Holmium laser enucleation of prostate (HoLEP) for the surgical treatment of BPH is now well established worldwide and is endorsed by each of the major guideline groups in the specialty. Understandably, there has been recent interest in the use of alternative energy sources for the enucleation component of the procedure as the popularity of HoLEP has grown. As has been typical of the history of laser prostatectomy, there are now a plethora of acronyms for each of these , including ThuVEP/ThuLEP (thulium:YAG laser vapoenucleation/thulium laser enucleation of the prostate), GreenEP (using the lithium borate laser), PkEP (plasmakinetic enucleation of the prostate), ELEP (eraser laser enucleation of the prostate) and now TUEB (transurethral enucleation with bipolar; using the transurethral resection in saline system), which is reported in the above paper by Hirasawa et al.
Unlike the initial report of enucleation with bipolar energy, which used a Gyrusaxipolar bare electrode , the study by Hirasawa et al. utilized a spatula attached to a standard tungsten wire loop, although the technique used was much the same. Similar devices have been employed for HoLEP, although they have not found wide utility to date and are no substitute for adequate training in the technique. As more interest and investment in enucleation by medical device companies occurs, a spectrum of different aides will likely be developed, further simplifying the technique and shortening the learning curve.
The question, however, is not whether enucleation is equivalent or superior to TURP (this question has already been answered in a number of randomized controlled trials) but, instead, what is the best energy source for this technique? HoLEP was compared with PkEP and bipolar electrosurgery in a study from our institution, which provided the first evidence that all varieties of enucleation may not be ‘created equal’. The operating time was longer, more patients required bladder irrigation and the recovery room time was prolonged in patients who had bipolar enucleation. The clinical results, however, were similar in both groups up to 12 months because the enucleation itself was equivalent. Technically, the dissection was more difficult with bipolar as a result of a number of factors. Primarily, visibility was reduced as a result of the glowing tip of the probe and the stream of bubbles arising from it, although there was also noticeably more bleeding. Secondarily, and potentially more importantly, electrosurgery does not provide the same tissue separation and ‘feel’ as the Holmium laser because of the pulsed nature of the energy. This will be an important consideration when HoLEP is compared with ‘continuous’ laser devices, such as thulium, ELEP and GreenEP.
The distinction between the ability to perform a true anatomical enucleation and the resection of large fragments, merely conforming to the lobar anatomy, will be one of the important considerations when comparing these devices. Given its multi-functionality, cost-effectiveness and proven ability, the Holmium laser will be hard to beat!