Abstract
In this month's article by Anderson and colleagues, 1 the authors retrospectively explore the current practice patterns in bladder outlet surgery in the United States using the American College of Surgeons National Surgical Quality Improvement Program database with a specific focus on holmium laser enucleation of the prostate (HoLEP) uptake over a 5-year period. They evaluated trends for common benign prostatic hyperplasia (BPH) procedures (transurethral resection of the prostate [TURP], redo-TURP, photovaporisation of the prostate [PVP], HoLEP, and open prostatectomy [OP]) but did not include any emerging techniques such as Urolift, Rezum, robotic simple prostatectomy, or prostate artery embolization. Although participation is not mandatory, >600 hospitals were enrolled at the end of the study period with >35,000 BPH procedures evaluated. Centralized data of this volume and quality is rare and gives valuable insight into the current trends in BPH surgery. In every year of the study period (2011–2015), TURP was the most commonly performed procedure for BPH (55%–60%). 1 HoLEP in contrast was utilized in only 4% to 5% of cases and remained stable with no growth across the study period. Transfusion rates were the lowest with PVP and HoLEP. In addition, lower rates of readmission, reoperation, and urinary tract infection (UTI) were seen in some but not all years with HoLEP. 1
As the traditional “gold-standard,” the enthusiasm for TURP is perhaps unsurprising and the uptake of bipolar TURP may have supported its continuation. The paradigm is shifting, however, with level 1 evidence supporting HoLEP. Yin and colleagues 2 conducted a meta-analysis of six randomized controlled trials (RCTs) comparing HoLEP with monopolar TURP. At 12 months postoperatively, Qmax and International Prostate Symptom Score were superior in the HoLEP group. Catheterization time, hospital stay, and blood transfusion rate were all lower in the HoLEP group. In addition, HoLEP has been shown to have durable results and low reoperation rates. 3
PVP/Greenlight was the commonest laser procedure in this series with 30% of patients treated most years. 1 This may reflect its excellent safety profile and short learning curve. In all but 1 year the PVP group had the highest international normalized ratio, suggesting this is the procedure of choice for patients on anticoagulation; however, HoLEP can also be safely performed on these patients. 4 Although no head-to-head RCT exists between the two treatments, long-term reoperation rates have been shown to favor HoLEP. 5
OP was the only procedure less frequently performed than HoLEP at 3% each year. 1 It is well documented that HoLEP is a size-independent procedure with no difference in complication rate or functional outcomes when stratified by prostate volume. 6,7 Furthermore, multiple well-designed RCTs have also shown HoLEP to be a far less morbid procedure with comparable functional outcomes and durability when compared with OP in large prostates. 8,9 The data from Anderson and colleagues 1 support these findings with OP having a substantially longer hospital stay of 3 to 4 days, and transfusion rates of up to 25% in some years. There is a strong argument that HoLEP will make OP a historical procedure, a view supported by the authors who perform >500 HoLEPs per year. There are also concerns that African American men seem to have reduced access to HoLEP and thus often need to endure the increased morbidity of OP in larger glands.
With Such Strong Evidence in Both Small and Large Prostates, Why Then Is HoLEP Being Overlooked?
Perhaps the most discussed barrier to widespread HoLEP implementation is overcoming the prolonged learning curve to optimize functional outcomes. There are concerns regarding early incontinence and morcellation in the initial cases. Previously, Shah and colleagues 10 showed number of cases to reach a plateau in enucleation efficiency to be around 50. Enikeev and colleagues 11 have recently shown, however, that with a structured mentoring approach to prostate enucleation, the learning curve can be reduced to 30 cases.
Financial concerns are also often proposed; however, cost analysis from a randomized trial has shown HoLEP to be 24.5% cheaper to perform than TURP at 1 year. 12 To cover the cost of the capital and realize the savings over TURP, the authors found the institution needs to perform 93 cases per year. 12 Immediate savings are likely secondary to shorter hospital stay and decreased rates of complication such as UTI and blood transfusion (as seen in this article). Furthermore, with a lower retreatment rate, long-term savings are likely.
The operative time for HoLEP was the longest for all treatment modalities in this series, and this is a common criticism of the technique impacting on hospital theatre scheduling. 1 As the authors point out, the size of the prostate was not available as part of the analysis. This may account for this finding, but other variables such as surgeon experience and the use of a tissue morcellator should be considered. When Ahyai and colleagues 13 performed a matched analysis from their trial database, they found resection speed and operative time for laser enucleation were actually faster than TURP (0.61 vs 0.51 gm per minute) and equivalent to OP.
The uptake of HoLEP remains slow despite the well-documented benefits over traditional surgical treatments for BPH. Barriers to implementation are often discussed but are not supported by the evidence. With mentorship and modular training, HoLEP can be definitely be learnt, perhaps optimally by those in residency rather than established urologists. TURP and PVP are reasonable options for smaller prostates and will come down to surgeon and patient preference. Outcomes for larger glands (>100 cc), however, clearly favor HoLEP and certainly in this group of patients, HoLEP or referral to a HoLEP center should be the standard of care.