Abstract
Over the past two decades, holmium laser enucleation of the prostate (HoLEP) has proved efficient for surgical management of benign prostatic obstruction (BPO) with minimal perioperative morbidity and acceptable short-term and long-term outcomes. 1 The latest American Urological Association guidelines released in 2018 and its amendment released in 2019 advocated HoLEP as a good option for patients indicated for surgical intervention to resolve BPO, irrespective of the prostate size and depending on surgeon's experience. 2,3 In this study, Ito and colleagues devised a new technique for HoLEP called “complete en-block technique with direct bladder neck incision,” provided a detailed description of the technique, and retrospectively compared the earlier clinical outcomes with other two well-established techniques for HoLEP: the three-lobe technique and the technique of en-block enucleation with incision of the adenoma. 4 The authors concluded that the new technique was comparable with the other two techniques in terms of perioperative outcomes and complications, with significantly shorter enucleation time and higher enucleation efficiency. 4 Nevertheless, the reader can argue that this conclusion might have been biased by several factors related to the study design and methodology that could be addressed as follows: first, the retrospective nature of the study with exclusion of 119 of 667 (18%) cases from the final analysis. Second, the three HoLEP techniques were performed by five different urologists in chronological order between 2011 and 2016, starting with the three-lobe technique, followed by the technique of en-block enucleation with incision of the adenoma, and ended by the new complete en-block technique. This supports the hypothesis that the significant shortening of enucleation time and the significant improvement of enucleation efficiency were due to the progress in the learning curve and the acquisition of expertise in HoLEP. This was quite evident from the gradual shortening in the enucleation time with the change of the enucleation technique over time (57.0 ± 25.3 min vs 40.5 ± 18.1 min vs 28.6 ± 14.6 min), respectively. Given the fact that the enucleation mass was almost the same among the three techniques (31.6 ± 21.2 g vs 28.8 ± 23.9 g vs 32.2 ± 26.8 g), the significant gradual shortening of the enucleation time led to significant improvement in the enucleation efficiency in the new complete en-block technique. Finally, the lack of intermediate- and long-term follow-up data regarding the outcomes of the three techniques is a source of bias as well.
Despite the fact that the authors devised a new technique for HoLEP, and should be congratulated for this, future randomized prospective studies from multiple centers are needed to externally validate this technique and its safety, and assess the learning curve, and provide more detailed short-term and long-term outcomes. One lesson from this study is that the HoLEP procedure will continue to undergo future technical modifications with the aim to shorten the learning curve, improve the enucleation efficiency, and obtain the best possible outcomes especially for the post-HoLEP continence status.