Is Thulium laser better than HoLEP?
Thulium is the newest laser treatment for BPH and has lower penetration depth. Some of us, soon will be operated by HoLEP, often wonder if we had made a wrong decision.
The answer is both procedures have equal outcomes and complications. The results from both procedures are excellent.
A RANDOMISED TRIAL COMPARING THULIUM VAPOENUCLEATION VERSUS HOLMIUM LASER ENUCLEATION OF THE PROSTATE: RESULTS AT 12-MONTHS
Christopher Netsch*, Benedikt Becker, Arcangelo Venneri Becci, Hamburg, Germany; Thomas Herrmann, Hannover, Germany; Andreas Gross, Hamburg, Germany
INTRODUCTION AND OBJECTIVES: To compare thulium vapoenucleation of the prostate (ThuVEP) with holmium laser enucle- ation of the prostate (HoLEP) for patients with symptomatic benign prostatic obstruction (BPO) with a 12-month follow-up.
METHODS: Ninety-four patients with symptomatic BPO were randomized to either ThuVEP (n1⁄448) or HoLEP (n1⁄446). Perioperative data, as well as International Prostate Symptom Score (IPSS), Quality of Life (QoL), maximum urinary flow rate (Qmax), post-void residual urine (PVR), PSA, and prostate volume measurement by transrectal ultrasound (TRUS) were obtained at one, six, and 12-months. The complications were noted and classified according to the modified Clavien classification system. Patient data were expressed as median (interquartile range) or numbers (%).
RESULTS: There were no significant differences between the surgical groups pre-operatively. Median age at surgery was 73 (67-76) yrs. and median prostate volume was 80 (46.75-100) gm. Fourty-three (45.7%) patients presented in urinary retention with an indwelling cath- eter. The operative time was 60 (41-79) minutes without differences between the groups. There were no differences between the groups regarding catheter time (2 (2-2) days) and postoperative stay (2 (2-3) days). Clavien 1 (13.8%), Clavien 2 (3.2%), Clavien 3a (2.1%), and Clavien 3b (4.3%) complications occurred without differences between the groups. At 6-month follow-up, Qmax (10.7 vs. 25.9 ml/s), PVR (100 vs. 6.5 ml), IPSS (20 vs. 5), and QoL (4 vs. 1) had improved significantly compared to baseline without differences between the groups. A significant decrease of prostate volume (80 vs. 16 ml) and PSA (4.14 vs. 0.71 mg/l) was seen at 6-month follow-up without differences between the groups. At the 12-month follow-up mark, Qmax (10.7 vs. 23.3 ml/s), PVR (100 vs. 11.1 ml), IPSS (20 vs. 5), and QoL (4 vs. 1) still differed significantly from baseline without differences between the groups. The reoperation rate was zero at 12- month follow-up. During the 12-month follow-up period, one episode (0.7%) of acute urinary retention occurred and 6 (6.4%) patients developed urinary tract infections without differences between the groups.
CONCLUSIONS: ThuVEP and HoLEP are highly effective procedures for the treatment of symptomatic BPO. Both procedures give equivalent and satisfactory micturition improvement with low morbidity and sufficient prostate volume reduction at 12-month follow-up.
Source of Funding: Boston Scientific: ISRURO4000004
Below is a review of a paper (2018) reporting the the results of a PAE clinical trial.
The purpose of the review is: "....the major attraction of PAE, at least in the public’s eyes, is its depiction as a minimally invasive procedure with less adverse events (AEs). Preservation of ejaculatory function is particularly promoted (4) . A look beyond the headlines is required to examine this image."
The most Critical information from this review is on PAE ejaculation dysfunction:
"The incidence of 56% of ejaculatory dysfunction in the PAE group is rather surprising (1) . Its mechanism is uncertain. By comparison, the incidence of ejaculatory dysfunction in 84% of patients after TURP is within the expected for this procedure, its mechanism is understood, and it is an essential item on the consent form for this procedure. It therefore follows that ejaculatory dysfunction should be declared as a significant possible AE after PAE rather than the current position of promoting it as an ejaculation-saving procedure! (4)".
(In the above link, plse replace the "?" sign by "." that is a period.)
Comparing PAE to TURP. A critical view. Re: Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non-inferiority trial.
This article (1) is a valuable contribution to our knowledge of the value of PAE (prostatic artery embolization) in the treatment of patients with BPH-LUTs. The paper’s special value lies in the fact that it reports on the results of a RCT, thus providing a high level of evidence.
The trial results show that, at the very short follow up period of 12 weeks, PAE reduces LUTs, as measured by IPSS, but to a lesser degree than TURP, and with unproven non-inferiority. Furthermore, one has to take into consideration that, by comparison, an observation period of 12 weeks is likely to disadvantages TURP far more than PAE. The ROPE study had shown that the improvement in the IPSS is at its best at 3 month for PAE. On the other hand, for TURP patients the improvement in symptoms continues up till the end of observation period of 12 months (2).
From the functional point of view the superiority of TURP is beyond any doubt in terms of improving Qmax, PVR and Pdet at Qmax.
Since the trial did not control for any of the relevant outcomes, one can simply compare the % change in baseline measurements. The results show that the % reduction in IPSS, at 12 weeks, is approximately 48% for PAE Vs. 61% for TURP. It is worthwhile remembering that α1-blockers reduce IPSS by approximately 30-40% (3). The improvement in the Qmax is approximately 74% Vs. 211%, the reduction of PVR is 58% Vs. 85%, and the reduction of Pdet at Q max is 21% Vs 54% for PAE Vs TURP, respectively.
When compared to the current standard surgical treatment, namely TURP, the major attraction of PAE, at least in the public’s eyes, is its depiction as a minimally invasive procedure with less adverse events (AEs). Preservation of ejaculatory function is particularly promoted (4) .
A look beyond the headlines is required to examine this image.
In relation to adverse events the emphasis in the paper, particularly in the abstract, is on the total number of AEs rather than its significance. The really significant AEs of treatment of this condition are not the irritation, pain, discomfort, UTI, or mild haeamturia, which constitute the main bulk of the number of AEs in this study, but the serious ones as well as the long term ones. The paper did not provide detailed information regarding serious AEs to allow valid judgment, and with the very short term follow up here the long term results are unknown. However, other longer-term studies showed more concern regarding log term results of PAE, in terms of reoperation rates, etc. (2,5) . When discussing AEs context is important.
The incidence of 56% of ejaculatory dysfunction in the PAE group is rather surprising (1) . Its mechanism is uncertain. By comparison, the incidence of ejaculatory dysfunction in 84% of patients after TURP is within the expected for this procedure, its mechanism is understood, and it is an essential item on the consent form for this procedure. It therefore follows that ejaculatory dysfunction should be declared as a significant possible AE after PAE rather than the current position of promoting it as an ejaculation-saving procedure! (4)
There are also other remarks to be made about this trial.
BPH- LUTs is a complex mixture of pathophysiology, symptoms and signs (physical and investigation results). The authors chose to give symptoms the prime importance. Although, ultimately, the objective is to relieve symptoms, it is not the only objective. One will have a good reason to believe that improving functional outcomes are just as important. They are likely to result in a more durable symptomatic improvement.
The authors use the term “refractory BPH-LUTs” to describe the participants. This is not entirely accurate. Approximately 15% of patients had not even tried medical treatment.
The exclusion criteria demonstrate the limitations of PAE. The exclusion list includes many common comorbidities, e.g. Atherosclerosis, as well as common findings in patients with BPH-LUTs e.g. eGFR
My own experience,having had a very slight increase of my psa reading over a two-year period from 4.2 to 4.6 led to an mri scan showing an enlarged prostate being some 140mm in size.Urologist told me I needed this procedure and failed to acknowledge that I have absolutely no symptoms.
I have,much to his surprise,declined his advice,deciding to pursue lifestyle changes inthe form of a Mediterranean diet,plenty of regular exercise,herbal treatments in the form of Pygeum,Saw Palmeto,Pumpkin Seeds,Lycpone, Garlic and Pomi T capsules.
Frankly,have never felt so good at the present time although I will still have a future psa and the almost obligatory dre.
Question.Am I avoiding the inevitable or with these lifestyle changes at the age of 67,can I defer surgical procedures indefinitely ?
Thanking you in anticipation.
Hi James. I am not sure if a 140mm prostate is enlarged as I am only used to the size being expressed in cubic centimeters (25-30 CCs is normal I understand). Regardless, I would think to comes down to what symptoms you are experiencing. Are you able to empty your bladder fully? Do you get up at night frequently to urinate, etc. Your PSA readings do not look bad (not suddenly rising) and if you are not experiencing any negative symptoms or impact to your lifestyle, I would not do any surgery. No reason to. I am 62. My prostate was 150CC +, I had a PSA reading of 25, and I was on the verge of severe urinary retention (actually had 2 episodes requiring catheterization) and could not fully empty my bladder. I was pretty miserable, so HoLEP was the best option for me and I am very glad I did it. I would wait and just work with your urologist and monitor things over time, lifestyle/diet changes as your doing, etc.. Others here I am sure will chime in but I hope this is helpful. Regards.
Thank you so much for your quick response and helpful comments so very much appreciated.
My prostate,on reflection, is 140 cc,not mm as expressed earlier !!
I am able to empty my bladder and usually only get up once a night to urinate.
Urologist suspected I was must be suffering some urine retention and to my displeasure,arranged for a nurse to contact me at home to show me catheterization procedure,which I politely declined as being not necessary in my particular case,being largely symptom free.
From ur post, u are lucky as have a very caring urologist. I would pay close attention to what he says.
140cc is a VERY LARGE prostate as the normal size is 20-25cc for a young man. There are two surgical correction techniques that I know of that can treat this large prostate, open prostectomy, in which the stomach is cut open then slices the prostate open to remove the prostate overgrown tissues and the other one is HoLEP, a minimum invasive procedure.
I could not understand why u are not suffering severe BPH symptoms. One possibility is that the prostate only grows outward and not inward and thus the growth does not press on the prostatic urethra and thus not restricting its flow. However, Such large prostate sometimes distorts the shape of the bladder. If this is the case, in the long run, may hurt ur bladder.
To be absolutely sure what is really happening inside the prostate and bladder, there is a test cystoscopy (costs more than $2000) in which the urologist inserts a scope through the penis into the prostatic urethra and bladder. This allow the uro to examine the prostate and bladder carefully. U may consider having it done.
There is another test urodynamic (costs more than a thousand dollars) in which a tube is inserted to the bladder thru the penis. The other end of the tube is hooked up with a water pump, controlled by a computer. Flow rate, pressure, retention, etc. could be measured.
If u are not suffering from any symptoms, like Blayneb said there is no reason to have a surgery except there is a risk. The risk is that if indeed ur urethra is restricted but ur bladder is compensating it by applying a larger pressure to force the urine out without u knowing it, then over time, the bladder smooth muscle called Detrusor will become thicken, known as trabeculation(?). The thickening will reduce the elasticity of the bladder, that is ur bladder is slowly losing its elasticity and is being slowly damaged over time.
Remember we are not urologists, we say things based on ur limited experience and reseach. I truly believe that u have a caring urology and when he asks u to do HoLEP, YOU DON'T WANT TO IGORE HIM. In my opinion, definitely unwise to come to this thread to seek opinion that counters the opinion of ur urlogist. If he is not caring, it would be a different story.
Hope it helps.
My final meeting with Dr. Krambeck was on October 1.
For background I will review my situation that led to my surgery. I was in urinary retention. I had a catheter a little over two months. My CT scan showed that I had a prostate of about 214 grams. My surgery took place at Methodist hospital in Indianapolis Indiana on Jan. 31, 2018. Dr. Amy Krambeck performed the surgery with Dr. Orr assisting. The surgery including morcellation took about 1 hour. Incredibly short for this size prostate. The operative report said that 100 grams of tissue was removed. The pathology report says 110 grams was removed. I have had several surgeries and each time to Doctor visited me just before surgery. Dr. Krambeck did not visit me she sent her assistant.
If you are interested, here is a video of Dr. Krambeck describing HoLEP cbs4indy.com/2017/12/07/treating-prostate-enlargements-with-holep-laser-procedure/
I had a good talk with one of her fellows. During our discussion I found out that stress incontinence is controlled by both the inner sphincter and the outer sphincter. She also said that the verumontanum was not damaged. She also said that approximately 90% of my inner sphincter was removed during the surgery. This insures that the bladder empties and that the patient will have retrograde ejaculation.
When I got to speak with Dr. Krambeck she indicated that when I regained continence I could stop the Kegel exercises but if incontinence resumed I have to restart the exercises.
Dr. Krambeck and Dr. Miller are friends both having trained under Dr. Lingeman. Dr. Krambeck indicated that Dr. Miller removes about 65% of the of the bladder neck sphincter. DL reports that Dr. Das removes about 40% of the internal sphincter. What a difference between doctors! In fact Dr. Krambeck said that the surgery that Dr. Das performed was not HoLEP, presumably because so much of the bladder neck sphincter remains.
Her only continuing directions were an annual PSA test and DRE.
Certainly I am happy that I can urinate without a catheter. I am still interested in new therapies that do not have the side effects of HoLEP. Dr. Lingeman says the sex is thee same but without out the mess. That may be true for most men but not for me.
The other take away is try to get multiple opinions. My local urologist is part of the IU health network thus the only referral he would make was within the network. When I got to Indianapolis I was handled like a side of beef in a butcher shop. There was no attempt to instruct me as to the details of the surgery, the exact condition of my prostate, no attempt to create any rapport. If I had been healthy (I was recovering from back to back surgeries.) I would have been more proactive in seeking out a surgeon.
I hope this is of some interest.
There is now no mystery as to why Dr. Das quoted for his patients such a low number of less than 2% having incontinence after HoLEP. Dr. Das is exactly the surgeon I want as I don't care about able to pee like a horse nor have RE to work well by cutting 90% of the internal sphincter. I do hope that 40% removal does not impact durability of HoLEP.
Ur experience during and after the surgery also help me to mentally prepare for HoLEP.
I read Dr. K's write up and video. RE was not pointed out in both.
She gave a very good simplified description of the procedure:
"She starts by inserting a tiny camera through the penis and then with the laser carefully cores out the three lobes of the enlarged prostate."
"It's like peeling an orange from the inside out," says Dr. Krambeck. "So I am taking all the pulp out down to the rine or capsule. But it's one solid mass. So we don't want our patients to have an incision or any sort. So it's through the natural orifice, the urethra."
"Dr. Krambeck uses the attached scope to lift, cut and dissect the prostate. It's a technique which takes some time to perfect because all three functions are performed with the same instrument. Once the tissue is removed there is one more step. The material is emulsified so that it can pass through the urethra."
Thanks again, Buster and I hope ur incontinence will not come back.
Just wondering What DRE is.
It sounds like you have the best doctor from the point about being least invasive.
I think I remember that one of Dr. Das’s patients said that he had ncontinence immediately after the surgery. Be sure and take your paper underwear and possibly a guard or two.
Thank u both for ur suooport ! Will bring guard.