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      BPH treatment: laser for everyone | Opinion: YES

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          Abstract

          During the past decades, transurethral resection of the prostate (TURP) has been the gold-standard procedure for surgical treatment of benign prostatic hyperplasia (BPH) and became the second most common surgery in men in the Western world (1). A number of other techniques were developed through the years, trying to replace TURP, including vaporization, microwave thermotherapy, transurethral needle ablation (TUNA) and various types of laser therapies. The rational of looking for new therapies for BPH lies on the intention of delivering the same results with less complications and adequate length of stay at the hospital or even as an outpatient procedure. Indeed, morbidity and mortality following TURP are continuous issues. Reich et al. (2) evaluated 10,654 patients that underwent TURP in state of Bavaria, Germany. The cumulative short-term morbidity rate was 11.1%. The most important complications were failure to void, surgical revision, bleeding, urinary tract infections and TURP syndrome. Rassweiler et al. (3) showed decreasing complication rates in a review conducted from 1989 to 2005. Bipolar TURP emerged as a significant evolution in the last years, especially because saline solution can avoid TURP syndrome and enables a greater volume of tissue resection However, Skolarikos et al. (4) recently showed similar results in safety and efficacy comparing monopolar and bipolar TURP, with the same possible complications throughout the years. In the other hand, various techniques of lasers were compared to TURP. Currently, holmium laser (HoLEP) and Greenlight are two of the most common used. Greenlight was released in 2006 and improved from 80W to 180W output (5). The GOLIATH study (6) compared Greenlight (GL) 180W with TURP (Monopolar and Bipolar) and considered Gl non-inferior to TURP in terms of International Prostate Symptom Score (IPSS), Qmax and proportion of patients free of complications. However, early reinterventions were lower in the GL group. These data clearly show GL has the same efficacy as TURP in relieving the symptoms and obstruction, but with the advantage of less early postoperative problems (Clavien III complication) (7). Stone et al. (8) also described good results in patients with prostate size greater than 150mL (median 202mL). Performing TURP in such individuals remains challenging. HoLEP is an enucleation technique and has the largest number randomized control trials available comparing TURP and open prostatectomy. A meta-analysis conducted recently demonstrated similar efficacy outcomes of bipolar TURP and photovaporization and better results than monopolar TURP (9). Gilling et al. (10) also described long-term results (mean 7.6 years). Although, HoLEP requires morcellation to retrieve the prostate tissue and needs a learning curve of 40 to 60 cases, it emerges as a novel widespread used procedure for surgical treatment of BPH. HoLEP success has been reproduced in a number of studies (11). Recently, some authors described similar results comparing HoLEP and 120W GL (12, 13). All these studies focused on all patients with BPH. If we considered special populations such as those receiving anticoagulants and anti-platelet and therefore not with suitable indication for TURP, both HoLEP and GL appears as feasible procedures (14, 15). Rajih et al. (16) compared men with high medical risk (HMR) by the American Society of Anesthesiologists (class 3) with healthier individuals and demonstrated similar results according to IPSS, Qmax, postvoid residual volume and quality of life. HMR group had more readmissions (3.7% vs. 1.3%; p=0.04), but regarding the comorbidities of these patients, we can consider only a few number of patients (3.7%) needed a new hospitalization. It seems the era of laser for BPH has finally come. Urologists must learn these new procedures and discuss the proper option with their patients.

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          Most cited references15

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          Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients.

          Transurethral resection of the prostate has for decades been the standard surgical therapy for lower urinary tract symptoms secondary to benign prostatic hyperplasia, the most common benign neoplasm in men. To generate a contemporary reference for evolving medical and minimally invasive therapies we analyzed complications and immediate outcomes of transurethral prostate resection in a statewide multicenter study. We prospectively evaluated 10,654 patients undergoing transurethral prostate resection in the state of Bavaria, Germany from January 1, 2002 until December 31, 2003. Case records containing 54 items concerning preoperative status, operation details, complications and immediate outcome, were recorded for each patient. The mortality rate for transurethral prostate resection was 0.10%. The cumulative short-term morbidity rate was 11.1%. The most relevant complications were failure to void (5.8%), surgical revision (5.6%), significant urinary tract infection (3.6%), bleeding requiring transfusions (2.9%) and transurethral resection syndrome (1.4%). The resected tissue averaged 28.4 gm. Incidental carcinoma of the prostate was diagnosed by histological examination in 9.8% of patients. Urinary peak flow rate increased significantly to 21.6 +/- 9.4 ml per second (baseline 10.4 +/- 6.8 ml per second, 1 tail p <0.0001), while post-void residual decreased to 31.1 +/- 73.0 ml (baseline 180.3 +/- 296.9 ml, 1-tail p <0.0001). In a large scale evaluation comprising 44 mostly nonacademic urological departments in Bavaria, unique real-world data for transurethral prostate resection were prospectively generated. This most contemporary information should be of use to potential patients and facilitate subsumption of emerging surgical and nonsurgical benign prostatic hyperplasia treatment options.
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            Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years.

            To assess the durability of holmium laser enucleation of prostate in comparison to transurethral resection of the prostate (TURP). Patients were enrolled in the present study between June 1997 and December 2000 and followed per protocol. All patients were urodynamically obstructed with a prostate volume of between 40 and 200 mL. At long-term follow-up, variables assessed included Benign Prostatic Hyperplasia Impact Index (BPHII), International Continence Society Short Form Male questionnaire (ICSmale-SF) and the International Index of Erectile Function (IIEF). Adverse events, including the need for retreatment, were specifically assessed. Thirty-one (14 holmium laser enucleation of the prostate [HoLEP] and 17 TURP) of the initial 61 patients were available, with 12 deceased and 18 lost to follow-up. The mean (range) follow-up was 7.6 (5.9-10.0) years and the mean (±sd) age at follow-up was 79.8 (±6.2) years. The mean (±sd) values (HoLEP vs TURP) were as follows: maximum urinary flow rate (Q(max)), 22.09 ± 15.47 vs 17.83 ± 8.61 mL/s; American Urological Association (AUA) symptom score, 8.0 ± 5.2 vs 10.3 ± 7.42; quality of life (QOL) score 1.47 ± 1.31 vs 1.31 ± 0.85; BPHII, 1.53 ± 2.9 vs 0.58 ± 0.79; IIEF-EF (erectile function), 11.6 ± 7.46 vs 9.21 ± 7.17; ICSmale Voiding Score (VS), 4.2 ± 3.76 vs 3.0 ± 2.41; ICSmale Incontinence Score (IS), 3.07 ± 3.3 vs 1.17 ± 1.4. There were no significant differences in any variable between the two groups beyond the first year. Of the assessable patients, none required re-operation for recurrent BPH in the HoLEP arm and three (of 17) required re-operation in the TURP arm . The results of this randomized trial confirm that HoLEP is at least equivalent to TURP in the long term with fewer re-operations being necessary. © 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.
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              Techniques and long-term results of surgical procedures for BPH.

              To provide an overview on the current status of the long-term outcomes of instrumental treatment options for patients with lower urinary tract symptoms that are suggestive of bladder outlet obstruction. Based on MEDLINE database searches, we performed a systematic review of the literature with a focus on peer-reviewed articles about surgical benign prostatic hyperplasia (BPH) therapy published between 2000 and 2005. Special emphasis was given to randomized controlled trials on long-term outcome with a minimum follow-up of five years. Data on clinical outcome with a follow-up of more than 10 years are available for open prostatectomy (OP), transurethral resection of the prostate (TURP), and transurethral microwave therapy. Studies with a follow-up of at least five years are obtainable for transurethral incision of the prostate, transurethral vaporisation of the prostate, transurethral needle ablation of the prostate, Holmium:YAG laser enucleation of the prostate, potassium-titanyl-phosphate laser vaporization of the prostate, and interstitial laser coagulation of the prostate. Among these long-term reports, OP and TURP provide the most durable results. The most substantial long-term data on surgical procedures for BPH are available for conventional therapy, namely TURP. Concerning the techniques that have emerged within the last decade, there is clear evidence that the outcomes are more sustainable for truly ablative and thus deobstructing procedures.
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                Author and article information

                Journal
                Int Braz J Urol
                Int Braz J Urol
                ibju
                International Brazilian Journal of Urology : official journal of the Brazilian Society of Urology
                Sociedade Brasileira de Urologia
                1677-5538
                1677-6119
                Mar-Apr 2018
                Mar-Apr 2018
                : 44
                : 2
                : 213-214
                Affiliations
                [1 ]Departamento de Urologia, AC Camargo Cancer Center, SP, Brasil
                [2 ]Divisão de Urologia, Universidade de São Paulo, USP, São Paulo, SP, Brasil
                Author notes
                Carlos Alberto Ricetto Sacomani, MD Departamento de Urologia, AC. Camargo Cancer Center, Rua Antonio Prudente, 211, Liberdade, São Paulo, SP, 01509-010, Brasil. E-mail: drsacomani@ 123456gmail.com
                Article
                S1677-5538.IBJU.2018.02.02
                10.1590/S1677-5538.IBJU.2018.02.02
                6050545
                29558093
                3ed9d4ce-b266-4b87-ace3-bbc4e88f324e

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 16, Pages: 2
                Categories
                Difference of Opinion

                lasers,therapeutics,prostatic hyperplasia,transurethral resection of prostate

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