Benign prostatic hyperplasia (BPH) is the main etiology of lower urinary
tract symptoms (LUTS) in ageing male.1 For several
decades, transurethral resection of prostate (TURP) has been accepted
and applied as the standard endoscopic treatment for symptomatic LUTS in
patients not responding to or cannot tolerate medical therapy as well as
in those developing BPH-related complications (e.g., bladder stone,
urinary retention, or renal insufficiency).2However, following its clinical introduction by Gilling et al. in 1998,
Holmium Laser Enucleation of the Prostate (HoLEP) proved itself to be a
minimally invasive, size-independent endoscopic management alternative
in the effective treatment of LUTS secondary to BPH. Several RCT’s have
shown comparable (even superior) long-term results to open prostatectomy
(OP) and TURP.3-6 Based on the successful outcomes
obtained, HoLEP has been considered as potentially “new gold standard”
endo-surgical treatment of BPH.7, 8 Complete removal
of the obstructing adenomatous tissue via enucleation, simultaneous
coagulation of the capsular surface and effective mechanical
morcellation are the distinct characteristics of HoLEP which make it
superior to other modalities.
Despite its excellent outcomes however, HoLEP has still not been widely
adopted in urology practice, due to its prolonged learning curve and
limited access to HP laser devices.9 Although various
technical modifications have been described to minimize the learning
curve and increase the efficiency of the procedure over the past 20
years10, 11, improved functional outcomes and low
complication rates seem to be correlated with the level of experience
obtained and the surgical technique
applied.12Beginning with its first clinical use in 1998, HoLEP procedure was
performed with HP holmium laser devices (≥80W).13During the following years, the popularity of the procedure increased
and even more powerful devices (140-150W) were introduced into clinical
practice with the perception that a more effective enucleation can be
performed with such laser devices creating relatively higher powers.
Related with this issue however, HP laser devices are still not
available in many urology clinics due to their higher costs and
available low-medium power (<80W) laser devices are being used
mainly for lithotripsy purposes in many hospitals.14Regarding the dilemma concerning the power of the device and its real
efficacy in adenoma enucleation, the first study evaluating the efficacy
and safety of medium power (MP) (50W) laser was published by Rassweiller
et al.in 2008.15 In the following years,
several studies focusing on the efficacy of low power (LP) and MP HoLEP
have been performed. 14, 16-20 Although these limited
number of studies have revealed that LP-HoLEP could achieve comparable
outcomes with HP-HoLEP, many urologist still prefer using HP-laser
devices. Taking the ongoing controversy about the efficacy and safety of
LP vs HP laser systems particularly in the removal of large prostatic
adenomas as well as the the importance of surgeon’s experience with
particular techniques created rather than the power of laser used into
account, in this first prospective , comparative study evaluating the
efficacy of both power levels (MP vs HP) with two different laser
devices we aimed to demonstrate the applicability of MP laser devices
for HoLEP procedure with high efficiency and limiter or no technical
difficulties.