Holmium laser bladder neck incision versus holmium enucleation of the prostate as outpatient procedures for prostates less than 40 grams: a randomized trial

PURPOSE: Bladder neck incision (BNI) is a common, minimally invasive treatment option for bladder outflow obstruction in men with a small prostate. We compared BNI using the holmium:YAG laser to holmium enucleation of the prostate (HoLEP) in a prospective, randomized, urodynamically based trial. MATERIALS AND METHODS: A total of 40 patients with urodynamic obstruction (Schafer grade 2 or greater) and a prostate of 40 gm or greater on transrectal ultrasound (TRUS) were randomized equally to holmium laser BNI (HoBNI) or HoLEP as an outpatient procedure. The outcomes assessed were operative time, catheter time and hospital time. American Urological Association and quality of life scores, and maximal urinary flow rates were measured at baseline, and 1, 3, 6 and 12 months postoperatively, while pressure flow studies and TRUS volume measurement were performed at baseline and 6 months. RESULTS: The 2 groups were well matched for all variables at baseline. HoBNI was significantly more rapid to perform than HoLEP (p <0.001). Two patients (10%) in the HoBNI group required recatheterization compared with none in the HoLEP group. There was no significant difference in catheter time (22.9 vs 23.2 hours) or hospital time (12.3 vs 13.7 hours) between the groups. Five patients remained obstructed urodynamically at 6 months. All were in the HoBNI group and 4 of the 5 men had a prostate that was greater than 30 gm. Four of these patients required HoLEP for persistent lower urinary tract symptoms. In the remaining unoperated patients there were no significant differences in American Urological Association and quality of life scores or in the maximal urinary flow rate at each assessment. At 6 months detrusor pressure at maximal urinary flow was significantly lower (p <0.05) and TRUS volume was significantly smaller (p <0.001) in the HoLEP group There was significantly more early stress incontinence postoperatively in the HoLEP group but no bladder neck contractures were detected. CONCLUSIONS: Relief of obstruction was better after HoLEP and fewer patients required recatheterization or reoperation, although more reported early postoperative stress incontinence. Catheter time, hospital time and perioperative morbidity were similar. HoBNI and HoLEP are safe and feasible as outpatient procedures in patients with a small prostate but HoBNI is more rapid to perform.