4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 surgeon. For high-bleeding patients, HoLEP, PVP or ThuLEP should be considered. In a sub-stratification of recommendations according to prostate size, the only surgical procedure that is represented across the spectrum of sizes, is HoLEP. This makes HoLEP the standard across multiple prostate sizes and other variables that we can compare other treatments to. In the EAU guidelines on BPH management released on 2021, OP is considered effective but invasive with less favorable safety profile compared to HoLEP. Compared to TURP, HoLEP demonstrated longer operative times, but a favorable perioperative safety profile compared to TURP. According to the EAU guidelines, if laser enucleation is not available, OP should be offered. 3 Similar to the AUAguidelines, we see HoLEP across the spectrum of the disease. Emerging techniques The science behind MOSES and MOSES 2.0 MOSES laser technology (Lumenis, Yokne’am, Israel) was launched in 2017 to reduce stone retropulsion and increase the efficiency in treatment of stones. This technology uses pulse modulation to maximize the photothermal effect that breaks down the stone, while minimizing the photomechanical effect that pushes the stone away. The first part of the pulse modulation (initiation sequence) creates an air bubble. The second pulse modulation (target sequence) passes through that bubble and pushes the energy towards the target and not back to the fiber. In this way, less energy is lost and energy transmission is optimized per working distance from stone, andwell as soft tissue. 25,26 MOSES 2.0 was optimized for soft tissue and specifically for BPH, by maximizing the photomechanical effect without increasing the photothermal charring effect. In a study comparing HoLEP using non-MOSES laser with MOSES 2.0, enucleation time was reduced by 43% in the MOSES 2.0 group, hemostasis time was decreased by 50%, and fiber degradation was decreased by 79%. 27 All of these advantages of MOSES 2.0 laser may help facilitate HoLEP for larger prostates by allowing for shorter operative times, allow expanded usage of HoLEP in anti-coagulated patients due to better hemostasis, and subsequently facilitate same-day discharge. Thulium fiber laser Tm-Fiber laser is a laser with custom wavelengths of 1800 to 2050nm, a frequency that can range to 2000Hz, delivered via relatively small-diameter laser fibers and unique characteristics which make it ideal for soft tissue applications as well as lithotripsy. Compared 9 HoLEP: the new gold standard for surgical treatment of benign prostatic hyperplasia References 1. Wei JT, Calhoun E, Jacobsen SJ. Urologic diseases in America project: benign prostatic hyperplasia. J Urol 2005;173(4): 1256-1261. 2. Egan KB. The epidemiology of benign prostatic hyperplasia associated with lower urinary tract symptoms: prevalence and incident rates. Urol Clin North Am 2016;43(3):289-297. 3. Gravas S, Cornu JN, Gacci M et al. EAU guidelines on management of non-neurogenic male LUTS, 2021 update. Presented at the EAU Annual Congress Milan 2021. to Ho:YAG laser, the depth of penetration in tissue is much lower (0.077 mm) but the energy absorption is much higher, which enables the laser to operate at lower energy and achieve the same results. 28-30 The reduction of penetrance length adds precision to tissue cutting without adding carbonization, and makes this laser an ideal candidate for soft tissue applications such as laser enucleation of the prostate. In a prospective trial comparing this modality with TURP, enucleation with thulium laser was shown to have good functional outcomes with a comparatively larger decrease in PSA, suggestive of a more complete removal of the adenoma. 31 Further studies about soft tissue applications and specifically laser enucleation of the prostate are currently being conducted. Conclusions HoLEP is a proven modality for the surgical treatment of BPH, with a growing body of evidence in the literature citing its safety, and efficiency in all prostate sizes. HoLEP can be performed on patients with higher bleeding risk, or after previous prostate reducing procedures. According to the recent AUA guidelines, HoLEP is the only procedure that should be offered to patients with all prostate sizes for surgical treatment of BPH. HoLEP is as effective as other procedures like TURP and OP, with fewer complications, shorter catheterization times, and shorter hospital stays. Penetrance of the procedure has been limited due to high initial cost, and a relatively steep learning curve, especially for larger prostates. Recent advancements in laser technology have further increased the efficiency of the procedure. Given all of these considerations, HoLEP has become the procedure of choice, and the gold-standard for the surgical treatment of BPH.