4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 7 HoLEP: the new gold standard for surgical treatment of benign prostatic hyperplasia of BPH and LUTS with age, less invasive treatments have become increasingly desirable. 7 In the 1990’s with advancements in laser technology, Holmium:YAGwas introduced in the application of BPH treatment, first for ablation and soon after for complete enucleation. With the development of morcellation devices, the procedure matured to what we call today holmium laser enucleation of the prostate (HoLEP). 8 What is a gold standard? A gold standard is the criteria by which scientific evidence (such as a procedure) is evaluated. This standard, necessarily, changes over time, as new treatments are developed andmore evidence becomes available. In defining the gold standard surgical treatment for BPH, many factors should be considered. First, prostate sizes and shapes vary significantly and may or may not have a prominent median lobe or intravesical component, thus a treatment considered the gold standard should be efficacious in treating a wide range of prostate sizes and shapes. Morbidity risk should also be considered. Surgical intervention for BPH is often done on an elective, quality of life basis; as such, treatments should demonstrate acceptably low rates of adverse quality of life impacts from treatment. Additionally, and perhapsmost importantly, functional outcome should be demonstrated via both objectively measured data and subjectively from patient reported symptomatic relief and improvement in quality of life. It should be taken into account the risk for/need for additional interventions or therapy in the planning of any surgical treatment for BPH. Lastly, cost must be considered, and the resultant economic burden on the healthcare system and on the patient himself. Comparison of historical standards Open prostatectomy (OP) This procedure, although the most invasive, has a high rate of symptomatic improvement and a low rate of treatment failure; however, it also carries considerable risk of surgical complications and cost. 9-11 The advantages of OP are its durability, efficiency (volume of the resected adenoma and resultant decrease in serum PSA), and the ability to detect incidental prostate cancer. Some of the disadvantages of OP are the relatively high risk of transfusion (reported at 7.5%), prolonged postoperative catheterization, hospitalization, and continence recovery. Further, it involves a lower abdominal incision and the subsequent recovery time. 11 Lin et al 12 conducted a systematic reviewandmetanalysis of nine randomized control trials including 758 patients comparing TURP with OP. Functional outcomes including maximum urinary flow rate, postvoid residual volume, PSAand IPSS scores were similar between the two groups. Operative time favored OP, while blood loss, catheter period, irrigation length and hospital stay favored transurethral enucleation. As for robotic “simple” prostatectomy – the considerations are similar, but the robotic procedure had less blood loss along with a high cost of disposables, similar to reported data for other robotic associated procedures. 13 TURP Historically, it took almost a century for the surgical paradigm to shift from OP to TURP. The eventual change was not dictated by better clinical outcomes, but rather based on convenience to the surgeon and the patient, therapeutic burden and economic considerations. 14 TURP has been shown to be an efficient and safe procedure, but has its limitations for patients at increased bleeding risk and in those with large prostates. Because of these limitations, other minimally invasive procedures were introduced in the early 1990’s with the purpose to transition the procedure from the operating room to the office, which would reduce cost, free up hospital beds, and allow for the management of high risk surgical patients not candidates for more invasive procedures. A large systematic review and meta- analysis covering 26 randomized controlled trials and 3,283 patients provided analysis of the efficacy and safety of TURP with transurethral enucleation of the prostate. 15 TURP had a shorter operative time, and functional outcome were similar at 6 months follow up; however, at 12 months postoperatively, IPSS and Qmax were significantly higher in the enucleation group, indicating a more complete treatment. Safety profiles and hospital stay also favored transurethral enucleation. These data support the claim that HoLEP should be considered the “gold standard” for smaller prostates. HoLEP technique At our institution, HoLEP is performed using a continuous flow 26Fr resectoscope with a laser-bridge and a 550-micron end-fire laser fiber, with laser settings of 50Hz/2J for resection and 30Hz/2J for hemostasis and apical dissection (both settings are set to wide/ long pulse). The high-power holmium laser generator (120W, Lumenis, Yokne’am, Israel) uses two pedals and enables alternation between the two laser settings.