Predictors of early catheter replacement after HoLEP. Results from a high-volume laser center.

INTRODUCTION: The aim of the study was to investigate clinical and surgical factors associated with early catheter replacement in patients treated with Holmium Laser Enucleation of the Prostate (HoLEP). MATERIALS AND METHODS: Data of patients treated with HoLEP at our Institution by a single surgeon from March 2017 to January 2021 were collected. Preoperative variables, including non-invasive uroflowmetry and abdominal ultrasonography (US), were recorded. Bladder wall modifications (BWM) at preoperative US were defined as the presence of single or multiple bladder diverticula or bladder wall thickening 5 mm. Clinical symptoms were assessed using validated questionnaires. Only events occurred within the first week after catheter removal were considered. RESULTS: Overall, 305 patients were included, of which 46 (15.1%) experienced early catheter replacement. Maintenance of anticoagulants/antiplatelets (AC/AP) therapy at surgery (p=0.001), indwelling urinary catheter (p=0.02) and the presence of BWM (p=0.001) were more frequently reported in patients needing postoperative re-catheterization. Intraoperative complications (p=0.02) and median lasing time (p=0.02) were significantly higher in this group. At univariate analysis, indwelling urinary catheter (p=0.02), BWM (p=0.01), ongoing AC/AP therapy (p=0.01) and intraoperative complications (p=0.01) were significantly associated with early catheter replacement. At multivariate analysis, indwelling urinary catheter (OR: 1.28; p=0.02), BWM (OR: 2.87; p=0.001), and AC/AP therapy (OR: 2.21; p=0.01) were confirmed as independent predictors of catheter replacement. CONCLUSIONS: In our experience the presence of indwelling urinary catheter before surgery, BWM and the maintenance of AC/AP therapy were shown to be independent predictors of early catheter replacement after HoLEP.

Transurethral resection versus holmium laser enucleation of the prostate: A prospective randomized trial comparing perioperative thrombin generation and fibrinolysis.

OBJECTIVES: The purpose of this study was to compare transurethral resection of the prostate (TURP) versus holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH) focusing on perioperative thrombin generation and fibrinolysis. METHODS: Sixty-five BPH patients were prospectively randomly assigned to undergo TURP (n = 32) or HoLEP (n = 33). The prothrombin fragment (PF) 1+2, thrombin-antithrombin complex (TAT), tissue plasminogen activator (t-PA), and plasminogen activator inhibitor-1 (PAI-1) were measured preoperatively, at the 1st day and 3rd day after surgery. RESULTS: PF1+2, TAT, t-PA, and PAI-1 significantly elevated at day 1 and day 3 after surgery (P < .05) and remarkedly decreased from the 1st day to the 3rd day (P < .05). The levels of PF1+2 and TAT were higher in TURP group postoperatively than that in HoLEP group (P < .05). There is no significant difference between 2 groups in regard of t-PA and PAI-1 (P > .05). CONCLUSION: The activation of thrombin generation and fibrinolysis system were noticed in BPH patients after TURP or HoLEP. TURP may associate with a higher hypercoagulable thrombotic risk than HoLEP.

Monopolar Transurethral Enucleo-Resection of the Prostate Versus Holmium Laser Enucleation of the Prostate: A Canadian Novel Experience.

OBJECTIVE: To study the functional outcome of patients undergoing transurethral enucleation and resection of the prostate (TUERP) vs patients undergoing holmium laser enucleation of the prostate (HoLEP) in men with bladder outlet obstruction. MATERIALS AND METHODS: We retrospectively analyzed our prospectively collected database of two groups of patients. Twenty-four patients underwent TUERP (group 1), and 27 underwent HoLEP (group 2). Preoperative characteristics, intervention parameters, postoperative functional outcomes, uroflowmetry, and complications were collected. RESULTS: Mean prostate size in groups 1 and 2 were 87.2 and 93.5 cc, respectively. The mean duration of surgery was 110 minutes in group 1 and 136 minutes in group 2. In group 1, prostate-specific antigen (PSA) dropped from 4.4 to 1.2 ng/cc after 12 months. International Prostate Symptom Score (IPSS) was 3.75 at 12 months with a preoperative value of 20.9. With respect to maximum urinary flow rate (Qmax), it increased to 21.8 mL/s from a preoperative value of 6.4 mL/s. In group 2, the PSA dropped from 7.6 to 1.3 ng/cc. IPSS dropped from 22.3 to 3.8, Qmax increased from 7.7 to 22.5 mL/s. Hemoglobin, complications, and all studied parameters were not statistically significant between both groups. CONCLUSION: In this study, TUERP was safe and efficacious in benign prostatic hyperplasia patients with large glands. Modifications can be implemented on the standard transurethral resection of the prostate technique to treat patients with prostate sizes >70 cc.

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.

Comparison of Photoselective Vaporization versus Holmium Laser Enucleation for Treatment of Benign Prostate Hyperplasia in a Small Prostate Volume.

OBJECTIVE: Photoselective vaporization of the prostate (PVP) using GreenLight and Holmium laser enucleation of the prostate (HoLEP) is an important surgical technique for management of benign prostate hyperplasia (BPH). We aimed to compare the effectiveness and safety of PVP using a 120 W GreenLight laser with HoLEP in a small prostate volume. METHODS: Patients who underwent PVP or HoLEP surgery for BPH at our institutions were reviewed from May 2009 to December 2014 in this retrospective study. Among them, patients with prostate volumes < 40 mL based on preoperative trans-rectal ultrasonography were included in this study. Peri-operative and post-operative parameters-such as International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax), post-void residual urine volume (PVR), and complications-were compared between the groups. RESULTS: PVP was performed in 176 patients and HoLEP in162 patients. Preoperative demographic data were similar in both groups, with the exception of PVR. Operative time and catheter duration did not show significant difference. Significant improvements compared to preoperative values were verified at the postoperative evaluation in both groups in terms of IPSS, QoL, Qmax, and PVR. Comparison of the postoperative parameters between the PVP and HoLEP groups demonstrated no significant difference, with the exception of IPSS voiding subscore at 1 month postoperatively (5.9 vs. 3.8, P< 0.001). There was no significant difference in postoperative complications between the two groups. CONCLUSION: Our data suggest that PVP and HoLEP are efficient and safe surgical treatment options for patients with small prostate volume.

Reoperation After Holmium Laser Enucleation of the Prostate for Management of Benign Prostatic Hyperplasia: Assessment of Risk Factors with Time to Event Analysis.

PURPOSE: To determine risk factors of reoperation after holmium laser enucleation of the prostate (HoLEP) for management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) with time to event analysis. METHODS: A prospectively maintained database was reviewed for patients undergoing HoLEP. Baseline and follow-up data were compared in terms of International Prostate Symptoms Score, quality of life, peak flow rate, residual urine, and prostate-specific antigen (PSA) at 1, 6, and 12-months and then annually. Perioperative and late adverse events were recorded. Reoperation was defined as the need for any surgical intervention to relieve bothersome LUTS after HoLEP. Multivariate logistic regression was used to determine covariates associated with reoperation and the Kaplan-Meier curve assessed the time to reoperation. RESULTS: A total of 1216 HoLEP procedures were performed between March 1998 and October 2013 with a mean prostate volume of 94.8 ± 52.7 cc. Catheter time and hospital stay were 1.4 ± 1.9 and 1.3 ± 1.6 days, respectively. After a median follow-up of 7.6 years (1-14 years), 52 (4.3%) patients needed reoperation for recurrent LUTS, including 13 (1.07%) for residual/recurrent adenoma, 14 (1.15%) for bladder neck contracture (BNC), and 25 (2.05%) for de novo urethral stricture. In multivariate regression, smaller prostate size (< 62 cc), PSA reduction < 50%, and history of previous prostate surgery were significantly associated with recurrence of adenoma. BNC was significantly associated with smaller glands (< 54 cc) while longer operative time and postoperative catheterization were significantly associated with urethral stricture. Kaplan-Meier curve demonstrates post-HoLEP freedom from reoperation of 96.9% at 5 years and 95.1% at 10 years. CONCLUSIONS: In a single center large series, HoLEP has 95% reoperation-free probability at 10 years. Relatively small-size prostate may have an impact on recurrence of adenoma and bladder neck contracture. PSA reduction < 50% was significantly associated with recurrence of adenoma while longer operative time and postoperative catheterization were significantly associated with postoperative urethral stricture.

Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction.

OBJECTIVE: To assess whether the penile cuff non-invasive urodynamic test serves as an effective diagnostic tool for predicting outcomes prior to disobstructive surgery for men presenting with voiding lower urinary tract symptoms. Patients with proven urodynamic obstruction do better after surgery. The current gold standard, invasive pressure-flow studies, imposes cost, resource demand, discomfort and inconvenience to patients. PATIENTS AND METHODS: Patients undergoing surgery for prostatic obstruction at Palmerston North Hospital had pre-operative non-invasive urodynamics and completed an International Prostate Symptom Score (IPSS). Catheterised patients were excluded. Two months post-operatively they completed a further IPSS score. An improvement of seven or greater was defined as a clinically successful outcome. Results were compared with the outcome predicted by the nomogram supplied with the urodynamic device. RESULTS: Data was obtained for 62 patients with mean age 70 years (range 49 to 86 years; SD 9 years). Follow-up was complete for all patients. Thirty-eight patients underwent transurethral resection and 24 holmium laser enucleation of the prostate. Mean IPSS score was 21 (range 5 to 35; SD 6) pre-operatively and 11 (range 1 to 31; SD 9) post-operatively. Thirty-five patients were predicted obstructed and 27 not obstructed. 94% of those predicted obstructed had a successful outcome (p < 0.01). 70% predicted as not obstructed did not have a successful outcome after surgery (p < 0.01). CONCLUSION: The penile cuff test is an exciting adjunct in the decision to proceed to surgery for prostatic obstruction. Patients predicted to be obstructed have an excellent likelihood of a good surgical outcome, yet 30% of those shown not to be obstructed will still do well. Whilst numbers in our study are small, outcomes compare favourably with published results on invasive urodynamic methods.

Evaluation of S-values and dose distributions for (90)Y, (131)I, (166)Ho, and (188)Re in seven lobes of the rat liver.

PURPOSE: Rats have been widely used in radionuclide therapy research for the treatment of hepatocellular carcinoma (HCC). This has created the need to assess rat liver absorbed radiation dose. In most dose estimation studies, the rat liver is considered as a homogeneous integrated target organ with a tissue composition assumed to be similar to that of human liver tissue. However, the rat liver is composed of several lobes having different anatomical and chemical characteristics. To assess the overall impact on rat liver dose calculation, the authors use a new voxel-based rat model with identified suborgan regions of the liver. METHODS: The liver in the original cryosectional color images was manually segmented into seven individual lobes and subsequently integrated into a voxel-based computational rat model. Photon and electron particle transport was simulated using the MCNPX Monte Carlo code to calculate absorbed fractions and S-values for (90)Y, (131)I, (166)Ho, and (188)Re for the seven liver lobes. The effect of chemical composition on organ-specific absorbed dose was investigated by changing the chemical composition of the voxel filling liver material. Radionuclide-specific absorbed doses at the voxel level were further assessed for a small spherical hepatic tumor. RESULTS: The self-absorbed dose for different liver lobes varied depending on their respective masses. A maximum difference of 3.5% was observed for the liver self-absorbed fraction between rat and human tissues for photon energies below 100 keV. (166)Ho and (188)Re produce a uniformly distributed high dose in the tumor and relatively low absorbed dose for surrounding tissues. CONCLUSIONS: The authors evaluated rat liver radiation doses from various radionuclides used in HCC treatments using a realistic computational rat model. This work contributes to a better understanding of all aspects influencing radiation transport in organ-specific radiation dose evaluation for preclinical therapy studies, from tissue composition to organ morphology and activity distribution.

Holmium laser treatment for low grade, low stage, noninvasive bladder cancer with local anesthesia and early instillation of mitomycin C.

PURPOSE: We evaluated the results of laser photocoagulation of recurrent low stage noninvasive bladder cancer. MATERIALS AND METHODS: The study included 36 patients with a recurrent superficial papillary tumor within 1 year of endoscopic resection. Patients underwent laser photocoagulation of the recurrence under local anesthesia and sedation. They received early instillation of 40 mg mitomycin C and were discharged home without a catheter a few hours after the operation. Patients completed a visual analog scale to quantify the perceived level of pain, including 1--no pain to 10--maximum pain. Patients were reviewed after 3, 6 and 12 months to evaluate tumor recurrence. RESULTS: The mean and median visual analog scale score was 3 points (range 1 to 10). No patient had urinary infection or a catheter at hospital discharge. The incidence of recurrence at 12 months was 25%, mainly in the first 15 cases. CONCLUSIONS: Laser photocoagulation with local anesthesia and sedation is easy to perform and well tolerated. There were no complications and the recurrence rate was similar to that of transurethral resection, as calculated using the recurrence calculator of the 2006 guidelines on TaT1 (nonmuscle invasive) bladder cancer from the European Association of Urology.

A randomised trial comparing holmium laser enucleation versus transurethral resection in the treatment of prostates larger than 40 grams: results at 2 years.

OBJECTIVE: To compare holmium laser enucleation of the prostate (HoLEP) with transurethral resection of the prostate (TURP) for treatment of men with bladder outflow obstruction (BOO) secondary to benign prostatic hyperplasia with a minimum of 24-month follow-up. PATIENTS AND METHODS: Sixty-one patients were randomised to either HoLEP or TURP. All patients had BOO proven on urodynamic studies pre-operatively (prostate size 40-200 g). One patient died before treatment, which left 30 patients in each group. Perioperative data, as well as symptom scores, Quality of Life (QoL) scores, and maximum urinary flow rates (Qmax) were obtained at one, three, six,12, and 24 months. Post-void residual volumes, transrectal ultrasound (TRUS) volumes, and pressure flow studies were obtained six months post-operatively. Continence and potency data were also recorded. RESULTS: There were no significant differences between the two surgical groups pre-operatively. Mean pre-operative TRUS volume was 77.8+/-5.6 g (42-152) in the HoLEP group and 70.0+/-5.0 g (46-156) in the TURP group. Patients in the HoLEP group had shorter catheter times and hospital stays. More prostate tissue was retrieved in the HoLEP group. At six months, HoLEP was urodynamically superior to TURP in relieving BOO. At 24 months, there was no significant difference between the two surgical groups with respect to American Urology Association scores, QoL scores, or Qmax values; however, two patients in the TURP group required re-operation. CONCLUSIONS: HoLEP has less perioperative morbidity and produces superior urodynamic outcomes than TURP, when treating prostates >40 g. At 24 months of follow-up, HoLEP is equivalent to TURP.

Holmium laser resection of the prostate versus transurethral resection of the prostate: results of a randomized trial with 4-year minimum long-term followup.

PURPOSE: It has previously been shown that holmium laser resection of the prostate (HoLRP) is superior to transurethral resection of the prostate (TURP) with regard to perioperative morbidity and is equivalent to TURP in the short term. We present the long-term results of a randomized, prospective trial comparing HoLRP to TURP since information regarding the durability of holmium prostatectomy is lacking in the literature to date. MATERIALS AND METHODS: A total of 120 patients with urodynamic obstruction were randomized (April 1996 to August 1997) into 2 comparable groups and assigned to HoLRP or TURP. All patients were assessed preoperatively and followed prospectively at 3 weeks, 3, 6, 12, 24 and 48 months postoperatively with an American Urological Association symptom score, quality of life score, peak urinary flow rate, and questionnaires concerning sexual function and continence. Preoperative pressure flow studies, ultrasound prostatic volume assessment and post-void residual volume measurement were repeated at the 6-month visit. All adverse events were noted. RESULTS: Of 120 patients 73 completed the 48-month assessment. HoLRP and TURP resulted in significant improvements in all parameters. There was no difference between the 2 techniques in terms of urodynamic parameters, potency, continence and symptom scores at the 48-month assessment. HoLRP took significantly longer to perform but perioperative morbidity, catheter time, nursing contact time and hospital stay were significantly less for HoLRP compared to TURP. CONCLUSIONS: HoLRP and TURP give equivalent and satisfactory long-term results, with no differences noted in major morbidity. This confirms the durability of these 2 treatments. Peri-operative morbidity is less with HoLRP.

Does perioperative outcome of transurethral holmium laser enucleation of the prostate depend on prostate size?

BACKGROUND AND PURPOSE: In conventional transurethral resection of the prostate (TURP), perioperative morbidity resulting from causes such as blood loss and TUR syndrome increases with prostate size. Therefore, TURP is restricted to small and medium-sized glands. The present study aimed to find out whether perioperative parameters of holmium laser enucleation of the prostate (HoLEP) other than operation time and weight of resected tissue were dependent on prostate size. PATIENTS AND METHODS: A total of 384 patients were treated with HoLEP (holmium:YAG laser, 2.0 J, 40 or 50 Hz, 80 or 100 W, 550-nm bare fiber) for acute removal of obstructing benign hyperplastic tissue. Among them, 111 patients (28.9%) had prostates of <40 g (group 1), 152 (39.6%) had prostates of 40 to 79 g (group 2), and 121 (31.5%) had prostates of >/=80 g (range 80-260) (group 3). The perioperative outcomes of the three groups were compared. A total of 346 patients completed the 1-month postoperative assessment. RESULTS: The mean prostate sizes were 31.8 g, 56 g, and 98.7 g for groups 1, 2, and 3 (P<0.0001 group 1 v group 2 v group 3). The mean resected tissue weight was 19.5 g v 34.4 g (P= 0.009) v 70.1 g (range 50-220) (P< 0.0001). The mean operation time was 64.3 v 84.2 (P= 0.009) v 118.4 minutes (P< 0.0001). The mean hemoglobin loss was 0.9 v 1.2 (NS) v 1.9 g/dL (P< 0.001). The overall correlation between hemoglobin loss and prostate size in all patients was very weak (r = 0.229) and just exceeded the level of significance (r = 0.2). In all three groups, the median postoperative catheter time was 1 day, and the median postoperative hospital stay was 2 days. The HoLEP resulted in an immediate and significant improvement of American Urological Association Symptom Scores, peak urinary flow rates, and postvoiding residual urine volumes (P< 0.0001) 1 month after the operation, without significant differences between the groups. The rate of complications was similar in all three groups. None of the patients needed blood transfusions. There were no perioperative deaths. CONCLUSION: In HoLEP, perioperative morbidity and postoperative micturition improvement do not depend on prostate size. Therefore, in contrast to TURP, HoLEP is equally suitable for small, medium-size, and large prostate glands.

Transurethral holmium laser enucleation of the prostate compared with transvesical open prostatectomy: 18-month follow-up of a randomized trial.

PURPOSE: This ongoing randomized study aims to find out whether transurethral holmium laser enucleation of the prostate (HoLEP) could be an alternative to open transvesical prostatectomy in patients with prostates >100 g. PATIENTS AND METHODS: A series of 120 urodynamically obstructed patients were randomized to HoLEP or open prostatectomy, 60 patients to each group. The HoLEP was performed with high-powered Ho:YAG lasers at 80 to 100 W (2.0 J, 40-50 Hz) and 550-nm bare laser fibers. The American Urological Association Symptom Scores, peak urinary flow rates, and postvoiding residual urine volumes were evaluated preoperatively and at 1, 3, 6, 12, and 18 months postoperatively. All complications were noted. RESULTS: By the Mann-Whitney test, there was no significant difference between the HoLEP and open surgery groups in patient age (69.0 years HoLEP v 71.0 years open surgery), prostate volume (115 cc [range 100-230 cc] v 113 cc [100-230 cc], or weight of resected tissue (94 g [range 57-220 g] v 96 g [range 61-220 g]). There were significant differences in the mean operative time (136 v 91 minutes; P< 0.0001), mean hemoglobin loss (1.9 v 2.8 g/dL; P< 0.0001), median catheter time (1 day v 6 days; P< 0.0001), and median hospital stay (2 days v 10 days; P< 0.0001). Both HoLEP and open prostatectomy resulted in pronounced and lasting postoperative improvements in Symptom Scores, peak urinary flow rates, and postvoiding residual volumes (P< 0.0001). The differences between HoLEP and open prostatectomy were not significant at any interval for any parameter. Blood transfusions were required in 0 HoLEP patients v 8 open surgery patients. Arterial bleeding occurred in three patients in each group. Secondary apical resection was required in two HoLEP patients and no open surgery patients. Bladder neck contracture occurred in none of the HoLEP patients and two of those having open surgery. Thus, the total number of patients having complications was 7 with HoLEP and 13 with open surgery. There were no deaths in either group. CONCLUSIONS: The HoLEP appears to be an endourologic alternative to open surgical enucleation of the prostate for large glands. It entails significantly less blood loss and a much shorter catheter time and hospital stay. The perioperative outcome strongly favors the holmium procedure. The rate of late complications is equally low with each procedure. The postoperative micturition improvement was significant and lasting and was equivalent in the two groups.