Holmium Laser Enucleation of the Prostate Versus Open Prostatectomy for Prostates >70 g: 24-Month Follow-up

doi:10.1016/j.eururo.2006.04.003

European Urology

Volume 50, Issue 3, September 2006, Pages 563-568

https://doi.org/10.1016/j.eururo.2006.04.003 Get rights and content

Abstract

Objective

Prospectively evaluate perioperative outcomes and 2-yr follow-up after holmium laser enucleation (HoLEP) and standard open prostatectomy (OP) for treating benign prostatic hyperplasia-related obstructed voiding symptoms, with prostates >70 g.

Methods

From March 2003 to December 2004, 80 consecutive patients were randomised for surgical treatment with HoLEP (n = 41) or standard OP (n = 39). All patients were preoperatively assessed with International Prostate Symptom Score and International Index of Erectile Function questionnaires and complete urodynamic evaluation. Intraoperative and perioperative parameters such as blood loss, catheter removal, and hospital stays were assessed. Early and late complications were recorded. Patients were evaluated at 1-, 3-, 12-, and 24-mo follow-ups with the same tests.

Results

Operating room time was significantly shorter for the OP group (72.09 ± 21.22 min vs. 58.31 ± 11.95 min, p < 0.0001); catheter removal (1.5 ± 1.07 d and 4.1 ± 0.5 d, p < 0.001) and hospital stay (2.7 ± 1.1 d vs. 5.4 ± 1.05 d, p < 0.001) were shorter in the HoLEP group. Blood loss was less and blood transfusions fewer in the HoLEP group (p < 0.001). In both groups urodynamic and uroflowmetry findings improved from baseline, were still evident at the 24-mo follow-up, and were comparable between the two groups. Late complications were also comparable.

Conclusions

HoLEP is a feasible technique for treating large prostates. Functional results are similar to OP at the 2-yr follow-up. Reduced catheterisation, hospital stay, and blood loss make HoLEP an attractive option for the treatment of large prostates.

Introduction

Open prostatectomy (OP) is the most common surgical approach for benign prostate hyperplasia (BPH) in large prostates in many parts of Europe [1], [2]. For the past 30 yr, the gold standard treatment for smaller prostates has been transurethral resection of the prostate (TURP) [3], but growing evidence suggests that holmium laser with prostate enucleation (HoLEP) can be an effective and safe alternative with overall functional results similar to standard TURP in terms of relief of subjective symptoms and urodynamic findings [4], [5], [6].

The good results achieved with relatively small prostates have also been confirmed with larger glands. In a series of studies, HoLEP was demonstrated to be safe and effective for the treatment of prostates 80–200 g and had encouraging results in terms of short hospital stay and catheterisation time with low perioperative morbidity [7], [8], [9], [10].

Despite the overall good long-term results and the low reoperation rates after OP, the high perioperative morbidity associated with this approach stresses the need to find an adequate alternative that can reproduce the same functional results and drastically reduce morbidity [11]. However, to our knowledge only one prospective randomised study compares OP with HoLEP for prostates >100 g with a minimum follow-up period of 18 mo [12].

Our paper describes the perioperative findings and 2-yr follow-up results that compare HoLEP and OP for the treatment of patients with urodynamically obstructed BPH with prostates >70 g.

Section snippets

Patients and methods

From March 2003 to December 2004, 80 consecutive patients who suffered from BPH-related obstructed voiding symptoms with prostate volume >70 g, as determined by transrectal ultrasound (TRUS), and who had not responded to pharmacologic therapy were considered eligible for surgical treatment and enrolled in this randomised prospective study. The following inclusion criteria were considered: postvoiding residue <150 ml, peak urinary flow rate <15 ml/s, and urodynamic obstruction (Schäfer grade > 2).

Results

The main characteristics of the patients are shown in Table 1. Time in the operating room was significantly longer for the HoLEP group; catheter removal and hospital stay were significantly shorter in the HoLEP group than in the OP group. Table 2 lists perioperative results from both groups. Blood loss was less (p = 0.0073) and blood transfusions were fewer in the HoLEP group both in terms of autologous (p < 0.001) and homologous (p < 0.007) transfusions. Only one patient from the HoLEP group

Discussion

HoLEP with morcellation has gained increasing credibility as a therapeutic option for bladder outlet obstruction (BOO) caused by symptomatic BPH and has been demonstrated to be at least as reliable and efficacious as TURP for small- to medium-sized prostates [5], [6], [7]. Many authors have described the feasibility and safety of the procedure in patients with larger prostates, especially since the introduction of the morcellator [4], [5], [6], [7], [8], [9], [15]. These results have launched

Conclusions

HoLEP is a safe and minimally invasive technique for the treatment of small and large prostates. Even though HoLEP takes longer to perform than OP, it is associated with reduced perioperative morbidity, significantly shorter catheterisation, and a shorter hospital stay. Furthermore, functional results are comparable at the 2-yr follow-up; thus, HoLEP is an attractive alternative to OP.

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Cited by (326)

Evaluation of Private Payer and Patient Out-of-Pocket Costs Associated With the Surgical Management of Benign Prostatic Hyperplasia
2024, Urology
To evaluate and compare the financial burden of various surgical interventions for the management of benign prostatic hyperplasia (BPH).
We identified commercially insured men with a diagnosis of BPH who underwent a procedure of interest (simple prostatectomy (SP), transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP), photovaporization of the prostate (PVP), prostatic urethral lift (PUL), or water vapor thermal therapy (WVTT)) between 2015 and 2021 with the OptumLabs Data Warehouse. Primary outcome was total health care costs (THC) which included both patient out-of-pocket (OOP) and health plan paid costs for the index procedure and combined follow-up years 1-5. A generalized linear model was used to estimate adjusted costs controlling for demographic and clinical characteristics. Patients undergoing WVTT were excluded from extended follow-up analyses due to limited data.
Among 25,407 patients with BPH, 10,117 (40%) underwent TURP, 6353 (25%) underwent PUL, 5411 (21%) underwent PVP, 1319 (5%) underwent SP, 1243 (5%) underwent WVTT, and 964 (4%) underwent HoLEP. Index procedure costs varied significantly with WVTT being the least costly [THC: $2637 (95% confidence interval (CI): $2513-$2761)], and SP being the costliest [THC: $14,423 (95% CI: $12,772-$16,075)]. For aggregate index and 5-year follow-up costs, HoLEP ($31,926 [95% CI: $29,704-$34,148]) was the least costly and PUL ($36,596 [95% CI: $35,369-37,823]) was the costliest.
BPH surgical treatment is associated with significant system-level health care costs. The level of impact varies between procedures. Minimally invasive options, such as WVTT, may offer initial cost reductions; however, HoLEP and SP are associated with lower follow-up costs.
Advancing Holmium Laser Enucleation of the Prostate Outcomes Reporting: An Assessment of Patient-Reported Outcomes in the Literature
2024, Urology
Holmium laser enucleation of the prostate (HoLEP) is a size-independent option for benign prostatic hyperplasia surgical management. Since lower urinary tract symptoms (LUTS) are a quality-of-life issue, studies should prioritize patient-reported outcomes (PROs). This HoLEP review assesses PROs inclusion in the top 20 cited HoLEP studies and defines their limitations. PROs were categorized by domain: LUTS, incontinence, sexual function, pain, hematuria, and patient satisfaction. On review, no top-cited study included all PRO domains. The nuanced patient experience after HoLEP could be better defined via standardized utilization of validated PROs, while also improving comparability between HoLEP studies.
Summary Paper on the 2023 European Association of Urology Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms
2023, European Urology
Lower urinary tract symptoms (LUTS) are common, often bothersome, and have multifactorial aetiology.
To present a summary of the 2023 version of the European Association of Urology guidelines on the management of male LUTS.
A structured literature search from 1966 to 2021 selected the articles with the highest certainty evidence. The Delphi technique consensus approach was used to develop the recommendations.
The assessment of men with LUTS should be practical. A careful medical history and physical examination are essential. Validated symptom scores, urine test, uroflowmetry, and postvoid urine residual, as well as frequency-volume charts for patients with nocturia or predominately storage symptoms should be used. Prostate-specific antigen should be ordered if a diagnosis of prostate cancer changes the treatment plan. Urodynamics should be performed for selected patients. Men with mild symptoms are candidates for watchful waiting. Behavioural modification should be offered to men with LUTS prior to, or concurrent with, treatment. The choice of medical treatment depends on the assessment findings, predominant type of symptoms, ability of the treatment to change the findings, and the expectations to be met in terms of the speed of onset, efficacy, side effects, and disease progression. Surgery is reserved for men with absolute indications, and for patients who fail or prefer not to receive medical therapy. Surgical management has been divided into five sections: resection, enucleation, vaporisation, and alternative ablative and nonablative techniques. The choice of surgical technique depends on patient’s characteristics, expectations, and preferences; surgeon’s expertise; and availability of modalities.
The guidelines provide an evidence-based approach for the management of male LUTS.
A clinical assessment should identify the cause(s) of symptoms and define the clinical profile and patient’s expectations. The treatment should aim to ameliorate symptoms and reduce the risk of complications.
Urinary incontinence after endoscopic enucleation of the prostate with the Holmium laser: Evolutionary aspects and associated predictive factors
2023, Progres en Urologie
Étudier les aspects évolutifs de l’incontinence urinaire d’effort et de l’incontinence urinaire par urgenturie après HoLEP à travers une série de 200 cas consecutif du même chirurgien puis de rechercher secondairement les facteurs prédictifs de survenue au service d’urologie du Centre hospitalier de Martigues.
Il s’agit d’une étude monocentrique, rétrospective, descriptive et analytique menée dans le service d’urologie du Centre hospitalier de Martigues. Ont été inclus dans l’étude tous les patients ayant été traités par HoLEP pour une hypertrophie bénigne de la prostate (HBP) entre septembre 2017 et mars 2021. Les patients ayant un âge supérieur à 75 ans, obèses ( IMC > 30) ou avec une maladie neurologique ont été exclus de cette étude.
Entre septembre 2017 à mars 2021, 204 patients ont été inclus dans notre étude. Le taux d’incontinence urinaire moyen était de 21,2 % 12,2 % 7,4 % et 2,7 % à respectivement 1 mois, 3 mois, 6 mois et 12 mois. Le taux d’incontinence urinaire d’effort était respectivement de 5,4 %, 9,2 %, 5,6 % et 1,8 % à respectivement 1 mois, 3 mois, 6 mois et 12 mois post HoLEP. Le taux d’incontinence urinaire par urgenturie était évaluée à 13,3 %, 3 % 1,8 % et 0,9 % à respectivement M1 M3 M6 et M12 post HoLEP. La dysfonction érectile pré opératoire, l’énergie délivrée, le poids prostatique énuclée et le temps total de l’intervention per opératoire étaient statistiquement associé à le survenue d’incontinence urinaire d’effort en post opératoire. Le temps operatoire et un Qmax operatoire faible étaient statistiquement associé à le survenue d’incontinence urinaire d’effort en post opératoire.
L’HoLEP est à risque d’une incontinence urinaire en post opératoire. L’information préopératoire des patients sur le risque d’incontinence urinaire est indispensable.
To study the evolutionary aspects of stress urinary incontinence and urinary incontinence by urgency after HoLEP through a series of 200 consecutive cases of the same surgeon then to seek secondarily the predictive factors of occurrence in the service of urology of the Hospital Center of Martigues.
This was a monocentric, retrospective, descriptive and analytical study conducted in the urology department of the Martigues Hospital. All patients who were treated with HoLEP for benign prostatic hypertrophy (BPH) between September 2017 and March 2021 were included in the study. Patients with an age greater than 75 years, obese (BMI > 30) or with neurological disease were excluded from this study.
Between September 2017 and March 2021, 204 patients were included in our study. The average urinary incontinence rate was 21.2% 12.2% 7.4% and 2.7% at 1 month, 3 months, 6 months and 12 months respectively. The rate of stress urinary incontinence was 5.4%, 9.2%, 5.6% and 1.8% at 1 month, 3 months, 6 months and 12 months post HoLEP respectively. Urge urinary incontinence was estimated at 13.3%, 3%, 1.8% and 0.9% at M1, M3, M6 and M12 post-HoLEP respectively. Preoperative erectile dysfunction, delivered energy, enucleated prostate weight and total intraoperative time were statistically associated with the occurrence of stress urinary incontinence postoperatively. The operative time and a low operative Qmax were statistically associated with the occurrence of postoperative stress urinary incontinence.
HoLEP is at risk of postoperative urinary incontinence. Preoperative information of the patients on the risk of urinary incontinence is essential.
Evaluation of the Cost-Effectiveness of Surgical Treatment Options for Benign Prostatic Hyperplasia
2023, Urology
To compare the cost-effectiveness of surgical interventions for BPH.
Using a Markov model, a cost-utility analysis was performed comparing HoLEP, B-TURP, WVTT, and PUL for prostate size <80cc (index patient 1) and HoLEP and SP for prostate size >80cc (index patient 2). Model probabilities and utility values were drawn from the literature. Analysis was performed at a 5-year time horizon with extrapolation to a lifetime horizon. Primary outcomes included quality-adjusted life years (QALYs), 2021 Medicare costs, and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100,000/QALY. Univariate and probabilistic sensitivity analyses were performed.
At 5 years, costs per patient for index patient 1 were $3292 (WVTT), $6532 (HoLEP), $6670 (B-TURP), and $10,257 (PUL). HoLEP resulted in the highest QALYs (4.66), followed by B-TURP (4.60), PUL (4.38), and WVTT (4.38). This translated to HoLEP being most cost-effective (ICER $11,847). For index patient 2, HoLEP was less costly ($6,585 vs $15,404) and more effective (4.654 vs 4.650) relative to SP. On sensitivity analysis for index patient 1, B-TURP became most cost-effective if cost of HoLEP increased two-fold or chronic stress incontinence following HoLEP increased ten-fold. When follow-up time was varied, WVTT was preferred at very short follow up (<1 year), and HoLEP became more strongly preferred with longer follow up.
At 5 years follow up, HoLEP is a cost-effective surgical treatment for BPH- independent of gland size.
Impact of Surgery for Benign Prostatic Hyperplasia on Sexual Function: A Systematic Review and Meta-analysis of Erectile Function and Ejaculatory Function
2022, European Urology Focus
Several sexual side effects, including erectile, ejaculatory, and orgasmic dysfunction, were reported with the majority of surgical procedures for benign prostatic obstruction (BPO).
To systematically review current evidence regarding the impact of benign prostatic hyperplasia (BPH) surgery on sexual function.
A comprehensive bibliographic search on the MEDLINE, Cochrane Library, Embase, Web of Science, and Google Scholar databases was conducted in July 2021. The population, intervention, comparator, and outcome (PICO) model was used to define study eligibility. Studies were Included if they assessed patients with BPO and related lower urinary tract symptoms (P) undergoing BPH surgery (I) with or without a comparison between surgical treatments (C) evaluating the impact on sexual function (O). Retrospective and prospective primary studies were included. A pooled analysis was conducted on studies including the postoperative assessment of International Index of Erectile Function (IIEF)-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD; Function and/or Bother), or retrograde ejaculation (RE) rate (PROSPERO database ID: CRD42020177907).
A total of 151 studies investigating 20 531 patients were included. Forty-eight randomized controlled trials evaluating 5045 individuals were eligible for the meta-analysis. In most studies (122, 80.8%), only erectile and/or ejaculatory function was evaluated. A substantial number of articles (67, 44.4%) also used nonvalidated tools to evaluate erectile and/or ejaculatory function. The pooled analysis showed no statistically significant changes in IIEF-5 score compared with baseline for the transurethral resection of the prostate (TURP; weighted mean difference [WMD] 0.76 pts; 95% confidence interval [CI] –0.1, 1.62; p = 0.08), laser procedure (WMD 0.33 pts; 95% CI –0.1, 0.77; p = 0.13), and minimally invasive treatment (WMD –1.37 pts; 95% CI –3.19, 0.44; p = 0.14) groups. A statistically significantly higher rate of RE was found after TURP (risk ratio [RR] 13.31; 95% CI 8.37, 21.17; p < 0.00001), other electrosurgical procedures (RR 34.77; 95% CI 10.58, 127.82; p < 0.00001), and the entire laser group (RR 17.37; 95% CI 5.93, 50.81; p < 0.00001). No statistically significant increase in RE rate was described after most of the minimally invasive procedures (p > 0.05). The pooled analysis of MSHQ-EjD scores was possible only for prostatic urethral lift, showing no statistically significant difference between baseline and post-treatment MSHQ-EjD Function scores (WMD –0.80 pts; 95% CI –2.41, 0.81; p = 0.33), but postoperative MSHQ-EjD Bother scores were significantly higher (WMD 0.76 pts; 95% CI 0.22, 1.30; p = 0.006).
Erectile function appears to be unaffected by most surgical procedures for BPO. RE is a very common adverse event of BPH surgery, although emerging minimally invasive surgical procedures could be associated with a lower risk.
Benign prostatic hyperplasia surgery can have an impact on sexual function, mainly involving ejaculatory function.

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Benign Prostatic ObstructionHolmium Laser Enucleation of the Prostate Versus Open Prostatectomy for Prostates >70 g: 24-Month Follow-up

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusions

Urology

Urology

J Urol

J Urol

J Urol

Urology

Eur Urol

Urology

J Urol

Urology

Urology

J Urol

J Urol

Benign Prostatic Obstruction
Holmium Laser Enucleation of the Prostate Versus Open Prostatectomy for Prostates >70 g: 24-Month Follow-up