Endoscopic Enucleation Research Articles

Simulation and quantitative evaluation of three surgical techniques of endoscopic enucleation of prostate on a realistic phantom model.

To evaluate the impact of three different AEEP techniques on the training performance of novices using a realistic hydrogel prostate phantom model. The experimental setup utilized realistic prostate phantom model provided by the Max Planck Institute for Intelligent Systems, Germany. For the enucleation, we utilized a new solid-state pulsed thulium laser (Thulio®, Dornier MedTech, Weßling, Germany). We explored three different AEEP techniques-bilobar, trilobar, and en-bloc-repeated ten times each, totaling 30 procedures. Median enucleation time was 9.5 min (range: 6-16), median laser time was 4.29 min (3.21-6.34), median total energy used was 25.8 kJ (19.4-38.1), and median number of laser pulses was 12.8 thousand (9.7-17). There were no significant differences in operation time, laser time, pulses, or joules among the en-bloc, two-lobe, and three-lobe techniques (p = 0.113, 0.143, 0.148, 0.141 respectively). Ultrasound evaluations showed the one-lobe technique to be superior in accuracy, smoothness, and circularity (p = 0.0002, 0.012, 0.00005 respectively) (Figs. 9, 10, 11), despite having the highest perforation rate, which was not statistically significant compared to other techniques (p = 1.4). The one-lobe technique's higher accuracy may increase the risk of perforation. In contrast, the three-lobe technique had the lowest perforation rate and removal efficiency due to its lower accuracy. The en-bloc, bilobar, and trilobar enucleation techniques exhibited comparable operation times. The one-lobe method emerged as superior in terms of accuracy, smoothness, and circularity. However, it also presented the highest rate of perforation.

Comparative analysis of the long-term efficacy and safety of minimally invasive simple prostatectomy and endoscopic enucleation of the prostate for large benign prostatic hyperplasia (>80 mL).

Minimally invasive simple prostatectomy (MISP) and endoscopic enucleation of the prostate (EEP) are appropriate candidates for the large prostate. However, their comparative effectiveness and safety remain unclear. This study aims to conduct a comprehensive analysis comparing the efficacy and safety of MISP and EEP. We conducted a systematic search of the PubMed, Embase, and Cochrane Library databases to identify eligible studies comparing MISP and EEP. Data analysis was performed using Review Manager 5.3. Risk of bias was assessed with the ROBINS-I and the ROB2.0 assessment tool. The results of analyzing 13 studies involving 2271 patients showed that EEP had significant lower operative time (MD [CI]: 41.59 [14.62-68.56]), catheterization time (MD [CI]: 4.35 [3.31-5.38]), length of stay (MD [CI]: 2.16 [0.70-3.61]), and Hb decreases (MD [CI]: 0.46 [0.06-0.87]). MISP demonstrated significantly better long-term (MD [CI]: -0.46 [-0.89; -0.03]) and short-term QoL (MD [CI]: -0.38 [-0.66; -0.10]) and short-term Qmax (MD [CI]: 2.04 [0.06-4.03]). Efficacy outcomes were comparable in postoperative IPSS, PVR and PSA between MISP and EEP procedures. No significant differences were observed in resection weight, overall complications, blood transfusions, or urinary incontinence between MISP and EEP. Overall, EEP and MISP are both effective treatment options for large-volume BPH, providing comparable efficacy outcomes and long-term maintenance. EEP, on the other hand appears to have better perioperative outcomes, but it has a higher rate of short-term postoperative incontinence.

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

To investigate the clinical trajectories and identify risk factors linked to post-enucleation urinary incontinence (UI). 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. 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. 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.

Urethral Strictures After Endoscopic Enucleation of the Prostate and Its Associated Clinical Outcomes in Aging Men.

Background and Objectives: Benign prostatic hyperplasia is a common condition among aging men, leading to bladder outlet obstruction and associated lower urinary tract symptoms. Surgical intervention, particularly endoscopic enucleation of the prostate, has become increasingly popular over traditional methods such as transurethral resection of the prostate. However, urethral strictures remain a major postoperative complication. This study evaluated the incidence, risk factors, and clinical outcomes of urethral strictures after endoscopic enucleation of the prostate. Materials and Methods: This study retrospectively analyzed prospectively collected data from 246 patients who underwent either thulium laser enucleation of the prostate or bipolar transurethral enucleation of the prostate at Chang Gung Memorial Hospital between October 2018 and December 2022. Patients were evaluated preoperatively using uroflowmetry, International Prostate Symptom Score (IPSS), and other relevant clinical metrics. Follow-up assessments at 2 weeks, 3 months, and 6 months post-surgery included uroflowmetry, IPSS evaluation, and cystoscopy when indicated. A urethral stricture was deemed to be present if a 5.5 mm fiber cystoscope was unable to pass through the urethra. Results: Of the 246 patients, 23 (9.3%) developed urethral strictures, with the membranous urethra being the most common site (69.2%). Patients with strictures had significantly smaller prostate volumes and enucleated tissue weights, higher trial without catheter (TWOC) failure rates, and a higher postoperative urinary tract infection (UTI) incidence. Multivariate analysis identified smaller prostate size, lower resected tissue weight, TWOC failure, and postoperative UTI as significant risk factors for stricture formation. The type of energy source used for enucleation (bipolar or Thulium laser) was not identified as a factor influencing the incidence of urethral stricture. Conclusions: Urethral strictures constitute a major complication following endoscopic enucleation of the prostate, particularly in patients with smaller prostates and those experiencing postoperative complications such as UTIs and TWOC failure. These findings underscore the importance of careful surgical technique and rigorous postoperative monitoring to reduce the incidence of this complication.

Prostate cancer screening and management in patients candidate for endoscopic enucleation of the prostate: an international survey.

To explore how urologists manage prostate cancer (PCa) screening and treatment in patients undergoing endoscopic enucleation of the prostate (EEP). A team of experts in EEP collaboratively formulated the survey questions through an interactive process. The survey opened in January 2024 and closed in February 2024. 102 urologists responded, revealing that most use PSA and digital rectal examination for screening, with high PSA and abnormal DRE prompting prostate MRI. 75% perform pre-EEP biopsies. For incidental low-grade PCa, active surveillance is preferred. For intermediate-grade PCa, most use PSA and MRI for workup, often choosing active surveillance if post-EEP biopsies are negative. There's no consensus on abnormal post-operative PSA thresholds. While urologists are aware of PCa management in EEP candidates, future work should focus on developing optimal post-EEP screening protocols.

General anesthesia is associated with lower perioperative bleeding and better functional outcomes than spinal anesthesia for endoscopic enucleation of the prostate: a single-center experience.

Holmium laser enucleation of the prostate (HoLEP) and bipolar transurethral enucleation of the prostate (B-TUEP) are safe and effective treatment options for benign prostatic hyperplasia (BPH). Spinal anesthesia (SA) is widely used for endoscopic enucleation of the prostate (EEP) in place of general anesthesia (GA). We aimed to assess the impact of GA vs. SA on blood loss, postoperative course and functional outcomes after HoLEP and B-TUEP. After propensity score matching, we analyzed data from 148 patients treated with EEP in our centre for symptomatic BPH. We recorded patient's characteristics, procedural data, type of anesthesia (SA vs. GA). Postoperatively we evaluated hemoglobin drop, catheterization time (CT), and length of hospital stay (LOS). Functional outcomes were evaluated with the International Prostate Symptoms Score (IPSS) at baseline and 3 months after surgery. Descriptive statistics and linear regression models tested the association between anesthesia type and EEP outcomes. After matching groups were comparable in terms of pre- and intra-operative variables. Of all, 111 (75%) patients were treated under SA. Haemoglobin drop was lower in GA compared to SA group (1 vs. 1.4g/dL, p < 0.01). CT was shorter in the GA group (1 vs. 2 days, p = 0.01). Postoperative IPSS score was lower in GA group (4 vs. 8, p = 0.04). Multivariable linear regression models revealed that prostate volume (p = 0.01) and SA vs. GA (p = 0.01) were associated with higher haemoglobin drop, after accounting for age and use of anticoagulants/antiplatelets. Similarly, SA vs. GA (p = 0.02) and postoperative complications occurrence (p < 0.001) were associated with a longer LOS, after accounting for age, prostate volume and use of anticoagulants/antiplatelets. EEP can be safely performed under both GA and SA. GA offers better outcomes in terms of perioperative bleeding and 3-month functional outcomes.

Осложнения и нарушения мочеиспускания после проведенного оперативного лечения ДГПЖ методом лазерной энуклеации.

Introduction. Benign prostatic hyperplasia (BPH) is a common disease in elderly men, manifested by symptoms of the lower urinary tract. Drug treatment of BPH often allows you to delay or even avoid performing surgery. Laser endoscopic enucleation, which shows excellent functional results regardless of the patient's age and prostate volume, can be considered the modern «gold standard» of surgical treatment of BPH. However, complications and urinary disorders after surgical treatment are also inherent in this method. The purpose of this article was to systematize information on the quality of urination and the preservation of symptoms of the lower urinary tract in patients after endoscopic enucleation of BPH. Materials and methods. The literature review was compiled from analyzed materials from three scientific databases (PubMed, Scopus and Web of Science, eLibrary), focusing on the following keywords: «laser enucleation», «lower urinary tract symptoms», «complications after enucleation of prostate». Results. The obtained results of many studies allow us to state the existence of a new «gold standard» of surgical treatment of BPH and to consider the possibility of introducing HoLEP into the standards of medical care for urological patients with BPH. In the postoperative period, long-term monitoring of patients is necessary. Currently, there are no clear standards for the necessary examinations and the timing of their implementation in the postoperative period. Conclusion. Laser enucleation is a reliable method of surgical treatment of LUTS due to BPH.

Comparing surgical techniques: ThuLEP and transurethral BPEP for prostate over 80 grams. Intraoperative and postoperative results. A prospective randomized trial

ABSTRACT Background and purpose Though TURP remains the primary treatment for BPH, advancements in energy and technology have introduced innovative transurethral surgical options. In this study, we assessed and compared the effectiveness and safety of using thulium laser and bipolar for endoscopic enucleation of prostate exceeding 80 g. Patients and methods Between January 2022 and July 2023, this study enrolled patients with LUTS due to BPH and a prostate size of ≥80 g. Group A underwent the BPEP procedure using a 26 Fr continuous flow resectoscope with plasma kinetic system enucleation loops, while Group B underwent the ThuLEP procedure using a 120–200 W Revolix DUO® Thulium laser. Data collection included prostate size, PSA levels, enucleation and morcellation time, and postoperative IPSS and IIEF-5 scores at one, 3, 6, and 12 months. Results A total of 108 patients, divided into Group A (BPEP) and Group B (ThuLEP), completed a 12-month follow-up. The mean age for group A was 67.72 ± 7.02 compared to group B which was 62.33 ± 5.86. While Group A compared to group B had higher mean enucleation (75.22 ± 10.55 vs. 67 ± 12.18) and total operative times (117.22 ± 17.76 vs.90.5 ± 18.29) (p = 0.037 & <0.001 respectively), no significant differences were observed in resected tissue weight, blood transfusion, and morcellation time. The ThuLEP group exhibited a shorter mean catheter period 2.94 ± 0.94 d compared to BPEP 3.33 ± 0.91 d and shorter mean hospital stay period of 1.94 ± 0.54 compared to2.11 ± 0.32, though not statistically significant. Postoperative outcomes, including IPSS, Qmax, PVRU, and IIEF-5 at 1, 3, 6, and 12 months, showed no differences between the groups. Conclusion ThuLEP shows better perioperative parameters in comparison to BPEP. Nevertheless, there are no notable differences in functional results and complications between the two techniques.

Anatomic endoscopic enucleation of the prostate using a novel hybrid thulium:yttrium-aluminium-garnet laser generator: surgical technique and clinical outcomes.

We aim to report here the first clinical series of patients treated with AEEP using a novel hybrid thulium:yttrium-aluminium-garnet (Tm:YAG) laser generator (RevoLix HTL, LISA Laser Products, Germany), i.e. capable of emitting both in pulsated and continuous-wave. We included 39 consecutive patients who underwent hybrid Tm:YAG AEEP (hybrid ThuLEP) at a single center starting from July 2022 and were followed-up until 3months after surgery. Complete baseline, intraoperative, and follow-up demographic and clinical data were collected. The International Prostatic Symptoms Score (IPSS) questionnaire was used to quantify urinary symptoms at baseline and during follow-up. Post-operative follow-up further included a PSA test, uroflowmetry with post-void residual volume (PVR) measurement. Clavien-Dindo classification was used to classify complications. Median (IQR) age at surgery and prostate volume were 68 (IQR 63-74) years and 85 (60-105) cc. Both en-bloc or two-lobes technique enucleation were performed according to the intraoperative and endoscopic anatomy, with a median operative time of 85 (63-108) minutes. Bladder catheter was removed in all cases on postoperative day two. Intraoperative bleeding requiring conversion to bipolar enucleation was observed in two patients. After discharge, one patient developed arm phlebitis which was treated with anticoagulants leading to new onset haematuria requiring short term catheterisation (Clavien-Dindo grade II) and two more patients had a single episode of acute urinary retention (Clavien-Dindo grade I). Median pre- vs postoperative Qmax and IPSS were 8.0 (7.0-9.4) vs. 25.0 (22.5-32.5) ml/s and 22 (20-28) vs. 1 (0-2), whereas PVR decreased from 70 (50-115) to 0 (0-26) ml. Hybrid ThuLEP is a feasible and effective surgical procedure for the management of benign prostatic obstruction.

SARS-CoV-2 coinfection in children with severe airway obstruction due to pulmonary tuberculosis.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic had a significant impact on tuberculosis (TB) control globally, with the number of new TB diagnoses decreasing. Coinfection with some viruses, especially measles, could aggravate TB in children. This is presumably a result of depressed cellular immunity. Reports on children with TB and SARS-CoV-2 coinfection are limited. A retrospective analysis of children up to 13 years old admitted to Tygerberg Hospital, Cape Town, South Africa, from March 2020 to December 2022 with suspected TB-induced airway compression requiring bronchoscopy. Children were included if they presented with severe intrathoracic airway obstruction and/or radiographic evidence of complicated TB. The patients were divided into two groups based on SARS-CoV-2 respiratory polymerase chain reaction results. Demographics, TB exposure, microbiology, SARS-CoV-2 laboratory data, imaging, inflammatory cytokine levels, and bronchoscopy data were collected. Statistical analyses compared SARS-CoV-2 positive and negative groups. Of the 50 children undergoing bronchoscopy for TB airway obstruction, 7 (14%) were SARS-CoV-2 positive. Cough was more prevalent in the SARS-CoV-2 positive group (p = 0.04). There was no difference in TB culture yield between groups. However, SARS-CoV-2 positive children showed slower radiological improvement at 1 month (p = 0.01), pleural effusions (p < 0.001), and a higher need for endoscopic enucleation (p < 0.001). FDG PET/CT scans indicated an ongoing inflammation in the SARS-CoV-2 positive group. Coinfection with SARS-CoV-2 in children with TB airway obstruction appears to complicate the disease course, necessitating more medical interventions and demonstrating a longer duration of the TB inflammatory process. Further research is needed to understand the impact of viral infections on TB progression and outcomes in pediatric patients.

Does concordance between preoperatively measured prostate volume and enucleated weight predict outcomes in endoscopic enucleation of the prostate? Results from the REAP database.

We aimed to determine if preoperative prostate volume-enucleated weight concordance predicts short-term anatomical endoscopic enucleation of the prostate (AEEP) outcomes using the REAP international database. 649 patients with data on both preoperative ultrasound-derived prostate volume and enucleated specimen weight were analyzed. Linear regression was used to investigate the effect of volume-weight concordance on postoperative outcomes. Model residuals were used to divide the cohort into 3 centiles: (1) less-than-expected enucleated specimen weight; (2) appropriate concordance between prostate volume and specimen weight; (3) more-than-expected specimen weight. Outcomes were also analyzed with only enucleated weight as a predictor (comparing ≤ 80g and > 80g). There was a trend towards more-than-expected enucleated specimen weight with increased age (p = 0.006). There was an increasing trend of operation time (p = 0.012) and enucleation time (p = 0.015) as specimen weight increased, and a decreasing trend of postoperative acute urinary retention (p = 0.005). Laser type, enucleation method, and early apical release were similar. In correlation analysis, greater-than-expected prostate weight was associated with greater Qmax improvement at 3 months. Prostate weight alone did not appear to be a significant predictor of outcomes. If enucleated specimen weight is more than expected according to preoperative ultrasound volume measurement, greater Qmax improvement and less postoperative acute urinary retention is expected. Although precision may be limited by ultrasound approximation and inexact specimen weight measurements, these shortcomings are similar in real-world clinical practice. Overall, preoperative prostate volume and actual enucleated specimen weight should be interpreted in the context of each other to predict clinical outcomes.

Real-world experience with the new pulsed solid-state Thulium: YAG laser (Thulio) for endoscopic enucleation of the prostate

PurposeThe solid-state Thulium laser (Tm: YAG) is a novel alternative to the widely used Holmium laser for endoscopic enucleation of the prostate (EEP) due to its relatively high peak power. The aim of this study was to examine the efficacy and safety of a new pulsed Tm: YAG laser in its first application in humans.MethodsData were retrospectively collected for the first 103 patients who underwent EEP with a new pulsed solid-state Tm: YAG laser (Thulio®, Dornier MedTech Systems GmbH, Weßling, Germany). Peri- and postoperative data were assessed. Procedure-specific complications were graded using Clavien-Dindo Classifications (CDC). Patients were interviewed 15 months after the surgery to evaluate functional and long-term outcomes. Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS®).ResultsThe mean preoperative prostate volume was 105.6 ± 55.0 ml. Median enucleation speed was 4.1 g per minute (range 1.1–9.7). Short-term postoperative complications occurred in 21 patients (20.4%), but no high-grade complications (CDC ≥ IV) were observed. Five patients suffered gross haematuria and required reintervention (CDC IIIb; 4.9%). After 15 months, 76 patients (73.8%) participated in the follow-up interview, where seven patients (9.2%) reported complications, including two reinterventions for urethral strictures (CDC IIIb; 2.6%). Most patients reported an improvement in continence (54.0%) and urine stream (93.4%), but no difference in erectile function (81.6%). No persistent dysuria was reported. Patient satisfaction with the surgery results was very high (96.1%).ConclusionEndoscopic enucleation of the prostate with the new pulsed solid-state Tm: YAG laser is a safe and effective option for surgical BPH treatment.Trial registrationGerman Clinical Trials Register number: DRKS00031676. Registration date: 10 May 2023, retrospectively registered.

Evaluation of safety and efficacy of insulated-gate bipolar transistor holmium laser technology for prostate enucleation in canine model: a preliminary study.

The evolution of laser medical devices for benign prostatic hyperplasia (BPH) treatment aims to enhance vaporization, coagulation, or tissue removal. In this study, we aim to evaluate the effectiveness and safety of the innovative application of insulated-gate bipolar transistor (IGBT) xenon lamp-pulsed drive technology holmium laser in endoscopic prostate enucleation operations using canine models. Six canines were used as an experimental unit, the breed of the canine unit used was beagle. Each canine served as its own control to minimize the number of experimental units. Endoscopic enucleation, performed by a single surgeon, involved enucleating the left hemi-prostate, leaving the right hem-prostate untouched to serve as the control. Throughout the study period, all canines maintained good health. No adverse events were observed in all six canines. Postoperatively, there were no indications of redness, swelling, or other adverse effects at the surgical sites. No abnormalities were observed in the appearance and morphology of major organs. The prostate and bladder, removed for further pathological evaluation, exhibited no abnormalities in size, color, or texture. No abnormalities or inflammation were observed, and the tissues were free of adhesions, indicating successful healing. In conclusion, our comparison of preoperative and postoperative parameters in canines suggests that the IGBT pulsed laser, at a power setting of 100W, demonstrates characteristics of safety, efficacy, minimal tissue damage, and no major postoperative complications. This study establishes a theoretical foundation for future applications in human settings, encouraging further exploration of the IGBT holmium laser's potential in clinical practice.

Evaluation of the learning curve for Thulium fiber laser enucleation of prostate (ThuFLEP): retrospective study of a single-surgeon experience in real-world settings.

To assess the learning curve of Thulium Fiber Laser Enucleation of prostate (ThuFLEP) of a single surgeon inexperienced in laser endoscopic enucleation of prostate (EEP). We retrospectively analyzed all patients with benign prostate hyperplasia undergoing ThuFLEP at our center between January 2022 and August 2023 by one surgeon. Inclusion criteria were International Prostate Symptom Score > 7, prostate volume < 200g, and maximal urinary flow rate < 15 mL/s. The surgeon was inexperienced in laser EEP and trained by watching educational videos of ThuFLEP before starting to perform the procedure under mentoring during the first 4 cases. Procedural data (enucleation and morcellation efficiency, complications) and functional results up to 3 months were evaluated. Patients were divided into 4 cohorts of 20 consecutive cases to evaluate outcomes evolution throughout time. The mean age of the patients was 69.9 years (SD 7.8) and mean prostate volume was 89.9g (SD 25.8). Preoperative functional parameters were comparable between the groups. Mean enucleation efficiency (EE) ratio and morcellation efficiency (ME) ratio reached respectively 0.78g/min (SD 0.55) and 2.49g/min (SD 1.03) and both variables significantly increased from group 1 to group 3 (p < 0,001). Perioperative complications remained low throughout the caseload with similar significant 3-month functional improvements between all groups. This is the first study to evaluate ThuFLEP learning curve for a single surgeon inexperienced in laser EEP with limited mentoring. Under these real-world conditions, nearly 60 cases were needed to complete the learning curve with a complications rate remaining low throughout the training process.

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

PurposeThe 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.MethodsThe 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.ResultsThe 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.ConclusionTheoretical 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.

Prostate Surgery for Benign Prostatic Syndrome >200 ml: Endoscopic, Robotic, or Open Approach

Surgical approaches for benign prostatic hyperplasia have evolved and diversified over the past decades. While numerous studies document the efficacy of surgical procedures for moderate prostate sizes, there remains insufficient data for large prostate volumes >200 ml, leaving important questions unanswered regarding their effectiveness and safety. Consequently, selecting and adapting suitable therapeutic options for this specific patient group often poses a significant challenge. In this context, this review comprehensively summarizes and discusses current insights into surgical treatment options for large prostate volumes (>200 ml) following an extensive literature review.In summary, the surgical treatment of prostate volumes >200 ml is a challenge regardless of the chosen surgical method. Minimally invasive approaches should be considered standard practice today. Anatomical endoscopic enucleation of the prostate is a size-independent method and has the lowest morbidity. As it may be performed in spinal anaesthesia, endoscopic enucleation is feasible in patients with an increased anaesthetic risk. In extremely large prostate glands, the procedure poses challenges even for highly experienced surgeons. Especially in obese patients, the surgeon should be familiar with different exit strategies. Robot-assisted simple prostatectomy provides a minimally invasive alternative that may also treat pathologies such as diverticula or large bladder stones in the same surgical session. Due to its transabdominal approach, the morbidity and anaesthetic risk is comparatively higher. Each centre and surgeon should individually decide in which method they have the greatest expertise and which option is best suited for the specific case. In cases of limited expertise, it is advisable to refer patients to a centre with appropriate specialization.

Real world propensity score matched analysis evaluating the influence of en-bloc vs. non en-bloc techniques, energy and instrumentation on enucleation outcomes for large and very large prostates

PurposeThe primary aim of the study was to evaluate if en-bloc vs. non en-bloc made a difference to intra-, peri- and post-operative surgical outcomes of anatomical endoscopic enucleation (AEEP) in large (> 80 cc) and very large prostates (> 200 cc). The secondary aim was to determine the influence of energy and instruments used.MethodsData of patients with > 80 cc prostate who underwent surgery between 2019 and 2022 were obtained from 16 surgeons across 13 centres in 9 countries. Propensity score matching (PSM) was used to reduce confounding. Logistic regression was performed to evaluate factors associated with postoperative urinary incontinence (UI).Results2512 patients were included with 991 patients undergoing en-bloc and 1521 patients undergoing non-en-bloc. PSM resulted in 481 patients in both groups. Total operation time was longer in the en-bloc group (p < 0.001), enucleation time was longer in the non en-bloc group (p < 0.001) but morcellation times were similar (p = 0.054). Overall, 30 day complication rate was higher in the non en-bloc group (16.4% vs. 11.4%; p = 0.032). Rate of late complications (> 30 days) was similar (2.3% vs. 2.5%; p > 0.99). There were no differences in rates of UI between the two groups. Multivariate analysis revealed that age, Qmax, pre-operative, post-void residual urine (PVRU) and total operative time were predictors of UI.ConclusionsIn experienced hands, AEEP in large prostates by the en-bloc technique yields a lower rate of complication and a slightly shorter operative time compared to the non en-bloc approach. However, it does not have an effect on rates of post-operative UI.

MP20-04 A Comparison Between Robotic Simple Prostatectomy and Endoscopic Enucleation of the Prostate for Management of Benign Prostatic Hyperplasia: A Systematic Review and Meta-Analysis

MP20-04 A Comparison Between Robotic Simple Prostatectomy and Endoscopic Enucleation of the Prostate for Management of Benign Prostatic Hyperplasia: A Systematic Review and Meta-Analysis

Development of endoscopic enucleation of the prostate

This article deals with lasers from their initial description to the most advanced applications in the treatment of benign prostate enlargement.

Antegrade ejaculation preservation in surgical treatment for benign prostatic hyperplasia: quest for balance between voiding and sexual function.

Surgical treatment of benign prostatic hyperplasia (BPH) carries a significant risk of ejaculation dysfunction. Preservation of antegrade ejaculation while providing effective, well tolerated, and durable treatment of BPH is a paramount component of physical and sexual well being for significant number of men. We reviewed available literature with an aim of providing status on antegrade ejaculation preserving BPH surgical therapies. Minimally invasive surgical therapies for BPH have been developed over the last decade, with significant marketing emphasis on their potential for preservation of antegrade ejaculation. However, the question about durability of relief of bladder outlet obstruction remains. Parallel to this technological development, the understanding of anatomical structures involved in ejaculation have resulted in technical modifications of well established surgical treatments modalities like transurethral resection of prostate, endoscopic enucleation of prostate and simple prostatectomy, thereby providing safe and durable relief of bladder outlet obstruction secondary to BPH with a satisfactory preservation of antegrade ejaculation. Preservation of antegrade ejaculation is an important goal for significant number of men needing BPH surgery. Novel minimally invasive surgical technologies have been developed for this purpose; but understanding of the anatomical structures essential for antegrade ejaculation have allowed technical modification of existing surgical techniques with excellent preservation of antegrade ejaculation.