Holmium laser resection of the prostate is more cost effective than transurethral resection of the prostate: results of a randomized prospective study

Is day-case surgery feasible for laser endoscopic enucleation of the prostate? A systematic review

PURPOSE

Laser endoscopic enucleation of the prostate (EEP) for benign prostatic obstruction has become increasingly prevalent worldwide. Considering the medical cost-savings and concomitantly fewer nosocomial infections, the feasibility of same-day postoperative discharge of patients who have undergone laser EEP in terms of its safety and effectiveness has become a subject matter of growing interest. We aimed to review those studies focussing on day-case surgery (DCS) in patients undergoing laser EEP.

METHODS

A systematic search was conducted using PubMed-MEDLINE and Web of Science databases until October 2022 with the following search terms: "same day discharge AND laser enucleation of the prostate", "day-case AND laser enucleation of the prostate", "same day surgery AND laser enucleation of the prostate" and "one day surgery AND laser enucleation of the prostate" by combining PICO (population, intervention, comparison, outcome) terms. We identified 15 eligible studies.

RESULTS

While 14 of the studies focussed on holmium laser EEP, one focused on thulium laser vapoenucleation of the prostate. We observed an improvement in functional parameters in all studies we reviewed, and DCS success and readmission rates ranged between 35.3-100% and 0-17.8%, respectively. The complication rates varied between 0 and 36.7%, most of the complicatons were Clavien-Dindo (CD) I and II. CD ≥ III complications did not significantly differ between same day discharge (SDD) and non-SDD groups in the studies.

CONCLUSION

Laser EEP is feasible and promising DCS treatment option delivering improved functional parameters compared to baseline values, and lower perioperative complication and readmission rates in certain patients.

Development of a Hemostatic Urinary Catheter for Transurethral Prostatic Surgical Applications

OBJECTIVE

To investigate a novel transurethral hemostatic catheter device with an integrated chitosan endoluminal hemostatic dressing (CEHD). Development and implementation of this technology may help address bleeding following surgery such as transurethral resection of prostate (TURP). Bleeding remains the most common complication following TURP, leading to increased morbidity and hospitalization.

METHODS

Investigation of hemostasis, delivery, safety and efficacy of the CEHD device is conducted using Female Yorkshire swine (N = 23). Hemostatic efficacy of the CEHD (N = 12) is investigated against a control of gauze (N = 12) in a splenic injury model (3 swine). The delivery, safety, and efficacy of the CEHD device (N = 10) are investigated against Foley-catheter control (N = 10) for 7 days using a swine bladder-neck-injury model.

RESULTS

In the splenic injury study, 9/12 CEHD dressings successfully achieved hemostasis within 150 seconds (mean 83 seconds) vs success of 6/12 (mean 150 seconds) for gauze (P = .04). In the 7-day study, the CEHD was successfully deployed in 10/10 animals and all dressings were tolerated without histologic or clinical adverse effect. Hemostasis of the CEHD device was found to be noninferior to control catheters. Noninferiority is attributed to low bleeding rates in the swine bladder neck injury model.

CONCLUSION

This investigation successfully demonstrated the feasibility of transurethral deployment of the CEHD in vivo. Routine use of safe and slowly dissolvable CEHDs could reduce the rate of complications and hospitalizations associated with bleeding and blood loss in TURP procedures. Further investigation is warranted.

Analysis of Holmium Laser Enucleation of Prostate Fixed Operating Room Times

OBJECTIVE

To evaluate factors influencing fixed operating room time during holmium laser enucleation of the prostate.

MATERIALS AND METHODS

A prospective observational study was performed for all holmium laser enucleation of the prostate (HoLEP) cases performed by a single surgeon over a 24-month period. Operating room (OR) time was divided into fixed and variable time. The variable time was defined as cut-to-close time. Fixed time included in room time to anesthesia release time (IRAT), anesthesia release time to cut time (ARCT), and close time to wheels out (CTWO). The effects of time of day and anesthesia personnel (AP) changes on fixed operating room time were evaluated.

RESULTS

A total of 406 HoLEPs were analyzed. There was no statistically significant difference in nonprocedural OR times between morning and afternoon surgeries (IRAT, P=0.38, ARCT P=0.10, CTWO P=0.77). Median nonprocedural OR times accounted for 27% (IQR: 22%-31%) of the total procedure time in the AM group and 29% (IQR: 24%-33%) in the PM group (P=0.005). Of the HoLEPs,78.1% (178/228) experienced one or more AP changes during the procedure. The median fixed OR time was not significantly different between procedures with 1 AP and procedures with ≥2 APs (IRAT, P=0.53; ARCT, P=0.71; CTWO, P=0.98).

CONCLUSIONS

Fixed operating room time makes up a significant portion of HoLEP procedures and should be considered when evaluating OR efficiency. The time of day and number of anesthesia personnel involved did not affect the fixed OR times.

Risk Factors for Transurethral Coagulation for Hemostasis During Holmium Laser Enucleation of the Prostate

PURPOSE

We aimed to identify risk factors for transurethral coagulation (TUC) using bipolar electrocautery for hemostasis during holmium laser enucleation of the prostate (HoLEP) surgery for benign prostatic hyperplasia (BPH).

METHODS

We analyzed the clinical outcomes of HoLEP surgery performed by a single surgeon between January 2010 and April 2020 at the Seoul National University Hospital. Patient characteristics and perioperative parameters were used to identify the risk factors for TUC. The TUC group was defined as a case of conversion to hemostasis using electrocautery during the hemostasis step after enucleation.

RESULTS

Of 1,563 patients, 357 underwent TUC (TUC group; 22.8%) as an adjuvant (n=299, 19.1%) or salvage (n=58, 3.7%) therapy. Patients in the TUC group were older (mean±standard deviation, 70.6±7.3 years vs. 69.3±7.0 years; P=0.002), had more 5-alpha reductase inhibitor (5-ARI) use (35.6% vs. 25.9%, P<0.001), higher serum prostate-specific antigen (PSA) (5.4 ±4.8 ng/mL vs. 3.8 ±4.5 ng/mL, P <0.001), larger total prostate volume (TPV) (89.5 ±44.7 mL vs. 66.0 ±32.6 mL, P<0.001), and larger transitional zone volume (TZV) (57.3±34.9 mL vs. 37.7±24.2 mL, P<0.001) than those who did not undergo TUC (non-TUC group). In univariate logistic regression analysis, age, 5-ARI use, PSA, TPV, and TZV correlated with TUC, whereas in multivariate logistic regression analysis, only TZV was associated with TUC. The odds ratios (ORs) of TUC were analyzed per TZV quartile. Compared to TZV<22.3 mL, the OR was 2.42 in 34.1 mL≤TZV<53.5 mL (95% confidence interval [CI], 1.58-3.72; P<0.001), 5.17 in ≥53.5 mL (95% CI, 3.44-7.77; P<0.001).

CONCLUSION

The risk of TUC during HoLEP surgery increases in patients with TZV >35 mL. Therefore, TUC may be potentially necessary in patients with a large transition zone volume in patients with BPH.

A Cost-Benefit Analysis of Bipolar TURP for the Treatment of Bladder Outflow Obstruction

Transurethral resection of the prostate (TURP) is the gold standard surgical technique for endoscopic treatment of benign prostatic hyperplasia (BPH). Introduced in 2001, the bipolar energy appeared to be a valid alternative to the classical monopolar one with reduced risk of complication related to the use of saline irrigation and to the increased hemostatic efficacy. More recently, raising attention has been given to laser enucleation and vaporization techniques, which appear to achieve further advantages in terms of reduced hospital stay and complications compared to the resection ones. Few studies have investigated the cost/benefit ratio related to these techniques. The aim of this systematic review was to analyze the cost/benefit ratio of bipolar TURP (B-TURP) compared with other endoscopic procedures.

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.

Learning From Those who Learned: A Survey of Fellowship Trained HoLEP Surgeons and Their Current Practice Patterns

OBJECTIVE

To gain insight from the experience of learning Holmium laser enucleation of the prostate (HoLEP), teaching HoLEP, and the current HoLEP practice patterns of fellowship-trained endourologists.

METHODS

Surveys were electronically distributed to United States (U.S.) practicing urologists who completed American Endourology fellowships (that included HoLEP) within the past 6 years. Questions focused on HoLEP training and current practice patterns.

RESULTS

As of September 2019, 12% (6/49) of U.S. endourology fellowships reported including HoLEP as a component of training. With a 73% response rate (16 of 22), 81% participated in over 20 cases during training, while 50% participated in over 50. A total of 25% independently completed over 50 cases from start to finish. At training completion, most (80%) felt comfortable/somewhat comfortable completing an entire HoLEP independently and managing post-op complications. Seventy-five percent practice HoLEP currently, and 25% teach to trainees. When asked "What is most challenging about HoLEP in current practice?" common responses were: efficiency/profitability concerns, poor reimbursement, educating OR/hospital staff, establishing case volume, minimizing sphincter trauma, and large glands (>200gm).

CONCLUSION

With diverse exposure in fellowship, most incorporate HoLEP into their practice after training. Aspects of the procedure remain challenging after several years of experience. Profitability/reimbursement concerns should be further explored to increase HoLEP adoption.

The cost-effectiveness of transurethral resection of the prostate vs thulium laser transurethral vaporesection of the prostate in the UNBLOCS randomised controlled trial for benign prostatic obstruction

OBJECTIVE

To determine the cost-effectiveness of the current 'gold standard' operation of transurethral resection of the prostate (TURP) compared to the new laser technique of thulium laser transurethral vaporesection of the prostate (ThuVARP) in men with benign prostatic obstruction (BPO) within the UK National Health Service (NHS).

PATIENTS AND METHODS

The trial was conducted across seven UK centres (four university teaching hospitals and three district general hospitals). A total of 410 men aged ≥18 years presenting with either bothersome lower urinary tract symptoms (LUTS) or urinary retention secondary to BPO, and suitable for surgery, were randomised (whilst under anaesthetic) 1:1 to receive the TURP or ThuVARP procedure. Resource use in relation to the operation, initial inpatient stay, and subsequent use of NHS services was collected for 12 months from randomisation (equivalent to primary effectiveness outcome) using hospital records and patient questionnaires. Resources were valued using UK reference costs. Quality adjusted life years (QALYs) were calculated from the EuroQoL five Dimensions five Levels (EQ-5D-5L) questionnaire completed at baseline, 3- and 12-months. Total adjusted mean costs, QALYs and incremental Net Monetary Benefit statistics were calculated: cost-effectiveness acceptability curves and sensitivity analyses addressed uncertainty.

RESULTS

The total adjusted mean secondary care cost over the 12 months in the TURP arm (£4244) was £9 (95% CI -£376, £359) lower than the ThuVARP arm (£4253). The ThuVARP operation took on average 21 min longer than TURP. The adjusted mean difference of QALYs (0.01 favouring TURP, 95% CI -0.01, 0.04) was similar between the arms. There is a 76% probability that TURP is the cost-effective option compared with ThuVARP at the £20 000 per QALY willingness to pay threshold used by National Institute for Health and Care Excellence (NICE).

CONCLUSION

One of the anticipated benefits of the laser surgery, reduced length of hospital stay with an associated reduction in cost, did not materialise within the study. The longer duration of the ThuVARP procedure is important to consider, both from a patient perspective in terms of increased time under anaesthetic, and from a service delivery perspective. TURP remains a highly cost-effective treatment for men with BPO.

Anatomical endoscopic enucleation of the prostate: The next gold standard? No! (or not yet!)

Most cases of lower urinary tract symptoms due to benign prostatic hyperplasia are initially managed through medical therapy. In cases that surgery is indicated, the anatomical endoscopic enucleation of the prostate (aEEP), first described in 1983, allegedly presents the same safety profile as the best endoscopic non-enucleating procedures and the same long-term functional outcomes as simple prostatectomy. Thus, why aEEP has not yet been consolidated as the gold-standard BPH surgical treatment? The main reasons are as follows: (a) Multiple energy sources and techniques; (b) High costs; (c) Steep learning curve; (d) Rare in-residency training; (e) Reimbursement issues; (f) Outcomes and (g) Complications. We do believe aEEP is an important advance and a "practice-changing" procedure that will play an important role in the BPH surgical options arsenal, especially for larger prostates. However, there is a need to start an in-residency training program, with a mentor guidance, and, over time, the cost will likely be reduced due to greater competition between companies and greater support from health insurers. Considering these points, in the future, EEP may be considered the gold-standard treatment for BPH… but not yet.

Transurethral procedures in the treatment of benign prostatic hyperplasia: A systematic review and meta-analysis of effectiveness and complications

BACKGROUND

With the progress of surgical techniques and instruments, various minimally invasive surgical therapies were developed to treat benign prostatic hyperplasisa (BPH). However, the efficacy and safety of different transurethral procedures for the treatment of BPH are still undefined.

METHOD

A systematic search was performed for all randomized controlled trials (RCTs), which compared the transurethral procedures for BPH from 1995 to 2016. The clinical baseline characteristics, International Prostate Symptom Score (IPSS), quality of life (QoL), postvoid residual (PVR), maximum flow rate (Qmax), short-term and long-term complications were analyzed using RevMan and ADDIS software.

RESULT

Eighty-eight randomly controlled trials and fifteen procedures were included in the network meta-analysis. HoLEP greatly inproved PVR. TmLRP had the best efficacy in improving QoL score. Diode laser vaporization of prostate was superior in improving IPSS and Qmax. Diode laser through vaporization required the shortest time in catheterization, while Nd:YAG was the longest procedure. For the hospitalization time, TUR was the longest and HoLEP was the shortest. TmLRP was related to the lowest postoperative hemoglobin decrease. TmLEP had the least rates of occurrence of hematuria, reoperation and erectile dysfunction. HoLEP was the best choice to reduce the incidence of recatheterization, urinary retention, urinary tract infection, stress urinary incontinence and retrograde ejaculation. The complications such as blood transfusion, urethral stricture, bladder neck contracture were relatively rare in the patients who underwent diode laser vaporization of prostate.

CONCLUSION

Compared with other transurethral procedures, thulium, holmium and diode lasers were associated with better efficacy and fewer complications.

Randomized, controlled trial of laser vs. bipolar plasma vaporization treatment of benign prostatic hyperplasia

INTRODUCTION

Prostate vaporization technology is becoming a standard of care for treatment of moderate, symptomatic benign prostatic hyperplasia (BPH). We compared two transurethral prostate vaporization technologies with respect to cost, efficiency, efficacy, safety, and surgical team satisfaction.

METHODS

Fifty-five patients meeting standardized symptom criteria for BPH were randomized to either Olympus Plasma Button^TM or Biolitec EVOLVE^® diode laser vaporization. Primary outcome of cost with secondary outcomes of clinical efficacy, resection time, surgical team satisfaction, and safety were analyzed. Followup was carried out at six and 12 weeks. Patient factors included baseline, as well as six- and 12-week International Prostate Symptom Score (IPSS) with quality of life (QoL) scores. We recorded surgical team satisfaction with a Likert-style survey investigating ease of set-up, reliability, efficiency, and ability to reach desired endpoint. All complications or side effects detected within three months and the resulting management were included in the cost analysis.

RESULTS

Mean cost per patient was $3418 for the Olympus group and $4564 for Biolitec (p<0.05). Surgical vaporization time was significantly less for the Olympus group, 24.3 vs. 33.5 minutes (p<0.05). Surgical and nursing staff preferred the Olympus device (p<0.05). IPPS symptom improvement and complication rates were similar between groups. Patients in the Biolitec arm had more intraoperative bleeding episodes requiring conversion to monopolar transurethral resection of the prostate (TURP) (three vs. none).

CONCLUSIONS

In a head-to-head randomized trial, Olympus Plasma Button transurethral vaporization was more cost-effective, faster, and preferred by surgical staff when compared to Biolitetec Diode Laser vaporization. Both devices showed similar safety and efficacy.

Different lasers in the treatment of benign prostatic hyperplasia: a network meta-analysis

All available surgical treatments for benign prostatic hyperplasia (BPH) have their individual advantages or disadvantages. However, the lack of head-to-head studies comparing different surgeries makes it unavailable to conduct direct analysis. To compare the efficacy and safety among different lasers and transurethral resection of prostate (TURP) for BPH, randomized controlled trials were searched in MEDLINE, EMBASE, Cochrane library, WHO International Clinical Trial Registration Platform, and Clinical Trial.gov by 2015.5; and the effectiveness-, perioperation- and complication-related outcomes were assessed by network meta-analysis. 36 studies involving 3831 patients were included. Holmium laser through resection and enucleation had the best efficacy in maximum flow rate. Thulium laser through vapo-resection was superior in improving international prostate symptom score and holmium laser through enucleation was the best for post-voiding residual volume improvement. Diode laser through vaporization was the rapidest in removing postoperative indwelling catheter, while TURP was the longest. TURP required the longest hospitalization and thulium laser through vapo-resection was relatively shorter. Holmium and thulium lasers seem to be relatively better in surgical efficacy and safety, so that these two lasers might be preferred in selection of optimal laser surgery. Actually, more large-scale and high quality head-to-head RCTs are suggested to validate the conclusions.

Evidence of the efficacy and safety of the thulium laser in the treatment of men with benign prostatic obstruction

In 2005, the high power thulium laser was introduced for the surgical treatment of benign prostatic obstruction. It has several properties that confer theoretical advantages over other lasers used for the same indication, such as technical versatility and a relatively small zone of thermal damage. Studies using the 70-150 W thulium laser systems demonstrate good efficacy of these procedures with low morbidity and few complications even in higher risk patients. Different techniques have been employed to treat the prostate with this technology, including enucleation, vapoenucleation, vaporization and resection. Comparative studies have been published comparing thulium laser prostatectomy to monopolar transurethral resection of prostate (TURP), bipolar TURP and holmium laser enucleation of prostate (HoLEP). In this review we discuss the current literature on the safety and efficacy of various thulium techniques for the treatment of benign prostatic hyperplasia and examine comparative studies.

One day surgery in the treatment of benign prostatic enlargement with thulium laser: A single institution experience

PURPOSE

Various articles have previously addressed the introduction of new surgical laser therapies for an enlarged prostate gland causing obstructive symptoms. The objective of this study was to report the feasibility of performing the thulium laser vapo-enucleation of the prostate (ThuVEP) procedure for benign prostatic obstruction in a 1-day surgery.

MATERIALS AND METHODS

From September 2011 to September 2013, we conducted a prospective study on patients who underwent ThuVEP in a 1-day surgery. The primary outcomes measured perioperatively included operative time, resected tissue weight, hemoglobin decrease, transfusion rate, postoperative irrigation and catheterization time, and postoperative hospital stay. Also, the preoperative and postoperative International Prostate Symptom Score (IPSS) and results of uroflowmetry performed on the 7th and 30th postoperative days were recorded. All perioperative and postoperative complications were monitored.

RESULTS

A total of 53 patients underwent the surgical treatment in a 1-day surgery. Seven patients continued antiaggregant therapy with aspirin. Mean preoperative prostatic adenoma volume was 56.6 mL. Mean operative time was 71 minutes. The average catheter time was 14.8 hours. The peak urinary flow rate on day 7 improved from 9.3 to 17.42 mL/s (p<0.001) and the IPSS improved from 18 to 10.2 (p<0.01). Patients were routinely discharged on the day of catheter removal. No complications were recorded.

CONCLUSIONS

ThuVEP can be safely conducted as a 1-day surgical procedure. This strategy results in cost savings. ThuVEP shows good standardized outcomes with respect to improvement in flow parameters and length of bladder catheterization.

Reoperation After Holmium Laser Enucleation of the Prostate for Management of Benign Prostatic Hyperplasia: Assessment of Risk Factors with Time to Event Analysis

PURPOSE

To determine risk factors of reoperation after holmium laser enucleation of the prostate (HoLEP) for management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) with time to event analysis.

METHODS

A prospectively maintained database was reviewed for patients undergoing HoLEP. Baseline and follow-up data were compared in terms of International Prostate Symptoms Score, quality of life, peak flow rate, residual urine, and prostate-specific antigen (PSA) at 1, 6, and 12-months and then annually. Perioperative and late adverse events were recorded. Reoperation was defined as the need for any surgical intervention to relieve bothersome LUTS after HoLEP. Multivariate logistic regression was used to determine covariates associated with reoperation and the Kaplan-Meier curve assessed the time to reoperation.

RESULTS

A total of 1216 HoLEP procedures were performed between March 1998 and October 2013 with a mean prostate volume of 94.8 ± 52.7 cc. Catheter time and hospital stay were 1.4 ± 1.9 and 1.3 ± 1.6 days, respectively. After a median follow-up of 7.6 years (1-14 years), 52 (4.3%) patients needed reoperation for recurrent LUTS, including 13 (1.07%) for residual/recurrent adenoma, 14 (1.15%) for bladder neck contracture (BNC), and 25 (2.05%) for de novo urethral stricture. In multivariate regression, smaller prostate size (< 62 cc), PSA reduction < 50%, and history of previous prostate surgery were significantly associated with recurrence of adenoma. BNC was significantly associated with smaller glands (< 54 cc) while longer operative time and postoperative catheterization were significantly associated with urethral stricture. Kaplan-Meier curve demonstrates post-HoLEP freedom from reoperation of 96.9% at 5 years and 95.1% at 10 years.

CONCLUSIONS

In a single center large series, HoLEP has 95% reoperation-free probability at 10 years. Relatively small-size prostate may have an impact on recurrence of adenoma and bladder neck contracture. PSA reduction < 50% was significantly associated with recurrence of adenoma while longer operative time and postoperative catheterization were significantly associated with postoperative urethral stricture.

GreenLight™ laser (XPS) photoselective vapo-enucleation versus holmium laser enucleation of the prostate for the treatment of symptomatic benign prostatic hyperplasia: a randomized controlled study

PURPOSE

After the advent of the GreenLight XPS™ (180 W) 532 nm laser, photoselective vapo-enucleation of the prostate could compete with holmium laser enucleation of the prostate as a size independent procedure. We assessed whether photoselective vapo-enucleation of the prostate-XPS is not less effective than holmium laser enucleation of prostate for improvement of lower urinary tract symptoms secondary to benign prostatic hyperplasia.

MATERIALS AND METHODS

A randomized controlled noninferiority trial comparing holmium laser enucleation of the prostate to photoselective vapo-enucleation of the prostate-XPS 180 W was conducted. I-PSS, flow rate, residual urine, prostate specific antigen and prostate volume changes as well as perioperative and late adverse events were compared. Noninferiority of I-PSS at 1 year was evaluated using a 1-sided test at 5% level of significance. The statistical significance of other comparators was assessed at the (2-sided) 5% level.

RESULTS

Overall 50 and 53 patients were included in the holmium laser enucleation and photoselective vapo-enucleation of the prostate groups, respectively. Operative time, hospital stay and time to catheter removal were comparable between the groups. There was significant, comparable improvement in I-PSS and post-void residual urine volume at 1, 4 and 12 months. After 4 months prostate size reduction was significantly higher in the holmium laser enucleation of prostate group (74.3% vs 43.1%, p=0.001). At 12 months maximum urine flow rate was significantly higher in the holmium laser enucleation of prostate group (26.4 ±11.5 vs 18.4 ±7.5 ml per second, p=0.03). Re-intervention was needed in 2 and 3 cases in the holmium laser enucleation and photoselective vapo-enucleation of the prostate groups, respectively (p=1.0). Mean estimated cost per holmium laser enucleation of prostate procedure was significantly lower than per photoselective vapo-enucleation of the prostate procedure.

CONCLUSIONS

Compared to holmium laser enucleation of prostate, GreenLight XPS laser photoselective vapo-enucleation of the prostate is safe, noninferior and effective in treatment of benign prostatic hyperplasia.

Enucleation techniques for benign prostate obstruction: which one and why?

PURPOSE OF REVIEW

Endoscopic enucleation of the prostate is the most advanced form of surgical management of benign prostate hyperplasia. The purpose of this review is to update the reader on various modalities currently in use, and in trial, for endoscopic enucleation.

RECENT FINDINGS

A recent paradigm shift has occurred for the proponents of electrosurgery technology to utilizes the advantages offered by laser enucleation with interest in bipolar enucleation. Holmium laser enucleation still has the greatest randomized evidence with the longest follow-up among all the various lasers used to perform enucleation.

SUMMARY

Randomized trials with longer follow-up are required to demonstrate whether nonholmium types of energy really have advantages in enucleation (speed, ease of use and hemostasis) and durability (decade plus) as compared to the holmium laser.

Holmium laser enucleation versus transurethral resection in patients with benign prostate hyperplasia: an updated systematic review with meta-analysis and trial sequential analysis

Background

Holmium laser enucleation (HoLEP) in surgical treatment of benign prostate hyperplasia (BPH) potentially offers advantages over transurethral resection of the prostate (TURP).

Methods

Published randomized controlled trials (RCTs) were identified from PubMed, EMBASE, Science Citation Index, and the Cochrane Library up to October 10, 2013 (updated on February 5, 2014). After methodological quality assessment and data extraction, meta-analysis was performed using STATA 12.0 and Trial Sequential Analysis (TSA) 0.9 software.

Results

Fifteen studies including 8 RCTs involving 855 patients met the criteria. The results of meta-analysis showed that: a) efficacy indicators: there was no significant difference in quality of life between the two groups (P>0.05), but compared with the TURP group, Qmax was better at 3 months and 12 months, PVR was less at 6, 12 months, and IPSS was lower at 12 months in the HoLEP, b) safety indicators: compared with the TURP, HoLEP had less blood transfusion (RR 0.17, 95% CI 0.06 to 0.47), but there was no significant difference in early and late postoperative complications (P>0.05), and c) perioperative indicators: HoLEP was associated with longer operation time (WMD 14.19 min, 95% CI 6.30 to 22.08 min), shorter catheterization time (WMD −19.97 h, 95% CI −24.24 to −15.70 h) and hospital stay (WMD −25.25 h, 95% CI −29.81 to −20.68 h).

Conclusions

In conventional meta-analyses, there is no clinically relevant difference in early and late postoperative complications between the two techniques, but HoLEP is preferable due to advantage in the curative effect, less blood transfusion rate, shorter catheterization duration time and hospital stay. However, trial sequential analysis does not allow us to draw any solid conclusion in overall clinical benefit comparison between the two approaches. Further large, well-designed, multicentre/international RCTs with long-term data and the comparison between the two approaches remain open.

Holmium laser enucleation of the prostate: a review of the clinical trial evidence

Transurethral resection of the prostate (TURP) has remained the procedure of choice for the surgical treatment of bladder outflow obstruction for almost five decades, but holmium laser enucleation of the prostate (HoLEP) is now emerging as a challenger as the gold standard procedure. This review summarizes the evidence base for HoLEP, with particular reference to randomized, controlled (level 1) evidence.

Best laser for prostatectomy in the year 2013

Lasers have come a long way in the management of benign prostatic hyperplasia. Over last nearly two decades, various different lasers have been utilized for prostatectomy. Neodymium: yttrium-aluminum-garnet laser that started this journey, is no longer used for prostatectomy. Holmium laser can achieve transurethral enucleation of the prostatic adenoma producing a fossa that can be compared with the fossa after Freyer's prostatectomy. Green light laser has a short learning curve, is nearly blood-less with good immediate results. Thulium laser is a faster cutting laser while diode laser is a portable laser device. Often laser prostatectomy is considered as a replacement for the standard transurethral resection of prostate (TURP). To be comparable, laser should reduce or avoid the immediate and long-term complications of TURP, especially bleeding and need for blood transfusion. It should also be safe in the ever increasing patient population on antiplatelet and anticoagulant drugs. We need to take stock of the situation and identify, which among the present day lasers has stood the test of time. A review of the literature was performed to see if any of these lasers could be called the “best laser for prostatectomy in 2013.”

Canadian trend in surgical management of benign prostatic hyperplasia and laser therapy from 2007-2008 to 2011-2012

INTRODUCTION

Clinically benign prostatic hyperplasia (BPH) is classically associated by the progressive development of lower urinary tract symptoms (LUTS). The incidence of bothersome LUTS is associated with age and may vary in patients over 50 years old. In many developing countries with an aging population, BPH associated with LUTS has become a major health issue. To optimize quality of care and control of cost, there is an imperative need to examine the pattern of BPH management. The goal of this study is to capture the Canadian trend in surgical management of BPH and the use of laser therapy during the last 5 years from 2007-2008 to 2011-2012.

METHODS

We collected the number of transurethral resection of the prostate (TURP) procedures performed in each province in Canada from the Canadian Institute for Health Information (CIHI) reports for the fiscal years (April 1(st)-March 31(st)) of 2007-2008, 2008-2009, 2009-2010, 2010-2011 and 2011-2012.

RESULTS

Overall, the total number of TURP procedures remained stable from 20 294 procedures per year in 2007 to 20 629 in 2011. In terms of distribution according to provinces, in 2011, about 40% of procedures were performed in Ontario, 20% in BC, 18 in Quebec and 8% in Alberta. These proportions between provinces have remained similar and stable between 2007 and 2011. In contrast, the number of alternative minimally invasive procedures has slowly grown from 767 interventions in 2007 to 1559 in 2011. Overall, laser procedures represented 7.6% of the total number of BPH surgeries in Canada in 2011. The contribution of laser therapy to the amount of total BPH procedures largely varied between provinces.

CONCLUSIONS

The use of minimally invasive laser procedure alternatives to TURP is progressively growing. Among the novel laser therapies, HoLEP and GreenLight vaporization are the only procedures that have demonstrated equivalent outcomes compared to TURP in randomized clinical trials. Furthermore, due to shorter hospital stay, these novel laser modalities have the potential to reduce healthcare expenses for the treatment of BPH. We can infer that following the trend observed in the United States, the number of laser therapies for BPH in Canada may increase significantly during the coming years.

Technical aspects of holmium laser enucleation of the prostate for benign prostatic hyperplasia

Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive procedure and a size-independent treatment for benign prostatic hyperplasia with excellent long-term surgical outcome. HoLEP has become an alternative to conventional transurethral resection of the prostate or open prostatectomy owing to its efficacy and safety. Although HoLEP is known to have a steep learning curve, very few articles have addressed the technical aspects of HoLEP. Herein, we described detailed techniques and tips for HoLEP as performed at Seoul National University Hospital in a step-by-step manner with extensive review of the literature.

Relationship of postoperative recatheterization and intraoperative bladder distention volume in holmium laser enucleation of the prostate for benign prostatic hyperplasia

Purpose

The purpose of this study was to identify the risk factors for recatheterization after holmium laser enucleation of the prostate (HoLEP).

Materials and Methods

A total of 166 consecutive patients treated with HoLEP by a single surgeon from January 2010 to June 2011 were enrolled in this study. We collected data on preoperative and intraoperative parameters, including intraoperative bladder distention volume. The patients were divided into two groups. Group 1 included patients who voided successfully after removal of the catheter, and group 2 included patients who required recatheterization. Analysis and comparison of the perioperative parameters of both groups was performed for identification of risk factors for recatheterization.

Results

Recatheterization was required in 9 of 166 (5.4%) patients. No significant differences in age or preoperative parameters, including prostate-specific antigen, prostate volume, International Prostate Symptom Score, peak flow rate, postvoid residual urine, maximal bladder capacity, and Abrahams Griffiths number, were observed between the two groups. Of the intraoperative parameters, intraoperative bladder distention volume was significantly smaller in group 1 than in group 2 (700.65 mL vs. 897.78 mL, p<0.001). In the multivariate logistic regression analysis, after adjustment for other variables, intraoperative bladder distention volume was found to be a statistically significant risk factor for postoperative recatheterization (hazard ratio, 1.006; confidence interval, 1.002 to 1.010; p=0.002).

Conclusions

Nine of 166 (5.4%) patients failed to void after HoLEP and required catheterization. Intraoperative bladder distention volume was found to be a statistically significant risk factor for recatheterization in this patient group.

Evolution and success of holmium laser enucleation of the prostate

Aims:

The purpose of this article is to review the development of instruments, current technique, and expected outcomes for holmium laser enucleation of the prostate (HoLEP).

Materials and Methods:

A review of published, peer-reviewed articles focusing on HoLEP was performed using the MEDLINE database.

Results:

Historically, the gold-standard management for symptomatic obstructing benign prostatic hyperplasia (BPH) has been transurethral resection of the prostate (TURP). With the development of new laser technology minimally invasive surgical procedures have been introduced in an attempt to decrease the morbidity experienced with standard TURP. Laser treatment of BPH has evolved from coagulation to complete adenoma enucleation. The holmium laser was initially utilized for prostate ablation and soon evolved into holmium laser tissue resection, but was limited by difficulties with extracting the prostate tissue from the bladder. With the development of a compatible tissue morcellator whole prostate lobes could be enucleated similar to an open prostate enucleation and the HoLEP procedure was developed. Currently HoLEP is the only procedure to demonstrate superior outcomes to TURP on urodynamic studies and long-term studies demonstrate its durability up to 7 years post procedure. Changes in enucleation technique have also increased the efficiency of the HoLEP procedure, such that any sized prostate can be treated.

Conclusions:

HoLEP is a safe and effective surgical treatment for symptomatic BPH, dependent on a high powered laser and morcellation system. The procedure continues to gain acceptance due to excellent short and long-term results, its wide application, and further simplification of technique.

An update on holmium laser enucleation of the prostate and why it has stood the test of time

PURPOSE OF REVIEW

Holmium laser enucleation of the prostate is an endoscopic alternative for the treatment of symptomatic benign prostatic hyperplasia for men with prostates of any size. Holmium laser enucleation of the prostate is superior to other modalities for the treatment of benign prostatic hyperplasia. We present the most current literature on this procedure.

RECENT FINDINGS

In the 18-month span of this review, there have been a number of articles published on holmium laser enucleation of the prostate. These studies assessed the safety, efficacy, and durability of this procedure. Among these is the largest study to date providing supporting evidence to the long-term efficacy and safety of holmium laser enucleation of the prostate. Other studies provide compelling evidence to suggest that holmium laser enucleation of the prostate can be used in prostates of any size and can provide long-term durable outcomes.

SUMMARY

Holmium laser enucleation of the prostate represents an effective, well tolerated, and durable procedure to relieve bladder outlet obstruction due to benign prostatic hyperplasia. Holmium laser enucleation of the prostate is a minimally invasive approach which accomplishes complete adenoma removal and, as such, provides unique advantages over other surgical treatments for men with benign prostatic hyperplasia.

Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial

OBJECTIVES

To report 5-year follow-up results of a randomised clinical trial comparing holmium laser enucleation of the prostate (HoLEP) with open prostatectomy (OP).

METHODS

One hundred twenty patients with prostates greater than 100g in weight according to transrectal ultrasound were randomised to either the HoLEP or the OP group (ie, 60 patients to each group). Preoperative and postoperative assessments included American Urological Association Symptom Score (AUA-SS), maximum urinary flow rates (Qmax), and postvoid residual urine (PVRU) volumes. Measurements were performed at 1, 3, 6, 12, 18, 24, 36, 48, and 60 mo. Postoperative outcome data were compared. All complications were recorded.

RESULTS

Five years postoperatively, a total of 46 patients (38.3%) were lost to follow-up or had to be excluded from the study. All the remaining 74 patients (42 HoLEP vs. 32 OP patients, p=0.11) had undergone the 5-yr follow-up assessments. Mean AUA-SS was 3.0 in both groups (p=0.98), mean Qmax was 24.4 ml/s in both groups (p=0.97) and PVRU volume was 11 ml in the HoLEP and 5 ml in the OP group (p=0.25). Late complications consisted of urethral strictures and bladder-neck contractures; reoperation rates were 5% in the HoLEP and 6.7% in the OP group (p=1.0). No patient developed benign prostatic hyperplasia recurrence.

CONCLUSIONS

Five years after the operation, the improvements in micturition obtained with HoLEP and OP were equally good, and reoperation rates similarly low. HoLEP seems to be a true endourological alternative to OP.