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Corresponding author. Instituto de Cirugía Urológica Avanzada, Clínica Cemtro II, Avenida Vestisquero de la Condesa 48, 28035 Madrid, Spain. Tel. +34 692934078.
Recent advances in technical aspects and surgical techniques have made anatomical endoscopic enucleation of the prostate (AEEP) a much more attractive surgical option for the treatment of benign prostatic obstruction (BPO). Technological improvements such as fast morcellators, slimmer scopes [
], and new energy sources that offer better hemostasis have helped AEEP to evolve to become a much faster surgical procedure that can be even performed in an ambulatory setting [
] is reducing the morbidity classically attributed to the procedure, making it more attractive for patients, urologists, and hospitals.
AEEP is rapidly gaining in popularity around the world. Logically, centers that are considering adoption of this technique wonder what tool to choose, as there is now evidence that the good results with AEEP are driven mainly by the anatomical completeness of removal of the adenoma rather than by the energy source used (enucleation is enucleation) [
Despite the feasibility of performing AEEP with various energy sources, their different physical properties in their interaction with prostatic tissue might result in substantial differences in the ability to develop and remain in the correct plane of dissection and the quality of first-pass hemostasis, which can in turn potentially influence critical clinical parameters such as intraoperative visibility, ease of learning, surgical procedure time, catheterization time, safety, and ability to perform the procedure as a day case [
The holmium laser was introduced in urology in 1992 and is currently the most widely used laser worldwide. It is versatile, as it allows for the treatment of stone disease, strictures, urothelial tumors and bladder outlet obstruction, with substantial scientific evidence supporting its use to treat these conditions, especially stones and benign prostatic hyperplasia.
The holmium laser emits pulses at 2100 nm with very high peak power of ∼10 kW (peak power = pulse power/pulse duration), which can also be defined as the maximum instantaneous optical power output by the laser (Fig. 1). Owing to the affinity of water for this wavelength, the pulse violently heats the water medium so that a cavitation bubble is formed, emitting a shockwave and exerting local pressure. When this bubble and the accompanying shockwave are pointed at the interface between the surgical capsule and the adenoma, they behave similarly to two scissor blades opening between the two layers, dissecting the virtual plane and thus helping urologists to perform enucleation following the actual anatomical plane [
MP26-16 The “scalpel and scissors effect” using infrared lasers – visiualisation of a principle and deduction of operative consequences in transurethral prostate enucleation.
] (Table 1). Holmium laser in regular mode has a good dissection effect during enucleation, but with irregular and suboptimal coagulation. Thulium fiber laser (TFL) produce bubbles that are four times smaller owing to its lower peak power (up to 3.7 kW) [
] and tenfold lower local pressure in comparison to Ho:YAG; its effect would be more similar to a surgical blade, which cuts very well, but does not particularly help in dissecting the anatomical plane, and might actually facilitate cutting out of the plane [
Fig. 1Schematic representation of pulses, peak power, and the working area of holmium and thulium lasers. The peak power and working area are considerably greater for holmium than for thulium. 1G = first-generation; 2G = second-generation.
A contemporary sophistication of the holmium laser has been the development of pulse modulation (MOSES, Boston Scientific, Marlborough, MA, USA; Virtual Basket, Quanta System, Samarate, Italy) [
], in which two consecutive rapid pulses are emitted. The first pulse interacts with water, generating violent deposition of heat and a cavitation bubble accompanied by a pressure wave, while the second pulse travels through the bubble and interacts with water over a greater distance than when a single pulse is emitted. This makes it possible to preserve the excellent dissection properties with the first pulse and improve the coagulation and cutting effect with the second pulse (Table 1). This translates into a better balance between dissection and coagulation, improving first-pass hemostasis, visibility, ablation efficiency, and surgical time, and reducing surgeon stress [
Contemporary outcomes for patients undergoing concurrent surgeries at the time of holmium laser enucleation of the prostate before and after Moses 2.0 BPH mode.
The efficiency of a laser enucleation procedure relies on various factors, including surgeon experience, energy source, water flow, scope size, and smooth movements (or not as soft during mechanical dissection with the endoscope tip), as well as characteristics related to the laser and its interaction with the tissue, such as the peak power, shape, bubble size, working distance, wavelength, and absorption coefficient. Undoubtedly, the most outstanding feature of the holmium laser for enucleation is in aiding the surgeon in dissecting the anatomical plane owing to its high peak power (Fig. 1) [
], which is much higher than that of thulium, pulsed thulium, and TFL lasers.
There is scarce evidence comparing holmium and thulium fiber laser enucleation (HoLEP and ThuFLEP). Both ThuFLEP and HoLEP are efficient ways of treating BPO and showed no apparent differences in functional outcomes in a recent study [
However, after using all of the laser types for prostate enucleation in our institution, our feeling is that the holmium laser facilitates staying in the anatomical plane more efficiently thanks to the effect described. Thulium, pulsed thulium, and TFL lasers provide excellent hemostasis; they have a significant cutting effect, with an even thin layer of coagulation and charring of the tissue, making the dissection in the proper plane less intuitive.
Of course, a seasoned surgeon can perform enucleation with all the laser sources mentioned and achieve excellent results, and gaining surgical experience with a particular wavelength allows surgeons to compensate for the differences in tissue effects and dissection versus cutting of the different lasers.
It also seems clear that the classic thulium and single-pulse holmium lasers have been significantly improved with the newer generation of thulium-based and pulse-modulation holmium lasers. These more recent lasers undoubtedly represent a significant leap forward in the features we need to perform AEEP safely and more efficiently and are already contributing to boosting interest in and adoption of this excellent surgical technique.
There is still not enough evidence to say that one laser is the best; large, randomized studies are needed to compare if there is a winner in providing measurable clinical advantages for surgeons, patients, or hospitals.
The new pulse-modulation holmium lasers are already delivering clinical advantages, with shorter surgical times, lower complication rates, easier learning curves, economic savings, and daycare possibilities, so we can confidently say, long live holmium!
Conflicts of interest: Fernando Gómez Sancha is a consultant for Lumenis, Quanta System, and Lisa Laser. The remaining authors have nothing to disclose.
References
Figueiredo F.C.A.
Cracco C.M.
Marins R.L.
Scoffone C.M.
Holmium laser enucleation of the prostate: problem-based evolution of the technique.
MP26-16 The “scalpel and scissors effect” using infrared lasers – visiualisation of a principle and deduction of operative consequences in transurethral prostate enucleation.
Contemporary outcomes for patients undergoing concurrent surgeries at the time of holmium laser enucleation of the prostate before and after Moses 2.0 BPH mode.
Thulium:YAG laser represents the most versatile laser generator, allowing continuous-wave and pulsed laser energy application. For the full spectrum of transurethral endoscopic surgical approaches for benign prostatic obstruction (BPO), thulium:YAG offers the widest range of applications with clinical momentum and usage and is thus currently regarded as a valid alternative to holmium:YAG and bipolar resection. In the absence of significant evidence of superiority of one laser over the other for endoscopic enucleation of the prostate (EEP), laser choice is mainly based on personal preference.
Over the past few years, numerous trials have supported the fact that endoscopic enucleation of the prostate (EEP) is both safe and efficient, whether its compared to transurethral resection of the prostate (TURP) or other laser-based techniques (eg, photovaporization of the prostate) [1,2]. The international guidelines consider EEP to be one of the techniques of choice for relief of benign prostatic obstruction (BPO). Most of the data on EEP support the fact that irrespective of which device is used, the efficacy of EEP will remain the same.
Nomination of the best laser for endoscopic treatment of benign prostatic hyperplasia (BPH) is a very arduous task, deserving further specifications as well as open-minded and in-depth considerations, as unequivocal choice of a single laser as the best would be a rushed and shallow simplification.
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