976
EUROPEAN UROLOGY 67 (2015) 972–976
Re: GreenLightTM Laser (XPS) Photoselective Vapoenucleation Versus Holmium Laser Enucleation of the Prostate for the Treatment of Symptomatic Benign Prostate Hyperplasia: A Randomized Controlled Study Elshal AM, Elkoushy MA, El-Nahas AR, et al J Urol 2015;193:927–34 Experts’ summary: This prospective randomized study compared GreenLight laser (XPS) photoselective vapo-enucleation of the prostate (PVP) and holmium laser enucleation of the prostate (HoLEP) for the treatment of symptomatic prostate enlargement. The authors found a significant improvement of voiding symptoms (International Prostate Symptom Score) and micturition parameters (maximum flow rate) during 12-mo follow-up. Prostate volume reduction was significantly higher after HoLEP, but patients in both arms had a comparable rate of reinterventions. The authors concluded that, compared with HoLEP, GreenLight PVP appears to be noninferior with regard to intraoperative safety and postoperative symptomatic improvement. Experts’ comments: The majority of urologists are performing surgery for benign prostate enlargement based on the following principle: You have to remove all adenoma tissue. Currently, a trend toward enucleating techniques in transurethral surgery can be noticed, and the current study adds to the existing literature. Besides HoLEP, other lasers and resection loops are currently used for enucleation [1]; however, the question of how much tissue has to be removed to receive the optimal result remains unanswered. Symptom relief does not necessarily correlate with the amount of tissues removed [2]. In particular, colleagues from the early days of transurethral resection of the prostate believe that in a patient with a prostate volume of 80 ml, the surgeon has to remove at least 60–70 ml; however, studies have shown that, depending on prostate size, only 40–60% of the preoperatively measured tissue will be removed [3]. Hypothetically, three groups of ‘‘benign prostatic hyperplasia surgeons’’ exist. The first group is composed of the more radical transurethral prostate tissue removers and enucleation promoters who argue that maximum tissue removal is necessary to receive satisfactory results. The second group is urologists who believe that the extent of tissue removal has to be significant and long lasting but not
necessarily the maximum possible. Although the dispute about how much tissue has to be removed is ongoing, a third group recently entered the stage: the ‘‘minimalists.’’ New emerging techniques such as UroLift (NeoTract, Inc., Pleasanton, CA, USA), Rezum (N X Thera, Maple Grove, MN, USA), prostatic emolization, and prostatic injectable drugs have gained wide attention in the urologic community. These techniques usually do not remove prostatic tissue immediately, or ever, and only unobstruct a small but seemingly relevant part of the prostatic fossa [4]. Despite encouraging results, the crucial question is, ‘‘How long and for what price?’’ Patient demand for these kinds of procedures seems high. If these procedures stand the test of time, urologists will able to offer a minimally invasive alternative to classic transurethral techniques. We should stop thinking that there are only two possible options: complete prostatic tissue removal or drug therapy. There might be something in between! Conflicts of interest: Alexander Bachmann is an advisor of American Medical Systems (AMS) GreenLight laser and principal investigator of the Goliath study. He has received honoraria from AMS for presentations, workshops, and proctoring of GreenLight laser prostatectomy. Malte Rieken has nothing to disclose.
References [1] Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013;64:118–40. [2] Hakenberg OW, Helke C, Manseck A, Wirth MP. Is there a relationship between the amount of tissue removed at transurethral resection of the prostate and clinical improvement in benign prostatic hyperplasia. Eur Urol 2001;39:412–7. [3] Green JS, Bose P, Thomas DP, et al. How complete is a transurethral resection of the prostate? Br J Urol 1996;77:398–400. [4] Chung A, Woo HH. What’s truly minimally invasive in benign prostatic hyperplasia surgery? Curr Opin Urol 2014;24:36–41.
Alexander Bachmann*, Malte Rieken Department of Urology, University Hospital Basel, Basel, Switzerland *Corresponding author. E-mail address: [email protected] (A. Bachmann). http://dx.doi.org/10.1016/j.eururo.2014.12.066
EUROPEAN UROLOGY 67 (2015) 972–976
Re: GreenLightTM Laser (XPS) Photoselective Vapoenucleation Versus Holmium Laser Enucleation of the Prostate for the Treatment of Symptomatic Benign Prostate Hyperplasia: A Randomized Controlled Study Elshal AM, Elkoushy MA, El-Nahas AR, et al J Urol 2015;193:927–34 Experts’ summary: This prospective randomized study compared GreenLight laser (XPS) photoselective vapo-enucleation of the prostate (PVP) and holmium laser enucleation of the prostate (HoLEP) for the treatment of symptomatic prostate enlargement. The authors found a significant improvement of voiding symptoms (International Prostate Symptom Score) and micturition parameters (maximum flow rate) during 12-mo follow-up. Prostate volume reduction was significantly higher after HoLEP, but patients in both arms had a comparable rate of reinterventions. The authors concluded that, compared with HoLEP, GreenLight PVP appears to be noninferior with regard to intraoperative safety and postoperative symptomatic improvement. Experts’ comments: The majority of urologists are performing surgery for benign prostate enlargement based on the following principle: You have to remove all adenoma tissue. Currently, a trend toward enucleating techniques in transurethral surgery can be noticed, and the current study adds to the existing literature. Besides HoLEP, other lasers and resection loops are currently used for enucleation [1]; however, the question of how much tissue has to be removed to receive the optimal result remains unanswered. Symptom relief does not necessarily correlate with the amount of tissues removed [2]. In particular, colleagues from the early days of transurethral resection of the prostate believe that in a patient with a prostate volume of 80 ml, the surgeon has to remove at least 60–70 ml; however, studies have shown that, depending on prostate size, only 40–60% of the preoperatively measured tissue will be removed [3]. Hypothetically, three groups of ‘‘benign prostatic hyperplasia surgeons’’ exist. The first group is composed of the more radical transurethral prostate tissue removers and enucleation promoters who argue that maximum tissue removal is necessary to receive satisfactory results. The second group is urologists who believe that the extent of tissue removal has to be significant and long lasting but not
necessarily the maximum possible. Although the dispute about how much tissue has to be removed is ongoing, a third group recently entered the stage: the ‘‘minimalists.’’ New emerging techniques such as UroLift (NeoTract, Inc., Pleasanton, CA, USA), Rezum (N X Thera, Maple Grove, MN, USA), prostatic emolization, and prostatic injectable drugs have gained wide attention in the urologic community. These techniques usually do not remove prostatic tissue immediately, or ever, and only unobstruct a small but seemingly relevant part of the prostatic fossa [4]. Despite encouraging results, the crucial question is, ‘‘How long and for what price?’’ Patient demand for these kinds of procedures seems high. If these procedures stand the test of time, urologists will able to offer a minimally invasive alternative to classic transurethral techniques. We should stop thinking that there are only two possible options: complete prostatic tissue removal or drug therapy. There might be something in between! Conflicts of interest: Alexander Bachmann is an advisor of American Medical Systems (AMS) GreenLight laser and principal investigator of the Goliath study. He has received honoraria from AMS for presentations, workshops, and proctoring of GreenLight laser prostatectomy. Malte Rieken has nothing to disclose.
References [1] Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013;64:118–40. [2] Hakenberg OW, Helke C, Manseck A, Wirth MP. Is there a relationship between the amount of tissue removed at transurethral resection of the prostate and clinical improvement in benign prostatic hyperplasia. Eur Urol 2001;39:412–7. [3] Green JS, Bose P, Thomas DP, et al. How complete is a transurethral resection of the prostate? Br J Urol 1996;77:398–400. [4] Chung A, Woo HH. What’s truly minimally invasive in benign prostatic hyperplasia surgery? Curr Opin Urol 2014;24:36–41.
Alexander Bachmann*, Malte Rieken Department of Urology, University Hospital Basel, Basel, Switzerland *Corresponding author. E-mail address: [email protected] (A. Bachmann). http://dx.doi.org/10.1016/j.eururo.2014.12.066
