Incidence of complications and urinary incontinence following endoscopic enucleation of the prostate in men with a prostate volume of 80 ml and above: results from a multicenter, real-world experience of 2512 patients.

PURPOSE: To evaluate complications and urinary incontinence (UI) after endoscopic enucleation of the prostate (EEP) stratified by prostate volume (PV). METHODS: We retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with different energy sources in 14 centers (January 2019-January 2023). INCLUSION CRITERIA: prostate volume ≥ 80 ml. EXCLUSION CRITERIA: prostate cancer, previous prostate/urethral surgery, pelvic radiotherapy. PRIMARY OUTCOME: complication rate. SECONDARY OUTCOMES: incidence of and factors affecting postoperative UI. Patients were divided into 3 groups. Group 1: PV = 80-100 ml; Group 2 PV = 101-200 ml; Group 3 PV > 200 ml. Multivariable logistic regression analysis was performed to evaluate independent predictors of overall incontinence. RESULTS: There were 486 patients in Group 1, 1830 in Group 2, and 196 in Group 3. The most commonly used energy was high-power Holmium laser followed by Thulium fiber laser in all groups. Enucleation, morcellation, and total surgical time were significantly longer in Group 2. There was no significant difference in overall 30-day complications and readmission rates. Incontinence incidence was similar (12.1% in Group 1 vs. 13.2% in Group 2 vs. 11.7% in Group 3, p = 0.72). The rate of stress and mixed incontinence was higher in Group 1. Multivariable regression analysis showed that age (OR 1.019 95% CI 1.003-1.035) was the only factor significantly associated with higher odds of incontinence. CONCLUSIONS: PV has no influence on complication and UI rates following EEP. Age is risk factor of postoperative UI.

Results from a global multicenter registry of 6193 patients to refine endoscopic anatomical enucleation of the prostate (REAP) by evaluating trends and outcomes and nuances of prostate enucleation in a real-world setting.

PURPOSE: To collect a multicentric, global database to assess current preferences and outcomes for endoscopic enucleation of the prostate (EEP). METHODS: Endourologists experienced in EEP from across the globe were invited to participate in the creation of this retrospective registry. Surgical procedures were performed between January 2020 and August 2022. INCLUSION CRITERIA: lower urinary tract symptoms not responding to or worsening despite medical therapy and absolute indication for surgery. EXCLUSION CRITERIA: prostate cancer, concomitant lower urinary tract surgery, previous prostate/urethral surgery, pelvic radiotherapy. RESULTS: Ten centers from 7 countries, involving 13 surgeons enrolled 6193 patients. Median age was 68 [62-74] years. 2326 (37.8%) patients had large prostates (> 80 cc). The most popular energy modality was the Holmium laser. The most common technique used for enucleation was the 2-lobe (48.8%). 86.2% of the procedures were performed under spinal anesthesia. Median operation time was 67 [50-95] minutes. Median postoperative catheter time was 2 [1, 3] days. Urinary tract infections were the most reported complications (4.7%) followed by acute urinary retention (4.1%). Post-operative bleeding needing additional intervention was reported in 0.9% of cases. 3 and 12-month follow-up visits showed improvement in symptoms and micturition parameters. Only 8 patients (1.4%) required redo surgery for residual adenoma. Stress urinary incontinence was reported in 53.9% of patients and after 3 months was found to persist in 16.2% of the cohort. CONCLUSION: Our database contributes real-world data to support EEP as a truly well-established global, safe minimally invasive intervention and provides insights for further research.

Correlation Between Transurethral Interventions and Their Influence on Type and Duration of Postoperative Urinary Incontinence: Results from a Systematic Review and Meta-Analysis of Comparative Studies.

Objective: To perform a systematic review to assess the incidence of transient (<6 months) and persistent (>6 months) stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence (MUI) after transurethral surgeries for benign prostatic hyperplasia. Materials and Methods: A systematic literature search was performed using Embase, PubMed, and Web of Science. We included studies comparing monopolar (M)/bipolar (B) transurethral resection of the prostate (TURP) vs ablation vs enucleation procedures. Incidence of incontinence was assessed using Cochran-Mantel-Haenszel Method and reported as odds ratio (OR), 95% confidence interval (CI), and p-values. Statistical significance was set at p < 0.05 Evidence Synthesis: Twenty-eight studies were included. Incidence of transient SUI was 4.6%, 6.0%, 3.0%, and 2.4% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent SUI was 1.1% after ablation, 1.7% after enucleation and M-TURP, and 1.0% after B-TURP. Incidence of transient UUI was 2.0%, 7.3%, 4.4%, and 2.8% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent UUI was 2.2% after M-TURP. The incidence of transient MUI was 5.1%, 0.8%, 5.4%, and 0.9% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent MUI was 3.1% after ablation and 4.8% after M-TURP. Incidence of transient and persistent SUI and UUI did not differ after TURP vs enucleation. Incidence of transient (OR 3.32, 95% CI 0.41-26.65, p = 0.26) and persistent SUI (OR 4.79, 95% CI 0.52-43.89, p = 0.17) was not significantly higher after ablation. Incidence of transient UUI was not significantly higher after ablation (OR 2.62, 95% CI 0.04-166.01, p = 0.65), whereas persistent UUI did not differ. Incidence of transient MUI was significantly higher after enucleation (OR 3.26, 95% CI 1.51-7.05, p = 0.003). Incidence of transient and persistent MUI did not differ after TURP vs ablation. Conclusions: Ablation, enucleation, and TURP have an impact on all forms of incontinence, but this is transient in most cases with no difference between the groups, except for MUI, which was higher after enucleation vs M-TURP.

The constant search for the greater good: evolving from TURP to anatomic enucleation of the prostate is a safe bet.

PURPOSE: In a troubling moment in history with an ongoing world pandemic and the impending economic crises, there is today a plethora of commercially available options for the minimally invasive treatment of BPH. New industry-driven evaluation criteria of these treatments, the logical marketing hype, a short follow-up for many of them, make challenging to interpret the role they will finally adopt in the armamentarium to treat BPH. METHOD: The author comments on recently published literature based in own experience and insight. RESULTS AND CONCLUSIONS: In this situation, choosing to evolve from TURP to the next step of endoscopic treatment, the size-independent anatomic endoscopic enucleation of the prostate is a safe bet. It is now exceedingly feasible when the paradigm of AEEP has changed, due to better learning opportunities and technological and surgical technique modifications that have refined this procedure significantly since its inception.

En-bloc endoscopic enucleation of the prostate: a systematic review of the literature.

INTRODUCTION: Transurethral resection of the prostate (TURP) remains the gold standard for treatment of benign prostatic hyperplasia (BPH). Yet, the introduction of lasers for the treatment of LUTS due to BPO has dramatically changed the surgical landscape of benign prostatic obstruction (BPO) treatment. Recently, "en-bloc" techniques have shown to prove advantageous in terms of better visualization, more prompt identification of the surgical capsule and the correct plane to dissect. Herein we provide a comprehensive overview of available series of en-bloc enucleation of the prostate, focusing on surgical techniques, perioperative and functional outcomes. EVIDENCE ACQUISITION: A systematic review of the literature was performed according to PRISMA recommendations and was conducted on surgical techniques and perioperative outcomes of minimally invasive en-bloc surgery for prostate adenoma detachment. EVIDENCE SYNTHESIS: Overall, 16 studies with 2750 patients between 2003 and 2019 were included. Specific technical nuances have been described to maximize perioperative outcomes of en-bloc prostatic enucleation, including early apical release, horse-shape incisions, inverted U-shape tractions and low power. Overall, regardless of the energy employed, en-bloc prostatic enucleation achieved favorable outcomes including low risk of major complications and quality of life improvement. However, a great heterogeneity of study design, patients' inclusion criteria, prostate volume and en-bloc surgical strategy was found. CONCLUSIONS: En-bloc endoscopic enucleation of the prostate has been shown to be technically feasible and safe, with potential technical advantages over the classic three-lobe technique. Larger comparative studies are needed to evaluate the ultimate impact of the en-bloc approach on postoperative outcomes, in light of the surgeon's learning curve.

Aquablation of the prostate: single-center results of a non-selected, consecutive patient cohort.

PURPOSE: Aquablation of the prostate using the AquaBeam™ system promises equivalent functional outcomes, reduced learning curve, and improved sexual function compared to transurethral prostate resection as shown in prospective randomized trials. This prospective cohort study aims to evaluate if published results can be transferred into the clinical routine in a non-selected patient collective. METHODS: This study includes all patients treated between September 2017 and June 2018 with Aquablation of the prostate. Patients have been evaluated prospectively for the perioperative course and early follow-up. Besides voiding parameter and symptom score, TRUS-volume change, ejaculatory function, and adverse events have been recorded. RESULTS: 118 consecutive patients have been treated in the given time. Aquablation could be carried out successfully in all patients. IPSS, QoL, Qmax, and PVR improved significantly after the procedure and continued to improve during 3-month follow-up. Mean OR time was 20 min, TRUS volume decreased by 65%, and 73% of the patients retained antegrade ejaculation. Thirteen adverse events (> Clavien-Dindo I) occurred in 10 patients. CONCLUSION: The surgical ablation of the prostate using Aquablation achieved significant and immediate improvement of functional voiding parameters Qmax and PVR as well as symptomatic improvement of IPSS and QoL. Aquablation seems to be safe and effective with a low perioperative complication profile even in a non-selected group of patients.

From "gold standard" resection to reproducible "future standard" endoscopic enucleation of the prostate: what we know about anatomical enucleation.

BACKGROUND: Open prostatectomy (OP) and transurethral resection of the prostate (TURP) have traditionally been the most common surgical approaches for the treatment of benign prostatic hyperplasia causing bladder outlet obstruction and have certainly passed the test of time. In time, many endoscopic surgical procedures have been described as an alternative mini-invasive treatment. Holmium laser enucleation (HoLEP) guaranteed functional outcomes similar to OP and TURP with lower perioperative complication rates for any prostate size. With the development of different kinds of lasers (such as thulium, "green light" and diode) and bipolar energy, the feasibility of endoscopic enucleation using these energies has been explored. EVIDENCE ACQUISITION: In this paper, recent techniques to perform true prostate enucleation have been reviewed through a search of PubMed and Web of Science, including articles published in the last 20 years in clinical journals. The review is based on a peer-review process of the authors after a structured data search. Search terms included "Thulium prostate enucleation, THULEP, TmLEP/Tm Yag enucleation" OR "Greenlight enucleation/prostate enucleation/vapo-enucleation/KTP prostate enucleation, PVP prostate enucleation, GreenLep/" OR "bipolar prostate enucleation" OR "HoLEP, Holmium prostate enucleation" OR "monopolar prostate enucleation" OR "Diode prostate enucleation" OR "DiLEP" OR "Eraser prostate enucleation" OR "ELEP". EVIDENCE SYNTHESIS: Following the example of HoLEP, many techniques have been described in the literature using a variety of energy sources and instruments either in a pure enucleative or a hybrid (mixed) fashion. However, the levels of evidence are too low and follow-up still too short to offer solid recommendations. CONCLUSIONS: HoLEP has become the conceptual and practical paradigm for the wide spread of enucleation thanks to the evidence provided by the literature and excellent outcomes. Higher level of evidence is required to assess efficacy of alternative enucleative techniques.

Comparison of GreenLight laser and transurethral resection of the prostate baseline characteristics and outcomes: lessons learned from the Clinical Research Office of the Endourological Society GreenLight Laser Study.

BACKGROUND: To compare baseline characteristics and outcomes of patients undergoing GreenLight laser vaporization (GL) or transurethral resection of the prostate (TURP) in a real life setting. METHODS: In this prospective observational cohort, the Clinical Research Office of the Endourological Society (CROES) collected data of consecutive GL or TURP treated patients. Treatment involved one of three GL laser powers (80 W, 120 W or 180 W) based on availability in each participating centre, or TURP. Data on baseline characteristics as well as functional measures were collected at three time points: 6-12 weeks, 6, and 12months after surgery. Functional measures included urinary flow parameters, perceived prostate function (IPSS), perceived erectile function (IIEF-5) and complications. RESULTS: Seven hundred thirteen patients underwent GL, and 234 patients underwent TURP. Overall, patients treated with GL show higher BMI, IIEF and medication use, together with lower urinary function (voided volume, incontinence, urinary retention) at baseline. After the procedure, despite higher antibiotic and antimuscarinic use and shorter hospital stay, readmission rates, PVR, PSA were higher, but Qmax, and IIEF were lower in the GL group. The rate of post-operative complications was 10.3% and 5.2% for the TURP and GL group, respectively (P=0.006). CONCLUSIONS: We were unable to categorically state which procedure is superior. This observational study confirms that treatment decision for either TURP or GL is not based on patient characteristics.

Learning curves and perioperative outcomes after endoscopic enucleation of the prostate: a comparison between GreenLight 532-nm and holmium lasers.

PURPOSE: To compare the learning curves, perioperative and early functional outcomes after HoLEP and GreenLEP. METHODS: Data from the first 100 consecutive cases treated by GreenLEP and HoLEP by two surgeons were prospectively collected from dedicated databases and analysed retrospectively. En-bloc GreenLEP and two-lobar HoLEP enucleations were conducted using the GreenLight HPS™ 2090 laser and Lumenis™ holmium laser. Patients' characteristics, perioperative outcomes and functional outcomes after 1, 3 and 6 months were compared between groups. RESULTS: Total energy delivered and operative times were significantly shorter for GreenLEP (58 vs. 110 kJ, p < 0.0001; 60 vs. 90 min, p < 0.0001). Operative time reached a plateau after 30 procedures in each group. Length of catheterization and hospital stay were significantly shorter in the HoLEP group (2 vs. 1 day, p < 0.0001; 2 vs. 1 day, p < 0.0001). Postoperative complications were comparable between GreenLEP and HoLEP (19 vs. 25 %; p = 0.13). There was a greater increase of Q max at 3 months and a greater IPSS decrease at 1 month for GreenLEP, whereas decreases in IPSS and IPSS-Q8 at 6 months were greater for HoLEP. Transient stress urinary incontinence was comparable between both groups (6 vs. 9 % at 3 months; p = 0.42). Pentafecta was achieved in four consecutive patients after the 18th and the 40th procedure in the GreenLEP and HoLEP group, respectively. Learning curves ranged from 14 to 30 cases for GreenLEP and 22 to 40 cases for HoLEP. CONCLUSION: Learning curves of GreenLEP and HoLEP provided roughly similar peri-operative and short-term functional outcomes.

GreenLight laser vaporization of the prostate: has it come of age?

PURPOSE OF REVIEW: To determine that GreenLight laser therapy is now an established treatment option for men with lower urinary tract symptoms (LUTS) associated with benign prostatic enlargement (BPE). RECENT FINDINGS: The three generations of the GreenLight laser, 80, 120 and 180 W, have been studied for efficacy and safety in the treatment of men with LUTS associated with BPE. Studies have also been conducted that compare outcome with transurethral resection of the prostate, historically considered the gold-standard treatment for this patient group. SUMMARY: GreenLight is an established therapeutic option for LUTS associated with BPE. It can be used safely and effectively in men on anticoagulants, in retention and with prostates of size greater than 80 ml. The safety and efficacy of this treatment are comparable to transurethral resection of the prostate.