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Context: There is a continuous decline in the number of transurethral resections of the prostate (TURP) and an increase use of minimally invasive surgical therapy (MIST) for lower urinary tract symptoms resulting from benign prostatic enlargement. Current results from randomised controlled trials (RCT) and methodologically sound prospective studies suggest that some of the proposed procedures have the potential to replace TURP., Objective: To determine the contemporary status of TURP and of the currently most commonly applied transurethral MISTs: (1) bipolar TURP, (2) bipolar transurethral vaporisation of the prostate (bipolar TUVP), (3) holmium laser enucleation of the prostate (HoLEP), and (4) potassium-titanyl-phosphate (KTP) laser vaporisation of the prostate., Evidence Acquisition: This meta-analysis was based on a systematic Medline search assessing the period 1997-2009. All RCTs comparing TURP and the most commonly discussed ablative treatments were included. The end points of our analyses were functional outcomes and treatment-related adverse events., Evidence Synthesis: Twenty-seven publications involving 23 different RCTs with a total of 2245 patients provided the highest level of evidence available (level 1b) and were fully assessed. Meta-analysis was conducted with SAS v.9.1.3 (SAS Institute, Cary, NC, USA). Forest plots were produced using the R software. Pooled odds ratios and 95% confidence intervals were calculated between various operative techniques versus TURP. Functional results between the specific transurethral procedures versus TURP were summarised as differences in means., Conclusions: This meta-analysis demonstrates statistically comparable efficacy and overall morbidity for MISTs versus contemporary TURP. Type, category (minor vs major), and the number of complications (safety profile) vary specifically for each of the different transurethral techniques. We feel that the individual patient's clinical profile should be carefully assessed to identify the most appropriate transurethral technique., ((c) 2010 European Association of Urology. All rights reserved.)

Context: Holmium laser enucleation of the prostate (HoLEP) and 532-nm laser vaporisation of the prostate (with potassium titanyl phosphate [KTP] or lithium borate [LBO]) are promising alternatives to transurethral resection of the prostate (TURP) and open prostatectomy (OP)., Objective: To assess safety, efficacy, and durability by analysing the most recent evidence of both techniques, aiming to identify advantages, pitfalls, and unresolved issues., Evidence Acquisition: A Medline search of recently published data (2006-2008) regarding both techniques over the last 2 yr (January 2006 to September 2008) was performed using evidence obtained from randomised trials (level of evidence: 1b), well-designed controlled studies without randomisation (level of evidence: 2a), individual cohort studies (level of evidence: 2b), individual case control studies (level of evidence: 3), and case series (level of evidence: 4)., Evidence Synthesis: In the last 2 yr, several case-control and cohort studies have demonstrated reproducibility, safety, and efficacy of HoLEP and 80-W KTP laser vaporisation. Four randomised controlled trials (RCTs) were available for HoLEP, two compared with TURP and two compared with OP, with follow-up >24 mo. Results confirmed general efficacy and durability of HoLEP, as compared with both standard techniques. Only two RCTs were available comparing KTP laser vaporisation with TURP with short-term follow-up, and only one RCT was available comparing KTP laser vaporisation with OP. The results confirmed the overall low perioperative morbidity of KTP laser vaporisation, although efficacy was comparable to TURP in the short term, despite a higher reoperation rate., Conclusions: Although they are at different points of maturation, KTP or LBO laser vaporisation and HoLEP are promising alternatives to both TURP and OP. Sufficient data proves HoLEP's durability for most prostate sizes at long-term follow-up; KTP laser vaporisation needs further evaluation to define the reoperation rate. Increasing the number of quality prospective RCTs with adequate follow-up is mandatory to tailor each technique to the right patient.

Purpose: The aim of this study was to evaluate the 2-year clinical outcome of patients who underwent holmium laser resection of the prostate (HoLRP) for management of benign prostatic hyperplasia (BPH)., Materials and Methods: All patients who underwent HoLRP before October 1995 were contacted by mail. Each patient completed an American Urological Association (AUA) symptom score index, a questionnaire, and a urinary flow rate. The questionnaire was used to evaluate the frequency of complications, incontinence, recatheterization, and patient satisfaction., Results: Two hundred twelve patients were contacted and 168 responded. Of these, 100 patients successfully completed all three investigations and had all preoperative information available. Mean length of follow-up was 27.5 months (range 24 to 34 months). Mean peak urinary flow was 21.6 mL/s (range 6 to 34 mL/s), mean voided volume was 348 mL (range 146 to 1,387 mL), and mean AUA symptom score index was 6.8 (range 0 to 27). Eighty-eight percent of patients stated they would have HoLRP again for management of their BPH. The perioperative recatheterization rate was 9%. Reoperation rate with a minimum of 2 years of follow-up was 5%; three patients required a bladder neck incision and two patients required a revision HoLRP. Urethral strictures occurred in 4% of patients, and 1% of patients had persistent incontinence requiring pads., Conclusions: Medium-term clinical results of HoLRP confirm that patient satisfaction is excellent, with complication rates similar to those historically reported for transurethral resection of the prostate (TURP). The HoLRP technique is an effective and durable surgical alternative to standard TURP.

Background and Purpose: The holmium laser (2140 nm) can be used to ablate, resect, and enucleate the enlarged prostate. The 2-year results of a randomized trial comparing holmium laser resection of the prostate (HoLRP) and transurethral resection (TURP) are presented., Patients and Methods: The 120 patients were randomized to either TURP (N = 59) or HoLRP (N = 61). The patients were reviewed at 1, 3, 6, 12, 18, and 24 months postoperatively. Eighty six (72%) of the patients were available for review at the 2-year mark., Results: At 2 years, there was no significant difference between the two groups in AUA Symptom Score, peak flow rate (Qmax) value, or quality of life score. Adverse events, including reoperations, incontinence, and loss of erectile potency, were also similar., Conclusions: The HoLRP and TURP procedures result in similar clinical outcomes at 2 years.

Background and Purpose: Treatment of the large (>100 g) prostatic adenoma often involves open prostatectomy, with its attendant risks and morbidity. Enucleation of the entire adenoma endoscopically is possible with the holmium:YAG laser and tissue removal from within the bladder by a transurethral tissue morcellator. These patients can usually be discharged from the hospital the following day without a catheter., Patients and Methods: A series of 43 patients with prostates 100 g was followed for 6 months after laser resection., Results: The mean morcellation time was 16.1 minutes. The mean catheter time was 19.7 hours, and the mean hospital time was 28.4 hours. One patient required readmission for evacuation of tissue fragments. The average AUA Symptom Score declined from 23.5 preoperatively to 2.8 at 6 months postoperatively, and the mean Qmax increased from 9.0 mL/sec to 24.8 mL/sec., Conclusion: The holmium:YAG laser can be used to enucleate the adenoma in a large prostate in much the way the surgeon's finger does during open prostatectomy.

Background and Purpose: Holmium laser resection (HoLRP) is an effective surgical alternative to transurethral resection of the prostate (TURP). We investigated whether an adequate histologic diagnosis could be made from HoLRP tissue specimens., Patients and Methods: A series of 120 patients were randomized to TURP (N = 59) or HoLRP (N = 61). Each histologic specimen was reviewed by a single pathologist, who was blinded to the treatment. Weight of tissue, histologic diagnosis, and degree of thermal artifact were assessed. Thermal damage was graded as follows: 1 = no significant thermal injury; 2 = <25% of the tissue damaged (minimal); 3 = 25% to 80% of the tissue damaged (moderate); and 4 = >80% of the tissue damaged, with loss of prostatic architecture (extensive)., Results: The mean weight of the TURP and HoLRP specimens was 15.6 g and 9.6 g, respectively. The mean grade of thermal artifact for the TURP group was 1.8 and for the HoLRP group 2.6. Of the HoLRP specimens, 56 (92%) were grade < or = 3. Of the entire series of 120 specimens, 5 contained malignant tissue, all of which were from the TURP group. Four of these specimens were adenocarcinoma of the prostate, whereas the other was a transitional-cell carcinoma. Of the four specimens that contained prostate cancer, two were stage pTla tumors., Conclusions: Although identifiable prostatic architecture was maintained in the majority of histologic specimens from the HoLRP group, the tissue quality was inferior to that of TURP. There was significantly more vaporization and subsequent tissue loss with HoLRP, and the thermal damage to tissue was greater.

The preliminary experience with 64 patients who have undergone HoLEP combined with intravesical morcellation is presented. The mean preoperative prostate volume was 75.3 cc. The mean laser time was 46.9 minutes and the morcellator time a further 10.5 minutes. A mean total of 35.5 g of tissue was obtained, and 93% of the patients were discharged the day after their surgery without a catheter. The American Urological Association Symptom Score at 1 month was 8.6 and the peak flow rate 23.4 mL/sec. This combination of procedures allows prostate glands of virtually any size to be safely treated transurethrally, and a complete anatomic enucleation of the prostatic adenoma is achieved.

As alternatives to transurethral resection of the prostate for treatment of benign prostatic hyperplasia, various types of laser prostatectomy-most notably, neodymium:yttrium-aluminum-garnet (YAG) and potassium titanyl phosphate laser procedures-have proved to be associated with considerably less morbidity (for example, bleeding, need for transfusion, intraoperative fluid absorption, and postoperative incontinence). Despite these advantages, certain disadvantages (need for prolonged postoperative catheterization and delayed symptomatic improvement) prompted investigation of the holmium:YAG laser for performance of prostatectomy. The holmium:YAG laser is highly absorbed by tissue water and causes rapid vaporization of exposed soft tissue. After initial studies in canine prostates and human prostatectomy specimens, clinical studies with the holmium:YAG laser showed no fluid absorption, appreciable blood loss, or complications, and voiding outcomes were improved immediately, similar to the result with transurethral resection of the prostate. In addition, the holmium:YAG laser has been used to perform transurethral incision of the prostate rapidly and hemostatically. Holmium laser resection of the prostate is a safe and efficacious procedure for relief of symptomatic bladder outlet obstruction due to benign prostatic hyperplasia.

Objective: To assess the results of holmium-laser resection of the prostate (HOLRP) in the treatment of benign prostatic hyperplasia., Patients and Methods: Between 1994 and 1997, 967 patients underwent HOLRP in Tauranga, New Zealand, and in Derby, United Kingdom. The patients were followed at 1, 3 and 6 months after treatment using measurements of symptom score and urinary flow rate., Results: There was a large and sustained improvement in symptom scores and urinary flow rates, with no mortality and low morbidity., Conclusion: We recommend this technique as an alternative to transurethral resection in the surgical treatment of bladder outlet obstruction due to benign prostatic hypertrophy.

We investigated the safety, technique, and effectiveness of holmium laser resection of bladder tumors (HoLRBT). Data are presented on 23 patients who were treated with the HoLRBT technique. Holmium:YAG laser has a wavelength of 2,140 nm, which is delivered in a pulsed fashion via an end-firing quartz fiber placed through a modified resectoscope. Twenty-three patients with newly diagnosed transitional cell carcinoma underwent HoLRBT. Cold cup biopsies of the bladder tumor base were taken and compared to the HoLRBT specimens. Twenty-two of 23 patients were discharged catheter-free within 24 hours. One patient required a catheter for 3 days. The mean total energy used was 13.14 kJ with a maximum of 34.31 kJ. Mean resection time was 18.6 minutes. Cold cup biopsy of the tumor base did not alter the stage of the bladder tumor. The HoLRBT technique can be used to safely and effectively treat bladder tumors. This laser technique did not alter the stage or the diagnosis of bladder tumors. Holmium resection of bladder tumors usually can be performed as an outpatient catheter-free procedure and is a viable alternative to the standard electrocautery transurethral resection of bladder tumors.

Objective: The authors review the current knowledge regarding the application of the Holmium: YAG laser for prostatectomy., Summary Background Data: Conventional surgical therapies for benign prostatic hyperplasia (BPH) are effective but associated with relatively high morbidity. Laser prostatectomy, using either Neodymium:YAG or potassium-titanyl-phosphate lasers, has emerged as a new and much safer operative approach to relieve symptoms of benign prostatic hyperplasia. However, these laser wavelengths possess key disadvantages that have limited their acceptability and dissemination in everyday urologic practice., Methods: THE authors review their own extensive experience in the development of clinical application of Holmium: YAG laser technology for prostatectomy, as well as the published reports in the current medical literature now dealing with this subject., Results: In multiple clinical trials, Holmium:YAG laser resection of the prostate has proven efficacious in relieving symptomatic BPH. Both objective urodynamic measures of voiding outcomes and symptomatic improvement have been shown to be equivalent to standard electrocautery resection of the prostate. At the same time, these studies have demonstrated the superior safety and hemostasis of Holmium:YAG laser prostatectomy compared to electrocautery resection, similar to prior laser prostatectomy procedure. Unlike prior forms of laser prostatectomy, Holmium:YAG laser resection of the prostate acutely removes all obstructing prostate tissue, so that the postoperative catheterization requirement is typically only overnight and improvement in voiding is immediate. Current operative techniques and the latest technological developments to facilitate Holmium:YAG laser prostatectomy are described., Conclusions: Holmium: YAG laser prostatectomy combines the best features of prior laser prostatectomy technologies, including minimal complications and morbidity, with the efficacy and immediacy of voiding outcomes associated with conventional electrocautery resection of the prostate.

We examined the holmium:YAG (Ho:YAG) laser as a tool to perform acute resection of obstructing prostatic tissue in the subgroup of men with benign prostatic hyperplasia (BPH) who present in urinary retention. A total of 36 men presented in acute urinary retention requiring catheterization before undergoing Ho:YAG laser resection of the prostate (HoLRP). Their mean age was 67 years. The mean laser energy delivery was 102 kJ (range 42-315 kJ). The mean postoperative catheterization time was 1.5 days (range 1-8 days), and only 3 men required a catheter for more than 48 hours. There were no acute perioperative complications. Improvement in voiding was immediate and sustained through 6 months of follow-up. At 6 months, the mean peak urinary flow rate was 22.5 mL/sec, and the AUA Symptom Index Score was 5.7. A meatal stricture requiring dilation in one man represents the sole late complication observed in this series. Late recurrence of urinary retention has occurred in two men who had contributing medical problems, for an overall treatment failure rate of 5.6%. Thus, HoLRP represents an effective surgical therapy for patients with bladder outlet obstruction presenting in urinary retention. Morbidity is minimal compared with electrocautery resection, while the efficacy and immediacy of voiding improvement appear similar.

Aim: To report the development of the technique of laser resection of the prostate using the holmium:YAG (Ho:YAG) laser and to present preliminary results., Methods: Four hundred and eleven patients underwent Ho:YAG laser resection of the prostate (HoLRP). Preoperative and postoperative symptom scores, and flow rates were assessed. A description of the technique and its development is presented., Results: The mean American Urological Association (AUA) symptom score reduced from 23.6 to 4.9, and the mean peak urinary flow rate improved from 7.7 ml/s to 22.6 ml/s at 6 months postoperatively. The mean hospital stay was 1.3 days and complication rates were lower than those generally associated with electrosurgical transurethral resection of the prostate (TURP)., Conclusion: Transurethral resection of the prostate using Ho:YAG laser produces early results equivalent to or better than those usually associated with electrosurgical TURP, with a shorter hospital stay and a lower rate of complications.

The holmium wavelength (2.1 microns) can be used for incision, ablation, and resection of prostate tissue. Four different techniques for the surgical management of benign prostate hyperplasia (BPH) have evolved using the holmium laser either alone or in combination with Nd:YAG energy. The results in 650 patients undergoing these procedures are presented. The holmium laser has been used most recently to perform a transurethral resection of the prostate in 381 patients to date. This procedure appears to be the most efficient way of using the holmium laser for the removal of obstructing prostatic tissue.

The holmium laser is a recent addition to the urologist's armamentarium, being used primarily for the destruction of urinary calculi. Its use as a tool for ablation of the prostate has not been previously described. Our initial experience with 110 patients who have undergone a combination procedure using the Nd:YAG laser for standard circumferential coagulation followed by holmium laser ablation is reported. A further 32 patients who have had a holmium-only technique are described. In the patients who had the combination technique, the AUA Symptom Score improved from a mean value of 19.8 preoperatively to 7.8 at 3 months. The peak urine flow rate likewise improved, from a mean of 8.9 mL/sec preoperatively to 15.1 mL/sec at 3 months. Only one patient who had the holmium-only technique required recatheterization, compared with nine patients who had the combination procedure. The combination Ho/Nd:YAG laser ablation technique is evolving. The early results of the holmium-only technique suggest an advantage over the combination with regard to catheterization time and degree of irritative symptoms. The longer-term results must be assessed to confirm this impression.

A retrospective analysis of 62 consecutive potent patients undergoing transurethral resection of the prostate is described. Each patient was interviewed a minimum of six months following surgery. Potency was retained in 89% of patients but 57% of these experienced a decrease from their preoperative level of function. Three factors were found to be significantly associated with a reduction in postoperative potency. These were systemic disease (p less than 0.001), small prostatic resections (p less than 0.001) and a reduced level of potency preoperatively (p less than 0.01). Of those men retaining a degree of potency, 90% achieved their first erection within two months of the procedure. The full extent of sexual dysfunction following transurethral resection of the prostate has not previously been appreciated, nor have the factors associated with this dysfunction.

Intracavernosal injection of vasoactive agents is a new technique for inducing penile erection. It has applications in the counselling, diagnosis and treatment of sexual dysfunction. Nineteen patients are reviewed representing our initial experience with this technique. Thirteen men (68%) achieved a full erection with this treatment and a further three (16%) had a partial response. The applications, method and complications are discussed.

Tuberculous infections of the male genital tract are very uncommon in Australasia. A case of isolated epididymal tuberculosis following a prolonged latent period is presented and the pathogenesis and treatment is discussed.