Authors (including presenting author) :
Brian W.H. Siu(1), David K.W. Leung(1), Rachel S.K. Wong(1), Alex Q. Liu(1), Chris H.M. Wong(1), Ivan C.H. Ko(1), Steffi K.K. Yuen(1), Chi Hang Yee(1), Jeremy Y.C. Teoh(1), Hilda Kwok(1), Irene Wu(1), Peter K.F. Chiu(1), Chi Fai Ng(1), Ka Lun Lo(1)
Affiliation :
S.H. Ho Urology Centre, Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
Introduction :
Benign prostatic hyperplasia (BPH) commonly causes lower urinary tract symptoms (LUTS), with 23% risk of acute urinary retention in men aged 60 years [1]. While transurethral resection of prostate (TURP) remains the gold standard [2,3], EAU guidelines recommend HoLEP, BipoLEP, and open prostatectomy for prostates >80ml [4]. Level 1 evidence suggests HoLEP offers favorable perioperative outcomes despite longer operation times compared to TURP [5,6].
Thulium fibre laser (TFL) has a shorter wavelength than Holmium:YAG (1940nm vs 2120nm), thus closely matching the near-infrared absorption peak of liquid water at 22 °C. The absorption coefficient of the TFL is more than four-fold higher than Holmium:YAG laser, resulting in a lower threshold and higher ablation efficiency at equivalent pulse energies [7]. Theoretically, a lower tissue and water penetration depth may also potentially add to the safety profile of the TFL. Despite these advantages, evidence supporting ThuFLEP's superiority remains limited, though recent data suggests improved Qmax (peak flow rate) and PVR (post void residual urine) compared to HoLEP [9].
The SOLTIVE™ Premium (Olympus) TFL is a novel energy source, designed for both urolithiasis and prostate enucleation [10]. The wavelength is between 1920 and 1960nm. Laser energy ranges from 0.025-6J, and frequency ranges from 1-2400Hz. Due to similarities in surgical skills, we also compared the outcomes with our recently published BipoLEP result to see any difference in the performance of the two modalities of energy [11].
Objectives :
To report the early-to-mid-term outcomes of the first Asian cohort undergoing ThuFLEP, using the SOLTIVE™ system.
Methodology :
A prospective registry was set up in our centre, and ethics approval was obtained (CRE2022.049). Informed consent was obtained from all participants and that the study was conducted in accordance with the Declaration of Helsinki. The inclusion criteria were men exhibiting indications for BPH surgery (i.e., bothersome LUTS, BPH related bladder stones, BPH related haematuria, and acute urinary retention). The exclusion criteria included active urinary tract infection and known functional or structural urinary tract abnormalities (including urethral stricture and neurogenic bladder). After the urologist assessed eligibility and obtained informed consent, patients were evaluated with standard preoperative assessments, including uroflowmetry and symptom scores assessment (for patients without catheter in situ), prostate size measurement. After surgery, patients were followed up according to our standardized protocol, including (1) A nurse led phone consultation scheduled at six weeks, enquiring on symptoms, complications (e.g. haematuria, dysuria, incontinence) and voiding symptom score (e.g. International Prostate Symptoms Score IPSS); (2) A physical follow up at three months, with questionnaires assessment, uroflowmetry and PSA testing; (3) A follow up visit at one year. The primary outcome of this study was the rate of Clavien Dindo grade 3 or above complications. Secondary outcomes included operation time, time to successful trial without catheter (TWOC), enucleation efficiency, morcellation efficiency, PSA change, Qmax, PVR, voiding symptoms scores, de novo urinary incontinence rate (pre and postoperative continence was defined as usage of at most one security pad per day). Thulium fibre laser enucleation was performed by the SOLTIVE™ SuperPulsed Laser Systems (Olympus). Thulium fibre laser enucleation was performed with a 550nm laser fibre. The procedure was performed by a single surgeon with over 500 cases of experience in BipoLEP. During enucleation, the setting was 1.5J, 40Hz with short pulse mode; during haemostasis, the setting was 1J, 50Hz with long pulse mode. The two settings were used alternatively to maintain a clear surgical field during enucleation. Both blunt dissection and sharp dissection (with laser) were used. With less vaporization of the water between laser fibre and tissue, TFL creates less bursting energy for tissue dissection and, hence, a better cutting efficiency. Thus, compared with our experience in BipoLEP, we utilized more sharp dissection in ThuFLEP.
Statistical analyses were performed with SPSS v.26.0 (IBM Corp., Armonk, NY, USA). The results were expressed in mean +/ standard deviation, median (interquartile range), or count (percentage) as appropriate. Changes in PSA were analysed using the paired t-test.
Result & Outcome :
Thirty consecutive men underwent ThuFLEP with SOLTIVE™ SuperPulsed Laser Systems from October 2022 to March 2024. The median age was 70.5years (IQR: 67.0-74.8years). The median prostate size was 60cc (49.8-71.5cc). 66.7% had acute urinary retention, 16.7% had BPH related bladder stones, 10% had BPH related haematuria, and 6.7% had bothersome LUTS. Overall, 50% of patients were catheter dependent. The median operation time was 85 mins (73 99.5mins. The median weight of prostate chips resected was 31g (20-39.3g). The median enucleation efficiency and morcellation efficiency were 0.97 g/min (0.64 1.02 g/min) and 0.82 g/min (0.71-1.2 g/min). The majority, 86.7% of patients had successful TWOC on day 1; catheter free rates on days 7 and 14 were 96.7% and 100%, respectively. No Clavien dindo (CD) grade 3 or above complications were reported. Four CD grade 1 2 complications occurred: two had urinary retention, one had epididymo orchitis resolved with antibiotic treatment, and one had haematuria requiring blood transfusion postoperatively. The median length of stay was 28 hours(26 30 hours). The median postoperative haemoglobin drop was 1.2g/dL (0.5 1.8g/dL). All patients reached 3 month follow up, and all remained catheter free. Mean absolute and percentage change in PSA were 5.62 ng/ml and 75.8% (p< 0.001). The median Qmax was 21 ml/s (13.1 26.2 ml/s) ;the median PVR was 50ml (26 67 ml). Fifteen (50%) patients reached one year follow up. There were no lost to follow ups. The median Qmax was 22.8ml/s (21.6-27.7ml/s) ;the median PVR was 40ml (30-54ml). The median IPSS and IPSS QoL were 5 (1.5-9.5) and 1 (1-3). The median OABSS was 1 (1-1). The patient who reported urinary incontinence at 3 months was a 79 year old gentleman who had 31g resected and enjoyed an uneventful perioperative course. He reported stress urinary incontinence (requiring two protection pads/day) at three months and was prescribed pelvic floor exercise; he did not report any stress urinary incontinence at 1 year follow up. We also compared the current result with our recently published BipoLEP result. The preoperative prostate sizes were smaller (60.0g vs 98.9g), and the proportion of catheter dependent patients (50.0% vs 75.5%) was lower in the current study. The resection ratio was similar (56.9% vs 59.3%), but the enucleation efficiency (0.97g/min vs 1.76g/min) was lower in the current ThuFLEP cohort. The ThuFLEP cohort experienced fewer 30 day complications (13.3% vs 26.7%) than BipoLEP.
