- Email: [email protected]
Re: Thulium Laser Versus Holmium Laser Transurethral Enucleation of the Prostate: 18-Month Follow-up Data of a Single Center
BENIGN PROSTATIC HYPERPLASIA
615
tissue (66.93% ⫾ 22.79% vs. 45.41% ⫾ 23.33%; P ⫽ 0.000) were higher with 120-w treatment compared to 70-w ThuVEP. One patient (1.2% of total patients) (in the 120-w group) required a blood transfusion postoperatively. Sixty-one patients (73%) were available for review at the 12-month follow-up time point. The quality of life (QoL), International Prostate Symptom Score (IPSS), maximum urinary flow rate (Q(max)), postvoiding residual urine (PVR) and prostate volume improved significantly after treatment (P ⱕ0.035) and were not significantly different between those treated with the different devices (70- and 120-w). The median prostate volume reduction was 81.70% and 82.19% with 70- and 120-w ThuVEP, respectively. The incidence of complications was low and did not differ between groups treated with the different devices. Two patients (2.4%) (one per group) had a bladder neck contracture at the follow-up. ThuVEP is a safe and efficacious procedure for the treatment of symptomatic BPO. The incidence of complications was low with both devices. The 120-w thulium:YAG device enhances the effectiveness of ThuVEP with regard to the percentage of resected tissue and the enucleation/operation efficiency. Editorial Comment: The quest for the ultimate and best laser therapy in urology continues, albeit at a much slower pace. One of the newer entrants is the thulium:YAG laser, which is most closely related to the holmium laser. Thulium:YAG vaporesection has met with modest improvement in treating men with lower urinary tract symptoms secondary to benign prostatic hyperplasia. However, because it is limited to relatively smaller glands, the manufacturers introduced a variant that uses enucleation (ThuVEP). In this prospective nonrandomized study efficacy of the 70 and 120 watt 2 m laser devices was compared. It appears that the more powerful laser resulted in increased efficacy as measured by subjective and objective parameters. Most impressively at 1 year the mean resected weight with the 120 watt laser device was reportedly almost 67%. Moreover, median prostate volume reduction was more than 80%. There were relatively low complications, although sexual function was not described. A number of issues evolve. Is it really feasible that there is an 80% decrease in prostate volume? Given how much tissue remains even after experienced and talented resectionists perform transurethral prostatectomy, the data seem dubious. Furthermore, I am always amused at how manufacturers of new technology tout their wares with precious few data, claiming them to be best, latest and greatest, only to come up with more powerful versions of their miracles within a few years. Finally, given the niche that holmium enucleation of the prostate has created, what is the advantage of the thulium version? One can rest assured that there will be ongoing studies, new technologies and little clarity on the optimal surgical therapy for benign prostatic hyperplasia. Steven A. Kaplan, M.D.
Re: Thulium Laser Versus Holmium Laser Transurethral Enucleation of the Prostate: 18-Month Follow-up Data of a Single Center F. Zhang, Q. Shao, T. R. Herrmann, Y. Tiana and Y. Zhang Department of Urology, Beijing Friendship Hospital, Capital Medical University, Beijing, China Urology 2012; 79: 869 – 874.
Objective: To compare the clinical outcomes between thulium laser transurethral enucleation of the prostate (ThuLEP) (70 W) and holmium laser transurethral enucleation of the prostate (HoLEP) (90 W) in a prospective randomized trial with 18 months of follow-up. Both ThuLEP and HoLEP effectively relieve the obstructive symptoms due to benign prostatic hyperplasia (BPH). Methods: A total of 133 consecutive patients with BPH were randomized to either ThuLEP (n ⫽ 71) or HoLEP (n ⫽ 62). An energy setting of 70 W and 90 W was used for the thulium and holmium laser in the enucleation procedure, respectively. The mushroom technique was used to fragment the enucleated lobes with the resection loop. The preoperative and postoperative parameters were compared. Results: ThuLEP required a longer operation time (72.4 vs 61.5 minutes, P ⫽ .034) but resulted in less
616
BENIGN PROSTATIC HYPERPLASIA
blood loss than HoLEP (130.0 vs 166.6 mL, P ⫽ .045). The catheterization time was comparable. At 18 months, the lower urinary tract symptom indexes were improved significantly in both groups compared with the baseline values. The International Prostate Symptom Score decreased to 5.2 in the ThuLEP group and 6.2 in the HoLEP group. The quality of life score and peak urinary flow rate were similar between the 2 groups (1.3 vs 1.2 and 23.4 vs 24.2 mL/s) and the postvoid residual urine volume decreased by 82.50% and 81.73% in the ThuLEP and HoLEP groups, respectively. The mean prostatespecific antigen decrease after HoLEP and ThuLEP was 30.43% and 43.36%, respectively. No urethral or bladder neck stricture were found in either group. Conclusion: Both ThuLEP (70 W) and HoLEP (90 W) relieve lower urinary tract symptoms equally with high efficacy and safety. ThuLEP was statistically superior to HoLEP in blood loss and inferior to HoLEP in operation time, although the differences were clinically negligible. The mushroom technique could be adequate, without an additional mechanical tissue morcellator. Editorial Comment: This is another in a series of single center studies touting laser prostatectomy. In this report 2 vaporizing enucleation technologies, ie ThuLEP and HoLEP, are compared. Not surprisingly, the authors report that both approaches are effective. Interestingly the authors did not use a morcellator, but rather a mushroom technique. Furthermore, they used mannitol and not saline, and observed a significant decrease in sodium. Finally, it is somewhat perplexing that preoperative prostate volume was 46.6 gm in the ThuLEP group and 43.5 gm in the HoLEP group, yet the resected weights were 37.6 gm and 40.4 gm, respectively. As someone who has done more than 3,000 transurethral electrosurgical procedures, would these data make me convert to laser? In this series the average prostate volume for both groups was 44.7 gm, while the mean operative time for the 2 techniques ranged from 61 to 72 minutes and mean catheterization was about 2.5 days. Bipolar electrovaporization can be done in about 20 minutes with catheterization of less than a day. Frankly, I will stick to transurethral prostatectomy. Steven A. Kaplan, M.D.
Re: National Trends in Surgical Therapy for Benign Prostatic Hyperplasia in the United States (2000 –2008) B. S. Malaeb, X. Yu, A. M. McBean and S. P. Elliott Department of Urology, University of Minnesota, Minneapolis, Minnesota Urology 2012; 79: 1111–1116.
Objective: To report an update of the change in usage trends for different surgical treatments of benign prostatic hyperplasia (BPH) among the United States Medicare population data from 2000 – 2008. The rate of usage of thermotherapy and laser therapy in the surgical treatment of BPH has been changing over the past decade in conjunction with a steady decrease of transurethral resection of the prostate (TURP). Methods: Using the 100% Medicare carrier file for the years 2000 –2008, we calculated counts and population-adjusted rates of BPH surgery. Rates of TURP, thermotherapy, and laser-using modalities were calculated and compared in relation to age, race, clinical setting, and reimbursement. Results: After years of a steady rise, the total rate of all BPH procedures peaked in 2005 at 1078/100,000 and then declined by 15.4% to 912/100,000 in 2008. TURP rates continued to decline from 670 in 2000 to 351/100,000 in 2008. Rates of microwave thermoablation peaked in 2006 at 266/100,000 and then declined 26% in 2008. Laser vaporization almost completely replaced laser coagulation and in 2008 was the most commonly performed procedure second to TURP, with the majority performed as outpatient procedures (70%) and an increasing percentage in the office (12%). Men between ages 70 and 75 had the highest rate of procedures. Reimbursement rates correlate using some but not all procedures. Racial disparities reported previously appear to have resolved. Conclusion: Surgical treatment of BPH continues to change rapidly. TURP continues to decline and laser
615
tissue (66.93% ⫾ 22.79% vs. 45.41% ⫾ 23.33%; P ⫽ 0.000) were higher with 120-w treatment compared to 70-w ThuVEP. One patient (1.2% of total patients) (in the 120-w group) required a blood transfusion postoperatively. Sixty-one patients (73%) were available for review at the 12-month follow-up time point. The quality of life (QoL), International Prostate Symptom Score (IPSS), maximum urinary flow rate (Q(max)), postvoiding residual urine (PVR) and prostate volume improved significantly after treatment (P ⱕ0.035) and were not significantly different between those treated with the different devices (70- and 120-w). The median prostate volume reduction was 81.70% and 82.19% with 70- and 120-w ThuVEP, respectively. The incidence of complications was low and did not differ between groups treated with the different devices. Two patients (2.4%) (one per group) had a bladder neck contracture at the follow-up. ThuVEP is a safe and efficacious procedure for the treatment of symptomatic BPO. The incidence of complications was low with both devices. The 120-w thulium:YAG device enhances the effectiveness of ThuVEP with regard to the percentage of resected tissue and the enucleation/operation efficiency. Editorial Comment: The quest for the ultimate and best laser therapy in urology continues, albeit at a much slower pace. One of the newer entrants is the thulium:YAG laser, which is most closely related to the holmium laser. Thulium:YAG vaporesection has met with modest improvement in treating men with lower urinary tract symptoms secondary to benign prostatic hyperplasia. However, because it is limited to relatively smaller glands, the manufacturers introduced a variant that uses enucleation (ThuVEP). In this prospective nonrandomized study efficacy of the 70 and 120 watt 2 m laser devices was compared. It appears that the more powerful laser resulted in increased efficacy as measured by subjective and objective parameters. Most impressively at 1 year the mean resected weight with the 120 watt laser device was reportedly almost 67%. Moreover, median prostate volume reduction was more than 80%. There were relatively low complications, although sexual function was not described. A number of issues evolve. Is it really feasible that there is an 80% decrease in prostate volume? Given how much tissue remains even after experienced and talented resectionists perform transurethral prostatectomy, the data seem dubious. Furthermore, I am always amused at how manufacturers of new technology tout their wares with precious few data, claiming them to be best, latest and greatest, only to come up with more powerful versions of their miracles within a few years. Finally, given the niche that holmium enucleation of the prostate has created, what is the advantage of the thulium version? One can rest assured that there will be ongoing studies, new technologies and little clarity on the optimal surgical therapy for benign prostatic hyperplasia. Steven A. Kaplan, M.D.
Re: Thulium Laser Versus Holmium Laser Transurethral Enucleation of the Prostate: 18-Month Follow-up Data of a Single Center F. Zhang, Q. Shao, T. R. Herrmann, Y. Tiana and Y. Zhang Department of Urology, Beijing Friendship Hospital, Capital Medical University, Beijing, China Urology 2012; 79: 869 – 874.
Objective: To compare the clinical outcomes between thulium laser transurethral enucleation of the prostate (ThuLEP) (70 W) and holmium laser transurethral enucleation of the prostate (HoLEP) (90 W) in a prospective randomized trial with 18 months of follow-up. Both ThuLEP and HoLEP effectively relieve the obstructive symptoms due to benign prostatic hyperplasia (BPH). Methods: A total of 133 consecutive patients with BPH were randomized to either ThuLEP (n ⫽ 71) or HoLEP (n ⫽ 62). An energy setting of 70 W and 90 W was used for the thulium and holmium laser in the enucleation procedure, respectively. The mushroom technique was used to fragment the enucleated lobes with the resection loop. The preoperative and postoperative parameters were compared. Results: ThuLEP required a longer operation time (72.4 vs 61.5 minutes, P ⫽ .034) but resulted in less
616
BENIGN PROSTATIC HYPERPLASIA
blood loss than HoLEP (130.0 vs 166.6 mL, P ⫽ .045). The catheterization time was comparable. At 18 months, the lower urinary tract symptom indexes were improved significantly in both groups compared with the baseline values. The International Prostate Symptom Score decreased to 5.2 in the ThuLEP group and 6.2 in the HoLEP group. The quality of life score and peak urinary flow rate were similar between the 2 groups (1.3 vs 1.2 and 23.4 vs 24.2 mL/s) and the postvoid residual urine volume decreased by 82.50% and 81.73% in the ThuLEP and HoLEP groups, respectively. The mean prostatespecific antigen decrease after HoLEP and ThuLEP was 30.43% and 43.36%, respectively. No urethral or bladder neck stricture were found in either group. Conclusion: Both ThuLEP (70 W) and HoLEP (90 W) relieve lower urinary tract symptoms equally with high efficacy and safety. ThuLEP was statistically superior to HoLEP in blood loss and inferior to HoLEP in operation time, although the differences were clinically negligible. The mushroom technique could be adequate, without an additional mechanical tissue morcellator. Editorial Comment: This is another in a series of single center studies touting laser prostatectomy. In this report 2 vaporizing enucleation technologies, ie ThuLEP and HoLEP, are compared. Not surprisingly, the authors report that both approaches are effective. Interestingly the authors did not use a morcellator, but rather a mushroom technique. Furthermore, they used mannitol and not saline, and observed a significant decrease in sodium. Finally, it is somewhat perplexing that preoperative prostate volume was 46.6 gm in the ThuLEP group and 43.5 gm in the HoLEP group, yet the resected weights were 37.6 gm and 40.4 gm, respectively. As someone who has done more than 3,000 transurethral electrosurgical procedures, would these data make me convert to laser? In this series the average prostate volume for both groups was 44.7 gm, while the mean operative time for the 2 techniques ranged from 61 to 72 minutes and mean catheterization was about 2.5 days. Bipolar electrovaporization can be done in about 20 minutes with catheterization of less than a day. Frankly, I will stick to transurethral prostatectomy. Steven A. Kaplan, M.D.
Re: National Trends in Surgical Therapy for Benign Prostatic Hyperplasia in the United States (2000 –2008) B. S. Malaeb, X. Yu, A. M. McBean and S. P. Elliott Department of Urology, University of Minnesota, Minneapolis, Minnesota Urology 2012; 79: 1111–1116.
Objective: To report an update of the change in usage trends for different surgical treatments of benign prostatic hyperplasia (BPH) among the United States Medicare population data from 2000 – 2008. The rate of usage of thermotherapy and laser therapy in the surgical treatment of BPH has been changing over the past decade in conjunction with a steady decrease of transurethral resection of the prostate (TURP). Methods: Using the 100% Medicare carrier file for the years 2000 –2008, we calculated counts and population-adjusted rates of BPH surgery. Rates of TURP, thermotherapy, and laser-using modalities were calculated and compared in relation to age, race, clinical setting, and reimbursement. Results: After years of a steady rise, the total rate of all BPH procedures peaked in 2005 at 1078/100,000 and then declined by 15.4% to 912/100,000 in 2008. TURP rates continued to decline from 670 in 2000 to 351/100,000 in 2008. Rates of microwave thermoablation peaked in 2006 at 266/100,000 and then declined 26% in 2008. Laser vaporization almost completely replaced laser coagulation and in 2008 was the most commonly performed procedure second to TURP, with the majority performed as outpatient procedures (70%) and an increasing percentage in the office (12%). Men between ages 70 and 75 had the highest rate of procedures. Reimbursement rates correlate using some but not all procedures. Racial disparities reported previously appear to have resolved. Conclusion: Surgical treatment of BPH continues to change rapidly. TURP continues to decline and laser