When drug therapy fails, surgery is the standard of care for symptomatic benign prostatic hyperplasia (BPH). For prostates around 80 ml, transurethral resection of the prostate (TURP) and open prostatectomy (OP) are the most common procedures. But for larger prostates — those greater than 100 ml — laser-energy techniques that are less invasive are increasingly popular, and a review found them of promise in treating lower urinary tract symptoms (LUTS) secondary to very large prostates.
The study by researchers in Montreal, Canada, “Management of Benign Prostatic Hyperplasia Larger than 100 ml: Simple Open Enucleation Versus Transurethral Laser Prostatectomy” was published in Current Urology Reports. It reviewed the efficacy and safety profiles of various transurethral laser techniques — called retrograde transurethral endoscopic laser enucleation — and compares them with the standard OP procedure.
OP is often recommended in men with BPH and very large prostates, representing the most effective and durable option for prostates larger than 80 ml. It has a relatively shorter time of operation than other endoscopic enucleation techniques, and retrieves large amounts of prostatic tissue. But it has limitations associated with open surgery, showing a perioperative morbidity of up to 42 percent.
One technique shown to provide comparable functional outcomes to OP in these patients is the minimally invasive simple prostatectomy (MISP). Similar to OP, it involves opening the patient. However, even though it involves a longer operative time, it is associated with lesser blood loss and shorter periods of hospital stay.
A number of minimally invasive endoscopic techniques for enucleation of the prostate (EP) have been developed to overcome the limitations of OP, including Transurethral Bipolar/Laser TURP, Holmium Laser EP (HoLEP), GreenLight 532 nm Laser, Thulium Laser and Diode Laser.
Transurethral Bipolar/Laser TURP is more effective in the treatment of large glands than monopolar TURP. It is also safer, with decreased overall blood loss, and reduced times of hospitalization. But there is little evidence comparing the safety and efficacy of this technique with OP.
Laser techniques are generally less invasive and associated with shorter hospitalization periods. HoLEP is the most intensively studied alternative to TURP and OP. Randomized clinical trials comparing HoLEP and OP have shown a similar efficacy in both treatments, but shorter periods of hospital stays and catheter times, and lesser blood loss and lower transfusion rates in HoLEP-treated patients.
HoLEP has a long learning curve before specialists are comfortable using the procedure, however, which has proven the greatest obstacle to its widespread implementation, the study reported. Almost half of centers that started practicing HoLEP have chosen to abandon this technique.
GreenLight Laser has a higher efficacy in prostates smaller than 80 ml, and lower reoperation rates. But this technique often requires conversion to monopolar TURP during surgery due to uncontrolled bleeding that impairs a surgeon’s vision, a complication not known to occurr in the use of HoLEP. Still, GreenLight Laser has been proven to be a good alternative to OP, as it has similar safety and efficacy, but decreased transfusion rates and hospital stays.
Thulium lasers can be used in four different modes, including vaporisation (ThuVAP), vaporesection (ThuVARP), vaponucleation (ThuVEP), or enucleation (ThuLEP). In patients with larger prostates, data from a randomized clinical trial has shown ThuVARP to be a good alternative to GreenLight laser, leading to reduced operation time and lower surgical costs. ThuLEP revealed excellent safety and efficacy in the management of obstructing BPH, leading to less residual tissue when compared to TURP and OP. A comparison of ThuLEP with HoLEP also demonstrated that both techniques have similar functional outcomes. Although few studies compare ThuVEP with other techniques, such as OP and HoLEP, current evidence on ThuLEP indicates that it is a safe and efficacious procedure for all prostatic sizes.
Diode lasers (DiLEP) can also be used for enucleation of the prostate. A clinical trial comparing DiLEP with bipolar TURP indicated that DiLEP leads to less blood loss and shorter catheter time and hospitalization. Nonetheless, there is lack of evidence comparing this technique with the standard enucleation procedures, such as OP or HoLEP.
The investigators concluded that “[i]t became obvious and supported by good-quality data that enucleation techniques should be advocated for large glands to maintain long-term functional improvement and minimize reoperation rates.” Still, “[w]ith so many choices available, surgical management of large prostates should be individualized based on the surgeon’s expertise, prostate size, patient’s comorbidities, and availability of the laser technology.”