Influence of prostate size on the outcome of holmium laser enucleation of the prostate

Authors


Hemendra Shah, Urology, R.G. Stone Urological Research Institute, 21-A, 14-A Road, Ahimsa Marg, Khar (W) Mumbai, Maharashtra, 400052, India.e-mail: drhemendrashah@yahoo.co.in

Abstract

OBJECTIVE

To analyse the effect of prostate size on the outcome of holmium laser enucleation of prostate (HoLEP, an established procedure for treating symptomatic benign prostatic hypertrophy, BPH), in the initial 354 patients at 1 year of follow-up.

PATIENTS AND METHODS

We retrospectively reviewed the records of 354 patients who had HoLEP at our institution from April 2003 to March 2007. In 235 patients the prostate weighed <60 g (group 1), in 77 it weighed 60–100 g (group 2) and in 42 >100 g (group 3). Demographic data and perioperative variables were recorded and compared among the three groups.

RESULTS

The mean prostate size was 38.1, 76.4 and 133.5 g for groups 1, 2 and 3, respectively (P < 0.001), and the respective mean weight of resected prostate was 18.47, 40.8 and 82.76 g, respectively (P < 0.001). The mean procedure efficiency increased from 0.36 g/min in group 1 to 0.49 g/min in group 2 and 0.58 g/min in group 3 (P < 0.001). The decrease in haemoglobin level after HoLEP was greater in group 3 than in the other groups. Overall, HoLEP resulted in a 75% reduction in American Urologic Association symptom score, a 225% increase in peak urinary flow rate and an 86% decrease in postvoid residual urine volume at 1 year of follow-up. Perioperative complications were evenly distributed among the three groups, except for a higher incidence of superficial bladder mucosal injury and stenotic complications in group 3.

CONCLUSIONS

HoLEP is a safe and effective procedure for treating symptomatic BPH, independent of prostate size, and is associated with low morbidity. The efficiency of HoLEP increases with increasing prostate size.

Abbreviations
HoLEP

holmium laser enucleation of the prostate

Qmax

maximum urinary flow rate

PVR

postvoid residual urine volume.

INTRODUCTION

Traditionally, the options for managing LUTS secondary to BPH have been limited. Patients are initially treated with medical therapy, and if this treatment failed they were advised to undergo surgery [1]. Surgical therapy centred on TURP; it is the most effective endoscopic surgical treatment for BPH, but the perioperative morbidity is closely related to prostate size, as the blood loss and incidence of TUR syndrome increase significantly with a longer operating time. Hence patients with an exceedingly large prostate or with associated bladder calculi or diverticulum were offered open simple prostatectomy as a curative treatment, despite the considerable blood loss and prolonged recovery associated with open surgery [2].

High-powered holmium lasers are used for ablation, resection and enucleation of the prostate, as this laser has excellent incisional, ablative and haemostatic properties. Holmium laser enucleation of the prostate (HoLEP) is a recent step in enabling a true anatomical enucleation of prostatic tissue of any size. HoLEP gives results comparable to TURP and open prostatectomy, with low morbidity and a short hospital stay [3]. In practice, a prostate of any size can be removed by this technique, once it is mastered. However, to our knowledge there are only two studies that have analysed the effect of prostate size on the outcome of HoLEP at 1 and 6 months [2,4]. In the present study we retrospectively analysed the effect of prostate size on the outcome of HoLEP in our initial 354 patients with a 1-year follow-up.

PATIENTS AND METHODS

From April 2003 onwards all patients with a diagnosis of BOO irrespective of prostate size were scheduled for HoLEP at our institution. The diagnosis of BOO was based on the presence of significant LUTS and an obstructed urinary flow rate. Urodynamic criteria were not used to diagnose BOO in the present study. Patients with a preoperative diagnosis of prostate cancer and those with associated neurogenic bladder or urethral stricture were excluded from the study. Six patients with ischaemic cardiomyopathy, left ventricular ejection fraction <30% and poor effort tolerance with an American Society of Anesthesiologists grade 4 anaesthesia risk were also excluded from study. All these six patients were in urinary retention and were treated with suprapubic catheterization in four, urethral catheterization in one and timely clean intermittent self-catheterization in remaining patient. The indications for surgery are summarized in Table 1.

Table 1.  The patient demographics
VariablesMean (range), n or n (%)
  • *

    A few patients had more than one associated comorbidy;

  • †includes 15 patients with recurrent haematuria not responding to medical management. COPD, chronic obstructive pulmonary disease.

Age, years 62.8 (49–103)
Associated medical comorbidities264 (74.5)*
 Hypertension128
 Ischaemic heart disease 69
 Rheumatic heart disease  3
 Diabetes mellitus 48
 Chronic renal failure  7
 Cardiac pacemakers  6
 COPD/bronchial asthma 26
 Liver cirrhosis  2
 Hypothyroidism  2
 Previous:
Cerebrovascular accident  4
Abdominoperineal resection for rectal cancer  1
 Inguinal hernia 12
 Bladder tumour  1
 Upper tract urolithiasis 11
Recurrent BPH
 After TURP 21
 After open prostatectomy  2
Associated coagulopathy 77 (21.7)
 Anti-platelet medication (low-dose aspirin/clopidogrel) 64
 Warfarin  6
 Thrombocytopenia  6
 Autoimmune dermatitis with  idiopathic coagulopathy  1
Indication for surgery
 Recurrent urinary retention 96 (27.1)
 Failure of medical management169 (47.7)
 Bladder calculi 42 (11.9)
 Recurrent UTI, including epididymitis  4 (1.1)
 Bladder diverticulum  4 (1.1)
 Obstructive uropathy  7 (2.0)
 Refusal of medical management 32 (9.0)

All patients were evaluated by a medical history including the AUA symptom score and a physical examination, including a DRE, PSA assay, urine analysis and urine culture. Abdominal ultrasonography was used to measure prostate volume and the postvoid residual urine volume (PVR), and uroflowmetry was used in all patients except those in urinary retention.

From April 2003 to March 2007, 354 men with BOO had HoLEP at our institute; of these, 264 (74.5%) had associated comorbid conditions and 77 (21.7%) had associated coagulopathy (Table 1).

For HoLEP, regional anaesthesia was administered in 333 patients; the remaining 21 had HoLEP under general anaesthesia, including those in whom antiplatelet medication (clopidogrel) was not stopped before surgery (five), patients who were changed from warfarin therapy to low molecular weight heparin (six), one with autoimmune dermatitis and associated idiopathic coagulopathy, one with thrombocytopenia, five with failed regional anaesthesia and three who refused regional anaesthesia. Anti-platelet therapy (low dose aspirin and/or clopidogrel) was stopped 5–7 days before surgery in 54 patients; it was restarted 3–5 days after HoLEP in these patients. Anti-platelet medications were not discontinued in remaining 10 patients, as advised by the cardiologist. All the six patients taking warfarin had HoLEP after changing to low molecular weight heparin. One patient with autoimmune dermatitis and idiopathic coagulopathy was given fresh frozen plasma 4 h before surgery and continued afterward for 24 h as advised by the haematologist.

The patients were placed in the lithotomy position and had an initial cystoscopic evaluation of the prostate and bladder. An Otis urethrotome was used and the urethra calibrated to 30 F. All HoLEP were carried out by one surgeon (H.N.S.) as described previously by Gilling et al.[5]. The energy source consisted of a 100 W Ho:YAG laser with a 550-µm laser fibre. A 26 F continuous-flow resectoscope (Karl Storz Endoscopy, CA, USA) with a laser bridge was used, with normal saline for irrigation. The laser fibre with its 6 F stabilizing ureteric catheter was introduced into the laser bridge. Most of the enucleation was done using a laser setting of 2 J and 50 Hz, changing to 2 J and 40 Hz during apical lobe dissection. After completing the enucleation, haemostasis was achieved by defocusing the laser over targeted areas at settings of 2.5 J and 40 Hz.

Enucleated prostatic tissue was removed by transurethral morcellation using a Versa Cut (Lumenis, Santa Clara, CA, USA) morcellator introduced through an offset rigid nephroscope. During morcellation the bladder was kept distended by using both the inflow and outflow channel of the nephroscope for irrigant inflow with two separate inflow tubes. Alligator forceps were used to remove medium-sized adenoma tissue that could not be morcellated safely. If the morcellation failed, Gilling and Froundorfer’s serrated loop was used through the resectoscope to section prostatic tissue intravesically. Throughout the procedure the urethra was lubricated intermittently every 20 min. At the end of surgery a 22 F urethral Foley catheter was placed.

Patients with associated vesical calculi or bladder diverticulum were treated synchronously with HoLEP, using holmium laser cystolithotrity and laparoscopic pre-peritoneal diverticulectomy, respectively.

The urethral catheter was removed once the urine remained clear for 12 h, and the patients were then discharged. The protocol for management after HoLEP did not change in patients with coagulopathy. Patients were restarted on antiplatelet medications 1 week after surgery. Immediate complications, if any, were recorded. Patients were recalled for regular follow-up at 1 and 4 weeks, 3 and 6 months, and yearly thereafter. The AUA symptom score was evaluated, and uroflowmetry and postvoid residual urine measured at 1, 3, 6 and 12 months and yearly thereafter.

The demographic, perioperative and follow-up data were analysed. Complications during and after surgery were identified to assess the morbidity of HoLEP. For the present study patients were divided into three subgroups based on the preoperative weight of the prostate on transabdominal ultrasonography; group 1 included those with a prostate of <60 g, group 2 of 61–100 g and group 3 of >100 g. The outcome of patients in these three groups was compared using an independent-sample t-test (two-tailed) with 95% CI, and the results shown as the mean (sd). The chi-square test was used to analyse qualitative data, with differences considered significant at P < 0.05.

RESULTS

The demographic data are shown in Table 2. There was refractory urinary retention in 42 (18%), 26 (34%) and 28 (67%) in groups 1, 2 and 3, respectively; 22% had associated coagulopathy and they were equally distributed amongst the three groups. Intraoperative complications were equally distributed amongst the three groups, except for a higher incidence of superficial mucosal injury in those with a large prostate (Table 3). Capsular perforation was the commonest complication during HoLEP, in 9.6% of patients (Table 3). Most of these perforations were either ‘threatened’ or ‘covered’ and did not change the subsequent management of the patients. A blood transfusion during HoLEP was needed in only one patient; he had a haemoglobin level of 7.2 g/dL and was on a urethral catheter for 5 months before HoLEP. He was given two units of packed cells before surgery and one unit of whole blood during surgery.

Table 2.  Patients demographics, intraoperative variables and outcome after HoLEP
VariableMean (sd) {n} for group*
1P, 1 vs 22P, 2 vs 33P 1 vs 3
  • *

    Variation in n at each point is due to either loss of follow-up data or patients not yet completing that particular follow-up duration.

Preop prostate weight, g 38.11 (13.40) {235}<0.001 76.44 (10.84) {77}<0.001133.50 (0.43) {42}<0.001
Resected prostate weight, g 18.47 (8.31) {235}<0.001 40.80 (8.15) {77}<0.001 82.76 (16.91) {42}<0.001
HoLEP efficiency, g/min  0.36 (0.091) {235}<0.001  0.49 (0.05) {77}<0.001  0.58 (0.04) {42}<0.001
Haemoglobin decrease, g/dL  0.68 (0.42) {230}0.914  0.67 (0.43) {76}0.002  0.95 (0.37) {42}0.001
Postop catheterization, h 23.63 (4.88) {235}<0.001 32.00 (4.61) {77}<0.001 43.02 (5.40) {42}<0.001
Preop AUA score 19.65 (6.69) {226}0.231 18.44 (6.17) {64}0.287 19.97 (6.69) {37}0.806
Preop Qmax, mL/min  8.39 (4.05) {168}0.658  8.14 (6.17) {59}0.034  7.07 (2.14) {34}0.079
Preop PVR, mL183.95 (1.48) {221}0.077119.37 (11.39) {69}0.814124.84 (93.81) {39}0.225
1-month AUA score  6.88 (3.72) {219}0.838  6.77 (3.18) {71}0.032  5.41 (2.24) {39}0.032
1-month Qmax, mL/min 18.72 (7.86) {221}0.394 19.70 (8.00) {71}0.194 17.56 (6.60) {39}0.431
1- month PVR, mL 46.13 (56.04) {220}0.142 30.45 (26.99) {70}0.726 28.50 (22.75) {39}0.211
3-month AUA score  5.56 (1.64) {188}0.849  5.51 (2.33) {60}0.277  4.96 (1.71) {32}0.079
3-month Qmax, mL/min 18.70 (6.49) {192}0.427 19.50 (6.48) {61}0.010 15.78 (5.26) {33}0.025
3-month PVR, mL 29.23 (42.15) {192}0.165 21.09 (19.20) {61}0.745 19.64 (19.05) {33}0.239
6-month AUA score  5.30 (1.83) {179}0.557  5.50 (2.14) {54}0.007  4.20 (1.19) {27}0.005
6-month Qmax, mL/min 17.89 (5.25) {178}0.720 17.55 (6.16) {53}0.304 16.10 (4.46) {26}0.114
6-month PVR, mL 30.92 (56.15) {178}0.077 15.83 (19.47) {53}0.713 17.44 (13.34) {26}0.236
1- year AUA score  5.06 (1.90) {135}0.030  4.53 (2.33) {43}0.436  4.73 (1.55) {20}0.584
1- year Qmax, mL/min 17.71 (4.98) {135}0.854 17.89 (4.27) {43}0.795 17.50 (4.64) {20}0.891
1- year PVR, mL 25.49 (35.50) {138}0.259 18.00 (15.58) {44}0.576 15.00 (15.87) {22}0.317
Table 3.  Complications during and after HoLEP
Complications, n (%)GroupTotal
123
During HoLEP01 (1.3)0 1 (0.28)
Blood transfusion01 (1.3)0 1 (0.28)
Capsular perforation   32 (9.0)
 Threatened13 (5.5)3 (3.9)2 (4.8)18 (5.1)
 Covered6 (2.6)3 (3.9)2 (4.8)11 (3.1)
 Free1 (0.42)01 (2.4) 2 (0.56)
 Subtrigonal01 (1.3)0 1 (0.28)
Superficial mucosal injury5 (2.1)4 (5.2)3 (7.1)12 (3.4)
Bladder perforation000 0
Superficial ureteric orifice injury2 (0.85)3 (3.9)2 (4.8) 7 (2.0)
After HoLEP1 (0.42)2 (2.6)1 (2.4) 4 (1.1)
Blood transfusion1 (0.42)2 (2.6)1 (2.4) 4 (1.1)
Cystoscopy with clot evacuation2 (0.85)01 (2.8) 3 (0.84)
Re-catheterization8 (3.4)3 (3.9)2 (4.8)13 (3.7)
Transient incontinence24 (10.2)9 (11.7)5 (11.9)38 (10.7)
Permanent incontinence1 (0.42)01 (2.4) 2 (0.56)
UTI5 (2.1)4 (5.2)2 (4.8)11 (3.1)
Epididymitis1 (0.42)1(1.3)0 2 (0.56)
Meatal/submeatal stenosis3 (1.3)2 (2.6)3 (7.1) 8 (2.3)
Bulbar stricture3 (1.3)2 (2.6)2 (4.8) 7 (2.0)
Bladder neck contracture1 (0.42)00 1 (0.28)
Acute myocardial infarction1 (0.42)00 1 (0.28)

All the complications after HoLEP were also evenly distributed amongst the three groups, except for a higher incidence of stenotic complications in group 3. A blood transfusion was required in four patients; one of whom had a haemoglobin level of 8.9 g/dL before HoLEP and was given two units of packed cells afterward. The remaining three patients who needed a blood transfusion after surgery had coagulopathy or were on antiplatelet treatment. Two of these three patients presented with secondary haemorrhage after HoLEP and needed cystoscopic clot evacuation.

At the 1-year follow-up, HoLEP resulted in a 75% decrease in the mean AUA symptom score (from 19.35 to 4.77), a 225% increase in the mean peak urinary flow rate (Qmax; from 7.86 to 17.70 mL/s) and an 86% decrease in mean PVR (from 142.7 to 19.5 mL). This improvement was comparable amongst the three groups.

DISCUSSION

The primary goal of therapy for BPH must be the effective relief of symptoms associated with BOO. The procedure should be safe and durable [6]. Prostate size is a major factor to consider when various treatments for BOO are evaluated [2]. TURP is accepted as the reference standard in the surgical treatment of BPH. The ideal resection, as described by Blandy (cited in [7]), involves complete removal of all prostatic tissue inside the surgical capsule between the verumontanum and bladder neck. TURP is occasionally used for very large adenomas but it becomes increasingly difficult and unsafe as prostate size increases. Modifications to the traditional technique, e.g. the use of bipolar technology, minimal rather than radical resection, removal of only one lateral lobe, and various loop modifications, have been done to increase the size of gland that can be safely removed [8]. However, significantly enlarged prostates traditionally have been managed by either retropubic or transvesical open prostatectomy, because the resection time required by TURP for large-volume BPH would increase the risk of TUR syndrome and other complications.

It is generally thought that open prostatectomy is used only in less technologically developed areas of the world, but studies from several European countries, e.g. Sweden and France, showed that this procedure is used for 12–14% of prostatectomies. Even more of these procedures are used in Mediterranean areas, e.g. Italy (32%) and Israel (40%) [9]. It is the preferred option for patients with a markedly enlarged prostate associated with bladder diverticulum or multiple or larger bladder stones [10]. A dramatic improvement in urinary flow rates is at least in part attributed to the more complete removal of prostatic tissue than with TURP. This is particularly true for subverumontanal prostatic tissue, which remains behind after TURP and has been considered to be responsible for the lower Qmax and greater PVR after TURP than after open prostatectomy [9]. Despite the successful results and low re-operation rates of open prostatectomy, it is still associated with a significant incidence of complications, especially bleeding needing blood transfusions, and a longer hospital stay (Table 4) [9–14]. Luttwak et al.[15] reported the results of 98 patients undergoing transvesical prostatectomy for prostates of >80 g with associated larger or numerous bladder calculi or bladder diverticulum. They reported that 40.8% patients in the series required one, 14.3% needed two and 2% needed four units of blood transfusion. Some bleeding also occurs during HoLEP and in previous reports the overall decrease in haemoglobin level was 0.2–2.12 g/dL [16]. In the present series the decrease in haemoglobin level was more in group 3 than in the other groups (Table 2). However, the difference was not clinically significant as the blood transfusion requirement was no greater in group 3 (Table 3). The overall blood transfusion requirement after HoLEP in the present series was 1.1%, which is comparable with that reported previously [16].

Table 4.  A summary of intraoperative variables and morbidity in recent contemporary series of open prostatectomy
VariableReference
[11][12][9][13][10][14]
  • *

    Heterologous blood transfusion;

  • †temporary incontinence.

No. of patients321804232201 56902
Prostate weight before surgery, g83.9  75104.5 82138.596.3
Enucleated tissue weight, g63 63.5112.384.8
Operative duration, min62.5   21380.8
Hospital stay, days 6.2   7  6 11.5  6.711.9
Blood transfusion, % 0*   8.2  6.8 18.9 35 7.5
Early re-intervention, %   1.1  3.5  3.6 3.7
Incontinence, % 9.4   3.7  0  0.5  5.4
UTI, %12.5  2.6 12.9 5.1
Wound problems, % 3.1  4.3  5.47
Late re-operation, %   3.6 (2 years)  3.9
Bladder neck stenosis, % 6.25   4.8  3.3   5.35
Stricture, % 0   1.9   5.35
Other complications, %Sepsis 8.6Mortality  0.2

Technical innovations that replace open surgery are meant to lessen the impact of such procedures on patients, while maintaining efficacy [17]. HoLEP has been gaining popularity as a therapeutic option for symptomatic BPH. The PSA and TRUS volume data suggest that the clearance of the adenoma is similar to that achieved with open prostatectomy, but with much less morbidity. The change from an ‘inside-out’ piecemeal debulking starting at the bladder neck (e.g. TURP/vaporization/ablation) to an ‘outside-in’ anatomical enucleation starting at the apex (HoLEP) has enabled huge glands to be safely treated at many institutions worldwide [8]. Kuntz et al.[2] from Germany showed that in HoLEP, the perioperative morbidity and improvement in voiding at 1 month do not depend on prostate size. Hence they concluded that by contrast with TURP, HoLEP is equally suitable for small, medium and large prostates. In a similar study, Seki et al.[4] from Japan confirmed these findings at 6 months of follow-up. They found no statistically significant difference in the incidence of adverse events amongst patients with different prostate sizes. The present study confirms the findings of these two earlier studies at 1 year of follow-up. We also confirmed the reported findings that the efficiency of HoLEP increases with increasing prostate size. The disadvantage of HoLEP is the training and experience required. However, in the era when minimally invasive techniques, especially complex procedures such as laparoscopic radical prostatectomy, are readily embraced, HoLEP is a procedure that can be readily learned. Morcellation and its associated risk of bladder injury are considered to be another limitation of HoLEP. However in the present series, all the morcellation injuries were superficial and mucosal, which did not alter their management after HoLEP. There was no bladder perforation, as was the case in most of the published HoLEP series [17].

High-powered KTP laser vaporization of the prostate has gained wide acceptance in the urological community, because it has a better safety profile even in the hands of the novice, and with acceptable efficacy. In addition to being easily learned, its advantages include haemostasis and lack of hyponatraemia due to the use of normal saline as the irrigant. Sandhu et al.[18] used the 80-W KTP laser in 64 men with a mean preoperative prostate volume of 101 mL. They found that at the 1-year follow-up the Qmax increased from 7.9 to 18.9 mL/s, whereas the PVR decreased from 189 to 109 mL. These mean PVR of 109 mL at 1 year is a concern, but the same group later described a vaporization-incision technique for treating large prostates. On comparing the results of that technique in 20 patients with their earlier results using the standard technique, the authors noted that the modified technique better delineated the prostate anatomy, improved intraoperative visualization and decreased the operative time per prostatic volume from 1.24 to 1.10 min/mL of tissue [19]. Similarly, to counteract the difficulty in treating large prostates with the 80-W KTP laser, Verger-Kuhnke et al.[20] combined it with low-pressure TUR. These authors found that patients in whom both procedures were combined had a greater improvement (122.4%) in Qmax than in the KTP-only group (65.6%). Te et al.[21] found that patients with a PSA level of ≥6 ng/mL (larger prostate) had a lesser improvement in AUA symptom index and Qmax at 1, 2 and 3 years than had patients with a PSA level of <6 ng/mL. This difference in efficacy was statistically significant, suggesting that patients with a larger prostate might have a worse outcome with KTP laser vaporization. These results raise scepticism about the efficacy of the KTP laser in very large prostates. Although vaporization of very large prostates is feasible, it also remains a technically demanding procedure. Access to the tissue can be challenging in complex gland geometry and with very large lobes. Moreover, the vaporization efficiency is impaired after using ≈150 J because of the functional deterioration of the laser fibre. Hence, usually more than one fibre needs to be used on a large prostate [22]. Recently Rajbabu et al.[23] described the results of 54 patients with a mean prostate size of 135 mL treated by KTP laser ablation. Four patients in that series required a repeat procedure for recurrent symptoms due to residual prostate; the authors noted that in all four the initial procedure was limited by bleeding. Hence the long-term efficacy of the procedure, especially for patients with a large prostate, is still doubtful. Increasing economic restraints make the issue of long-term efficacy of utmost importance for assessing upcoming instrumental procedures for BPH [6]. Similarly, randomized trials are lacking for these procedures [24].

Using the experience gained from laparoscopic radical prostatectomy, the laparoscopic approach to large benign adenomas was also developed [8]. In 2002, Mariano et al.[25] were the first to describe a laparoscopic simple prostatectomy for BPH. Since then, several others have described extraperitoneal laparoscopic prostatectomies for obstructing BPH [26]. Both the transvesical and transcapsular (Millin) techniques have been used laparoscopically. Most investigators have found laparoscopic simple prostatectomy to be a feasible alternative to the open technique [27]. However, this technique is difficult to learn and requires significant laparoscopic expertise. In future, urologists with advanced laparoscopic capabilities might choose this approach [8].

In urology, the introduction of ESWL to treat urinary calculi converted a major operation into an outpatient procedure, taking <1 h, with very little morbidity. Randomized clinical trials of ESWL were difficult to conduct, as having an (unnecessary) incision was thought to be a considerable drawback to patients. However, one mistake made early in the use of ESWL was to assume that it was the best way to treat all stones. It is now clear after many years of experience that ESWL, percutaneous nephrolithotomy and open surgery each have a place in treating urinary calculi [16]. Similar lessons might apply to ablative laser prostatectomy.

For the relief of BOO there is clear evidence that the outcomes are more sustainable for procedures that are truly ablative and thus de-obstructing [6]. TURP and open prostatectomy provide the most durable long-term efficacy because of urodynamically confirmed de-obstruction. HoLEP allows whole lobes of the prostate to be removed, mimicking the action of the index finger in open prostatectomy [24]. In the present study, HoLEP resulted in an overall 75% reduction in the AUA symptom score, a 225% increase in Qmax and 86% decrease in PVR at 1 year. Although the mean AUA symptom score of 4.77 and mean Qmax of 17.7 mL/s at the 1-year follow-up appear to be lower than in most of the published open prostatectomy and HoLEP series, the percentage improvement is comparable with that reported previously [3]. The completeness of resection and the safety profile of HoLEP is unparalleled by any other endoscopic technique [28]. The ability of HoLEP to treat every size and configuration of prostate makes it more appealing. Our study confirms the statement made by Elzayat et al.[3] that HoLEP is a serious contender for becoming a new size-independent reference standard. For all urologists who manage to master the technique, HoLEP has doubtless made TURP and open prostatectomy a operation of the past [24]. However, in the management of BOO the best results are in the hands of the expert. The challenge is to translate those results to consistent application in the community.

ACKNOWLEDGEMENTS

The authors sincerely thank Dr Tenaz S. Hegde for grammatical editing of the manuscript.

CONFLICT OF INTEREST

None declared.

Ancillary