Year : 2006 | Volume
: 22 | Issue : 2 | Page : 164--165
Holmium laser enucleation of prostate for patients in large prostatic gland with urinary retention
Naval Khurana, Saurabh Agarwal, Aneesh Srivastava
Department of Urology, SGPGIMS, Lucknow, India
Department of Urology, SGPGIMS, Lucknow
|How to cite this article:|
Khurana N, Agarwal S, Srivastava A. Holmium laser enucleation of prostate for patients in large prostatic gland with urinary retention.Indian J Urol 2006;22:164-165
|How to cite this URL:|
Khurana N, Agarwal S, Srivastava A. Holmium laser enucleation of prostate for patients in large prostatic gland with urinary retention. Indian J Urol [serial online] 2006 [cited 2020 Feb 24 ];22:164-165
Available from: http://www.indianjurol.com/text.asp?2006/22/2/164/26584
This retrospective study from May 2000 to May 2004, included 169 patients with a mean age of 74 years, with urinary retention secondary to Benign prostatic hyperplasia (BPH). Most patients had already tried medical therapy, which had failed. Mean preoperative prostate volume was 101 ml. A single surgeon performed all laser surgeries. The mean enucleation time and morcellation time was 96.4 and 19.4 minutes, respectively. The mean catheter time and hospital stay was 1.6 and 1.7 days, respectively. The peak urinary flow rate, postvoid residual urine volume, International Prostate Symptom Score (IPSS) and Quality-of-life score (QOL) were significantly improved by 1 month after surgery and continued to improve during subsequent follow-up. Three patients (1.75%) were unable to void postoperatively; one required a suprapubic catheter and two used clean intermittent catheterization. Bladder neck contracture and urethral stricture developed in 1.7 and 1.2% of patients, respectively.
TURP is still the reference standard for treatment of benign prostatic obstruction. Pickard et al performed a prospective study of 3,966 men undergoing prostatectomy, of whom 1,242 presented with urinary retention. The authors found that the urinary retention group had an increased risk of perioperative morbidity, including significantly greater rates of intraoperative complications, most commonly characterized as either uncontrolled bleeding or cardio-respiratory problems, blood transfusion and unplanned return to the operating room, most commonly for bleeding compared with the group of men not in urinary retention. There is a need for alternative treatment modality for patients with a large prostate volume and urinary retention
Several studies have secured the place of Holmium laser enucleation of prostate (HoLEP) as a safe and effective alternative to TURP and open prostatectomy in patients of BPH without urinary retention. A recent randomized trial by Tan AH et al for treatment of bladder outlet obstruction secondary to BPH, comparing HoLEP with TURP, has shown urodynamically, that HoLEP is better than TURP at relieving outflow obstruction. It is likely that greater amount of tissue removed by HoLEP compared with TURP, will lead to lower reoperation rate as shown by trial of Westenburg et al also.
Role of laser in BPH with a large prostate volume and urinary retention is still not proven. Numerous studies with small number of patients and short follow-up, comparing Visual laser ablation of prostate (VLAP) with TURP have not proven the efficacy of VLAP over TURP., This study using Holmium as energy source has shown improvement in mean Qmax up to 19.5 ml/sec, with a 95% decrease in the PVR volume, 78% decrease in the IPSS and 85% improvement in the QOL score at 3 years. 98% of patients were able to void immediately postoperatively, with low incidence of intraoperative and post operative complications. A similar retrospective study by Matthew D et al with large prostate volume (mean prostate volume 107 ml) and urinary retention with one year follow- up, has shown similar results. Although these studies with short term results do prove the efficacy of HoLEP, without randomization with TURP and long term follow up, the place of HoLEP as a safe and effective alternative to TURP and open prostatectomy in patients of BPH with urinary retention, cannot be secured.
Despite the advantages of HoLEP over both TURP and open prostatectomy in BPH without urinary retention with four year minimum long term follow up, it has been slow to gain popularity. One of the main reasons is that, it requires the surgeon to undertake at least 10-30 cases with proper mentoring before outcomes can be consistently achieved. Seki et al found that when self-taught, there is evidence of a learning curve effect for as many as 50 cases.
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