Comparative Analysis of Greenlight Laser Photovaporization and Holmium Laser Enucleation of the Prostate for Benign Prostatic Hyperplasia Surgery.

To evaluate short-term outcomes of holmium laser enucleation of the prostate (HoLEP) and photoselective vaporisation of the prostate (PVP) in patients with benign prostatic hyperplasia (BPH) and chronic urinary retention (CUR). A retrospective chart review was performed of all patients with CUR who underwent HoLEP or PVP at our institution over a 3-year period. CUR was defined as a persistent post-void residual urine volume (PVR) of >300 mL or refractory urinary retention requiring catheterisation. We identified 72 patients with CUR who underwent HoLEP and 31 who underwent PVP. Preoperative parameters including median catheterisation duration (3 vs 5 months, P = 0.71), American Urological Association Symptom Index score (AUASI; 18 vs 21, P = 0.24), and PVR (555 vs 473 mL, P = 0.096) were similar between the HoLEP and PVP groups. The HoLEP group had a larger prostate volume (88.5 vs 49 mL, P < 0.001) and higher PSA concentration (4.5 vs 2.4 ng/mL, P = 0.001). At median 6-month follow-up, 71 (99%) HoLEP patients and 23 (74%) PVP patients were catheter-free (P < 0.001). Of the voiding patients, postoperative AUASI (3 vs 4, P = 0.06), maximum urinary flow rate (23 vs 18 mL/s, P = 0.28) and PVR (56.5 vs 54 mL, P = 1.0) were improved in both groups. Both HoLEP and PVP are effective at improving urinary parameters in men with CUR. Despite larger prostate volumes, HoLEP had a 99% successful deobstruction rate, thus rendering patients catheter-free.

Is There a Way to Predict Stress Urinary Incontinence After Holmium Laser Enucleation of the Prostate?

To compare serial changes of postoperative storage symptoms between PVP and HoLEP, and to identify the predictors influencing postoperative improvement of storage symptoms. A total of 486 men (PVP group: 213 cases; HoLEP group: 273 cases), in whom 12-month follow-up data were available, were included in this retrospective study. Surgical outcomes were evaluated at 1-, 3-, 6-, and 12 months postoperatively using the IPSS, uroflowmetry with post-void residual urine volume (PVR) and serum PSA levels. Improvement of storage symptoms was defined as a reduction by ≥50 % of the subtotal storage symptom score postoperatively compared to baseline. In both PVP and HoLEP groups, total IPSS, quality-of-life index, frequency score, nocturia score, maximum flow rate and PVR were significantly decreased compared to baseline starting from 1 month after surgery. Whereas urgency score was numerically increased compared to baseline at 1 month after PVP, it was reduced compared to baseline at 1 month after HoLEP. While the subtotal storage symptom score was significantly decreased compared to baseline starting from 3 months after PVP, it was significantly reduced starting from 1 month after HoLEP. On logistic regression analysis, a higher baseline subtotal storage symptom score was the only independent predictor of improvement in storage symptoms after PVP or HoLEP. Our data suggest that improvement in storage symptoms after HoLEP begins earlier than that after PVP. Also, this study indicates that patients with more severe baseline storage symptoms have a higher likelihood of improvement after PVP or HoLEP compared to those with less severe symptoms.

Holmium:YAG Transurethral Incision Versus Laser Photoselective Vaporization for Benign Prostatic Hyperplasia in a Small Prostate

To assess the degree of postoperative storage symptoms after GreenLight™ laser photoselective vaporization of the prostate (PVP) and Holmium laser enucleation of the prostate (HoLEP) for management of benign prostatic hyperplasia (BPH) and its predictors. A retrospective review was performed for patients who underwent HoLEP or PVP for non catheter-dependent patients with BPH. Patients were followed up at 1, 3, 6, and 12 months and then annually by International Prostate Symptoms Score (IPSS), quality of life index, peak flow rate, residual urine volume, and prostate-specific antigen (PSA) level. Moderate or severe storage symptoms were defined as IPSS storage subscore ≥ 9. Of 1673 laser procedures, a total of 1100 procedures met the inclusion criteria including 809 HoLEPs and 291 PVPs. The HoLEP group had significantly larger preoperative prostates and longer operative time. In the HoLEP group, postoperative IPSS was significantly better than in the PVP group at all follow-up points (P<0.05). Storage subscore was significantly higher after PVP and did not improve until 6 months postoperatively when it became comparable with that of the HoLEP group. The number of patients with IPSS-storage score ≥ 9 were significantly higher in the PVP group at 1 and 3 months follow-up (37.3% vs 15.1%, P<0.001) and (26.4% vs 17.5%, P=0.004), respectively. XPS-180W was associated with the lowest storage symptoms among the three GreenLight generations at all follow-up visits. In multivariate analysis, baseline IPSS-storage subscore ≥ 9, prolonged operative time >100 minutes, and lower percent of postoperative PSA level reduction significantly predicted less improvement of postoperative storage symptoms regardless of the laser procedure. Storage urinary symptoms significantly improved more after HoLEP compared with PVP, irrespective of the generation of GreenLight laser used. Recovery from bothersome storage urinary symptoms after prostate vaporization is time dependent, and baseline degree of storage symptoms, prolonged operative time, and lower percent of postoperative PSA level reduction negatively predicts postoperative improvement of storage symptoms regardless of the laser procedure.

Photoselective Prostatic Vaporization for Bladder Outlet Obstruction: 12-Month Evaluation of Storage and Voiding Symptoms

Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for the treatment of benign prostatic hyperplasia. HoLEP has been shown to have excellent improvements in prostate symptom scores and maximum flow rates that have been durable for 2 decades. However, the steep learning curve associated with HoLEP has prevented its widespread adoption. New advancements in lasers, specifically the Moses™ pulse-modulation technology, have resulted in improvements in hemostasis and achieving same-day discharges and catheter removals. We aimed to perform a cost-comparison to analyze if Moses-augmented HoLEP (m-HoLEP) resulted in cost-savings. A retrospective review was performed of a single expert surgeon's experience from May 2018 to November 2020, comparing m-HoLEP with HoLEP. Perioperative and postoperative variables were abstracted from the medical record. Univariate and multivariate analyses were performed using SAS® 9.4. Two-sided significance was set at p <0.05. A total of 312 men underwent HoLEP during the study period (192 in m-HoLEP group and 120 in HoLEP group). The m-HoLEP group had more same-day discharges (p <0.001) and emergency department visits (6.3% vs 1.7%, p=0.0071). m-HoLEP resulted in hospital cost savings of $840 for the initial surgical episode (p=0.0297). When factoring in emergency department visits/readmissions, the cost savings decreased to $747 per case (p=0.0574). m-HoLEP was associated with same-day discharge and hospital cost savings of $840 for the initial surgical episode. Further study in other institutions with surgeons of varying experience levels will need to be performed to see if these findings can be replicated.

The objective of this review is to provide an evidence-based update on laser surgery for BPH with a focus on comparing Greenlight Photoselective Vaporisation of the Prostate (PVP) to Holmium Laser Enucleation of the Prostate (HoLEP). We reviewed all HoLEP and PVP papers identified by a Pubmed search using the keywords: laser, prostate, BPH, holmium, HoLE, PVP and greenlight. The published randomised trials investigating HoLEP and PVP are summarised. As there are no head to head randomised trials comparing HoLEP to PVP, we compare data from individual HoLEP and PVP papers. Data on multiple aspects of laser surgery for BPH are summarised and contrasted for the 2 procedures including: Perioperative management, subjective and objective measures of success, complications, sexual function, prostate volume reduction, durability, and surgery for men with large prostates and those in urinary retention. PVP and HoLEP are very different laser techniques. An important difference between the Greenlight laser and holmium and thulium is that its only urological application is prostate ablation. HoLEP is the most advanced laser technique currently available. In contrast to PVP, it has been rigorously evaluated in 8 randomised trials. It is a size independent procedure suitable for any prostate, and highly effective at treating urinary retention. HoLEP has been reported to be durable to periods up to 6 years. More tissue is removed with HoLEP than PVP and this raises concerns regarding the long term durability of PVP for which there is no comparable data. The increase in HoLEP expertise worldwide and the development of lasers that are faster at ablating tissue and have other urological uses (eg thulium) may threaten the longevity of Greenlight PVP.

This retrospective study compares the efficacy and safety of transurethral resection of the prostate (TURP), green-light photoselective vaporization of the prostate (PVP), and holmium laser enucleation of the prostate (HoLEP) in treating small-volume benign prostatic hyperplasia (BPH). Data from 645 patients with small-volume BPH (2012–2022, Zhejiang Provincial People’s Hospital) were analyzed. Baseline characteristics, surgical details, complications, and follow-up outcomes were compared. Logistic regression identified risk factors for urinary incontinence (UI) and bladder neck contracture (BNC). TURP was associated with a longer operative duration (53.15 ± 21.96 min) and catheterization time (5.29 ± 1.31 days) compared to PVP (48.53 ± 22.38 min, 4.84 ± 1.05 days) and HoLEP (45.00 ± 19.04 min, 4.79 ± 0.96 days). The incidence of BNC was significantly higher in the TURP group (9.4%) than in the PVP (4.8%) and HoLEP (5.7%) groups. Within 1 month postoperatively, the TURP group had a significantly higher proportion of patients with urinary incontinence. Between 1 and 3 months post-surgery, only UI with need for drug use (UIWD) remained significantly higher in the TURP group (8.2%). Preoperative indwelling catheterization, detrusor underactivity, severely elevated detrusor pressure, and undergoing TURP were identified as independent risk factors for UI. Green-light PVP was found to be a protective factor against BNC (OR = 0.40, P = 0.043). Green-light PVP and HoLEP showed similar efficacy and safety, with PVP offering the shortest operative time. TURP was associated with higher rates of BNC and UI. Laser techniques are preferable for high-risk patients.

Holmium Laser Enucleation versus Transurethral Resection of the Prostate: 3-Year Follow-Up Results of a Randomized Clinical Trial

Re: Holmium Laser Enucleation Versus Transurethral Resection of the Prostate

HOLMIUM LASER ENUCLEATION VERSUS TRANSURETHRAL RESECTION OF THE PROSTATE: RESULTS FROM A 2-CENTER, PROSPECTIVE, RANDOMIZED TRIAL IN PATIENTS WITH OBSTRUCTIVE BENIGN PROSTATIC HYPERPLASIA

Holmium Laser Enucleation of the Prostate: Long-Term Durability of Clinical Outcomes and Complication Rates During 10 Years of Followup

A Prospective, Randomized Clinical Trial Comparing Plasmakinetic Resection of the Prostate with Holmium Laser Enucleation of the Prostate Based on a 2-Year Followup

Purpose: The main objective of this multicentric retrospective pilot study was to evaluate the 1-year follow-up safety (i.e., minor [Clavien-Dindo I-II] and major [Clavien-Dindo ≥III] complications) of holmium laser enucleation of the prostate (HoLEP), GreenLight photoselective vaporization of the prostate (GL PVP), and transurethral resection of the prostate (TURP) performed after kidney transplantation (KT). The secondary objectives were to evaluate the efficacy and to assess the impact of these procedures on graft function. Materials and Methods: We retrospectively included all KT recipients who underwent a HoLEP or GL PVP or TURP for benign prostatic hyperplasia (BPH) in three French university centers. Results: From January 2013 to April 2018, 60 BPH endoscopic surgical procedures in KT recipients were performed: 17 HoLEP (HoLEP group), 9 GL PVP (GL PVP group), and 34 TURP (TURP group). Age, body mass index, preoperative serum creatinine, preoperative International Prostatic Symptom Score, preoperative Qmax, preoperative prostate-specific antigen, medical history of acute urinary retention (AUR), urinary tract infection (UTI), and indwelling urethral catheter were similar in all study groups. Mean preoperative prostate volume was higher in HoLEP group. The rate of overall postoperative complications was statistically higher in the HoLEP group (11/17 [64.7%] vs 1/9 [11.1%] vs 12/34 [35.3%] in HoLEP group, GL PVP group, and TURP group, respectively, p = 0.02), with higher rate of long-term UTI and AUR. Qmax improved in all groups after operation. Delta postoperative month 12-preoperative serum creatinine was similar in the all groups. Conclusions: Although our study is underpowered, the rate of postoperative complications is higher with HoLEP procedure, in comparison with GL PVP, for the treatment of BPH after KT. One-year efficacy is similar in HoLEP, GL PVP, and TURP groups. Further prospective randomized controlled trials are needed to confirm our results.