Prospective study of urinary incontinence recovery following endoscopic enucleation of the prostate.

OBJECTIVE: To investigate the clinical trajectories and identify risk factors linked to post-enucleation urinary incontinence (UI). PATIENTS AND METHODS: In this prospective study (April 2020 to March 2022) at a single institution, 316 consecutive patients receiving endoscopic enucleation due to benign prostatic enlargement were included. Patient information and perioperative details were collected. Follow-ups, from 1 to 6 months, assessed postoperative UI using International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and a four-item pad questionnaire, classified per International Continence Society definitions. Logistic regression analysed predictors at 1 week, while generalised estimating equation assessed risk factors from 1 to 3 months postoperatively. RESULTS: Patients with a median prostate volume of 57 mL underwent enucleation, with 22.5% experiencing postoperative UI at 1 week, 5.6% at 3 months, decreasing to 1.9% at 6 months. Multivariable analysis identified age (>80 years), specimen weight (>70 g), en bloc with anteroposterior dissection, and anal tone (Digital Rectal Examination Scoring System score <3) as potential factors influencing UI. Subgroup analysis revealed that specimen weight was associated with both continuous and stress UI. Anal tone was related to both other types and stress UI, while overactive bladder symptoms were associated with urge UI. CONCLUSION: In summary, our study elucidates transient risk factors contributing to temporary post-enucleation UI after prostatectomy. Informed decisions and personalised interventions can effectively alleviate concerns regarding postoperative UI.

The prospective evaluation of learning curve of bipolar anatomic endoscopic prostate enucleation (AEEP) with Herrmann's vapoenucleation probe.

PURPOSE: We aimed to evaluate the learning curve of Bipolar Endoscopic Prostate Enucleation (BIPOLEP) in benign prostate enlargement without a mentorship. METHODS: The prospective data of 55 patients underwent BIPOLEP surgery by a single surgeon during 3 years were evaluated. The demographic, peri-operative and follow-up data were recorded. Trifecta was defined as a combination of complete enucleation and morcellation within < 90 min and without any conversion to standard TURP. Pentafecta was defined as a combination of Trifecta without postoperative complications or stress urinary incontinence at 3 months. The learning curve was considered to have been overcome when the surgeon obtained Trifecta/Pentafecta in four consecutive patients. RESULTS: The mean age of the study group was 67.9 ± 6.8 years with mean prostate volume of 102.3 ± 56.4 ml. The mean operation time and enucleation time were 103.5 ± 41.1 and 65.78 ± 22.6 min, respectively. Trifecta and Pentafecta were achieved in 23rd (from 19th to 23rd) and 34th (from 30 to 34th) patients, respectively. Among the seven consecutive patients between Trifecta and Pentafecta, prostate capsule perforation was occurred during the surgery in four patients (26th, 27th and 29th patients). The mean follow-up duration was 16.7 ± 6.4 (3-24 months, range) months. Urethral stricture was observed in four (7. 2%) patients while bladder neck contracture was observed 1 (1.8%) patient. After the 3rd month, no patient reported stress incontinence. CONCLUSION: Bipolar endoscopic enucleation of prostate is a safe surgical method and has similar and/or short learning curve compared to HOLEP even without a mentorship program.

The safety and efficacy of five surgical treatments in prostate enucleation: a network meta-analysis.

PURPOSE: The aim of our study was to investigate the comparative outcomes of five different energy types on surgical efficacy and postoperative recovery in patients with benign prostate hyperplasia. METHODS: The literature was systematically reviewed on December 1st, 2023, encompassing studies retrieved from PubMed, Embase, Web of Science, and The Cochrane Library databases that incorporated clinical studies of holmium laser enucleation of the prostate (HoLEP), Thulium:YAG laser enucleation of the prostate (ThuLEP), transurethral plasmakinetic enucleation of prostate (PKEP), diode laser enucleation of the prostate (DiLEP) and thulium fiber laser enucleation of the prostate (ThuFLEP) in the treatment of prostatic hyperplasia. Two independent reviewers extracted study data and conducted quality assessments using the Cochrane Collaboration's Risk of Bias tool and Newcastle-Ottawa Scale (NOS). Network meta-analysis (NMA) was employed to indirectly analyze the outcomes of endoscopic enucleation of the prostate (EEP) techniques. RESULTS: The study included a total of 38 studies, comprising 21 non-randomized controlled trials (nRCTs) and 17 randomized controlled trials (RCTs), incorporating five distinct techniques: holmium laser, Thulium:YAG laser, bipolar plasma, diode laser and thulium fiber laser. In comparing treatment durations, ThuLEP and HoLEP had shorter overall hospital stays than PKEP, while the enucleation time of ThuLEP and HoLEP was shorter than that of ThuFLEP. Moreover, the enucleation tissue weight of both thulium fiber laser and holmium laser was heavier than bipolar plasma. However, the analysis did not reveal any statistically significant variation in complications among the various types of enucleation. In postoperative follow-up, the IPSS at 3 months post-operation was superior in the Thulium:YAG laser group compared to the holmium laser group. The thulium fiber laser technique demonstrated significant advantages over other enucleation methods in terms of QoL and PVR at 12 months after surgery. CONCLUSION: Theoretical properties may vary among different energy sources; however, there are no discernible clinical differences in operation-related parameters, postoperative complications, and postoperative follow-up. Therefore, the choice of laser does not significantly impact the outcome. However, due to the limited number of included studies, future research should focus on larger sample sizes and multicenter investigations to further validate the findings of this study.

Impact of American Society of Anesthesiologists score on postoperative holmium enucleation of the prostate outcomes and complications.

INTRODUCTIONS: The American Society of Anesthesiologists Physical Status Classification System (ASA) is a validated risk stratification method for patients undergoing surgery. There is an increased prevalence of benign prostatic hyperplasia and comorbidities in our aging population. The role of ASA related to postoperative complications in patients undergoing holmium laser enucleation of the prostate (HoLEP) has not been described. METHODS: A review of our database was performed for patients who underwent HoLEP from July 2018 to December 2020. Patients were stratified based on ASA score. Preoperative, perioperative, and complication data were analyzed using SAS analytics software. RESULTS: Of 472 patients undergoing HoLEP, 320 (67.8%) were ASA 3-4 patients. There was a statistically significant difference found in age (72.3 ± 9.8 vs. 69.1 ± 9.0 years, p < 0.001), body mass index (BMI) (29.0 ± 5.9 vs. 27.3 ± 4.2, p = 0.004), and use of antiplatelet/anticoagulant medications (14.6% vs. 2.6%, p < 0.001) in the ASA 3-4 group. There was no significant difference between prostate volume (p = 0.158) or catheter-dependent urinary retention (p = 0.376). No difference was found in enucleation time (52.76 ± 24.8 vs. 54.16 ± 23.7 min, p = 0.587), OR specimen weight (70.24 ± 58.5 vs. 81.53 ± 65.9, p = 0.094). or intraoperative complications (2.8% vs. 1.3%, p = 0.330). There were higher postoperative complications in the ASA 3-4 group (12.8% vs. 7.9%, p = 0.03), but no difference in Clavien ≥3 complications (p = 0.068). ASA 3-4 patients had similar postoperative international prostate symptom score (p = 0.159). CONCLUSION: HoLEP is feasible and effective in patients who are ASA 3-4. The high-risk cohort had an increased rate of low-grade complications. Patients with an ASA score of 3-4 should be counseled regarding a higher rate of low-grade complications.

Comparison of EEP and TURP long-term outcomes: systematic review and meta-analysis.

OBJECTIVE: To compare long-term reoperation rate and functional outcomes between EEP (endoscopic enucleation of the prostate) and TURP (transurethral resection of the prostate). EVIDENCE ACQUISITION: A systematic literature review of Medline, Scopus, and Web of Science was conducted with primary outcome assessed being reoperation rate and secondary outcomes after a long term (> 3 years) being functional outcomes or related values (prostate volume, PSA level, etc.). EVIDENCE SYNTHESIS: Five studies were found with long-term follow-up 4-7 years. EEP reoperation rate ranged from 0 to 1.27%, while from 1.7 to 17.6% for TURP. Meta-analysis showed significantly lower OR for EEP, 0.27 (95% CI 0.24-0.31), with notable homogeneity of the results, I2 = 0%. Long-term Qmax and IPSS were significantly better for EEP. Qmax pooled mean difference was 1.79 (95% CI 1.72-1.86) ml/s with a high concordance among the studies, I2 = 0%. IPSS mean difference -1.24 (95% CI - 1.28 to - 1.2) points, I2 = 57% but QoL did not differ, with mean difference being 0.01 (95% CI - 0.02 to 0.04), I2 = 0%. IIEF-5 score was also significantly better for EEP, mean difference 1.08 (95% CI 1.03-1.13), but heterogeneity was high, I2 = 70%. PSA level and prostate volume were only reported in one study and favored EEP slightly yet statistically significant. CONCLUSION: EEP had a significantly lower reoperation rate and better functional outcomes (Qmax and IPSS) at long term compared with TURP. It may also be beneficial in terms of IIEF-5, PVR, and PSA level.

Same-day discharge for endoscopic enucleation of the prostate: a systematic review and meta-analysis.

PURPOSE: To systematically review studies focused on the feasibility and outcomes of outpatient endoscopic enucleation of the prostate for benign prostatic obstruction. METHODS: A literature search was conducted through December 2022 using PubMed/Medline, Web of Science, and Embase databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. Risk of bias assessment was performed according to the Newcastle-Ottawa Scale for case control studies. RESULTS: Of 773 studies, ten were included in the systematic review (n = 1942 patients) and four in the meta-analysis (n = 1228 patients). The pooled incidence of successful same-day discharge was 84% (95% CI 0.72-0.91). Unplanned readmission was recorded in 3% (95% CI 0.02-0.06) of ambulatory cases. In the reported criteria-selected patients submitted to SDD surgery, the forest plot suggested a lower rate of postoperative readmission (OR 0.56, 95% CI 0.34-0.91, p = 0.02) and complications (OR 0.69, 95% CI 0.48-1, p < 0.05) rates compared to standard protocols. CONCLUSION: We provide the first systematic review and meta-analysis on SDD for endoscopic prostate enucleation. Despite the lack of randomized controlled trials, we confirm the feasibility and safety of the protocol with no increase in complications or readmission rate in well-selected patients.

Temperature assessment study of ex vivo holmium laser enucleation of the prostate model.

PURPOSE: There isscarce evidence to date on how temperature develops during holmium laser enucleation of the prostate (HoLEP). We aimed to determine the potential heat generation during HoLEP under ex vivo conditions. METHODS: We developed two experimental setups. Firstly, we simulated HoLEP ex vivo using narrow-neck laboratory bottles mimicking enucleation cavities and a prostate resection trainer. Seven temperature probes were placed at different locations in the experimental setup, and the heat generation was measured separately during laser application. Secondly, we simulated high-frequency current-based coagulation of the vessels using a roller probe. RESULTS: We observed that the larger the enucleated cavity, the higher the temperature rises, regardless of the irrigation flow rate. The highest temperature difference with an irrigation flow was approximately + 4.5 K for a cavity measuring 100ccm and a 300 ml/min irrigation flow rate. The higher flow rate generates faster removal of the generated heat, thus cooling down the artificial cavity. Furthermore, the temperature differences at different irrigation flow rates (except at 0 ml/min) were consistently below 5 K. Within the resection trainer, the temperature increase with and without irrigation flow was approximately 0.5 K and 3.0 K, respectively. The mean depth of necrosis (1084 ± 176 µm) achieved by the roller probe was significantly greater when using 144 W energy. CONCLUSION: Carefully adjusted irrigation and monitoring during HoLEP are crucial when evacuating the thermal energy generated during the procedure. We believe this study of ours provides evidence with the potential to facilitate clinical studies on patient safety.

[Treatment of benign prostatic hyperplasia with the use of lasers]. / Leczenie lagodnego przerostu prostaty z zastosowaniem laserów.

Lasers are becoming more and more widely used in medicine, gaining significant clinical acceptance in the treatment of diseases of the genitourinary system. The aim of this study is to present contemporary methods of treatment of Benign Prostate Hyperplasia with the use of lasers, taking into account the physical characteristics of these devices and the safety of the therapy. According to the recommendations of the European Urological Association, in the treatment of BPH, laser systems based on laser devices can be used, which are characterized by various physical properties such as wavelength, intensity, power, frequency and duration of the emitted light. An important aspect raised in the study is the safety assessment of these methods in patients using anticoagulants, which are commonly used in the treatment of cardiovascular diseases.

Systematic review of the endoscopic enucleation of the prostate learning curve.

INTRODUCTION: It has been shown that endoscopic enucleation of the prostate (EEP) allows for similar efficacy and safety, no matter what energy and type of instruments we use, but the length of learning may differ greatly. The aim of this systematic review is to verify if there is any significant difference between EEP methods in learning. EVIDENCE ACQUISITION: We performed a systematic literature search in three databases and included only the articles containing their own data on the EEP learning curve assessment during the last 10 years. The primary endpoint was to determine the necessary experience needed to achieve a plateau. The secondary endpoints were to review methods used to evaluate a learning curve. EVIDENCE SYNTHESIS: The final sample included 17 articles, containing a total of 4615 EEPs performed by 76 surgeons, the most common method was HoLEP (9/17). The majority of articles studying HoLEP report a learning curve of experience level achievement in roughly 30-40 (min 20; max 60) cases. The studies of GreenLight laser showed high heterogeneity in the results with minimum of 20 cases and maximum of 150-200 cases. TUEB required roughly 40-50 cases to reach the plateau. CONCLUSION: Although EEP is considered challenging, it shows a steep learning curve with a plateau after 30-50 cases. Proper criteria are critical for accurate assessment of the learning curve. The Trifecta and Pentafecta criteria are currently the most appropriate method to evaluate EEP learning.

Track and Teach: Identifying Key Movement Patterns in Endoscopic Transurethral Enucleation of the Prostate.

PURPOSE: We evaluated a system for noninvasive quantitative motion tracking to recognize differences in the movement pattern of experienced surgeons and beginners. Since performing endoscopic procedures requires extensive training, and tissue damage due to disruptive movements with sudden acceleration is possible, the learning curve for beginners is of clinical relevance. Steepening this curve may improve patient outcome. MATERIALS AND METHODS: We used a commercial gyroscope sensor with a wireless data link, which was attached to the resectoscope handle (RH). After recording, orientation was retrieved by application of the calculated rotation matrices to the RH vector relative to the sensor under the boundary condition of rotational movement around and quasi-constant distance to the pivot point at pelvic floor level. Data alignment, normalization, interpolation, and analysis were performed in custom software scripts. RESULTS: Experienced surgeons and beginners were recorded in n = 36 and n = 14 holmium laser enucleation of the prostate (HoLEP), respectively. Prostate size, patient age, and recorded procedure duration were comparable. Mean lever angle of the individual normalized motion patterns was considerably lower (19.28 ± 0.54° [SEM]) in the advanced than in the beginners' group (24.52 ± 1.00°; p = 0.0001). Further parameters such as velocity and motion variation demonstrated additional differences between both groups. CONCLUSIONS: We demonstrate the feasibility of motion tracking in HoLEP. Pronounced differences exist between different stages of surgeon experience with this procedure. The method can easily be adopted to aide young surgeons in resectoscope handling and identification of improvable motion patterns. Damage to the pelvic floor and surrounding tissue may thus be reduced.

Surgical training for anatomical endoscopic enucleation of the prostate.

Anatomical endoscopic enucleation of the prostate has been proposed as a potentially superior benign prostatic hyperplasia surgery than conventional transurethral resection of prostate. However, the learning curve of the procedure is steep, hence limiting its generalisability worldwide. In order to overcome the learning curve, a proper surgical training is extremely important. This review article discussed about various aspects of surgical training in anatomical endoscopic enucleation of the prostate. In summary, no matter what surgical technique or energy modality you use, the principle of anatomical enucleation should be followed. When one starts to perform prostate enucleation, a 50 to 80 g prostate appears to be the 'best case' to begin with. Mentorship is extremely important to shorten the learning curve and to prevent drastic complications from the procedure. A proficiency-based progression training programme with the use of simulation and training models should be the best way to teach and learn about prostate enucleation. Enucleation ratio efficacy is the preferred measure for assessing skill level and learning curve of prostate enucleation. Morcellation efficiency is commonly used to assess morcellation performance, but the importance of safety rather than efficiency must be emphasised.

The ex vivo and in vivo Characteristics of New DrillCutTM Prostate Morcellator after Holmium Laser Enucleation of the Prostate: A Pilot Study.

INTRODUCTION: The DrillCutTM morcellator is marketed for its fast and highly efficient removal of prostatic tissue and a higher level of patient safety. However, a paucity of publications has looked into its actual efficacy and safety. The aim of our study was to evaluate its ex vivo and in vivo efficiency and to compare its results with other devices presented in the literature. PATIENTS AND METHODS: We conducted a prospective pilot study on patients who underwent holmium laser enucleation of the prostate (HoLEP) from 2017 to 2018 using the Top-Down technique. Enucleated adenomas were morcellated using the DrillCutTM morcellator. We collected both preoperative and operative data. Operative data included the enucleated adenoma weight and operative time. Various morcellator parameters were collected including morcellation time and efficiency. We recorded the encountered complications and device malfunction. Ex vivo characteristics were evaluated in terms of morcellation speed and aspiration power. RESULTS: Sixty consecutive patients with a median age of 72.8 years were included. The enucleated adenoma was retrieved in 12.5 min (4-58). The median resected prostatic weight was 90 g (44-242). The DrillCutTM efficiency was calculated as 6.46 g/min (2.7-15). Only one patient had a simple bladder mucosal injury. Device malfunction was encountered in 4 patients (6.6%) due to blockage of the morcellator blades. The ex vivo aspiration speed was 52 s/L, while the morcellation power was 14 g/2 min. CONCLUSION: Our results showed that the DrillCut morcellator was effective and safe in managing our patients post-HoLEP. The DrillCutTM has better ex vivo morcellation power but modest aspiration speed in comparison to other morcellators.

[Comparative analysis of the effectiveness of various techniques of endoscopic prostate enucleation in a single center]. / Sravnitel'nyi analiz éffektivnosti razlichnykh metodik éndoskopicheskoi énukleatsii prostaty.

AIM: To compare electro- and laser enucleation (thulium, holmium) of prostate hyperplasia. MATERIAL AND METHODS: 693 prostate hyperplasia patients were enrolled. 489 patients underwent holmium enucleation (HoLEP), 51 - monopolar enucleation, 153 - thulium enucleation (ThuLEP). Prostate volume was 91.7 (50-250) cm3. There were no significant differences in preoperative variables between both groups (I-PSS, QoL, Qmax, residual urine volume) (p>0.05). RESULTS: Mean time of HoLEP was 97.0±42.2 min, monopolar enucleation - 112.9±36.3 min, ThuLEP duration was significantly less (77.4±36.3 min, p<0.01). An efficacy of all methods was confirmed in 6 months after surgery by significant (p<0.01) improvement of functional parameters (I-PSS, QoL, Qmax, residual urine volume). CONCLUSION: High efficiency of thulium and holmium enucleation allows to consider them as 'gold standard' of prostate hyperplasia management. Despite higher incidence of complications an efficacy of monopolar enucleation is comparable to that in laser techniques.

Low- vs. High-Power Laser for Holmium Laser Enucleation of Prostate.

Holmium laser enucleation of the prostate (HoLEP) constitutes an established technique for treating patients with symptomatic bladder outlet obstruction. Most surgeons perform surgeries using high-power (HP) settings. Nevertheless, HP laser machines are costly, require high-power sockets, and may be linked with increased postoperative dysuria. Low-power (LP) lasers could overcome these drawbacks without compromising postoperative outcomes. Nevertheless, there is a paucity of data regarding LP laser settings during HoLEP, as most endourologists are hesitant to apply them in their clinical practice. We aimed to provide an up-to-date narrative looking at the impact of LP settings in HoLEP and comparing LP with HP HoLEP. According to current evidence, intra- and post-operative outcomes as well as complication rates are independent of the laser power level. LP HoLEP is feasible, safe, and effective and may improve postoperative irritative and storage symptoms.

Holmium Laser Enucleation of Prostate in Patients with Pre-Existing Localized Prostate Cancer, Dual Center Study.

Background: Holmium laser enucleation of the prostate (HoLEP) has been used as an effective minimally invasive technique for management of enlarged prostates. We aimed to report the role of HoLEP in prostate cancer (PCa) patients either on active surveillance with bothersome lower urinary tract symptoms (LUTS) or for prostate debulking before radiation therapy and the impact on PCa management plans. Methods: Prospectively maintained database in two institutions was reviewed for patients with localized PCa managed by HoLEP with at least a follow-up of 1 year. We assessed prostate-specific antigen (PSA) trends, effect on international prostate symptom score (IPSS) and further management of PCa. Results: Out of >2000 HoLEP patients, 117 patients with a median follow-up of 30 months were included. Mean (standard deviation) age was 72.3 (±8.3) years with median (interquartile range, IQR) IPPS of 22 (16-28) and median (IQR) PSA at 7.6 (5.3-14.9) ng/mL. Gleason grade group was 1, 2, 3, and 4 in 47 (73.2%), 32 (27.35%), 7 (5.9%), and 4 (3.4%) patients, respectively. Median (IQR) PSA has significantly dropped to 1.3 (0.6-3.1), 1.4 (0.75-2.9), and 1.7 (0.86-2.75) ng/mL at 6-week, 3-month, and 1-year follow-up, respectively (p < 0.001). IPSS scores post-HoLEP obviously improved with mean (IQR) IPSS of 10 (5-13), 7 (3-12), and 3 (2-5) at 6-week, 3-month, and 1-year, respectively (p < 0.001). Eighty-eight (72%) patients stayed on active surveillance, whereas 27 (23%) patients had radiotherapy ± androgen deprivation therapy for persistently high or relapsing PSA. Within 36 intermediate-risk patients, 15 (41.6%) and patients had radiotherapy, whereas 21 (58.3%) patients continued active surveillance. Conclusions: HoLEP is beneficial in debulking large prostate in PCa patients with bothersome LUTS on active surveillance or before radiotherapy. HoLEP reduces the contribution of large adenoma to PSA level, thus reflecting PSA level better and helping reduce overtreatment.

Incidence and predictors of urinary incontinence rates post-holmium laser enucleation of prostate.

INTRODUCTION: One of the main adverse outcomes following Holmium laser enucleation of the prostate (HoLEP) is the development of transient de novo urinary incontinence (UI). We aimed to evaluate the correlation of multiple risk factors to UI rates post-HoLEP. METHODS: A review of prospectively maintained 7 year database for HoLEP patients in a single center was performed. UI data at 6 week, 3 month, and 1 year follow-up intervals were assessed with bivariate and multivariate analysis of multiple potential risk factors. RESULTS: The study included 666 patients with median (IQR) age of 72 (66-78) years old and median (IQR) preoperative prostate volume of 89 (68-126) gm. UI was seen in 287 (43%), 100 (15%) and 26 (5.8%) at 6 week, 3 month, and 1 year follow up occasions respectively. At 6 weeks follow up, UI type was stress, urge and mixed in 121 (18.16%), 118 (17.72) and 48 (7.21%) patients respectively. Using a multivariate regression analysis, obesity and pre-operative UI were associated with postoperative UI rate at both 6 week (p = .0065, .031) and 3 month (p = .0261, .044) follow up encounters respectively. Also, larger specimen weight was another predictor for 6 week UI (p = .0399) while higher frailty score was a predictor for UI at 3 month occasion (p = .041). CONCLUSION: Patients with preoperative UI, obesity, frailty, and large prostate volume are at higher risk of short-term UI post-HoLEP up to 3 months. Patients with one or more of these risk factors should be counseled regarding the higher risk of UI.

A Novel Modified Two-Lobe Holmium Prostate Enucleation Technique: Demirtas-Erciyes Enucleation Prostatectomy.

Objective Endoscopic enucleation of the prostate has evolved and became popular for the surgical treatment of benign prostatic hyperplasia (BPH) during the last decade. Different surgical techniques have been described so far. We hereby described a new modified two-lobe technique for urologists who are inexperienced in endoscopic enucleation. We aimed here to present the data on a learning curve of this stepwise technique named Demirtas-Erciyes Enucleation Prostatectomy (DEEP): reverse S-J incision technique and its postoperative outcomes. Material and methods The study included 102 patients who underwent holmium laser enucleation of the prostate (HoLEP) with the DEEP technique between October 2020 and December 2021. Demographic, preoperative, and postoperative variables were recorded. The operation was performed with a 150 W holmium laser system (Quanta System, Varese, Italy) with cutting and coagulation settings of 2J × 50 Hz with virtual basket mode and 2J × 12 Hz in bubble blast mode, respectively. Bladder irrigation was done for one day, and then, on the next day, the urethral catheter was removed. Postoperatively, uroflowmetry studies, continence status, and ejaculation status were recorded during follow-up. The data of all patients were divided into two groups (first 51 and final 51 patients). All variables were analyzed between two groups. Results The mean age of the patients was 68.48±8.74 years. The median Charlson Comorbidity Index (CCI) score was 3. The median International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF) values ​​were 26 (10-35) and 10 (0-25), respectively. Of the patients, 60.8% had Foley catheters due to urinary retention. The median anesthesia time, laser time, enucleation time, morcellation time, and enucleated tissue amount were 102.5 minutes, 17 minutes, 25 minutes, 20 minutes, and 50 g, respectively. Enucleation was performed in two stages in five patients due to bigger prostate volume or incomplete morcellation. The median catheter removal time was 48 hours. In six patients, the postoperative catheterization time was prolonged due to hematuria. The median increase in Qmax was 19.35 mL/second. The overall complication rate was 5.9%, which were all Clavien grade II. Enucleation time, laser time, and anesthesia time were significantly lower in the last 51 patients. Conclusion DEEP enucleation technique seems to provide effective and safe postoperative results for beginners in prostate enucleation.

Network Meta-Analysis of the Treatment Safety and Efficacy of Different Lasers in Prostate Enucleation.

Purpose: This study aimed to compare different laser systems for the enucleation of benign prostate hyperplasia. Methods: Randomized controlled trials (RCTs) on different lasers for prostate enucleation were searched from PubMed, Embase, and CNKI databases. Pairwise and network meta-analyis (NMA) were performed to analyze the outcome regarding surgery time, complications, short-term postvoid residual (PVR), long-term PVR, and short-term international prostate symptom score (IPSS), long-term IPSS, short-term maximum urine flow rate (Qmax), and long-term Qmax. RevMan software was used for paired meta-analysis. Considering the variance uncertainty caused by the different source regions of RCTs and the different primary conditions of surgeons and patients, this study uses Bayesian NMA conducted with ADDIS software to compare different treatment methods indirectly. Node-splitting analysis was used to test inconsistency for closed-loop indirect comparison. Results: Nine studies were included in this study, involving four types of lasers: diode laser, holmium laser, thulium laser, and greenlight laser. In safety paired meta-analysis, holmium laser could bring more complication risk than thulium laser (odds ratio: 2.70, 95% confidential interval [CI]: 1.79-4.00, p < 0.001), and no other significant result was detected. In the efficacy comparisons, holmium laser could offer better postoperative long-term PVR (standardized mean difference [SMD]: -0.35, 95%CI: -0.62, -0.09, p = 0.011), better postoperative long-term IPSS (SMD: -0.30, 95%CI: -0.57, -0.04, p = 0.011), better postoperative short-term Qmax (SMD: 0.44, 95%CI: 0.17, 0.70, p = 0.001) compared with greenlight laser. According to the results of NMA, greenlight laser may bring more complication risks when applied to prostate enucleation than the other three lasers. Thulium laser may be the recommended laser system for prostate enucleation. Conclusion: Thulium laser may be the recommended laser system since it can bring less complication risk with comparable efficacy. More RCTs are still needed to validate this study.

Same Day Discharge is a Successful Approach for the Majority of Patients Undergoing Holmium Laser Enucleation of the Prostate.

BACKGROUND: Limited research has focused on success with hospital discharge on the same day of surgery after holmium laser enucleation of the prostate (HoLEP). OBJECTIVE: To determine the success of same-day discharge in our HoLEP cohort and factors associated with this approach. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of our prospectively maintained HoLEP database demonstrated that 473 adult males underwent HoLEP from July 2018 to December 2019 at a tertiary referral center and high-volume HoLEP hospital. Patients were divided into groups according to planned inpatient admission (PIA), successful same-day discharge (SDD), or unplanned admission (UA). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The PIA, SDD, and UA groups were assessed for differences in preoperative demographic data, perioperative surgical data, and postoperative follow-up data. SDD and UA were then compared to determine if any specific factors predicted UA, including univariate and multivariate logistic regression analyses. RESULTS AND LIMITATIONS: Age (p = 0.0049), use of anticoagulation (p = 0.037), American Society of Anesthesiologists score of 3-4 (p = 0.0017), and enucleation time (p=0.0178) were significantly higher in the PIA group. Morcellation time (p = 0.0059) and the rate of bedside catheter irrigation (p = 0.04) were higher in the UA group. The SDD group had the highest rate of successful voiding trial (p = 0.0001). Among the three groups, there was no difference in the rate of postoperative complications (p = 0.141). In a comparison of the SDD and UA groups, morcellation time (p = 0.041), the rate of bedside clot evacuation (p = 0.004), and successful voiding trial (p = 0.003) all favored SDD. There was no difference in 90-d complications (p = 0.536). A limitation is the retrospective nature of this study. CONCLUSIONS: HoLEP can be successfully performed as day surgery without an increase in postoperative complications. HoLEP as day surgery is possible for any patient who does not require admission for medical comorbidities. PATIENT SUMMARY: Same-day discharge (SDD) after holmium laser enucleation of the prostate (HoLEP) is possible and is successful in 87.4% of patients. Patients with longer morcellation times and with post-procedure hematuria with clots are more likely to have an unplanned admission. Use of a 120-W modulated-pulse laser resulted in a higher rate of SDD success. The culture change to day surgery is time-intensive owing to education of the postsurgical care units and clinic staff, and in our experience took approximately 9 mo to seamlessly integrate SDD as our HoLEP standard of care.