Indian Journal of Urology
UROSCAN
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

Correspondence Address:
Naval Khurana
Department of Urology, SGPGIMS, Lucknow
India




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


Full Text

 Summary



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.

 Comments



TURP is still the reference standard for treatment of benign prostatic obstruction. Pickard et al[1] 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[2] 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[3] 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.[4],[5] 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[6] 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,[3] 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[7] found that when self-taught, there is evidence of a learning curve effect for as many as 50 cases.

References

1Pickard R, Emberton M, Neal DE. The management of men with acute urinary retention. National Prostatectomy Audit Steering Group. Br J Urol 1998;81:712-20.
2Tan AH, Gilling PJ, Kennett KM, Frampton C, Westenberg AM, Fraundorfer MR. A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). J Urol 2003;170:1270-4.
3Westenburg A, Giling P, Kennett K, Frampton C, Fraundorfer M. Holmium laser resection of the prostate versus transurethral resection of the prostate: Results of a randomized trial with 4-year minimum long term follow up. J Urol 2004;172:616-9.
4Choe JM, Sirls LT. High-energy visual laser ablation of the prostate in men with urinary retention: pressure-flow analysis. Urology 1996;48:584-8.
5Gujral S, Abrams P, Donovan JL, Neal DE, Brookes ST, Chacko KN, et al . A prospective randomized trial comparing transurethral resection of the prostate and laser therapy in men with chronic urinary retention: The CLasP study. J Urol 2000;164:59-64.
6Peterson MD, Matlaga BR, Kim SC, Kuo RL, Soergel TM, Watkins SL, et al . Holmium laser enucleation of the prostate for men with urinary retention. J Urol 2005;174:998-1001;discussion 1001.
7Seki N, Mochida O, Kinukawa N, Sagiyama K, Naito S. Holmium laser enucleation for prostatic adenoma: Analysis of the learning curve over the course of 70 consecutive cases. J Urol 2003;170:1847-50.