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

© The Canadian Journal of Urology TM : International Supplement, August 2020 energies. Due to these unique properties, HoLEPmay be safely utilized in patients with bleeding disorders or those on anticoagulation. 42,43 El Tayeb et al performed a study which compared 116 HoLEP patients who required anticoagulation (AC) or antiplatelet (AP) therapy to 1558 HoLEP patients who were not on AC/AP therapy. 44 The study showed that other than prolonged hospitalization (p < 0.001) and duration of continuous bladder irrigation (p < 0.001), the use of intermittent or continuous AC/AP therapy did not adversely affect outcomes. With regard to antiplatelet therapy, Sun et al performed a large retrospective study of 1124 HoLEP patients comparing patients who were receiving dual antiplatelet therapy (DAPT), continuous single antiplatelet (AP) therapy, single AP therapy but intermittent during preoperative time, and no AP therapy. 45 Similar complication 30-day complication rates were found (p = 0.678) between all groups, with all patients demonstrating improved IPSS, QoL scores, and PVR at 12-month follow up. This literature along with current AUAguidelines recommend that HoLEP is a safe and attractive option for use in patients who are at higher risk of bleeding, such as those on anticoagulation. 3 In addition to excellent hemostatic properties, previously described size-independent treatment efficacy, HoLEP has also shown an age-independent treatment efficacy and safety profile. Mmeje et al retrospectively analyzed and compared outcomes and morbidity in 311 HoLEP patients aged 50-59, 60-69, 70- 79, and ≥ 80 years, with functional outcomes assessed using IPSS, Q max , PVR, and urinary continence. 46 No significant differences were observed between groups with regard to morbidity rates, hospitalization time, 1-year functional outcomes, incidence of Clavien 3+ complications, and change in serumhemoglobin levels. Intraoperative and postoperative complications from HoLEP are rare, with Krambeck et al describing 24 incidents (2.3%) in a study of 1065 HoLEPs described above. 36 These complications included clot retention (7 patients), significant hematuria prolonging hospitalization (5 patients), open cystotomy to remove adenoma (3 patients), myocardial infarction (3patients), andatrialfibrillationrequiringcardioversion, morcellator bladder injury, cerebral vascular accident, and sepsis (1 patient, respectively). Urethral stricture requiring office dilation ranged from up to 1.3% at short/intermediate term follow up to 0% at long term followup, while bladder neck contracture rates ranged from 0.8 to 6% over the same follow up period. At the most recent follow up in their study, 3 patients (0.3%) were in urinary retention and significant stress and urge incontinence was noted in 9 (0.8%) and 6 (0.6%) patients, respectively. Similarly, Elmansy et al reported lowcomplication rates, and rates of persistent stress and urge incontinence of 1 and 0.5% in their 10-year follow up data of 949 HoLEP patients. 37 Additionally, 0.8% of patients developed bladder neck contracture, and 1.6% of patients developed urethral stricture with only 0.7% of patients requiring reoperation due to residual adenoma. 37 In the 18-year follow up study described above, Ibrahim et al also reported low complication rates with perioperative blood transfusion required in 0.8% of patients, and postoperative urethral stricture and bladder neck contracture development in 21 (1.4%) and 30 patients (2.1%), respectively. 38 Notably, only 21 patients (1.4%) required repeat HoLEP. With durable long term data and multiple studies, the literature strongly indicates HoLEP as a safe procedure with low complication and treatment failure rates. Despite its long termdurable treatment efficacy and safety profile, HoLEP does carry the risk of ejaculatory dysfunction and altered orgasmperception. 47 Placer et al reported loss of antegrade ejaculation in 70.3%of 202 sexually active HoLEP patients, while 21% reported a reduction in semen quantity. 48 However, rates of sexual side effects appear comparable between HoLEP and TURP/OSP. 33,49,50 Furthermore, Klett et al reported in a retrospective study with 3-year follow up data in 393 HoLEP patients that there was a significant subjective improvement in IPSS compared to baseline (p = 0.0001) with no significant change frombaseline inmean IIEF- 5 scores at 3, 6, 12, 24, and 36 months. 51 Additionally, attempts have been made to maintain ejaculatory function with HoLEP, with Kim et al demonstrating an overall success rate of ejaculation preservation in 46.2% of their patients who received an ejaculatory hood sparing technique. 52 The results of these studies highlight the importance of proper patient counseling prior toHoLEP regarding sexual side effects, while also providing data on promising future directions with regards to optimization of surgical technique. Patient preference and learning curve While HoLEP has its distinct advantages and side effect profile, it can be difficult to assess patients’ perspectives and satisfaction across the multiple treatment modalities for symptomatic BPH. Abdul- Muhsin et al utilized an independent third-party survey sent to all patients who underwent any surgical treatment for BPH over a 6-year period to help address this question. 53 There was a response rate of 55.6% (479 respondents), including patients who receivedHoLEP (n = 214), TURP (n = 210), holmium laser ablation of the prostate (n = 21), photoselective vaporization Das et al. 48