for International prostate symptom score (IPSS), quality of life (QL), maximum flow rate (Qmax).

RESULTS

PSM retrieved 118 patients in each group. Baseline characteristics were similar except for PSA and number of men on indwelling catheter (higher in MoLEP group). Median surgical time was significantly longer in the MoLEP group despite the enucleation and morcellation times being similar. Median catheter dwelling time and postoperative length of stay were similar. Most of the early complications were Clavien ≤ 2 grade. There were only two Clavien grade 3 complications (one for each group), one grade 4 in MoLEP group. Rate and type of early and persistent incontinence (> 3 months) were similar. At 12-month, proportion of patients reaching a decrease (Δ) of IPSS ≥ 18 from baseline was significantly larger in MoLEP group, with no significant difference in ΔQmax > 12 ml/sec and ΔQL ≥ -3.

CONCLUSION

MoLEP and ThuFLEP were safe and efficacious procedures with similar short-term operative and functional outcomes. At 1-year, MoLEP patients had a sustained reduction of IPPS score.

Osteitis pubis following holmium laser enucleation of the prostate

Osteitis pubis is a rare, inflammatory condition involving the pubic symphysis. While osteitis pubis has been reported following many urological procedures, including those addressing bladder outlet obstruction such as transurethral resection of the prostate, it has never been reported after holmium laser enucleation of the prostate (HoLEP). Here, we detail the clinical course of a patient found to have osteitis pubis following HoLEP. This patient presented several weeks after surgery with non-specific, persistent symptoms of groin pain and difficulty ambulating, alerting our clinicians to consider osteitis pubis which was confirmed on MRI of the pelvis. While the majority of osteitis pubis cases are managed with locally invasive techniques, our patient's symptoms were successfully managed conservatively with Foley catheter placement, oral antibiotics and close follow-up. At 9 months postoperative, the patient has reported complete resolution of symptoms and continues to be followed closely.

Comparison of Contemporary Surgical Outcomes Between Holmium Laser Enucleation of the Prostate and Robotic-Assisted Simple Prostatectomy

PURPOSE OF REVIEW

This study reviews contemporary literature on RASP and HoLEP to evaluate perioperative outcomes, common complications, cost analytics, and future directions of both procedures.

RECENT FINDINGS

RASP is indicated for prostates > 80 mL, while HoLEP is size-independent. No notable differences were found in operative time, PSA nadir (surrogate for enucleation volume), re-catheterization rates, or long-term durability. Prolonged incontinence and bladder neck contracture rates are low for both surgeries. Patients experience similar satisfaction outcomes and improvements in uroflowmetry and post-void residual volumes. HoLEP demonstrates shorter hospitalizations, lower transfusion rates, lower costs, and higher rates of same-day discharge. RASP offers a shorter learning curve and lower rates of early postoperative urinary incontinence. HoLEP is a size-independent surgery that offers advantages for patients seeking a minimally invasive procedure with the potential for catheter-free same-day discharge. Future directions with single-port simple prostatectomy may offer parity in same-day discharge, but further research is needed to determine broader feasibility.

Improving Prostatic Preoperative Volume Estimation and Planning before Laser Enucleation

We aimed to validate a formula for improving the estimation of prostatic volume by abdominal ultrasound (AUS) prior to transurethral laser enucleation. A total of 293 patients treated for benign prostate hyperplasia (BPH) by laser enucleation from 2019−2022 were included. The preoperative AUS volume was adjusted by the formula 1.082 × Age + 0.523 × AUS − 53.845, which was based on specimens retrieved by suprapubic prostatectomy. The results were compared to the weight of the tissue removed by laser enucleation as determined by the intraclass correlation coefficient test (ICC). The potential impact of preoperative planning on operating time was calculated. The ICC between the adjusted volumes and the enucleated tissue weights was 0.86 (p < 0.001). The adjusted volume was more accurate than the AUS volume (weight-to-volume ratio of 0.84 vs. 0.7, p < 0.001) and even more precise for prostates weighing >80 g. The median operating time was 90 min. The adjusted volume estimation resulted in an overall shorter expected preoperative operating time by a median of 21 min (24%) and by a median of 40 min in prostates weighing >80 g. The adjustment formula accurately predicts prostate volume before laser enucleation procedures and may significantly improve preoperative planning, the matching of a surgeon’s level of expertise, and the management of patients’ expectations.