Peri-operative complications of holmium laser enucleation of the prostate: experience in the first 280 patients, and a review of literature

Perioperative Outcomes and Complication Rates in Holmium Laser Enucleation of the Prostate Patients After Prior Prostate Biopsy-Does It Really Make a Difference? A Propensity Score Matched Analysis

Introduction: Before holmium laser enucleation of the prostate (HoLEP), many patients have undergone short-term prostate biopsy (PB) to rule out the presence of prostate cancer. The aim of this study is to determine whether a short-term PB before HoLEP has an impact on the perioperative outcomes or complications of HoLEP. Methods: In total, 734 consecutive patients treated with HoLEP at a tertiary care university hospital between January 2021 and July 2023 were retrospectively enrolled. Patients who had PB within 6 months before HoLEP were matched to patients who underwent PB more than 6 months or had no PB before HoLEP using propensity score matching (PSM) based on age, prostate volume (PV), prostate-specific antigen (PSA), preoperative urinary tract infection (UTI), and surgeon. Perioperative parameters, such as operation time (OT), enucleation efficiency (EF), as well as complications according to the Satava classification, the Clavien-Dindo classification (CDC), and the Comprehensive Complication Index (CCI) were evaluated. Results: In total, 206 patients were matched. Age, PV, PSA, as well as the presence of a preoperative UTI and surgeons did not differ significantly between both groups after PSM. There were no significant differences in mean OT (75 vs. 81 minutes, p = 0.28) and EF (2.13 vs. 2.13 g/min, p = 0.99). No differences were noted regarding intraoperative (16 vs. 25, p = 0.16) or postoperative complications graded by CDC (p = 0.53) and CCI (p = 0.92). Conclusion: PB within 6 months preoperatively before HoLEP showed no effect on perioperative outcomes or intra- and postoperative complications.

Incidence and management of BPH surgery-related urethral stricture: results from a large U.S. database

INTRODUCTION AND OBJECTIVES

Urethral stricture (US) is a well-known complication after surgical treatment of benign prostatic hyperplasia (BPH). This study aimed to evaluate the contemporary incidence of the US after different types of BPH surgery, to identify associated risk factors and to assess its management.

METHODS

A retrospective analysis was conducted using the PearlDiver™ Mariner database, containing de-identified patient records compiled between 2011 and 2022. Specific International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify population characteristics and outcomes. All the most employed surgical procedures for BPH treatment were considered. Multivariable logistic regression was employed to evaluate factors associated with diagnosis of post-operative US.

RESULTS

Among 274,808 patients who underwent BPH surgery, 10,918 developed post-operative US (3.97%) within 12 months. Higher incidence of US was observed following TURP (4.48%), Transurethral Incision of the Prostate (TUIP) (3.67%), Photoselective Vaporization of the Prostate (PVP) (3.92%), HoLEP/ThuLEP (3.85%), and open Simple Prostatectomy (SP) (3.21%). Lower incidence rates were observed after laparoscopic\robot-assisted SP (1.76%), Aquablation (1.59%), Prostatic Urethral Lift (PUL) (1.07%), Rezum (1.05%), and Prostatic Artery Embolization (PAE) (0.65%). Multivariable analysis showed that patients undergoing PUL, Rezum, Aquablation, PAE, and PVP were associated with a reduced likelihood of developing US compared to TURP. US required surgical treatment in 18.95% of patients, with direct visual internal urethrotomy (DVIU) and urethroplasty performed in 14.55% and 4.50% of cases, respectively. Urethral dilatation (UD) in an outpatient setting was the primary management in most cases (76.7%).

CONCLUSIONS

The present analysis from a contemporary large dataset suggests that the incidence of US after BPH surgery is relatively low (<5%) and varies among procedures. Around 94% of US cases following BPH surgery are managed using minimally invasive treatment approaches such as UD and DVIU.

Evaluation of learning curves for contact laser vaporization of the prostate using the 980 nm diode laser for benign prostatic hyperplasia

OBJECTIVES

We investigated the background of patients who underwent contact laser vaporization of the prostate (CVP) surgery and the learning curve of the operators.

METHODS

A total of 207 patients who underwent CVP surgery for benign prostatic hyperplasia between August 2018 and March 2023 were included in this study. Patient background, perioperative results, pre- and postoperative urinary flow tests, and complications were collected retrospectively.

RESULTS

We enrolled 12 doctors who were divided into expert (five doctors) and novice (seven doctors) groups based on the number of TURP experiences before CVP. The median patient age was 73 years (51-92 years) and prostate volume was 56 cc (15-190 cc) with no difference between the expert and novice groups. Complications included urinary retention (eight cases), hematuria (four), urinary tract infection (four), intraoperative perforation (two), and postoperative stricture (one). Both cases of intraoperative perforation occurred in the novice group. The expert group had a significantly shorter operative time (38 vs. 66 min) and a higher operative efficacy of prostate volume divided by operative time (1.43 vs. 0.88 cc/min). Postoperatively, IPSS, quality of life scores, and postvoid residual urine volume decreased, and maximal flow rate increased; however, there was no significant difference between the groups. The expert group showed stable operative time and operative efficacy after about five to eight cases, while the novice group showed stable after about 15 cases.

CONCLUSIONS

Our findings suggest that CVP was safely performed at our hospital, and operators with limited experience in TURP can achieve stable perioperative results.

Are adverse events during surgery for benign prostatic hyperplasia device related? A review of the MAUDE database

PURPOSE

The Manufacturer and User Facility Device Experience database contains anonymous, voluntary medical device reports. A review of device-related adverse events associated with Benign Prostatic Hyperplasia surgeries was completed. The objective was to evaluate the occurrence and contributing factors to clinically significant complications in a cohort of patients electing to undergo surgical intervention for Benign Prostatic Hyperplasia.

METHODS

The Manufacturer and User Facility Device Experience database was queried for "Aquablation, Greenlight Laser, Holmium Laser, Morcellator, Water Vapor Thermal Therapy, Loop Resection, and Prostatic Urethral Lift" from 2018 through 2021. A complication classification system (Level I-IV) based on the Clavien-Dindo system was used to categorize events. These events were then correlated with procedural technology malfunctions and classified as "device related" and "non-device related." Chi squared analysis was performed to identify associations between procedural technology and complication classification distribution.

RESULTS

A total of 873 adverse events were identified. The adverse events were classified into level I (minimal harm) versus levels II-IV (clinically significant). Aquablation (p < 0.017) and Water Vapor Thermal Therapy (p < 0.012) were associated with a higher proportion of reports with Level II-IV complications compared with other procedure types. Level II-IV complications were not associated with a reported device related malfunction.

CONCLUSIONS

Aquablation and water vapor thermal therapy demonstrated noteworthy clinically significant complications which were not driven by device-related malfunctions.

Advancing Holmium Laser Enucleation of the Prostate Outcomes Reporting: An Assessment of Patient-Reported Outcomes in the Literature

Holmium laser enucleation of the prostate (HoLEP) is a size-independent option for benign prostatic hyperplasia surgical management. Since lower urinary tract symptoms (LUTS) are a quality-of-life issue, studies should prioritize patient-reported outcomes (PROs). This HoLEP review assesses PROs inclusion in the top 20 cited HoLEP studies and defines their limitations. PROs were categorized by domain: LUTS, incontinence, sexual function, pain, hematuria, and patient satisfaction. On review, no top-cited study included all PRO domains. The nuanced patient experience after HoLEP could be better defined via standardized utilization of validated PROs, while also improving comparability between HoLEP studies.

Comparison of the efficacy of HoLEP and TURP in the treatment of elderly benign prostatic hyperplasia patients: a retrospective study

OBJECTIVE

To prove that holmium laser prostatectomy (HoLEP) is safe and effective in the treatment of benign prostatic hyperplasia (BPH), and is superior to transurethral prostatectomy (TURP) for elderly patients.

METHODS

We retrospectively studied 565 HoLEP patients and 76 TURP elderly patients. HoLEP patients were first divided into three groups according to their age(Under 65 years old group, 65-79 years old group and over 80 years old group), and their preoperative, intraoperative, and postoperative characteristics were then compared. Secondly, the same characteristics of HoLEP and TURP patients over 80 years were compared. Chi-square test, one-way ANOVA and Fisher's exact test were used in this study.

RESULTS

Firstly, we compared HoLEP patients in different age groups and found that there was statistically significant difference in diabetes, CCVD and bladder stones, among the three groups (P<0.05).Secondlye, we compared HoLEP and TURP treatments in elderly patients (≥80 years old). The patients with HoLEP had a higher share of diabetes, CCVD and anticoagulation (P<0.05). Moreover, compared with TURP patients, HoLEP patients had shorter enucleation duration, more enucleate prostate weight, fewer hemoglobin diminutions, shorter bladder irrigation time, shorter catheter-indwelling period, and shorter hospital period (P<0.05). Although there was no difference in IPSS, Qmax and QOL between the two groups before operation (P>0.05), the difference was statistically significant, 6 months after the operation (P<0.05).

CONCLUSION

HoLEP is safe and effective for BPH patients, and is superior to transurethral TURP for elderly patients.

Factors predicting indistinct plane of surgical capsule in patients underwent HoLEP procedures

PURPOSE

To evaluate factors that effectively predict indistinct plane (IP) in patients who underwent holmium laser enucleation of the prostate (HoLEP).

METHODS

Data of 208 consecutive patients from our HoLEP database were reviewed and analyzed. IP was defined in 107 cases, as the plane could be identified only depending on endoscopic beak dissection rather than laser dissection in the initial stage of HoLEP, whereas the control group consisted of 101 cases. Variables including age, body mass index, prostatic volume (PV), intravesical prostatic protrusion, prostate-specific antigen, prostate-specific antigen density, bladder stones, urinary tract infection, microscopic hematuria, prior biopsy (PB), diabetes, hypertension, history of acute urinary retention, 5-alpha reductase inhibitor treatment, catheter dependency, residual urine, region, smoking, and alcohol consumption were compared between the two groups. The risk factors for predicting the presence of IP were determined using a multivariable binary logistic regression model using a forward selection approach with a focus on improvement in the area under the receiver operating characteristic curve (AUC).

RESULTS

The incidence of IP was 51.4% (107/208). PV (OR = 0.977, p < 0.001) and PB (OR = 0.297, p = 0.028) were identified as the independent predictors of capsule plane status. PV with a cutoff of 54 ml had the best predictive effectiveness for IP based on AUC (0.727; 95% CI 0.659-0.795). The specificity and sensitivity of this cutoff were 82.2% and 53.3%, respectively.

CONCLUSION

PV is the most reliable factor to predict IP during HoLEP procedures. There is a high possibility of IP in patients with a PV less than 54 ml.

Does Resectoscope Sheath Size Influence Holmium Laser Enucleation of the Prostate Outcomes? A Prospective Randomized Controlled Trial

Introduction: Holmium laser enucleation of the prostate (HoLEP) is routinely performed with a 24F, 26F, or a 28F scope. Proponents of the larger scopes propose that a bigger sheath size allows for superior flow and visibility leading to a more efficient operation and better hemostasis. Those utilizing the smaller scopes suggest that the smaller sheath is less traumatic, resulting in lower stricture rates and temporary incontinence. We sought to compare outcomes of ambulatory HoLEP using the 24F and 28F laser scope. Materials and Methods: From May 2022 to March 2023, we randomized patients undergoing HoLEP (<200 cm3 in size) 1:1 to either a 24F or 28F scope. The primary outcome was differences in surgical duration between groups (minutes). Secondary outcomes included surgeon scope evaluation and postoperative patient results. Results: There was no difference in patient characteristics in those randomized to 28F (n = 76) vs 24F (n = 76) (p > 0.05) scopes. Procedural duration and efficiencies were not different between groups (all p > 0.05). The 28F scope was associated with improved surgeon-graded irrigation flow and visibility (p < 0.001). Patients treated with the 28F scope were more likely to achieve effective same-day trial of void (SDTOV) (28F 94.3% vs 24F 82.1%, p = 0.048) and have a shorter length of stay (LOS) (28F 7.0 vs 24F 11.9 hours, p = 0.014), however, rates of same-day discharge (SDD) were not statistically different (28F 87.8% vs 24F 78.4%, p = 0.126). There was no difference between the cohorts in rates of 90-day emergency room presentations, re-admissions, complications, or functional ouctomes (p > 0.05). Conclusions: We identified no clear advantage of scope size with regard to intraoperative or postoperative outcomes at 3-month follow-up due to scope size. However, if SDD is part of your postoperative pathway, the 28F scope may shorten LOS and increase rates of effective SDTOV. Clinicaltrials.gov: NCT05308017.

Holmium Laser Enucleation of the Prostate vs Transvesical Single-port Robotic Simple Prostatectomy for Large Prostatic Glands

OBJECTIVE

To compare the perioperative outcomes of transvesical single-port robotic simple prostatectomy (SP-RASP) and holmium laser enucleation of the prostate (HoLEP).

MATERIALS AND METHODS

A retrospective review was performed of patients undergoing SP-RASP and HoLEP from 2019 to 2022 with preoperative prostatic volume (PPV) >80 cm3. Percent of prostate adenoma removed (%PAR) was estimated by specimen weight normalized by PPV. Univariate analysis was performed using chi-square, Fisher exact, and Wilcoxon rank-sum tests. A subgroup analysis with 1:1 matching for PPV was also performed.

RESULTS

A total of 50 SP-RASP and 90 HoLEP cases were analyzed. The median (interquartile range) PPV was 169 (128-244)cm3 for SP-RASP and 129 (100-150)cm3 for HoLEP, (P < .01). The median (interquartile range) %PAR was 57(44-68) for SP-RASP vs 51(42-62) for HoLEP (P = .10). Overall, 11(12%) HoLEP and 5(10%) SP-RASP patients experienced complications (P = .51). Same-day discharge occurred in 24(48%) SP-RASP vs 7(8%) HoLEP patients (P < .01). Median foley catheter duration was longer in SP-RASP (6 vs 1 day, P < .01) and trial of void was successful at first attempt in >94% (P = .68). Transient de novo incontinence was reported in 24(28%) HoLEP vs 2(5%) SP-RASP (P < .01). No differences in voiding parameters were observed at latest follow up. Subgroup postmatched analysis revealed analogous findings.

CONCLUSION

SP-RASP and HoLEP have similar favorable perioperative outcomes for management of large prostatic adenomas. SP-RASP may be considered in patients unwilling to accept the risk of transient incontinence and in those with unfavorable urethral access, large bladder stone burden, or diverticula.

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.

The outcomes of same-day discharge following holmium laser enucleation of the prostate (HoLEP) surgeries: our experience during the COVID-19 pandemic

OBJECTIVE

To describe the outcomes of Same-Day Discharge (SDD) following Holmium Laser Enucleation of the Prostate (HoLEP) in patients during the COVID-19 pandemic.

METHODS

A retrospective review of HoLEP surgeries at a single institution between January 2021 and March 2022 was performed. Patient demographic and operative data were collected, and postoperative outcomes were evaluated in terms of safety and efficacy and compared in both groups using a t-test and chi-square test. Logistic regression was also performed to identify factors that correlate with the failure of SDD.

RESULTS

A total of 155 patients were identified; 135 patients were successfully discharged on the same day and 20 were admitted (87% SDD rate). Admitted HoLEP patients had a significantly higher median prostate-specific antigen (5.7 vs 3.9 ng/dL, P < 0.001), prostate volume (152.3 vs 100.6 mL, P < 0.001), and enucleated tissue weight (90.3 vs 56.9 g, P = 0.04) compared to the SDD group. The SDD group had a 2.9% (n = 4) readmission rate and a 5.2% (n = 7) Emergency Department (ED) visit rate. There was no significant difference in the rate of postoperative ED visits (P = 0.64), readmissions (P = 0.98), complications, and catheterization time (P = 0.98) between both groups. Preoperative predictors of SDD failure included prostate gland volume > 150 mL (OR = 7.17; CI 2.01-25.67; P < 0.01) and history of antiplatelet/anticoagulation use (OR = 6.59; CI 2.00-21.67; P < 0.01).

CONCLUSION

Same-day discharge following HoLEP is a safe and effective approach that can be performed in most patients using a liberal discharge criteria and relying on postoperative findings only.

Comparison of the short-term efficacy and safety of bipolar transurethral electro vaporization and holmium laser enucleation of the prostate for moderate and large benign prostatic enlargement

BACKGROUND

To compare the efficacy and safety of bipolar transurethral vaporization of the prostate (B-TUVP) with holmium laser enucleation of the prostate (HoLEP) for moderate [prostate volume (PV) 30-80 ml] and large (≥ 80 ml) benign prostatic enlargement (BPE).

MATERIALS AND METHODS

Male patients with lower urinary tract symptom (LUTS) or urinary retention who underwent B-TUVP or HoLEP treatment in two regional centers were respectively enrolled. Patient characteristics and treatment outcomes were retrospectively compared between B-TUVP and HoLEP.

RESULTS

In patients with moderate and large prostate volume,B-TUVP showed shorter operative time (P < 0.001) and less hemoglobin decrease (P < 0.001) than in HoLEP. In uncatheterised patients, voiding symptoms and patients' quality of life improved after B-TUVP and HoLEP, but these improvement rates were consistently bigger in HoLEP than in B-TUVP. In catheterised patients, the rate of achieving catheter-free status after surgery was higher in HoLEP than in B-TUVP for patients with PV > 80 ml.(P < 0.001) The incidence of postoperative fever was higher in B-TUVP than in HoLEP for patients with PV 30-80 ml (P < 0.001) but not for those with PV > 80 ml.(P=0.08) The Incidence of postoperative stress incontinence(SUI) was higher in HoLEP than in B-TUVP for patients with moderate and large prostate volume.

CONCLUSIONS

There are few studies that investigated the short-term efficacy and safety of second-generation B-TUVP in comparison with HoLEP for moderate and large BPE. Improvement in LUTS and achievement of catheter-free status were predominant in HoLEP, and these outcomes were more prominent in patients with large BPE of PV > 80 ml. However, B-TUVP resulted in less blood loss, shorter operative duration, and less SUI suggesting that B-TUVP is also well-tolerated surgical modality.

[Urinary incontinence after endoscopic enucleation of the prostate with the Holmium laser: Evolutionary aspects and associated predictive factors]

OBJECTIVE

To study the evolutionary aspects of stress urinary incontinence and urinary incontinence by urgency after HoLEP through a series of 200 consecutive cases of the same surgeon then to seek secondarily the predictive factors of occurrence in the service of urology of the Hospital Center of Martigues.

PATIENTS AND METHODS

This was a monocentric, retrospective, descriptive and analytical study conducted in the urology department of the Martigues Hospital. All patients who were treated with HoLEP for benign prostatic hypertrophy (BPH) between September 2017 and March 2021 were included in the study. Patients with an age greater than 75 years, obese (BMI>30) or with neurological disease were excluded from this study.

RESULTS

Between September 2017 and March 2021, 204 patients were included in our study. The average urinary incontinence rate was 21.2% 12.2% 7.4% and 2.7% at 1 month, 3 months, 6 months and 12 months respectively. The rate of stress urinary incontinence was 5.4%, 9.2%, 5.6% and 1.8% at 1 month, 3 months, 6 months and 12 months post HoLEP respectively. Urge urinary incontinence was estimated at 13.3%, 3%, 1.8% and 0.9% at M1, M3, M6 and M12 post-HoLEP respectively. Preoperative erectile dysfunction, delivered energy, enucleated prostate weight and total intraoperative time were statistically associated with the occurrence of stress urinary incontinence postoperatively. The operative time and a low operative Qmax were statistically associated with the occurrence of postoperative stress urinary incontinence.

CONCLUSION

HoLEP is at risk of postoperative urinary incontinence. Preoperative information of the patients on the risk of urinary incontinence is essential.

Incidence and risk factors for postoperative urinary incontinence after various prostate enucleation procedures: systemic review and meta-analysis of PubMed literature from 2000 to 2021

PURPOSE

To evaluate the risk of urinary incontinence (UI) after various prostate enucleation procedures (PEP).

METHODS

PubMed was searched from January 2000 to July 2021 for studies investigating UI after PEP. The articles were divided into 5 subgroups: holmium, thulium, greenlight laser, electrocautery, and simple prostatectomy. Meta-analysis was performed to examine rate of stress (SUI), urge (UUI) or unspecified UI at short (< 3 months), intermediate (3-6 months), and long-term (> 6 months). The impact of age, prostate size, surgery time, laser time, postoperative nadir PSA level and technical modifications on UI was analyzed.

RESULTS

Most (69.4%) of 49 articles included employed holmium laser. There was no significant difference in incidence of short-, intermediate-, and long-term UI, SUI and UUI between five sub-groups and within different technical modifications. Although not statistically significant, the incidence of UI was higher (15%) at short-term with green-light and simple prostatectomy (95% CI 9-23 and 1-84), and higher (4%) at intermediate-term with holmium laser (95% CI 2-8). SUI was more prevalent at short-term with holmium laser (4%; 95% CI 2-5%), and at intermediate term with simple prostatectomy (3%; 95% CI 1-14). UUI was higher in the thulium group (10%, 95% CI 7-16). Increased age, surgery time, laser time and prostate size up to 80 cc were associated with higher UI. There was no correlation between postoperative PSA and UI.

CONCLUSIONS

There is no significant difference in incidence of UI, SUI and UUI after various PEP. Patients age, prostate size, surgery and laser time are linearly associated with UI.

Impact of diabetes mellitus on urinary continence after holmium laser enucleation of the prostate due to lower urinary tract symptoms: a retrospective study

Introduction

Diabetes mellitus (DM) is known as a risk factor of stress urinary incontinence after Holmium laser enucleation of the prostate (HoLEP). We aimed to compare the postoperative continence status of patients with and without DM, after HoLEP surgery.

Material and methods

A total of 214 patients who underwent HoLEP between January 2017 and January 2020 were retrospectively assessed. Functional outcomes, perioperative total operation time (TOT)(min), enucleation time (ET)(min), enucleation efficiency (EE)(g/min), enucleated tissue weight (ETW)(g), morcellation efficiency (ME)(g/min), morcellation time (MT)(min), continence status, intraoperative and postoperative complications according to Clavien–Dindo classification were recorded.

Results

A total of 96 patients had DM additional to benign prostate hyperplasia (BPH) (Group 1), while 118 patients had only benign prostate hyperplasia without DM (Group 2). When comparing preoperative and postoperative functional outcomes, a statistically significant improvement was observed in both groups from baseline to the 1^st and 6^th month follow-up (p ≤0.001). There were no statistically significant differences between groups in postoperative stress urinary incontinence at postoperative months 1 and 6 (1.7% vs 2.1%, p = 1 and 0.8% vs 1%, p = 1; respectively). There was no significant difference between groups in intraoperative and postoperative complications (p >0.05).

Conclusions

HoLEP is safe to perform in patients with DM at low complication and urinary incontinence rates.

Safety and Efficacy of Laser Enucleation of the Prostate in Elderly Patients - A Narrative Review

Benign prostatic hyperplasia (BPH) is a common health condition in aging men resulting in lower urinary tract symptoms (LUTS) and low quality of life (QoL). We aimed to review studies on laser enucleation of the prostate (LEP) due to LUTS in elderly patients (>65 years) comparing different age groups, particularly considering functional outcomes, safety, and perioperative complications. A comprehensive search was conducted using the PubMed-MEDLINE, Web of Science, Wiley Online Library and Cochrane Library databases over the last 10 years until 7 October 2021 with the following search terms solely or in combination: “laser enucleation”, “prostate”, “laser prostatectomy”, “aging”, “elderly patients”, “older patients” and “age”. We identified 12 articles for inclusion in our analysis. Five studies focussed mainly on holmium laser enucleation of the prostate (HoLEP), one compared HoLEP to other laser prostatectomy procedures, two studies examined thulium laser enucleation of the prostate (ThuLEP), and two studies focused on GreenLight laser, one study focussed on potassium-titanyl-phosphate (KTP) laser, and another study compared laser prostatectomy to transurethral resection of the prostate (TURP). These studies showed that LEP improved IPSS, Qmax and QoL compared to baseline regardless of age; no significant difference was reported among age groups. Although ASA scores and anticoagulation/antiplatelet therapy rates are higher in elderly patients, studies revealed no significant difference in perioperative complication rates between age groups. Laser enucleation of the prostate is an effective and safe procedure in elderly patients, resulting in good functional outcomes, low morbidity, and few perioperative complications.

Conversion of Holmium Laser Enucleation of Prostate to Open Prostatectomy

OBJECTIVES

To determine the incidence and predictive factors for conversion to an open procedure during Holmium Laser Enucleation of Prostate (HoLEP).

METHODS

A retrospective review was performed on files of all patients that underwent HoLEP at our institution between 2013 and 2020. Data collected included demographics, pre-operative estimated prostate size, intraoperative data, pathologic data, and functional baseline. A univariate and multivariate comparison between the pre-operative data of converted and un-converted cases was conducted.

RESULTS

Among a total of 807 HoLEP procedure performed during the above period, 20 cases were converted to open procedures (2.4%). Median pre-operative estimated prostate size in cases of conversion was 228ml compared to 95ml for unconverted cases (p<0.001). The reasons for conversion were anatomical in 8 cases (40%), bleeding that was difficult to control endoscopically in 4 cases (20%), expected procedure to be too long due to large prostate size in 6 cases (30%), one case of morcellation technical malfunction, and one case with very large bladder stones not suitable for endoscopic treatment. Prostate size was the only factor that was found to be associated with conversion in univariate and multivariate analysis.

CONCLUSIONS

The risk of conversion of HoLEP to open procedures is size-dependent. The risk for conversion to open prostatectomy/cystotomy must be communicated to patients who choose HoLEP to improve the informed consent process and provide the highest quality of patient care and transparency. Open prostatectomy/cystotomy should be a part of the armamentarium of every HoLEP surgeon operating on large prostates.

Comparison of different en bloc holmium laser enucleation of the prostate techniques to reduce the rate of postoperative transient urinary incontinence

Objective

To investigate postoperative risk factors for transient urinary incontinence (TUI) after different en bloc holmium laser enucleation of the prostate (HoLEP) techniques.

Methods

We retrospectively analyzed 169 consecutive patients who underwent HoLEP using the original en bloc technique (n = 41), en bloc with early mucosal strip detachment technique (n = 72), and three horseshoe-shaped incisions technique (n = 56) to treat bladder outlet obstruction from January 2017 to October 2019. Preoperative variables and surgical quality indexes were compared between the groups. TUI was defined as any hygienic or social problem caused by involuntary loss of urine at 2 weeks postoperatively. The postvoid residual urine volume, maximum urinary flow rate, and International Prostate Symptom Score (IPSS) were assessed.

Results

Among all three techniques, the three horseshoe-shaped incisions technique was significantly associated with the lowest incidence of TUI and the lowest IPSS. Although not statistically significant, the three horseshoe-shaped incisions group also showed a trend toward a faster enucleation time. No life-threatening intraoperative complications occurred in any group.

Conclusion

Use of three horseshoe-shaped incisions in en bloc HoLEP prevented urethral sphincter damage with a low rate of postoperative TUI. Further long-term, multicenter comparative assessment is required.

Research Registry number: 6848

Initial experience with holmium laser enucleation of the prostate in a urology specialist hospital in Nigeria

Background

Holmium laser enucleation of the prostate (HoLEP) is a more recent procedure for the management of Benign Prostatic Hyperplasia compared to open prostatectomy or Transurethral Resection of the Prostate. HoLEP is not commonly done in Nigeria. The objective of the study was to determine whether our initial experience with HoLEP in Abuja, favourably compared to those of other centres across the world.

Methods

A retrospective study was done on 40 patients who had HoLEP between October 2018 and December 2019. Pre- and post-operative International Prostate Symptom Score (IPSS), prostate-specific antigen (PSA), prostate sizes, maximum flow rate (Qmax) and post-void residual urine volume (PVR) were collated. The duration of irrigation, catheterization and length of hospital stay were also recorded and analysed. Complications were documented.

Results

There were improvements in IPSS from 19.67 to 5.41, PSA from 8.07 to 2.03 ng/ml,Qmax from 11.27 to 29.67 ml/min, PVR from 88.99 to 32.8 ml, while average prostate sizes reduced from 116.54 to 30.3 g after surgery. Following HoLEP, the duration of irrigation was 18.00 h, catheterization was 26.76 h and length of hospital stay was 1.82 days. Two (5.0%) patients were recatheterized, 4 (10.0%) developed post-operative bladder neck stenosis.

Conclusions

The outcome of HoLEP in our experience compared favourably with those from other centres. With adequate training and requisite equipment in resource-poor environments, technical procedures like HoLEP can be embarked on with favourable results.

Magnetic resonance imaging-guided transurethral ultrasound ablation for benign prostatic hyperplasia: 12-month clinical outcomes of a phase I study

OBJECTIVES

To investigate the safety and feasibility of magnetic resonance imaging (MRI)-guided transurethral ultrasound ablation (TULSA) for the treatment of benign prostatic obstruction (BPO).

PATIENTS AND METHODS

An investigator-initiated, prospective, registered (NCT03350529), phase I study enrolled men with lower urinary tract symptoms due to benign prostatic hyperplasia in need of surgical intervention. Patients were followed for 12 months after TULSA. Uroflowmetry, prostate-specific antigen (PSA) level, and a comprehensive set of functional questionnaires including the Expanded Prostate cancer Index Composite-26, International Prostate Symptom Score (IPSS) and five-item version of the International Index of Erectile Function were obtained at baseline and every 3 months afterwards. MRI was obtained at baseline, and at 3 and 12 months after TULSA. Medication use before and after TULSA were recorded. Adverse events (AEs) were reported using the Clavien-Dindo classification.

RESULTS

A total of 10 men underwent TULSA with no severe AEs encountered. The baseline median (interquartile range [IQR]) age and prostate volume were 68 (63-72) years and 53 (45-66) mL, respectively. At baseline, six patients were moderately symptomatic and four patients severely symptomatic. Nine patients at baseline were on BPO medication. The median (IQR) improvement in the IPSS was 82%, from 17.5 (15.3-23.0) at baseline to 4.0 (2.3-6.3) at 12 months. Similarly, the median maximum urinary flow rate improved by 101%, from a median (IQR) of 12.4 (8.8-17.6) mL/s at baseline to 21.8 (17.6-26.5) mL/s at 12 months. Improvements were already seen at 3 months. The median prostate volume and PSA reduction at 12 months were 33% and 48%, respectively. There were no changes in continence, sexual, erectile or bowel functions. At 12 months, five out of six men with normal ejaculatory function before TULSA reported normal antegrade ejaculations. All patients taking BPO medication before TULSA discontinued medication after TULSA.

CONCLUSION

TULSA appears to be a safe and effective treatment for BPO, with promising 12-month follow-up outcomes. Further studies with larger cohorts are needed to confirm the observed results.

Morcellation After Endoscopic Enucleation of the Prostate: Efficiency and Safety of Currently Available Devices

CONTEXT

Although several studies have compared different morcellators and enucleation techniques for the management of benign prostatic hyperplasia (BPH), there is sparse literature on morcellation, so further experimental and clinical research is required for its optimization.

OBJECTIVE

To critically appraise the contemporary literature on prostate morcellation and to evaluate the safety and efficiency of currently available morcellators for endoscopic enucleation of the prostate (EEP) in the context of BPH.

EVIDENCE ACQUISITION

A comprehensive review of the English and French literature relevant to prostate morcellation was performed using the PubMed-MEDLINE, Cochrane Library, Web of Science, and Wiley Online Library database from 1998 to 2020 using PICOS (patient population, intervention, comparison, outcome, and study design) criteria.

EVIDENCE SYNTHESIS

We retrieved 26 studies involving 5652 patients treated with a morcellator that were eligible for data extraction and analysis. The mean patient age was 67.4 (range 61.4-72.8) yr. The weighted mean efficiency of Piranha, VersaCut, and DrillCut morcellators was 5.29, 3.95, and 5.3 g/min, respectively. Several approaches, such as en bloc, two-lobe, inverse, and improved techniques, may increase morcellation efficiency and safety. The lowest weighted mean rate of bladder wall injury was 1.24% for Piranha, followed by 1.98% for DrillCut, and 5.23% for VersaCut, while the VersaCut morcellator had the lowest weighted mean rate of device malfunction at 0.74%, compared to 2.07% for Piranha and 7.86% for DrillCut.

CONCLUSIONS

All three morcellators are efficient and safe for prostatic morcellation after EEP. Further development of devices and techniques may improve the efficiency and safety profile of morcellation. To increase safety, surgeon expertise, technical equipment, and patient characteristics should be considered. Therefore, interdisciplinary exchange of knowledge and further technological innovations are strongly encouraged.

PATIENT SUMMARY

We reviewed the safety and efficacy of devices called morcellators. These devices cut tissue into small pieces that are easier to remove from the body, and are used during laser surgery for benign enlargement of the prostate. Three morcellators are currently available on the market and are comparable in safety and efficacy.

Safety and Efficacy of High-Powered Holmium Laser Enucleation of the Prostate within 1-3 Weeks Following Prostate Biopsy

PURPOSE

We aim to document the feasibility, perioperative safety, and the 12-month efficacy of holmium laser enucleation of the prostate (HoLEP) within 1-3 weeks following transrectal ultrasound (TRUS)-guided prostate biopsy.

METHODS

Data of the patients who underwent HoLEP following TRUS-guided prostate biopsy between March 2017 and July 2020 were analyzed retrospectively. Patients were divided into 2 groups: group 1 had undergone HoLEP in the early period after TRUS-guided prostate biopsy, while group 2 patients were biopsy-naive ("control group"). All patients were assessed preoperatively by a physical examination with the digital rectal examination; time from biopsy to HoLEP; measurement of Qmax, postvoiding residual volume, and prostate volume by transabdominal ultrasonography; serum prostate-specific antigen level, the International Prostate Symptom Score (IPSS); the International Index of Erectile Function-5 questionnaire; and urine analysis. The patients were reevaluated at 3- and 12-month follow-up. Perioperative and postoperative complications were documented according to the modified Clavien-Dindo System.

RESULTS

Group 1 comprised 66 patients with a mean age of 67.3 ± 6.7 (range, 53-86) years, and group 2 comprised 114 patients with a mean age of 69.4 ± 9.4 (range, 36-95) years. The operation, enucleation, and morcellation efficiencies were not statistically significant between the groups. Preoperative Qmax and IPSS values were significantly improved after HoLEP surgery in the 3rd and 12th months in all patients. Our complication rates were similar in both groups.

CONCLUSION

High-powered HoLEP using 140 W energy within 1-3 weeks following TRUS-guided prostate biopsy is a feasible procedure with high enucleation efficiency, low perioperative morbidity, and excellent functional outcomes. A recent TRUS-guided prostate biopsy is not a contraindication to HoLEP.

En-Bloc Holmium Laser Enucleation of the Prostate with Early Apical Release: Are We Ready for a New Paradigm?

Background: Holmium laser enucleation of the prostate (HoLEP) is considered a safe and effective treatment in case of bladder outlet obstruction (BOO). Despite technical execution has evolved over time, from the standard three-lobes to the more recent en-bloc approaches, data comparing these two techniques are missing. The aim of the present study was to describe our en-bloc HoLEP with early apical release technique and compare peri- and postoperative results with the classical three-lobe approach in a single referral center. Materials and Methods: We prospectively analyzed all consecutive cases between 2017 and 2019 divided according to the type of approach. Patients were preoperatively studied through instrumental assessment and clinical evaluation, using validated questionnaires and then postoperatively at specific time frames. Linear regression analysis was performed to evaluate possible predictor of continuous variables. All the procedures were carried out by one single expert surgeon. Results: Overall, 168 patients were included, of which 81 were treated with classical three-lobes and 87 with en-bloc with early apical release technique. The two cohorts were comparable related to preoperative features and postoperative complication rate. Mean enucleation time (ET), lasing time, amount of energy delivered, and overall operative time were significantly lower in en-bloc procedures (p < 0.05). Stepwise multivariable linear regression showed that en-bloc strategy can significantly predict shorter ET and lower energy delivered. Stress incontinence rate at 1-month follow-up was found to be significantly reduced in the en-bloc group, compared with the counterpart. Conclusions: Both techniques are effective and safe treatment options for BOO, since peri- and postoperative surgical and functional outcomes were favorable. En-bloc strategy may significantly decrease ET and the amount of energy delivered leading to a reduced early stress incontinence rate compared with the standard approach.

Safety and Feasibility of Outpatient Surgery in Benign Prostatic Hyperplasia: a Systematic Review and Meta-Analysis

Purpose: Most of the endourologic procedures along the urinary tract have been widely practiced as outpatient operations, including surgery for benign prostatic hyperplasia (BPH). This systematic review and meta-analysis was conducted to assess safety and feasibility of outpatient surgery for patients suffering from symptomatic BPH candidate for endoscopic disobstruction. Materials and Methods: PubMed, Web of Science, Cochrane, and Embase were searched up until March 30, 2020. Methodological index for nonrandomized studies (MINORS) tool was utilized to assess the quality of included studies, and a pooled measure of failure rate (FR) or event rate (ER) estimate was calculated. Further sensitivity analysis, subgroup analysis, and meta-regression were conducted to investigate contribution of moderators to heterogeneity. Results: Twenty studies with a total of 1626 patients treated according to outpatient criteria for endoscopic BPH surgery were included. In total, 18 studies reporting data on immediate hospital readmission and/or inability to discharge after endoscopic procedure presented FR estimates ranging from 1.7% to 51.1%. Pooled FR estimate was 7.8% (95% confidence interval [CI]: 5.2-10.3); Heterogeneity: Q = 76.85; degree of freedom = 17, p < 0.001; I² = 75.12%. Subgroup analysis according to surgical technique revealed difference among the three approaches with pooled FR of 3% (95% CI: 1-4.9), 7.1% (95% CI: 3.9-10.4), and 11.8% (95% CI: 7-16.7) for transurethral resection of the prostate, Green-light, and holmium laser vaporesection, respectively (p < 0.001). At meta-regression analysis, none of the retrieved covariates was able to significantly influence the cumulative outcomes reported. ER for postoperative complications and early outpatient visit showed a pooled estimate of 18.6% (95% CI: 13.2-23.9) and 7.7% (95% CI: 4.3-11), respectively. Conclusions: Our analysis revealed how transurethral procedures for BPH on an outpatient setting are overall reliable and safe. Of note, there were significant outcome differences between groups with regard to type of surgical procedure, perioperative prostate volume, and discharge protocol suggesting the need for further prospective analysis to better elucidate the best strategy in such outpatient conduct.

Holmium laser enucleation of the prostate with Virtual Basket mode: faster and better control on bleeding

BACKGROUND

To compare clinical intra and early postoperative outcomes between conventional Holmium laser enucleation of the prostate (HoLEP) and Holmium laser enucleation of the prostate using the Virtual Basket tool (VB-HoLEP) to treat benign prostatic hyperplasia (BPH).

METHODS

This prospective randomized study enrolled consecutive patients with BPH, who were assigned to undergo either HoLEP (n = 100), or VB-HoLEP (n = 100). All patients were evaluated preoperatively and postoperatively, with particular attention to catheterization time, operative time, blood loss, irrigation volume and hospital stay. We also evaluated the patients at 3 and 6 months after surgery and assessed maximum flow rate (Qmax), postvoid residual urine volume (PVR), the International Prostate Symptom Score (IPSS) and the Quality of Life score (QOLS).

RESULTS

No significant differences in preoperative parameters between patients in each study arm were found. Compared to HoLEP, VB-HoLEP resulted in less hemoglobin decrease (2.54 vs. 1.12 g/dl, P = 0.03) and reduced operative time (57.33 ± 29.71 vs. 42.99 ± 18.51 min, P = 0.04). HoLEP and VB-HoLEP detrmined similar catheterization time (2.2 vs. 1.9 days, P = 0.45), irrigation volume (33.3 vs. 31.7 l, P = 0.69), and hospital stay (2.8 vs. 2.7 days, P = 0.21). During the 6-month follow-up no significant differences in IPSS, Qmax, PVR, and QOLS were demonstrated.

CONCLUSIONS

HoLEP and VB-HoLEP are both efficient and safe procedures for relieving lower urinary tract symptoms. VB-HoLEP was statistically superior to HoLEP in blood loss and operative time. However, procedures did not differ significantly in catheterization time, hospital stay, and irrigation volume. No significant differences were demonstrated in QOLS, IPSS, Qmax and PVR throughout the 6-month follow-up.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN72879639; date of registration: June 25th, 2015. Retrospectively registred.

Retrospective Assessment of Endoscopic Enucleation of Prostate Complications: A Single-Center Experience of More Than 1400 Patients

Introduction: Endoscopic enucleation of the prostate (EEP) is a safe method of treating benign prostatic hyperplasia, regardless of prostate volume and type of applied energy. To date, however, there has been no study that examines complication rates with respect to the type of applied energy. This study aims to address this problem by providing a retrospective analysis of >1400 patients who have undergone prostate enucleation. Materials and Methods: We performed a retrospective analysis of all patients undergoing EEP between 2013 and 2018 at a single tertiary institution. This analysis included patients who had undergone one of three forms of EEP: holmium laser enucleation of the prostate (HoLEP), thulium fiber laser enucleation of the prostate (ThuFLEP), or monopolar enucleation of the prostate (MEP). We compared intraoperative and early postoperative complications, as well as complications at 3 and 6 months follow-up. Results: A total of 1413 patients were included in this study; 36% patients underwent HoLEP, 57.5% had ThuFLEP, and 6.5% MEP. The most frequent complication in the early postoperative period was a mild fever (2.76% of the cases). The morcellation was delayed to a separate stage because of intensive hemorrhaging in 1.4% of the cases. Bladder tamponade was found in 1.1% of the cases. We found no correlation between complication rate and either prostate volume or energy source. Stress urinary incontinence was found in 3.9% of patients at 3 months and in only 1.4% of patients at 6 months after the operation. Urethral stricture at 6 months after the surgery was found in 1.4% of patients, whereas bladder neck sclerosis was found in only 0.9% of these cases. No significant difference was observed between these complication frequencies and any preoperative factors or energy source. Conclusions: All EEP types are safe with equal rates of complications intraoperatively, postoperatively, and at 6 months follow-up.

Significance of Membranous Urethral Length for Recovery From Postoperative Urinary Incontinence Following Holmium Laser Enucleation of the Prostate

PURPOSE

The aim of this study was to determine the significance of the membranous urethral length (MUL), including the thickness of the urethral sphincter, for recovery from postoperative stress urinary incontinence (SUI) following holmium laser enucleation of the prostate (HoLEP).

METHODS

We analyzed 78 patients who underwent HoLEP between June 2013 and September 2018, all of whom preoperatively received magnetic resonance imaging. MUL was measured using sagittal T2-weighted fast spin-echo images. The clinical and anatomical factors associated with MUL were evaluated. The recovery time of urinary incontinence was compared between patients with a long MUL (≥14 mm) and a short MUL (<14 mm). SUI included both stress and mixed urinary incontinence. Continence was defined as complete dryness.

RESULTS

The median MUL in patients without incontinence at 1 month postoperatively was significantly longer than the MUL in patients with incontinence (15.3 mm vs. 12.7 mm, P<0.001). The continence rates at 1 month after HoLEP in patients with longer MULs and shorter MULs were 80.4% and 30.0%, respectively. The recovery time of urinary incontinence in patients with longer MULs (≥14 mm) was significantly shorter than that in patients with shorter MULs (<14 mm) (log-rank test, P=0.001). After 6 months, the continence rates in patients with longer MULs and shorter MULs were similar (97%). MUL was significantly correlated with the recovery period of urinary incontinence (r=-0.459, P<0.001).

CONCLUSION

MUL was useful for predicting early recovery from urinary incontinence following HoLEP. This study provides evidence that postoperative urinary incontinence following a transurethral procedure for benign prostatic hyperplasia was associated with anatomical factors. A long MUL was associated with better tolerance to urinary sphincter damage by the transurethral procedure.

[SURGEON QUESTIONNAIRE FOR ESTABLISHING A SURGEON EDUCATION SYSTEM FOR TRANSURETHRAL LASER RESECTION OF THE PROSTATE (HoLEP)]

(Introduction)HoLEP's role in the surgical management of benign prostatic hyperplasia (BPH) is steadily growing. In this study, a questionnaire containing questions about perioperative management was submitted to HoLEP surgeons to help establish standard surgical training procedures. (Methods)We sent a comprehensive 17 questionnaires on HoLEP procedures to 18 surgeons. The questionnaire asked, "Which method are you using, the 1-LOBE or 3-LOBE method?", "What educational methods are being used for surgeons?", "How long is the catheter insertion period after HoLEP?", and "What is the most difficult problem encountered in surgical HoLEP education and what aspect of training is the most emphasized?" (Results)Sixteen (88.9%) surgeons answered these questionnaires. Five surgeons reported using the one lobe method, five surgeons reported using the three lobe method, and four surgeons answered that it depends on the case. Regarding educational methods, the main answer was that it is important to evaluate pre-HoLEP imaging tests such as MRI and cystoscopy and to simulate surgery for education. Regarding the postoperative catheter insertion period, 1 day: 1 surgeon, 2 days: 9 surgeons, 3 days: 3 surgeons, 4 days or more: 1 surgeon. The most important thing reported for surgical education was to help beginners understand the characteristics of lasers, including direction, distance to prostate tissue, and adenoma removal. (Conclusions)The surgeons' responses clearly indicated some differences in practices between institutions. More detailed data from these results will provide a step towards designing standardized surgical and educational protocols for HoLEP.

Stress Urinary Incontinence post-Holmium Laser Enucleation of the Prostate: a Single-Surgeon Experience

Purpose

To identify incidence and predictors of stress urinary incontinence (SUI) following Holmium laser enucleation of the prostate (HoLEP).

Materials and Methods

We performed a retrospective review of 589 HoLEP patients from 2012-2018. Patients were assessed at pre-operative and post-operative visits. Univariate and multivariate regression analyses were performed to identify predictors of SUI.

Results

52/589 patients (8.8%) developed transient SUI, while 9/589 (1.5%) developed long-term SUI. tSUI resolved for 46 patients (88.5%) within the first six weeks and in 6 patients (11.5%) between 6 weeks to 3 months. Long-term SUI patients required intervention, achieving continence at 16.4 months on average, 44 men (70.9%) with incontinence were catheter dependent preoperatively. Mean prostatic volume was 148.7mL in tSUI patients, 111.6mL in long-term SUI, and 87.9mL in others (p <0.0001). On univariate analysis, laser energy used (p <0.0001), laser “on” time (p=0.0204), resected prostate weight (p <0.0001), overall International Prostate Symptom Score (IPSS) (p=0.0005), and IPSS QOL (p=0.02) were associated with SUI. On multivariate analysis, resected prostate weight was predictive of any SUI and tSUI, with no risk factors identified for long-term SUI.

Conclusion

Post-HoLEP SUI occurs in ~10% of patients, with 1.5% continuing beyond six months. Most patients with tSUI recover within the first six weeks. Prostate size >100g and catheter dependency are associated with increased risk tSUI. Larger prostate volume is an independent predictor of any SUI, and tSUI.

Urethral Complications While Using 26F vs 28F Resectoscope Sheaths in Holmium Laser Enucleation of the Prostate: A Retrospective Observational Study

Objective: To determine the rate of the urethral stricture (US) and bladder neck contracture (BNC) between patients who undergo Holmium Laser Enucleation of Prostate (HoLEP) surgery with 26F vs 28F resectoscope sheaths (RS). Studies report rates of 2.8-4.4% and 3.6-5.4% for US and BNC, respectively. To date, there are no studies that have shown the difference between RS size and urethral complications. Methods: We retrospectively reviewed charts of patients who had HoLEP surgery between August 2015 and June 2018, by a single surgeon. Those with a prior history of US or BNC were excluded. The operative set-up for an HoLEP includes Ho:YAG laser, urethral dilation, a 26F or 28F continuous flow RS, and a tissue morcellator. Primary endpoints include postoperative US or BNC. Secondary endpoints include postoperative catheterization time, success of voiding trial, and urinary incontinence. Statistical analysis was performed by using appropriate methods. Results: Out of 502 HoLEP patients, 339 consecutive patients had surgery with a 28F RS (Group A) and 163 consecutive patients had surgery with a 26F RS (Group B). Twelve patients (A) and three patients (B) had post-op US (p = 0.41). Eight (A) and zero (B) patients had post-op BNC (p = 0.0585). Stress urinary incontinence at 6 weeks, 3-6 months, and 1 year was present in 15.9% (both A & B), 6.5% (A) vs 6.1% (B) (p = 0.88), and 3.2% (A) vs 1.8% (B) (p = 0.564), respectively. Both blood loss and change in hemoglobin were higher in the 28F group with no significant difference in rate of transfusion. Conclusions: RS size had no impact on the rate of US or BNC; however, there was lower incidence in the 26F sheath cohort for both. The 28F sheath had a larger change in hemoglobin levels and estimated blood loss, but the higher rate of transfusion was not statistically significant. There was no difference in the stress incontinence rates, length of stay, and enucleation rates.

Introduction of a New Score to Assess Surgical Efficiency in Holmium Laser Enucleation of the Prostate

INTRODUCTION

While holmium laser enucleation of the prostate (HoLEP) is accepted as safe and efficient, a long learning curve is considered the main reason for its slow adoption in clinical practice. So far, no standardized and easy-to-use parameter has been implemented to measure surgical experience or efficiency which could be useful for training and quality control purposes. The aim of the present study was to evaluate the learning curves of 2 HoLEP beginners and to identify applicable efficiency outcome measures as well as potentially complicating factors in performing HoLEP.

PATIENTS AND METHODS

A total of 594 patients treated by HoLEP between September 2016 and May 2019 were enrolled. The procedures were initially performed by 1 HoLEP expert (reference surgeon); over time, 2 further surgeons were trained. Baseline characteristics, enucleation weight, morcellation and enucleation time, laser energy usage, and postoperative results were recorded prospectively. The learning curves of the 2 novices were analyzed and compared to the reference surgeon. Logistic regression analyses were performed to identify predictors for postoperative grade ≥2 complications.

RESULTS

Median enucleation ratio and complication rates did not significantly alter along the learning curves. Median enucleation speed and laser energy application of the 2 novices significantly improved with growing experience. Combining these variables, we introduced the "HoLEP efficiency score" (HES) which demonstrated the most appropriate value to reflect the surgical experience and efficiency. The median HES for the reference surgeon was 82.8 min kJ/g. For the 2 novices, a drop from 130 and 124.4 min kJ/g by -57 and -30%, respectively, was observed. Among several tested clinical parameters, the presence of prostate cancer (p = 0.047) and the surgical caseload (p < 0.001) influenced the HES. On multivariable logistic regression, American Society of Anesthesiologists score and prostate cancer were independent predictors for grade ≥2 complications (p = 0.002, odds ratio [OR] 2.042 and p = 0.038, OR 1.940).

CONCLUSION

We introduce the HES as an objective and measurable tool to quantify surgical efficiency. In clinical practice, the HES may find application in training and quality control purposes as well as in comparing surgical modifications and hardware. Patients with prostate cancer seem to be more challenging cases and have a higher risk for complications, and may preferably be treated by experienced surgeons.

Bipolar plasmakinetic transurethral enucleation and resection versus bipolar plasmakinetic transurethral resection for surgically treating large (≥60 g) prostates: a propensity score-matched analysis with a 3-year follow-up

BACKGROUND

There are extremely limited published studies comparing bipolar plasmakinetic transurethral resection of prostate (BP-TURP), bipolar plasmakinetic transurethral enucleation and resection of prostate (BP-TUERP) for enlarged prostates. Our purpose was to evaluate the safety and efficiency of BP-TUERP and BP-TURP for large (≥60 g) prostates with a 3-year follow-up.

METHODS

We retrospectively identified 229 patients according to inclusion criteria between 2014 and 2016. After applying propensity score matching method, preoperative results and three-year follow-up outcomes in International Prostate Symptom Score (IPSS), urinary peek flow rate (Q<inf>max</inf>), postvoid residual urine (PVRU) volume and quality of life (QoL) score were compared.

RESULTS

Finally, within the well-balanced matched cohort, the BP-TUERP was significantly associated with longer mean operating time (OT) (P=0.039), shorter mean catheter time (CT) (P=0.001) and lower mean hemoglobin decrease (P=0.002) with more prostatic tissue removed (P=0.001) than the BP-TURP, but the median hospital stay lengths and the short- and long-term complication rates were similar between the two series. The patients in the BP-TUERP group had better long-term outcomes in IPSS, Q<inf>max</inf> and PVRU volume than these in the BP-TURP group, but not in QoL score.

CONCLUSIONS

For patients with large (≥60 g) prostates, BP-TUERP and BP-TURP are safe options, but the former is a more effective choice in long-term follow-up outcomes. BP-TUERP is related to reduced CT and hemoglobin decrease with more removal of prostatic tissue at the expense of longer OT than BP-TURP.

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.

GreenLight Laser photoselective vapo-enucleation of the prostate with front-firing emission versus plasmakinetic resection of the prostate for benign prostate hyperplasia

Background

Although the conventional, monopolar transurethral resection of the prostate (TURP) has proven to be an effective and relatively safe treatment for patients with benign prostatic hyperplasia (BPH), many new endoscopic technologies have been introduced to treat BPH. With the development of laser, there are several alternative transurethral procedures embracing laser therapies. Herein, this study sought to explore the efficacy, safety and follow-up of GreenLight laser photoselective vapo-enucleation of the prostate (PVEP) with front-firing emission compared with plasmakinetic resection of the prostate (PKRP) used to surgically manage BPH.

Methods

Data from patients who underwent either GreenLight laser PVEP or PKRP were retrospectively collected from March 2013 to May 2018. Perioperative data from both groups were compared.

Results

Totally, 43 and 45 patients were included in the PVEP and PKRP groups, respectively. No significant difference was observed in excision efficiency ratio (resected prostate weight/operation time) between the two groups (P=0.372). The efficiency ratio of the first 20 PVEP procedures (0.36±0.09 g/min) was significantly lower than that of the second 23 PVEP procedures (0.45±0.18 g/min) (P=0.042). The PVEP group experienced a shorter duration of catheterization, postoperative hospital stay and irrigation time than the PKRP group (P<0.001, P=0.001 and P<0.001, respectively). There was no statistically significant difference between the two groups (P=0.937) in terms of overall postoperative complications. Three months after surgery, the international prostate symptoms (IPSS) score, quality of life (QOL) score, postvoid residual (PVR) volume and maximum urinary flow rate (Q_max) were decreased in both groups (P<0.001 for all) and were comparable between both groups (P=0.635, 0.662, 0.671 and 0.924, respectively).

Conclusions

GreenLight laser PVEP with front-firing emission was safe and effective modality in treating patients with BPH with short-term follow-up. PVEP was associated with shorter catheterization and postoperative hospital stay time compared with PKRP.

Anteroposterior dissection three-lobe technique: an effective surgical method for inexperienced surgeons performing holmium laser enucleation of the prostate

PURPOSE

To evaluate the effectiveness of anteroposterior dissection three-lobe technique for surgeons with no prior experience of holmium laser enucleation of the prostate (HoLEP) METHODS: In this retrospective single-center study, we compared perioperative complications and postoperative urinary conditions between an experienced surgeon and surgeons with no prior experience of HoLEP. Forty patients were operated by one experienced surgeon (group A), and another 40 patients were operated by four inexperienced surgeons (group B) under the guidance of the instructor. The enucleation procedure was performed by anteroposterior dissection three-lobe technique.

RESULTS

Patient characteristics were comparable in the two groups in age, body mass index, and preoperative prostate volume. The enucleation efficiency rate [0.96 vs 0.56 g/min (P < 0.001)] was significantly different between groups A and B. However, there were no significant differences in enucleate prostate weight, hemoglobin decrease, or postoperative catheter-indwelling period between the two groups. There were no significant differences with respect to postoperative urinary incontinence rate at 1 month [43 vs 50% (P = 0.65)], 3 months [13 vs 20% (P = 0.55)], and 6 months [0 vs 3% (P = 1.00)] between the two groups. Both groups showed a significant improvement in the maximum flow rate and postvoid residual volume after HoLEP compared with baseline levels (P < 0.01).

CONCLUSION

Anteroposterior dissection HoLEP three-lobe technique was found to be a safe and effective enucleation method for surgeons with no prior experience of HoLEP under the guidance of the instructor.

How to optimise urinary continence in anatomical endoscopic enucleation of the prostate?

The traditional transurethral resection of the prostate (TURP) is considered as gold-standard surgical treatment to relieve symptoms resulting from bladder outlet obstruction by prostate enlargement. However, with the advances of novel laser technologies and more experienced surgeon conquering the steep learning curve, anatomical endoscopic enucleation of prostate (AEEP) has become a more popular alternative surgical technique. Although AEEP has compatible functional outcome, less blood loss, shorter catheterisation duration and hospital stay, the risk of post-operative urinary incontinence (UI) is often an issue of concern. In this review, we focus on discussion about risk factors related to increased incidence of UI, some surgical tips to avoid damaging external urinary sphincter and treatment strategies to facilitate recovery of urinary continence after surgery.

[Anastomosis stenosis after radical prostatectomy and bladder neck stenosis after benign prostate hyperplasia treatment: reconstructive options]

Bladder neck stenosis (BNS) after simple prostatectomy and vesicourethral anastomosis stenosis (VUAS) after radical prostatectomy for prostate cancer are common sequelae. However, the two entities differ in their pathology, anatomy and their surgical results. VUAS has an incidence of 0.2-28%. Commonly, VUAS occurs within the first 2 years after surgery. Initial therapy should be performed endourologically: dilatation, (laser) incision or resection. After three unsuccessful treatment attempts, open reconstruction should be considered. Different surgical approaches (abdominal, perineal, abdominoperineal) have been described. All are associated with good success rates. However, they are accompanied by high rates of urinary incontinence. Incontinence can be treated safely by implantation of an artificial urinary sphincter. The incidence of BNS is around 5% for all types of surgery for benign prostate hyperplasia. It occurs within the first 2 years after surgery. Initial treatment should be performed endourologically. In case of recalcitrant BNS, open reconstruction is indicated. The YV-plasty is an established procedure, and the T‑plasty represents a modification. Success rates of both procedures are high. Robot-assisted reconstructive procedures have been described for both VUAS and BNS.

Complications of anatomical endoscopic enucleation of the prostate

Transurethral resection of the prostate (TURP) remains the 'gold standard' for surgical treatment of benign prostatic obstruction (BPO). Recently, anatomical endoscopic enucleation of the prostate (AEEP) using holmium laser, thulium laser and plasma, etc., is extensively applied in clinical practice. However, perioperative complications of AEEP are inevitable in spite of lower incidence compared with TURP. This study reviewed the literature related to the aetiology, prevention and treatment of common complications of AEEP, which would contribute to the diagnosis and treatment of BPO.

Holmium Laser Enucleation of the Prostate Is Safe and Feasible as a Same Day Surgery

OBJECTIVE

To assess the safety, feasibility and treatment outcomes of holmium laser enucleation of the prostate (HoLEP) as a same day surgery (SDS).

METHODS

HoLEPs performed from November 2013 to December 2018 at our institution were reviewed retrospectively. Inclusion criteria for same day surgery (SDS) included living in the local metropolitan area with access to local hospital and Eastern Cooperative Oncology Group (ECOG) 0-2, regardless of prostate size and anticoagulation status. Those patients who were discharged directly from the postoperative care unit were identified as SDS cases. Patients admitted overnight after HoLEP during the same period were used as a matched cohort. Patient demographics, disease characteristics and treatment outcomes were compared.

RESULTS

A total of 377 patients were identified, including 199 SDS and 178 non-SDS patients. No statistical difference was present between the 2 groups regarding the post-op complication and readmission rates. The non-SDS group had a significantly higher percentage of patients with history of urinary retention, lower pre-op Q_max, and larger prostate volume. The SDS group had shorter operative time, length of stay (LOS), and catherization time (all P <.05). At 1-year follow-up, no statistically different change in Q_max, PVR, or IPSS score was noted between the 2 groups.

CONCLUSION

Same day outpatient surgery for HoLEP is safe in patients who live in close proximity and have ECOG status 0-2. Our readmission rate and complication rate are comparable to those reported in the literature with markedly decreased LOS. Long-term functional outcome is not compromised by SDS.

Holmium laser enucleation of the prostate for the treatment of size-independent BPH: A single-center experience of 600 cases

OBJECTIVE

Holmium laser enucleation of the prostate (HoLEP) is an endourologic minimal invasive intervention of benign prostate hyperplasia (BPH). The interest on HoLEP is increasing in the literature. The aim of the present study was to evaluate the learning curve and our preliminary results.

MATERIAL AND METHODS

A retrospective analysis on 600 patients with BPH who underwent HoLEP between July 2015 and April 2019 was performed. Perioperative measures including enucleation efficiency (EE), morcellation efficiency (ME), and percentage of resected tissue weight (PRW) were recorded. Hospitalization time (HT) and catheterization time (CT) were measured. Functional outcomes, Clavien-Dindo classification complications, and continence status were assessed at 1-, 3-, and 6-month follow-up.

RESULTS

The mean age, prostate size, and prostate-specific antigen levels of the patients were 64.54 years, 91 g, and 4.54 ng/mL, respectively. There were 38.3% of patients with ≥100 g prostate size. The measured EE, ME, and PRW were 1.12 g/min, 4 g/min, and 72%, respectively. The mean HT and CT were 24.53 h and 21.50 h, respectively. Functional outcomes showed significant improvement at 1-, 3-, and 6-month follow-up. Intraoperative and postoperative complications were comparable with the literature. The most common perioperative complication was superficial bladder mucosal injury (n=8, 1.33%). Only one patient had persistent stress urinary incontinence at 6-month follow-up.

CONCLUSION

As mentioned in the literature, HoLEP indications are independent from prostate size. Our results showed similarity with the literature on functional outcomes, complication rates, and continence status. With its superior results, our HoLEP series from Turkey supports that HoLEP will replace transurethral resection of the prostate as the known current gold standard.

Our clinic's first experience with HoLEP

OBJECTIVE:

The present study reports a retrospective evaluation of the first Holmium laser prostate enucleation (HoLEP) cases and their results in our clinic.

METHODS:

Twenty four patients who underwent HoLEP surgery between April 2017 and November 2017 were evaluated for demographic characteristics, duration of operation, amount of hemorrhage, amount of energy used, tissue weight removed, catheterization time and complications. IPSS and uroflowmetry results were compared before and after the surgery.

RESULTS:

Patients with hemoglobin, IPSS, uroflowmetry, and voiding speeds (Qmean, Qmax) were compared before and after the surgery. There was a significant difference in IPSS, Qmean and hemoglobin values but not in Qmax, statistically. Our complications rates were correlated with the literature.

CONCLUSION:

HoLEP stands out as a surgical method that can be applied with high confidence in the treatment of benign prostatic hyperplasia and it has similar functional results to gold standard surgeries, causes fewer complications, improves patient comfort due to short catheterization and hospitalization and is more advantageous regarding cost.

Safety and efficacy of Holmium laser enucleation of the prostate (HoLEP) in patients with previous transperineal biopsy (TPB): outcomes from a dual-centre case-control study

Background

We investigated the surgical feasibility, safety and effectiveness of 50 W (low power) Holmium Laser enucleation of the prostate (HoLEP) in patients who have undergone previous template biopsy of the prostate (TPB).

Methods

Data encompassing pre-operative baseline characteristics, intra-operative measures and post-operative outcomes was collected for 109 patients undergoing HoLEP across two UK centres. Patients were stratified into two groups; group 1 (n = 24) had undergone previous TPB were compared with ‘controls’ (no previous TPB) in group 2 (n = 85). The primary outcome was successful HoLEP.

Results

There were no statistically significant differences in either key baseline characteristics or mass of prostate enucleated between groups 1 and 2. There was no statistically significant difference in enucleation or morcellation times parameters between the two groups other than enucleation efficiency in favour of group 1 (p = 0.024). Functional outcomes improved, without any statistically significant difference, in both groups.

Conclusions

In patients with a previous TPB, HoLEP is surgically feasible, safe and effective. TPB should not be considered a contraindication to HoLEP. Our work provides a strong foundation for further research in this area.

Prostate Artery Embolization for Giant Prostatic Enlargement: Short-Term Efficacy and Safety

Eight patients with giant prostatic enlargement > 200 mL and lower urinary tract symptoms who underwent bilateral prostatic artery embolization (PAE) were reviewed. Mean prostate volume decreased from 318.2 mL to 212.2 mL (P < .01). At 5-month mean follow-up, International Prostate Symptom Score decreased by 16.7 points (P < .05), and urinary quality of life improved by 3.0 points (P < .01). Three of 4 catheter-dependent patients no longer needed catheterization after the procedure. No major complications were encountered. Preliminary results suggest PAE is safe and effective in patients with giant prostatic enlargement > 200 mL.

Evidence-based outcomes of holmium laser enucleation of the prostate

PURPOSE OF REVIEW

Holmium laser enucleation of the prostate (HoLEP) has been a mainstay therapy for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostate hyperplasia (BPH) for nearly 20 years. We briefly review current and sentinel publications that provide outcomes data after HoLEP.

RECENT FINDINGS

Current literature continues to support HoLEP as a versatile and durable surgical option for men with LUTS secondary to BPH. Despite evidence supporting durable symptom relief beyond 10 years even in large prostate glands, HoLEP is still not widely available to all patients. Concerns surrounding the learning curve of the procedure, high rates of retrograde ejaculation, and transient urinary incontinence seem to persist and limit the adoption of HoLEP by established urologists and residency training programs.

SUMMARY

Recent publications continue to show excellent short-term and long-term outcomes after HoLEP, in the categories of voiding function and patient satisfaction. Continued attempts to demonstrate equivalent outcomes of alternate-BPH surgical techniques are being met with renewed efforts by those performing HoLEP to demonstrate equivalent outcomes and patient safety during the learning phase of HoLEP for both mentored and self-directed surgical training.

Factors Influencing Intraoperative Blood Loss in Patients Undergoing Holmium Laser Enucleation of the Prostate (HoLEP) for Benign Prostatic Hyperplasia: A Large Multicenter Analysis

OBJECTIVE

To assess blood loss during holmium laser enucleation of the prostate (HoLEP) and investigate the factors influencing it.

PATIENTS AND METHODS

Analysis of patients with benign prostatic hyperplasia (BPH) treated with HoLEP at 3 centers. Hemoglobin and hematocrit were measured before surgery and hospital discharge. All blood transfusions performed during and after HoLEP were recorded. Blood loss outcomes were analyzed regarding antithrombotic (antiplatelet/anticoagulant) therapies and drug treatments for BPH and other conditions.

RESULTS

The analysis included 963 patients with a mean age of 72 years. Mean (range) prostate size was 102 (40-316) g; 28% of patients were receiving antiplatelets and 11% anticoagulants. Mean (range) prostate-specific antigen was 6.0 (0.3-43.5) ng/dL. Mean (range) operation time was 77 (28-178) minutes. Bladder calculi were found in 54 (5.6%) patients; all of them were successfully treated with cystolitholapaxy. Forty-eight (5%) patients required blood transfusion during or immediately after the HoLEP procedure. Overall, mean (SD) hemoglobin decreased from 14.6 (1.5) g/dL to 12.3 (2.1) g/dL (P <.001), and mean (SD) hematocrit decreased from 44.3% (4.7) to 37.7% (6.5) (P <.001). Neither hemoglobin nor hematocrit decreases were significantly different between patients receiving and not receiving antithrombotic therapy or BPH therapy.

CONCLUSION

HoLEP is safe and has no remarkable impact on blood loss. Patients at high risk, such as those receiving antithrombotic therapy, had the same outcome than the rest regarding blood loss, although showed a higher transfusion rate. Operating time may influence hemoglobin decrease; therefore, it should be considered in patients with higher risk of bleeding.