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AbstractObjectiveTo compare prostatic artery embolisation (PAE) with transurethral resection of the prostate (TURP) in the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia in terms of patient reported and functional outcomes.DesignRandomised, open label, non-inferiority trial.SettingUrology and radiology departments of a Swiss tertiary care centre.Participants103 patients aged ≥40 years with refractory lower urinary tract symptoms secondary to benign prostatic hyperplasia were randomised between 11 February 2014 and 24 May 2017; 48 and 51 patients reached the primary endpoint 12 weeks after PAE and TURP, respectively.InterventionsPAE performed with 250-400 μm microspheres under local anaesthesia versus monopolar TURP performed under spinal or general anaesthesia.Main outcomes and measuresPrimary outcome was change in international prostate symptoms score (IPSS) from baseline to 12 weeks after surgery; a difference of less than 3 points between treatments was defined as non-inferiority for PAE and tested with a one sided t test. Secondary outcomes included further questionnaires, functional measures, magnetic resonance imaging findings, and adverse events; changes from baseline to 12 weeks were compared between treatments with two sided tests for superiority.ResultsMean reduction in IPSS from baseline to 12 weeks was −9.23 points after PAE and −10.77 points after TURP. Although the difference was less than 3 points (1.54 points in favour of TURP (95% confidence interval −1.45 to 4.52)), non-inferiority of PAE could not be shown (P=0.17). None of the patient reported secondary outcomes differed significantly between treatments when tested for superiority; IPSS also did not differ significantly (P=0.31). At 12 weeks, PAE was less effective than TURP regarding changes in maximum rate of urinary flow (5.19 v 15.34 mL/s; difference 10.15 (95% confidence interval −14.67 to −5.63); P<0.001), postvoid residual urine (−86.36 v −199.98 mL; 113.62 (39.25 to 187.98); P=0.003), prostate volume (−12.17 v −30.27 mL; 18.11 (10.11 to 26.10); P<0.001), and desobstructive effectiveness according to pressure flow studies (56% v 93% shift towards less obstructive category; P=0.003). Fewer adverse events occurred after PAE than after TURP (36 v 70 events; P=0.003).ConclusionsThe improvement in lower urinary tract symptoms secondary to benign prostatic hyperplasia seen 12 weeks after PAE is close to that after TURP. PAE is associated with fewer complications than TURP but has disadvantages regarding functional outcomes, which should be considered when selecting patients. Further comparative study findings, including longer follow-up, should be evaluated before PAE can be considered as a routine treatment.Trial registrationClinicaltrials.gov NCT02054013.

PurposeTo compare endoscopic enucleation of the prostate using a thulium: yttrium–aluminum–garnet (Tm:YAG) laser and a super-pulsed thulium fiber laser set in continuous-wave (CW) mode, and to evaluate whether theoretical advantages of thulium fiber lasers, related to their shorter wavelength, translate into relevant clinical differences.MethodsIn total, 110 patients suffering from lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia were randomized to undergo either thulium:YAG laser enucleation of the prostate (ThuLEP) or CW thulium fiber laser enucleation of the prostate (CW-ThuFLEP). Intraoperative and postoperative variables and complications were compared. Micturition improvement was assessed at 3-month follow-up using the International Prostate Symptom Score (IPSS), post-void residual urine (PVR) and maximum flow rate (Qmax). Erectile function was evaluated using the International Index of Erectile Function-5 (IIEF-5).ResultsNo significant differences between the ThuLEP and CW-ThuFLEP groups were found in terms of operative time (70.69 vs 72.41 min), enucleation time (50.23 vs 53.33 min), enucleated tissue weight (40.2 vs 41.9 g), enucleation efficiency (0.80 vs 0.79 g/min), catheterization time (2.45 vs 2.57 days), hospital stay (2.82 vs 2.95 days) and hemoglobin drop (1.05 vs 1.27 g/dl). At 3-month follow-up, no significant differences were found in IPSS (5.09 vs 5.81), Qmax (26.51 vs 27.13 ml/s), PVR (25.22 vs 23.81 ml) and IIEF-5 (14.01 vs 14.54).ConclusionThuLEP and CW-ThuFLEP were equivalent in relieving patients from LUTS and improving micturition. Theoretical advantages of the TFL, such as shallower penetration depth and improved vaporization capacity, did not translate into relevant perioperative outcomes or clinical differences.

PurposeTo compare the perioperative and functional outcomes of holmium laser enucleation of the prostate (HoLEP) and thulium laser enucleation of the prostate (ThuLEP) for the treatment of large-volume benign prostatic hyperplasia (BPH) (> 80 ml).MethodsA total of 116 consecutive patients with BPH were randomized to be treated surgically with either HoLEP (n = 58) or ThuLEP (n = 58), following the classical three-lobe enucleation technique. Follow-up was assessed at 1, 3, 6, 12 and 18 months after surgery.ResultsAt 18 months, the lower urinary tract symptom index was improved significantly in both groups compared with the baseline values. The operative time (78.4 ± 8.0 vs. 71.4 ± 6.4 min) and enucleation time (61.2 ± 5.4 vs. 56.4 ± 8.4 min) were significantly shorter for ThuLEP compared to HoLEP (both p < 0.001). There were no significant differences between the two groups regarding morcellation time, resected weight, hemoglobin decrease, catheter time and hospital stay (p > 0.05). The HoLEP and ThuLEP groups had equivalent International Prostate Symptom Scores (3 [3–3] vs. 3 [3–3], p = 0.776), quality of life (1 [1–2] vs. 2 [1–2], p = 0.809), Qmax (25.3 ± 4.8 ml/s vs. 24.7 ± 4.4 ml/s, p = 0.470), postvoid residual urine (PVR) (6.1 [2.6–20.8] vs. 7.7 [3.1–22.8] ml, p = 0.449) and PSA (0.84 ± 0.32 vs. 0.90 ± 0.34 ml, p = 0.309) at 18 months postoperatively.ConclusionBoth HoLEP and ThuLEP relieve lower urinary tract symptoms in a comparable way with high efficacy and safety. ThuLEP was statistically superior to HoLEP in operation time and enucleation time, although the differences were clinically negligible.

Background Patient outcomes were assessed 2 years after treatment with the Optilume BPH Catheter System, a minimally invasive surgical therapy for the treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Methods One-hundred forty-eight adult males with symptomatic BPH were enrolled and randomized in a 2:1 fashion to Optilume BPH or Sham (100 Optilume BPH; 48 Sham). Long-term measures include International Prostate Symptom Score (IPSS), peak urinary flow rate (Qmax), Post-Void Residual Urine (PVR), quality of life measures and sexual function. Follow-up beyond one year was limited to those treated with Optilume BPH. Results At 2 years, 67.5% (56/83 CI 56.3%, 77.4%) of participants in the Optilume BPH arm were symptomatic responders as defined by ≥30% improvement in IPSS without medical or surgical retreatment. IPSS significantly improved from 23.4 ± 5.5 ( n  = 100) to 11.0 ± 7.0 ( n  = 74). Qmax improved by 116.8.% (8.9 ± 2.2 ( n  = 97) to 19.0 ± 16.3 ( n  = 65)), while PVR showed a slight reduction (83.7 ± 70.3 ( n  = 99) to 65.9 ± 74.5 ( n  = 65)). Improvement in uroflowmetry measures was consistent across all prostate volumes. BPH-II improved from 7.0 ± 2.9 ( n  = 98) to 2.3 ± 2.5 at 1 year ( n  = 89) and remained consistent at 2.3 ± 2.9 at the 2-years ( n  = 74), representing a 53.9% improvement. IPSS QoL also improved from 4.6 ± 1.3 ( n  = 100) at baseline to 2.2 ± 1.5 ( n  = 74). The most common adverse events reported in the Optilume BPH arm were hematuria and urinary tract infection (UTI). No device and/or treatment related serious adverse events were reported occurring beyond 12 months post-procedure. There was no impact to sexual function. Conclusions In the PINNACLE study, participants treated with the Optilume BPH Catheter System demonstrated continued and durable results at 2 years, affirming tolerability, safety, and the enduring effectiveness. The Optilume BPH Catheter System provides lasting results that are comparable to the more invasive therapies, while preserving the advantages with being a minimally invasive therapy. Registration ClinicalTrials.gov NCT04131907.

Introduction Benign prostatic hyperplasia (BPH) is a common urological condition, particularly among middle-aged and elderly men. Trans urethral resection of prostate (TURP) has some drawbacks, particularly concerning ejaculatory function. Ejaculation preserving TURP (Ep-TURP) is one such technique that aims at preserving the tissues that are primarily responsible for antegrade ejaculation. Methods and material In this prospective study, patients with bothersome LUTS were randomized into Ep-TURP and standard TURP groups. Supramontal tissue was preserved in Ep-TURP while standard TURP group had resection of the entire prostatic tissue up to the verumontanum. The outcomes with regard to IPSS, Qmax, IIEF(Q9), Ejaculation and PVR were studied. Ejaculation projection score was separately calculated and assessed. Results About 60 patients were studied, with 30 in each group. At 6 months’ follow-up, complication rates were the same in both groups. The IPSS, Qmax, IIEF were similar and comparable. There was no change in erection in all patients (P = 0.559). The ejaculation was well preserved in Ep-TURP (p<0.001). Ejaculation projection score was maintained at 3.77 in the Ep-TURP group while in the standard group it was 0 (P<0.001). Conclusions Ep-TURP is a safe and a cost-effective method of preserving ejaculation in patients undergoing TURP. This procedure adds a better quality of life that greatly aids in enhancing the improving his psychological outlook towards life. Ep-TURP has now emerged as the standard procedure of choice in sexually active young males needing TURP, as the degree of ejaculation is largely well preserved in patients undergoing this procedure.

The 2-1μm thulium laser resection of the prostate-tangerine technique （TmLRP-TT） has been introduced as a minimally invasive treatment for benign prostatic hyperplasia （BPH）. This study was undertaken to assess the clinical efficacy and safety of TmLRP-TT for the treatment of BPH patients with previously negative transrectal prostate biopsy. A prospective analysis of 51 patients with previously negative transrectal prostate biopsy who underwent surgical treatment using TmLRP-TT was performed from December 2011 to December 2013. Preoperative status, surgical details, and perioperative complications were recorded. The follow-up outcome was evaluated with subjective and objective tests at I and 6 months. TmLRP-TT was successfully completed in all patients. Mean prostate volume, operative duration, and catheterization time were 93.3 ± 37.9 ml, 69.5 ± 39.5 min, and 6.5 ± 1.3 days, respectively. The mean International Prostate Symptom Score, quality of life score, maximum urinary flow rate, and post-void residual urine volume changed notably at 6-month follow-up （22.5 ± 6.9 vs 6.1 ± 3.2, 4.8 ± 1.3 vs 1.1 ± 0.9, 7.3 ± 4.5 vs 18.9 ± 7.1 ml s^-1, and 148.7 ± 168.7 vs 28.4 ± 17.9 ml）. Two （3.9%） patients required blood transfusion perioperatively, while 3 （5.9%） patients experienced transient hematuria postoperatively, and 2 （3.9%） patients received 3 days recatheterization due to clot retention. TmLRP-TT is a safe and effective minimally invasive technique for patients with previously negative transrectal prostate biopsy during the 6-month follow-up. This promising technology may be a feasible surgical method for previously negative transrectal prostate biopsy in the future.

Purpose The purpose of this study was to investigate the efficacy of Transurethral Holmium Laser of the Prostate (HoLEP) with Double-n Technology in the treatment of benign prostatic hyperplasia (BPH), with a focus on preserving sexual function postoperatively. Methods Conducted as a multicenter, prospective, single-blind randomized controlled trial, this study enrolled sexually active male patients with BPH. Participants were randomized into three groups: standard HoLEP (Group A), single-n technology (Group B), and innovative double-n technology (Group C), which emphasizes the preservation of the urethral mucosa and nearby structures. The primary endpoints included maximum urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), and International Index of Erectile Function (IIEF). Results Of the 180 initial participants, 139 completed the study. All groups showed significant improvements in Qmax and IPSS. Initial declines in IIEF scores were noted across all groups, stabilizing to baseline by 3 months without further improvement. Group A had modest antegrade ejaculation rates, starting at 15.4% at 3 months and reaching 23.1% at 12 months. Group B showed a significant improvement, with AE rates rising from 31.8% at 3 months to 45.5% at 12 months, significantly higher than Group A ( p  < 0.05). Group C had the highest AE rates, starting at 57.8% at 3 months and reaching 77.8% at 12 months, significantly surpassing both Group A and B ( p  < 0.05). Regarding semen reduction, Group A had 100% reduction at 3 months, which decreased to 77.8% at 12 months. Group B followed a similar trend, from 100% at 3 months to 68.2% at 12 months. Group C showed a more pronounced decline, starting at 84.6% at 3 months and dropping to 37.1% at 12 months, with values significantly lower than both Groups A and B ( p  < 0.05). Conclusions The double-n HoLEP technique shows promising results in improving urinary symptoms while better preserving ejaculatory function and sexual quality of life in BPH patients. This technique could offer a significant advancement in the surgical management of BPH, particularly for sexually active patients.

Purpose We aimed to assess the efficacy and safety of transurethral enucleation with bipolar system (TUEB) regardless of the prostate size using a specially developed TUEB loop. Methods A total of 251 patients who underwent TUEB were categorized into two groups depending on the prostate volume (PV): small-PV (≤ 80 mL) group, 133 patients; large-PV (> 80 mL) group, 118 patients. Comparisons of background information and treatment outcomes were performed between the groups. Results Operation (113.5 vs 166.4 min), enucleation (49.4 vs 68.1 min), and morcellation (11.4 vs 26.4 min) times were longer and hemoglobin decreased significantly (0.84 vs 1.30 g/dL) in the large PV group. However, the enucleation efficiency (enucleated weight per enucleation time; 0.71 vs 0.97 g/min) and prostate-specific antigen reduction rate (24.6% vs 16.1%) were significantly better in the large-PV group, with similar enucleation rates (enucleated weight per transitional zone volume; 82% vs 81%). The International Prostate Symptom Score, uroflowmetry maximum flow rate, and post-void residual urine in both groups improved at 3, 6, and 12 months compared with baseline. No patient underwent blood transfusion. There were no differences in the frequency of postoperative clot retention, urethral stricture, or stress incontinence at 3, 6, and 12 months. Conclusion TUEB using a TUEB loop resulted in high levels of satisfaction regarding the enucleation efficiency, efficacy, and safety for BPH surgery regardless of the prostate size. TUEB should be considered one of the best treatment options for large BPH that is uncontrollable with medication.

Introduction and objectives To compare the perioperative and functional outcomes of low-power and high-power thulium:YAG VapoEnucleation (ThuVEP) of the prostate for the treatment of large-volume benign prostatic hyperplasia (BPH) (> 80 ml). Patients and methods A prospective analysis of 80 patients with symptomatic BPO and prostatic enlargement (more than 80 ml) was conducted. They were divided randomly into two groups (40 patients in each group). One group was treated with low-power ThuVEP, and the other group was treated with high-power ThuVEP. All patients were assessed preoperatively and early postoperatively, and 12-month follow-up data were analyzed. The complications were noted and classified according to the modified Clavien classification system. Results The mean age at surgery was 68 (± 6.1) years, and the mean prostate volume was 112 (± 20.1) cc, and there were no differences between the groups ( p  = 0.457). The mean operative time was 88.4 ± 11.79 min for group A and 93.4 ± 16.34 min for group B, while the mean enucleation time was 59.68 ± 7.24 min for group A and 63.13 ± 10.75 min for group B. There were no significant differences between the groups regarding catheterization time and postoperative stay. The quality of life (QoL), International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), postvoiding residual urine (PVR), and prostate volume improved significantly after treatment and were not significantly different between those treated with the different energies. The incidence of complications was low and did not differ between both the groups. Conclusion Low-power ThuVEP is feasible, safe, and effective with comparable results with high-power ThuVEP in the treatment of BPO.

Benign prostatic hyperplasia (BPH) is a prevalent condition among the elderly male population, characterised by prostate enlargement and bothersome urinary symptoms. Holmium Laser Enucleation of the Prostate (HoLEP) is a minimally invasive surgical option that is preferred for larger prostates due to its precision and minimal complications. Although high-power HoLEP is an efficacious procedure, recent studies indicate that low-power settings may offer comparable benefits with diminished postoperative discomfort. This study compares the efficacy of low-power (LP) and high-power (HP) HoLEP in a prospective, multicentre, randomised controlled trial involving 102 men with prostates larger than 80 ml. The participants were randomly assigned to either the LP or HP groups and were followed for a period of six months following the operation. The primary outcome measure was the international prostate symptom score (IPSS), with secondary outcomes including perioperative and postoperative parameters and Qmax, PVR, and Clavien-Dindo classification of complications at one, three, and six months post-surgery. Both LP and HP HoLEP resulted in significant improvements in IPSS, Qmax, and PVR compared to the baseline ( p  < 0.05). The LP group demonstrated a longer laser application time ( p  < 0.001) and required a greater volume of irrigation fluid ( p  < 0.001), yet exhibited a reduction in total energy usage ( p  = 0.01). Additionally, they reported significantly diminished postoperative pain at 24 and 48 h ( p  < 0.05). No significant differences were observed between the groups with regard to the incidence of complications, the duration of catheterisation, or the length of hospital stay. The results demonstrate that LP-HoLEP is as efficacious as HP-HoLEP in improving urinary symptoms, with the additional benefit of reduced postoperative discomfort. These findings support the use of LP-HoLEP as a viable option for the treatment of large prostates, although further research is required to confirm long-term outcomes.