A new prospective trial has shown that holmium laser enucleation of the prostate (HoLEP) is associated with a lower risk of haemorrhage and shorter postprocedure bladder irrigation time than bipolar transurethral resection of the prostate (TURP), the current gold standard.

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280 patients with BPH with similar baseline characteristics were randomly assigned to undergo either the TURP procedure or HoLEP. Overall, few differences could be found between the two groups in terms of outcomes. Patients in both groups had significantly improved lower urinary tract characteristics (for example, post-void residual volume and urinary incontinence status). No differences in quality of life between the groups were evident 2 years after surgery.

Despite these similarities, the perioperative data were different between the two groups, which might have some important implications for patients and surgeons. For example, patients in the HoLEP group required shorter periods of bladder irrigation to resolve haematuria than the men who underwent TURP. Also, the amount of material removed from the prostate was considerably higher in men who had HoLEP, which was reflected in a sharper drop in PSA levels after surgery. “HoLEP broadens the scope of minimally invasive treatments for men with BPH,” lead investigator Zhong Wang explains. “HoLEP can be combined with mechanical morcellation, we can expose the surgical capsule easily and, importantly, treat even very large prostates.” TURP, by contrast, is associated with a higher risk of bleeding when treating very enlarged prostates.

Although some critics have suggested that the steep learning curve for HoLEP is a hindrance to its widespread adoption, a recent review by van Rij and Gilling suggest its learning curve is similar to other surgical procedures. Regardless, if patients spend less time in the hospital and require less perioperative care with HoLEP, the technique might replace TURP on the basis of cost even if long-term outcomes are not different. “Based on our 6 years of experience in treating BPH surgically, we consider HoLEP the most promising technique to replace TURP as the gold-standard of care,” concludes Wang.