Patient reported outcome and quality of life measured by a simple questionnaire in patients with symptomatic benign prostate hyperplasia treated by holmium laser enucleation of the prostate (HoLEP)

Introduction

Holmium Laser Enucleation of the Prostate (HoLEP) is established as an effective transurethral treatment option for LUTS due to BPH with improved postoperative outcome. The aim of this study was to evaluate the medium-term results by patient reported outcome measurement and to detect potential risk factors for postoperative complications or impaired outcome.

Methods

We performed a retrospective single-center cohort study including all patients undergoing HoLEP in the study center between April 2019 and December 2021. Therefore, perioperative parameters and postoperative outcome was documented and all patients were asked for their outcome (PROM), complications, IPSS, QoL and changes in sexual and continence function by a questionnaire at a single time point.

Results

In the study period, a total of 541 patients with a mean age of 72.5 ± 8.4 years were treated by HoLEP in the study center. 71.7% of the questionnaires were returned after a mean observation period of 14.9 ± 6.3 month. 91% of the patients reported to the single-timepoint questionnaire reporting a good satisfaction with the procedure and a low postoperative complication rate. The international prostate symptom score could be reduced significantly to 6.2 ± 5.7 (preoperative 19.0 ± 7.2; p < 0.001). Patients with an ASA score ≥ 3, prostate volume > 80 ml, medication with platelet inhibitors or DOAK or preoperative need of an indwelling catheter didn't show an increased complication rate.

Conclusion

The overall satisfaction with the procedure and its results are high. We could not identify any independent risk factors for postoperative complications after HoLEP. The used questionnaire is a simple tool for postoperative patient reported outcome measurement with a good correlation to clinical parameters.

Holmium laser enucleation of the prostate as a secondary surgery following prostatic urethral lift

Introduction

Prostatic urethral lift is a treatment option for benign prostatic hyperplasia, yet information on surgeries following this procedure is scarce.

Case presentation

A 71-year-old man with persistent urinary retention following prostatic urethral lift underwent a secondary holmium laser enucleation of the prostate. The morcellation procedure, complicated by the presence of implants from the previous surgery, broke the morcellator blade. The fragmented blade was successfully retrieved without any organ damage. Postoperatively, the patient encountered no complications and showed improvement in his urinary symptoms.

Conclusion

This case highlights the potential risk of device breakage when a secondary surgery, specifically the morcellation process, is performed following prostatic urethral lift. Care must be taken to prevent interaction between the implants and the morcellator. Our case demonstrates the efficacy of holmium laser enucleation of the prostate as a salvage surgical intervention for patients in whom prostatic urethral lift has failed.

Observation of complications assessed by Clavien-Dindo classification in different endoscopic procedures of benign prostatic hyperplasia: An observational study

The Clavien-Dindo classification (CDC) was widely used in the assessment of surgical complications, but some inconsistencies always existed in urological literature. This study was aimed to report complications of the transurethral resection of the prostate (TURP), plasmakinetic resection of the prostate (PKRP), and holmium laser enucleation of the prostate (HoLEP) by using a more detailed way under the framework of CDC. A total of 623 eligible cases underwent endoscopic procedures from January 2018 and December 2020 were divided into the TURP group (212 cases), the PKRP group (208 cases), and the HoLEP group (203 cases) according to the surgical type. Patients' surgical complications assessed by the CDC were compared among the 3 groups. The operation time, intraoperative irrigation volume, postoperative irrigation time and volume, decrease in hemoglobin and sodium, postoperative catheterization time, visual analogue scale, hospital stay of the PKEP group and the HoLEP group were significantly less than those of the TURP group, and the decrease in hemoglobin and visual analogue scale in the HoLEP group were significantly lower than those in the PKEP group (all P < .05). The electrolyte disturbance, urinary tract irritation, and patients with grade II of CDC in the PKRP group were significantly lower than those in the TURP group; The electrolyte disturbance, lower abdominal pain, urinary tract irritation, intraoperative hemorrhage, secondary hemorrhage, clot retention, patients with grade I, II, III of CDC in the HoLEP group were significantly lower than those in the TURP group, and the urinary tract irritation, grade I, II of CDC in the HoLEP group was significantly lower than that in the PKRP group (all P < .05). The CDC should be recommended because of the enhanced insight into surgical complications, and the HoLEP should be given a priority for Benign prostatic hyperplasia (BPH) surgical treatment in terms of the merits in surgical characteristics and complications.

Age and metabolic syndrome are associated with unsatisfactory improvement in nocturia after holmium laser enucleation of the prostate

Objective

To investigate the association between age, metabolic syndrome (MetS) and improvement in nocturia in patients with benign prostate hyperplasia (BPH) receiving holmium laser enucleation of the prostate (HoLEP).

Methods

The retrospective study was conducted on patients treated for BPH using HoLEP between January 2021 and May 2022. Lower urinary tract symptoms (LUTS) were measured before surgery and at 3 months postoperatively using the International Prostate Symptom Score (IPSS). The criteria of the Adult Treatment Panel III (ATP III) were adopted to diagnose the MetS. Unsatisfactory improvement in nocturia was defined as <50% reduction in nocturia from baseline on the IPSS.

Results

One hundred and seventy-five patients were eventually enrolled, with a median age of 69 years (IQR: 63/73). Unsatisfactory improvement in nocturia was reported in 95 patients (54%) after HoLEP. These patients were older (73; IQR: 67/79 vs. 66; IQR: 60/71, P < 0.001) and more likely to present with higher postoperative total (6; IQR: 4/9 vs. 3; IQR:2/5, P < 0.001), voiding (1; IQR: 0/3 vs. 1; IQR: 0/2, P = 0.017), and storage (4; IQR: 3/6 vs. 2; IQR: 1/4, P < 0.001) IPSS when compared to patients with satisfactory improvement in nocturia. Overall, 63 of 175 (36%) patients were diagnosed with MetS and of these, 44 (70%) reported unsatisfactory improvement in nocturia (P = 0.002) after HoLEP. Multivariate analysis revealed that age (OR = 1.117, 95% CI: 1.068-1.169, P < 0.001) and MetS (OR = 3.613, 95% CI: 1.727-7.562, P = 0.001) were independent risk factors for unsatisfactory improvement in nocturia after HoLEP.

Conclusion

Our findings suggest that increased age and MetS were associated with unsatisfactory improvement in nocturia in patients with BPH after HoLEP. Lifestyle management, including weight loss, may be of great importance in the improvement of nocturia.

Travel characteristics and outcomes for patients seeking HoLEP

INTRODUCTION

Holmium laser enucleation of the prostate (HoLEP) is an effective but underutilized option for the surgical management of benign prostatic hyperplasia (BPH). With low adoption, questions arise surrounding patients access to care. It is unclear whether patients undergoing HoLEP are local or specifically seek care from afar. We looked to determine the proportion of patients who traveled out-of-state for HoLEP treatment and the impact of travel on peri and postoperative metrics.

MATERIALS AND METHODS

We performed a retrospective cohort study evaluating patients that underwent HoLEP at a single institution from 2007-2019. Patient demographic, perioperative data, postoperative outcomes, travel distance and income data were compared between those who traveled and did not travel out-of-state for care.

RESULTS

From 2007-2019, 1565 patients underwent HoLEP at our institution. The mean age was 70.0 years, average body mass index (BMI) of 27.9 kg/m2, and 91.6% identified as Caucasian; 44.2% of patients traveled from out-of-state for HoLEP care, traveling a median of 597 miles. Patients who came from out-of-state had larger prostates (p = 0.005) and worse preoperative International Prostate Symptom Score (IPSS) total and bother scores (p = 0.002). There was no difference in immediate, 30 or 90 day complications rates. In- and out-of-state patients had similar postoperative urinary and functional outcomes.

CONCLUSIONS

A large proportion of patients specifically seek out HoLEP and travel out-of-state for care. The reasons are likely multifactorial -including advanced disease, lack of local care and healthcare consumerism. These results have implications both for those currently providing HoLEP as a treatment option as well as those motivated to start a HoLEP practice.

[Our experience of holmium laser enucleation of the prostate]

INTRODUCTION

Surgical treatment of benign prostatic hyperplasia (BPH) is influenced by a rapidly growing number of technologies.

AIM

To determine the surgical potential of holmium laser enucleation of the prostate (HoLEP) and the rate of postoperative complications during the learning curve.

MATERIALS AND METHODS

A total of 98 patients undergoing HoLEP in the surgical department of the Clinical Hospital "Mother & Child" during the period from January 2018 to May 2020 were included in the study. HoLEP was performed by a single surgeon with previous experience in transurethral procedures. The criteria for inclusion in the study group were as follows: moderate-to-severe lower urinary tract symptoms, prostate volume > 40 cm3, maximum flow <15 ml/sec, the volume of residual urine > 50 ml. The exclusion criteria were the following: inflammatory process in the lower urinary tract, genitourinary malignancy, previous urinary tract interventions. The evaluated criteria included age, prostate size, International Prostate Symptoms Score (IPSS and QoL), bladder diary, PSA, uroflowmetry, total operative time, length of catheterization, complications according to the Clavien-Dindo Classification, and length of stay.

RESULTS

During pathologic study, two cases of incidental prostate cancer (2.1%) were detected. The relationships between the prostate size and operative time (p<0.05), operative time and length of stay (p<0.05) were found. The total rate of complications was 16.3%. There were no complications more or equal IIIb according to the Clavien-Dindo Classification. The most dangerous complications were injuries of the bladder wall and ureteral orifice (31.25% and 18.75% among all complications, respectively).

DISCUSSION

It should be considered that a large "middle lobe" is associated with a high risk of injury of the ureteral orifices. In our series, there were 5 cases of bladder tamponade, while bladder injuries during the morcellation developed in the first 10 patients.

CONCLUSION

HoLEP is a reasonable alternative to TURP for surgical treatment of BPH and is considered a safe procedure for patients taking anticoagulant and antiplatelet drugs. Past experience of TURP allows to learn the technique faster and to reduce the number of complications.

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.

Incidental prostate cancer after holmium laser enucleation of the prostate-A narrative review

Prostate cancer can be detected incidentally after surgical therapy for benign prostatic obstruction such as holmium laser enucleation of the prostate (HoLEP), thus called incidental prostate cancer (iPCa). We aimed to review the studies on iPCa detected after HoLEP and investigate its prevalence. A detailed search of original articles was conducted via the PubMed-MEDLINE, Web of Science, Wiley Online Library and Cochrane Library databases in the last 10 years up to 1 May 2021 with the following search string solely or in combination: "prostate cancer", "prostate carcinoma", "holmium laser enucleation of the prostate" and "HoLEP". We identified 19 articles to include in our analysis and divided them into six main categories: HoLEP versus open prostatectomy and/or transurethral resection of the prostate in terms of iPCa, oncological and functional outcomes, the role of imaging modalities in detecting iPCa, predictive factors of iPCa, the role of prostate-specific antigen kinetics in detecting iPCa and the management of iPCa after HoLEP. We found that the iPCa after HoLEP rate ranges from 5.64% to 23.3%. Functional and oncological outcomes were reported to be encouraging. Oncological treatment options are available in a wide range.

Does the use of a small-size resectoscope during enucleation prevent transient urinary leakage and urethral stricture following holmium laser enucleation of the prostate?

OBJECTIVE

To investigate the effect of the use of a small-size resectoscope for enucleation during holmium laser enucleation of the prostate (HoLEP) on the prevention of transient urinary leakage (TUL) and urethral stricture (US).

METHODS

One hundred patients were included in a retrospective single-center study from January 2019 to December 2020. The patients were divided into two groups according to the resectoscope size which was used for enucleation (22F in group A [n = 40] and 26F in group B [n = 60]). Patients were evaluated at 4, 12, and 24 weeks postoperatively for TUL and US. Univariate and multivariate regression analyses were implemented to assess the variables which are associated with TUL at 4 weeks.

RESULTS

Baseline characteristics and perioperative data were observed to be well balanced between groups. A statistically significant higher occurrence of TUL was detected at 4 weeks in group B compared to group A (P = .018). Higher improvement in International Prostate Symptom Score (IPSS) and quality of life (QoL) was observed in group A at 4 and 12 weeks postoperatively. On univariate analysis, resectoscope size, specimen weight, and body mass index were significant predictive factors for TUL at 4 weeks. Multivariate analysis illustrated that the resectoscope size was independently associated with TUL at 4 weeks after HoLEP (odds ratio = 3.1 [1.02-9.38]). One patient in group A (2.5%) and two patients in group B (5%) demonstrated US (P = .648).

CONCLUSION

Enucleation with a 22F resectoscope provides better QoL and IPSS by reducing TUL rates in the early postoperative period.

T-L technique for HoLEP: perioperative outcomes of a large single-centre series

Introduction

The aim of this article was to describe, step-by-step, an original technique (T-L technique) in a single centre series of patients who underwent holmium laser enucleation of the prostate (HoLEP) for symptomatic benign prostatic hyperplasia and analyze perioperative outcomes.

Material and methods

We retrospectively analyzed data of 567 patients who underwent HoLEP. The T-L technique consists of a series of incisions used as landmarks, performed at the beginning of the procedure before enucleation. Two T-shape incisions are performed at the level of bladder neck (at the 5-7 and 12 o’clock positions); two L-shape incisions are performed at the level of verumontanum, bilaterally, to mark the apex and to limit the sphincter. Another T-shape incision is performed on the bladder neck at the 12 o’clock position posterior to the level of verumontanum.

Results

The median operative time (OT) was 80 minutes (IQR 64–105); 50 minutes (IQR 35–70) and 15 minutes (IQR 10–20) for enucleation and the morcellation phase, respectively. Conversion to transurethral resection of the prostate (TURP) was necessary in 3/567 (0.6%) patients. Intraoperative complications occurred in 3.4% of cases, capsule perforation occurred in 12/567 (2%) of cases, while bladder perforation during morcellation occurred in 8/567 (1.4%) of cases. Postoperative complications were observed in 20/567 (3.5%) of patients. Specifically, grade 1–2 occurred in 19/567 (3.3%) and grade 3 was recorded in 1/567 (0.2%).

Conclusions

The T-L technique for HoLEP is safe and reproducible with a low rate of perioperative complications. The positioning of some landmarks before enucleation allows for the better orientation during enucleation and could be very useful in case of large prostates.

The impact of preoperative lower urinary tract symptoms medication on the functional performance of holmium laser enucleation of the prostate

Introduction

Medical treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) targets prostate size, to prevent disease progression, and prostate smooth muscle tone for rapid relieve of LUTS. Holmium laser enucleation of the prostate (HoLEP) is a size-independent method for surgical treatment of LUTS/BPO in medication-refractory patients and offers durable long-term results with reduced perioperative morbidity. As up to 50% of patients receive medical treatment for LUTS/BPO prior to surgery, we analyzed the impact of alpha-blockers and 5-alpha reductase inhibitors (5-ARI) on outcomes and perioperative morbidity in patients undergoing HoLEP for LUTS.

Material and methods

We retrospectively gathered data of 1,057 patients, who underwent HoLEP for LUTS/BPO from 2013–2018, and divided patients into group 1 (no medication), group 2 (α-blockers), and group 3 (5-ARI and α-blockers). Perioperative parameters, short-term functional outcomes and safety were assessed and statistical analysis was performed using SPSS V26.0 software.

Results

Even though preoperative LUTS profile was significantly different between groups, all patients improved significantly after HoLEP, irrespective of preoperative LUTS medication. Median improvement of IPSS was 9, 8 and 7 points, of Q_max was 10, 12 and 9.5 ml/s, with significant improvement of quality of life (QoL) and reduction of post-void residual volume (PVR) for groups 1–3, respectively, 30 days after surgery. With only 4.0% (42/1,057) of patients experiencing a Clavien-Dindo grade ≥II complication, there was no difference in prevalence of perioperative complications between groups (p = 0.943).

Conclusions

Although preoperative LUTS medication does not impair efficacy of HoLEP with acceptable perioperative morbidity, the time gap between medical therapy and surgical treatment may favor an earlier response.

Holmium laser enucleation of the prostate: A truly size-independent method?

OBJECTIVES

To evaluate the impact of prostate size on functional outcomes and perioperative morbidity, we analyzed patients undergoing holmium laser enucleation of the prostate (HoLEP) for lower urinary tract symptoms (LUTS). As LUTS secondary to benign prostatic obstruction (BPO) are a chronic progressive disease, prevalence and prostate size increase with age. HoLEP is a size-independent method for surgical treatment of LUTS/BPO and can be offered in medication-refractory patients with durable long-term results and reduced perioperative morbidity.

METHODS

We retrospectively collected data of 852 patients who underwent HoLEP for LUTS secondary to BPO between 2014-2018. Patients were divided into group 1 (≤60 cc), group 2 (>60 < 120 cc), group 3 (≥120 cc). Perioperative parameters, safety and short-term functional outcomes were assessed and analyzed.

RESULTS

Patients in group 3 were significantly older and showed a significantly higher median prostate-specific antigen level. Perioperative parameters, such as enucleation time and morcellation time significantly differed in favor of smaller prostate sizes, while enucleation and morcellation speed showed favorable results for larger prostate sizes. Larger prostates ≥120 cc showed a significantly higher postoperative drop in hemoglobin. However, patients did not differ in postoperative functional outcomes or Clavien-Dindo grade ≥II complications (4.8% of all patients [41/852]). There was no difference in perioperative complications between all groups (P = 0.760).

CONCLUSION

While larger prostates take significantly longer to operate on, postoperative functional outcomes show no difference between all sizes. In conclusion, HoLEP is a size-independent and effective method for surgical treatment of LUTS/BPO in prostates ≥30 cc.

Spinal versus general anesthesia for Holmium laser enucleation of the prostate of high-risk patients - A propensity-score-matched-analysis

OBJECTIVE

To compare perioperative management and functional outcome of spinal anesthesia (SpA) to general anesthesia (GA) in high-risk patients treated for lower urinary tract symptoms (LUTS) with Holmium laser enucleation of the prostate (HoLEP).

METHODS

In the current retrospective analysis, a propensity-score-matching of patients treated for LUTS with HoLEP (n=300) in SpA with ASA>2 (n=100), GA with ASA>2 (GA-high-risk) (n=100) or GA with ASA≤2 (GA-low-risk) (n=100) was performed. The impact of anesthesiologic mode on perioperative anesthesiologic outcome, early functional outcome and treatment related adverse events (according to Clavien Dindo), was evaluated.

RESULTS

Hypotensive episodes were significantly less frequent in the SpA-cohort (9%) compared to the GA-high-risk cohort (32%) and the GA low-risk cohort (22%) (each p<0.05 respectively). SpA-patients showed a significantly shorter median time in post anesthesia care unit (PACU-time: 135min; 120-166.5) compared to GA-high-risk patients (186min; 154-189.5), with significant less referrals to Intermediate care unit (ICU) (1% vs. 9 %); (each p<0.05). PACU-time (99min) and ICU referrals (0%) for GA-low-risk were lower than for both other cohorts. Postoperative requirement for analgesics was significantly lower in the SpA-cohort (2%), compared to both GA-cohorts (74% and 61% respectively; p<0.05). No significant difference was found regarding early functional outcome or treatment related adverse events (AE) (p-range:0.201-1.000).

CONCLUSION

For patients undergoing HoLEP, SpA provides greater hemodynamic stability and allows faster overall postoperative recovery with preferable pain management. Yielding a comparable functional outcome, it is a safe and efficient alternative to GA in high-risk patients.

Superiority of Holmium Laser Enucleation of the Prostate over Transurethral Resection of the Prostate in a Matched-Pair Analysis of Bleeding Complications Under Various Antithrombotic Regimens

Introduction: To compare holmium laser enucleation of the prostate (HoLEP) with transurethral resection of the prostate (TURP) in patients under continuous antithrombotic therapy with regard to bleeding complications. Materials and Methods: We conducted a retrospective matched-pair analysis of 221 patients with continuous antiplatelet therapy or anticoagulative medication, who were treated with HoLEP (n = 111) or TURP (n = 110). Matching criteria were prostate size (50 cc) and total surgical time (60 minutes). Patients were further stratified by their antithrombotic medication. We evaluated functional outcomes, perioperative morbidity, and bleeding complications according to Clavien-Dindo (CD). Results: Our perioperative assessment showed a significantly higher percentage of resected tissue for HoLEP (median 71.43%; interquartile range [IQR]: 61.82-78.57) than for TURP (median 45.45% IQR: 39.02-56.20) (p < 0.001). Total perioperative hemoglobin drop was significantly lower for the HoLEP cohort (median 0.7 g/dL; IQR: 0.3-1.1 g/dL) than for the TURP cohort (median 2.20 g/dL; IQR: 1.18-2.80 g/dL) (p < 0.001). For all subgroups, perioperative blood loss was always significantly lower for HoLEP than for TURP. The median hemoglobin drop was 0.5 g/dL vs 1.1 g/dL for the acetylsalicylic acid 100 mg (ASS) subgroup, 0.70 g/dL vs 2.95 g/dL for the ASS+ADP-receptor inhibitor subgroup, 0.65 g/dL vs 2.4 g/dL for the vitamin K antagonist subgroup, and 0.90 g/dL vs 2.70 g/dL for the direct oral anticoagulant subgroup (all, p < 0.001). Perioperative adverse events were significantly less frequent after HoLEP (5.4%) than after TURP (16.4%) (p < 0.05). Conclusion: HoLEP is an efficient and safe procedure for patients under diverse continuous antithrombotic regimens. It provides a superior perioperative hemostatic control and causes less bleeding complications in this high-risk population.

The clinical value of holmium laser enucleation of the prostate in octogenarians

OBJECTIVES

With holmium laser enucleation of the prostate (HoLEP) a size-independent method for surgical treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) has been introduced. HoLEP offers durable long-term results with reduced perioperative morbidity. As the risk of disease progression increases with age, the main goals, when offering surgery to an elderly population, are reducing perioperative morbidity and preserving quality of life (QoL). We therefore analyzed the impact of age on outcomes and perioperative morbidity in patients undergoing HoLEP for LUTS at our tertiary referral center.

METHODS

We retrospectively collected data of 487 patients who underwent HoLEP for LUTS secondary to BPO between 2018 and 2019. Patients were divided into group 1 (<70 years), group 2 (70-79 years), and group 3 (≥80 years). Perioperative parameters, safety, and short-term functional outcomes were assessed and analyzed.

RESULTS

Perioperative Clavien-Dindo grade ≥II complications were seen in 4.1% of patients (20/487). There was no difference in perioperative complications between all age groups (P = .176). Functional outcome was assessed 30 days post surgery. There was significant improvement in median International Prostate Symptom Score of 14, 10, and 8 points for groups 1, 2, and 3 (P < .001), respectively, with constant improvement of median QoL of 3 points for all groups. Median maximum flow rate (Q_max ) showed significant improvement of 14.5, 10.5, and 13 mL/s for groups 1 to 3 (P = .467), respectively.

CONCLUSION

HoLEP offers acceptable perioperative complication rates even in the oldest patient cohort (≥80 years). Therefore, HoLEP is a safe and efficient option even in oldest patients.

Comparison Study of Learning Curve Using Cumulative Sum Analysis Between Holmium Laser Enucleation of the Prostate and Transurethral Resection of the Prostate: Is Holmium Laser Enucleation of the Prostate a Difficult Procedure for Beginner Urologists?

Objectives: Although there is no comparison study about the learning curves for holmium laser enucleation and other surgical modalities to treat benign prostatic hyperplasia (BPH), beginner urologists are hesitant to perform holmium laser enucleation because of its steep learning curve. Therefore, we investigated the degree of surgical difficulty of holmium laser enucleation by comparing its learning curve with that of transurethral resection. Patients and Methods: Two beginner urologists performed surgery for BPH: H.J.Y. performed holmium laser enucleation and K.H.K. performed transurethral resection. Of 141 patients, 72 were enrolled in the holmium laser enucleation group and 69 in the transurethral prostate resection group. After retrospectively reviewing medical records, we performed a cumulative sum analysis of resection speed (RS) and resected ratio (RR) to compare the learning curves of holmium laser enucleation and transurethral resection. Results: Both surgeons achieved RS competency with a speed <0.13 g/min. The surgeon who performed holmium laser enucleation achieved RR competency with a ratio <0.40, whereas the surgeon who performed transurethral resection achieved competency with a ratio <0.35. To achieve RS competency of 0.13 g/mL, the holmium laser enucleation and transurethral resection groups required 12 and 23 cases, respectively. To achieve RR competency of 0.35, the holmium laser enucleation and transurethral resection groups required 12 and 5 cases, respectively. Conclusions: Holmium laser enucleation is not a difficult procedure compared with transurethral resection in beginner urologists. Therefore, it is unnecessary to avoid holmium laser enucleation because the concerns that it may be difficult are unfounded.

Holmium laser enucleation of the prostate using Moses 2.0 vs non-Moses: a randomised controlled trial

OBJECTIVES

To compare the enucleation efficiency of Moses 2.0 with non-Moses technology in patients undergoing holmium laser enucleation of the prostate (HoLEP).

PATIENTS AND METHODS

A double-blinded, randomised study of patients undergoing HoLEP at the Mayo Clinic in Arizona, using the Lumenis Pulse™ 120H laser system. Patients were randomised to either right lobe enucleation using Moses 2.0 and left lobe enucleation using non-Moses, or the opposite. The primary outcome was individual lobe enucleation efficiency. Secondary outcomes included individual lobe laser time, laser energy, individual enucleation and haemostasis laser energies, and fibre burn back. Two independent reviewers watched videos of the procedures and provided a subjective evaluation of the technologies.

RESULTS

A total of 27 patients were included in the study. For the entire cohort, Moses 2.0 had less fibre degradation (3.5 vs 16.8 mm, P < 0.01) compared to non-Moses. When HoLEP procedures were performed by an expert, Moses 2.0 resulted in shorter enucleation time (21 vs 36.7 min, P = 0.016) and higher enucleation efficiency (1.75 vs 1.05 g/min, P = 0.05) compared to non-Moses. When HoLEP was performed by trainees, the Moses 2.0 cohort had a shorter haemostasis laser time (4.1 vs 9 min, P = 0.035) compared to the non-Moses. Fibre degradation was lower with Moses 2.0 compared to non-Moses for both experts and trainees. Moses 2.0 received a higher score than the standard technology for the incision sharpness, fibre control, tissue separation, tissue damage, haemostasis, visibility, and charring. The overall inter-observer correlation coefficient was 0.63.

CONCLUSION

Moses 2.0 has higher enucleation efficiency compared to non-Moses when used by experts. The subjective evaluation favoured Moses 2.0.

Comparison Between 1-Day and Inpatient Procedure of Holmium Laser Enucleation in Patients With Benign Prostate Hyperplasia

Holmium laser enucleation of the prostate (HoLEP) is one of the minimally invasive procedures that is used for patients with benign prostate hyperplasia. The procedure usually requires patients to stay in the hospital 2 nights or longer. The present study evaluated the safety and feasibility of HoLEP with discharge of the patients on Day 1 after surgery (1-day surgery). A total of 1,164 patients were included in the study, with 510 of them planned for 1-day surgery and others planned for inpatient surgery. The primary outcomes included complication rate and clinical outcomes. A total 489 out of 510 patients received 1-day HoLEP and were discharged on Day 1 after surgery. In a 30-day follow-up period, no significant differences were found between the 1-day and inpatient surgery groups in terms of the rate of complications and clinical outcomes. Patients in the 1-day surgery group had a significantly shorter waiting time for admission (9.5 ± 4.8 vs. 17.6 ± 7.4 days, p < .05), and the mean hospitalization cost was lower (CNY$ 9140.6 ± 1452.2 vs. 10533.4 ± 1594, p < .05).The 1-day HoLEP surgery was safe and had satisfactory clinical outcomes. This treatment strategy could reduce the waiting time for admission and cost of hospitalization. Majority of the patients found this 1-day surgery beneficial, especially elderly patients who prefer to have an early return home and rapid resumption of activities.

Safety and efficacy of male urethral slings for management of persistent stress urinary incontinence after holmium laser enucleation of the prostate

Holmium laser enucleation of the prostate gland (HoLEP) is an alternative to the traditional transurethral resection of the prostate, especially for large-volume prostates. One complication is urinary incontinence, which is usually stress urinary incontinence (SUI). Little data exist on surgical interventions for SUI after HoLEP. This retrospective case series examined the safety and possible efficacy of a midurethral sling (MUS) following HoLEP. Between January 2016 and February 2019, 610 HoLEPs were performed at our institution. Three (0.5%) had persistent, overly bothersome symptoms of SUI. All three underwent MUS placement with a transobturator AdVance^® male sling after failed pelvic floor rehabilitation. The degree of SUI was evaluated by pad use pre-HoLEP, post-HoLEP, and post-MUS placement. Surgical times for HoLEP and MUS were evaluated. No patients were using pads for incontinence before HoLEP. The average pad use was 7 post-HoLEP and 0.3 post-MUS. The average morcellated prostate was 48 g, and surgical time was 68 min (52 for enucleation and 15 for morcellation). No complications were reported with MUS placement intraoperatively or postoperatively. MUS for persistent and bothersome SUI after HoLEP shows promise as a safe and effective surgical option.

[IMPACT OF MEMBRANOUS URETHRAL LENGTH IN DE NOVO STRESS URINARY INCONTINENCE FOLLOWING HOLMIUM LASER ENUCLEATION OF THE PROSTATE]

(Purpose) Holmium laser enucleation of the prostate (HoLEP) is widely performed in recent years; however, difficulties of surgical techniques and high frequency of postoperative stress urinary incontinence (SUI) remain as significant problems. We determined the predictive factors for de novo SUI after HoLEP. (Patients and methods) A total of 303 patients with benign prostatic hyperplasia who underwent HoLEP were retrospectively evaluated between July 2013 and April 2019. Of these, 109 patients underwent MRI preoperatively. Patients who were unable to answer the questionnaire regarding their SUI because of dementia, those who presented with SUI preoperatively, and those with placed Foley catheter at the time of MRI were excluded. Hence, a total of 83 patients were eligible for the present study. We recorded the MRI findings and clinical variables, including membranous urethral length (MUL), transitional zone (TZ) volume, serum prostate-specific antigen levels, operative time, and presence or absence of SUI. The predictive factors for de novo SUI were determined using multivariable logistic regression analysis. (Results)De novo SUI occurred in 19 (22.9%) patients but disappeared in 16 (84.2%) patients at a mean duration of 14 weeks. The mean MUL was 17.2 mm. Univariate analysis showed that MRI TZ volume >40 mL, MUL ≤17 mm, operative time >100 min, and enucleation time >50 min were associated with de novo SUI. In multivariable logistic regression analysis, MUL ≤17 mm (odds ratio [OR], 23.81; 95% confidence interval [CI], 4.34-447.19; P < 0.0001) and operative time >100 min (OR, 3.91; 95% CI, 1.20-14.01; P = 0.023) were significantly associated with de novo SUI. (Conclusions) Although de novo SUI occurred occasionally after HoLEP, most of them improved in about 3 months. The MRI measurement of MUL was shown to be a practical tool for predicting de novo SUI after HoLEP.

Correlating Patient Anxiety with Urinary Symptoms Before and After Holmium Laser Enucleation of the Prostate

Introduction and Objective: Preoperative anxiety has been shown to correlate with certain urinary symptoms in patients with certain types of voiding dysfunction, particularly overactive bladder. The purpose of this study was to evaluate if patient-reported anxiety correlates with pathologic characteristics, voiding symptoms, and objective metrics of bladder emptying in male patients undergoing holmium laser enucleation of the prostate (HoLEP). Patients and Methods: We began collecting patient-reported anxiety scores (generalized anxiety disorder 7-item or GAD-7) in addition to patient-reported scores of lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) starting in November 2018 for men with LUTS due to benign prostate hyperplasia (BPH). We retrospectively evaluated the relationship between preoperative GAD-7 score with preoperative age, body mass index (BMI), preoperative urine flow metrics, preoperative postvoid residual (PVR), and preoperative symptom scores for LUTS (American Urological Association, BPH impact index [BII], and Michigan incontinence symptom index [MISI]) and ED (sexual health inventory for men and male sexual health questionnaire for ejaculatory dysfunction [MSHQ-EjD]). We then compared preoperative GAD-7 score with enucleated prostate weight, postoperative GAD-7 scores, postoperative urine flow metrics, postoperative PVR, and postoperative symptom scores for LUTS and ED. Results: We included 139 patients for analysis. The preoperative GAD-7 score positively correlated with preoperative BII scores (r_s = 0.202, p = 0.019), MISI total (r_s = 0.260, p = 0.002), and MISI bother (r_s = 0.345, p < 0.001) scores. Preoperative GAD-7 negatively correlated with preoperative MSHQ-EjD (r_s = -0.191, p = 0.031). Following HoLEP, all four of these correlations disappear. The GAD-7 score did not correlate with age, BMI, preoperative urine flow metrics, preoperative PVR, or other preoperative LUTS and ED symptom scores. In addition, preoperative GAD-7 score showed no correlation with enucleated prostate weight, postoperative urine flow metrics, postoperative PVR, and postoperative LUTS and ED symptom scores. Conclusions: Higher preoperative anxiety correlated with more severe preoperative urinary LUTS, particularly incontinence symptoms, in patients undergoing HoLEP. Following HoLEP, these symptoms improve regardless of patient anxiety level.

Surgical blood loss during holmium laser enucleation of the prostate (HoLEP) is not affected by short-term pretreatment with dutasteride: a double-blind placebo-controlled trial on prostate vascularity

Five α-reductase inhibitors (5ARIs) are able to reduce prostate volume and are a useful treatment for reducing perioperative bleeding during prostate surgery. Holmium laser enucleation of the prostate (HoLEP) is an effective surgical technique for the definitive cure of benign prostate enlargement.

We investigated whether pretreatment with dutasteride before HoLEP could reduce intraoperative bleeding. A total of 402 patients were included in this double-blind placebo-controlled trial to receive daily 0.5 mg of dutasteride or placebo over 8 weeks before HoLEP. Vascular endothelial growth factor (VEGF) and microvascular density (MVD) were evaluated. Analysis was also stratified according to prostate volume (<70 mL vs ≥70 mL).

Hemoglobin and hematocrit values before and after surgery were not statistically different between the two groups. MVD and VEGF index in smaller prostates were 23.35±1.96 and 4.06±0.76 in the treatment group and 19.04±0.96 and 2.55±0.55 in placebo (p<0.05); in patients with larger prostates MVD and VEGF were 26.83±2.812 and 8.54±1.18 in the treatment group and 20.76±0.79 and 3.21±0.54 in placebo (p<0.05).

Vascularization of the prostate was affected by 5ARIs therapy. HoLEP is less burdened in perioperative bleeding and for this reason we did not find any difference in hemoglobin/hematocrit values pre- and post- surgery.

[Low power seven-step two-lobe holmium laser enucleation of the prostate technique for surgical treatment of benign prostatic hyperplasia]

OBJECTIVE

To evaluate the safety and efficacy of the seven-step two-lobe holmium laser enucleation of the prostate (HoLEP) technique with low power laser device, and to introduce the detailed operating procedures, key points, short-term outcomes of this modified HoLEP technique.

METHODS

From March 2016 to November 2017, 90 patients underwent HoLEP in Peking University Third Hospital. The patients were divided into two groups: high-power group (32 patients) were performed with traditional Gilling's three-lobe enucleation using high power (90 W) laser; Low-power group (58 patients) were performed with seven-step two-lobe enucleation using low power (40 W) laser. The main steps of the low power seven-step two-lobe HoLEP phase included: (1) The identification of the correct plane between adenoma and capsule at 5 and 7 o'clock laterally to the veru montanum; (2) The connection of the bilateral plane by making a adenoma incision at the proximal point of veru montanum; (3) The extension of the dorsal plane under the whole three lobes between adenoma and capsule towards the bladder neck; (4) The separation of the middle lobe from two lateral lobes by making two retrograde incisions separately from apex 5 and 7 o'clock towards the bladder neck; (5) The enucleation of the middle lobe adenoma by extending the dorsal plane through into the bladder; (6) The prevention of the apex mucosa by making a circle incision at the apex of the prostate; (7) The en-bloc enucleation of the two lateral lobe adenomas by extending the lateral and ventral plane between adenoma and capsule from 5 and 7 o'clock to 12 o'clock conjunction and through into the bladder.

RESULTS

The mean patient age was (66.25±5.37) years vs. (68.00±5.18) years; The mean body mass indexes were (24.13±4.06) kg/m² vs. (24.57±3.50) kg/m²; The mean prostate specific antigen values were (3.23±2.47) μg/L vs. (6.00±6.09) μg/L; The average prostatic volumes evaluated by ultrasound was (49.03±20.63) mL vs. (67.55±36.97) mL. There was no significant difference between the two groups. Furthermore, there were no significant differences in terms of perioperative and follow up data, including operative time; enucleation efficiencies; hemoglobin decrease; blood sodium and potassiumthe change postoperatively; catheterization duration and hospital stay; the international prostate symptom scores and quality of life scores pre- and post-operatively. There was 1 transurethral resection of the prostate (TURP) conversion in high-power group and 1 transfusion in low-power group during the operations. The follow-up one month after operation showed no severe stress incontinence in both the groups, whereas 3 cases ejaculatory dysfunctions in high-power group versus 1 case in low-power group were observed; Other surgeryrelated complications included: 2 cases postoperative hemorrhage (Clavien II and Clavien IIIb) in high-power group, 2 cases postoperative temperature more than 38 °C (Clavien I) and 1 case dysuria following catheter removal (Clavien I) in low-power group.

CONCLUSION

Low power laser device can be applied safe and effectively for HoLEP procedure using the seven-step two-lobe HoLEP technique. The outcomes comparable with high power laser HoLEP can be achieved.

Preoperative multiparametric prostate magnetic resonance imaging: a safe clinical practice to reduce incidental prostate cancer in Holmium laser enucleation of the prostate

Introduction

Purpose of the study was to investigate the correlation of a preoperative multiparametric magnetic resonance imaging of the prostate (mpMRI) in patients with a suspicion of prostate cancer and eligible for Holmium Laser Enucleation of the Prostate (HoLEP).

Material and methods

Data of 228 patients who had undergone HoLEP was selected and retrospectively analyzed from a multicentric database. All patients presented with a raised serum PSA and/or an abnormal digital rectal examination (DRE). Prostate cancer (PCa) was excluded either with a negative mpMRI (group ‘NEGATIVE MRI’ n = 113) or a standard biopsy (group ‘NO MRI’ n = 115). Preoperative characteristic surgical and histological outcomes were confronted. A univariate and multivariate logistic regression model was performed to investigate independent predictors of incidental Prostate Cancer (iPCa).

Results

Both groups presented with no statistical differences in preoperative characteristics besides previous acute urinary retention rates and post-voided residual volume, found to be higher (27.8% vs. 14.2% and median 120cc vs. 80cc) in NO MRI and NEGATIVE MRI respectively.

No differences were registered in surgical time, removed tissue, catheterization time, hospital stay and complications rate.

Statistically lower rate of iPCa (p = 0.03) was detected in the NEGATIVE MRI group (6.2%) in comparison with NO MRI group (14.8%). In multivariate logistic regression only presence of a preoperative negative mpMRI correlated (p = 0.04) as an independent predictive factor (OR 2.63; 95% CI: 1.02–6.75).

Conclusions

A negative mpMRI might be a useful tool to be included in a novel preoperative assessment to patients eligible for HoLEP with a suspicion of PCa in order to avoid an incidental PCa.

Favorable long-term oncological and urinary outcomes of incidental prostate cancer following holmium laser enucleation of the prostate

The aim of the present study was to investigate the impact of incidental prostate cancer (IPCa), which was diagnosed by holmium laser enucleation of the prostate (HoLEP), on long-term oncological and functional outcomes. A total of 482 patients who underwent HoLEP for benign prostatic hyperplasia (BPH) between 2008 and 2016 at our institution were retrospectively reviewed. We defined IPCa as prostate cancer (PCa) according to the enucleated tissue of transitional zone. Therefore, 64 patients were excluded for the following reasons: Prostate-specific antigen (PSA) ≥4.0 ng/ml and no prostate biopsy (n=46); and PSA ≥4.0 ng/ml and diagnosed with PCa by prostate biopsy performed during HoLEP (n=18). Notably, 418 patients were included in the study and divided into two groups: The BPH group and the IPCa group. For 5 years, postoperative PSA and functional outcomes were evaluated. Of 418 patients, 25 (6%) were diagnosed with IPCa by HoLEP, 21 patients (84%) had a Gleason score ≤6 and 5 patients (20%) received adjuvant therapy for PCa following HoLEP. No significant differences were observed between groups for preoperative PSA, PSA density, or urinary and sexual function outcomes; however, age at the time of HoLEP significantly differed between groups (71.7 vs. 75.5 years, P=0.026). Long-term (5-year) urinary outcomes demonstrated sustained improvement. Postoperative PSA increased gradually in the IPCa group (3-year, P=0.033; 4-year, P=0.037); International Index of Erectile Function 5 conversely decreased (5-year, P=0.068). According to the present results, if standard PSA screening and prostate biopsy are performed, watchful waiting for IPCa is feasible, and IPCa does not impact on 5-year urinary outcomes.

Transurethral resection versus holmium laser enucleation of the prostate: A prospective randomized trial comparing perioperative thrombin generation and fibrinolysis

OBJECTIVES

The purpose of this study was to compare transurethral resection of the prostate (TURP) versus holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH) focusing on perioperative thrombin generation and fibrinolysis.

METHODS

Sixty-five BPH patients were prospectively randomly assigned to undergo TURP (n = 32) or HoLEP (n = 33). The prothrombin fragment (PF) 1+2, thrombin-antithrombin complex (TAT), tissue plasminogen activator (t-PA), and plasminogen activator inhibitor-1 (PAI-1) were measured preoperatively, at the 1st day and 3rd day after surgery.

RESULTS

PF1+2, TAT, t-PA, and PAI-1 significantly elevated at day 1 and day 3 after surgery (P < .05) and remarkedly decreased from the 1st day to the 3rd day (P < .05). The levels of PF1+2 and TAT were higher in TURP group postoperatively than that in HoLEP group (P < .05). There is no significant difference between 2 groups in regard of t-PA and PAI-1 (P > .05).

CONCLUSION

The activation of thrombin generation and fibrinolysis system were noticed in BPH patients after TURP or HoLEP. TURP may associate with a higher hypercoagulable thrombotic risk than HoLEP.

Holmium laser versus thulium laser enucleation of the prostate: a matched-pair analysis from two centers

Background

The aim of our study was to compare perioperative and functional outcomes of two different prostatic laser enucleation techniques performed in two high-volume centers: 100 W holmium laser enucleation of the prostate (HoLEP) (Lyon, France) and 110 W thulium laser enucleation of the prostate (ThuLEP) (Varese, Italy).

Materials and Methods

A nonrandomized, observational, retrospective and matched-pair analysis was performed on two homogeneous groups of 117 patients that underwent prostate laser enucleation in the HoLEP or ThuLEP centers between January 2015 and April 2017, following the classical 'three lobes' enucleation technique. The American Society of Anesthesiologists (ASA) score and prostate volume were the main parameters considered for matching the patients between the two groups. Patients on anticoagulant therapy, with documented detrusor hypoactivity or hyperactivity or with the finding of concurrent prostate cancer were excluded from the study. Follow up was assessed at 3, 6 and 12 months after surgery.

Results

Median enucleation and morcellation time was 75.5 and 11.5 min, respectively, in the HoLEP group versus 70.5 and 12 min, respectively, in the ThuLEP group (p = 0.001 and 0.49, respectively). Enucleated adenoma weight was comparable (44 g versus 45.6 g, p = 0.60). Energy index (3884.63 versus 4137.35 J/g, p = 0.30) and enucleation index (0.57 versus 0.6 g/min, p = 0.81) were similar in the two groups. Catheterization time was comparable (1 versus 1 day; p = 0.14). The International Prostate Symptom Score and Quality of Life score significantly decreased, as well as maximal urinary flow rate. Median prostate-specific antigen (PSA) drop 1 year after surgery was 2.1 ng/ml in the HoLEP group (-52.83%) versus 1.75 ng/ml in the ThuLEP group (-47.85%) (p = 0.013).

Conclusion

Both HoLEP (100 W) and ThuLEP (110 W) relieve lower urinary tract symptoms in a comparable way with high efficacy and safety, with negligible clinical differences.

Prostatic vascular damage induced by cigarette smoking as a risk factor for recovery after holmium laser enucleation of the prostate (HoLEP)

Purpose

To evaluate the relationship between prostatic vessel changes induced by cigarette smoking and the perioperative outcome of holmium laser enucleation of the prostate (HoLEP).

Materials and Methods

A total of 268 postoperative patients with benign prostatic hyperplasia (BPH) were prospectively analysed in our department. They were divided into two groups (smokers and non-smokers) according to smoking history. Transrectal colour Doppler ultrasound was performed to evaluate the prostate vascular changes. Pathologically, HE staining, CD31 and CD34 were analysed in prostatic section chips. Furthermore, postoperative outcomes were determined during a 6-month follow-up period.

Results

The preoperative prostate volume was significantly decreased in smoking patients (P = 0.04). CPI was significantly lower in smoking BPH patients (P < 0.01), whereas RI was significantly increased in smokers compared with non-smokers (P < 0.01). Histological assays revealed elevated CD34 in the smoking BPH individuals presenting an increased number of microvessels. The HoLEP duration was increased in smokers. Interestingly, we identified significantly increased overactive bladder syndrome score (OABSS) and decreased Qmax in smoking individuals during the 6-month follow-up with no difference being observed preoperatively. However, no significant difference between the groups was observed for the International Prostate Symptom Score (IPSS).

Conclusions

The significantly lower CPI and higher RI values in smoking BPH patients indicated the presence of considerable vascular damage in these subjects. Moreover, cigarette smoking extended the surgical duration and prolonged the recovery period of overactive bladder (OAB) syndrome. Thus, integrated treatment should be suggested for various BPH individuals.

[Modified morcellation procedure in holmium laser enucleation of the prostate]

OBJECTIVE

To evaluate the efficiency and safety of the modified versus conventional morcellation procedure in holmium laser enucleation of the prostate (HoLEP).

METHODS

We treated 195 patients with benign prostatic hyperplasia (BPH) by HoLEP, using conventional morcellation for 100 cases and modified morcellation for the other 95. We recorded the morcellation time, the total volume of resected tissue, the rate of morcellation, and associated complications, and compared the data obtained between the two groups.

RESULTS

The volumes of resected tissue were similar between the conventional and modified morcellation groups (［72.3±19.8］ vs ［71.1±17.7］ g, P>0.05). The morcellation time was significantly longer in the conventional than in the modified morcellation group (［12.8±2.8］ vs ［8.5±2.0］ min, P<0.01), and the morcellation rate was remarkably lower in the former than in the latter (［4.9±1.4］ vs ［7.1±0.9］ g/min, P<0.01). No statistically significant differences were observed in the incidence of complications, bladder injury for instance, between the two groups of patients.

CONCLUSIONS

The modified morcellation procedure can be used for mocellation of various types of tissue, with a higher efficiency than the conventional technique, and therefore deserves wide clinical application.

[Holmium laser enucleation of the prostate (HOLEP) for small, large and giant prostatic hyperplasia. Practice guidelines. Experience of more than 450 surgeries]

INTRODUCTION

and objectives. Most of modern endoscopic procedures (e.g., TURP) are only confined to small and medium-sized glands (up to 80 cm3), but not HoLEP, which allows to enucleate large and extremely large prostates (200 cm3). The aim of the study was to compare the efficiency of HoLEP for prostates of different sizes.

METHOD

s. A total of 459 patients were divided into three groups: Group 1 included 278 patients (prostate volume <100 cm3); mean prostate volume, 70.8+/-16.1 cm3; IPSS, 18.7+/-5.5; QoL, 4.1+/-0.5; Qmax, 6.2+/-1.5 mL/s; post-voided residual volume, 64.2+/-30.5 mL. Group 2 included 169 patients (prostate volume 100-200 cm3); mean prostate volume, 148.1+/-25.2 cm3; IPSS, 19.7+/-3.3; QoL, 4.2+/-0.7; Qmax, 5.9+/-0.7 mL/s; post-voided residual volume, 70.9+/-20.1 mL. Group 3 included 12 patients (prostate volume >200 cm3); mean prostate volume, 230.1+/-18.1 cm3; IPSS, 19.5+/-4.5; QoL, 4.1+/-0.3; Qmax, 4.7+/-0.9 mL/s; post-voided residual volume, 72.3+/-10.9 mL. All the patients underwent HoLEP from 2013 to 2015. For the prostate to be enucleated, a 100-W laser system, 550-micron end-fire fiber, and a morcellator for tissue evacuation were used.

RESULTS

The average duration of surgery in Group 1 was 56.5+/-10.7 min; in group 2, 96.4+/-24.9 min; in Group 3, 120.9+/-35 min. The average duration of morcellation in Group 1 was 37.5+/-7.3 min; in Group 2, 63.3+/-11.2 min; in Group 3, 84.0+/-25.6 min. The efficiency of enucleation in Group 3 (1.70 g/min) was significantly higher (p < 0.05) than in Group 1 (1.05 g/min) and Group 2 (1.23 g/min). Similar results were obtained for the efficiency of morcellation. It was lower in Group 1 and Group 2 (1.58 and 1.87 g/min, respectively) than in Group 3 (2.45 g/min) (p<0.05). In order to compare the long-term results of HoLEP for prostates of different sizes, all the 459 patients were followed up for 18 months. IPSS, Qmax, QoL, and post-voided residual volumes were measured. There were no significant differences (p>0.05) in the postoperative outcomes for 1, 3, 6, 12, and 18 months after surgery.

CONCLUSIONS

It follows from our two years experience that HoLEP is a safe, highly efficacious and a size-independent procedure, which is why it has become a new gold standard for treatment of extremely large prostatic hyperplasia in our clinic.

Postoperative infectious complications in patients undergoing holmium laser enucleation of the prostate: Risk factors and microbiological analysis

OBJECTIVES

To examine the incidence of postoperative bacteriuria and febrile complications, and to investigate bacterial strains in the urine of patients undergoing holmium laser enucleation of the prostate.

METHODS

We retrospectively analyzed 190 evaluable patients treated with holmium laser enucleation of the prostate at the Gifu University Hospital, Gifu, Japan, between September 2005 and May 2014. All patients presented with lower urinary tract symptoms as a result of benign prostatic hyperplasia. We also evaluated the causative bacteria and compared the findings with the results of preoperative urine cultures. We analyzed the relationship between the emergence of postoperative febrile complications, antibiotic prophylaxis, patient background and surgical procedure.

RESULTS

The frequency of bacterial isolation in preoperative and postoperative urine cultures was 41% and 23%, respectively. Preoperatively, Enterococcus faecalis was the most frequently cultured bacteria, second was methicillin-resistant Staphylococcus epidermidis, and third was Escherichia coli. Postoperatively, Enterococcus faecalis was still the most frequently cultured bacteria, whereas the second was Escherichia coli. Risk factors for postoperative bacteriuria were evaluated. Multivariate analysis showed that the rate of postoperative bacteriuria in patients who had taken dutasteride preoperatively was significantly lower than that in the other patients. Risk factors for febrile complications could not be identified.

CONCLUSIONS

The use of perioperative prophylactic antibacterial agents for holmium laser enucleation of the prostate keeps the rate of postoperative infectious complications low. Dutasteride treatment administered before surgery might reduce the risk of postoperative bacteriuria.

Case of vascular air embolism during holmium laser enucleation of the prostate

Vascular air embolism is a rare complication during transurethral surgery. A case of air embolism during holmium laser enucleation of the prostate in a 76-year-old man is presented. During the step of morcellation, the patient's blood pressure suddenly oscillated up and down, and end-tidal CO2 and arterial saturation decreased. Transesophageal and transthoracic echocardiography showed air collection in the right atrium. It was also discovered that incorrect assembly of the tube from the morcellator caused rapid entrainment of air into the vein. Computed tomography and abdominal X-ray showed niveau formation in the femoral vein and air collection in the pelvic retroperitoneal space. The patient recovered with careful observation and was discharged 7 days after the operation with no sequelae. This report is presented to remind urologists of this unusual complication that can occur during holmium laser enucleation of the prostate procedures.

Surgical therapy for benign prostatic hypertrophy/bladder outflow obstruction

Monopolar transurethral resection of the prostate (TURP) with endoscopic electrocautery remains the gold standard surgical technique for benign prostatic hypertrophy (BPH) by which all new procedures are compared. We reviewed the current literature, and international urological guidelines and consensus opinion on various surgical options for BPH and present a brief overview of alternative techniques including bipolar TURP, transurethral incision of the prostate, transurethral vaporization of the prostate, laser prostatectomy (with holmium, thulium and potassium titanyl phosphate greenlight lasers) and open prostatectomy (with mention of new techniques including laparoscopic and robotic prostatectomy). Emerging, experimental and less established techniques are also described including endoscopic heat generation (transurethral microwave thermotherapy, radiofrequency transurethral needle ablation of the prostate, high intensity focused ultrasound, hot water induced thermotherapy, pulsed electromagnetic radiofrequency), injection therapy (transurethral ethanol ablation and botulinum toxin) and mechanical devices (intraprostatic stents and urethral lift devices). Despite a plethora of surgical options, none have realistically improved outcomes in the long-term compared with TURP. Improvements have been made on improving surgical morbidity and time in hospital. Questions remain in this area, including what specific elements of bladder outflow obstruction (BOO) result in damage to the urinary tract, how does BPH contribute to BOO and how much prostate volume reduction is necessary to relieve BOO or lower urinary tract symptoms. Given these unanswered questions and the multitude of procedures available, it is clear that appropriate counselling is necessary in all men who undergo BPH surgery.

Holmium laser enucleation of the prostate: a paradigm shift in benign prostatic hyperplasia surgery

Holmium laser enucleation (HoLEP) was developed in the 1990s as a more efficient and cost effective method of benign prostatic hyperplasia surgery than laser vaporization and resection techniques. As a true anatomical enucleation it mimics open prostatectomy and is as durable. There is a significant body of level 1 evidence in support of HoLEP, including 2 meta-analyses and 14 randomized trials which compare HoLEP with a number of other procedures. This review describes the development of and summarizes the evidence for HoLEP.

Bone dissemination of prostate cancer after holmium laser enucleation of the prostate: a case report and a review of the literature

We report a case of dissemination of prostate cancer after holmium laser enucleation of the prostate in an 80-year-old patient. The patient presented at hospital because of nocturia. Transrectal ultrasound-guided biopsy was carried out because of high serum prostate-specific antigen (3.55 ng/mL), but it showed no malignancies. Benign prostate hyperplasia was diagnosed, and he was started on an α1-blocker. Although the urinary symptom improved with silodosin, acute urinary retention occurred 3 years after therapy began. Holmium laser enucleation of the prostate for relief of bladder outlet obstruction enabled discharge of urine. Pathological examination of the resected tissue found adenocarcinoma with a high Gleason score, 4 + 5. Serum alkaline phosphatase increased rapidly after holmium laser enucleation, and bone scintigraphy confirmed multiple bone metastases. Prostate cancer, T1bN0M1b, was diagnosed.