madman
Super Moderator
Ejaculation‑sparing thulium laser enucleation of the prostate (ES‑ThuLEP): outcomes on a large cohort
Abstract
Purpose To assess the effects of a new ejaculation-sparing thulium laser enucleation of the prostate (ES-ThuLEP) technique on sexual functions and micturition, in patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH) and to evaluate how the surgical technique of ES-ThuLEP can lead to ejaculation preservation.
Methods A prospective study was carried out between January 2015 and January 2018 on patients with a surgical indication for BPH, who wished to preserve ejaculation. The patients were treated with ES-ThuLEP and were evaluated before and 3 and 6 months after surgery. Three validated questionnaires (ICIQ-MLUTSsex, IIEF-5, and IPSS) were used to assess changes in ejaculation, erectile function, and urinary symptoms. Uroflowmetry (Qmax and Qavg), post-void residual volume, and voided volume were also evaluated, to assess micturition improvement. Patients with moderate to severe erectile dysfunction were excluded. Statistical analysis was performed with the Student’s t-test, Chi-square test, and logistic regression analysis.
Results Two hundred and eighty-three patients were enrolled. Ejaculation was spared in 203 and 219 patients at 3 and 6 months after surgery. No significant differences were observed between erectile function before and after surgery: baseline IIEF-5=16.2±4.47 vs 16.7±2.9 (p=0.419) and 17.7±3.2 (p=0.410) at 3 and 6 months. Significant improvement in urinary symptoms was achieved: baseline IPSS=19.4±7.24 vs 5.8±4.3 (p=0.032) and 3.9±4.1 (p=0.029) at 3 and 6 months.
Conclusion ES-ThuLEP effectively preserved ejaculation in over two-thirds of the patients without compromising micturition improvement or erectile function. ES-ThuLEP could be a valid treatment option for BPH in young and sexually active men.
Introduction
Benign prostatic hyperplasia (BPH) is a common condition in aging men, which leads to lower urinary tract symptoms (LUTS) and sexual dysfunction, negatively impacting on the patients’ quality of life [1, 2]. Despite allowing relief from LUTS, classical medical, and surgical treatments for BPH have always been burdened by important consequences on the patients’ ejaculatory function. Over the past three decades research has focused on the development of new surgical strategies to reduce morbidity and complications of conventional surgical procedures, such as transurethral resection of the prostate (TURP) and open prostatectomy (OP), but in most cases overlooking the impact on the patients’ ejaculatory function. Thanks to the advent of laser technologies, endoscopic enucleation of the prostate (EEP) techniques have been developed [3, 4]. These mimick an OP, which is achieved endoscopically, using a laser, or a bipolar resector to enucleate the adenoma, imitating the use of the finger during OP, but maintaining minimal invasiveness of TURP. Holmium laser enucleation of the prostate (HoLEP) [5] and thulium laser enucleation of the prostate (ThuLEP) [6] is the most demanded laser EEP techniques (LEEP). Both determine the excellent resolution of LUTS and improvement in voiding parameters, comparable to those of TURP and OP, but with reduced morbidity, catheterization time, and hospital stay. Moreover, they allow treating prostates of virtually all sizes [7–10]. Reasons for which, EAU Guidelines recommend to resort to OP only in the absence of an EEP system [11]. Despite the well-documented advantages of LEEP techniques over TURP and OP, they have not been able to overcome postoperative ejaculatory dysfunction (EjD) [12, 13].
The only recommended ejaculation-sparing (ES) procedure today [11], is the prostatic urethral lift, which consists of the positioning of suture-based implants under cystoscopic guidance, to compress the lateral lobes [14]. Despite being a valid treatment option, especially in elderly and frail patients [15] and despite excellent outcomes on ejaculation, it does not achieve the same micturition improvement of TURP [16]. Moreover, it is only recommended for small prostates (<70 ccs) and it does not remove the hyperplastic tissue. Other novel, minimally invasive, non-ablative surgical techniques such as Aquablation, Rezum, and prostatic artery embolization, despite presenting more favorable outcomes on ejaculation compared to TURP, are still considered “under investigation” by EAU Guidelines, due to the lack of randomized controlled trials, with a long-term follow-up, investigating their safety and efficacy [11, 17].
Conclusions
ES-ThuLEP allows to effectively preserve ejaculation in more than two-thirds of the patients, no matter what prostate size, without compromising micturition improvement or erectile function and maintaining a low complication rate, making it a valid treatment alternative for young and sexually active men suffering from BPH.
Abstract
Purpose To assess the effects of a new ejaculation-sparing thulium laser enucleation of the prostate (ES-ThuLEP) technique on sexual functions and micturition, in patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH) and to evaluate how the surgical technique of ES-ThuLEP can lead to ejaculation preservation.
Methods A prospective study was carried out between January 2015 and January 2018 on patients with a surgical indication for BPH, who wished to preserve ejaculation. The patients were treated with ES-ThuLEP and were evaluated before and 3 and 6 months after surgery. Three validated questionnaires (ICIQ-MLUTSsex, IIEF-5, and IPSS) were used to assess changes in ejaculation, erectile function, and urinary symptoms. Uroflowmetry (Qmax and Qavg), post-void residual volume, and voided volume were also evaluated, to assess micturition improvement. Patients with moderate to severe erectile dysfunction were excluded. Statistical analysis was performed with the Student’s t-test, Chi-square test, and logistic regression analysis.
Results Two hundred and eighty-three patients were enrolled. Ejaculation was spared in 203 and 219 patients at 3 and 6 months after surgery. No significant differences were observed between erectile function before and after surgery: baseline IIEF-5=16.2±4.47 vs 16.7±2.9 (p=0.419) and 17.7±3.2 (p=0.410) at 3 and 6 months. Significant improvement in urinary symptoms was achieved: baseline IPSS=19.4±7.24 vs 5.8±4.3 (p=0.032) and 3.9±4.1 (p=0.029) at 3 and 6 months.
Conclusion ES-ThuLEP effectively preserved ejaculation in over two-thirds of the patients without compromising micturition improvement or erectile function. ES-ThuLEP could be a valid treatment option for BPH in young and sexually active men.
Introduction
Benign prostatic hyperplasia (BPH) is a common condition in aging men, which leads to lower urinary tract symptoms (LUTS) and sexual dysfunction, negatively impacting on the patients’ quality of life [1, 2]. Despite allowing relief from LUTS, classical medical, and surgical treatments for BPH have always been burdened by important consequences on the patients’ ejaculatory function. Over the past three decades research has focused on the development of new surgical strategies to reduce morbidity and complications of conventional surgical procedures, such as transurethral resection of the prostate (TURP) and open prostatectomy (OP), but in most cases overlooking the impact on the patients’ ejaculatory function. Thanks to the advent of laser technologies, endoscopic enucleation of the prostate (EEP) techniques have been developed [3, 4]. These mimick an OP, which is achieved endoscopically, using a laser, or a bipolar resector to enucleate the adenoma, imitating the use of the finger during OP, but maintaining minimal invasiveness of TURP. Holmium laser enucleation of the prostate (HoLEP) [5] and thulium laser enucleation of the prostate (ThuLEP) [6] is the most demanded laser EEP techniques (LEEP). Both determine the excellent resolution of LUTS and improvement in voiding parameters, comparable to those of TURP and OP, but with reduced morbidity, catheterization time, and hospital stay. Moreover, they allow treating prostates of virtually all sizes [7–10]. Reasons for which, EAU Guidelines recommend to resort to OP only in the absence of an EEP system [11]. Despite the well-documented advantages of LEEP techniques over TURP and OP, they have not been able to overcome postoperative ejaculatory dysfunction (EjD) [12, 13].
The only recommended ejaculation-sparing (ES) procedure today [11], is the prostatic urethral lift, which consists of the positioning of suture-based implants under cystoscopic guidance, to compress the lateral lobes [14]. Despite being a valid treatment option, especially in elderly and frail patients [15] and despite excellent outcomes on ejaculation, it does not achieve the same micturition improvement of TURP [16]. Moreover, it is only recommended for small prostates (<70 ccs) and it does not remove the hyperplastic tissue. Other novel, minimally invasive, non-ablative surgical techniques such as Aquablation, Rezum, and prostatic artery embolization, despite presenting more favorable outcomes on ejaculation compared to TURP, are still considered “under investigation” by EAU Guidelines, due to the lack of randomized controlled trials, with a long-term follow-up, investigating their safety and efficacy [11, 17].
Conclusions
ES-ThuLEP allows to effectively preserve ejaculation in more than two-thirds of the patients, no matter what prostate size, without compromising micturition improvement or erectile function and maintaining a low complication rate, making it a valid treatment alternative for young and sexually active men suffering from BPH.
