Early Surgical Intervention is Beneficial in Avoiding Complications in Patients with Male Lower Urinary Tract Symptoms.

In 2018, owing to the variety of true minimally invasive and effective treatment modalities available, early surgery in patients suffering from lower urinary tract symptoms due to benign prostatic enlargement is a valid, safe, and effective option compared to long-term less effective medical treatment.

"Finding the needle in a haystack": oncologic evaluation of patients treated for LUTS with holmium laser enucleation of the prostate (HoLEP) versus transurethral resection of the prostate (TURP).

PURPOSE: To evaluate oncologic parameters of men with bothersome LUTS undergoing surgical treatment with HoLEP or TURP. METHODS: Five hundred and eighteen patients undergoing HoLEP (n = 289) or TURP (n = 229) were retrospectively analyzed for total PSA, prostate volume, PSA density, history of prostate biopsy, resected prostate weight, and histopathological features. Univariate and multivariate logistic regression models were used to identify independent predictors of incidental PCa (iPCa). RESULTS: Men undergoing HoLEP had a significantly higher total PSA (median 5.5 vs. 2.3 ng/mL) and prostate volume (median 80 vs. 41 cc), and displayed a greater reduction of prostate volume after surgery compared to TURP patients (median 71 vs. 50%; all p < 0.001). With a prevalence of incidental PCa (iPCa) of 15 and 17% for HoLEP and TURP, respectively, the choice of procedure had no influence on the detection of iPCa (p = 0.593). However, a higher rate of false-negative preoperative prostate biopsies was noted among iPCa patients in the HoLEP arm (40 vs. 8%, p = 0.007). In multivariate logistic regression, we identified patient age (OR 1.04; 95% CI 1.01-1.07, p = 0.013) and PSA density (OR 2.13; 95% CI 1.09-4.18, p = 0.028) as independent predictors for the detection of iPCa. CONCLUSIONS: Despite differences in oncologic parameters, the choice of technique had no influence on the detection of iPCa. Increased patient age and higher PSA density were associated with iPCa. A higher rate of false-negative preoperative prostate biopsies was noted in HoLEP patients. Therefore, diagnostic assessment of LUTS patients requires a more adapted approach to exclude malignancy, especially in those with larger prostates.

Long-term follow-up data more than 5 years after surgical management of benign prostate obstruction: who stands the test of time?

PURPOSE OF REVIEW: Surgical techniques are an integral part of the urologist's armamentarium for the treatment of benign prostatic obstruction. Currently, several techniques are available. The purpose of the current review is to analyse the long-term outcomes of currently available techniques. RECENT FINDINGS: Open prostatectomy shows a low long-term reoperation rate. Available evidence suggests that bipolar transurethral resection of the prostate (TURP) is an attractive alternative to monopolar TURP as both techniques lead to a long-lasting and comparable efficacy. For patients with a larger prostate volume, bipolar enucleation of the prostate appears as safe and effective alternative to open prostatectomy. Holmium laser enucleation of the prostate appears as a durable alternative to TURP and open prostatectomy with comparable long-term results. For photoselective vaporization of the prostate, differently powered models are available. Currently, only long-term data with lower powered 80 W laser are available, reporting reoperation rates higher than those reported from other surgical techniques. On the thulium laser, currently only one study reported 5-year results and despite encouraging results further confirmation seems necessary. SUMMARY: Various surgical methods have proven to be safe and effective for the treatment of benign prostate obstruction and stand the test of time. The choice of the technique depends on prostate size, risk factors of the patient as well as expertise of the surgeon.

A Multicenter Randomized Noninferiority Trial Comparing GreenLight-XPS Laser Vaporization of the Prostate and Transurethral Resection of the Prostate for the Treatment of Benign Prostatic Obstruction: Two-yr Outcomes of the GOLIATH Study.

BACKGROUND: The GOLIATH study is a 2-yr trial comparing transurethral resection of prostate (TURP) to photoselective vaporization with the GreenLight XPS Laser System (GL-XPS) for the treatment of benign prostatic obstruction (BPO). Noninferiority of GL-XPS to TURP was demonstrated based on a 6-mo follow-up from the study. OBJECTIVE: To determine whether treatment effects observed at 6 mo between GL-XPS and TURP was maintained at the 2-yr follow-up. DESIGN, SETTING, AND PARTICIPANTS: Prospective randomized controlled trial at 29 centers in nine European countries involving 281 patients with BPO. INTERVENTION: Photoselective vaporization using the 180-W GreenLight GL-XPS or conventional (monopolar or bipolar) TURP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was the International Prostate Symptom Score for which a margin of three was used to evaluate the noninferiority of GL-XPS. Secondary outcomes included Qmax, prostate volume, prostate specific antigen, Overactive Bladder Questionnaire Short Form, International Consultation on Incontinence Questionnaire Short Form, occurrence of surgical retreatment, and freedom from complications. RESULTS AND LIMITATIONS: One hundred and thirty-six patients were treated using GL-XPS and 133 using TURP. Noninferiority of GL-XPS on International Prostate Symptom Score, Qmax, and freedom from complications was demonstrated at 6-mo and was sustained at 2-yr. The proportion of patients complication-free through 24-mo was 83.6% GL-XPS versus 78.9% TURP. Reductions in prostate volume and prostate specific antigen were similar in both arms and sustained over the course of the trial. Compared with the 1(st) yr of the study, very few adverse events or retreatments were reported in either arm. Treatment differences in the Overactive Bladder Questionnaire Short Form observed at 12-mo were not statistically significant at 24-mo. A limitation was that patients and treating physicians were not blinded to the therapy. CONCLUSIONS: Twenty-four-mo follow-up data demonstrated that GL-XPS provides a durable surgical option for the treatment of BPO that exhibits efficacy and safety outcomes similar to TURP. PATIENT SUMMARY: The long-term effectiveness and safety of GLP-XLS was similar to conventional TURP for the treatment of prostate enlargement.

The Continuing Story of the Cost-Effectiveness of Photoselective Vaporization of the Prostate versus Transuretheral Resection of the Prostate for the Treatment of Symptomatic Benign Prostatic Obstruction.

BACKGROUND: In 2008, a UK assessment of technologies for benign prostatic obstruction concluded negatively about photoselective vaporization of the prostate (PVP), and the 2010 National Institute for Health and Care Excellence guidance caused several UK institutions to abandon PVP. OBJECTIVE: To reassess the costs and effects of PVP versus transurethral resection of the prostate (TURP) on the basis of most recent data. METHODS: The same model was used as in 2008. Transition probabilities were estimated using a Bayesian approach updating the 2008 estimates with data from two meta-analyses and data from GOLIATH, the latest and largest trial comparing PVP with TURP. Utility estimates were from the 2008 assessment, and estimates of resource utilization and costs were updated. Effectiveness was measured in quality-adjusted life-years gained, and costs are in UK pounds. The balance between costs and effects was addressed by multivariate sensitivity analysis. RESULTS: If the 2010 National Institute for Health and Care Excellence analysis would have updated the cost-effectiveness analysis with figures from its own meta-analysis, it would have estimated the change in quality-adjusted life-years at -0.01 (95% confidence interval [CI] -0.05 to 0.01) instead of at -0.11 (95% CI -0.31 to -0.01) as in the 2008 analysis. The GOLIATH estimate of -0.01 (95% CI -0.07 to 0.02) strengthens the conclusion of near equivalence. Estimates of additional costs vary from £491 (£21-£1286) in 2008 to £111 (-£315 to £595) for 2010 and to £109 (-£204 to £504) for GOLIATH. PVP becomes cost saving if more than 32% can be carried out as a day case in the United Kingdom. CONCLUSIONS: The available evidence indicates that PVP can be a cost-effective alternative for TURP in a potentially broad group of patients.

The 80-W KTP GreenLight laser vaporization of the prostate versus transurethral resection of the prostate (TURP): adjusted analysis of 5-year results of a prospective non-randomized bi-center study.

This study aims to compare long-term results of photoselective vaporization of the prostate (PVP) with an 80-W potassium titanyl phosphate (KTP) laser and monopolar transurethral resection of the prostate (TURP) in terms of efficacy, durability, and safety in an adjusted patient population. This prospective, non-randomized bi-center study included 120 (PVP) and 68 (TURP) patients in each arm. Patients were evaluated at 60 months of follow-up. Data from 30 (PVP) and 31 (TURP) patients were available for analysis. The primary outcome measurement was the International Prostate Symptom Score (IPSS) at 5 years. Secondary outcome measurements included voiding symptoms (quality of life (QoL) score), micturition parameters (maximal flow rate, Q max), post-void residual (PVR) volume, prostate-specific antigen (PSA) value, and reoperation rate. At study inclusion, voiding symptoms and micturition parameters were comparable between both groups. Age, prostate volume, and the proportion of patients with platelet aggregation inhibition or oral anticoagulation were significantly higher in the PVP group. No significant difference could be detected between patients available at 60 months and those lost to follow-up in terms of preoperative characteristics in either group. Sixty months postoperatively, the improvement of IPSS, QoL, Q max, and PVR volume showed no significant difference between both groups. PSA reduction was significantly higher after TURP. The reoperation rate due to urethral stricture (PVP, 13 %; TURP, none), bladder neck contracture (PVP, 3 %; TURP, none), and persisting or recurrent adenoma (PVP, 18 %; TURP, 3 %) was significantly higher after the 80-W PVP. Eighty-watt PVP leads to comparable functional outcomes to TURP. However, during a long-term follow-up, significantly more reoperations are necessary after PVP with the 80-W KTP laser, suggesting inferior tissue ablation capacity of the 80-W KTP laser.

GreenLight laser vs diode laser vaporization of the prostate: 3-year results of a prospective nonrandomized study.

BACKGROUND AND OBJECTIVE: Laser vaporization of the prostate is one of the alternatives to transurethral resection of the prostate. Short-term studies report a comparable outcome after laser vaporization with the 532 nm 120-W GreenLight high-performance system (HPS) laser and the 980 nm 200 W high-intensity diode (diode) laser. In this study, we analyzed the intermediate-term results of both techniques. MATERIALS AND METHODS: From January 2007 to January 2008, 112 consecutive patients with symptomatic benign prostate enlargement were nonrandomly assigned to treatment with the GreenLight laser or the diode laser. Perioperative parameters, postoperative functional outcome, complications, and the reoperation rate at 3 years were analyzed. RESULTS: Improvement of voiding symptoms (International Prostate Symptom Score, quality-of-life) and micturition parameters (maximum flow rate, postvoid residual volume) showed no significant difference between the HPS group and the diode group. A significantly higher reoperation rate was observed in the diode group in comparison to the HPS group (37.5% vs 8.9%, p=0.0003) due to obstructive necrotic tissue (16.1% vs 0%, p=0.0018), bladder neck stricture (16.1% vs 1.8%, p=0.008), and persisting or recurrent adenoma (5.4% vs 7.1%, p=0.70), respectively. CONCLUSIONS: Both lasers lead to comparable improvement of voiding parameters and micturition symptoms. Treatment with the 200 W diode laser led to a significantly higher reoperation rate, which might be attributed to a higher degree of coagulation necrosis. Thus, a careful clinical application of this diode laser type is warranted.

A European multicenter randomized noninferiority trial comparing 180 W GreenLight XPS laser vaporization and transurethral resection of the prostate for the treatment of benign prostatic obstruction: 12-month results of the GOLIATH study.

PURPOSE: We present the 1-year results of the GOLIATH prospective randomized controlled trial comparing transurethral resection of the prostate to GreenLight XPS for the treatment of men with nonneurogenic lower urinary tract symptoms due to prostate enlargement. The updated results at 1 year show that transurethral resection of the prostate and GreenLight XPS remain equivalent, and confirm the therapeutic durability of both procedures. We also report 1-year followup data from several functional questionnaires (OABq-SF, ICIQ-SF and IIEF-5) and objective assessments. MATERIALS AND METHODS: A total of 291 patients were enrolled at 29 sites in 9 European countries. Patients were randomized 1:1 to undergo GreenLight XPS or transurethral resection of the prostate. The trial was designed to evaluate the hypothesis that GreenLight XPS is noninferior to transurethral resection of the prostate on the International Prostate Symptom Score at 6 months. Several objective parameters were assessed, including maximum urinary flow rate, post-void residual urine volume, prostate volume and prostate specific antigen, in addition to functional questionnaires and adverse events at each followup. RESULTS: Of the 291 enrolled patients 281 were randomized and 269 received treatment. Noninferiority of GreenLight XPS was maintained at 12 months. Maximum urinary flow rate, post-void residual urine volume, prostate volume and prostate specific antigen were not statistically different between the treatment arms at 12 months. The complication-free rate at 1 year was 84.6% after GreenLight XPS vs 80.5% after transurethral resection of the prostate. At 12 months 4 patients treated with GreenLight XPS and 4 who underwent transurethral resection of the prostate had unresolved urinary incontinence. CONCLUSIONS: Followup at 1 year demonstrated that photoselective vaporization of the prostate produced efficacy outcomes similar to those of transurethral resection of the prostate. The complication-free rates and overall reintervention rates were comparable between the treatment groups.

Anesthesia-free procedures for benign prostate obstruction: worth it?

PURPOSE OF REVIEW: Perhaps, 30% of patients with benign prostate obstruction experience no symptom relief with drug therapy, necessitating surgical intervention. General anesthesia can be too dangerous for elderly or frail men, making local anesthesia desirable. Such minimally invasive procedures may offer time-saving, effective, gentle, and well tolerated alternatives. RECENT FINDINGS: Recent interest has focused on the mechanical devices and intraprostatic injections. The commercially available UroLift system demonstrates promising short-term data in randomized multicenter trials. Rezum steam injection therapy is intriguing, although currently study-based with limited data. NX1207 and PRX302 are new intraprostatic injection drugs demonstrating interesting results in phase I and II studies, whereas conflicting results surround the prostatic injection of botulinum toxin A. For transurethral microwave therapy, definitive evaluations regarding the treatment of chronic urinary retention in nonsurgical patients are ongoing. SUMMARY: Although none of these minimally invasive procedures must be performed under general anesthesia, all require local anesthesia with possible sedation. In most studies, pain therapy management is rudimentary or not described. Although good short-term results are described, no long-term data are available.

A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update.

CONTEXT: A number of transurethral ablative techniques based on the use of innovative medical devices have been introduced in the recent past for the surgical treatment of benign prostatic obstruction (BPO). OBJECTIVE: To conduct a systematic review of the literature and a meta-analysis of available randomized controlled trials (RCTs), and to evaluate the efficacy and safety of transurethral ablative procedures for BPO. EVIDENCE ACQUISITION: A systematic literature search was performed for all RCTs comparing any transurethral surgical technique for BPO to another between 1992 and 2013. Efficacy was evaluated after a minimum follow-up of 1 yr based on International Prostate Symptom Score, maximum flow rate, and postvoid residual volume. Efficacy at midterm follow-up, prostate volume, perioperative data, and short-term and long-term complications were also assessed. Data were analyzed using RevMan software. EVIDENCE SYNTHESIS: A total of 69 RCTs (8517 enrolled patients) were included. No significant difference was found in terms of short-term efficacy between bipolar transurethral resection of the prostate (B-TURP) and monopolar transurethral resection of the prostate (M-TURP). However, B-TURP was associated with a lower rate of perioperative complications. Better short-term efficacy outcomes, fewer immediate complications, and a shorter hospital stay were found after holmium laser enucleation of the prostate (HoLEP) compared with M-TURP. Compared with M-TURP, GreenLight photoselective vaporization of the prostate (PVP) was associated with a shorter hospital stay and fewer complications but no different short-term efficacy outcomes. CONCLUSIONS: This meta-analysis shows that HoLEP is associated with more favorable outcomes than M-TURP in published RCTs. B-TURP and PVP have resulted in better perioperative outcomes without significant differences regarding efficacy parameters after short-term follow-up compared with M-TURP. Further studies are needed to provide long-term comparative data and head-to head comparisons of emerging techniques. PATIENT SUMMARY: Bipolar transurethral resection of the prostate, photovaporization of the prostate, and holmium laser enucleation of the prostate have shown efficacy outcomes comparable with conventional techniques yet reduce the complication rate. The respective role of these new options in the surgical armamentarium needs to be refined to propose tailored surgical treatment for benign prostatic obstruction relief.

Seven hours to adequate antimicrobial therapy in urosepsis using isothermal microcalorimetry.

Urosepsis can progress toward severe sepsis, septic shock, and, ultimately, death. Rapid antimicrobial susceptibility testing is crucial to decrease mortality and morbidity. This report shows that isothermal microcalorimetry can provide an antibiogram within 7 h with a sensitivity of 95% and specificity of 91% using Vitek-2 system as a reference.

Expert opinion 2011 on the use of new anti-resorptive agents in the prevention of skeletal-related events in metastatic bone disease.

Bisphosphonates have been a mainstay in the treatment of cancer-related bone disease and have greatly reduced the risk of skeletal complications. More recently, clinical studies suggested additional benefits of denosumab over zoledronic acid in the prevention of skeletal related events. Similar adverse event profiles have been reported for bisphosphonates and denosumab, with infrequent occurrences of osteonecrosis of the jaw with both agents, higher incidence of renal deterioration with zoledronic acid, and higher incidence of hypocalcaemia with denosumab. Based on current evidence, the American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines do not recommend one drug class over the other in patients with metastatic bone disease. Denosumab, however, may present advantages over bisphosphonates in patients suffering from chronic renal insufficiency. Further research and growing clinical experience will refine the evidence based on which decisions in daily clinical practice can be taken.

EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction.

OBJECTIVE: To present a summary of the 2013 version of the European Association of Urology guidelines on the treatment and follow-up of male lower urinary tract symptoms (LUTS). EVIDENCE ACQUISITION: We conducted a literature search in computer databases for relevant articles published between 1966 and 31 October 2012. The Oxford classification system (2001) was used to determine the level of evidence for each article and to assign the grade of recommendation for each treatment modality. EVIDENCE SYNTHESIS: Men with mild symptoms are suitable for watchful waiting. All men with bothersome LUTS should be offered lifestyle advice prior to or concurrent with any treatment. Men with bothersome moderate-to-severe LUTS quickly benefit from α1-blockers. Men with enlarged prostates, especially those >40ml, profit from 5α-reductase inhibitors (5-ARIs) that slowly reduce LUTS and the probability of urinary retention or the need for surgery. Antimuscarinics might be considered for patients who have predominant bladder storage symptoms. The phosphodiesterase type 5 inhibitor tadalafil can quickly reduce LUTS to a similar extent as α1-blockers, and it also improves erectile dysfunction. Desmopressin can be used in men with nocturia due to nocturnal polyuria. Treatment with an α1-blocker and 5-ARI (in men with enlarged prostates) or antimuscarinics (with persistent storage symptoms) combines the positive effects of either drug class to achieve greater efficacy. Prostate surgery is indicated in men with absolute indications or drug treatment-resistant LUTS due to benign prostatic obstruction. Transurethral resection of the prostate (TURP) is the current standard operation for men with prostates 30-80ml, whereas open surgery or transurethral holmium laser enucleation is appropriate for men with prostates >80ml. Alternatives for monopolar TURP include bipolar TURP and transurethral incision of the prostate (for glands <30ml) and laser treatments. Transurethral microwave therapy and transurethral needle ablation are effective minimally invasive treatments with higher retreatment rates compared with TURP. Prostate stents are an alternative to catheterisation for men unfit for surgery. Ethanol or botulinum toxin injections into the prostate are still experimental. CONCLUSIONS: These symptom-oriented guidelines provide practical guidance for the management of men experiencing LUTS. The full version is available online (www.uroweb.org/gls/pdf/12_Male_LUTS.pdf).

The effect of increased maximum power output on perioperative and early postoperative outcome in photoselective vaporization of the prostate.

BACKGROUND AND OBJECTIVE: Preclinical studies suggest an increased vaporization rate and speed of the 532 nm 180-W XPS GreenLight laser (180-W) compared with the 120-W HPS GreenLight laser (120-W) and the 80-W PV GreenLight laser (80-W). To test the clinical relevance of this observation we analyzed intraoperative data and early postoperative results after photoselective vaporization of the prostate (PVP) with the 180-W, 120-W, and 80-W laser. STUDY DESIGN/MATERIALS AND METHODS: A retrospective pair-to-pair comparison was performed including 80 consecutive patients who underwent PVP for the treatment of benign prostate enlargement with the 180-W, 120-W, and 80-W laser. The groups matched concerning age, prostate volume, PSA-value, and preoperative catheterization. Primary study outcome measurement was PSA-value reduction at 3 months; intraoperative data, perioperative complications, and early postoperative functional course were secondary study outcome measurements. RESULTS: Energy application per case (kJ), preoperative prostate volume (kJ/ml) operating time (kJ/minute), and lasing time (kJ/minute) was significantly higher with the 180-W laser. Prevalence of impaired visibility due to bleeding was comparable between the 180-W and the 120-W laser but significantly lower with 80-W. Duration of hospitalization was shorter with the 180-W laser compared to the former laser systems. During the postoperative course of 3 months voiding parameters and micturition symptoms significantly improved in all groups, the incidence of postoperative dysuria was comparable. Postoperative PSA-value reduction was significantly higher after treatment with the 180-W laser. CONCLUSIONS: With the 180-W laser, higher energy application and higher speed of tissue vaporization leads to increased tissue vaporization compared to the former 120-W and 80-W laser systems. Clinical efficacy and perioperative safety are maintained with the higher powered laser.

Photoselective vaporisation of the prostate using 80-W and 120-W laser versus transurethral resection of the prostate for benign prostatic hyperplasia: a systematic review with meta-analysis from 2002 to 2012.

CONTEXT: Photoselective vaporisation (PVP) of the prostate is being used increasingly to treat symptomatic benign prostatic hyperplasia, due to the associated lower morbidity. Holmium laser enucleation of the prostate was considered to be the treatment with the highest evidence; however, evidence for PVP has dramatically increased recently. OBJECTIVE: To conduct a systematic review and meta-analysis of level 1 evidence studies to determine the effectiveness of PVP versus transurethral resection of the prostate (TURP) for surgical treatment of benign prostatic hyperplasia. Outcomes reviewed included perioperative data, complications, and functional outcomes. EVIDENCE ACQUISITION: Biomedical databases from 2002 to 2012 and American Urological Association and European Association of Urology conference proceedings from 2007 to 2011 were searched. Trials were included if they were randomised controlled trials, had PVP as the intervention, and TURP as control. Meta-analysis was performed using a random effects model. EVIDENCE SYNTHESIS: Nine trials were identified with 448 patients undergoing PVP (80 W in five trials and 120 W in four trials) and 441 undergoing TURP. Catheterisation time and length of stay were shorter in the PVP group by 1.91 d (95% confidence interval [CI], 1.47-2.35; p<0.00001) and 2.13 d (95% CI, 1.78-2.48; p<0.00001), respectively. Operation time was shorter in the TURP group by 19.64 min (95% CI, 9.05-30.23; p=0.0003). Blood transfusion was significantly less likely in the PVP group (risk ratio: 0.16; 95% CI, 0.05-0.53; p=0.003). There were no significant differences between PVP and TURP when comparing other complications. Regarding functional outcomes, six studies found no difference between PVP and TURP, two favoured TURP, and one favoured PVP. CONCLUSIONS: Perioperative outcomes of catheterisation time and length of hospital stay were shorter with PVP, whereas operative time was longer with PVP. Postoperative complications of blood transfusion and clot retention were significantly less likely with PVP; no difference was noted in other complications. Overall, no difference was noted in intermediate-term functional outcomes.

Laser prostatectomy of lower urinary tract symptoms due to benign prostate enlargement: a critical review of evidence.

PURPOSE OF REVIEW: Different transurethral prostatic laser systems are available. In 2011, new Oxford evidence levels (LoEs) were published with significant changes compared with the former version. They are easier to use and incorporate more clinical aspects. Randomized trials of laser systems used before 2002, except Holmium laser, were not included in this critical evidence analysis, as these techniques are not in clinical use any more. RECENT FINDINGS: Twenty-five [18 Holmium enucleation of the prostate (HoLEP) and seven photoselective vaporization of the prostate (PVP)] randomized trials covering transurethral electroresection of the prostate or HoLEP, PVP or Thulium laser enucleation were identified. According to evidence levels, there is a large gap in terms of long-term follow-up. The majority of randomised controlled trials are of low quality. Typically with HoLEP, many articles were published covering the same patient population (LoE II). Only one randomised controlled trial was published with Tm:YAG prostatectomy (LoE II) and none with diode lasers (980-1340 nm, LoE IV-V). Large cohort studies (LoE III-IV) provide additional evidence for PVP and HoLEP, typically for subgroups. SUMMARY: In 2011, higher evidence on HoLEP and PVP has been published. Evidence levels for HoLEP and PVP are comparable with meta-analysis (LoE II). However, evidence that laser prostatectomy is better than transurethral electroresection of the prostate in terms of efficacy is lacking (LoE II). All lasers are safer in terms of perioperative bleeding (LoE II).

Complications of laser prostatectomy: a review of recent data.

INTRODUCTION: Laser techniques for the treatment of bladder outlet obstruction (BOO) due to benign prostate enlargement (BPE) have emerged as an alternative to transurethral resection of the prostate (TURP) and open prostatectomy (OP). MATERIALS AND METHODS: A Medline search over the past 4 years was performed to assess the safety, intra- and postoperative morbidity of various laser techniques. RESULTS: Data on holmium laser enucleation of the prostate (HoLEP) show the highest grade of evidence with two meta-analyses available and prove the low intra- and postoperative morbidity with reproducible long-term results. Photoselective vaporization of the prostate (PVP) with the Greenlightlaser (potassium titanyl phosphate, KTP or lithium borate, LBO) is characterized by excellent haemostatic properties in patients with or without oral anticoagulation. Long-term results show a reoperation rate comparable with TURP; however, there is a lack of randomized trials. Various types of diode lasers with different wavelengths are available for laser vaporization; despite their favourable haemostatic properties, a higher invasion depth seems to result in necrosis of the tissue leading to a higher rate of reoperation. Thulium-laser resection of the prostate shows promising intra- and postoperative morbidity, but data are limited and initial results need to be confirmed in large-scale trials. CONCLUSION: In summary, HoLEP- and KTP-, or LBO-laser vaporization of the prostate are the most mature techniques of laser prostatectomy and treatment alternatives to TURP and OP, whereas the clinical value and durability of procedures with diode laser systems and the thulium laser need to be confirmed in high-quality prospective RCTs.

Plasma vaporisation of the prostate: initial clinical results.

BACKGROUND: Laser vaporisation of the prostate has had a considerable impact in recent years. In an attempt to achieve tissue vaporisation with bipolar high-frequency generators, plasma vaporisation was recently introduced. OBJECTIVE: To provide the first clinical information on bipolar plasma vaporisation of the prostate for patients with lower urinary tract symptoms (LUTS) due to bladder outlet obstruction (BOO). DESIGN, SETTING, AND PARTICIPANTS: Thirty patients were included in this prospective bicentre study. INTERVENTION: All patients underwent bipolar plasma vaporisation with a novel electrode (Olympus Winter & Ibe GmbH, Hamburg, Germany). MEASUREMENTS: International Prostate Symptom Score (IPSS), bother score, maximum flow rate (Q(max)), and postvoid residual were evaluated at baseline and at the time of discharge as well as at 1, 3, and 6 mo after the intervention. RESULTS AND LIMITATIONS: Mean preoperative prostate volume was 59±32 ml (range: 30-170), and mean operating time was 61±26 min (range: 20-140). Besides one reoperation (conventional transurethral prostatectomy) due to persistent obstruction, no major complication occurred intra- or postoperatively and no blood transfusion was required. Catheterisation time averaged 41±35 h (range: 18-192). Transient mild to moderate dysuria was noted in four patients (13%). At 1, 3, and 6 mo, Q(max) increased from 6.6±2.7 ml/s preoperative to 17.3±4.7 ml/s (p<0.01), 18.5±4.6 ml/s (p<0.01), and 18.1±5.0 ml/s (p<0.01), respectively. The IPSS decreased from 20.8±3.6 to 10.4±3.5 (p<0.01), 8.2±2.9 (p<0.01), and 8.1±3.1 (p<0.01), respectively. These data represent a small nonrandomised study cohort with limited follow-up. CONCLUSIONS: Our initial experience indicates that bipolar plasma vaporisation might be a safe and effective treatment option for patients with LUTS due to BOO. To define the potential role of this novel technique, randomised trials with longer follow-up are mandatory.