Comparing salvage and primary holmium laser enucleation of the prostate in patients with benign prostatic hyperplasia.

This study compared the safety and effectiveness of salvage (S) and primary (P) holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH). It also evaluated what were the procedures leading to S-HoLEP in these patients. The authors concluded that S-HoLEP was similar to P-HoLEP in safety and effectiveness but required longer operative times and hospitalization stays. 

BPH involves an enlarged prostate. It is commonly associated with lower urinary tract symptoms (LUTS) such as increased frequency and urgency of urination, problems beginning a urine stream, a weak or interrupted stream, waking up at night to urinate, urine dribbling, urinary retention, urinary incontinence (leakage) and painful urination.

There are many treatments for BPH-associated LUTS. Medications are often not enough and invasive procedures such as transurethral resection of the prostate (TURP; removal of excess prostate tissue that blocks urine flow). Newer procedures involve the removal of excess prostate tissue by lasers.

P-HoLEP is a type of laser surgery that effectively treats urinary obstruction from BPH  as primary surgical treatment. This treatment option has a low retreatment rate and is suitable for patients with large prostate glands or those on medication such as blood thinners. S-HoLEP is an approach used for recurring BPH in patients that previously underwent surgical treatment such as TURP. While salvage treatment has been recognized for certain advantages, its safety and effectiveness compared to P-HoLEP remain unknown.

This study included 633 patients with BPH who underwent HoLEP. 217 of these patients underwent S-HoLEP after prior surgery for bladder outlet obstruction. 416 patients had P-HoLEP. The outcomes evaluated were the International Prostate Symptom Score (IPSS; a standardized measurement of LUTS), maximum flow rate (Q_max), and post-void residual volume (PVR; urine volume remaining in the bladder immediately after urination). The procedures performed before S-HoLEP were also evaluated. 

Commonly performed procedures before S-HoLEP were TURP (40.1%), transurethral microwave thermotherapy (TUMT; uses microwaves to destroy excess prostate tissue; 20.3%), photoselective vaporization of the prostate (PVP; uses a laser to burn excess prostate tissue; 11.1%), and prostatic urethral lift (PUL; a procedure that widens the urethra; 11.1%).

Overall, S-HoLEP had longer procedure times, longer catheter duration, and hospital stays. After surgery, the maximum flow rate, IPSS, and complications over 90 days were similar between S-HoLEP and P-HoLEP.

The study suggested that S-HoLEP is a safe, effective option for patients with BPH requiring further surgical treatment and was similar to P-HoLEP, with the exception of longer operative times and hospitalization stays.

The study design did not allow for long-term follow-up. Additionally, it was not based on a randomized controlled trial design, increasing the possibility of introducing bias.