HIGH POWER TRANSURETHRAL THULIUM:YAG LASER VAPOENUCLEATION OF PROSTATE – A NEW STANDARD IN BENIGN PROSTATE HYPERPLASIA SURGERY

According to current reccomandations, open adenomectomy is considered the most efficient surgical option for patients with large benign prostatic hyperplasia. In order to reduce surgical trauma and to improuve postoperative recovery, there have been proposed several minimally invasive techniques for the treatment of large benign prostatic hyperplasia, the most innovative being laser surgery. High power Thulium:YAG laser vapoenucleation of prostate is becoming popular for minimal invasive surgical management of benign prostate hyperplasia.

One of the most effective is the application of Thulium: YAG laser energy in BPH surgery. This type of laser allows several types of surgery to be performed: resection, vaporization, enucleation and vapoenucleation (2). Enucleation and vapoenucleation are destinated for the surgical treatment of large BPH. The postoperative results obtained are very promising for a long term, are independent of prostate volume and demonstrate a low complication rate (3)(4)(5).

Material and methods
Between November 2019 and February 2020, 43 patients with BPH were included in the study on surgical treatment: ThuVEP (22 patients) and AE (21 patients). All patients were evaluated preoperatively and postoperatively at 1,3 and Postoperatively, the following values were recorded: operative duration, reduction of hemoglobin level, catheterization and hospital stay period. The patients undergone 24 hours surveillance after the urinary catheter removal.

Results
The patients included in the study completed the evidence questionnaires.
During the visits, all the parameters were analyzed. There were no statistically significant differences in research groups. The groups examined were relatively homogeneous (Table 1). Surgical indices were recorded ( Table 2). The volume of the removed prostatic tissue was similar in both groups. At the same time, the duration of the intervention was longer in the ThuVEP group, which is explained by the complete vapoenucleation of the adenomatous tissue and its subsequent fragmentation. The reduction of hemoglobin level was greater in the AE group. The duration of catheterization after AE was substantially longer (+400%) due to operative trauma and the inability to perform good hemostasis. The duration of hospital stay was determined by the duration of postoperative catheterization and thus was essentially longer in patients in the AE group (+140%). The improvement in symptom scores IPSS and QoL occurred substantially faster and significantly better in the ThuVEP group. Thus, at 1 month postoperatively, the patients from the ThuVEP group reported a good improvement of IPSS and Qol. A fast positive dynamics was also noted at 3 and 6 months postoperatively. This difference, compared to the AE group, is probably determined by reduced trauma and faster healing of the prostate lodge (Table 3). The volume of residual urine underwent similar positive changes in both groups during the surveillance. Transrectal ultrasound examination of the prostate demonstrated a similar and constant reduction of the total prostate volume over the duration of surveillance (Table 4).  The incidence of postoperative complications was significantly higher in the  YAG laser to perform efficient resection and simultaneous vaporization with optimal coagulation and hemostasis effects (8). Therefore, due to its excellent ablation capacity, the Thulium:YAG laser can easily vaporize and detach the prostate tissue from the surgical capsule with almost no bleeding (13-15).

Conclusions
The advantages of ThuVEP over AE are obvious. The biophysical properties of this method bring indisputable advantages, ensuring good hemostasis and reduced operative trauma. Considering the superior functional postoperative results and a significantly lower complication rate in the high power ThuVEP group, we consider it advisable to use high power Thulium: YAG laser vapoenucleation as a first line option in the surgical treatment of large BPH.