TAU0010.1177/1756287218779784Therapeutic Advances in UrologyGM Pirola, G Saredi 779784research-article2018 Therapeutic Advances in Urology Original Research Ther Adv Urol Holmium laser versus thulium laser 1 –11 DOI:https://doi.org/10.1177/1756287218779784 10.1177/ enucleation of the prostate: a matched- 1756287218779784https://doi.org/10.1177/1756287218779784 © The Author(s), 2018. Reprints and permissions: pair analysis from two centers http://www.sagepub.co.uk/ journalsPermissions.nav Giacomo Maria Pirola , Giovanni Saredi, Ricardo Codas Duarte, Lorraine Bernard, Andrea Pacchetti, Lorenzo Berti, Eugenio Martorana, Giulio Carcano, Lionel Badet and Hakim Fassi-Fehri Abstract Background: The aim of our study was to compare perioperative and functional outcomes of two different prostatic laser enucleation techniques performed in two high-volume centers: 100 W holmium laser enucleation of the prostate (HoLEP) (Lyon, France) and 110 W thulium laser enucleation of the prostate (ThuLEP) (Varese, Italy). Materials and Methods: A nonrandomized, observational, retrospective and matched-pair analysis was performed on two homogeneous groups of 117 patients that underwent prostate laser enucleation in the HoLEP or ThuLEP centers between January 2015 and April 2017, following the classical ‘three lobes’ enucleation technique. The American Society of Anesthesiologists (ASA) score and prostate volume were the main parameters considered for matching the patients between the two groups. Patients on anticoagulant therapy, with documented detrusor hypoactivity or hyperactivity or with the finding of concurrent prostate cancer were excluded from the study. Follow up was assessed at 3, 6 and 12 months after surgery. Results: Median enucleation and morcellation time was 75.5 and 11.5 min, respectively, in the HoLEP group versus 70.5 and 12 min, respectively, in the ThuLEP group (p = 0.001 and 0.49, respectively). Enucleated adenoma weight was comparable (44 g versus 45.6 g, p = Correspondence to: Pirola Giacomo Maria 0.60). Energy index (3884.63 versus 4137.35 J/g, p = 0.30) and enucleation index (0.57 versus Department of Urology, 0.6 g/min, p 0.81) were similar in the two groups. Catheterization time was comparable (1 University of Modena and = Reggio Emilia, Via del versus 1 day; p = 0.14). The International Prostate Symptom Score and Quality of Life score Pozzo 71, Modena, 41124, Italy significantly decreased, as well as maximal urinary flow rate. Median prostate-specific antigen [email protected] (PSA) drop 1 year after surgery was 2.1 ng/ml in the HoLEP group (−52.83%) versus 1.75 ng/ml Giovanni Saredi Andrea Pacchetti in the ThuLEP group (−47.85%) (p = 0.013). Lorenzo Berti Conclusion: Both HoLEP (100 W) and ThuLEP (110 W) relieve lower urinary tract symptoms in Department of Urology, Ospedale di Circolo e a comparable way with high efficacy and safety, with negligible clinical differences. Fondazione Macchi, Varese, Italy Ricardo Codas Duarte Keywords: endoscopic enucleation of the prostate, holmium laser enucleation of the prostate, Lionel Badet Hakim Fassi-Fehri matched-pair analysis, thulium laser enucleation of the prostate Department of Urology and Transplantation, Edouard Herriot Hospital, Lyon, Received: 22 November 2016; revised manuscript accepted: 25 January 2018. France Lorraine Bernard Clinical Research Unit, Hospices Civils de Lyon, Introduction affirm its efficacy. A retrospective study by Elmansy Lyon, France Thulium laser enucleation of the prostate and colleagues1 reported long-term outcomes of Eugenio Martorana Department of Urology, (ThuLEP) and holmium laser enucleation of the HoLEP with a maximum follow up of 10 years University of Modena and prostate (HoLEP) are two endoscopic enuclea- (mean 62 months), reporting durable functional Reggio Emilia, Modena, Italy tion of the prostate techniques. results with low reoperation rates. A recent meta- Giulio Carcano analysis by Cornu and colleagues2 compared func- Department of Surgery, HoLEP is part of the usual treatment in many uro- tional outcomes of different surgical treatments for Ospedale di Circolo e Fondazione Macchi, logical centers, and consistent literature findings benign prostatic hyperplasia (BPH), showing that Varese, Italy journals.sagepub.com/home/tau 1 Therapeutic Advances in Urology 00(0) HoLEP had more satisfactory outcomes than clas- Anesthesiologists (ASA) score and preopera- sic monopolar transurethral resection of the pros- tive symptomatology. To maximize the clarity tate (TURP), in terms of short-term urinary and correctness of data reporting, we referred function recovery, complication rate, and hospital in this paper to Strengthening the Reporting of stay. Observational Studies in Epidemiology state- ments reporting guidelines for observational In 2010, Herrmann and colleagues first proposed studies.8 a similar technique for prostatic adenoma enu- cleation using a thulium laser, called ThuLEP.3 Similarly to HoLEP, a number of studies have Clinical setting confirmed the feasibility and efficacy of ThuLEP. HoLEP (holmium laser enucleation of the prostate) A review by Barbalat and colleagues4 showed that Center, Lyon, France. HoLEP is routinely prac- thulium laser prostatectomy represents a safe and ticed in this institution by two experienced sur- effective procedure. geons since May 2013, who performed 80 interventions each, during the first 18 months of Regarding their physical properties, both lasers their experience. We didn’t consider for this study are ideal for endourological applications as they any patient who underwent the operation at the are completely absorbed by water, with a tissue beginning of the surgeon’s learning curve. During penetration depth of 0.4 mm for holmium and of the study period, 200 patients underwent the pro- 0.25 mm for thulium laser. The main difference is cedure. According to Shah and colleagues,9 a sur- that holmium has a pulsed energy, while thulium geon can be considered completely confident emits a continuous laser wave.5 with HoLEP after 50 cases, so the two surgeons could be considered experts at the time of this The only comparative study in a clinical setting of analysis. HoLEP and ThuLEP is that of Zhang and col- leagues6 that reported a monocentric randomiza- ThuLEP (thulium laser enucleation of the prostate) tion of 133 patients with a maximum prostate Center, Varese, Italy. ThuLEP has been practiced volume of 80 ml undergoing HoLEP or ThuLEP. in this center by two expert surgeons since June Adenoma enucleation was performed followed by 2012, with about 300 patients treated before the a ‘mushroom’ monopolar electroresection of the time considered for this study (about 150 proce- prostate lobes, following the technique described dures for each surgeon). As initially assessed by by Hochreiter and colleagues7 demonstrating Bach,10 the learning curve to acquire a complete their similar efficacy and safety. surgical skill in thulium laser enucleation is rela- tively fast; shorter than for HoLEP. In a previous In this study, we want to further investigate the work from our study group, 30 procedures were possible differences in terms of intraoperative var- shown as sufficient to fully achieve the skills iables, surgical complications, and outcomes required for the procedure.11 In May 2015, an ‘en between the two techniques. We herein present a bloc’ technique was introduced by one of the sur- matched-pair comparison between a large group geons (GS), although the patients treated with of HoLEP and ThuLEP procedures in two highly this new technique are not considered in the pres- experienced centers. ent study.12 Patients and methods Surgical indication This observational, retrospective and matched- Indications for prostatic enucleation were similar pair analysis was a controlled, but not rand- in both centers (see inclusion and exclusion crite- omized, study, based on the retrospective ria sections). Indication for prostatic enucleation analysis of prospectively collected data of a was symptomatic BPH refractory to medical ther- series of patients that underwent prostate laser apy. Independently from PV, patients were enucleation for symptomatic lower urinary enrolled for surgery if they presented a maximal tract symptoms (LUTS) between January 2015 urinary flow rate (Qmax) less than 15 ml per s, an and April 2017 in two different urological cent- International Prostate Symptom Score (IPSS) ers. Comparability was guaranteed by a strict greater than 15 points, a history of repeated uri- analysis of clinical databases in terms of nary tract infections or recurrent episodes of uri- prostate volume (PV), American Society of nary retention. The IPSS questionnaire13 was 2 journals.sagepub.com/home/tau GM Pirola, G Saredi et al. administered to patients in national validated Surgical technique forms14,15 before surgery and thereafter during A similar surgical technique was practiced for follow-up controls. both HoLEP and ThuLEP. Following the initial depiction by Gilling and Fraundorfer for HoLEP16 Preoperative patient assessment included a physi- and Herrmann and colleagues for ThuLEP,3 a cal examination with digital rectal examination, three-lobe enucleation was performed. PSA assay, transrectal ecographic estimation of prostate volume, uroflowmetry, measurement of The ureteral orifices were first identified and postvoid residual urine (PVR), urine analysis and marked at short distance using coagulation. Then, urine culture. Moreover, symptomatologic ques- the median lobe was progressively incised at 5