Is Enucleation Technologies the best available now for surgical treatment of LUTS/BPO

• 15 Jul 2020 10:42:09 AM
• |Endo Urology

Dear All,

We are now in an era where many believe that Enucleation Technologies, Monopolar, Bipolar, Lasers are the way to go about when considering Surgical options for LUTs/BPO. There are more new options that are being touted as probably better or equal options for even these Enucleation methods. But these newer options need more evaluations before being touted as the way to go about for the surgical Treatment for LUTS/BPO.

Recently we did have 3 Webinars addressing this subject from India and abroad. These webinars addressed Enucleation Technologies barring one where Aquablation was also mentioned. Each of the proponents of a particular technology tried to sell their views. But it is nice to remember that inspite of their preference, the famous quotation ‘Rose is a Rose is a Rose’ (interpreted as ‘things are what they are’ is worth remembering). It is also worth remembering that it is the man behind the technology that is more important than technology. Huxley stated a few years ago that a patient should go to the surgeon he trusts and not for technology he can offer.

A recent study published by Hashim Hashim, Paul Abrams et al (2020) on ‘Thulium Laser Vapo-resection vs TURP for LUTS or Urinary Retention UNBLOCS Trial RCT’ concluded by stating ‘TURP and ThuVARP were equivalent for urinary symptom improvement (IPSS) 12-months post surgery, and TURP was superior for Qmax. Anticipated laser benefits for ThuVARP of reduced hospital stay and complications were not observed’. This is concerning Vaporesection and not enucleation.

https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930537-7

Stamey as early as 1994 stated that ‘it is sad but true that TURP will soon be relegated to History’ but it has continued to stay alive and kicking and many are still practicing it with vigour. The results of newer technologies are compared with TURP even now. If TURP was not such an effective tool as being proposed now, why then should the results of newer technologies compared with TURP.

In this context I would like to provide the link for the original article of Yasunori Hiraoka (1983) who gave us the concept of Enucleation of prostate. Those who like historical aspects of Urology will like this article.

https://www.jstage.jst.go.jp/article/jnms1923/50/6/50_6_896/_pdf 

It is our common practice to praise all that is new punching holes into existing technologies as inferior. Comparing Surgical Technologies used for Urological ailments are difficult unlike medical therapies. The main problems encountered at such comparison of surgical techniques are Surgeon Oriented and his expertise will go a long way in predicting the outcome.

All techniques available are beneficial if used with caution.

With warm regards,

Venu

Comments(2)

• 

  Venugopal P

  16 Jul 2020 10:52:15 AM

  Dear All,

  In continuation of the topic posted, I am providing an article on ‘Anatomical Endoscopic Enucleation of Prostate next Gold standard No – Not Yet’ for your reading and understanding.

  https://onlinelibrary.wiley.com/doi/pdf/10.1111/and.13707 (PDF can be downloaded from the link if required)

  There are many Exponents of Enucleation technologies amongst us and will mention that Enucleation technologies have become the Gold Standard and should be offered when surgical treatment for LUTS/BPO are found essential.

  I would appreciate if these experts state that Enucleation technologies are the future Gold Standard.

  With warm Regards,

  Venu

   

• 

  Ajay Bhandarkar

  24 Jul 2020 07:42:32 PM

  Respected Sir,

  I was reading this post of yours with great interest. As usual, you always post your questions with excellent literature support. I have always admired your academic views in every topics and subjects you select. But, for Surgical management of BPH, you still have soft corner and biased views for TURP. You rightly asked this question of Enucleation Modalities in the management of BPH. You also quoted "Rose is a Rose is a Rose..." of Thomas Hermann which he said for Enucleation procedure. My arguments in the support of HoLEP or for that matter Enucleation procedures are as follows:

  
  

  1." TURP is a "Gold Standard" procedure for BPH. "  I have an objection for using term "Gold Standard" as it was utilized in 19th and early 20th Century by monetary systems dealing with currencies. We are in 21st Century. We need to move forward. We cannot have fixed ideas and views always.TURP is an excellent, time tested procedure for BPH for sure. TURP is existing for several decades. HoLEP is there for two decades only. Many people were/are skeptical about HoLEP today. Because, laser procedure preceding HoLEP invention was Nd YAG laser which failed miserably after its initial hype. Laser Procedure became more popular after HoLEP invention is/was PVP laser. There was hardly any learning curve involved in GreenLight Laser, one of the reason for its widespread adoption initially. But, it has its limitations. 

  HoLEP has proved its superiority in many trials and it is the most challenged, debated and ultimately accepted procedure. Way back in 2013, at least six randomized controlled trials have shown that HoLEP has equivalent or significantly greater improvements in postoperative clinical outcomes with decreased complications. (Yin L, Teng J, Huang C-J, et al. Holmium laser enucleation of the prostate versus transurethral resection of the prostate: A systematic review and meta-analysis of randomized controlled trials. J Endourol 2013;27:604–611.)
  

  EAU guidelines has given Level 1A recommendation for HoLEP for any size of Prostate and accepted it as first line treatment modality for BPH > 80 grams. AUA guidelines have given Grade B recommendation for HoLEP. Unfortunately in USA, not many centers practice more than 10 cases of HoLEP per year ( JOURNAL OF ENDOUROLOGY Volume 34, Number 7, July 2020.Pp. 770–777 DOI: 10.1089/end.2019.0603" Mind the Gaps:Adoption and Underutilization of Holmium Laser Enucleation of the Prostate in the United States from 2008 to 2014" Jennifer Robles, MD, MPH, Vernon Pais, MD, and Nicole Miller, MD)  

  In India, many centers have started practicing HoLEP successfully. Unfortunately we do not publish our data. 

  
  

  2. HoLEP has steep learning Curve: 

  I think, learning curve for any procedure has to be same. It largely depends on mentorship, perseverance of the surgeon and importantly, volume of case load. My learning for Robotic Radical Prostatectomy will definitely be steep, if I am going to do one case in a month. If HoLEP is taught during residency program, along with TURP, one can actually judge the learning curve by new comer. Practicing Urologists have many more hurdles, priorities and reasons for steep learning curve. But, HoLEP can be learnt with proper guidance. Now, there are more than enough centers, workshops and videos available to learn this efficiently. 

  
  

  3. Enucleation versus Resection:

  I think, we discussed this long time back. Enucleation procedure for BPH has undoubtedly superior outcome. Enucleation done for larger prostate has less morbidity for sure. Debate is only for Enucleation done for small and medium size of BPH. HoLEP is considered size independent gold standard by few. But, if one can do HoLEP efficiently for large gland, they can also do good job for small gland too. Advent of Bipolar Technology has helped experienced resectionists in favor of  TURP. But, there are enough studies which have documented that, Enucleation procedure removes larger amount of tissue compared to resection. Resection of adenoma is based on intuition of the resectionist for the removal of the tissue, where as for anatomical enucleation, once you are in correct plane and follow the right procedure, complete adenoma is removed. That is one of the reason of lower(<3.4%) re-treatment rates for enucleation compared to resection procedure (11-14%). 

  4. Enucleation is Energy Independent:

  In last decade, we all have realized that, enucleation of Prostate 

  adenoma can be done by any energy source, be it Bipolar, Thulium, Low Power Holmium or Monopolar electrocautery with mechanical force. As you rightly said, man behind the machine is more important. Technique of enucleation is more important. Experience of getting into right cleavage planes, identifying important anatomical landmarks and maintaining capsular integrity is very important and can be done with any energy source. We have no long term (> 5 Years follow-up) data for Bipolar enucleation, but, it has promising future. 

  
  

  So, I think, Enucleation versus Resection is surgeon's choice. One can choose to be a surgeon who can offer all types of techniques possible for him. Yes, end result has to be good. Or else, he must be able to guide his patients to a better center in select cases. 

  
  

  Dr. Ajay Bhandarkar. 

  Vadodara, Gujarat.