A commentary on “Comparison of different laser-based enucleation techniques for benign prostate hyperplasia: A systematic review and meta-analysis” (Int J Surg 2021; 94:106135)

Abstract

Dear Editor, Benign Prostatic Hyperplasia (BPH) is the most common cause of lower urinary tract symptoms (LUTS) in men [1]. Surgery is a therapeutic option in moderate-to-severe LUTS and is an absolute indication in very severe conditions. Over the past two decades, we have witnessed development of laser technology with reduced morbidity in traditional surgery using transurethral resection of prostate (TURP) and open prostatectomy (OP). Since the introduction of holmium laser enucleation of prostate (HoLEP) in 1998 [2], endoscopic enucleation of prostate (EEP) has become widely accepted as an alternative approach to TURP and OP. Several randomized clinical trials have shown at least non-inferiority of HoLEP when compared to TURP and OP in terms of functional outcomes, and superiority in terms of morbidity (less bleeding, shorter catheterization time and hospital stay) [3,4]. Moreover, various techniques have been developed for EEP: removal of all nodes as a single unit (en bloc) or a step-by-step removal of adenomatous nodes (two- and three-lobe techniques). To summarize the current evidence on different laser-based enucleation techniques for BPH and to compare the efficacy and safety of en-bloc, two-lobe and three-lobe techniques, You et al. [5] performed a systematic review and meta-analysis and demonstrated that the en-bloc and two-lobe enucleation techniques to be feasible and safe alternatives to the three-lobe technique, with comparable surgical and functional outcomes. A superior enucleation effectiveness was associated with the en-bloc technique when compared to the two-lobe and the three-lobe techniques. The main objective of the “en-bloc” technique is to overcome the technical limitations of the classical “three lobes” technique, which are: (1) difficulty in identification of correct capsular planes in different prostatic lobes, with the risk of developing enucleation planes on different levels by mismatching incisions, in particular the anterior plane where it is difficult to identify the plane by pushing the adenoma. Thus, the anterior plane is created by developing lateral planes. (2) incomplete removal of adenoma due to loss of correct enucleation planes. (3) risks of capsular perforation which can cause significant bleeding when the correct planes are not followed. The “En-bloc” technique have some advantages over the classical “three-lobe” one, mostly by shortening operation time, improving effectiveness of enucleation and reducing total amount of energy utilized for enucleation. Operation time is reduced using the “En-bloc” technique because it is not necessary to isolate and enucleate the median lobe, which is enucleated together with the right lobe. In addition, the capsular plane is identified just once using a single incision instead of three times in the classical technique. Based on our experience, the surgeon’s skill is the main attribute of successful surgery, and the device is only the secondary attribute. A good technique of enucleation by an experienced surgeon by following the correct enucleation plane, and the ability to deal with intraoperative complications are of the greatest importance. Ethical approval No Ethical Approval was given. Sources of funding NA. Author contribution Yanmei Wei: comment the paper. Chengshan Li: review. Research registration unique identifying Number (UIN) NA. Unique identifying Number (UIN): NA Trial registry number – ISRCTN. Guarantor Chengshan Li. “Provenance and peer review Commentary, internally reviewed” Declaration of competing interest No conflict of interest.