3rd Annual Jefferson Urology Symposium: Men’s Health Forum

© The Canadian Journal of Urology TM : International Supplement, August 2020 Das et al. standard HoLEP (2 J, 50 Hz) found no difference in enucleation efficiency, postoperative dysuria and sexual function or objective flow rates between the two techniques. 19 As low-power holmium lasers are widespread given their use in treating urinary calculi, this could aid in adoption of the HoLEP technique. Another promising change in operative efficiency has come from novel improvements in morcellator technologies. Currently, three main prostate morcellators exist: VersaCut (Versapulse; Lumenis Inc., Santa Clara, CA, USA), Piranha (Richard Wolf Inc., Knittlingen, Germany), and DrillCut (Karl Storz Inc., Tuttlingen, Germany). VersaCut was the first morcellator used for HoLEP and utilizes reciprocating non-toothed blades controlled by a foot pedal and continuous suction. The Piranha and DrillCut morcellators use oscillating toothed blades which rotate at variable rates with intermittent suction. Studies have compared the morcellator technologies with seemingly variable conclusions. El Tayeb et al performed a prospective randomized trial comparing the Piranha to the VersaCut, which revealed that despite the Piranha having a statistically significant increased cost (p < 0.001) and a more complicated design (less user-friendly for operating room staff), 75%of urology faculty, fellows, and residents preferred it over the VersaCut, reporting more efficient tissue removal. 20 Rivera et al examined cost comparisons between VersaCut and Piranha and found that both morcellation efficiency (p < 0.01) and expense of operating room time (p < 0.005) significantly favored the Piranha, even when controlling for disposable costs (p < 0.05). 21 Another retrospective study done by McAdams et al found that the Piranha’s oscillating morcellation efficiency was nearly double that of VersaCut (8.6 g/min versus 3.8 g/min, p < 0.0001) with no apparent learning curve. 22 In contrast, Maheshwari et al revealed in their study that while VersaCut demonstrated significantly higher morcellation efficiency, the safety profile of the Piranha was significantly better. 23 Hodhod et al demonstrated that the DrillCut morcellator had superior ex vivo morcellation power but modest aspiration speed in comparison to other morcellators. 24 In a different study, Ibrahim et al conducted a prospective, randomized controlled trial comparing the DrillCut to the VersaCut, revealing that the DrillCut was associated with significantly lower morcellation rate (p = 0.03) and significantly higher cost of disposables (p < 0.01). 25 Lastly, the recent advancements in laser technology in the formof a larger vapor bubble per pulse have shown potential usefulness inquicker dissection of adenoma off the capsule with better hemostasis. This technology is currently being evaluated at several centers to see if there is a true reduction in enucleation time with improved coagulation compared to standard holmium lasers. Efficacy, outcomes, and durability HoLEP has been extensively studied and many large trials have examined efficacy and outcomes. To our knowledge, Tan et al performed the first randomized trial comparing HoLEP to TURP for the treatment of BOO secondary to BPH. 26 Their study demonstrated that HoLEP was superior to TURP with more prostate tissue removed (40.4 versus 24.7 grams), shorter mean catheter time (17.7 versus 44.9 hours), shorter hospital stay (27.6 versus 49.9 hours), and greater relief of obstruction at 6month followup as assessedby pressure flow studies, though at the cost of increased operative time for HoLEP (62.1 versus 33.1 minutes). Long term followupdata at 7 years showed thatHoLEPwas at least equivalent to TURPwith no significant differences Q max , AUA symptom score (AUA-SS), quality of life (QoL) score, BPH Impact Index (BPHII), International Index of Erectile Function (IIEF), International Continence Society Short Form Male questionnaire (ICSmaleSF) Voiding Score, or ICSMale Incontinence Score (IS) after 1 year. 27 No patients who underwent HoLEP required re- operation, while three (17.6%) of those who underwent TURP required further intervention. 27 Kuntz et al found in a prospectively randomized comparison of HoLEP and TURP done for BOO in patients with prostates less than 100 g that while having longer operative times, HoLEP had comparatively shorter catheter time, LOS, and blood loss. 28 Ahyai et al reported 3-year follow up data, showing AUA-SS and PVR were better in the HoLEP grouped compared to TURP. 29 Q max and reoperation rates were similar between the two groups. These results strongly suggest HoLEP to be a true alternative with unique advantages over TURP. Meta- analyses of other trials comparingHoLEP to TURP also found comparable symptom improvement 30 or superior results seen in patients who underwent HoLEP, again demonstrating its advantage over TURPwith regard to blood loss, catheterization time, and hospital stay. 30,31 Yin et al found in their meta-analysis that while TURP demonstrated significantly shorter operative times (p = 0.001) and lower incidence of postoperative dysuria (p = 0.003) compared to HoLEP, Q max and International Prostate symptom score (IPSS) were significantly improved in the HoLEP group (p < 0.0001 and p = 0.01, respectively) at 12 months postoperatively. 31 In extensive analysis, HoLEP has been found to be at least as effective as the prior gold standard, TURP, for treatment of BPH, with unique advantages. 46