A Retrospective Comparison of 1470nmDiode Laser Enucleation and Bipolar Transurethral Resection of the Prostate for the Treatment of Benign Prostatic Hyperplasia
Sina H.B. Monfared, BS, Annaliese Ionson, MSc, Michael Emmerling, MA, Wesley Pate, MD, Mark H. Katz, MD, David S. Wang, MD, Richard K. Babayan, MD, Shaun E.L. Wason, MD.
Boston University School of Medicine, Boston, MA.
Introduction: One in 12 patients with BPH will require surgical management. TURP is the gold standard, but new technologies may provide similar outcomes with lower complication rates. The 1470nmdiode laser is a novel technology for use in endoscopic laser enucleation of the prostate(DiLEP). There is a paucity of data comparing bipolar TURP to 1470nmDiLEP. We compared procedure efficacy, perioperative outcomes and complication rates between B-TURP and 1470nmDiLEP.
Methods: This is an IRB-approved retrospective review of patients who underwent DiLEP(n:114; November 2016-February 2020) or TURP(n:194; January 2016-December 2018). Patients with history of prostate cancer and/or prior TURP were excluded from analysis. DiLEP was performed by a single surgeon, while TURP was performed by multiple surgeons. Prostate sizing was calculated via transabdominal ultrasound. Patient characteristics, peri-operative outcomes, treatment efficacy(Qmax, PVR) and complications(Clavien-Dindo) were compared. Statistical analyses with STATA were conducted using independent Student's t-tests, Fisher exact test, Wilcoxon rank-sum test, and Wilcoxon signed-rank test.
Results: Patients undergoing DiLEP had significantly larger prostates(92 ml(65.2-115) vs. 65(48-88), p<0.0001) and a greater proportion of median lobes(77% vs.57%, p = 0.01; Table 2). Both groups had significant improvements in Qmax and PVR from baseline at all postoperative time points(1, 3, 6 and 12 months) with no significant difference between groups at any timepoint(Figure 1). DiLEP had a greater percentage of prostate tissue resected(36%(27-47) vs 31%(20-42), p =0.001) and a shorter length of stay (16.9 hours(2.9-25) vs.27.7 hours(24-33), p <0.0001), but had longer operative times (133 minutes(108-157) vs. 54 minutes (39-74), p<0.0001). 53(46%) patients undergoing DiLEP were discharged from the PACU, as compared to none undergoing TURP. Catheterization times were equivalent(24.5 hours (20-64) vs. 22.1 hours(18-67), p=0.13). Postoperative and <30-day complications were similar in both groups(Table 3), however, DiLEP had significantly fewer complications >30 days post procedure and no grade IV complications.
Conclusions: DiLEP and TURP had similar efficacy for relieving obstruction and reducing PVR, however, when compared to TURP, DiLEP had longer operative times, but a lower >30-day complication rate and a greater percentage of prostate resected. In addition, patients undergoing DiLEP had a shorter length of stay and just under half of patients were discharged home from the recovery room. These results support the non-inferiority of DiLEP relative to TURP for the surgical treatment of BPH.
| Variable | TURP(n=194) | DiLEP(n=114) | p-value |
| Age (Mean ± SD) | 68.8 ±8.5 | 69.5±9.7 | 0.56a |
| Race (%) | |||
| White | 75 (39%) | 57 (50%) | |
| Black | 75 (39%) | 34 (30%) | |
| Other/Unknown | 43 (22%) | 23 (20%) | 0.25b |
| Ethnicity (%) | |||
| Hispanic or Latino | 51 (26%) | 31 (27%) | |
| Not Hispanic or Latino | 142 (73%) | 83 (73%) | 0.93b |
| BMI (kg/m2) (Mean ± SD) | 27.7±4.9 | 28.2±4.4 | 0.33a |
| ASA (%) | |||
| 1 | 2 (1%) | 0 (0%) | |
| 2 | 73 (38%) | 52 (46%) | |
| 3 | 90 (46%) | 60 (53%) | |
| 4 | 0 (0%) | 1 (1%) | 0.50b |
| Charlson Co-morbidity Index Median (IQR) | 0 (0-2) | 0 (0-2) | 0.43c |
| a Unpaired t-test (for normally distributed variables)b Fisher's exact analysis c Wilcoxon rank-sum test (for non-normally distributed variables) | |||
| Preoperative (baseline) Variables | |||
| Variable | TURP | DiLEP | p-value |
| Creatinine (Mean ± SD) | 1.1±0.4 | 1.1±0.3 | 0.65a |
| Preoperative PSA (ng/mL) Median (IQR) | 2.7 (1.2-5.4) | 4.0 (1.9-5.6) | 0.05c |
| Preoperative IPSS (n=54 for TURP, n=84 for LEP) (Mean ± SD) | 21.9±6.4 | 22.6±7.8 | 0.49a |
| Preoperative QoL (n=21 for TURP, n=68 for LEP) (Mean ± SD) | 4.9±1.1 | 4.7±1.1 | 0.38a |
| Preoperative Qmax (cc/sec) | 8 (5-10) | 9.2 (6.4 - 12) | 0.54c |
| Preoperative PVR (cc) Median (IQR) | 77 (40.5-200) | 85.5 (23.5-207) | 0.70c |
| Preoperative Prostate size (g) Median (IQR) | 65 (48-88) | 92 (65.2-115) | <0.0001c |
| Median Lobe (%) | |||
| Yes | 111 (57%) | 88 (77%) | |
| No | 43 (22%) | 10 (8.8%) | 0.001b |
| Preoperative Catheter Use (%) | |||
| None | 141 (73%) | 78 (68%) | |
| Indwelling Catheter | 42 (22%) | 30 (26%) | |
| Daily CIC | 11 (5.7%) | 6 (5.2%) | 0.65b |
| Operative Outcomes | |||
| Operative Time (min) Median (IQR) | 53 (38-72) | 133.5 (111-158) | <0.0001c |
| Catheter Removal Time (hours) Median (IQR) | 22.1 (18-62) | 24.5 (20-64) | 0.13c |
| % Prostate Resected Median (IQR) | 31 (20-42) | 36 (27-47) | 0.001c |
| Length of Stay (hours) Median (IQR) | 27.7 (24-33) | 16.9 (2.9-25) | <0.0001c |
| a Unpaired t-test (for normally distributed variables)b Fisher's exact analysis c Wilcoxon rank-sum test (for non-normally distributed variables) | |||
| TURP Complications; % = percentage of total TURP patients (n=194) | |||||
| Complication Grade | Operative | D30 | D30+ | Total n (%) | |
| I | AUR (8)Vasovagal episode (3) | AUR (5)UTI (3) | AUR (5)UTI (4) | 28 (14%) | |
| II | Arrhythmia (1)Blood transfusion (3) | Urosepsis (2)Epididymitis (1) | Urosepsis (1) | 8 (4%) | |
| IIIa | 0 | Diagnostic Cystoscopy (1) | Diagnostic Cystoscopy (4)Urethral Structure LA (3) | 8 (4%) | |
| IIIb | 0 | Clot evacuation GA (1) | Urethral Stricture GA (3)TUIBNC (3)Repeat TURP (2) | 9 (5%) | |
| IV | SICU for hyperglycemia (1)SICU for vasovagal (1)MICU for blood transfusion & fulguration (1) | SICU for blood loss anemia and clot retention (1) | 0 | 4 (2%) | |
| Total n (%) | 18 (9%) | 14 (7%) | 25 (13%) | 57 (29%) | |
| DiLEP Complications; % = percentage of total DiLEP patient (n=114) | |||||
| I | False Passage (1)AUR (3) | AUR (1)UTI (2) | AUR (2) | 9 (8%) | |
| II | Urosepsis (1) | Seizure 2/2 UTI (1)Blood transfusion (1) | 0 | 3 (3%) | |
| IIIa | 0 | 0 | Diagnostic Cystoscopy (1) | 1 (1%) | |
| IIIb | Clot evacuation & fulguration (2) | 0 | Urethral Stricture GA (1) | 3 (3%) | |
| Total n (%) | 7 (6%) | 5 (4%) | 4 (4%) | 16 (14%) | |
| D30 = Post-operative day 30; D30+ = Beyond 30 days post-operation; AUR = acute urinary retention; UTI = urinary tract infection; 2/2 = secondary to; LA = repair under local anesthetic; GA = repair under general anesthetic; TUIBNC = transurethral incision of bladder neck contracture | |||||
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