Endoscopic enucleation of the prostate (EEP). The same but different—a systematic review

Abstract

Purpose Various techniques for EEP exist. They differ by surgical steps and the source of energy. It is assumed that the latter is of minor importance, whereas adherence to the anatomical enucleation template determines the postoperative result. So far, no systematic review highlights the differences between the energy sources in use for anatomical EEP. This study will address selfsame topic. Methods A systematic review of the literature was completed on September 1st, 2020. Studies comparing HoLEP, ThuLEP, DiLEP, or BipolEP with TUR-P providing 12 months of postoperative follow-up were included. Two frequentist network meta-analyses were created to compare the techniques of EEP indirectly. Results 31 studies, including 4466 patients, were found eligible for our meta-analysis. Indirect pairwise comparison showed differences in surgery time between BipolEP and HolEP (MD − 16.72 min., 95% CI − 27.75 to − 5.69) and DiLEP and HoLEP (MD − 22.41 min., 95% CI − 39.43 to − 5.39). No differences in the amount of resected prostatic tissue, major and minor complications and postoperative catheterization time were found. The odds for blood transfusions were threefold higher for BipolEP than for HoLEP (OR 3.27, 95% CI 1.02–10.5). The difference was not statistically significant when comparing prospective trials and matched-pair analysis only (OR 3.25, 95% CI 0.94–11.18). The Qmax 12 months after surgery was 2 ml/sec. higher for BipolEP than for DiLEP (MD 2.00, 95% CI 0.17–3.84) and 1.94 ml/sec. lower for DiLEP than for HoLEP (MD − 1.94, 95% CI − 3.65 to − 0.22). Conclusion The energy source used for EEP has an impact on the intervention itself. BipolEP promotes surgical efficiency; laser techniques lower the risk of bleeding. Registry This meta-analysis is registered in the PROSPERO international prospective register registry with the registration number CRD42020205836.

Comparison of holmium laser enucleation with bipolar transurethral enucleation of the prostate in patients with benign prostatic hyperplasia: Results of a multicentre study

“…The endoscopic enucleation of the prostate involves the anatomical removal of the prostate, similar to open surgery. Currently, HoLEP and BipolEP are successfully applied in BPH treatment and reported to have high efficacies with low complication rates (Gravas et al, 2021; Gu et al, 2020; Hirasawa et al, 2012; Pallauf et al, 2021). According to the current version of the European Association of Urology Guidelines (Gravas et al, 2021), TURP is the first choice in the surgical treatment of patients with a prostate volume between 30 and 80 ml, while other surgical options include HoLEP, BipolEP, laser vaporization and prostatic urethral sling procedure.…”

“…However, the patients in the HoLEP group had a shorter operative time and length of hospital stay and earlier catheter removal. In a recent meta‐analysis (Pallauf et al, 2021), various endoscopic enucleation techniques were compared with TURP in terms of 12‐month postoperative follow‐up data. This meta‐analysis included 31 studies including 4466 patients, and the authors reported that surgery time was significantly shorter in the HoLEP group than the BipolEP group; however, there was no significant difference in the amount of resected prostatic tissue and postoperative catheterization time.…”

“…The authors reported that acute urinary retention (1.3%–3.8%), urinary tract infection (3.5%–4.5%), transient stress urinary incontinence (9.7%–15.4%), urethral stricture (1.6%–4.3%), clot retention (1.7%–3%), re‐intervention requirement (0.2%–1.2%) and transfusion requirement (0.9%) could be seen in the postoperative period. In a more recent meta‐analysis mentioned above, the rates of minor and major complications were determined to be similar between the HoLEP and BipolEP groups (Pallauf et al, 2021). In the current study, we observed that the complication rates did not significantly differ between the two groups.…”

Is the Peripheral Zone Thickness an Indicator of a Learning Curve in Bipolar Transurethral Plasma Enucleation of the Prostate?—A Single Center Cohort Study

“…Anatomical endoscopic enucleation of the prostate (AEEP) is a popular technique for the surgical intervention of severe BPH, and has been widely accepted and recommended by many urologists (3). Less blood loss, shorter postoperative hematuria time, less diluted hyponatremia, and higher prostate adenoma removal rate are considered as significant advantages of this technique (4)(5)(6). At present, BPH is thought to be caused by hyperplasia of the transitional zone (7), which makes the adenoma of the transitional zone more circular under pressure (8).…”

TURPxit or not: contemporary management options for benign prostatic obstruction

“…As stated above, the quest for best energy source for each signature patients in AEEP is an ongoing debate. Lukas Lusuardi and colleagues [27] are revisiting that discussion in a systematic review of EEP-same but different.…”