Transurethral resection of the prostate (TURP) and open prostatectomy have been the standard treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) [1,2]. Minimally invasive procedures such as GreenLight photoselective vaporization of the prostate (PVP) or holmium laser enucleation of the prostate (HoLEP) have been developed to decrease morbidity, with the goal to achieve comparable outcome as compared to TURP . HoLEP and PVP are recommended alternatives to TURP in men with moderate-to-severe LUTS [4▪].
Cornu et al.[5▪▪] evaluated a total of 69 randomized controlled trials (RCTs) in a meta-analysis for surgical techniques of BPO with regard to perioperative, short-term, and long-term outcome. They concluded that PVP should be offered to patients with prostates more than 100 ml and those at high risk of bleeding or complications. Enucleation should be advocated especially to patients with large prostates. Bipolar TURP should be considered as an alternative to monopolar TURP [5▪▪]. However, no clear algorithms exist to date as to which procedure to choose in which clinical situation [3,4▪,5▪▪]. During the past decade, a variety of laser technologies have been described with a bewildering array of acronyms , although long-term data for procedures other than HoLEP and PVP are limited [1–3,4▪,5▪▪,6].
Every approach of laser prostatectomy can be subdivided into three principles, independent of the energy source used: vaporization, resection, and enucleation . In this article, we reviewed recent findings about vaporization and enucleation techniques for the treatment of BPO.
ENUCLEATION PROCEDURES: PRELIMINARY STATEMENTS
All transurethral enucleation techniques are based on the surgical descriptions by Hiraoka and Akimoto  and Fraundorfer and Gilling . Briefly, either the beak of the resectoscope is used to bluntly dissect the prostate off the pseudocapsule and then the source of energy is used to coagulate the bleeding vessels or the source of energy is continuously applied to the layer of enucleation using a two-lobe or three-lobe technique [8,9]. A mechanical morcellator is used for fragmentation and suction of the free floating adenomas after enucleation or prostatic tissue is progressively released towards the bladder neck during the enucleation process and then removed by electrocautery resection, the so-called mushroom technique [9,10].
HOLMIUM LASER ENUCLEATION OF THE PROSTATE
HoLEP has been proven to be a size-independent treatment with excellent long-term results [3,4▪,5▪▪]. Currently, a prospective randomized trial (PRT) comparing HoLEP and TURP by Sun et al. was published. At 12-month follow-up, maximum uroflometry (Qmax) (19.77 vs. 18.88 ml/s), postvoid residual volume (PVR) (12.66 vs. 23.22 ml), International Prostate Symptom Score (IPSS) (4.95 vs. 7.48), and quality of life (QoL) (1.57 vs. 1.84) were significantly better improved in the HoLEP group (<0.037) . The transfusion rate was significantly higher in TURP than in HoLEP (11 vs. 1.2%, P < 0.05), confirming prior studies that compared HoLEP with TURP [3,4▪,5▪▪].
Klett et al. examined the sexual long-term outcomes 36-months after HoLEP. They found mean International Index of Erectile Function 5 (IIEF-5) scores which were not significantly changed from baseline. However, they did not perform a subgroup analysis of those patients with normal erectile function and those with erectile dysfunction .
Numerous studies analysed factors affecting the outcomes of HoLEP: HoLEP appeared to be a viable option for men with BPO and detrusor hypocontractility. Detrusor acontractility did not appear to adversely affect postoperative results . Kwon et al. found that overactive bladder symptoms and urodynamic parameters were significantly improved by HoLEP. They showed significant improvements in IPSS, overactive bladder questionnaire score, and frequency–volume chart parameters. Qmax, PVR, maximal cystometric capacity, and bladder outlet obstruction index had also improved significantly. The number of patients who showed involuntary detrusor contraction in urodynamic studies decreased significantly from 45.5 to 36.4% (P < 0.001). Wisenbaugh et al. examined the influence of prostate morphology and HoLEP technique used (two or three-lobe technique) on postoperative outcomes. Patients with a trilobular prostate had a significant greater decrease in PVR compared to the two-lobe group. All other outcomes appeared to be similar after two or three-lobe HoLEP . Jaeger and Krambeck  compared patients with secondary HoLEP after prior BPO surgery (n = 37) in comparison to primary HoLEP (n = 74), with similar outcomes. Mmeje et al. analysed the age dependent morbidity, and functional outcomes after HoLEP. Overall morbidity, hospital stay, and 1-year functional outcomes of HoLEP were similar among all age groups. They concluded that HoLEP is a well tolerated and effective treatment for BPO regardless of age. Choi et al. applied the modified Clavien classification system on the HoLEP procedure. The total morbidity rate was 17.6% and with only four grade III (1%) complications. To note, all 402 patients included in this study were treated by a single surgeon.
Patel et al. retrospectively analysed patients (n = 372) with concomitant procedures (n = 38) at the time of HoLEP. As expected, patients with complex secondary surgical procedures at the time of HoLEP had statistical differences in operative time (221 vs. 65 min), estimated blood loss (92 vs. 33 mL), catheter time (8.5 vs. 1 day), and length of hospitalization (2 vs. 1 day) compared to the control group. However, postoperative outcomes (Qmax, PVR, IPSS) were affected not by the complexity of the secondary procedure .
Becker et al. evaluated the feasibility of HoLEP in patients with known prostate cancer (PCa) and LUTS (n = 62), concluding that HoLEP represents a feasible, well tolerated, and effective treatment option in these subgroups of patients. Rivera et al. found that in patients with known PCa with persistently elevated post-HoLEP prostate specific antigen (PSA) levels or low percentage change PSA levels, one should raise suspicion for high risk PCa.
THULIUM VAPOENUCLEATION OF THE PROSTATE
On the basis of the HoLEP technique, the thulium vapoenucleation of the prostate (ThuVEP) procedure was first described by Bach et al.[22,23]. ThuVEP can even be performed with reasonable efficiency during the initial learning curve (n = 32) of the surgeon when closely mentored . In a single-centre study of 1080 patients, Gross et al.[25▪▪] demonstrated that ThuVEP is size independent, well tolerated, and efficacious for the treatment of BPO with low perioperative morbidity. Complication rates were independent of prostate size [25▪▪,26]. Median catheter time and hospital stay were 2 and 4 days and did not increase with prostate size in these series [25▪▪,26]. Low perioperative morbidity, efficient tissue reduction, immediate and durable improvement of Qmax, PVR, IPSS, and QoL were also observed at 60-month follow-up . Postoperative PSA levels, as a surrogate marker for complete removal of the adenoma, declined by 83.6 and 87% at 12-month follow-up [27,28]. The feasibility and efficacy of ThuVEP has also been shown in patients at high cardiopulmonary risk on ongoing oral anticoagulants . In this bicentric study, no perioperative thromboembolic events occurred, with four patients requiring (7.1%) blood transfusion. Complications within the first 30 days included urinary tract infections (1.7%), urinary retention (3.6%), and delayed bleeding (7.1%) . Regarding the erectile function after ThuVEP, a marginal, nonsignificant erectile function improvement was reported 12-months after surgery . However, although promising results have been reported for ThuVEP, the ThuVEP procedure has not been studied in PRTs yet.
THULIUM LASER ENUCLEATION OF THE PROSTATE
Thulium laser enucleation of the prostate (ThuLEP) is a transurethral enucleation technique using the sheath of the resectoscope for blunt dissection of the adenoma with consecutive coagulation using the Tm:YAG fibre . Outcome of ThuLEP vs. HoLEP was studied in one PRT  as follows: low perioperative morbidity, efficient tissue reduction, and micturition improvement was without differences between the groups. The improvement in Qmax, PVR, IPSS, and QoL remained stable during the 18-month follow-up period .
GREENLIGHT LASER ENUCLEATION OF THE PROSTATE
Feasibility of GreenLight laser enucleation was published by Gomez Sancha and Green  in 2010. The procedure consisted of an initial vaporization of the para-sphincteric areas in order to simplify the subsequent enucleation . Brunken et al. reported a feasibility study using the 120-W GreenLight laser involving 21 men with a mean prostate size of 75 ml. Catheterization time was 1.2 days and hospitalization was 3.6 days. The procedure allowed the removal of 35 g prostate tissue, which was equivalent to 47% of the total prostate weight. Significant improvements in IPSS and PVR were reported at the mean follow-up of 5.8 months . A detailed description of the technique from anatomic PVP to photoselective en-bloc enucleation has been published [34▪].
DIODE LASER ENUCLEATION OF THE PROSTATE
Buisan et al. described diode laser enucleation of the prostate (DiLEP) with a 980-nm diode-pulsed laser. In this feasibility study, 17 patients with a mean prostate volume of 61.26 cc were included. Significant improvements in IPSS and Qmax were noted at 3-month follow-up. Major complications were not seen .
In a retrospective nonrandomized series, Yang et al. used a 980-nm diode laser for enucleation technique, ‘the 4-U incision DiLEP technique’. The surgical outcomes and the perioperative complications were compared with patients undergoing TURP. DiLEP resulted in a significantly lower drop in hemoglobin levels, shorter catheterization times, and shorter postoperative stays. However, transfusion rates were not significantly different . After 12-months Qmax, IPSS and PVR improved significantly in DiLEP and TURP without differences between groups . However, randomization method, dropout rate, potency data, and complication rates were not reported.
Yang et al. evaluated a consecutive series of 120 patients treated by DiLEP. A subgroup analysis according to prostate size showed comparable improvements in IPSS, Qmax, and PVR at 6-month follow-up. Twenty-three patients reported sexual activity measured by IIEF-5 score and did not change after surgery or between the groups. The bladder neck contracture (BNC) and ultrasound (US) rates were 1.5 and 3.1% in both groups .
In a PRT, Xu et al. compared DiLEP with plasmakinetic enucleation and resection of the prostate. The hemoglobin drop was significantly lower in DiLEP than in plasmakinetic enucleation and resection of the prostate. The duration of enucleation was not different between the groups, whereas the total operating time was significantly shorter in DiLEP. Although catheterization was significantly shorter in the DiLEP group, there were no differences in hospital stay. At follow-up, IPSS, QoL, Qmax, and PVR had significantly improved without differences between study arms. In addition, no US or BNC occurred at 12-month follow-up .
ERASER ENUCLEATION OF THE PROSTATE
Eraser enucleation of the prostate (ELAP), using a 1.318 nm continuous-wave diode laser, was designed to mimic HoLEP. This technique was described in an RCT comparing ELAP (n = 30) with bipolar TURP (n = 30) , finding that ELAP was superior to TURP with regard to blood loss, catheter time, and hospital stay. Qmax, PVR, IPSS, and QoL improved significantly after ELAP and bipolar TURP without differences and remained stable (6-month follow-up) . The complication rate was exceptionally low with three grade Id and one grade II complications. At 6-month follow-up, there were no US or BNC. These results were confirmed by a series from the same institution . One Clavien grade 3b complication occurred as follows: a periprostatic abscess, which was treated successfully by transperineal needle aspiration and high-dose antibiotic therapy.
BIPOLAR ENUCLEATION OF THE PROSTATE
Bipolar enucleation of the prostate (BipolEP) was introduced in an RCT vs. HoLEP by Gilling  and found to be associated with longer operative and recovery room times, as well as higher postoperative irrigation requirement . However, the transfusion rates, catheterization and hospitalization times were similar. At follow-up, no differences in IPSS (7.6 vs. 7.3) and Qmax (19 vs. 22.1 ml/s) and for the complications occurred . Liu et al. carried out bipolar enucleation with the mushroom technique, reporting a retrospective series of 1100 patients and concluded that this procedure is an alternative to TURP and open prostatectomy : transfusion rate was 0.8%, mean catheter time 1.8 days, and mean hospital stay 5.3 days. IPSS, QoL, Qmax, and PVR improved significantly and remain stable at 6-year follow-up. US and BNC developed 1.1 and 0.9% of the patients . Zhu et al.[43▪▪] presented a PRT of patients with prostates at least 70 ml who were either treated by plasmakinetic enukleation of the prostate (PkEP) or bipolar TURP and found PkEP was associated with less blood loss, shorter hospital stay, and catheterization time. Postoperative improvements in functional outcomes were comparable between both groups, although the results in the PkEP expanded to be superior during follow-up [43▪▪]. Rao et al. performed a PRT comparing PkEP with open prostatectomy in prostates above 80 ml, being associated with less perioperative morbidity, catheterization time, and hospital stay [43▪▪]. Reoperation rate tended to be higher in the open prostatectomy group (2.5 vs. 12.5%, P = 0.075) [43▪▪]. These results were confirmed in another PRT comparing bipolar plasma enucleation of the prostate with open prostatectomy . Kan et al. compared BipolEP with TURP (n = 86) in prostates above 70 g. He confirmed the significant improvement of bipolar enucleation from other series regarding complications [44–46]. Xiong et al. analysed the learning curve of transurethral enucleation resection of the prostate (TUERP). They found that the ratio of conversion to conventional bipolar TURP decreased after 30 cases, and the efficiency of enucleation and resection increased significantly with accumulative experience after 50 cases .
A variety of vaporization procedures using different energy sources have been described . Long-term data and the number of RCTs for procedures other than PVP are limited [3,4▪,5▪▪,48]. In principle, all of these vaporization techniques create a channel through the prostatic adenoma to produce a TUR-like cavity .
GREENLIGHT VAPORIZATION OF THE PROSTATE OR PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE
PVP for the treatment of BPO was introduced in 1998 by Malek et al. using a 60-W GreenLight kalium titanyl phosphate (KTP) laser. Numerous RCTs have been published on efficacy and safety of the 80-W GreenLight KTP laser [3,4▪,5▪▪], followed by the development of higher powered lasers at 120-W (HPS) , and 180-W (XPS) [52,53]. The functional results of PVP are comparable with TURP [4▪], long-term results are still pending [3,4▪,5▪▪].
In the GOLIATH trial, a European randomized controlled multicentre study [54▪▪], the 180-W GreenLight laser proved noninferiority to TURP in terms of IPSS, Qmax, complication rates. Although lower in the early postoperative course, reintervention rate was similar after 6 months.
Kumar et al. compared monopolar (n = 60), bipolar (n = 57), and 120-W PVP (n = 58) in a PRT and found all procedures equally effective at 12-month follow-up. PVP has added advantages in terms of blood loss, blood transfusion, and catheterization time . Twelve-month follow-up confirmed the expected short-term results [3,4▪,5▪▪,55].
Whelan et al. performed a prospective trial comparing 120-W PVP with TURP as an outpatient procedure showing that 120-W PVP was well tolerated and cost-effective outpatient treatment of LUTS and could be completed with minimal blood loss . However, follow-up was only assessed by telephone, outcomes were not clearly defined  and the different sample sizes [PVP (n = 140), TURP (n = 24)], make it difficult to interpret the results of the study. Office-based PVP using the 120-W HPS GreenLight laser was retrospectively evaluated in 47 patients by Osterberg et al., also finding office-based PVP to be well tolerated and feasible for men with smaller sized prostates.
Ben-Zvi et al. retrospectively evaluated a hybrid technique involving the 120-W HPS laser using a vapour-incision technique in 25 consecutive men with prostates greater than 80 cc and matched with 25 patients who received only standard PVP. Vapour-incision technique was superior in short-term outcomes compared with standard 120-W HPS PVP in prostates greater than 80 cc.
The superiority of the 180-W XPS GreenLight was shown in one single-centre (200 patients) and one multicentre study (1809 patients) [59,60] as follows: operative time, fibres used, and PSA reduction were more favourable with the 180-W XPS system, suggesting cost-effective and efficient tissue removal [59,60].
Lebdai et al. analysed PSA levels during a 4-year period for 80-W, 120-W, and 180-W PVP. At 6-month follow-up, the maximum change was 60% for 80-W, 48.67% for 120-W, and 53.36% for 180-W PVP . To note, these PSA changes are significantly lower compared to enucleation procedures.
Chen et al. evaluated the outcomes of early palliative 120-W HPS GreenLight PVP in patients with acute urinary retention (AUR) induced by advanced PCa (T3/4) and found 120-W HPS PVP to be well tolerated and effective treatment for advanced PCa with AUR. The 12-month reoperation rate was 13.8%, although nine patients developed hormone refractory PCa on the basis of progressive PSA or local disease progression and received second-line hormonal manipulation or chemotherapy.
Elshal et al. compared the perioperative, functional outcomes of treating BPO secondary to a small prostate (<40 cc) by holmium laser incision of the prostate and PVP. There were no differences between the groups in terms of early and late complications. Reoperation rates were 10.4 and 6.4% in the PVP and holmium laser transurethral incision of the prostate group at 5-year follow-up (P > 0.05). Elshal et al. concluded that both techniques were equally effective, well tolerated, and durable in small prostates.
Kumar et al. assessed the sexual function after 120-W HPS GreenLight laser treatment, showing nonsignificantly decreased IIEF-5 scores postoperatively. Interestingly, these results were in contrast to previously published results using an 80-W KTP GreenLight laser from the same working group, in which patients demonstrated a significant decrease in IIEF-5 scores . The differences in these results between 80-W and 120-W GreenLight treatment were explained by decreased amounts of energy at the apex in the 120-W GreenLight group.
Bruyère et al. performed contrast ultrasonography in 12 patients before, after 180-W XPS GreenLight PVP in the operating room, and postoperatively. He found a nonvascularized area with a thickness of 11.1 mm beyond the created cavity. This area was reduced 1 month postoperatively and disappeared at 6 months , concluding that an area of necrosis is induced around the cavity through the GreenLight laser. This must be taken into account to limit the depth of vaporization . Misraï et al. analysed the learning curves for XPS 180-W PVP. Interestingly, the PVP learning curves required at least 120 procedures to meet all parameters of experts in this field (e.g. lasing time/operative time ratio: 66–80%). These learning curves are significantly longer than previously thought and even longer than published for HoLEP and ThuVEP.
THULIUM VAPORIZATION OF THE PROSTATE
Mattioli et al. reported data of thulium vaporization of the prostate (ThuVAP) on 99 patients with small prostates, showing efficient vaporization. Vargas et al. currently analysed the efficacy and safety undergoing ThuVAP as major outpatient surgery. At 6-month follow-up, IPSS and Qmax had improved significantly. Early complications were AUR (1.8%), urinary tract infection (3.6%), and macrohematuria (3.6%). The only late complication observed was BNC in one patient (1.8%) . Pariser et al. also currently presented the 3-month outcomes of 68 patients after ThuVAP. They found significant improvements in IPSS, QoL, PVR, and Qmax .
BIPOLAR VAPORIZATION OF THE PROSTATE
Botto et al. reported initial results of a bipolar vaporization technique in 2001. Subsequently, several studies revealed a reduced morbidity and comparable functional short-term results to conventional TURP, although midterm results have been reported to be inferior .
A bipolar device using a hemispherical electrode was launched and Reich reported the initial experience on a series of 30 patients . No major complication occurred perioperatively and no blood transfusion was required. Voiding parameter improved after surgery and during follow-up. Geavlete et al. evaluated bipolar vaporization of the prostate (BPVP) in a PRT comparing BPVP with transurethral resection in saline and monopolar TURP. They found that the rates of postoperative hematuria, blood transfusion, and clot retention were significantly higher in the TURP group. The operation time was significantly shorter for BPVP patients, the catheterization period and hospital stay were significantly reduced . At 18-month follow-up, there were no differences in functional outcome between the groups. These results were confirmed by Falahatkar et al., comparing bipolar TURP with BPVP and showing similar complications, better outcomes, superior hemostasis, and efficacy compared to TURP. Geavlete et al. also showed the superiority of continuous BPVP over standard BPVP and TURP with regard to operation time. Both continuous BPVP and standard BPVP had better perioperative safety and improved follow-up voiding and symptom scores than TURP .
Kranzbühler et al. published their experience with BPVP in a consecutive series of 83 patients. One-third of the patients were treated under platelet aggregation inhibition. No major intraoperative complications occurred, transfusions were not necessary. Three patients developed US and four patients developed BNC. At 12-month follow-up, IPSS, QoL, Qmax, and PVR were significantly improved .
HoLEP and PVP are recommended in the current EAU guidelines as alternatives to TURP in men with moderate-to-severe LUTS. A variety of laser technologies mimicking HoLEP and PVP have been described during the past decade, namely ThuVEP, ThuLEP, GreenLight laser enucleation of the prostate, DiLEP, ELAP, BipolEP, PkEP, bipolar plasma enuclation of the prostate, TUERP, ThuVAP, and BPVP. Only very few PRTs with short-term to intermediate-term follow-up have been published limiting the evidence of these procedures No clear algorithms exist to date as to which procedure to choose in which clinical situation. The decision for the adequate transurethral approach to BPO should depend on the patient's comorbidities, the surgeon's personal expertise in different surgical procedures, and the availability of transurethral (laser) procedures.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
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