Comparison of Holmium Laser Enucleation of the Prostate with Bipolar Plasmakinetic Enucleation of the Prostate: A Randomized, Prospective Controlled Trial at Midterm Follow-Up

Safety and efficacy of transurethral holmium laser enucleation of the prostate versus bipolar transurethral resection of the prostate in the treatment of benign prostatic hyperplasia: a prospective randomized controlled trial

PURPOSE

To evaluate the safety and efficacy of transurethral holmium laser enucleation of the prostate (HoLEP) compared to bipolar transurethral resection of the prostate (bTUR-P) in the treatment of benign prostatic hyperplasia (BPH).

METHODS

A total of 220 BPH patients hospitalized from January 2022 to September 2023 were included in this study. These patients were randomly assigned to HoLEP and bTUR-P groups, with 110 participants in each group. We collected preoperative general information, perioperative data, complications, and postoperative follow-up indicators from both groups of patients.

RESULTS

The baseline characteristics of patients in both groups were similar, with no statistical significance (P > 0.05). Compared to the bTUR-P group, the HoLEP group exhibited significantly less intraoperative bleeding (P < 0.001), shorter bladder irrigation time (P = 0.002), shorter catheter retention time (P < 0.001), and reduced postoperative hospitalization (P = 0.002). Additionally, the pain score during urination after catheter removal was significantly lower in the HoLEP group (P < 0.001). Postoperative complications occurred in both groups; however, they were less frequent in the HoLEP group (4 cases), primarily consisting of urinary retention and postoperative bleeding. The bTUR-P group experienced more complications (9 cases). Significant reductions in postoperative residual urine volume (RUV) were observed in both groups (P < 0.001). Both groups also showed significant improvements in Quality of Life (QoL) scores and International Prostate Symptom Scores (IPSS), with the HoLEP group demonstrating a more significant decrease in IPSS (P < 0.001).

CONCLUSION

After comprehensive evaluation, HoLEP was superior to bTUR-P in terms of safety and efficacy. Therefore, HoLEP may be a preferable choice for the treatment of BPH.

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.

The learning curve for transurethral enucleation with bipolar energy for benign prostate hyperplasia: a single-surgeon experience of 494 patients

This study was performed to investigate the learning curve of transurethral enucleation with bipolar energy (TUEB) for benign prostatic hyperplasia. The study involved 494 consecutive patients who underwent TUEB for benign prostatic hyperplasia from August 2018 to March 2022 by one surgeon (SJJ, Seoul National University Bundang Hospital, Seongnam, Korea). The patients were followed up at 1 week, 1 month, 3 months, and 6 months postoperatively. To evaluate the learning curve of TUEB, perioperative parameters including the enucleation ratio (enucleated tissue weight/transitional zone volume), TUEB efficiency (enucleated tissue weight/operation time), and enucleation efficiency (enucleated tissue weight/enucleation time) were analyzed. Functional outcomes and postoperative complications were also assessed, including the International Prostate Symptom Score (IPSS), IPSS quality-of-life (QoL) score, and uroflowmetry outcomes. The patients' median age was 72 (interquartile range [IQR]: 66-78) years, and the estimated prostate volume and transitional zone volume were 63.0 (IQR: 46.0-90.6) ml and 37.1 (IQR: 24.0-60.0) ml, respectively. The enucleation ratio, TUEB efficiency, and enucleation efficiency were 0.60 (IQR: 0.46-0.54) g ml -1 , 0.33 (IQR: 0.22-0.46) g min -1 , and 0.50 (IQR: 0.35-0.72) g min -1 , respectively, plateauing after 70 cases. The functional outcomes, including total IPSS, IPSS QoL score, and uroflowmetry outcomes, significantly improved at 6 months after TUEB (all P < 0.05), but without significant differences over the learning curve. Sixty-five (13.2%) patients developed complications after TUEB, 21.5% of whom experienced major complications (Clavien-Dindo grade ≥3). The rate of major complications declined as the number of TUEB cases increased ( P = 0.013). Our results suggest that the efficiency of TUEB stabilized within 70 procedures.

Reoperation after surgical treatment for benign prostatic hyperplasia: a systematic review

Context

Surgical treatment is important for male lower urinary tract symptom (LUTS) management, but there are few reviews of the risks of reoperation.

Objective

To systematically evaluate the current evidence regarding the reoperation rates of surgical treatment for LUTS in accordance with current recommendations and guidelines.

Evidence acquisition

Eligible studies published up to July 2023, were searched for in the PubMed® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), and Web of Science™ (Clarivate™, Philadelphia, PA, USA) databases. STATA® (StataCorp LP, College Station, TX, USA) software was used to conduct the meta-analysis. Random-effects models were used to calculate the pooled incidences (PIs) of reoperation and the 95% confidence intervals (CIs).

Evidence synthesis

A total of 119 studies with 130,106 patients were included. The reoperation rate of transurethral resection of the prostate (TURP) at 1, 2, 3, and 5 years was 4.0%, 5.0%, 6.0%, and 7.7%, respectively. The reoperation rate of plasma kinetic loop resection of the prostate (PKRP) at 1, 2, 3, and 5 years was 3.5%, 3.6%, 5.7%, and 6.6%, respectively. The reoperation rate of holmium laser enucleation of the prostate (HoLEP) at 1, 2, 3, and 5 years was 2.4%, 3.3%, 5.4%, and 6.6%, respectively. The reoperation rate of photoselective vaporization of the prostate (PVP) at 1, 2, 3, and 5 years was 3.3%, 4.1%, 6.7%, and 7.1%, respectively. The reoperation rate of surgery with AquaBeam® at 1, 2, 3, and 5 years was 2.6%, 3.1%, 3.0%, and 4.1%, respectively. The reoperation rate of prostatic artery embolization (PAE) at 1, 2, 3, and 5 years was 12.2%, 20.0%, 26.4%, and 23.8%, respectively. The reoperation rate of transurethral microwave thermotherapy (TUMT) at 1, 2, 3, and 5 years was 9.9%, 19.9%, 23.3%, and 31.2%, respectively. The reoperation rate of transurethral incision of the prostate (TUIP) at 5 years was 13.4%. The reoperation rate of open prostatectomy (OP) at 1 and 5 years was 1.3% and 4.4%, respectively. The reoperation rate of thulium laser enucleation of the prostate (ThuLEP) at 1, 2, and 5 years was 3.7%, 7.7%, and 8.4%, respectively.

Conclusion

Our results summarized the reoperation rates of 10 surgical procedures over follow-up durations of 1, 2, 3, and 5 years, which could provide reference for urologists and LUTS patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023445780.