madman
Super Moderator
ABSTRACT
Objective: To evaluate efficacy and safety of holmium laser enucleation of the prostate (HoLEP), bipolar enucleation of the prostate (bTUEP), and transurethral resection of the prostate (TURP) in medium-sized prostates (50cc).
Methods: We present a retrospective analysis of 2230 patients treated for lower urinary tract symptoms. We analyzed perioperative parameters, short-term clinical outcomes, and adverse events in matched-pair cohorts.
Results: Both HoLEP and bTUEP were superior in terms of efficacy compared to TURP (surgery time: 51min and 50min vs. 60min; p < 0.001; tissue retrieval percentage: 71.4% and 70% vs. 50%; p < 0.001) and showed stronger improvement of LUTS (change IPSS: -15 and -14 vs. -10; p = 0.008). Furthermore, urodynamic parameters (Qmax: +15 ml/s and +19 ml/s vs. +12 ml/s; p < 0.001; PVR: -100 ml and -95 ml vs. - 80ml; p < 0.008) were significantly more improved after enucleation than after TURP. All techniques showed an equally low complication rate (6.9% and 6.9% vs. 10.3%; p = 0.743). No relevant difference of clinical outcomes was identified between HoLEP and bTUEP.
Conclusions: Both resection and enucleation are efficient and safe procedures in patients with medium-sized prostates (50cc), but irrespective of the technical approach, transurethral enucleation is superior to TURP in terms of perioperative and functional outcomes.
Introduction
In recent years the portfolio of surgical treatment modalities of lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) has been constantly evolving. On the one hand, emerging novel minimally invasive approaches strive for equal efficiency to standard resection, but with a more favorable safety profile (1, 2). On the other hand, novel ablative techniques anticipate the potential to outdo the standards on various technical and functional aspects. Laser-based approaches in combination with modified enucleation techniques such as holmium laser enucleation of the prostate (HoLEP) have been introduced with success and the efficacy and safety of this size-independent procedure have led to the integration into several international guidelines (3). However, enucleation itself is also possible in bipolar technique using a button-shaped electrode or specially designed loops. The first results resemble those reported for HoLEP. Bipolar transurethral enucleation of the prostate (bTUEP) was at least equally effective, but showed better hemostatic control, fewer complications, and both shorter catheterization and hospital stay (4-8). Some data suggest that the underlying laser physics of HoLEP offers superior outcomes compared to bTUEP (9, 10). A direct comparison between TURP, HoLEP and bTUEP in medium-sized prostates (50cc), where TURP has set the benchmark for decades, is lacking. This prompted us to investigate the true benefits of the enucleation procedure as performed with two different technical approaches compared to the current standard.
Discussion
The current study was not only designed to reveal the true benefits of enucleation techniques but also to demonstrate, that even with our standard TURP equipment, we are able to achieve those goals following the principles of anatomic enucleation. Our results in concert with published data clearly confirmed the quality features of the reference method TURP, but here we showed that these outcomes could still be optimized using refined surgical techniques (21, 22). This trend is mirrored by current guideline recommendations, which integrated enucleation techniques for surgical options for prostate sizes ranging from 30cc to 80cc (23). Most importantly, the surgeons’ proficiency must be assured to accomplish the clinical benefits reported for techniques like HoLEP. Once the surgeon is comfortable with an enucleation technique, it seems that the energy source is of a secondary matter. A growing body of clinical evidence suggests that the enucleation in expert hands is the key factor. To our knowledge, our results are the first to show in a matched-pair analysis of common LUTS patients, that enucleation as a general principle offers better results than resection in medium-sized prostates. We have to emphasize that in the current study no special equipment was used for surgery. Enucleation was executed mainly with the tip of the resectoscope without any technical modification. The energy was only applied when necessary. Nevertheless, the outcomes are equivalent to the laser-based approach.
The retrospective single-center design with the short-term follow-up needs to be acknowledged as a shortcoming of our study. However, the presented data clearly pinpoints the enucleation principle as the crucial factor for superior outcomes. In the end, the success is not exclusively depending on the energy source, but foremost on the surgical precision of a correct enucleation procedure. The presented outcomes demonstrated the benefits for medium-sized prostates, but for the complete appraisal, additional studies are warranted to confirm the trend for larger prostates >80cc. Long-term prospective randomized controlled trials are necessary to answer the question about the most complete technique.
Conclusion
The convincing body of clinical evidence proves that the technique of endoscopic enucleation has come of age. Both resection and enucleation are efficient and safe procedures in patients with LUTS due to BPO with medium-sized prostates, but irrespective of the technical approach, transurethral enucleation is superior to TURP in terms of perioperative and functional outcomes. No relevant differences in perioperative parameters, clinical outcomes, and the safety profile were identified between HoLEP and bTUEP. Performing a successful enucleation with the standard equipment as used for TURP showcases the importance of the technical principle.
Objective: To evaluate efficacy and safety of holmium laser enucleation of the prostate (HoLEP), bipolar enucleation of the prostate (bTUEP), and transurethral resection of the prostate (TURP) in medium-sized prostates (50cc).
Methods: We present a retrospective analysis of 2230 patients treated for lower urinary tract symptoms. We analyzed perioperative parameters, short-term clinical outcomes, and adverse events in matched-pair cohorts.
Results: Both HoLEP and bTUEP were superior in terms of efficacy compared to TURP (surgery time: 51min and 50min vs. 60min; p < 0.001; tissue retrieval percentage: 71.4% and 70% vs. 50%; p < 0.001) and showed stronger improvement of LUTS (change IPSS: -15 and -14 vs. -10; p = 0.008). Furthermore, urodynamic parameters (Qmax: +15 ml/s and +19 ml/s vs. +12 ml/s; p < 0.001; PVR: -100 ml and -95 ml vs. - 80ml; p < 0.008) were significantly more improved after enucleation than after TURP. All techniques showed an equally low complication rate (6.9% and 6.9% vs. 10.3%; p = 0.743). No relevant difference of clinical outcomes was identified between HoLEP and bTUEP.
Conclusions: Both resection and enucleation are efficient and safe procedures in patients with medium-sized prostates (50cc), but irrespective of the technical approach, transurethral enucleation is superior to TURP in terms of perioperative and functional outcomes.
Introduction
In recent years the portfolio of surgical treatment modalities of lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) has been constantly evolving. On the one hand, emerging novel minimally invasive approaches strive for equal efficiency to standard resection, but with a more favorable safety profile (1, 2). On the other hand, novel ablative techniques anticipate the potential to outdo the standards on various technical and functional aspects. Laser-based approaches in combination with modified enucleation techniques such as holmium laser enucleation of the prostate (HoLEP) have been introduced with success and the efficacy and safety of this size-independent procedure have led to the integration into several international guidelines (3). However, enucleation itself is also possible in bipolar technique using a button-shaped electrode or specially designed loops. The first results resemble those reported for HoLEP. Bipolar transurethral enucleation of the prostate (bTUEP) was at least equally effective, but showed better hemostatic control, fewer complications, and both shorter catheterization and hospital stay (4-8). Some data suggest that the underlying laser physics of HoLEP offers superior outcomes compared to bTUEP (9, 10). A direct comparison between TURP, HoLEP and bTUEP in medium-sized prostates (50cc), where TURP has set the benchmark for decades, is lacking. This prompted us to investigate the true benefits of the enucleation procedure as performed with two different technical approaches compared to the current standard.
Discussion
The current study was not only designed to reveal the true benefits of enucleation techniques but also to demonstrate, that even with our standard TURP equipment, we are able to achieve those goals following the principles of anatomic enucleation. Our results in concert with published data clearly confirmed the quality features of the reference method TURP, but here we showed that these outcomes could still be optimized using refined surgical techniques (21, 22). This trend is mirrored by current guideline recommendations, which integrated enucleation techniques for surgical options for prostate sizes ranging from 30cc to 80cc (23). Most importantly, the surgeons’ proficiency must be assured to accomplish the clinical benefits reported for techniques like HoLEP. Once the surgeon is comfortable with an enucleation technique, it seems that the energy source is of a secondary matter. A growing body of clinical evidence suggests that the enucleation in expert hands is the key factor. To our knowledge, our results are the first to show in a matched-pair analysis of common LUTS patients, that enucleation as a general principle offers better results than resection in medium-sized prostates. We have to emphasize that in the current study no special equipment was used for surgery. Enucleation was executed mainly with the tip of the resectoscope without any technical modification. The energy was only applied when necessary. Nevertheless, the outcomes are equivalent to the laser-based approach.
The retrospective single-center design with the short-term follow-up needs to be acknowledged as a shortcoming of our study. However, the presented data clearly pinpoints the enucleation principle as the crucial factor for superior outcomes. In the end, the success is not exclusively depending on the energy source, but foremost on the surgical precision of a correct enucleation procedure. The presented outcomes demonstrated the benefits for medium-sized prostates, but for the complete appraisal, additional studies are warranted to confirm the trend for larger prostates >80cc. Long-term prospective randomized controlled trials are necessary to answer the question about the most complete technique.
Conclusion
The convincing body of clinical evidence proves that the technique of endoscopic enucleation has come of age. Both resection and enucleation are efficient and safe procedures in patients with LUTS due to BPO with medium-sized prostates, but irrespective of the technical approach, transurethral enucleation is superior to TURP in terms of perioperative and functional outcomes. No relevant differences in perioperative parameters, clinical outcomes, and the safety profile were identified between HoLEP and bTUEP. Performing a successful enucleation with the standard equipment as used for TURP showcases the importance of the technical principle.
