Laser Prostatectomy: Holmium Laser Enucleation and Photoselective Laser Vaporization of the Prostate

Treatment Update

TreaTmenT UpdaTe Laser Prostatectomy: Holmium Laser Enucleation and Photoselective Laser Vaporization of the Prostate Yakup Bostanci, MD, Amir Kazzazi, MD, Bob Djavan, MD, PhD Department of Urology, New York University School of Medicine, New York, NY Historically, transurethral resection of the prostate has been the gold standard for the treatment of benign prostatic hyperplasia (BPH). Laser technology has been used to treat BPH for  15 years. Over the past decade, it has gained wide acceptance by experienced urologists. This review provides an evidence-based update on laser surgery for BPH with a focus on photoselective laser vaporization and holmium laser enucleation of the prostate surgeries and assesses the safety, efficacy, and durability of these techniques. [ Rev Urol. 2013;15(1):1-10 doi: 10.3909/riu0553] ® © 2013 MedReviews , LLC Key words Benign prostatic hyperplasia • Laser prostatectomy • Lithium triborate laser • Potassium-titanyl-phosphate laser T ransurethral resection of the prostate (TURP) and simple open prostatectomy (OP) for the larger prostate are currently the gold standard surgical therapies in the treatment of benign prostatic hyperplasia (BPH). Although these techniques have demonstrated long-term, durable results, they are not without complications, which include bleeding, fluid absorption, and associated transurethral resection (TUR) syndrome, prolonged catheterization, urethral stricture, and bladder neck contracture.1 In addition, patients undergoing treatment for BPH are progressively older and have more comorbidities. Therefore, the need for even more minimally invasive surgical techniques is constantly growing to treat every prostate size.2,3 In recent years, various laser techniques have been developed to overcome the complications of TURP and OP while striving to achieve comparable functional results. During the past decade, the development of laser therapy has been dramatic and growth of clinical experience has produced more refined techniques Vol. 15 No. 1 • 2013 • Reviews in Urology • 1 4004170006_RIU0553.indd 1 11/04/13 3:24 PM Laser Prostatectomy: HoLEP and PVP continued and devices that challenge TURP.4,5 The four groups of laser systems that are currently used for BPH include the following6 • Kalium titanyl phosphate ([KTP]: Nd:YAG) and lithium borat ([LBO]:Nd:YAG) lasers • Diode lasers • Holmium:yttrium-aluminumgarnet (YAG) lasers • Thulium:YAG lasers surgery.8 Despite the benefits of HoLEP, the procedure has been slow to gain widespread acceptance. HoLEP is perceived as having a steep learning curve that requires specialized training to overcome.9 During the HoLEP procedure, the surgical capsule of the prostate is exposed by incision and vaporization of the periurethral prostatic tissue. After identifying the plane at the surgical capsule, the pros- Despite the benefits of HoLEP, the procedure has been slow to gain widespread acceptance. HoLEP is perceived as having a steep learning curve that requires specialized training to overcome. BPH can be treated with a range of laser treatments using different laser systems and applications. The different systems produce different qualitative and quantitative effects in tissue, such as coagulation, vaporization or resection, and enucleation via incision. Holmium laser enucleation of the prostate (HoLEP) and photoselective laser vaporization of the prostate (PVP) are the most studied options, with accumulating evidence suggesting that they have the potential to become valid alternatives to both OP and TURP; they currently dominate the arena of BPH laser treatment. This review provides an evidence-based update on laser surgery for BPH with a focus on PVP and HoLEP surgeries, and assesses the safety, efficacy, and durability of these techniques. HoLEP In 1996, Gilling and colleagues developed the first holmium resection technique for the prostate.7 Since that time, HoLEP has gained worldwide attention and has been rigorously assessed and compared with TURP and OP with regard to efficacy, efficiency, safety, cost, and durability.1 HoLEP represents the endourological alternative to OP and is the most technically advanced form of laser prostate tatic adenoma is separated from the capsule, similarly to OP. The entire lobes are enucleated, moved into the bladder, and morcellated.10 This instrument is not dependent on prostate size, and tissue can be preserved for histology.8 Systematic meta-analysis and large series support the place of HoLEP as a safe and effective alternative to TURP and OP. Several randomized clinical trials (RCTs) have compared HoLEP with TURP and OP, with the main findings given in Table 1. Efficacy Tan and colleagues11 performed a meta-analysis of the available RCTs comparing HoLEP with TURP. At 6 and 12 months after treatment, the weighted mean difference (WMD) stay (27.6-59.0 vs 48.3-85.5 days; P 5 .001). In contrast, TURP was superior to HoLEP with regard to the duration of operation (33.1-73.8 vs 62.1-94.6 h, respectively; P 5 .001). Lourenco and associates12 observed that HoLEP improved symptom score during the entire follow-up period of up to 30 months, with larger mean changes in postoperative measurements. However, the differences in the individual studies were not statistically significant (WMD −0.82; 95% confidence interval [CI], −1.76-0.12; P 5 .09). In the same meta-analysis, the same result was found for Qmax at 12-month follow-up. Compared with TURP, significantly higher Qmax rates were reported for HoLEP (WMD 1.48 mL/s; 95% CI, 0.582.40; P 5 .002). According to another meta-analysis, the reduction in International Prostate Symptom Score (IPSS) and the increase in Qmax were significantly more pronounced after HoLEP than after TURP. As a consequence, HoLEP is the only endoscopic procedure to date with proven superior efficacy compared with TURP.13 In this meta-analysis, operation time was significantly longer compared with TURP. Interestingly, when comparing mean tissue retrieval rates (grams per minute) of HoLEP and TURP within the analyzed studies, there was no significant difference Interestingly, when comparing mean tissue retrieval rates (grams per minute) of HoLEP and TURP within the analyzed studies, there was no significant difference (0.52 g/min vs 0.57 g/min), suggesting that the two procedures are equally (time) efficient. for peak urinary flow rate (Qmax) was 1.06 and 0.59 mL/s, respectively, favoring HoLEP, but did not reach statistical significance. In this meta-analysis, HoLEP was superior to TURP with regard to catheterization time (17.7-31.0 h vs 43.4-57.8 h, respectively; P  .001), and hospital (0.52 g/min vs 0.57 g/min), suggesting that the two procedures are equally (time) efficient. Two randomized trials comparing HoLEP with OP for large prostates reported equivalent improvements in symptoms and Qmax rates but significantly longer 2 • Vol. 15 No. 1 • 2013 • Reviews in Urology 4004170006_RIU0553.indd 2 11/04/13 3:24 PM 4004170006_RIU0553.indd 3 HoLEP OP HoLEP TURP HoLEP TURP HoLEP TURP HoLEP TURP HoLEP TURP HoLEP OP KTP PVP TURP KTP PVP TURP KTP PVP OP KTP PVP OP LBO PVP TURP LBO PVP TURP Kuntz RM et al26 24 36 18 12 6 12 60 12 36 24 24 12 18 Follow-up (Mo) 60 60 100 100 41 39 30 30 100 100 52 48 60 60 38 38 39 37 65 60 65 60 60 60 50 50 n 115 113 53 50 113 124 78 77 53 50 70 56 115 113 42 33 86 88 93 96 93 96 61 60 51 53 Prostate Volume (mL) 90 90 92 82 61 63 77 70 87 84 81 82 86 86 49 50 30 68 55 62 50 60 60 65 67 63 Change in Symptoms (%) 23.6 (721) 24.4 (778) 23.0 (569) 21.8 (469) 11.4 (245) 11.8 (242) 12.6 (250) 11.0 (233) 24.1 (491) 21.6 (366) 16.9 (306) 17.2 (326) 20.5 (639) 20.8 (678) 12.1 (167) 9.2 (149) 5.8 (157) 13.8 (225) 7.4 (86) 7.1 (89) 7.4 (186) 7.0 (187) 9.6 (239) 13.6 (312) 13.7 (155) 13.9 (173) Change in Qmax (mL/s) (%) 97 98 98 88 NA NA NA NA 96 91 NA NA 96 98 81 69 87 74 82 86 84 86 79 80 NA NA PVR Change (%) HoLEP, holmium laser enucleation of the prostate; KTP, kalium titanyl phosphate; LBO, lithium borat; NA, not applicable; OP, open prostatectomy; PVP, photoselective laser vaporization of the prostate; TURP, transurethral resection of the prostate. Capitán C et al48 Al-Ansari A et al46 Skolarikos A et al52 Alivizatos G et al47 Horasanli K et al44 Bouchier-Hayes DM et al45 Kuntz RM et al14 Montorsi F et al25 Ahyai SA et al16 Wilson LC et al38 Naspro R et al15 Kuntz RM et al26 Treatment Author/Year Efficacy of HoLEP and PVP TABLe 1 Laser Prostatectomy: HoLEP and PVP Vol. 15 No. 1 • 2013 • Reviews in Urology • 3 11/04/13 3:24 PM Laser Prostatectomy: HoLEP and PVP continued operating time for HoLEP.14,15 Kuntz and colleagues14 found that there was no statistically significant difference between the HoLEP and OP groups with regard to the American Urological Association Symptom Score (AUASS) (3.0 vs 3.0), Qmax (24.3 mL/s vs 24.4 mL/s), and PVR volume (10.6 mL vs 5.3 mL) 5 years after surgery. The perioperative outcomes favored HoLEP, as demonstrated by a significantly lower transfusion rate (0% vs 13.3%), shorter length of catheterization (LOC; 30 h vs 194 h), and shorter hospital stay (70 h vs 250 h). Although operative time was significantly longer for HoLEP (136 min vs 91 min), the authors attributed this to an initial lack of availability of a morcellating device, as they reported a significant decrease in operative time when performing HoLEP with morcellation. The authors concluded that HoLEP is a viable alternative to OP with regard to safety profile, efficacy, and long-term durability, and suggest that HoLEP may be regarded as the new gold standard for the treatment of large glands. In a RCT, Ahyai and associates16 reported 3-year follow-up results comparing HoLEP and TURP for the treatment of glands smaller than 100 cc. In this study, both procedures resulted in statistically significant improvements in AUASS, Qmax, and PVR. AUASS was significantly better at 2-year followup in the HoLEP group (1.7 vs 3.9; P  .0001) and similar at 3-year follow-up (2.7 vs 3.3; P 5 .17). Qmax was similar in the HoLEP and TURP groups at all points of followup (29.0 vs 27.5 mL/s at 3 years). At all points, PVR volume was significantly better in the HoLEP group. Perioperative results heavily favored HoLEP because patients in this group had significantly less blood loss and no transfusion requirement. In addition, patients in the HoLEP group had a significantly shorter median LOC than patients in the TURP group (1 d vs 2 d) as well as a shorter median hospital stay (2 d vs 3 d). Intraoperative Complications Potential intraoperative complications consist of capsular perforation, injury to the bladder mucosa,15,17-20 or postponed morcellation.18,21 So far, TUR syndrome after HoLEP has never been reported, even in very large prostates. None of the RCTs report the need for blood transfusion, but some of the prospective trials do in 1% to 1.7% of cases (Table 2).18,21,22 One review showed a capsular perforation rate ranging from 0.3%23 to 10%.24 Superficial mucosal laceration with the morcellation device was reported ranging from 0.5%24 to 18.2%.25 The rate of TABLe 2 Treatment-specific Complications Complications Intraoperative Bleeding Capsular perforation Conversion Injury of the mucosa Transfusion TUR syndrome Perioperative AUR, recatheterization Clot retention Secondary apical resection Secondary coagulation revision Secondary hemorrhage Episodes of hematuria Urosepsis UTI, fever Late Bladder neck stenosis Urethral stricture Reintervention due to BPE Secondary treatment Transient dysuria Urgency Stress UI HoLEP % (Range) 3.5 0.0 0.2 (0-2) 0.0 3.3 (0.0-18.2) 0.0 0.0 8.8 5.9 (0.0-16.6) 0.0 0.5 (0.0-3.3) 1.4 (0-5) 0.0 0.0 0.0 0.9 (0.0-4.9) 13.3 1.2 (0-3) 4.4 (2-8) 0.0 0.0 1.2 (0-10) 5.6 (0-44) 0.9 (0-3) PVP % (Range) 3.5 0.0 0.0 3.5 (0-8) 0.0 0.0 0.0 24.7 9.9 (7.7-15.3) 0.0 2.1 (0.0-5.2) 0.0 0.7 (0-3) 0.0 0.0 12.0 (0-17) 25.4 5.0 (0-13) 6.3 (3-10) 5.6 (0-18) 0.0 8.5 (0-22) 0.0 0.0 AUR, acute urinary retention; BPE, benign prostate enlargement; HoLEP, holmium laser enucleation of the prostate; PVP, photoselective laser vaporization of the prostate; TUR, transurethral resection; UI, urinary incontinence; UTI, urinary tract infection. Data from Ahyai SA et al.13 4 • Vol. 15 No. 1 • 2013 • Reviews in Urology 4004170006_RIU0553.indd 4 11/04/13 3:24 PM Laser Prostatectomy: HoLEP and PVP superficial ureteric orifice injury ranged from 1.0%26 to 2.1%.19 The incidence of incomplete morcellation ranged from 1.9%21 to 3.7%27 of all cases. Cardiac events were reported in up to 1.2%19 of patients undergoing surgery. Two meta-analyses11,12 have investigated the safety and perioperative morbidity of HoLEP. One Hemorrhage requiring coagulation is reported in 0% to 6%31 and clot retention in 0%32 to 3.6%.22,33 Two meta-analyses have demonstrated that, in comparison with TURP and OP, patients undergoing HoLEP have a shorter catheterization time and hospital stay, reduced blood loss, and a smaller likelihood of blood transfusions, but compa- Two meta-analyses have demonstrated that, in comparison with TURP and OP, patients undergoing HoLEP have a shorter catheterization time and hospital stay, reduced blood loss, and a smaller likelihood of blood transfusions, but comparable functional outcomes. meta-analysis found a lower rate of blood transfusion after HoLEP (relative risk 0.27; 95% CI, 0.07-0.95; P 5 .04) compared with TURP,12 a finding supported by a second meta-analysis.11 Analysis of the occurrence of complications reveals a correlation with grade of experience of the surgeon.28,29 In trained hands, prostate size had no statistically significant influence on complications.30 Capsular perforations are more likely to occur with smaller prostates, whereas injury of the ureteric orifice occurs more often during resection of large and endovesically growing median lobes.19,28 Early Postoperative Complications In an RCT comparing HoLEP and OP for patients with prostates  70 g, transitory urge incontinence was equally observed in 34.1% (HoLEP) and 38.6% (OP) of patients at 3-month follow-up, whereas dysuria was significantly more frequent in the HoLEP group (68.2 vs 41.0%; P  .001).15 In contrast, the reported rate of transitory urge incontinence showed no significant difference in a multicenter RCT comparing HoLEP and TURP. Dysuria occurred significantly more often in patients after HoLEP (58.9% vs 29.5%; P 5 .0002).25 rable functional outcomes.11,12 In the meta-analysis by Tan and colleagues11 there were no statistically significant differences between pooled estimates between HoLEP and TURP for urethral stricture (2.6% vs 4.4%), blood transfusion (0% vs 2.2%), and re-intervention (4.3% vs 8.8%). However, the overall complication rate was 8.1% in the HoLEP group and 16.2% in the TURP group. Pooled data suggest that catheterization time, hospital stay, and blood loss were significantly lower in the HoLEP group compared with TURP. In one meta-analysis, postoperative urgency was slightly higher in HoLEP patients and occurred in 5.6% and 2.2% of cases after HoLEP and TURP, respectively.13 Of note, in contradiction to the majority of comparative RCTs, more early and transient dysuria and urgency after HoLEP compared with TURP or OP may be encountered.15,17 An extensive review showed low complication rates, including perioperative mortality (0.05%), transfusion (1%), urinary tract infection (UTI; 2.3%), urethral stricture/bladder neck contracture (3.2%), and reoperation (2.8%).34 In addition, RCTs indicated that HoLEP was better than OP for blood loss, catheterization, and hospitalization time.15,35 Late Complications and Durability In a meta-analysis, no statistically significant differences were noted between HoLEP and TURP for urethral stricture (2.6% vs 4.4%; P 5 .944), stress incontinence (1.5% vs 1.5%; P 5 .980), blood transfusion (0 vs 2.2%; P 5 .14), and reintervention (4.3% vs 8.8%; P 5 .059). No obvious publication bias was noted (P 5 0.170, Egger test).11 In a 6-year follow-up analysis, urge incontinence was reported in 7.9%, mixed incontinence in 10.5%, and stress incontinence in 2.6% of patients. Reoperation was necessary in 1.4% after 5 years and one patient underwent urethrotomy at 6 months.36 Comparable long-term results were reported from other studies with a reoperation rate of 4.2% due to residual adenoma, urethral strictures (1.7%), meatal stenosis (0.8%), and bladder neck contracture (0.8%), resulting in a 5-year surgical retreatment rate of 8%. The earlier group of patients showed a higher retreatment rate (8% vs 1.4%).22 Another study observed a reoperation rate of 2.7% during 36-month follow-up. In the group of patients with prostates  50 mL, the incidence of urethral stenosis and bladder neck contracture was significantly higher.20 Reoperation rates in an RCT were comparable at 3-year followup with a rate of 7.2% and 6.6% for HoLEP and TURP, respectively.16 These data are confirmed by other prospective trials comparing HoLEP with TURP.15 Kuntz and colleagues observed a reoperation rate at 5-year follow-up of 5% and 6.7% for HoLEP and OP, respectively.14 The impact on erectile dysfunction (ED) and retrograde ejaculation was very similar between HoLEP and TURP/OP.15,37 The overall erectile function (EF) did not decrease Vol. 15 No. 1 • 2013 • Reviews in Urology • 5 4004170006_RIU0553.indd 5 11/04/13 3:24 PM Laser Prostatectomy: HoLEP and PVP continued from baseline.14 After HoLEP and TURP, 75% and 62% of patients reported retrograde ejaculation, respectively.38,39 Another metaanalysis evaluated the risk of ED after HoLEP compared with standard treatment. ED rates were similar to that with TURP.12 Even longer-term data on the durability of HoLEP have been reported. Naspro and colleagues3 evaluated medium and long-term durability of HoLEP. Patients with a mean follow-up of 43.5 months were analyzed and showed the durability of functional results, with a mean Qmax of 21.9 mL/s and a mean reoperation rate of 4.3% (0-14.1%). Gilling and associates36 published results at a mean 6-year follow-up. In this cohort of 38 patients, the mean IPSS, quality of life (QoL) score, and Qmax 6 years after surgery were 8.5, 1.8, and 19 mL/s, respectively. No significant differences in these postoperative values were identified at any time point of follow-up, aside from Qmax at 6 months and 6 years, further demonstrating the durability of this procedure. In summary, HoLEP is at least as effective as TURP. Despite no statistically significant differences in overall morbidity, complications are less frequent after HoLEP compared with TURP. In addition, long-term follow-up of HoLEP shows durability of the excellent postoperative results. These findings, plus the fact that the HoLEP procedure is prostate-size– independent in contrast to TURP, make HoLEP a strong competitor for the new reference standard in transurethral surgery for BPH.13 PVP PVP currently represents one of the most promising new technologies applied to the treatment of BPH.40 Using this technique, laser energy is directed toward prostatic tissue using a 70° 600 μm side-firing probe. Under direct vision, vaporization is performed with a fibersweeping technique, starting at the bladder neck and continuing with the lateral lobes and the apex. The prostate gland is vaporized from the inside to its outer layers.41 Initial vaporization procedures were performed using 60 W KTP lasers, but due to the slow vaporization times, high-powered 80 W KTP and 120 W LBO systems were developed and, more recently, the 180 W LBO system has been marketed to further improve vaporization speed. These high-powered lasers have allowed for increased ablative efficiency and, in the short-term, appear to generate outcomes similar to TURP with regard to improvement in AUASS, Qmax, and QoL scores when used to treat smaller glands.42 However, few robust data on the long-term outcomes and reoperation rates associated with these procedures exist at this time.43 Efficacy Currently, six RCTs are available: four comparing PVP with TURP44-47 and two comparing PVP with OP (Table 1).47,48 BouchierHayes and colleagues showed that the improvement of voiding variables was similar in the two groups with a mean increase in Qmax of 136% and a 61% mean IPSS improvement for the 80 W laser group.45 However, one study in patients with large prostates reported a significant difference in IPSS and Qmax at 6 months in favor of TURP.44 When compared with OP, 80 W laser showed similar improvement in IPSS score, QoL, and Qmax, whereas there was a statistically significantly greater reduction of prostate volume after OP.47 For small to midsized prostates, Hamann and colleagues and Ruszat and associates demonstrated that the KTP laser may be equivalent to TURP.49,50 For larger prostates, however, further prospective studies are warranted. It is not unlikely that these studies incorporating the 120 W LBO laser could potentially tackle larger prostates more efficiently and overcome the current significantly longer operating times of the KTP laser. One RCT showed equivalent results to TURP51 at 1-year followup, whereas another study comparing KTP treatment with OP showed equivalence in Qmax improvement, PVR, and symptom score reduction at 18-month follow-up.52 Prostatespecific antigen (PSA), as a surrogate marker of tissue removal, decreased by 68.2% with OP and 61.2% with PVP.52 However, other studies have reported much lower rates for PSA reduction using PVP, including 45%,53 41.7%,54 and 37%55 reduction. Only one RCT and a few case studies evaluating the safety and efficacy of the GreenLight HPS® (American Medical Systems, Minnetonka, MN) prostatectomy have been published. Al-Ansari and colleagues46 compared the new HPS 120 W laser machine with TURP. There was dramatic improvement in Qmax, IPSS, and PVR and the degree of improvement was comparable in both groups during 36-month follow-up. Intraoperative and early operative complications were in favor of GreenLight HPS, whereas more patients treated with laser had dysuria/urge compared with patients who had TURP. Intraoperative Complications Several studies have proven the intraoperative safety of PVP with KTP and LBO lasers. An RCT comparing 80 W KTP with TURP demonstrated significantly smaller blood loss in KTP (0.45 g/dL) versus TURP (1.46 g/dL; P  .005), resulting in a blood transfusion rate 6 • Vol. 15 No. 1 • 2013 • Reviews in Urology 4004170006_RIU0553.indd 6 11/04/13 3:24 PM Laser Prostatectomy: HoLEP and PVP in TURP.45 Another RCT of 80 W KTP compared with TURP supported these findings with a blood transfusion rate of 8.1% for TURP.44 In an RCT comparing LBO with OP, the transfusion rate was 0% following KTP, but 13.3% for OP.52 A total of 7.69% of patients in the KTP group required intraoperative conversion to TURP for the control of bleeding, most probably due to capsule perforation.52 A study comparing LBO laser therapy with TURP reported a blood transfusion rate of 20%, a capsule perforation rate of 16.7%, and a TURP syndrome of 5% for the TURP treatment arm, but none of these complications were reported for LBO PVP.46 Conversion to TURP because of impaired visibility caused by bleeding is the only documented intraoperative adverse event of KTP laser vaporization. However, the good hemostatic properties of the KTP laser and its use with saline irrigation avoid the risk of blood transfusion and TUR syndrome, even in patients with ongoing anticoagulation and longer operation times.56 In one meta-analysis, intraoperative complications with the KTP laser were statistically significantly lower compared with TURP.13 Rieken and colleagues39 reviewed the recent data on complications of laser prostatectomy and indicated that PVP had low intraoperative morbidity and early postoperative complications comparable with OP or TURP. Early Postoperative Complications Comparing PVP with TURP in patients with prostates larger than 70 mL, Horasanli and associates observed a higher rate of urinary retention after PVP (15.3% vs 2.7%; P 5 −.02).44 Another RCT reported 0% and 16.7% clot retention in KTP and TURP, respectively, whereas transient urinary retention with recatheterization occurred in 5% of both groups. Urinary tract infection (UTI) occurred in 3.3% and 5% of KTP and TURP, respectively, whereas re-admissions were necessary in 1.6% and 5%, respectively.45 Compared with TURP, prolonged postoperative storage symptoms after KTP laser are not uncommon. Most of the reviewed trials report a mean rate of 10% (range, 10-22) for transient dysuria.45,50,57-62 Surgical experience, previous treatment with finasteride, total laser energy used, and the degree of laser fiber degradation are potential explanations for this phenomenon.63,64 No difference in the incidence of postoperative complications was documented in an RCT trial comparing PVP with OP for prostatic adenomas  80 mL. Prolonged dysuria was noted in 7.6% of KTP and 11.6% of OP patients, whereas UTIs were reported in 21.5% of KTP versus 27% of OP patients.52 In an RCT comparing LBO with TURP, clot retention occurred in 10% of TURP-treated patients compared with none in the LBO group. In the same study, dysuria within 30 days following surgery was reported in 31.7% of TURP and 93.3% of LBO patients.46 Ruszat and colleagues supported the aforementioned findings with data from a major study of 500 patients. Following PVP using the KTP laser, hematuria was reported in 9.8%, blood transfusion in 0.4%, taking anticoagulation treatment (17.2% vs 5.4%; P 5 .001)65 or with prostates  80 mL (17.2% vs 9.8%; P  .05).50 Patients with prostates  40 mL had a significantly higher rate of dysuria than the overall study population (24.3% vs 14.8%; P  .01).50 Late Complications and Durability In an RCT with a 6-month follow-up, 8.1% in the TURP group and 5.1% in the KTP PVP group underwent internal urethrotomy in response to a urethral stricture. Reintervention was required in 17.9% of patients treated with KTP PVP, whereas no reintervention was necessary in the TURP group.44 Another RCT with a 12-month follow-up reported submeatal/urethral strictures or bladder neck stenosis in 13.3% of TURP patients and 8.3% of KTP PVP patients.45 In an RCT with 18-month followup, the reoperation rates due to urethral stricture were 3.1% versus 1.6%, bladder neck contracture (0% vs 3.3%), or need for apical resection (1.5%), with a total of 4.6% of KTP PVP and 5% OP, respectively.52 Another RCT with a follow-up of 36 months comparing LBO PVP with TURP reported a significantly lower retreatment rate of 1.8% for LBO PVP versus 11% for TURP. Bladder neck contractures were incised in 3.6% and 7.4%, respectively.46 Still, there is a need for more No difference in the incidence of postoperative complications was documented in an RCT trial comparing PVP with OP for prostatic adenomas > 80 mL. Prolonged dysuria was noted in 7.6% of KTP and 11.6% of OP patients, whereas UTIs were reported in 21.5% of KTP versus 27% of OP patients. revision in 0.6%, acute renal failure in 0.6%, urosepsis in 0.4%, dysuria in 14.8%, transient urge incontinence in 2.4%, and UTI in 6.8%.50 Hematuria was significantly more common in patients medium- and long-term follow-up specifically to evaluate the risk for reintervention. Referring to a recently published updated cohort study, the rate of reintervention was 6.7% for the KTP laser versus 3.9% Vol. 15 No. 1 • 2013 • Reviews in Urology • 7 4004170006_RIU0553.indd 7 11/04/13 3:24 PM Laser Prostatectomy: HoLEP and PVP continued for TURP, which was statistically significant at 2-year follow-up.57 In contrast, the most extended nonRCT follow-up data (with some patients completing up to 5 years following KTP laser vaporization of the prostate) demonstrated a TURP-like reintervention rate of 6.9%.50,66 Data on sexual function after PVP are limited. In an RCT, the reported rate of retrograde ejaculation was 56.7% and 49.9% (P 5 .21) for patients who underwent TURP and PVP, respectively,44 whereas no difference could be detected between patients undergoing OP/TURP and PVP concerning EF.45,47 Sexual function seemed to be maintained after PVP, although in patients with normal preoperative EF there was a significant decrease in EF. There was no difference in EF between patients who underwent an 80-W or 120-W procedure.67 Few reports exist regarding the long-term durability of PVP. Hai has retrospectively reported his 60-month experience with PVP. At 5 years, patients experienced a stable 78.7% reduction in AUASS and a 171.8% improvement in Qmax. A total of 19 patients (7.7%) had to be retreated for recurrent or persistent obstruction.68 Similarly, Ruszat and associates50 reported a retreatment rate of 14.8% due to recurrent or persisting adenoma (6.8%), bladder neck strictures (3.6%), or urethral strictures (4.4%). In a meta-analysis, the overall complication rate wasn’t statistically significantly different compared with TURP (P 5 .472).13 More RCTs with medium- to long-term follow-up are needed to determine the durability of PVP. Overall, in small to midsized prostates, the PVP shows promising results with comparable efficacy with TURP. In large prostates, these results are controversial, which further stresses the need for evidencebased guidelines on indications for vaporization techniques, specifically with respect to prostate size. More than ever, TURP is being challenged by HoLEP and PVP, which both represent valid clinical alternatives. Current evidence supports the conclusion that HoLEP offers favorable and durable outcomes for any prostate size with low early and late morbidity. PVP has achieved a higher level of acceptance, although long-term results from high-quality studies are awaited.6 All authors read and approved the final draft. There is no financial or commercial interest for this article, and the work had no specific funding. The authors have no real or apparent conflicts of interest to report. References 1. 2. 3. 4. 5. 6. Mandeville J, Gnessin E, Lingeman JE. New advances in benign prostatic hyperplasia: laser therapy. Curr Urol Rep. 2011;12:56-61. Djavan B, Eckersberger E, Finkelstein J, et al. Benign prostatic hyperplasia: current clinical practice. Prim Care. 2010;37:583-597, ix. Naspro R, Bachmann A, Gilling P, et al. A review of the recent evidence (2006-2008) for 532-nm photoselective laser vaporisation and holmium laser enucleation of the prostate. Eur Urol. 2009;55:1345-1357. Djavan B, Margreiter M, Dianat SS. An algorithm for medical management in male lower urinary tract symptoms. Curr Opin Urol. 2011;21:5-12. Juliao AA, Plata M, Kazzazi A, et al. American Urological Association and European Association of Urology guidelines in the management of benign prostatic hypertrophy: revisited. 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