Abstract
The acronym EEP, coding for transurethral Endoscopic Enucleation of the Prostate, was introduced in 2016 by the European Association of Urology (EAU) guidelines panel on management of non-neurogenic male lower urinary tract symptoms (LUTS) and benign prostatic obstruction (BPO). Since then, a laser-based treatment, Holmium Laser Enucleation of the Prostate (HoLEP), and the current-based treatment of bipolar enucleation of the prostate (BipoLEP) are equally appreciated as valuable options for the management of benign prostatic obstruction (BPO). This was mainly inspired by the results of two meta-analyses on randomized controlled trials, comparing open prostatectomy with either Holmium Laser Enucleation of the Prostate (HoLEP) or bipolar enucleation of the prostate (BipoLEP). Prior to that, HoLEP was embraced as the only valid option for transurethral enucleation, although evidence for equivalence existed as early as 2006, but was not recognized due to a plethora of acronyms for bipolar energy-based treatments and practiced HoLEP-centrism. On the other hand, the academic discourse focused on different (other) laser approaches that came up, led by Thulium:Yttrium-Aluminum-Garnet (Tm:YAG) Vapoenucleation (ThuVEP) in 2009 and, finally, transurethral anatomical enucleation with Tm:YAG support (thulium laser enucleation of the prostate, ThuLEP) in 2010. Initially, the discourse on lasers focused on the different properties of lasers rather than technique or surgical anatomy, respectively. In and after 2016, the discussion ultimately moved towards surgical technique and accepting anatomical preparation as the common of all EEP techniques (AEEP). Since then, the unspoken question has been raised, whether lasers are still necessary to perform EEP in light of existing evidence, given the total cost of ownership (TCO) for these generators. This article weighs the current evidence and comes to the conclusion that no evidence of superiority of one modality over another exists with regard to any endpoint. Therefore, in the sense of critical importance, AEEP can be safely and effectively performed without laser technologies and without compromise.
Highlights
The evolution of Endoscopic Enucleation of the Prostate (EEP) began humbly in 1983, with the introduction of the blueprint of all transurethral anatomical enucleating techniques, using a prostate detachment probe to dissect along the false capsule of fibrous tissue between the peripheral zone and adenoma (Hiroaoka 1983) [1]
In and after 2016, the discussion moved towards surgical technique and accepting anatomical preparation as the common of all EEP techniques (AEEP)
Inspired by the academic discussion Herrmann et al [4] proposed a concept of anatomical enucleation by a widely blunt dissection of the transitional zone (ThuLEP) in 2010
Summary
The evolution of Endoscopic Enucleation of the Prostate (EEP) began humbly in 1983, with the introduction of the blueprint of all transurethral anatomical enucleating techniques, using a prostate detachment probe to dissect along the false capsule of fibrous tissue between the peripheral zone and adenoma (Hiroaoka 1983) [1] It was not until 2005 when Frauendorfer and Gilling developed and introduced the pulsed Holmium-Laser and, subsequently, the Holmium-Laser Enucleation of the Prostate (HoLEP) into clinical practice [2]. The 2016 update of the European Association of Urology (EAU) guidelines on management of non-neurogenic male lower urinary tract symptoms (LUTS), with the reception of two meta-analyses [13], promoted both HoLEP and bipolar enucleation as the treatment of choice for benign prostatic obstruction (BPO) of large volume prostatic glands This resulted in the change of scientific reception—away from highlighting the impact of a single energy source (back) to the overarching principle of the common ground of enucleating techniques: endoscopic enucleation (EEP) or anatomical enucleation (AEEP). The present article aims to enlighten this daring thesis and to inspire a reflection on “essentiality” of energy sources for AEEP
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