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.     

Randomized trial of safety and efficacy of transurethral resection of the prostate using contact laser versus electrocautery

The aim of this study was to prospectively evaluate the safety and efficacy of contact laser ablation of the prostate (CLAP) vs. transurethral resection of the prostate (TURP) in symptomatic benign prostatic hypertrophy (BPH). During a 1-year period (1995-1996), 37 males 50 years of age or older were randomized to either CLAP using Nd:YAG laser treatment or TURP. Patients with Qmax <15 mL/s, American Urological Association (AUA) symptom score >12, and postvoid residual (PVR) >125 mL were enrolled. Patients were excluded if they had prior surgical treatment for BPH or known conditions that could affect bladder function. Comparisons of preoperative and postoperative symptom scores, Qmax, PVR, total catheter time, hospital stay, complications, and hematocrit changes were performed. A 2:1 randomization was used, which resulted in 26 CLAP and 12 TURP patients. One-year follow-up data were available for 21 CLAP and 7 TURP patients. The mean prostate volume, age, AUA symptom score, and Qmax were not significantly different between the two arms. Significant differences in favor of CLAP were shorter catheter time (27.2 vs. 40.4 hours; p < .05) and shorter hospital stays (28.5 vs. 60.0 hours; p < .05). The only other significant difference between the two arms was a lower AUA symptom score in favor of TURP at 1 year (4.7 vs. 8.4; p < .05). Qmax, PVR, and postoperative hematocrit were similar between the groups. The only complications included recatheterizations, which occurred more frequently in the TURP patients (25% vs. 14%). CLAP appears to be slightly less effective in AUA symptom score reduction; however, it is equally safe and is superior for shortening catheter time and hospital stay compared to TURP.     

钬激光前列腺剜除术与电切术安全性及疗效比较

目的 比较并探讨钬激光前列腺剜除术(HoLEP)和传统经尿道前列腺电切术(TURP)的安全性及疗效,旨在为良性前列腺增生症的临床治疗提供理论依据.方法 回顾性分析哈尔滨医科大学附属第四医院2015年1月-2016年1月收治的349例良性前列腺增生症患者的病例资料,并将其随机分成两组.其中172例患者选择行钬激光前列腺剜除术,另外177例患者选择行传统经尿道前列腺电切术.比较两组患者术中出血量、手术时间、术后导尿管留置时间、术后住院天数以及术后并发症(尿失禁、膀胱痉挛、出血)的发病率.随访3个月,重新评估IPSS、QOL、Qmax指标并比较疗效.结果 与传统经尿道前列腺电切术组相比,钬激光前列腺剜除术组患者的手术时间明显缩短、术中出血量及术后住院天数显著降低(P＜0.05),术后导尿管留置时间[钬激光前列腺剜除术组:(2.4±0.5)d;传统经尿道前列腺电切术组:(5.7±0.6)d,P＜0.05].明显减少,术中切除前列腺重量明显增加,术后并发症的发病率[钬激光前列腺剜除术组:5/172(2.9％);传统经尿道前列腺电切术组:19/177(10.7％),P＜0.01]显著下降.3个月后,两组术后PVR、IPSS、QOL以及Qmax较术前相比明显改善(P＜0.01),组间比较差异无统计学意义(P＞0.05).结论 钬激光前列腺剜除术与传统经尿道前列腺电切术相比疗效相当,但安全性更高.钬激光前列腺剜除术治疗临床前列腺增生症具有重要意义.     

Safety and efficacy of transurethral resection of prostate glands up to 150 ml: a prospective comparative study with 1 year of followup

PURPOSE: We investigated the safety and efficacy of transurethral resection of the prostate (TURP) for prostate glands between 70 and 150 ml. MATERIALS AND METHODS: We prospectively evaluated 113 patients treated with TURP for benign prostatic hyperplasia. A total of 57 patients with a prostate volume of less than 70 ml were assigned to group 1, while 56 with a prostate volume of between 70 and 150 ml were assigned to group 2. Preoperative parameters considered in each patient were prostate volume, International Prostate Symptom Score (I-PSS), urinary flow rate measurement (Qmax) and post-void residual urine volume (PVR). Operative time, resected tissue weight and all complications were recorded. All patients were evaluated 3 months and 1 year postoperatively. Preoperative, perioperative and postoperative data on the 2 groups were compared. RESULTS: Each group achieved significant improvement in I-PSS, Qmax and PVR. Operative time was significantly longer in group 2 but the complication rate was similar in the 2 groups. Group 2 resulted in better improvements in Qmax and I-PSS. At 1 year of followup PVR was significantly lower in group 1 than in group 2. Multivariate analysis revealed that only age was a significant independent predictor of complications, and only age and initial Qmax were independent predictive variables of outcome. CONCLUSIONS: TURP for large prostate glands is a safe procedure without showing a different complication rate compared with TURP for recommended volumes. Patients with a baseline prostate volume of greater than 70 ml seem to achieve better improvement in obstruction and symptoms.     

The diode laser: a novel side-firing approach for laser vaporisation of the human prostate--immediate efficacy and 1-year follow-up

OBJECTIVES: A prototype diode laser was used to evaluate the feasibility and postoperative outcome of diode laser vaporisation of the prostate in patients with bladder outlet obstruction (BOO) necessitating interventional desobstruction. METHODS: Ten patients were included in this pilot study. The prostate was vaporised via a side-fire laser fibre (diode laser at 1470 nm, 50 W; Biolitec-AG, Jena, Germany). IPSS, quality of life, Q(max), and PVR volume were measured pre- and postoperatively and 1 yr after the intervention. RESULTS: Prostate volumes were 35-78 ml. A mean 121 kJ (61-200 kJ) of energy was delivered. No patient had significant blood loss or fluid absorption. Three-way catheters were removed after a median of 33 h. Q(max) increased from 8.9 ml/s (3.6-13.2 ml/s) preoperatively to 15.7 ml/s (10.5-22 ml/s) (p<0.01) postoperatively. After the 12-mo follow-up, Q(max) increased to 22.35 ml/s (+/-4.32 ml/s; p<0.001). PVR volume changed from a baseline of 243 ml to 26.9 ml (p<0.001) after 12 mo. Volume reduction was estimated by transrectal ultrasound postoperatively (15 cc+/-6.39), and by PSA levels before surgery (3.8 ng/ml+/-2.3) and after 6 mo (2.64 ng/ml+/-1.51). No patient is incontinent. Two patients required recatheterisation postoperatively on days 1 and 2, respectively. Two patients required TURP within 2 mo. All patients without reintervention have presented for the 1-yr follow-up examination and are satisfied with the outcome. CONCLUSIONS: Our preliminary findings indicate that 50-W diode laser vaporisation prostatectomy at 1470 nm is feasible and appears to be effective for acutely relieving BOO.     

Thick loop prostatectomy in the endoscopic treatment of benign prostatic hyperplasia: results of a prospective randomised study

OBJECTIVE: The thick loop is a new device employed for transurethral resection of the prostate (TURP) using the standard resectoscope. The loop is broader and thicker than the standard one, resulting in better hemostasis because of its ability to cut, coagulate and vaporize tissue simultaneously. We evaluated the safety and efficacy of the thick loop device compared with the standard loop. PATIENTS AND METHODS: 103 patients with symptomatic benign prostatic hyperplasia were randomized to undergo either thick loop (51 patients) or standard loop TURP (52 patients). Patients were considered for surgery with the American Urological Association (AUA) symptom score greater than 7 and a maximum urinary flow rate <15 ml/s. Serum hemoglobin, hematocrit, electrolytes, operative time, prostate resected weight, catheterization time and complications were recorded. Twelve months later, the AUA score, maximum urinary flow rate (Q(max)) and postvoiding residual urine volume were evaluated. RESULTS: There were no significant differences between thick and standard loop TURP regarding the operative and catheterization time, prostate resection weight and postoperative levels of hemoglobin, hematocrit and electrolytes. Twelve months after TURP, the AUA score was significantly lower and Q(max) greater in the thick loop compared to the standard loop groups. CONCLUSIONS: Thick loop TURP is as safe as standard loop TURP with respect to blood loss, operative time and complications. Operating in a virtually bloodless field could allow a more radical TURP and provide an explanation for the better functional results (Q(max) and AUA score) obtained by the thick loop resection.     

Two-year results of transurethral resection of the prostate versus four 'less invasive' treatment options

OBJECTIVE: The aim of this study was to compare the efficacy or transurethral resection of the prostate (TURP) versus four less invasive treatment options during a 2-year follow-up. MATERIAL AND METHODS: 95 elderly men with lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) were assigned prospectively to the following five treatment arms; transurethral resection of the prostate (TURP; n = 28), transurethral electrovaporization (TUVP; n = 17), visual laser ablation of the prostate (VLAP; n = 17), transrectal high intensity focused ultrasound (HIFU; n = 20) and transurethral needle ablation (TUNA); n = 15). Preoperative workup included the International Prostate Symptom Score (IPSS), uroflowmetry, post-void residual volume (PVR), prostate volume determined by transrectal ultrasonography and a multichannel pressure flow study. Postoperative follow-up at 6, 12, 18 and 24 months included assessment of IPSS, PVR and uroflowmetry. RESULTS: At study entry, patients assigned to one of the five treatment arms were comparable with respect to age, peak flow rate (Q(max)), IPSS, prostate size and the degree of bladder outflow obstruction. During study, 1 patient in the TURP group (4%) required a secondary TURP, as compared to 23.5% (n = 4) after TUVP, 26.7% (n = 4) after VLAP, 15% (n = 4) after HIFU and 20% (n = 3) following TUNA. In patients not subjected to a secondary procedure, the IPSS decreased a mean 13. 9 after TURP, as compared to 12.7 after TUVP, 12.9 after VLAP, 7.0 after HIFU, and 9.8 after TUNA. Q(max) increased 11.5 ml/s (mean) after TURP, as compared to 11.1 ml/s after TUVP, 5.6 ml/s after VLAP, 2.5 ml/s after HIFU and 2.3 ml/s after TUNA. CONCLUSION: In up to a quarter of the patients, a secondary TURP is performed within the first 2 years after 'less invasive' procedures. These data underline the need for long-term studies to reliably assess the role of less invasive procedures and to indicate that TURP is still competitive.     

A systematic review and meta-analysis of efficacy and safety comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for patients with prostate volume less than 100 mL or 100 g

BackgroundTo assess the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TURP) for patients with prostate volume less than 100 mL or 100 g.MethodsWe searched PubMed, Embase, Cochrane Library and Web of Science from inception to July 2021 to collect randomized controlled trials. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias of the included studies by using the Cochrane risk of bias tool. Review Manager 5.3 software was used for meta-analysis. We synthesised effect estimates using risk ratios (RR), mean difference (MD), and standardized mean differences (SMD).ResultsA total of eight studies were included, involving 764 patients, 384 patients in the HoLEP group and 380 patients in the TURP group. The meta-analysis showed that the catheterization time (SMD =−1.44; 95% CI: −2.17 to −0.70; P=0.0001), hospital stay (SMD =−1.01; 95% CI: −1.58 to −0.44; P=0.0005), haemoglobin loss (MD =−0.29; 95% CI: −0.52 to −0.07; P=0.01), and transfusion rate (RR =0.16; 95% CI: 0.05–0.49; P=0.001) in the HoLEP group were lower than those in the TURP group. In addition, the 12-month postvoid residual volume (PVR) of the HoLEP group (MD =−9.93 95% CI: −18.59 to −1.27; P=0.02) were superior to the TURP group. Although the operation time of the HoLEP group was longer (MD =17.89; 95% CI: 9.18–26.60; P<0.0001), more tissues were removed (SMD =0.47; 95% CI: 0.10–0.85; P=0.01).DiscussionCompared with TURP, HoLEP has a shorter catheterization time and hospital stay, with more tissue removed, a lower blood transfusion rate and better results in the short-term follow-up after surgery. Therefore, HoLEP has better efficacy and safety in the treatment of small- and medium-sized benign prostatic obstruction. Our results found that HoLEP is also suitable for patients with prostate volume <100 mL/100 g, suggesting that it is necessary to redefine the prostate size that is best for HoLEP. Overall, the certainty of evidence was assessed to be moderate to low due to potential risk of bias and inconsistent outcome indicators in some studies. More data on the efficacy of HoLEP and TURP on small- and medium-sized prostates are needed to determine the optimal prostate volume of HoLEP.     

A Review of the Recent Evidence (2006–2008) for 532-nm Photoselective Laser Vaporisation and Holmium Laser Enucleation of the Prostate

Context

Holmium laser enucleation of the prostate (HoLEP) and 532-nm laser vaporisation of the prostate (with potassium titanyl phosphate [KTP] or lithium borate [LBO]) are promising alternatives to transurethral resection of the prostate (TURP) and open prostatectomy (OP).

Objective

To assess safety, efficacy, and durability by analysing the most recent evidence of both techniques, aiming to identify advantages, pitfalls, and unresolved issues.

Evidence acquisition

A Medline search of recently published data (2006–2008) regarding both techniques over the last 2 yr (January 2006 to September 2008) was performed using evidence obtained from randomised trials (level of evidence: 1b), well-designed controlled studies without randomisation (level of evidence: 2a), individual cohort studies (level of evidence: 2b), individual case control studies (level of evidence: 3), and case series (level of evidence: 4).

Evidence synthesis

In the last 2 yr, several case-control and cohort studies have demonstrated reproducibility, safety, and efficacy of HoLEP and 80-W KTP laser vaporisation. Four randomised controlled trials (RCTs) were available for HoLEP, two compared with TURP and two compared with OP, with follow-up >24 mo. Results confirmed general efficacy and durability of HoLEP, as compared with both standard techniques. Only two RCTs were available comparing KTP laser vaporisation with TURP with short-term follow-up, and only one RCT was available comparing KTP laser vaporisation with OP. The results confirmed the overall low perioperative morbidity of KTP laser vaporisation, although efficacy was comparable to TURP in the short term, despite a higher reoperation rate.

Conclusions

Although they are at different points of maturation, KTP or LBO laser vaporisation and HoLEP are promising alternatives to both TURP and OP. Sufficient data proves HoLEP's durability for most prostate sizes at long-term follow-up; KTP laser vaporisation needs further evaluation to define the reoperation rate. Increasing the number of quality prospective RCTs with adequate follow-up is mandatory to tailor each technique to the right patient.     

Prostatic Artery Embolisation Versus Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia: 2-yr Outcomes of a Randomised,Open-label,Single-centre Trial

BackgroundProstatic artery embolisation (PAE) for the treatment of lower urinary tract symptoms secondary to benign prostatic obstruction (LUTS/BPO) still remains under investigation.ObjectiveTo compare the efficacy and safety of PAE and transurethral resection of the prostate (TURP) in the treatment of LUTS/BPO at 2 yr of follow-up.Design, setting, and participantsA randomised, open-label trial was conducted. There were 103 participants aged ≥40 yr with refractory LUTS/BPO.InterventionPAE versus TURP.Outcome measurements and statistical analysisInternational Prostate Symptoms Score (IPSS) and other questionnaires, functional measures, prostate volume, and adverse events were evaluated. Changes from baseline to 2 yr were tested for differences between the two interventions with standard two-sided tests.Results and limitationsThe mean reduction in IPSS after 2 yr was 9.21 points after PAE and 12.09 points after TURP (difference of 2.88 [95% confidence interval 0.04–5.72]; p = 0.047). Superiority of TURP was also found for most other patient-reported outcomes except for erectile function. PAE was less effective than TURP regarding the improvement of maximum urinary flow rate (3.9 vs 10.23 ml/s, difference of –6.33 [–10.12 to –2.54]; p < 0.001), reduction of postvoid residual urine (62.1 vs 204.0 ml; 141.91 [43.31–240.51]; p = 0.005), and reduction of prostate volume (10.66 vs 30.20 ml; 19.54 [7.70–31.38]; p = 0.005). Adverse events were less frequent after PAE than after TURP (total occurrence n = 43 vs 78, p = 0.005), but the distribution among severity classes was similar. Ten patients (21%) who initially underwent PAE required TURP within 2 yr due to unsatisfying clinical outcomes, which prevented further assessment of their outcomes and, therefore, represents a limitation of the study.ConclusionsInferior improvements in LUTS/BPO and a relevant re-treatment rate are found 2 yr after PAE compared with TURP. PAE is associated with fewer complications than TURP. The disadvantages of PAE regarding functional outcomes should be considered for patient selection and counselling.Patient summaryProstatic artery embolisation is safe and effective. However, compared with transurethral resection of the prostate, its disadvantages regarding subjective and objective outcomes should be considered for individual treatment choices.     

A randomised trial comparing holmium laser enucleation versus transurethral resection in the treatment of prostates larger than 40 grams: results at 2 years

OBJECTIVE: To compare holmium laser enucleation of the prostate (HoLEP) with transurethral resection of the prostate (TURP) for treatment of men with bladder outflow obstruction (BOO) secondary to benign prostatic hyperplasia with a minimum of 24-month follow-up. PATIENTS AND METHODS: Sixty-one patients were randomised to either HoLEP or TURP. All patients had BOO proven on urodynamic studies pre-operatively (prostate size 40-200 g). One patient died before treatment, which left 30 patients in each group. Perioperative data, as well as symptom scores, Quality of Life (QoL) scores, and maximum urinary flow rates (Qmax) were obtained at one, three, six,12, and 24 months. Post-void residual volumes, transrectal ultrasound (TRUS) volumes, and pressure flow studies were obtained six months post-operatively. Continence and potency data were also recorded. RESULTS: There were no significant differences between the two surgical groups pre-operatively. Mean pre-operative TRUS volume was 77.8+/-5.6 g (42-152) in the HoLEP group and 70.0+/-5.0 g (46-156) in the TURP group. Patients in the HoLEP group had shorter catheter times and hospital stays. More prostate tissue was retrieved in the HoLEP group. At six months, HoLEP was urodynamically superior to TURP in relieving BOO. At 24 months, there was no significant difference between the two surgical groups with respect to American Urology Association scores, QoL scores, or Qmax values; however, two patients in the TURP group required re-operation. CONCLUSIONS: HoLEP has less perioperative morbidity and produces superior urodynamic outcomes than TURP, when treating prostates >40 g. At 24 months of follow-up, HoLEP is equivalent to TURP.     

Transurethral RollerLoop vapor resection of prostate for treatment of symptomatic benign prostatic hyperplasia: a 2-year follow-up study

OBJECTIVE: We compared the 2-year safety and efficacy of two transurethral resection techniques-transurethral vapor resection of the prostate (TUVRP) and conventional loop transurethral resection of the prostate (TURP)-in the surgical management of benign prostatic hyperplasia. MATERIAL AND METHODS: Between August 1997 and September 2002, 441 patients underwent transurethral prostatectomy, either TUVRP (n = 221) or TURP (n = 220). TUVRP was performed using a "RollerLoop" resection loop. All patients were assessed preoperatively by means of International Prostate Symptom Score (IPSS), quality of life (QOL) score, prostate volume, peak urinary flow (Qmax) and post-void residual volume (PVR) measurements and a sexual function questionnaire. Patients were followed up for 3, 6, 12 and 24 months after surgery, and this was followed by a comparison of the incidences of sexual dysfunction, complications and re-treatment. RESULTS: After 2 years of follow-up, no differences were noted between the TUVRP and TURP groups with respect to average IPSS (p = 0.9), QOL scores (p = 0.56), Qmax (p = 0.89) or PVR (p = 0.55), as well as the incidences of bladder neck contracture or urethral stricture (p = 0.34), re-treatment (p = 0.49) or sexual dysfunction (p = 0.57). However, significant reductions in operative time (p = 0.005), decrease in serum hemoglobin levels (p < 0.001), catheterization time (p < 0.001), postoperative hospital stay (p < 0.001) and hospitalization costs (p < 0.001) were observed in the TUVRP group compared to the TURP group. CONCLUSION: Our results suggest that TUVRP provides equivalent safety and efficacy to TURP during a 2-year follow-up period, in which short-term advantages in perioperative morbidity and cost savings were also demonstrated.     

经尿道80W绿激光汽化术联合等离子电切治疗大体积前列腺增生症

目的 探讨经尿道80 W绿激光前列腺汽化术(PVP)联合等离子电切术(PKRP)治疗大体积(＞100毫升)的良性前列腺增生(BPH)的临床疗效及安全性.方法 2006年1月至2008年12月采用PVP联合PKRP治疗体积100毫升以上的前列腺增生症共计87例,方法为先行PKRP术,切除大部分增生的腺体,再以PVP对...     

Four-Year Outcome of a Prospective Randomised Trial Comparing Bipolar Plasmakinetic and Monopolar Transurethral Resection of the Prostate

Background

No data have been published on the midterm efficacy of bipolar transurethral resection of the prostate (TURP).

Objective

To evaluate 4-yr results from a prospective randomised trial comparing bipolar TURP with standard monopolar TURP.

Design, setting, and participants

Seventy patients with symptomatic benign prostatic hyperplasia were enrolled in this prospective randomised controlled trial in a tertiary-care institution. Inclusion criteria were age >50 yr, good performance status, urinary retention, International Prostate Symptom Score (IPSS) ≥18, and maximal flow rate (Q_max) ≤15 ml/s. Exclusion criteria were prostate volume <30 cm³, documented or suspected prostate cancer, neurogenic bladder, bladder stone or diverticula, urethral stricture, and maximal bladder capacity >500 ml.

Intervention

Patients underwent standard or bipolar plasmakinetic TURP performed by the same surgeon using the same surgical technique.

Measurements

Treatment efficacy was evaluated at 1, 2, 3, and 4 yr by comparing urinary flow rates, IPSS, and estimated postvoid residual (PVR) urine volume. Midterm complications were also recorded.

Results and limitations

The number of dropouts was not statistically significantly different in the two groups (p = 0.2). The significant improvements in both groups were maintained at 4 yr for the IPSS, quality of life score, Q_max, and PVR versus baseline values. The main outcome variables at 4 yr for bipolar and monopolar TURP were mean IPSS 6.9 and 6.4 (p = 0.58); mean Q_max 19.8 ml/s and 21.2 ml/s (p = 0.44), and mean PVR volume 42 ml and 45 ml (p = 0.3). Overall, 2 of 32 (6.2%) and 3 of 31 (9.6%) patients required reoperation because of late complications (p = 0.15). The major study limitation was the small sample size.

Conclusions

This study represents the secondary, midterm analysis of a previously published trial. Our 4-yr data confirm our initial positive findings for the efficacy and safety of bipolar plasmakinetic TURP. Larger well-designed studies are needed to corroborate these findings.     

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.     

Holmium laser enucleation of the prostate (HoLEP): long-term results, reoperation rate, and possible impact of the learning curve

OBJECTIVES: To evaluate long-term outcomes and reoperation rate of holmium laser enucleation of the prostate (HoLEP) for patients with symptomatic enlarged prostate, including patients who were operated during the learning curve. METHODS: A retrospective analysis of 118 patients who underwent HoLEP between March 1998 and February 2001 at our institution. This analysis represented our initial experience with the technique reflecting our learning curve. The voiding outcome parameters, operative duration time, enucleation time, morcellation time, eucleated tissue weight, catheterization time, hospital stay, and complications were recorded. RESULTS: The mean patient age was 76.5 yr (range: 59-93) and the mean preoperative prostate volume was 59.3 cc (range: 20-172). The mean follow-up period was 49.4+/-28.1 mo. The mean catheter time and hospital stay was 1.3 and 1.5 d, respectively. Seventy-eight percent of the patients were discharged home within 24h after surgery. For the patients (n=26) who had objective data at 6 yr postoperatively, mean maximum flow rate increased from 6.3 to 16.2ml/s and mean postvoid residual urine decreased from 232 to 41.2ml (p<0.0001). Mean International Prostate Symptom Score improved from 17.3 to 5.6 (p<0.0001). Bladder-neck contracture and urethral stricture developed in 0.8% and 1.7% of patients, respectively. The reoperation rate for recurrent benign prostatic hyperplasia obstruction was 4.2%. CONCLUSIONS: HoLEP represents a safe and effective treatment for patients with symptomatic enlarged prostate. The improvement in outcome parameters is durable, and the late complications and reoperation rate are very low.     

Randomized clinical trial comparing transurethral needle ablation with transurethral resection of the prostate for the treatment of benign prostatic hyperplasia: results at 18 months

PURPOSE: To compare the efficacy and safety of transurethral needle ablation (TUNA) and transurethral resection of the prostate (TURP) for the treatment of benign prostatic hyperplasia (BPH) during an 18-months follow-up. PATIENTS AND METHODS: A series of 59 patients older than 40 years were included in this study. The entry criteria were prostate size <70 g, maximum urinary flow rate (Q(max)) <15 mL/sec, International Prostate Symptom Score (IPSS) >13, and no suspicion of prostate cancer according to the clinical or laboratory findings. Of the patients, 26 (44%) were treated with TUNA and 33 (56%) with TURP. At 3 and 18 months of follow-up, Q(max), postvoiding residual volume (PVR), IPSS, and the quality of life (QOL) score were compared with the baseline values. The results were also compared in patients undergoing TUNA v TURP. RESULTS: Improvements in Q(max), PVR, IPSS, and QOL score were statistically significant for both groups at 3 and 18 months of follow-up. The increase in the mean Q(max) of the TURP group was higher than that in the TUNA group, whereas no significant differences were found in the two groups regarding improvements in IPSS and QOL score. There were no complications associated with the TUNA procedure, while 16 retrograde ejaculation, 4 erectile impairment, 2 urethral stenosis, and 1 urinary incontinence cases were observed after TURP. CONCLUSIONS: The TUNA procedure is an effective and safe minimally invasive treatment with negligible adverse effect for selected patients with symptomatic BPH compared with TURP. It should be considered as an alternative treatment option for younger patients who want to preserve sexual function.     

HoLEP与TURP治疗BPH的并发症比较

目的:比较经尿道钬激光前列腺剜除术(HoLEP)与经尿道前列腺电切术(TURP)在治疗良性前列腺增生(BPH)中的并发症差异。方法:将112例BPH患者分为两组,分别采用HoLEP(A组)或TURP(B组)治疗,比较两组患者术后早期并发症及随访1年后的并发症差异。结果:A组术后早期并发症发生率均低于B组,其中术后尿路刺激症状、拔管后血尿差异有统计学意义(P0.05)。随访1年后,A组远期并发症低于B组,差异有统计学意义(P0.05)。结论:HoLEP治疗BPH的术后早期并发症及远期并发症比TURP更低,疗效更好。     

Three-year outcome following holmium laser enucleation of the prostate combined with mechanical morcellation in 330 consecutive patients

OBJECTIVES: A prospective study to assess safety, efficacy, and medium-term durability of holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation for the treatment of bladder outlet obstruction (BOO) due to benign prostate enlargement (BPE). METHODS: Between January 2000 and July 2003, 330 consecutive patients underwent HoLEP at our institution. All patients were pre-operatively assessed with transrectal ultrasound gland volume evaluation, maximum urinary flow rate (Q(max)), international prostate symptoms score (IPSS), and the single-question quality of life (QoL). Intra-, peri-, and postoperative parameters were evaluated and the patients were reassessed at 1-, 3-, 6-, 12-, 18-, 24-, and 36-mo follow-up with the same examinations. RESULTS: Patients' mean age was 66+/-8.1 yr; prostate volume was 62+/-34 cc. Enucleation time was 45.4+/-22.9 min and morcellation time 17.3+/-14 min, whilst resected weight was 40+/-27.5 g. Catheter time was 23+/-14.7h and hospital stay was 48+/-26 h. Mean serum hemoglobin and sodium did not drop significantly from baseline after the procedure (p=013). A significant improvement occurred in Q(max) (25.1+/-10.7 ml/s), IPSS (0.7+/-1.3), and QoL (0.2+/-0.5) at the 3-yr follow-up compared with baseline (p<0.05). Twenty-eight percent of patients complained of irritative urinary symptoms, typically self-limiting after 3 mo; transient stress incontinence was reported in 7.3% of patients. Nine patients (2.7%) had persistent BOO, requiring reoperation. CONCLUSIONS: HoLEP represents an effective and safe surgical intervention. The relief from BOO also proved to be durable after 3-yr follow-up. The present report adds to the evidence that HoLEP could be the standard "size-independent" surgical treatment for symptomatic BPE-related BOO.     

A prospective randomized study of combined visual laser ablation and transurethral resection of the prostate versus transurethral prostatectomy alone

INTRODUCTION: Visual laser ablation of the prostate (VLAP) has a clinical failure rate of up to 18% which is 3 times higher than transurethral resection of the prostate (TURP) alone. Prolonged spontaneous passage of necrotic debris is the major shortcoming of this method. Therefore combined visual laser-assisted and transurethral prostatectomy was compared to TURP alone. MATERIALS AND METHODS: 105 patients were evaluated in a prospective randomized study comparing TURP alone and VLAP combined with TURP. The patients were evaluated 1, 3 and 12 months after surgery. First VLAP was performed using a neodymium:yttrium-aluminum-garnet laser with the prolase fiber followed by standard resection of the necrotic and remaining prostatic tissue. Treatment efficacy was assessed by the American Urological Association (AUA) symptom score, measurements of peak urinary flow, residual urine volume, intraoperative bleeding, and by the occurrence of intra- and postoperative complications. RESULTS: The use of VLAP and consecutive TURP improved the AUA symptom score, urinary flow and residual volume and was comparable in all patients treated. Intraoperative bleeding was significantly reduced from 522 +/- 45 ml by TURP to 214 +/- 33 ml by VLAP+TURP (p < 0.05). There was a significant improvement in the postoperative values of the parameters observed in both groups. CONCLUSIONS: It appears that the combined method for treatment of benign prostatic hyperplasia reduced the specific intraoperative morbidity of TURP while achieving the same clinical effect as TURP alone.