7° Congresso Nazionale

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7° Congresso Nazionale Associazione Italiana di Endourologia
ml/sec at 3 months post-operatively. Only 2 patients’
required bladder irrigation for hematuria and 5% of
patients’ required recatheterization. Similar results were
confirmed by other larger studies that demonstrated that
HoLRP has equivalent or even better results than TURP
(50). In 1999 Gilling et al (51) (level1) published the
results of a prospective randomized trial with 1-year follow-up
of patients assigned to HoLRP (n=61) and TURP
(n=59). The improvement in flow rate and symptoms score
was similar but the operating time was longer in the HoLRP
group, however the nursing contact, catheter time (20 vs
37.2 hours) and hospital stay (26.2 vs 47.5 hours) were
significantly shorter than the TURP group. At 12 months,
8.3% of the HoLRP group and 10.6% in the TURP group
had deterioration in their level of potency compared to the
preoperative level. Retrograde ejaculation developed in
96% and 86% of the HoLRP and TURP groups, respectively.
Re-operations included 1 bladder neck incision in the
HoLRP group and 2 bladder neck incision sand 2 revisions
in the TURP group. The long-term results showed no significant
difference between the two groups in terms of
symptom score or flow rate at 2 years and 4 years follow up
(52). Fraundorfer et al (53) reported a comparison between
HoLRP and TURP in terms of cost effectiveness. HoLRP
offers a 24.5% cost saving over TURP and 93 procedures
annually would cover the initial and maintenance cost of
the laser machine. The 2 major critiques of the HoLRP procedure
are the longer operative time than TURP (average
16 minute) and the resulting difficulties with pathological
interpretation of the resected small pieces of the adenoma
that may have been affected by thermal damage (54).
HOLMIUM LASER ENUCLEATION OF THE PROSTATE
(HoLEP)
Holmium Laser Enucleation of the prostate (HoLEP) is the
most recent step in the evolution of holmium laser prostatectomy.
Refinement of the holmium laser technique and development
of an efficient tissue morcellator have led to the true
anatomic enucleation of a prostatic adenoma of any size.
Ho: YAG laser fiber acts like the index finger of the surgeon
during an open prostatectomy peeling the median and lateral
lobes off the surgical capsule. In contrast to TURP,
HoLEP is equally suitable for small, medium sized and
large prostate glands with a similar clinical outcome that is
independent of the prostate size (55). Randomized comparative
trials (level 1 evidence) have shown similar results
for HoLEP and traditional surgery used to treat BPH. Tan
et al (56) found that HoLEP is superior to TURP for relieving
bladder outlet obstruction. HoLEP is also superior to
TURP with less bleeding, amount of tissue removed,
decreased catheter time and hospital stay (57,58). HoLEP
group in contrast to the TURP group where the transfusion
rate was 3.3%. In another study Montorsi et al (59) found
that HoLEP and TURP were equally effective with similar
rate of complications at 1 year follow-up. The erectile function
did not show a decrease from baseline in either group.
There was no TUR syndrome in the HoLEP group, versus
in 2.2% of patients in the TURP group. Transient urge
incontinence was reported in 44% and 38% of the HoLEP
and TURP groups, respectively. This complication is usual-
Archivio Italiano di Urologia e Andrologia 2007, 79, 3, Supplemento 1
ly short term and self-limiting. Urethral stricture occurred
in 1.7% in HoLEP group and 7.4% in the TURP group.
Kuntz et al (60) reported that the AUA symptom scores
improved 13-fold in the HoLEP and more than 5 fold in
the TURP group, however, the maximum flow rate
improved about 5-fold in each group. Of sexually active
patients, 74% in the HoLEP group and 70.3% in the TURP
group had retrograde ejaculation. The operative time was
longer than TURP, which seems to be due to the significant
learning curve of HoLEP, which is the main problem of the
HoLEP Procedure Unlike HoLRP, there are no thermal tissue
artefacts in the enucleated specimen in the HoLEP procedure
which improves the histological assessment compared
to TURP (61) HoLEP has the advantage of safely
treating patients and anticoagulated patients, with low
perioperative morbidity regardless of the prostate size (62).
This justifies the suggestion that HoLEP is the modern
gold standard alternative to TURP and open prostatectomy.
It appears to be at least as effective as the traditional surgery
of BPH in terms of its short and long- term efficacy
and low perioperative complications (63).
BIPOLAR TRANS-URETHRAL RESECTION IN SALINE
(TURIS)
The use of bipolar systems permits the coagulation at a
much lower peak voltage of 65-120 V compared with
monopolar systems of 500-800 V. it has been suggested
that this lower peak volume of energy will cause fewer filling
symptoms after resection than standard monopolar
systems (64). The bipolar resection system makes it possible
to use physiologic 0,9% saline as the irrigation fluid,
which reduces the risk of TUR syndrome (65).
Ho et al (66) presented the outcomes of a single-blind,
prospective randomised trials comparing TURIS and
TURP. TUR syndrome did not occur in the TURIS group.
Recatheterisation (TURIS vs. TURP: 10,4% vs. 7,7%) and
reoperation for bleeding (TURIS vs. TURP: 6,2% vs. 3,8%)
were comparable in the two groups. The mean improvement
rate in terms of flow max, post-voidal residual and
IPSS score assessed at 1, 3, 6 and 12 months postoperatively
was similar in both groups.
CONCLUSION
Various alternative to conventional TURP are currently
available, which seem to have a comparable efficacy and
better safety profile than TURP. However, more long-term
data with follow-up of 5 years are needed to confirm the
efficacy of all these techniques illustrated in many several
study. Faced with the plethora of new, minimally invasive
alternatives to TURP, the question of which modality to
use in any given clinical setting is pertinent. It is apparent
that different groups of clinicians have different skill sets
and access to equipment; this translates in real life practice
to centres that have expertise in certain areas. In reality,
many factors lead to the adoption of a new surgical technology
but only the improved efficacy and safety profiles
are the most important. Until both procedural and contextual
factors are in favour of a shift to a new “gold standard”,
TURP will remain the primary choice for most practicing
urologist.