V3-12: Comparison of the different techniques for laser enucleation of the prostate: PVEP, HoLEP, ThuVEP

Video

Introductions and Objectives
Transurethral laser enucleation of the prostate was first described in the late 1990s as an endoscopic alternative to open prostatectomy. Ever since, these procedures have experienced increasing popularity worldwide. Herein, we compare the technique and clinical outcomes of three commonly used lasers: Holmium laser enucleation of the prostate (HoLEP), thulium vapoencleation of the prostate (ThuVEP), and 532nm photoselective vapoenucleation of the prostate (PVEP).

Methods
This video illustrates the surgical technique of three different laser prostate enucleations (HoLEP, ThuVEP, PVEP) as performed by experts. The relative advantages and potential drawbacks of each are discussed according both to expert opinion and clinical evidence.

Results
Prior work reported on 1065 HoLEPs (JL), 1080 ThuVEPs (AG), and 170 PVEP (AT) has shown all techniques are highly effective at treating lower urinary tract symptoms (LUTS) in men and can be applied to prostates of any size and to actively anticoagulated patients. In the PVEP group, median prostate volume was 83 ml and median followup was 24.7 months. Mean international prostate symptom score (IPSS) improved from 17 to 5, quality of life from 3 to 1, and Qmax from 11 to 16.5 ml/s, and no patient required a blood transfusion or retreatment for LUTS. In the HoLEP group 313 patients had greater than 12 month followup with a mean IPSS improvement from 20.3 to 5.3, and mean Qmax improvement from 8.4 to 22.7 ml/s. The transfusion rate among the first 507 patients was 0.4%. In the ThuVEP group median Qmax improved from 8.9 to 18.9 ml/s and post void residual reduced from 120 to 20ml. In first 124 ThuVEP patients at 24 months followup, median IPSS improved from 21 to 3 and quality of life improved from 5 to 1. Noted complications were infrequent for patients in each group including urethral strictures (≤ 1.3%), bladder neck contractures (≤ 1.8%), and transfusions (≤ 1.7%). There were no mortalities in any group.

Conclusions
Endoscopic prostatic enucleation can be successfully performed with a number of different lasers and surgical techniques including HoLEP, ThuVEP and PVEP. HoLEP has the most robust evidence base and longest follow-up. The holmium and thulium laser have urologic indications outside of the prostate making them potentially more cost effective, but appear to require a longer learning curve. PVEP may cause less immediate postoperative stress urinary incontinence and retrograde ejaculation. Short-term outcomes and complications appear favorable for HoLEP, ThuVEP and PVEP when performed by an expert.

Funding: August Kurten Foundation