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

© The Canadian Journal of Urology TM : International Supplement, August 2020 Amultitude of data exist comparingHoLEP tomore invasive procedures such as open simple prostatectomy (OSP) or robot-assisted simple prostatectomy (RSP). Kuntz et al reported 5-year follow up results on their randomized controlled trial comparing HoLEP versus OSP for prostates > 100 grams anddemonstrated similar improvements in AUA-SS, Q max , and PVR between the two groups. 32 Both groups also demonstrated similarly lowreoperationrates(5%inHoLEP,6.9%inOSP[p=1.0]). A separate randomized control trial performed by Naspro et al compared HoLEP and OSP in prostates > 70 grams with 2-year follow up data. 33 Their study revealed findings favoringHoLEP, including decreased catheterization time (p < 0.001), shorter hospital stays (p < 0.001), and decreased blood loss with lower transfusion rates (p < 0.001). 33 The study also found similar improvements from baseline in urodynamic parameters, and comparable late complication rates between the two groups, though OSP was found to have decreased operative time. These studies suggest that HoLEP is a minimally invasive alternative to OSP with at least similar efficacy in large prostates. With regard toRSP, Zhang et al performed a study comparing perioperative outcomes between32RSPpatients and600 HoLEPpatients at two separate academic institutions. 34 Results showed that HoLEP demonstrated reduced mean operative times (p < 0.001), decreased blood loss with lower transfusion rates, shorter hospital stay, and decreased catheterization time, with no difference in Clavien 3+ complication rates. This suggests that in expert hands, HoLEP appears to have a favorable perioperative profile compared to RSP, though long term follow up data are not yet available. Ahyai et al contends that prior studies finding increased operative time for HoLEP, as compared to TURP and OSP likely had some confounding variables, including limited surgeon experience with HoLEP, unavailability of tissue morcellators, and the fact that significantly more tissue was being treated during HoLEP thanwith other modalities. 35 The study compared 100 TURP and 60 OSP cases from previous randomized controlled trials with a matched pair analysis of 1000 HoLEP cases. These were matched based on documented resected prostate tissue, and resection speed in grams per minute was calculated. The study revealed that resection speed and operative time for HoLEP were significantly faster than TURP (p < 0.01) and similar to those of simple OSP (p ≥ 0.21). In addition to comparative studies comparing HoLEP to other surgical BPH management options, many large-volume studies with long term data exist. Krambeck et al performed a retrospective analysis of 1065 HoLEPs at a single institution, which showed that 47 Holmium laser enucleation of the prostate (HoLEP): size-independent gold standard for surgical management of benign prostatic hyperplasia HoLEP effectively improved both AUA-SS and Q max ; mean AUA-SS decreased from 20.3 preoperatively to 5.3 at 12-month follow up, while Q max increased from 8.4 mL/sec preoperatively to 22.7 mL/sec at 12-month follow up. 36 Elmansy et al retrospectively analyzed 949 patients who underwent HoLEP and had durable improvement in both objective and subjective outcomes at 62-month follow up. 37 To our knowledge, the longest followup studywas performed by Ibrahim et al, and consisted of 1476 patients over an 18-year period who underwent HoLEP at a single institution with over 9 years of follow up data. 38 These patients were found to have significant improvements inmean IPSS (p < 0.001) and QoL (p < 0.001) compared to preoperative values with only 21 patients requiring reoperation (1.4%). Furthermore, in the 132 patients who could be followed more than 10 years, Q max (p < 0.001) and PVR (p < 0.001) were significantly improved. The currentAUAguidelines for surgicalmanagement of BPH recommendHoLEP and ThuLEP (thulium laser enucleation of the prostate) as the only size-independent treatment options. 3 HoLEP has been more rigorously scrutinized, withmore publications, trials, is performed at more institutions, and has been around longer than ThuLEP. Humphreys et al retrospectively analyzed 507 patients who underwent HoLEP and evaluated both objective and subjective measures stratified by prostate size (<75 g, 75-125 g, >125 g). 39 No significant differences were found between the three cohorts with regard to hospitalization, catheterization time, AUA-SS, average Q max , average PSA, and complications (i.e. transient stress incontinence, transient dysuria, blood transfusion requirement, strictures). Similar studies have been performed in patientswith large prostates > 175 grams 40 and ≥ 200 grams, 41 demonstrating that HoLEP is a safe and effective procedure with satisfactory outcomes and low morbidity, independent of prostate size. Safety, complications, and adverse effects HoLEP has demonstrated its safety advantages over TURP and OSP, including decreased blood loss and lower transfusion rates. 8,9,28,30,31,33 The unique properties of the holmium laser allow it to coagulate tissue as it cuts, significantly improving hemostasis during HoLEP. The relatively short wavelength of the holmium laser allows for rapid tissue vaporization, while a shallow depth of penetration and coagulation (0.4 and 0.3 mm, respectively) minimizes damage to surrounding tissue. Additionally, the pulsed laser energy of the holmium laser enables efficient cutting and coagulation of vessels, compared to other laser