Transurethral holmium laser enucleation versus transurethral resection of the prostate and simple open prostatectomy--which procedure is faster?

PURPOSE: The longer operative time of holmium laser enucleation of the prostate compared to transurethral resection of the prostate or simple open prostatectomy reported in the literature might have been biased by the unavailability of a soft tissue morcellator, limited surgical experience with holmium laser prostate enucleation or the fact that significantly more tissue was removed by enucleation than by resection. We objectively compared the resection speed of contemporary holmium laser enucleation vs transurethral resection of the prostate and of holmium laser enucleation vs simple open prostatectomy. MATERIALS AND METHODS: The study cohort consisted of 100 cases of transurethral prostate resection and 60 of simple open prostatectomy from our previous randomized, controlled trials. These cases were subjected to matched pair analysis with greater than 1,000 from our prospective contemporary database on holmium laser prostate enucleation. Exact matches were made for the same amount of resected tissue. In all contemporary holmium laser enucleation cases a mechanical soft tissue morcellator was used. We calculated and compared the specific resection speed in gm per minute and operative time for the same amount of resected tissue. RESULTS: In groups 1 and 2 we matched 99 exact laser enucleation-transurethral resection pairs and 53 exact laser enucleation-simple open prostatectomy pairs, respectively. Resection speed and operative time for laser enucleation were statistically significantly faster than for resection (0.61 vs 0.51 gm per minute and 62 vs 73 minutes, p <0.01) and similar to those of simple open prostatectomy (0.92 vs 1.0 gm per minute and 101 vs 90 minutes, respectively, p ≥0.21). CONCLUSIONS: Resection speed seems to be an objective criterion for comparing the efficacy of prostatic tissue removal. Based on resection speed holmium laser enucleation of the prostate is faster than transurethral resection of the prostate and similar to simple open prostatectomy.

Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement.

CONTEXT: There is a continuous decline in the number of transurethral resections of the prostate (TURP) and an increase use of minimally invasive surgical therapy (MIST) for lower urinary tract symptoms resulting from benign prostatic enlargement. Current results from randomised controlled trials (RCT) and methodologically sound prospective studies suggest that some of the proposed procedures have the potential to replace TURP. OBJECTIVE: To determine the contemporary status of TURP and of the currently most commonly applied transurethral MISTs: (1) bipolar TURP, (2) bipolar transurethral vaporisation of the prostate (bipolar TUVP), (3) holmium laser enucleation of the prostate (HoLEP), and (4) potassium-titanyl-phosphate (KTP) laser vaporisation of the prostate. EVIDENCE ACQUISITION: This meta-analysis was based on a systematic Medline search assessing the period 1997-2009. All RCTs comparing TURP and the most commonly discussed ablative treatments were included. The end points of our analyses were functional outcomes and treatment-related adverse events. EVIDENCE SYNTHESIS: Twenty-seven publications involving 23 different RCTs with a total of 2245 patients provided the highest level of evidence available (level 1b) and were fully assessed. Meta-analysis was conducted with SAS v.9.1.3 (SAS Institute, Cary, NC, USA). Forest plots were produced using the R software. Pooled odds ratios and 95% confidence intervals were calculated between various operative techniques versus TURP. Functional results between the specific transurethral procedures versus TURP were summarised as differences in means. CONCLUSIONS: This meta-analysis demonstrates statistically comparable efficacy and overall morbidity for MISTs versus contemporary TURP. Type, category (minor vs major), and the number of complications (safety profile) vary specifically for each of the different transurethral techniques. We feel that the individual patient's clinical profile should be carefully assessed to identify the most appropriate transurethral technique.

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

OBJECTIVES: To report 5-year follow-up results of a randomised clinical trial comparing holmium laser enucleation of the prostate (HoLEP) with open prostatectomy (OP). METHODS: One hundred twenty patients with prostates greater than 100g in weight according to transrectal ultrasound were randomised to either the HoLEP or the OP group (ie, 60 patients to each group). Preoperative and postoperative assessments included American Urological Association Symptom Score (AUA-SS), maximum urinary flow rates (Qmax), and postvoid residual urine (PVRU) volumes. Measurements were performed at 1, 3, 6, 12, 18, 24, 36, 48, and 60 mo. Postoperative outcome data were compared. All complications were recorded. RESULTS: Five years postoperatively, a total of 46 patients (38.3%) were lost to follow-up or had to be excluded from the study. All the remaining 74 patients (42 HoLEP vs. 32 OP patients, p=0.11) had undergone the 5-yr follow-up assessments. Mean AUA-SS was 3.0 in both groups (p=0.98), mean Qmax was 24.4 ml/s in both groups (p=0.97) and PVRU volume was 11 ml in the HoLEP and 5 ml in the OP group (p=0.25). Late complications consisted of urethral strictures and bladder-neck contractures; reoperation rates were 5% in the HoLEP and 6.7% in the OP group (p=1.0). No patient developed benign prostatic hyperplasia recurrence. CONCLUSIONS: Five years after the operation, the improvements in micturition obtained with HoLEP and OP were equally good, and reoperation rates similarly low. HoLEP seems to be a true endourological alternative to OP.

Holmium laser enucleation versus transurethral resection of the prostate: 3-year follow-up results of a randomized clinical trial.

OBJECTIVES: To report 3-yr follow-up results of a randomised clinical trial comparing holmium laser enucleation of the prostate (HoLEP) with transurethral resection of the prostate (TURP). METHODS: A total of 200 patients with urodynamic obstruction and a prostate volume of less than 100 cc were prospectively randomised and assigned to HoLEP or TURP. All patients were assessed preoperatively and followed at 1, 6, 12, 18, 24, and 36 mo postoperatively. American Urological Association Symptom Score (AUA SS), maximum flow rate (Q(max)), and postvoid residual (PVR) [urine] volume were obtained at each follow-up. Perioperative data and postoperative outcome were compared. All complications were recorded. RESULTS: AUA SS were significantly better 2 yr postoperatively in the HoLEP group (1.7 vs. 3.9, p<0.0001) and similar at 3 yr (2.7 vs. 3.3, p=0.17). PVR volume was significantly better 2 yr (5.6 vs. 19.9 ml, p<0.001) and 3 yr (8.4 vs. 20.2 ml, p=0.012) postoperatively in HoLEP patients. Q(max) was similar in the HoLEP and TURP groups at 2 yr (28.0 vs. 29.1 ml/s, p=0.83) and at 3 yr (29.0 vs. 27.5 ml/s, p=0.41) postoperatively. Late complications consisted of urethral strictures, bladder-neck contractures, and BPH recurrence; reoperation rates were 7.2% in the HoLEP and 6.6% in the TURP group (p=1.0). CONCLUSIONS: After 2 and 3 yr of follow-up, HoLEP micturition outcomes compare favourably with TURP. Late complications are equally low. HoLEP may be a real alternative to TURP.

Laser treatment of benign prostatic hyperplasia.

To evaluate the role of lasers that allow acute removal of obstructing tissue in the surgical treatment of benign prostatic hyperplasia (BPH). A MEDLINE search over the last 6 years focused on randomized trials, large case series and review articles. A total of more than 4,000 patients were analyzed with respect to the morbidity and outcome, and the advantages and disadvantages of the various lasers. Laser treatment of BPH has evolved from coagulation to enucleation. Blood loss is significantly reduced as compared to transurethral resection and open prostatectomy. Ablative/vaporizing techniques have recently become popular again with the marketing of new high-powered 80 W potassium-titanyl-phosphate (KTP) and 100 W holmium lasers. Vaporization immediately removes obstructing tissue, but tissue specimen cannot be obtained. KTP short-term results are promising, but long-term results and randomized trials are lacking. Postoperative volume reduction is less than with holmium laser enucleation of the prostate (HoLEP), and the KTP laser can be used for BPH treatment only. HoLEP allows whole lobes of the prostate to be removed. Prostates of all sizes can be operated on. It is at least as safe and effective as TURP and open prostatectomy, with significantly lower morbidity, as shown by several well-designed randomized clinical trials. It provides specimen for histological evaluation. In addition, the holmium laser can be used for the endourological treatment of stones, strictures and tumors. HoLEP appears to be a size-independent new "gold standard" in the surgical treatment of BPH.

Current role of lasers in the treatment of benign prostatic hyperplasia (BPH).

OBJECTIVE: Evaluate the current role of lasers in the treatment of benign prostatic hyperplasia (BPH). METHODS: The results of a MEDLINE search for randomised trials and case series of the last 5 yr and published review articles were analysed for the safety and efficacy of neodymium:yttrium aluminum garnet (Nd:YAG), potassium-titanyl-phosphate (KTP), and holmium (Ho):YAG laser prostatectomy. The analysis includes 12 reports on randomised clinical trials, 2 comparative studies, 10 review articles, and a total of >5000 patients. RESULTS: Laser treatment of BPH has evolved from coagulation to enucleation. Blood loss is significantly reduced compared with transurethral resection and open prostatectomy. Visual laser ablation of the prostate and interstitial laser coagulation cause coagulative necrosis with secondary ablation. Long postoperative catheterisation, unpredictable outcomes, and high reoperation rates have restricted the use of these techniques. Ablative/vaporising techniques have become popular again with the marketing of new high-powered 80-W KTP and 100-W Ho lasers. Vaporisation immediately removes obstructing tissue. Short-term results are promising, but large series, long-term results, and randomised trials are lacking. Holmium laser enucleation (HoLEP) allows whole lobes of the prostate to be removed, mimicking the action of the index finger in open prostatectomy. Prostates of all sizes can be operated on. It is at least as safe and effective as transurethral resection of the prostate and open prostatectomy, with significantly lower morbidity. It is the only laser procedure that provides a specimen for histologic evaluation. CONCLUSIONS: HoLEP appears to be a size-independent new "gold standard" in the surgical treatment of BPH.

Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients.

PURPOSE: Transurethral electrocautery resection (TURP) is generally regarded as the gold standard surgical treatment for bladder outflow obstruction due to benign prostatic hyperplasia despite its rather high morbidity. The high powered holmium:YAG laser can be used endoscopically to enucleate obstructing prostatic tissue in a relatively bloodless manner. The technique of transurethral holmium laser enucleation of the prostate (HoLEP) was compared to standard TURP for the surgical management of prostate adenomas in a randomized, prospective clinical trial. MATERIALS AND METHODS: A total of 200 urodynamically obstructed patients with a prostate of less than 100 gm on transrectal ultrasound were randomized to HoLEP or TURP. All patients were assessed preoperatively, and 1, 6 and 12 months postoperatively. Patient baseline characteristics, perioperative data and postoperative outcome were compared. All complications were noted. RESULTS: HoLEP was significantly superior to TURP in terms of catheter time, hospital stay and hemoglobin loss but operative time was longer. HoLEP and TURP resulted in a significant improvement in American Urological Association symptom scores, peak urinary flow rates and post-void residual urine volumes with symptoms scores and residual volume significantly better in the holmium group. Effects on continence and potency were similar in the 2 groups but adverse events were less frequent in the holmium group. CONCLUSIONS: HoLEP and TURP are highly effective procedures for removing obstructing prostatic adenomas. HoLEP resulted in significantly better micturition parameters and less perioperative morbidity.

Does perioperative outcome of transurethral holmium laser enucleation of the prostate depend on prostate size?

BACKGROUND AND PURPOSE: In conventional transurethral resection of the prostate (TURP), perioperative morbidity resulting from causes such as blood loss and TUR syndrome increases with prostate size. Therefore, TURP is restricted to small and medium-sized glands. The present study aimed to find out whether perioperative parameters of holmium laser enucleation of the prostate (HoLEP) other than operation time and weight of resected tissue were dependent on prostate size. PATIENTS AND METHODS: A total of 384 patients were treated with HoLEP (holmium:YAG laser, 2.0 J, 40 or 50 Hz, 80 or 100 W, 550-nm bare fiber) for acute removal of obstructing benign hyperplastic tissue. Among them, 111 patients (28.9%) had prostates of <40 g (group 1), 152 (39.6%) had prostates of 40 to 79 g (group 2), and 121 (31.5%) had prostates of >/=80 g (range 80-260) (group 3). The perioperative outcomes of the three groups were compared. A total of 346 patients completed the 1-month postoperative assessment. RESULTS: The mean prostate sizes were 31.8 g, 56 g, and 98.7 g for groups 1, 2, and 3 (P<0.0001 group 1 v group 2 v group 3). The mean resected tissue weight was 19.5 g v 34.4 g (P= 0.009) v 70.1 g (range 50-220) (P< 0.0001). The mean operation time was 64.3 v 84.2 (P= 0.009) v 118.4 minutes (P< 0.0001). The mean hemoglobin loss was 0.9 v 1.2 (NS) v 1.9 g/dL (P< 0.001). The overall correlation between hemoglobin loss and prostate size in all patients was very weak (r = 0.229) and just exceeded the level of significance (r = 0.2). In all three groups, the median postoperative catheter time was 1 day, and the median postoperative hospital stay was 2 days. The HoLEP resulted in an immediate and significant improvement of American Urological Association Symptom Scores, peak urinary flow rates, and postvoiding residual urine volumes (P< 0.0001) 1 month after the operation, without significant differences between the groups. The rate of complications was similar in all three groups. None of the patients needed blood transfusions. There were no perioperative deaths. CONCLUSION: In HoLEP, perioperative morbidity and postoperative micturition improvement do not depend on prostate size. Therefore, in contrast to TURP, HoLEP is equally suitable for small, medium-size, and large prostate glands.

Transurethral holmium laser enucleation of the prostate compared with transvesical open prostatectomy: 18-month follow-up of a randomized trial.

PURPOSE: This ongoing randomized study aims to find out whether transurethral holmium laser enucleation of the prostate (HoLEP) could be an alternative to open transvesical prostatectomy in patients with prostates >100 g. PATIENTS AND METHODS: A series of 120 urodynamically obstructed patients were randomized to HoLEP or open prostatectomy, 60 patients to each group. The HoLEP was performed with high-powered Ho:YAG lasers at 80 to 100 W (2.0 J, 40-50 Hz) and 550-nm bare laser fibers. The American Urological Association Symptom Scores, peak urinary flow rates, and postvoiding residual urine volumes were evaluated preoperatively and at 1, 3, 6, 12, and 18 months postoperatively. All complications were noted. RESULTS: By the Mann-Whitney test, there was no significant difference between the HoLEP and open surgery groups in patient age (69.0 years HoLEP v 71.0 years open surgery), prostate volume (115 cc [range 100-230 cc] v 113 cc [100-230 cc], or weight of resected tissue (94 g [range 57-220 g] v 96 g [range 61-220 g]). There were significant differences in the mean operative time (136 v 91 minutes; P< 0.0001), mean hemoglobin loss (1.9 v 2.8 g/dL; P< 0.0001), median catheter time (1 day v 6 days; P< 0.0001), and median hospital stay (2 days v 10 days; P< 0.0001). Both HoLEP and open prostatectomy resulted in pronounced and lasting postoperative improvements in Symptom Scores, peak urinary flow rates, and postvoiding residual volumes (P< 0.0001). The differences between HoLEP and open prostatectomy were not significant at any interval for any parameter. Blood transfusions were required in 0 HoLEP patients v 8 open surgery patients. Arterial bleeding occurred in three patients in each group. Secondary apical resection was required in two HoLEP patients and no open surgery patients. Bladder neck contracture occurred in none of the HoLEP patients and two of those having open surgery. Thus, the total number of patients having complications was 7 with HoLEP and 13 with open surgery. There were no deaths in either group. CONCLUSIONS: The HoLEP appears to be an endourologic alternative to open surgical enucleation of the prostate for large glands. It entails significantly less blood loss and a much shorter catheter time and hospital stay. The perioperative outcome strongly favors the holmium procedure. The rate of late complications is equally low with each procedure. The postoperative micturition improvement was significant and lasting and was equivalent in the two groups.

Transurethral holmium laser enucleation versus transvesical open enucleation for prostate adenoma greater than 100 gm.:: a randomized prospective trial of 120 patients.

PURPOSE: Prostate adenomas greater than 100 gm. have traditionally been treated with open prostatectomy. This procedure may involve considerable blood loss, morbidity, prolonged hospital stay and recovery time. The high powered holmium:YAG laser can be used endoscopically to enucleate obstructing prostatic tissue in a relatively bloodless manner. The technique of transurethral holmium laser enucleation of the prostate is compared to open prostatectomy for the surgical management of large prostate adenomas in a prospective randomized study. MATERIALS AND METHODS: A total of 120 urodynamically obstructed patients with a prostate larger than 100 gm. on transrectal ultrasound were randomized to undergo holmium laser enucleation of the prostate or open prostatectomy. All patients were assessed preoperatively and 1, 3 and 6 months postoperatively. Patient baseline characteristics, perioperative data and postoperative outcome were compared. All complications were noted. RESULTS: Holmium laser enucleation of the prostate and open prostatectomy resulted in a similar and significant improvement in American Urological Association symptom scores, peak urinary flow rates and post-void residual urine volumes. Operating time was significantly longer in the holmium group but blood loss was significantly less, and catheterization time and hospital stay were significantly shorter. Effects on continence and potency were similar in both groups but adverse events were less frequent in the holmium group. None of the holmium group patients needed blood transfusions in contrast to 8 patients in the prostatectomy group. CONCLUSIONS: Holmium laser enucleation of the prostate and open prostatectomy are equally effective procedures for removal of large prostatic adenomas. Holmium laser enucleation resulted in significantly less perioperative morbidity and may become the endourological alternative to open prostatectomy.