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Purpose: To evaluate perioperative parameters, clinical outcomes, and the learning curve of holmium laser enucleation of the prostate (HoLEP) of a single surgeon in 500 consecutive cases., Methods: Demographic parameters, outcomes, and adverse events were evaluated. The learning curve for HoLEP in en-bloc technique of the first 500 consecutive patients was analyzed in clusters of 100 (clusters 1-5) using the Wilcoxen rank test, Chi² test and Kruskal Wallis test., Results: Enucleation weight was similar in the clusters 1,2,3, and 5 (62 g, 63 g, 61 g, 61 g), in cluster 4 it was slightly higher at 73 g. There was a significant reduction in operating time from 67 min (cluster 1) to 57 min (cluster 2), 46 min (cluster 3), 53 min (cluster 4), and 43 min (cluster 5), p < 0.001. Enucleation efficiency (g/min) showed a steady increase (1.72, 2.24, 2.79, 2.92 vs. 2.99, p < 0.001). Laser energy efficiency also improved (2.17 vs. 2.12 vs. 1.71 vs. 1.65 vs. 1.55; p < 0.001). There was no measurable learning curve regarding the length of hospital stay (mean 2.5 days), catheterization time (1.9 days), hemoglobin drop (approx. 1 g/dl) or complications (p > 0.1)., Conclusions: HoLEP using the en-bloc technique is a safe and highly effective method. Over time, a slight but steady learning curve and improvement in operation time, enucleation efficiency and laser energy efficiency were shown even for an experienced surgeon - after 500 cases, still no plateau was reached. There was no measurable learning curve regarding blood loss, complications, length of hospital stay, and catheterization time., (© 2024. The Author(s).)

As life expectancy increases and there is growing demand for BPH treatments, innovative technologies have been developed, allowing for swift recovery, symptom relief, low complication rates, and the possibility of performing procedures on an outpatient basis, often under local anaesthesia. This review aims to describe the outcomes of newly developed minimally-invasive surgical therapies (MIST) for BPH treatment in terms of functional voiding parameters and sexual function. These therapies are categorized into primarily ablative (Aquablation [Aquabeam]), non-ablative (Prostatic Urethral Lift (PUL, Urolift), temporary implantable devices [iTind]), and secondarily ablative procedures (convective water vapor ablation, Rezum, Prostate Artery Embolization [PAE]). All MIST technologies have advanced the medical care of patients with BPH while preserving ejaculation. However, there is a shortage of long-term data specifically addressing re-intervention rates and the preservation of functional voiding parameters. Although there is promising data from regulatory trials and randomized studies, all MIST therapies are potentially associated with severe complications. Patients considering such methods must be thoroughly informed about their inferiority compared with established transurethral procedures like TUR-P and enucleation., Competing Interests: C. Netsch: R. Wolf (Consultant, Proctor); B. Becker: R. Wolf (Consultant, Proctor); A. Gross: R. Wolf (Consultant, Proctor); T. R.W. Herrmann: K. Storz (Consultant, Proctor), (Thieme. All rights reserved.)

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., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

The need for intervention due to postoperative bleeding represents a significant complication in Thulium Laser Enucleation of the Prostate (ThuLEP). This study aimed to retrospectively analyse this complication in the treatment of benign prostatic enlargement. This study focuses on investigating potential causative factors for postoperative bleeding requiring intervention as well as the use of intraoperative electrocoagulation. A total of 503 ThuLEP procedures performed between 08/2021 and 07/2022 were examined. Postoperatively, 4.2% (n=21) of patients experienced bleeding requiring intervention. Study data revealed a significant association between these instances of bleeding and a high prostate volume (p=0.004), high enucleation weight (p=0.004), and intraoperative electrocoagulation (p=0.048). In total, intraoperative electrocoagulation was applied in 41.2% (n=207) of cases. In these cases, statistically significant factors leading to the application of electrocoagulation included intraoperative capsule perforation (p=0.005) and high enucleation weight (p=0.002)., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

This article deals with lasers from their initial description to the most advanced applications in the treatment of benign prostate enlargement., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: To identify expert laser settings for BPH treatment and evaluate the application of preventive measures to reduce complications., Methods: A survey was conducted after narrative literature research to identify relevant questions regarding laser use for BPH treatment (59 questions). Experts were asked for laser settings during specific clinical scenarios. Settings were compared for the reported laser types, and common settings and preventive measures were identified., Results: Twenty-two experts completed the survey with a mean filling time of 12.9 min. Ho:YAG, Thulium fiber laser (TFL), continuous wave (cw) Tm:YAG, pulsed Tm:YAG and Greenlight™ lasers are used by 73% (16/22), 50% (11/22), 23% (5/22), 13.6% (3/22) and 9.1% (2/22) of experts, respectively. All experts use anatomical enucleation of the prostate (EEP), preferentially in one- or two-lobe technique. Laser settings differ significantly between laser types, with median laser power for apical/main gland EEP of 75/94 W, 60/60 W, 100/100 W, 100/100 W, and 80/80 W for Ho:YAG, TFL, cwTm:YAG, pulsed Tm:YAG and Greenlight™ lasers, respectively (p = 0.02 and p = 0.005). However, power settings within the same laser source are similar. Pulse shapes for main gland EEP significantly differ between lasers with long and pulse shape modified (e.g., Moses, Virtual Basket) modes preferred for Ho:YAG and short pulse modes for TFL (p = 0.031)., Conclusion: Ho:YAG lasers no longer seem to be the mainstay of EEP. TFL lasers are generally used in pulsed mode though clinical applicability for quasi-continuous settings has recently been demonstrated. One and two-lobe techniques are beneficial regarding operative time and are used by most experts., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Context: Although several studies have compared different morcellators and enucleation techniques for the management of benign prostatic hyperplasia (BPH), there is sparse literature on morcellation, so further experimental and clinical research is required for its optimization., Objective: To critically appraise the contemporary literature on prostate morcellation and to evaluate the safety and efficiency of currently available morcellators for endoscopic enucleation of the prostate (EEP) in the context of BPH., Evidence Acquisition: A comprehensive review of the English and French literature relevant to prostate morcellation was performed using the PubMed-MEDLINE, Cochrane Library, Web of Science, and Wiley Online Library database from 1998 to 2020 using PICOS (patient population, intervention, comparison, outcome, and study design) criteria., Evidence Synthesis: We retrieved 26 studies involving 5652 patients treated with a morcellator that were eligible for data extraction and analysis. The mean patient age was 67.4 (range 61.4-72.8) yr. The weighted mean efficiency of Piranha, VersaCut, and DrillCut morcellators was 5.29, 3.95, and 5.3 g/min, respectively. Several approaches, such as en bloc, two-lobe, inverse, and improved techniques, may increase morcellation efficiency and safety. The lowest weighted mean rate of bladder wall injury was 1.24% for Piranha, followed by 1.98% for DrillCut, and 5.23% for VersaCut, while the VersaCut morcellator had the lowest weighted mean rate of device malfunction at 0.74%, compared to 2.07% for Piranha and 7.86% for DrillCut., Conclusions: All three morcellators are efficient and safe for prostatic morcellation after EEP. Further development of devices and techniques may improve the efficiency and safety profile of morcellation. To increase safety, surgeon expertise, technical equipment, and patient characteristics should be considered. Therefore, interdisciplinary exchange of knowledge and further technological innovations are strongly encouraged., Patient Summary: We reviewed the safety and efficacy of devices called morcellators. These devices cut tissue into small pieces that are easier to remove from the body, and are used during laser surgery for benign enlargement of the prostate. Three morcellators are currently available on the market and are comparable in safety and efficacy., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Treatment of lower urinary tract symptoms secondary to benign prostatic obstruction may affect ejaculatory function. However, preservation of ejaculation via minimally invasive surgical therapies might impair the long-term durability of voiding improvement., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: Transurethral resection of the prostate and open prostatectomy have been the standard of care for the surgical treatment of benign prostatic obstruction (BPO) over decades. New emerging techniques for the surgical management of BPO have been currently introduced, but might be associated with new, unusual complications., Methods: We herewith report on two patients with a rectal perforation after aquablation treatment of BPO., Results: In the first case, the diagnosis was made 2 days after the aquablation procedure due to unspecific postoperative symptoms. A complex combined open/endoscopic repair of the defect was carried out thereafter. As a consequence, a rectoscopy was routinely performed since then following each aquablation procedure. In the second case, intraoperative rectoscopy after uneventful aquablation revealed the rectal perforation. The perforation was clipped immediately with an over the scope-clip by colonoscopy., Conclusions: These two cases of a rectal perforation after aquablation of the prostate demonstrate an unusual complication and its complex management. Diagnostic delay complicates its treatment. Therefore, immediate rectoscopy should be performed routinely after the aquablation procedure., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Due to demographic changes in today's society, the number of patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) is increasing. Similarly, the proportion of patients with cardiovascular risk factors undergoing antiplatelet (AP) or anticoagulation (AC) therapy is growing as well., Methods: This review discusses the current literature on various techniques used for anatomic endoscopic enucleation of the prostate (AEEP) in patients on AC/AP therapy., Results: The large number of energy sources used for AEEP makes it difficult to compare them. Overall, fewer bleeding-associated complications arise in patients under AP compared to AC or bridging therapy with low molecular weight heparin. However, perioperatively both AP and AC therapy lead to a higher risk of bleeding complications compared to patients not taking anticoagulants., Conclusions: The literature shows that AEEP is possible and efficacious in patients under AC/AP therapy, with only slight differences compared to patients not taking AC/AP drugs, on a short and long-term basis. Nevertheless, the sparse data, the retrospective nature of many studies and the inclusion of prostate sizes between 50 and 110 ml only, make it difficult to come to strong conclusions., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To summarize the current evidence and the reasons to go for thulium-based anatomical endoscopic enucleation of the prostate (AEEP)., Methods: This review discusses the available literature on thulium-based AEEP., Results: Thulium lasers operate at a wavelength between 1940 and 2013 nm. This wavelength, which has a low penetration depth in water, allows to perform smooth cuts in the prostatic tissue and allows urologists to perform various procedures: resection, vaporization, enucleation, or vapoenucleation of the prostate. Depending on the type of thulium laser, it can be used either in a continuous, or pulsed mode., Conclusion: In recent years, an increasing amount of evidence has described the thulium laser as a minimally invasive and size-independent treatment option for benign prostatic enlargement with excellent long-term results., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Surgical treatment of benign prostatic obstruction (BPO) is one of the most common procedures in urology. Numerous alternative methods have been developed in recent years to overcome the potential limitations of transurethral resection of the prostate (TURP) while providing comparable effectiveness and less morbidity. In a randomized study with a currently available follow-up of 3 years, the Aquabeam® system has shown comparable functional results with a lower rate of adverse events compared to TURP. Sufficient functional results were also found in a cohort study in patients with prostate volumes up to 150 ml. However, the rate of transfusions raises the question of optimal coagulation. Further cohort studies with short-term follow-up confirmed the results of the randomized studies. Prostate artery embolization (PAE) has been compared to TURP in several randomized trials. In randomized studies, the reduction of BPO-associated symptoms after PAE is only slightly inferior to that after TURP. In contrast, the improvement of functional parameters after embolization is inferior to that after TURP. This is primarily due to the inferior desobstruction. In addition, long-term results from randomized studies are lacking, so that no final assessment has yet been possible with regard to the durability of the desobstruction. In summary, both Aquabeam® and PAE are potential alternatives to standard methods, which-in case of adequate patient selection-can supplement the operative armamentarium in the wider concept of an individualized therapy of BPO.

Thulium lasers operate at wavelengths between1940-2013 nm either in a continuous wave or in a pulsed mode, which enables smooth incisions with fast vaporization or effective laser lithotripsy for urolithiasis. Thulium laser enucleation is a minimally invasive and size-independent treatment for benign prostatic hyperplasia (BPH) with excellent long-term results. Since its introduction, several modifications in the technology and surgical techniques have been proposed such as vaporesection, vaporization and enucleation with regard to BPH treatment. Recent developments in the thulium laser technology include the introduction of a super pulsed thulium fiberlaser.  This technique delivers the laser energy through anactive fiber with an absorption maximum in water at awavelength of 1940 μm. Preclinical studies showed asignificantly higher stone fragmentation rate in differentex vivo models compared to the Ho:YAG laser. Another innovative thulium laser that works, as a hybrid laser has yet not been tested clinically, however, will soon be introduced. With the introduction of both new thulium lasers as novel devices, the armamentarium in the field of endourology for lithotripsy and enucleation increases. We here present different thulium lasers and surgical techniques that are possible to perform with each device including the reasons and advantages of each modification.

Objective: To compare the efficacy and safety of a novel thulium fiber laser for endoscopic enucleation of the prostate with monopolar transurethral resection of the prostate in patients with smaller glands (<80 cc)., Methods: A total of 51 patients underwent thulium fiber laser enucleation of the prostate, and 52 patients underwent monopolar transurethral resection of the prostate. All patients were assessed preoperatively, and at 3, 6, and 12 months postoperatively (International Prostate Symptom Score, maximum urine flow rate, International Prostate Symptom Score-quality of life). Preoperative prostate volumes and prostate-specific antigen levels were comparable (P = 0.543 and P = 0.078, respectively). The complications were graded according to the Clavien classification., Results: Mean surgery time was longer in the thulium fiber laser enucleation of the prostate group (46.6 ± 10.2 vs 39.9 ± 8.6 min, P < 0.001), while catheterization and hospital stay were greater in the transurethral resection of the prostate group (P < 0.001). At 12 months, there were no differences in functional outcomes (International Prostate Symptom Score, maximum urine flow rate). Despite comparable prostate volumes at 12 months (P = 0.864), the prostate-specific antigen level in the thulium fiber laser enucleation of the prostate group (0.5 ± 0.5 ng/mL) was lower than in the transurethral resection of the prostate group (1.1 ± 1.0 ng/mL; P < 0.001). Hemoglobin and serum sodium decrease was lower in the thulium fiber laser enucleation of the prostate group (1.01 ± 0.4 g/dL and 1.1 ± 1.1 mmol/L) than in the transurethral resection of the prostate group (1.8 ± 0.8 g/dL and 4.1 ± 1.1 mmol/L; P < 0.001). Urinary incontinence rates at 12 months were comparable (P = 0.316)., Conclusions: Thulium fiber laser enucleation of the prostate with novel thulium fiber laser in patients with smaller prostate glands (<80 cc) is comparable to transurethral resection of the prostate in voiding parameters improvement and complication rates. At the same time, the technique allows for a more substantial prostate-specific antigen decrease, indicating more complete removal of adenoma., (© 2019 The Japanese Urological Association.)

The purpose of this prospective study of 90 consecutive patients is to assess the long-term durability of ThuVEP in patients with benign prostatic hyperplasia (BPH) and prostate volumes ≥ 85 ml. Ninety patients with prostates ≥ 85 ml underwent ThuVEP between 2008 and 2010 at our institution. Patient demographics and short-term and long-term follow-up were evaluated. Maximum urinary flow rate (Qmax), post-void residual urine (PVR), international prostate symptom score (IPSS), quality of life (QoL), complications, and PSA were assessed at follow-up. Median age at surgery was 71 (66-75.25) years. Thirty-seven (41.1%) of the patients were in urinary retention at the time of surgery. Prostate volume was 100 (88-122) ml. Median follow-up was 36.5 (16-60) months. At 12-month follow-up, IPSS, QoL, Qmax, and PVR had improved significantly compared with preoperative assessment and continued to do so during follow-up (p < 0.001). At 4-year postoperative, median Qmax (19.1 vs. 7.75 ml/s), PVR (31.9 vs. 150 ml), IPSS (4.5 vs. 24), and QoL (1 vs. 5) differed significantly from baseline (p ≤ 0.027). PSA decreased from 7.4 (4.14-14) to 0.70 (0.36-1.64) μg/l (p < 0.001) at 48-month follow-up, corresponding to a PSA reduction of 86.48% (79.85-95.25%). Urinary tract infections occurred in 2 (2.2%) patients. Urethral stricture and bladder neck contracture developed in 1 (1.1%) patient each. One patient (1.1%) had recurrent adenoma of the prostate and was treated with thulium vaporesection of the prostate. ThuVEP is a durable modern alternative to open prostatectomy for patients with substantially enlarged prostates due to BPH. The incidence of complications with ThuVEP during long-term follow-up was low.

Purpose: Aquablation of the prostate using the AquaBeam™ system promises equivalent functional outcomes, reduced learning curve, and improved sexual function compared to transurethral prostate resection as shown in prospective randomized trials. This prospective cohort study aims to evaluate if published results can be transferred into the clinical routine in a non-selected patient collective., Methods: This study includes all patients treated between September 2017 and June 2018 with Aquablation of the prostate. Patients have been evaluated prospectively for the perioperative course and early follow-up. Besides voiding parameter and symptom score, TRUS-volume change, ejaculatory function, and adverse events have been recorded., Results: 118 consecutive patients have been treated in the given time. Aquablation could be carried out successfully in all patients. IPSS, QoL, Qmax, and PVR improved significantly after the procedure and continued to improve during 3-month follow-up. Mean OR time was 20 min, TRUS volume decreased by 65%, and 73% of the patients retained antegrade ejaculation. Thirteen adverse events (> Clavien-Dindo I) occurred in 10 patients., Conclusion: The surgical ablation of the prostate using Aquablation achieved significant and immediate improvement of functional voiding parameters Qmax and PVR as well as symptomatic improvement of IPSS and QoL. Aquablation seems to be safe and effective with a low perioperative complication profile even in a non-selected group of patients.

The spectrum of surgical procedures for the minimally invasive treatment of benign prostatic hyperplasia (BPH) has significantly increased over the last two decades. The simple suprapubic prostatectomy (subtotal prostatectomy, SP) has largely lost relevance in current practice. On the other hand, transurethral resection of the prostate (TURP) has been further standardized and potentially made safer by the introduction of the bipolar technique and low-pressure systems.Transurethral (endoscopic) enucleation techniques (endoscopic enucleation of the prostate, EEP) are increasingly competing with the current gold standard TURP and are replacing SP for treatment of larger adenomas. This approach is especially related to the rapid development of laser technology, which has sustainably changed the face of modern BPH treatment in a similar way to stone therapy. This has been incorporated in the clinical patient management, clinical studies and standardization of numerous surgical techniques that are systematically described in this article. Additionally, efforts have also been made to use other energy sources, such as bipolar current in EEP. With respect to scientific objectivity, high-quality clinical trials are regularly published which further strengthen the position of EEP.

Introduction and Objectives: To evaluate the safety of holmium laser enucleation of the prostate (HoLEP) in patients on oral anticoagulation (OA) with respect to intra- and postoperative bleeding complications., Methods: Between January 2013 and October 2016, 2178 patients were included in this study, of whom 94 received direct oral anticoagulants (DOACs) and 151 received vitamin K antagonists (VKAs) before HoLEP. All patients either ceased OA (DOACs) or were bridged subtherapeutically (VKAs, international normalized ratio <2) during surgery. These patients were compared to a sample size of 1933 nonanticoagulated patients., Results: A significant longer postoperative stay was noted for the patients on DOACs (5.2 [4-6] days) and VKAs (5.3 [4-5] days) compared to the control group (4.5 [4-4] days). The mean drop in hemoglobin was significantly higher in the VKA group compared to the DOAC and control group. There was a significantly higher rate of postoperative bladder tamponades/secondary coagulation in patients on OA with 6 (7.9%)/3 (3.9%) patients in the DOAC group, 10 (7.4%)/6 (4.4%) patients in the VKA group compared to 37 (2.2%)/21 (2.1%) patients in the control group, respectively (p < 0.001). Eight patients required blood transfusions with a distribution of 1 (1.3%), 3 (2.2%), and 4 (0.2%) patients in the DOAC, VKA, and control group, respectively (p < 0.001)., Conclusions: Our findings indicate that bridged patients who's DOACs and VKAs were ceased before HoLEP are at higher risk of intra- and postoperative bleeding complications. Nonetheless, HoLEP appears to be a safe and effective procedure in those patients.

Purpose: We compared the perioperative and postoperative characteristics of thulium vapoenucleation and holmium laser enucleation of the prostate for the treatment of large volume benign prostatic hyperplasia., Materials and Methods: A total of 94 patients with benign prostatic hyperplasia and a median prostate size of 80 (IQR 46.75-100) cc were either randomized to thulium vapoenucleation or holmium laser enucleation of the prostate. Patients were assessed preoperatively, 1 and 6 months postoperatively., Results: The median operative time was 60 (IQR 41-79) min without significant differences between the groups. There were no significant differences between the groups regarding catheter time [2 (IQR 2-2) days] and postoperative stay [2 (IQR 2-3) days]. Clavien 1 (13.8%), 2 (3.2%), 3a (2.1%), and Clavien 3b (4.3%) complications occurred without significant differences between the groups. At 6-month follow-up, median maximum flow rate (10.7 vs. 25.9 ml/s), post-void residual urine (100 vs. 6.5 ml), I-PSS (20 vs. 5), quality of life (4 vs. 1), PSA (4.14 vs. 0.71 µg/l), and prostate volume (80 vs. 16 ml) had improved significantly (p < 0.001) compared to baseline without significant differences between the groups. Median PSA decrease was 79.7% (58.8-90.6%) and prostate volume reduction was 74.5% (68.57-87.63%) without differences between the groups. The reoperation rate was zero at 6-month follow-up., Conclusions: Thulium vapoenucleation and holmium laser enucleation of the prostate are safe and effective procedures for the treatment of large volume benign prostatic hyperplasia. Both procedures give satisfactory micturition improvement with low morbidity and sufficient prostate volume reduction at 6-month follow-up.

Endoscopic enucleation of the prostate (EEP) techniques such as HoLEP (holmium laser enucleation of the prostate), ThuLEP (thulium laser enucleation of the prostate) and electroenucleation (mono- or bipolar) are highly effective and safe. They have been endorsed by the latest version of the European Association of Urology guidelines as an alternative to not only open adenomectomy but also transurethral resection of the prostate (EAU Guidelines on Treatment of Non-neurogenic Male LUTS 2018). Therefore, many urologists face the possibility of replacing the treatments of BPH. In this article, we analyze the history of EEP techniques, both their pros and cons and, what are they today - just a popular trend or a new standard procedure for the surgical treatment of BPH?

Purpose: To analyze the 12-month outcomes of low-powered holmium laser enucleation of the prostate (LP-HoLEP) for patients with symptomatic benign prostatic obstruction (BPO)., Methods: A total of 54 patients with symptomatic BPO were treated with LP-HoLEP. All patients were treated by two experienced LP-HoLEP surgeons. A 50-W Ho:YAG laser was used at 39.6-W (2.2 J, 18 Hz). All patients were assessed preoperatively by International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), post-void residual urine (PVR), PSA, and whole prostate volume measurement by transrectal ultrasound. The patients were reassessed at 1-, 6-, and 12-month follow-up. The complications were classified according to the modified Clavien classification system. Patient data were expressed as median (interquartile range) or numbers (%)., Results: The median age was 72.5 (67-77.25) years and the median preoperative prostate volume 74.5 (45-110) ml. 12 (22.2%) patients were treated with ongoing anticoagulant treatment. The median operative time was 65 (41-81) min and the enucleation efficiency 1.11 (0.82-1.79) g/min, respectively. Clavien 1 (11.1%), Clavien 2 (3.7%), Clavien 3a (3.7%), and Clavien 3b (5.5%) complications occurred. At 6-month follow-up, median prostate volume (74.5 vs. 15.5 ml) and PSA (4.03 vs. 0.54 µg/l) had improved significantly compared to baseline (p ≤ 0.009). At 12-month follow-up, Qmax (12 vs. 29.3 ml/s), PVR (155 vs. 11.15 ml), IPSS (22 vs. 6) and QoL (5 vs. 1) had improved significantly (p < 0.001)., Conclusions: LP-HoLEP is technically feasible, safe and effective for the treatment of symptomatic BPO. For experienced surgeons, power is less relevant than technique.

Introduction: To evaluate the intermediate-term outcomes of thulium vapoenucleation of the prostate (ThuVEP) and thulium vaporesection of the prostate (ThuVaRP) in patients with benign prostate obstruction (BPO)., Materials and Methods: A bicentric retrospective matched-paired comparison of patients treated by ThuVEP (n = 80) or ThuVaRP (n = 80) was performed. The patients were preoperatively assessed with International Prostate Symptom Score (IPSS), quality of life (QoL), post-void residual urine (PVR), maximum urinary flow rate (Qmax), prostatespecific antigen (PSA) and re-evaluated at 12- and 24-month follow-up., Results: Median prostate volume was 65 mL and not different between the groups. The immediate re-operation rate was significantly different between ThuVEP and ThuVaRP (5 vs. 0%, p ≤ 0.0434). IPSS, QoL, Qmax and PVR had improved significantly compared to preoperative assessment in both groups at 12- and 24-month follow-up (p ≤ 0.001). Median Qmax (18.2 vs. 21.0 mL/s) and PVR (29.4 vs. 0 mL) were significantly different between ThuVEP and ThuVaRP at 24-month follow-up (p ≤ 0.001), while IPSS and QoL showed no differences between the groups. However, the PSA reduction was significantly higher after ThuVEP compared to ThuVaRP (78.93 vs. 23.39%, p ≤ 0.006) at 24-month follow-up., Conclusions: ThuVEP and ThuVaRP are safe and efficacious procedures for patients with BPO. Although the peri-operative re-intervention rates were lower after ThuVaRP, the low PSA reduction rate after ThuVaRP at 24-month follow-up favours the ThuVEP procedure., (© 2017 S. Karger AG, Basel.)

Background: Transurethral resection of the prostate (TURP) is considered to be the standard treatment for patients with benign prostatic obstruction (BPO) ≤80 mL. However, up to 14.7% of the patients require secondary TURP due to recurrent BPO. The aim of our study was to describe specific features of holmium laser enucleation of the prostate (HoLEP) and thulium laser enucleation of the prostate (ThuLEP) in patients with recurrent BPO after previous prostate surgery., Materials and Methods: A total of 768 consecutive patients from our prospective collected database were retrospectively reviewed and divided into 4 groups: group A (489 patients) and group C (253 patients) underwent primary HoLEP and ThuLEP treatment, while group B (17 patients) and D (9 patients) included patients with recurrent BPO who were treated with HoLEP and ThuLEP, respectively., Results: There were no significant differences in preoperative parameters between the groups at primary (A and C) and secondary (B and D) treatment except their age. At 6-month follow-up, voiding parameters and symptom scores showed statistically significant improvements compared to baseline without differences between the groups. The mean operative time was comparable between the groups and did not differ significantly (p > 0.05)., Conclusions: Laser enucleation for the treatment of recurrent BPO is feasible and seems to be a safe and effective procedure., (© 2018 S. Karger AG, Basel.)

Introduction and Objectives: To compare the perioperative outcomes of thulium vapoenucleation of the prostate (ThuVEP) with holmium laser enucleation of the prostate (HoLEP) for patients with symptomatic benign prostatic obstruction (BPO)., Methods: Forty-eight and 46 patients were prospectively randomized to ThuVEP and HoLEP. All patients were assessed preoperatively and 4-week postoperatively. The complications were noted and classified according to the modified Clavien classification system. Patient data were expressed as median (interquartile range) or numbers (%)., Results: Median age at surgery was 73 (67-76) years and median prostate volume was 80 (46.75-100) cc and not different between the groups (p = 0.207). The median operative time was 60 (41-79) minutes without significant differences between both groups (p = 0.275). There were no significant differences between the groups regarding catheterization time [2 (2-2) days, p = 0.966] and postoperative stay [2 (2-3) days, p = 0.80]). Clavien 1 (13.8%), Clavien 2 (3.2%), Clavien 3a (2.1%), and Clavien 3b (4.3%) complications occurred without significant differences between the groups. However, the occurrence of acute postoperative urinary retention was higher after HoLEP compared to ThuVEP (15.2 vs. 2.1%, p ≤ 0.022). At 1-month follow-up, peak urinary flow rates (10.7 vs. 22 ml/s), post-void residual volumes (100 vs. 20 ml), International Prostate Symptom Score (20 vs. 10) and Quality of Life (4 vs. 3) had improved significantly (p ≤ 0.005) without significant differences between the groups., Conclusions: ThuVEP and HoLEP are safe and effective procedures for the treatment of symptomatic BPO. Both procedures give equivalent and satisfactory immediate micturition improvement with low perioperative morbidity.

Introduction and Objectives: To assess the 5-year outcomes of thulium vapoenucleation of the prostate (ThuVEP) in patients with benign prostatic obstruction (BPO) retrospectively., Methods: Five-hundred patients were treated with ThuVEP between January 2007 and January 2010 at our institution. Patients were reassessed 1 and 5-years after ThuVEP with International Prostate Symptom Score (IPSS), Quality of Life (QoL), urinary peak flow (Qmax), postvoid residual volume (PVR), PSA and prostate volume. Patient data were expressed as median (interquartile range)., Results: One-hundred and thirty-one patients completed the 5-year follow-up. According to preoperative prostate volume, patients were divided into two groups: group A (<60 ml, n = 80) and B (≥60 ml, n = 51). IPSS, QoL, Qmax, and PVR improved significantly at discharge and continued to do so during 5-year follow-up (p ≤ 0.001). At 1-year follow-up, prostate volume had decreased significantly (50 vs. 13 mL, p < 0.001) corresponding to a prostate volume reduction of 80.8%. PSA was significantly reduced at 5-year (0.72 µg/l) follow-up compared to preoperative PSA (3.39 µg/l, p ≤ 0.001). PSA-reduction (total 77.1%) at 5-year follow-up was significantly different between group A (70.2%) and B (83.5%) (p ≤ 0.006). IPSS was significantly lower in group B than in A (2.5 vs. 6, p < 0.001) at 5-year follow-up. Bladder neck contractures (n = 4) and urethral strictures (n = 4) occurred in 3.1% of the patients each. Three patients (2.3%) were re-treated for regrowth of prostatic tissue., Conclusions: ThuVEP is a durable procedure with regard to micturition improvement and PSA-reduction. The reintervention rate after ThuVEP was low during long-term follow-up.

Introduction & Objectives: Transurethral enucleation of the prostate for the management of benign prostatic obstruction (BPO) involves two steps: the enucleation and morcellation procedure. The aim of our study was to assess the efficacy of a morcellator device using disposable and reusable blades with different settings of morcellation speed., Methods: A prospective randomized study was initiated for patients with symptomatic BPO undergoing Thulium laser enucleation of the prostate. Mechanical tissue morcellation was performed using the Piranha™ morcellator (R. Wolf, Knittlingen, Germany) with disposable or reusable blades at 850 (n = 24) or 1500 revolutions per minute (rpm) (n = 24). Patient characteristics, intraoperative complications, and the morcellation rate (g/min) were recorded. Data are expressed as median and interquartile range (IQR)., Results: Forty-eight patients were randomized using disposable (n = 24) or reusable blades (n = 24). For reusable blades, the morcellation rate did not increase when changing the morcellation speed from 850 to 1500 rpm (5 vs 4.53 g/min, p = 0.843). The morcellation rate increased significantly when changing the morcellation speed from 850 to 1500 rpm using single-use blades (4.77 vs 10 g/min, p ≤ 0.014). The morcellation rate was not different at 850 rpm between reusable and single-use blades (5 vs 4.77 g/min, p = 0.671). Conversely, the morcellation rate was significantly different at 1500 rpm between reusable and single-use blades (4.53 vs 10 g/min, p ≤ 0.017). The total morcellation rate (at 850 and 1500 rpm) was significantly increased using single-use blades compared to reusable blades (7.67 vs 4.8 g/min, p ≤ 0.026). Interestingly, enucleated weight (g) and the morcellation rate (g/min) correlated inversely using single-use blades at 1500 rpm (r = -0.742, p ≤ 0.004). Only one superficial bladder injury occurred at 1500 rpm, which needed no further interventions., Conclusions: The Piranha morcellator facilitates efficient tissue removal with single-use and reusable blades. Disposable morcellator blades increase tissue removal significantly at 1500 rpm.

Objective: To assess the current treatment of benign prostatic obstruction (BPO) in patients on ongoing oral anticoagulation (OA)., Methods: An Internet survey was sent to all active members of the Endourological Society. The survey contained 32 questions regarding transurethral treatment of BPO in patients on ongoing OA, different techniques, and arising complications., Results: Out of all members (n = 2000) of the Endourological Society, 133 participated in our survey. Eighty-eight percent of the participants indicated to perform transurethral therapy of BPO on ongoing OA, whereas 60% of this group temporarily pause the OA during the intervention. Sixteen percent perform >30 transurethral interventions of BPO on ongoing OA per year. Most operations are performed under continuation of aspirin (58.2%). The continuation of adenosine diphosphate (ADP)-receptor inhibitors (22.1%), vitamin K antagonists (18.9%), factor Xa inhibitors (15.6%), or the combination of two oral anticoagulants (16.4%) is continued less often. The decision for the operation on ongoing OA is usually approved by the cardiologist (58%) or it cannot be stopped in case of emergency (29%). GreenLight laser (39%) was the most frequently used technique on ongoing OA, followed by monopolar or bipolar transurethral resection of the prostate (35%) as well as other sources of laser [holmium (12%), thulium (12%), diode laser (2%)]. Although OA was continued during the interventions, cardiovascular complications were observed in 31.6%., Conclusions: Current practice shows that the majority of a representative group of the Endourological Society members perform transurethral therapy of BPO in patients on ongoing OA. The incidence of perioperative complications under transurethral therapy of BPO on ongoing OA is lower than previously assumed.

Purpose: TUR-prostate (TUR-P) is considered the reference method for surgical treatment of benign prostatic obstruction (BPO); Greenlight laser photoselective vaporization (PVP) and thulium laser vapoenucleation (ThuVEP) have also been established as treatments of BPO. Objective of this prospective observation was to compare a large numbers of patients treated in everyday routine., Methods: This prospective multicentre data collection assesses morbidity and perioperative course of consecutive men treated with BPO-related transurethral surgery between 2011 and 2014 in a German metropolis area with TUR-P, PVP or ThuVEP., Results: Two thousand six hundred and forty-eight patients have been treated in the time period. All treatment options achieved immediate improvement of voiding parameters. Multivariate analyses proved shorter hospital stay after laser treatments as compared to resection (p < 0.001). In terms of hospital stay, the advantage of ThuVEP compared to TUR-P increased with prostate volume (p < 0.001). Patients with ongoing anticoagulation or bridging had prolonged hospital stay (p < 0.001). Overall adverse events were least frequent in PVP (p 0.016), as were Clavien 3b events (p < 0.001)., Conclusions: Surgical treatment of BPO is effective and safe independent of the surgical procedure. Volume reduction is most effective in ThuVEP; PVP has the lowest rate of severe complications. Laser treatment is associated with shorter hospital stay. Surgery under ongoing anticoagulation prolonged the post-operative hospital stay.

Backround: Only few studies have assessed the safety and efficacy of transurethral surgery (TS) for the treatment of benign prostatic obstruction (BPO) in patients on oral anticoagulants. The aim of our study was to evaluate current treatment strategies and complication rates of TS for the treatment of BPO in patients on OA using an online survey., Materials and Methods: A total of 300 German departments of urology received an e‑mail with a link for the online survey. The items of the questionnaire assessed the present practice of TS for BPO in patients on OA and the occurrence of complications., Results: Seventy-five (23.4 %) departments responded to the online questionnaire. Of the respondents, 94.7 % performed TS in patients with BPO on OA and 42.7 % answered that they perform more than 30 prostate surgeries per year under OA. The respondents indicated that surgeries were carried out under aspirin (96 %), clopidogrel (46.7 %) or phenprocoumon (26.7 %). Indications for surgeries under OA were made by cardiologist recommendation (82.7 %), the surgeon (37.3 %), a need for emergency surgery (52 %), or the patient's will (10.7 %). Sixty-two (82.7 %) of the respondents perform bipolar or monopolar transurethral resection of the prostate (TUR-P) in patients on OA. In addition, 69.3 % of the respondents indicated that they use laser prostatectomy in patients on OA (thulium 24 %, Greenlight 24 %, holmium 16 %, and diode laser 5.3 %). Cardiovascular complications occurred in 12 % of the respondents., Conclusions: Despite the poor evidence for performing TS of BPO under OA, our survey showed surprising results: TS of BPO under OA is frequently performed, especially bipolar and monopolar TUR-P. Although our data were obtained using an online survey, the complication rates appear to be lower than previously thought.

Introduction: To evaluate the short-term results of thulium vaporesection of the prostate (ThuVEP) and thulium vapoenucleation of the prostate (ThuVARP) in patients with benign prostatic obstruction on oral anticoagulants (OA)., Methods: A 3-centre retrospective matched-paired comparison of patients treated by ThuVEP (n = 26) or ThuVARP (n = 26) was performed. Thirty-four patients were on aspirin/ticlopidin, 7 on clopidogrel or clopidogrel and aspirin, and 11 on phenprocoumon at the time of surgery., Results: Haemoglobin decrease was higher after ThuVEP compared to ThuVARP (1.5 vs. 0.3 g/dl, p < 0.001). The rate of postoperative blood transfusions (3.9 vs. 0%), clot retention (3.9 vs. 0%), and re-operation (7.7 vs. 0%) was not different between ThuVEP and ThuVARP (p = 0.274). Catheterization time was shorter for ThuVARP (1 vs. 2 days, p < 0.01). Qmax was significantly higher after ThuVEP at 6-month follow-up (31 vs. 21.5 ml/s, p < 0.001), while improvements in International Prostate Symptom Score, quality of life, and post-voiding residual urine showed no differences between the groups. Urethral or bladder neck strictures did not occur during the 6-month follow-up in both groups., Conclusions: ThuVEP and ThuVARP are safe and efficacious procedures in patients on OA. Although patients assigned to ThuVEP had higher Qmax at 6-month follow-up, ThuVARP resulted in similar functional outcomes., (© 2015 S. Karger AG, Basel.)

Background: Numerous studies have shown that thulium vapoenucleation of the prostate (ThuVEP) is a size-independent minimally invasive procedure for the treatment of benign prostatic enlargement. All ThuVEP series have been performed with a 2-µm thulium laser device so far. The aim of this study was to evaluate the complications and early postoperative results of two thulium-devices with different wavelengths for ThuVEP in prostates larger than 80 ml., Materials and Methods: A retrospective bi-centric matched-paired analysis with 296 patients was performed. Based on prostate size, 148 were matched at each centre and laser device, respectively. A 2-µm (RevoLix, LISA Laser products, Katlenburg, Germany n=148) and a 1.9-µm (vela XL, starmedtec, Starnberg, Germany, n=148) thulium laser with a power output of 90 and 80 W was used. Patients' data were assessed and compared., Results: The median prostate volume (interquartile) was 100 ml (range 86.25-120 ml). At discharge, Qmax (preoperative 7.9 and 9 ml/s vs. postoperative 19.35 and 16.2 ml/s) and postvoiding-residual urine (preoperative 130 and 45 ml vs. postoperative 20 and 25 ml) were significantly improved after 2-µm and 1.9-µm ThuVEP (p<0.001). The median catheterization time and hospitalization times were 2 and 4 days in both groups. Perioperative complications occurred in 89 patients (30.1%): Clavien 1 (12.2%), Clavien 2 (9.1%), Clavien 3a (0.7%), Clavien 3b (7.1%), and Clavien 4a (1%). Regarding the occurrence of complications, there were no differences between the two thulium devices., Conclusion: ThuVEP represents a safe and effective treatment for prostates larger than 80 ml. Both thulium laser devices give satisfactory immediate micturition improvement with low perioperative morbidity.

Introduction: To evaluate the current role of thulium vapoenucleation of the prostate (ThuVEP) for the treatment of benign prostatic obstruction (BPO)., Methods: A Medline search for randomized trials, case series, and comparative studies being published since the initial description of the ThuVEP procedure (2009-2014) was performed to assess the safety, the perioperative morbidity, the efficacy, and the durability of the technique., Results: A total of 14 peer-reviewed original articles, seven case series [level of evidence (LOE) 4] and seven comparative studies (LOE 3b), have been identified. ThuVEP has been shown to be a size-independent, safe, efficacious, and durable procedure for the treatment of BPO in large, prospective, and retrospective series (LOE 4/3b). The feasibility and safety of the ThuVEP procedure has also been confirmed in patients at high cardiopulmonary risk on oral anticoagulants (LOE 4). It has also been demonstrated that the erectile function is not impaired by the ThuVEP procedure (LOE 4). However, published ThuVEP series are from very few centers of excellence not exceeding a LOE of 3b. Randomized controlled trials comparing ThuVEP with standard procedures for the treatment of BPO, namely transurethral resection of the prostate, open prostatectomy, or holmium laser enucleation of the prostate, have not been published so far., Conclusions: ThuVEP appears to be a size-independent, safe, efficacious, and durable procedure for the treatment of BPO (LOE 4/3b). Multicentric PRT are however needed to define the current role of ThuVEP in the armamentarium of minimally invasive transurethral surgery of the prostate.

Purpose: Retrograde transurethral anatomical enucleation of the prostate is gaining momentum as a new concept in transurethral surgery of benign prostatic hyperplasia. Its adaptation is boosted by the familiarity of urologists with the finger-assisted anatomical enucleation of the adenoma during open prostatectomy and the combination of this well-established concept with the minimal invasive characteristics of transurethral surgery. The thulium laser appears as an ideal energy source for such operation. In this work, current evidence on thulium laser-assisted anatomical enucleation of the prostate (ThuLEP) is being reviewed., Materials and Methods: A comprehensive literature review was performed on Medline, PubMed, and Cochrane databases retrieving all literature on thulium laser-assisted prostatectomy between 2006 and 2015. Experimental studies, review articles and editorial comments as well as studies on thulium laser-assisted approaches other than ThuLEP (i.e., ThuVEP, ThuVAP or ThuVARP) were excluded from the analysis., Results: In total, six original articles on either surgical technique or clinical outcomes were retrieved. With regard to functional results, ThuLEP presented no significant differences toward the standard treatment (TURP/HoLEP) arm in two randomized controlled trials and favorable outcomes in available prospective cohorts. Observed morbidity was minimum and comparable with the rest of transurethral literature., Conclusions: ThuLEP literature is still very limited. Based on the available data, the approach is safe and effective, demonstrating favorable outcomes, comparable with the current standard treatment options. Further documentation of ThuLEP outcomes is necessary to define the optimum indications of this novel technique.

Purpose of Review: This article discusses enucleation and vaporization procedures which have been developed on the surgical techniques of holmium laser enucleation of the prostate (HoLEP) and photoselective vaporization of the prostate (PVP) by reviewing the most recent publications., Recent Findings: Enucleation procedures have been described using holmium, thulium, diode or GreenLight lasers in addition to bipolar energy sources. Most of the current literature for these enucleation procedures consists of initial descriptions of the surgical techniques or prospective series from single centres, although the availability of prospective randomized trial for these procedures other than HoLEP is limited. PVP have been described using 80-W, 120-W, or 180-W GreenLight lasers. To date, only sparse literature is available for thulium or bipolar vaporization of the prostate., Summary: A variety of alternative vaporization and enucleation procedures are available for transurethral treatment of benign prostatic obstruction. Only very few PRT have been published for these procedures limiting their evidence for the treatment of benign prostatic obstruction. To date, best evidence is still available for the HoLEP and PVP procedure.

Introduction: To evaluate Thulium VapoEnucleation of the prostate (ThuVEP) for patients with symptomatic benign prostatic obstruction (BPO) with long-term follow-up., Methods: A prospective analysis of 124 patients who underwent ThuVEP between January 2007 and July 2008 at our institution was done. ThuVEP was carried out using the 70-Watt 2-μm continuous wave Tm:YAG laser. Patient demographic, perioperative complications, and follow-up data were analysed., Results: The median (interquartile range) preoperative prostate volume was 58.5 (45-70.75) cc. The median operation and enucleation time were 74 (60-100) and 32.54 (25.62-37.52) min, respectively. The median catheter time and postoperative hospital stay were 2 (2-2) and 4 (3-5) days, respectively. Nine (7.3 %) patients required a second-look operation in the immediate postoperative course (failed morcellation = 2, clot retention = 3, and residual adenoma = 4). Two patients needed blood transfusions (1.6 %) postoperatively. At 12-month follow-up, International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax), and postvoiding residual urine (PVR) improved significantly in comparison with preoperative assessment (p < 0.001). A significant decrease of median PSA (4.7 vs. 0.92 μg/l) was seen at one-year follow-up (p < 0.001). At the 48-month follow-up mark, Qmax, PVR, IPSS, and QoL still differed significantly from baseline (p < 0.001). Bladder neck contractures and urethral strictures each developed in 1.6 and 0.8 % of the patients during follow-up. None of the patients were re-treated during follow-up for recurrent prostatic tissue., Conclusions: ThuVEP is a safe, efficacious, and durable procedure for the treatment of BPO. The incidence of late complications with ThuVEP was low.

Introduction: To evaluate the safety and efficacy of Thulium VapoEnucleation of the prostate (ThuVEP) for patients on oral anticoagulants (OA) with symptomatic benign prostatic obstruction (BPO)., Methods: Fifty-six patients, undergoing ThuVEP at two institutions, were evaluated from May 2009 until June 2011. All patients were at high cardiopulmonary risk and presented with a median American Society of Anesthesiology score of 3 [interquartile range (IQR) 2-3]. Thirty-two patients were on aspirin, 8 were on clopidogrel or clopidogrel and aspirin, and 16 on phenprocoumon at the time of surgery. Patient demographic, perioperative, and follow-up data were analyzed., Results: Median prostate volume was 50 (IQR 34-76) cc, and resected tissue weight was 32 (IQR 20-50) g. The median operative time was 61.5 (IQR 40-100.75) min, and the catheter time 2 (IQR 2-3) days. There were no perioperative thromboembolic events. Five patients (8.9%) required a second-look operation in the immediate postoperative course (hemorrhage n = 4, residual adenoma n = 1) and four (7.1%) blood transfusions. Complications within the first 30 days included urinary tract infections (1.7%), urinary retention (3.6%), and delayed bleeding (7.1%). These complications were managed conservatively. At 12-month follow-up, median QoL [5 (IQR 3.75-5) vs. 1 (IQR 1-2)], IPSS [21.5 (IQR 15.5-23.75) vs. 5 (IQR 3-8)], Qmax [7.7 (IQR 6.3-10) vs. 28.3 (IQR 21.25-39.2) ml/s], and postvoiding residual urine [100 (IQR 46-200) vs. 17.5 (IQR 0-36) ml] improved significantly (p < 0.002)., Conclusions: Thulium VapoEnucleation of the prostate seems to be a safe and efficacious procedure for the treatment of symptomatic BPO in patients at high cardiopulmonary risk on OA.

Objective: To evaluate the association between perioperative morbidity and prostate size in patients with benign prostatic obstruction treated with thulium:YAG vapoenucleation of the prostate (ThuVEP)., Methods: 687 patients were prospectively analyzed. Prostate size was <40 ml in 196 (group A), 40-79 ml in 336 (group B) and ≥80 ml in 155 (group C) patients., Results: The mean prostate sizes were 27.94 ± 6.77, 54.38 ± 10.54 and 109.8 ± 28.31 ml for groups A, B and C, respectively (p < 0.001). Hemoglobin loss (g/dl) differed significantly among group A (1.09 ± 1.02), group B (1.28 ± 1.27) and group C (1.62 ± 1.49) (p < 0.001). The correlation between hemoglobin loss and prostate size was very weak in all patients (r = 0.13, p ≤ 0.001). Peak urinary flow rates and post-voiding residual urine improved significantly (p < 0.001) without differences among the groups. The incidence of complications was low and not different among the groups (acute urinary retention 8%, urinary tract infection 4.66%, secondary apical resection 2.91%, transfusion rate 2.03%)., Conclusions: Perioperative morbidity and micturition improvement are not associated with prostate size in ThuVEP., (© 2014 S. Karger AG, Basel.)

Background: Thulium vapoenucleation of the prostate (ThuVEP) has been introduced as a minimally invasive treatment for benign prostatic obstruction (BPO)., Objective: To analyze immediate outcomes and the institutional learning curve of ThuVEP, and to report its standardized complication rates, using the modified Clavien classification system (CCS) to grade perioperative complication rates., Design, Settings, and Participants: A prospective evaluation of 1080 patients undergoing ThuVEP from January 2007 until May 2012 at our institution., Intervention: ThuVEP was performed using the 2-μm, continuous-wave, thulium:yttrium-aluminum-garnet laser., Outcome Measurements and Statistical Analysis: Preoperative status, surgical details, and immediate outcome were recorded for each patient. Perioperative complications were classified according to the modified CCS., Results and Limitations: Median prostate size was 51 ml (interquartile range [IQR]: 36-78.7). Median operation time was 56 min (IQR: 40-80), and median enucleation time was 32.5 min (IQR: 22-50). Median catheterization time was 2 d (IQR: 2-2); median length of hospital stay was 4 d (IQR: 3-5). Median resected tissue weight was 30 g (IQR: 16.00-51.25). Incidental carcinoma of the prostate was detected in 59 (5.5%) patients. Median maximum urinary flow rate (8.9 vs 18.4 ml/s) and postvoid residual urine volume (120 vs 20 ml) changed significantly (p<0.001). Minor complications occurred in 24.6% of the patients (Clavien 1: 20.8%; Clavien 2: 3.8%). Early reinterventions were necessary in 6.6% of the patients (Clavien 3a: 0.6%; Clavien 3b: 6%). One Clavien 4 complication occurred (0.09%). The overall complication rates decreased significantly over time due to decreasing Clavien 1, 2, and 3b events. The major limitations of the study are the prospective, unicentric study design, the lack of a control group, and that only short-term data were documented on morbidity and efficacy of the ThuVEP procedure., Conclusions: ThuVEP is a safe and effective procedure for the treatment of symptomatic BPO, with low perioperative morbidity., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Unlabelled: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Thulium VapoEnucleation of the prostate (ThuVEP) has been introduced as a minimally invasive treatment modality of benign prostate obstruction (BPO). This study reports the largest series of patients with symptomatic BPO undergoing ThuVEP. Efficacy of this procedure was confirmed by prostate volume and PSA measurements at 12-month follow up, which have not been reported after ThuVEP so far., Objective: To evaluate the safety and efficacy of 120-W 2-µm thulium:yttrium-aluminium-garnet (YAG) vapoenucleation of the prostate (ThuVEP) for patients with symptomatic benign prostatic obstruction., Method: In total, 207 consecutive patients undergoing ThuVEP at our institution were evaluated prospectively. ThuVEP was carried out using the 120-W 2-µm continuous-wave Tm:YAG laser. The enucleated tissue was then morcellated within the bladder. Patient demographic, perioperative and 12-month follow-up data were analysed. The complications were assessed., Results: Mean preoperative prostate volume was 57.8 ± 31.5 mL. Total operation duration averaged 64.9 ± 29.9 min, and the enucleation time was 36.5 ± 20.1 min. The mean catheter time was 2.2 ± 0.6 days. Thirteen (6.28%) patients required a second-look operation in the immediate postoperative course (failed morcellation n= 1, clot retention n= 4, residual tissue at the apex of the prostate n= 8). Four patients needed blood transfusions (1.93%) postoperatively. In all, 147 (71%) patients were available for review at the 12-month follow-up mark. Quality of life (4.4 ± 1.3 vs 1.2 ± 1.1), international prostate symptom score (21.9 ± 7.2 vs 5.1 ± 4), maximum urinary flow rate (9.4 ± 3.8 vs 23.5 ± 10.9 mL/s), postvoiding residual urine (159.2 ± 153.2 vs 26.7 ± 38.3 mL), prostate-specific antigen (5.0 ± 5.2 vs 0.6 ± 0.5 ng/mL) and prostate volume (57.8 ± 31.5 vs 10.7 ± 4.4 mL) changed significantly (P= 0.000). Median prostate-specific antigen reduction and prostate volume reduction were 87% and 80% respectively at follow-up. Urethral stricture and bladder neck contracture developed in 1.45% and 1.93% respectively of the patients., Conclusion: 120-W ThuVEP is a safe and efficacious procedure for the treatment of symptomatic benign prostatic obstruction. The incidence of complications with ThuVEP was low., (© 2011 BJU INTERNATIONAL.)

This study compared the efficacy of 70- and 120-w 2-µm thulium:YAG VapoEnucleation of the prostate (ThuVEP) for patients with benign prostatic obstruction (BPO). A prospective analysis of 84 patients with symptomatic BPO and prostatic enlargement (≥60 ml) who underwent either 70-w (n=44) or 120-w ThuVEP (n=40) non-randomly was carried out. Patient demographics and perioperative and 12-month follow-up data were analysed. The mean prostate volume was 79.90±27.49 ml in patients who had received 70-w ThuVEP, which was less than in those who had received 120-w ThuVEP (88.53±25.10; P=0.033). The mean enucleation (resected weight/laser time, 2.16±1.21 g min(-1) vs. 1.23±0.60 g min(-1); P=0.013), operation efficiency (resected weight/total operation time, 0.76±0.35 g min(-1) vs. 0.42±0.27 g min(-1); P=0.000) and percentage of resected tissue (66.93%±22.79% vs. 45.41%±23.33%; P=0.000) were higher with 120-w treatment compared to 70-w ThuVEP. One patient (1.2% of total patients) (in the 120-w group) required a blood transfusion postoperatively. Sixty-one patients (73%) were available for review at the 12-month follow-up time point. The quality of life (QoL), International Prostate Symptom Score (IPSS), maximum urinary flow rate (Q(max)), postvoiding residual urine (PVR) and prostate volume improved significantly after treatment (P≤0.035) and were not significantly different between those treated with the different devices (70- and 120-w). The median prostate volume reduction was 81.70% and 82.19% with 70- and 120-w ThuVEP, respectively. The incidence of complications was low and did not differ between groups treated with the different devices. Two patients (2.4%) (one per group) had a bladder neck contracture at the follow-up. ThuVEP is a safe and efficacious procedure for the treatment of symptomatic BPO. The incidence of complications was low with both devices. The 120-w thulium:YAG device enhances the effectiveness of ThuVEP with regard to the percentage of resected tissue and the enucleation/operation efficiency.

Purpose: Tm:YAG vapoenucleation was introduced as a minimally invasive treatment in patients with benign prostatic obstruction. The efficiency and safety of Tm:YAG vapoenucleation must still be confirmed in large volume prostates to prove the size independence of this promising treatment option. We evaluated the safety and efficiency of Tm:YAG vapoenucleation in patients with a prostate volume of 80 cc or greater and benign prostatic obstruction during a 12-month followup., Materials and Methods: Included in this trial were 90 consecutive patients undergoing 90 W Tm:YAG vapoenucleation. Vapoenucleation was done using the 2 μm continuous wave Tm:YAG laser combined with a mechanical tissue morcellator. We analyzed patient demographic, perioperative and 12-month followup data. Complications were assessed., Results: Mean preoperative prostate volume was 108.6 cc (range 80 to 200), mean International Prostate Symptom Score was 23.5 (range 8 to 35) and mean quality of life score was 4.3 (range 1 to 6). There was an 86% reduction (range 67% to 99%) in prostate volume on transrectal ultrasound by 12 months and an 88% decrease (range 58% to 100%) in prostate specific antigen. International Index of Erectile Function score remained stable. Peak urinary flow rate, International Prostate Symptom Score and quality of life improved significantly (p <0.001), as did post-void residual urine. The overall complication rate was manageable. Two patients required blood transfusion and 10 experienced early postoperative stress incontinence. During followup 7% of patients had symptomatic urinary tract infection and 2 had persistent grade I stress urinary incontinence. The reoperation rate due to urethral stricture was 1.8% during the 12-month followup., Conclusions: Tm:YAG vapoenucleation is a safe, effective and size independent treatment option for benign prostatic obstruction. As shown by reductions in transrectal ultrasound prostate volume and prostate specific antigen, complete removal of the adenoma can be achieved by this procedure., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Thulium:YAG (Tm:YAG) VapoEnucleation has been introduced and relief of obstruction was demonstrated. The aim of this study was to proof durability of the outcomes in patients with an postoperative follow-up >12 month., Methods: VapoEnucleation was performed using a 70 Watt continuous-wave-laser. After enucleation tissue was morcellated within the bladder. Patients were followed in terms of improvement of uroflow, intra- and postoperative course and for occurring complications., Results: 88 consecutive patients with prostatic enlargement underwent our initial series of VapoEnucleation. Prostatic volume was 61.3 +/- 24.0 cc (30-160). OR-time was 72 min +/-26.6 (35-144) and laser-time 32.4 +/- 10.1 min (16.3-59.3). Applied laser energy was 123.7 +/- 40.6 kJ (67.8-240.9). Foley catheter-time was 2.1 +/- 1.06 days on average. In 79/88 patients the postoperative period extended 12 month (mean: 16.5 month). 2 patients deceased during the follow-up, 15 patients did not respond. Therefore, 62/77 patients were available for follow-up. Flow-rate and post-voiding residual urine improved significantly [3.5 vs. 23.3 ml/s (p < 0.001); 121.3 vs. 33.4 ml (p < 0.05)]. IPSS decreased from 18.4 to 6.8, QoL dropped from 4.6 to 1.4. Early complications were urinary tract infection (n: 6/6.8%), bleeding (n: 5/5.6%) and immediate re-treatment (n: 2/2.2%), as well as urethral stricture (n: 1/1.6%) during follow-up. Postoperative short-term dysuria was recorded in 27% of the patients., Conclusion: VapoEnucleation is a safe and effective minimal invasive treatment modality for BPO. The improvement in voiding and bother is durable in patients with a postoperative period extending 12 month.