Morcellation After Endoscopic Enucleation of the Prostate: Efficiency and Safety of Currently Available Devices.

CONTEXT: Although several studies have compared different morcellators and enucleation techniques for the management of benign prostatic hyperplasia (BPH), there is sparse literature on morcellation, so further experimental and clinical research is required for its optimization. OBJECTIVE: To critically appraise the contemporary literature on prostate morcellation and to evaluate the safety and efficiency of currently available morcellators for endoscopic enucleation of the prostate (EEP) in the context of BPH. EVIDENCE ACQUISITION: A comprehensive review of the English and French literature relevant to prostate morcellation was performed using the PubMed-MEDLINE, Cochrane Library, Web of Science, and Wiley Online Library database from 1998 to 2020 using PICOS (patient population, intervention, comparison, outcome, and study design) criteria. EVIDENCE SYNTHESIS: We retrieved 26 studies involving 5652 patients treated with a morcellator that were eligible for data extraction and analysis. The mean patient age was 67.4 (range 61.4-72.8) yr. The weighted mean efficiency of Piranha, VersaCut, and DrillCut morcellators was 5.29, 3.95, and 5.3 g/min, respectively. Several approaches, such as en bloc, two-lobe, inverse, and improved techniques, may increase morcellation efficiency and safety. The lowest weighted mean rate of bladder wall injury was 1.24% for Piranha, followed by 1.98% for DrillCut, and 5.23% for VersaCut, while the VersaCut morcellator had the lowest weighted mean rate of device malfunction at 0.74%, compared to 2.07% for Piranha and 7.86% for DrillCut. CONCLUSIONS: All three morcellators are efficient and safe for prostatic morcellation after EEP. Further development of devices and techniques may improve the efficiency and safety profile of morcellation. To increase safety, surgeon expertise, technical equipment, and patient characteristics should be considered. Therefore, interdisciplinary exchange of knowledge and further technological innovations are strongly encouraged. PATIENT SUMMARY: We reviewed the safety and efficacy of devices called morcellators. These devices cut tissue into small pieces that are easier to remove from the body, and are used during laser surgery for benign enlargement of the prostate. Three morcellators are currently available on the market and are comparable in safety and efficacy.

Novel thulium fiber laser for endoscopic enucleation of the prostate: A prospective comparison with conventional transurethral resection of the prostate.

OBJECTIVE: To compare the efficacy and safety of a novel thulium fiber laser for endoscopic enucleation of the prostate with monopolar transurethral resection of the prostate in patients with smaller glands (<80 cc). METHODS: A total of 51 patients underwent thulium fiber laser enucleation of the prostate, and 52 patients underwent monopolar transurethral resection of the prostate. All patients were assessed preoperatively, and at 3, 6, and 12 months postoperatively (International Prostate Symptom Score, maximum urine flow rate, International Prostate Symptom Score-quality of life). Preoperative prostate volumes and prostate-specific antigen levels were comparable (P = 0.543 and P = 0.078, respectively). The complications were graded according to the Clavien classification. RESULTS: Mean surgery time was longer in the thulium fiber laser enucleation of the prostate group (46.6 ± 10.2 vs 39.9 ± 8.6 min, P < 0.001), while catheterization and hospital stay were greater in the transurethral resection of the prostate group (P < 0.001). At 12 months, there were no differences in functional outcomes (International Prostate Symptom Score, maximum urine flow rate). Despite comparable prostate volumes at 12 months (P = 0.864), the prostate-specific antigen level in the thulium fiber laser enucleation of the prostate group (0.5 ± 0.5 ng/mL) was lower than in the transurethral resection of the prostate group (1.1 ± 1.0 ng/mL; P < 0.001). Hemoglobin and serum sodium decrease was lower in the thulium fiber laser enucleation of the prostate group (1.01 ± 0.4 g/dL and 1.1 ± 1.1 mmol/L) than in the transurethral resection of the prostate group (1.8 ± 0.8 g/dL and 4.1 ± 1.1 mmol/L; P < 0.001). Urinary incontinence rates at 12 months were comparable (P = 0.316). CONCLUSIONS: Thulium fiber laser enucleation of the prostate with novel thulium fiber laser in patients with smaller prostate glands (<80 cc) is comparable to transurethral resection of the prostate in voiding parameters improvement and complication rates. At the same time, the technique allows for a more substantial prostate-specific antigen decrease, indicating more complete removal of adenoma.

Thulium vapoenucleation of the prostate (ThuVEP) for prostates larger than 85 ml: long-term durability of the procedure.

The purpose of this prospective study of 90 consecutive patients is to assess the long-term durability of ThuVEP in patients with benign prostatic hyperplasia (BPH) and prostate volumes ≥ 85 ml. Ninety patients with prostates ≥ 85 ml underwent ThuVEP between 2008 and 2010 at our institution. Patient demographics and short-term and long-term follow-up were evaluated. Maximum urinary flow rate (Qmax), post-void residual urine (PVR), international prostate symptom score (IPSS), quality of life (QoL), complications, and PSA were assessed at follow-up. Median age at surgery was 71 (66-75.25) years. Thirty-seven (41.1%) of the patients were in urinary retention at the time of surgery. Prostate volume was 100 (88-122) ml. Median follow-up was 36.5 (16-60) months. At 12-month follow-up, IPSS, QoL, Qmax, and PVR had improved significantly compared with preoperative assessment and continued to do so during follow-up (p < 0.001). At 4-year postoperative, median Qmax (19.1 vs. 7.75 ml/s), PVR (31.9 vs. 150 ml), IPSS (4.5 vs. 24), and QoL (1 vs. 5) differed significantly from baseline (p ≤ 0.027). PSA decreased from 7.4 (4.14-14) to 0.70 (0.36-1.64) µg/l (p < 0.001) at 48-month follow-up, corresponding to a PSA reduction of 86.48% (79.85-95.25%). Urinary tract infections occurred in 2 (2.2%) patients. Urethral stricture and bladder neck contracture developed in 1 (1.1%) patient each. One patient (1.1%) had recurrent adenoma of the prostate and was treated with thulium vaporesection of the prostate. ThuVEP is a durable modern alternative to open prostatectomy for patients with substantially enlarged prostates due to BPH. The incidence of complications with ThuVEP during long-term follow-up was low.

Perioperative Safety in Patient Under Oral Anticoagulation During Holmium Laser Enucleation of the Prostate.

INTRODUCTION AND OBJECTIVES: To evaluate the safety of holmium laser enucleation of the prostate (HoLEP) in patients on oral anticoagulation (OA) with respect to intra- and postoperative bleeding complications. METHODS: Between January 2013 and October 2016, 2178 patients were included in this study, of whom 94 received direct oral anticoagulants (DOACs) and 151 received vitamin K antagonists (VKAs) before HoLEP. All patients either ceased OA (DOACs) or were bridged subtherapeutically (VKAs, international normalized ratio <2) during surgery. These patients were compared to a sample size of 1933 nonanticoagulated patients. RESULTS: A significant longer postoperative stay was noted for the patients on DOACs (5.2 [4-6] days) and VKAs (5.3 [4-5] days) compared to the control group (4.5 [4-4] days). The mean drop in hemoglobin was significantly higher in the VKA group compared to the DOAC and control group. There was a significantly higher rate of postoperative bladder tamponades/secondary coagulation in patients on OA with 6 (7.9%)/3 (3.9%) patients in the DOAC group, 10 (7.4%)/6 (4.4%) patients in the VKA group compared to 37 (2.2%)/21 (2.1%) patients in the control group, respectively (p < 0.001). Eight patients required blood transfusions with a distribution of 1 (1.3%), 3 (2.2%), and 4 (0.2%) patients in the DOAC, VKA, and control group, respectively (p < 0.001). CONCLUSIONS: Our findings indicate that bridged patients who's DOACs and VKAs were ceased before HoLEP are at higher risk of intra- and postoperative bleeding complications. Nonetheless, HoLEP appears to be a safe and effective procedure in those patients.

A Feasibility Study Utilizing the Thulium and Holmium Laser in Patients for the Treatment of Recurrent Benign Prostatic Hyperplasia after Previous Prostatic Surgery.

BACKGROUND: Transurethral resection of the prostate (TURP) is considered to be the standard treatment for patients with benign prostatic obstruction (BPO) ≤80 mL. However, up to 14.7% of the patients require secondary TURP due to recurrent BPO. The aim of our study was to describe specific features of holmium laser enucleation of the prostate (HoLEP) and thulium laser enucleation of the prostate (ThuLEP) in patients with recurrent BPO after previous prostate surgery. MATERIALS AND METHODS: A total of 768 consecutive patients from our prospective collected database were retrospectively reviewed and divided into 4 groups: group A (489 patients) and group C (253 patients) underwent primary HoLEP and ThuLEP treatment, while group B (17 patients) and D (9 patients) included patients with recurrent BPO who were treated with HoLEP and ThuLEP, respectively. RESULTS: There were no significant differences in preoperative parameters between the groups at primary (A and C) and secondary (B and D) treatment except their age. At 6-month follow-up, voiding parameters and symptom scores showed statistically significant improvements compared to baseline without differences between the groups. The mean operative time was comparable between the groups and did not differ significantly (p > 0.05). CONCLUSIONS: Laser enucleation for the treatment of recurrent BPO is feasible and seems to be a safe and effective procedure.

Thulium laser vaporesection of the prostate: Can we operate without interrupting oral antiplatelet/anticoagulant therapy?

PURPOSE: Thulium vaporesection of the prostate (ThuVARP) is a new and safe approach for patients receiving anticoagulant therapy in whom transurethral resection of the prostate (TURP) may possess a high bleeding risk. We aimed to demonstrate the efficacy and safety of ThuVARP in patients receiving oral antiplatelet/anticoagulant (OAP/OAC) therapy. MATERIALS AND METHODS: A total of 103 patients who underwent ThuVARP between 2011 and 2013 were enrolled in the study. Patients were divided into 2 groups. Group A consisted of 47 patients who underwent low molecular weight heparin (LMWH) bridging and group B consisted of 56 patients who were operated on while receiving OAP/OAC therapy. RESULTS: The drop in hemoglobin levels in the pre- and postoperative periods was significantly higher in group A than in group B. When subgroups were analyzed, the mean drop in hemoglobin was significantly lower in the warfarin and ticlopidine subgroups of group B than in group A. International Prostate Symptom Scores were significantly lower 3, 12, 18, and 24 months after surgery in group A than in group B. Quality of life scores, maximal flow rate values, and postmicturition residual urine volumes (mL) were similar between the 2 groups. A total of 38 and 41 patients in groups A and B, respectively, had no complications. CONCLUSIONS: Our study showed the safety profile of continuing different OAP/OAC therapies in terms of bleeding problems in patients undergoing ThuVARP. We strongly recommend abandoning LMWH bridging and maintaining the OAP/OAC regimen patients are already receiving.

A Prospective Randomized Study Comparing Disposable with Reusable Blades for a Morcellator Device.

INTRODUCTION & OBJECTIVES: Transurethral enucleation of the prostate for the management of benign prostatic obstruction (BPO) involves two steps: the enucleation and morcellation procedure. The aim of our study was to assess the efficacy of a morcellator device using disposable and reusable blades with different settings of morcellation speed. METHODS: A prospective randomized study was initiated for patients with symptomatic BPO undergoing Thulium laser enucleation of the prostate. Mechanical tissue morcellation was performed using the Piranha™ morcellator (R. Wolf, Knittlingen, Germany) with disposable or reusable blades at 850 (n = 24) or 1500 revolutions per minute (rpm) (n = 24). Patient characteristics, intraoperative complications, and the morcellation rate (g/min) were recorded. Data are expressed as median and interquartile range (IQR). RESULTS: Forty-eight patients were randomized using disposable (n = 24) or reusable blades (n = 24). For reusable blades, the morcellation rate did not increase when changing the morcellation speed from 850 to 1500 rpm (5 vs 4.53 g/min, p = 0.843). The morcellation rate increased significantly when changing the morcellation speed from 850 to 1500 rpm using single-use blades (4.77 vs 10 g/min, p ≤ 0.014). The morcellation rate was not different at 850 rpm between reusable and single-use blades (5 vs 4.77 g/min, p = 0.671). Conversely, the morcellation rate was significantly different at 1500 rpm between reusable and single-use blades (4.53 vs 10 g/min, p ≤ 0.017). The total morcellation rate (at 850 and 1500 rpm) was significantly increased using single-use blades compared to reusable blades (7.67 vs 4.8 g/min, p ≤ 0.026). Interestingly, enucleated weight (g) and the morcellation rate (g/min) correlated inversely using single-use blades at 1500 rpm (r = -0.742, p ≤ 0.004). Only one superficial bladder injury occurred at 1500 rpm, which needed no further interventions. CONCLUSIONS: The Piranha morcellator facilitates efficient tissue removal with single-use and reusable blades. Disposable morcellator blades increase tissue removal significantly at 1500 rpm.

Current Management in Transurethral Therapy of Benign Prostatic Obstruction in Patients on Oral Anticoagulation: A Worldwide Questionnaire.

OBJECTIVE: To assess the current treatment of benign prostatic obstruction (BPO) in patients on ongoing oral anticoagulation (OA). METHODS: An Internet survey was sent to all active members of the Endourological Society. The survey contained 32 questions regarding transurethral treatment of BPO in patients on ongoing OA, different techniques, and arising complications. RESULTS: Out of all members (n = 2000) of the Endourological Society, 133 participated in our survey. Eighty-eight percent of the participants indicated to perform transurethral therapy of BPO on ongoing OA, whereas 60% of this group temporarily pause the OA during the intervention. Sixteen percent perform >30 transurethral interventions of BPO on ongoing OA per year. Most operations are performed under continuation of aspirin (58.2%). The continuation of adenosine diphosphate (ADP)-receptor inhibitors (22.1%), vitamin K antagonists (18.9%), factor Xa inhibitors (15.6%), or the combination of two oral anticoagulants (16.4%) is continued less often. The decision for the operation on ongoing OA is usually approved by the cardiologist (58%) or it cannot be stopped in case of emergency (29%). GreenLight laser (39%) was the most frequently used technique on ongoing OA, followed by monopolar or bipolar transurethral resection of the prostate (35%) as well as other sources of laser [holmium (12%), thulium (12%), diode laser (2%)]. Although OA was continued during the interventions, cardiovascular complications were observed in 31.6%. CONCLUSIONS: Current practice shows that the majority of a representative group of the Endourological Society members perform transurethral therapy of BPO in patients on ongoing OA. The incidence of perioperative complications under transurethral therapy of BPO on ongoing OA is lower than previously assumed.

[Current Practice in the Transurethral Treatment of Benign Prostatic Obstruction under Oral Anticoagulants : A Nation-wide Survey]. / Aktuelle Behandlungsstrategien in der transurethralen Therapie des benignen Prostatasyndroms unter oraler Antikoagulation : Eine bundesweite Umfrage.

BACKROUND: Only few studies have assessed the safety and efficacy of transurethral surgery (TS) for the treatment of benign prostatic obstruction (BPO) in patients on oral anticoagulants. The aim of our study was to evaluate current treatment strategies and complication rates of TS for the treatment of BPO in patients on OA using an online survey. MATERIALS AND METHODS: A total of 300 German departments of urology received an e­mail with a link for the online survey. The items of the questionnaire assessed the present practice of TS for BPO in patients on OA and the occurrence of complications. RESULTS: Seventy-five (23.4 %) departments responded to the online questionnaire. Of the respondents, 94.7 % performed TS in patients with BPO on OA and 42.7 % answered that they perform more than 30 prostate surgeries per year under OA. The respondents indicated that surgeries were carried out under aspirin (96 %), clopidogrel (46.7 %) or phenprocoumon (26.7 %). Indications for surgeries under OA were made by cardiologist recommendation (82.7 %), the surgeon (37.3 %), a need for emergency surgery (52 %), or the patient's will (10.7 %). Sixty-two (82.7 %) of the respondents perform bipolar or monopolar transurethral resection of the prostate (TUR-P) in patients on OA. In addition, 69.3 % of the respondents indicated that they use laser prostatectomy in patients on OA (thulium 24 %, Greenlight 24 %, holmium 16 %, and diode laser 5.3 %). Cardiovascular complications occurred in 12 % of the respondents. CONCLUSIONS: Despite the poor evidence for performing TS of BPO under OA, our survey showed surprising results: TS of BPO under OA is frequently performed, especially bipolar and monopolar TUR-P. Although our data were obtained using an online survey, the complication rates appear to be lower than previously thought.

Transurethral anatomical enucleation of the prostate with Tm:YAG support (ThuLEP): review of the literature on a novel surgical approach in the management of benign prostatic enlargement.

PURPOSE: Retrograde transurethral anatomical enucleation of the prostate is gaining momentum as a new concept in transurethral surgery of benign prostatic hyperplasia. Its adaptation is boosted by the familiarity of urologists with the finger-assisted anatomical enucleation of the adenoma during open prostatectomy and the combination of this well-established concept with the minimal invasive characteristics of transurethral surgery. The thulium laser appears as an ideal energy source for such operation. In this work, current evidence on thulium laser-assisted anatomical enucleation of the prostate (ThuLEP) is being reviewed. MATERIALS AND METHODS: A comprehensive literature review was performed on Medline, PubMed, and Cochrane databases retrieving all literature on thulium laser-assisted prostatectomy between 2006 and 2015. Experimental studies, review articles and editorial comments as well as studies on thulium laser-assisted approaches other than ThuLEP (i.e., ThuVEP, ThuVAP or ThuVARP) were excluded from the analysis. RESULTS: In total, six original articles on either surgical technique or clinical outcomes were retrieved. With regard to functional results, ThuLEP presented no significant differences toward the standard treatment (TURP/HoLEP) arm in two randomized controlled trials and favorable outcomes in available prospective cohorts. Observed morbidity was minimum and comparable with the rest of transurethral literature. CONCLUSIONS: ThuLEP literature is still very limited. Based on the available data, the approach is safe and effective, demonstrating favorable outcomes, comparable with the current standard treatment options. Further documentation of ThuLEP outcomes is necessary to define the optimum indications of this novel technique.

Vaporization vs. enucleation techniques for BPO: do we have a standard?

PURPOSE OF REVIEW: This article discusses enucleation and vaporization procedures which have been developed on the surgical techniques of holmium laser enucleation of the prostate (HoLEP) and photoselective vaporization of the prostate (PVP) by reviewing the most recent publications. RECENT FINDINGS: Enucleation procedures have been described using holmium, thulium, diode or GreenLight lasers in addition to bipolar energy sources. Most of the current literature for these enucleation procedures consists of initial descriptions of the surgical techniques or prospective series from single centres, although the availability of prospective randomized trial for these procedures other than HoLEP is limited. PVP have been described using 80-W, 120-W, or 180-W GreenLight lasers. To date, only sparse literature is available for thulium or bipolar vaporization of the prostate. SUMMARY: A variety of alternative vaporization and enucleation procedures are available for transurethral treatment of benign prostatic obstruction. Only very few PRT have been published for these procedures limiting their evidence for the treatment of benign prostatic obstruction. To date, best evidence is still available for the HoLEP and PVP procedure.

Impact of thulium VapoEnucleation of the prostate on erectile function: a prospective analysis of 72 patients at 12-month follow-up.

OBJECTIVE: To evaluate changes in erectile function after thulium VapoEnucleation of the prostate (ThuVEP) for the treatment of benign prostatic obstruction at 12-month follow-up. MATERIALS AND METHODS: We prospectively evaluated 72 patients who underwent ThuVEP between January and July 2011. Preoperative evaluation included maximum urinary flow rate (Qmax), international prostate symptom score (IPSS), quality of life (QoL), postvoiding residual urine (PVR), and the Erectile function domain of the International Index of Erectile Function (IIEF-EF). According to preoperative IIEF-EF score, patients were classified into subgroup A (IIEF-EF ≥19, n = 38) and subgroup B (IIEF-EF <19, n = 34). All complications during the perioperative period were noted and classified according to the modified Clavien classification system. All patients were reassessed at 12-month follow-up by Qmax, IPSS, QoL, PVR, and IIEF-EF score. Patient data were expressed as median (interquartile range). RESULTS: Median patient age was 70 (65-73) years, and the median prostate volume was 52.5 (39.75-72) mL, respectively. At 12-month follow-up, IPSS (20 vs 4), QoL (4 vs 1), Qmax (9.7 vs 22.15 mL/s), and PVR (100 vs 15 mL) improved significantly in comparison with preoperative assessment (P ≤.001) without differences between subgroup A and B. A slight but not statistically significant increase of the IIEF-EF domain score was reported at 12-month follow-up (19.5 vs 20), which could be shown in subgroup A (25 vs 26) and B (6 vs 8). CONCLUSION: ThuVEP is a safe and effective procedure for the treatment of benign prostatic obstruction. At 12-month follow-up, marginal nonsignificant erectile function improvement was reported after surgery.

Development of bladder outlet obstruction after a single treatment of prostate cancer with high-intensity focused ultrasound: experience with 226 patients.

PURPOSE: To investigate the occurrence of bladder outlet obstruction (BOO) after high-intensity focused ultrasound (HIFU) therapy of prostate cancer, the need for secondary transurethral interventions for BOO, and the benefit of transurethral resection of the prostate (TURP) before HIFU. PATIENTS AND METHODS: After a single HIFU treatment between 2002 and 2007, 226 consecutive patients were examined and followed at least 2 years. The Ablatherm Maxis and the Integrated Imaging devices were used. The sites of BOO were recorded. RESULTS: Median follow-up after HIFU was 52 months (range 24-80 mos). BOO developed in 58 (25.66%) patients. Repeated BOO episodes were observed in 27 (11.94%), three to seven episodes in 13 (5.75%) patients. Patients with repeated BOO were older than patients with singular BOO (71.75 ± 4.97 vs 68.18 ± 5.03; P = 0.024). In primary BOO, multiple sites of obstruction were more often involved than in repeated BOO (25/58 vs 8/27). Conversely, isolated bladder neck stenosis was predominantly found in patients with ≥two episodes of BOO. The rate of primary BOO was significantly different between patients who had undergone TURP the same day as HIFU or within 2 days of HIFU (33/96; 34.38%) and patients with TURP more than 1 month (16/89; 17.98%) before HIFU (P = 0.032). BOO occurred in 21.95% (9/41) of the patients who were treated with HIFU only. CONCLUSIONS: BOO after HIFU is common, particularly affecting the bladder neck. The risk of repeated BOO is associated with age. A longer interval between TURP and HIFU (>1 month) might reduce the risk for the development of BOO.

Thulium:YAG laser enucleation (VapoEnucleation) of the prostate: safety and durability during intermediate-term follow-up.

PURPOSE: Thulium:YAG (Tm:YAG) VapoEnucleation has been introduced and relief of obstruction was demonstrated. The aim of this study was to proof durability of the outcomes in patients with an postoperative follow-up >12 month. METHODS: VapoEnucleation was performed using a 70 Watt continuous-wave-laser. After enucleation tissue was morcellated within the bladder. Patients were followed in terms of improvement of uroflow, intra- and postoperative course and for occurring complications. RESULTS: 88 consecutive patients with prostatic enlargement underwent our initial series of VapoEnucleation. Prostatic volume was 61.3 +/- 24.0 cc (30-160). OR-time was 72 min +/-26.6 (35-144) and laser-time 32.4 +/- 10.1 min (16.3-59.3). Applied laser energy was 123.7 +/- 40.6 kJ (67.8-240.9). Foley catheter-time was 2.1 +/- 1.06 days on average. In 79/88 patients the postoperative period extended 12 month (mean: 16.5 month). 2 patients deceased during the follow-up, 15 patients did not respond. Therefore, 62/77 patients were available for follow-up. Flow-rate and post-voiding residual urine improved significantly [3.5 vs. 23.3 ml/s (p < 0.001); 121.3 vs. 33.4 ml (p < 0.05)]. IPSS decreased from 18.4 to 6.8, QoL dropped from 4.6 to 1.4. Early complications were urinary tract infection (n: 6/6.8%), bleeding (n: 5/5.6%) and immediate re-treatment (n: 2/2.2%), as well as urethral stricture (n: 1/1.6%) during follow-up. Postoperative short-term dysuria was recorded in 27% of the patients. CONCLUSION: VapoEnucleation is a safe and effective minimal invasive treatment modality for BPO. The improvement in voiding and bother is durable in patients with a postoperative period extending 12 month.