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Thulium laser enucleation of the prostate

Netsch, Christopher; Gross, Andreas J.

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Current Opinion in Urology: May 2019 - Volume 29 - Issue 3 - p 302-303
doi: 10.1097/MOU.0000000000000610
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Various, more minimally invasive laser-based procedures have been introduced into clinical practice for the treatment of symptomatic benign prostatic obstruction (BPO) during the past 20 years as alternatives to open prostatectomy and transurethral resection of the prostate to decrease perioperative morbidity and to achieve comparable outcomes. The most prominent role played the frequency-doubled neodymium:yttrium–aluminium–garnet (YAG) laser or GreenLight laser and the holmium:YAG laser [1].

Since the introduction of holmium laser enucleation of the prostate (HoLEP) in 1998, this procedure has gained worldwide acceptance because of complete dissection of the prostate adenoma from the prostatic pseudocapsule [2]. HoLEP has been proven to be a size-independent, well tolerated and efficient procedure with excellent long-term outcomes [1]. The shallow learning curve of the HoLEP technique has, however, limited its widespread use [3]. A learning curve of at least 25–50 cases was found acceptable using a structured mentorship programme [4].

On the basis of HoLEP, a wide array of so-called ‘me too’ laser-based transurethral enucleation techniques have been described during the past 12 years using diode, GreenLight and thulium lasers, of whom the latter played the most prominent role [5]. Thulium:YAG vapoenucleation of the prostate (ThuVEP) has been found to be a size-independent, well tolerated and effective procedure with low-perioperative morbidity and excellent long-term results [6–8]. The durability of ThuVEP was demonstrated by a prostate-specific antigen (PSA)-reduction rate of 77.1% at 5-year follow-up [8]. The completeness of adenoma removal by ThuVEP was currently confirmed by a retrospective matched-paired comparison between ThuVEP and thulium vaporesection of the prostate (ThuVARP) [9]: the PSA-reduction was significantly higher after ThuVEP compared with ThuVARP (78.9 vs. 23.4%) at 24-month follow-up, which may lead to a higher reoperation rate after ThuVARP during long-term follow-up.

In a prospective analysis of the learning curves of the ThuVEP technique, the safety and efficacy was confirmed during the initial learning course of the procedure giving reasonable efficiency after 8–16 procedures using a structured mentorship programme [10]. The use of the thulium:YAG laser with its physical properties might be the reason for the short learning curve: contrary to the pulsed holmium:YAG laser, the energy of the thulium:YAG laser is delivered in a continuous wave mode and offers a high ablation capacity combined with an excellent hemostasis and coagulation, to perform a smooth incision or tissue vaporization. This specification allows an uncomplicated correction of the layer of enucleation during ThuVEP combined with maximum safety because of excellent tissue vaporization, avoids poor outcome and may facilitate to become adapt with the ThuVEP technique [10,11].

A prospective randomized trial comparing HoLEP with ThuVEP in patients with significantly enlarged prostates (prostate volume 80 ml) was currently published. The perioperative morbidity was low and comparable between ThuVEP and HoLEP [12]. Both procedures led to equivalent, satisfactory micturition improvement, PSA (4.14 vs. 0.71 μg/l) and prostate volume (80 vs. 16 ml) drop at 6-month follow-up [13]. These results were recently confirmed by a matched-paired analysis of these procedures [14].

ThuVEP is now a well established procedure giving equivalent and satisfactory micturition improvement with low-perioperative morbidity and durable micturition improvement comparable with HoLEP. It is not just another ‘me too’ technique mimicking HoLEP. The continuous wave thulium:YAG laser offers a high ablation capacity combined with excellent hemostasis and coagulation. This technical feature allows an uncomplicated correction of the layer of enucleation during ThuVEP changing from enucleation to vaporization or vaporesection, which is beneficial during the learning course. This might also be an advantage in patients with prostate cancer, when clear layers between adenoma and prostatic pseudocapsule are not identifiable. Contrary to GreenLight enucleation of the prostate (GreenLEP), a bare-ended laser fibre is used in ThuVEP, which facilitates the separation of the adenoma from the pseudocapsule compared with the use of a side-fire laser fibre in GreenLEP. The cost for re-usable laser fibres for ThuVEP or HoLEP are below the 20€ border, whereas the single-use laser fibre for GreenLEP costs above 1000€. This increases the costs of the GreenLEP procedure significantly compared with HoLEP or ThuVEP. In addition, this is contradictory to the past marketing strategy for the GreenLight laser: it was made for pure (incomplete) vaporization of the prostate (for retreatment during intermediate to long-term follow-up) with single-use laser fibres and advertised for that purpose over a decade. Finally, although different techniques for transurethral endoscopic enucleation of the prostate with different energy sources exist, the final goal of endoscopic enucleation remains the same [7]: complete removal of the prostatic adenoma [15].



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Conflicts of interest

There are no conflicts of interest.


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