Thulium Laser versus Standard Transurethral Resection of the Prostate: A Randomized Prospective Trial

european urology 53 (2008) 382 390 available at www.sciencedirect.com journal homepage: www.europeanurology.com Benign Prostatic Obstruction Thulium Laser versus Standard Transurethral Resection of the Prostate: A Randomized Prospective Trial Shu-Jie Xia *, Jian Zhuo, Xiao-Wen Sun, Bang-Min Han, Yi Shao, Yi-Nan Zhang Department of Urology, First People s Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200080, China Article info Article history: Accepted May 22, 2007 Published online ahead of print on June 4, 2007 Keywords: Benign prostatic hyperplasia Prostatectomy Laser surgery Thulium Tangerine technique Abstract Objective: Thulium laser resection of the prostate-tangerine technique (TmLRP-TT) is a transurethral procedure that uses thulium laser fiber to dissect whole prostatic lobes off the surgical capsule, similar to peeling a tangerine. To our knowledge we report the first prospective, randomized study comparing TmLRP-TT and standard TURP for symptomatic BPH. Methods: From November 2004 to December 2005, 100 consecutive BPH patients were randomized for surgical treatment with TmLRP-TT (n = 52) or TURP (n = 48). All patients were preoperatively assessed with subjective symptoms score, International Index of Erectile Function questionnaire, and complete urodynamic evaluation. Preoperative and perioperative parameters at 1-, 6-, and 12-mo follow-up were also evaluated. All complications were recorded. Results: TmLRP-TT was significantly superior to TURP in terms of catheterization time (45.7 25.8 h vs. 87.4 33.8 h, p < 0.0001), hospital stay (115.1 25.5 h vs. 161.1 33.8 h, p < 0.0001), and drop in hemoglobin (0.92 0.82 g/dl vs. 1.46 0.65 g/dl, p < 0.001), whereas it required equivalent time to perform (46.3 16.2 vs. 50.4 20.7 min, p > 0.05). TmLRP-TT and TURP resulted in a significant improvement from baseline in terms of subjective symptoms scoring and urodynamic finding, but no significant difference was found between the two groups. Late complications were also comparable. Conclusions: TmLRP-TT is an almost bloodless procedure with high efficacy and little perioperative morbidity. TmLRP-TT is superior to TURP in safety and is as efficacious as TURP in 1-yr follow-up. It is a promising technology in the clinical practice field. # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, First People s Hospital Affiliated to Shanghai Jiaotong University, No. 85, Wujin Road, Shanghai 200080, China. Tel. +86 21 63250686. E-mail address: xsj@citiz.net (S.J. Xia). 0302-2838/$ see back matter # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2007.05.019

european urology 53 (2008) 382 390 383 1. Introduction Transurethral resection of prostate (TURP) is generally considered the gold standard for surgical treatment of benign prostatic hyperplasia (BPH) [1]. Complications and morbidity related to this procedure, such as blood loss, fluid balance disturbances, excessive fluid absorption, incontinence, and erectile dysfunction led to the development and investigation of new techniques. Technological alternatives such as laser treatments may further minimize the risks of this technically difficult procedure [2], and will probably challenge TURP and open prostatectomy [3]. Holmium laser enucleation of the prostate (HoLEP) appears to be a sizeindependent new gold standard [4]. It allows patients with large prostates who traditionally require open prostatectomy to be treated endoscopically [5]. Potassium-titanyl-phosphate laser vaporization achieves genuine instant tissue ablation, promising durable results. However, its potential has to be confirmed by randomized, controlled, long-term studies in the future [6]. Thulium laser is a new surgical laser, with tunable wavelength between 1.75 mm and 2.22 mm. It may have several advantages over the holmium laser, including improved spatial beam quality, more precise tissue incision, and operation in continuous-wave/pulsed modes [7]. Thulium laser has been proved capable of rapid vaporization and coagulation of prostate tissue [8], whereas cutting and ablation characters are excellent at 50-W energy level. Therefore a thulium laser procedure called thulium laser resection of prostate-tangerine technique (TmLRP-TT) was designed and performed for the treatment of BPH [9]. To our knowledge we describe the first prospective, randomized trial comparing TmLRP-TT and TURP for urodynamically obstructive BPH at 1-yr follow-up. 2. Patients and methods 2.1. Patients From November 2004 to December 2005, 100 consecutive BPH patients were randomized to surgical treatment with TmLRP- TT (52 in group 1) or TURP (48 in group 2). Inclusion criteria were age younger than 85 yr, maximum urinary flow rate (Q max ) less than 15 ml/s, postvoid residual (PVR) urine volume less than 150 ml, medical therapy failure, transrectal ultrasound (TRUS) adenoma volume less than 100 g, and urodynamic obstruction (Schäfer grade 2 or greater). Exclusion criteria were neurogenic bladder; a diagnosis of prostate cancer and any previous prostatic, bladder-neck, or urethral surgery; and the presence of an indwelling catheter. All patients were evaluated preoperatively by scoring subjective symptoms with the International Prostate Symptom Score (IPSS), quality of life score (QoLs), and the 5-item version of the International Index of Erectile Function (IIEF-5) questionnaires; physical examination with digital rectal examination (DRE); laboratory analysis with total serum prostate-specific antigen (PSA); kidney-bladder ultrasound; and TRUS measurement of prostate volume, PVR volume, Q max, and pressure flow urodynamic assessment. Both procedures were performed by experienced surgeons. 2.2. Instruments and surgical techniques 2.2.1. TmLRP-TT All the patients were in lithotomy position, and epidural anesthesia was achieved. An average power of 50-W thulium lasers (LISA laser products OHG, Germany) operated in continuous-wave mode was used for this procedure. The energy was delivered via 550-mm end-firing PercuFib fibers. The laser fibers were introduced via a Karl Storz 26F continuous flow resectoscope. Saline irrigation was used in all cases. The entire procedure is similar to peeling a tangerine; thus, it is called the tangerine technique (Figs. 1 5). It has been previously described in detail [9]. TURP was performed with the use of a standard tungsten wire loop with a cutting current of 160 W and a coagulating current of 80 W. At the end of both procedures, a 22F triple lumen catheter was inserted into the bladder. All tissue retrieved from each patient was investigated histologically. For the TURP group only, irrigation was started until hematuria had sufficiently decreased. For both groups, 500 mg levofloxacin was used 1 h before operation and in the postoperative days (once a day). Oculentum aureomycin inunction was rubbed at the external orifice of the urethra until catheter removal (twice a day). 2.3. Assessment Perioperatively the primary outcomes measured included operative time (time that the resectoscope sheath was within the urethra), resected tissue weight (actual weight of tissue retrieved), hemoglobin decrease, serum sodium decrease, postoperative catheterization time, and postoperative hospital day in the two groups. For each procedure the feasibility of catheter removal and suitability for discharge to home were assessed at 7:00 10:00 AM each postoperative day. More than three doctors who were not aware of the technique used for a particular patient decided catheter removal. Catheters were removed if the urine color was satisfactorily light. If the catheter could not be removed, the patient remained in the hospital another night and was reassessed the following day. All patients were kept 3 d in hospital after catheter removal; meanwhile therapeutic effects and complications were monitored. Postoperatively in the two groups, IPSS, QoLs, Q max, and PVR volume were evaluated at 1, 6, and 12 mo. A pressure flow urodynamic assessment was performed at the 12-mo follow-up. All perioperative and postoperative complications were recorded.

384 european urology 53 (2008) 382 390 Fig. 1 2.4. Outcome analysis With a = 0.05 and a power of 80% (b = 0.20), a sample size of 45 patients per group was calculated. The calculation assumed that the relevant difference in IPSS was 2 points 3 SD and, in Q max, it was 3 5 ml/s. All measurement data were statistically analyzed with the two-tailed Student t test and are presented as mean standard deviation (SD) of the mean. Perioperative and postoperative adverse events were compared with the two-tailed chi-square test (exact Fisher test). The study was approved by our ethics committee and all patients provided an informed written consent. 3. Results Fig. 2 Table 1 lists the baseline characteristics of all men. There was no statistically significant difference in any parameters between the two groups. Table 2 lists perioperative data. A mean total of 50 kj of energy was used in the TmLRP-TT group, which required the same time as TURP. Although the resected weight of tissue in the TmLRP-TT group was significantly less than that in the TURP group, there was no significant difference in estimated

european urology 53 (2008) 382 390 385 Fig. 5 Fig. 3 resection tissue weight between the two groups because we discerned that 0.45 g of tissue was vaporized per minute. Hemoglobin and serum sodium decreases were significantly greater in the TURP group. Catheter time and hospital stay were significantly lower in the TmLRP-TT group compared with the TURP group. Fig. 4 All 100 patients completed the 12-mo assessment. In comparison with baseline, there was highly significant improvement in each parameter at all intervals in each group. At the 1-, 6-, and 12-mo follow-ups, we did not find any statistical difference between the two groups in IPSS, QoLs, Q max, or PVR volume at any time (Table 3). One year after the operation, mean IPSS improved 6-fold in the TmLRP- TT and more than 5-fold in the TURP group. QoLs and Q max improved about 5-fold and 3-fold, respectively, in each group. PVR volume decreased by 94% in the TmLRP-TT and 93% in the TURP group. Table 4 lists data on urodynamic parameters in each group. All cases were obstructed at baseline (Schafer s grade 2 or greater). Bladder outlet obstruction had clearly resolved at the 12-mo follow-up visit. Of the patients, 25 (48%) with TmLRP-TT and 24 (50%) with TURP had erections sufficient for intercourse preoperatively. Erectile function, which was measured with the erectile function domain of the IIEF-5, showed no significant reduction in the followup period in either group (Table 5). At 12 mo postoperatively, only 2 of 52 patients with TmLRP- TT (3.8%) and 7 of 48 with TURP (14.6%) had slightly reduced erectile function compared with the preoperative level. Table 6 lists adverse events. In the TURP group, one case of transurethral resection syndrome (TURS) was observed. None of the patients with TmLRP-TT required blood transfusion, whereas two with TURP did. Postoperatively 27 patients (27%) (12 in the TmLRP-TT and 15 in the TURP groups) complained of some degree of urinary incontinence within the following months. At the 1-mo follow-up, 4% of the TmLRP-TT group and 8% of the TURP group were diagnosed with urinary tract infection. The

386 european urology 53 (2008) 382 390 Table 1 Baseline characteristics Mean SD (range) p value TmLRP-TT TURP No. of pts 52 48 Age 68.9 7.7 (57 85) 69.3 7.3 (52 82) 0.79 PSA (ng/ml) 2.1 1.1 (0.24 3.88) 2.3 1.4 (0.03 3.92) 0.43 TRUS vol (ml) 59.2 17.7 (30 97) 55.1 16.3 (32 84) 0.23 IPSS 21.9 6.7 (12 35) 20.8 5.8 (12 34) 0.38 QoLs 4.7 0.9 (3 6) 4.5 1.1 (3 6) 0.32 Q max (ml/s) 8.0 2.8 (3.2 14) 8.3 3.0 (3.3 14) 0.63 PVR vol (ml) 93.1 32.1 (30 150) 85.0 36.7 (25 150) 0.24 PdetQ max (cm H 2 O) 85.9 29.3 (44 138.3) 83.4 33.3 (40.5 197.8) 0.69 Schäfer grade 3.8 1.1 (2 6) 3.6 1.2 (2 6) 0.48 SD, standard deviation; TmLRP-TT, thulium laser resection of the prostate-tangerine technique; TURP, transurethral resection of the prostate; pts, patients; PSA, prostate-specific antigen; TRUS, transrectal ultrasound; vol, volume; IPSS, International Prostate Symptom Score; QoLs, quality of life score; Q max, maximum flow rate; PVR, postvoid residual; vol, volume; Pdet Q max, detrusor pressure at maximum flow rate. Table 2 Perioperative data Mean SD (range) p value TmLRP-T TURP Operative time (min) 46.3 16.2 (20 88) 50.4 20.7 (20 92) 0.28 Resected weight (g) 21.2 10.3 (10 55) 38.8 14.4 (18 66) 0.0001 Vaporization weight (g) 20.8 7.3 (9 39.6) Estimated resection weight (g) 42.0 16.2 (19 88) 38.8 14.4 (18 66) 0.29 Retrieval rate (g/m) 0.91 0.14 (0.68 1.27) 0.79 0.16 (0.56 1.37) 0.0001 Preop hemoglobin (g/dl) 14.01 1.62 (10.1 17.2) 13.93 1.84 (10.3 17.4) 0.82 Hemoglobin decrease (g/dl) 0.92 0.82 (0.2 5.9) 1.46 0.65 (0.7 3.1) 0.0004 Serum sodium decrease (mmol/l) 0.38 0.77 (0 3) 4.40 3.47 (0 14) 0.0001 Catheterization time (h) 45.7 25.8 (20 95) 87.4 33.8 (21 165) <0.0001 Hospital stay (h) 115.1 25.5 (87 166) 161.1 33.8 (95 240) <0.0001 SD, standard deviation; TmLRP-TT, thulium laser resection of the prostate-tangerine technique; TURP, transurethral resection of the prostate; preop, preoperative. Table 3 Follow-up data Parameter Mean preop SD (range) Mean 1 mo postop SD (range) Mean 6 mo postop SD (range) Mean 12 mo postop SD (range) IPSS TmLRP-TT 21.9 6.7 (12 35) 6.8 3.6 (0 15) 4.0 2.4 (0 9) 3.5 2.9 (0 12) TURP 20.8 5.8 (12 34) 6.6 3.9 (0 14) 3.8 2.8 (0 12) 3.9 2.7 (0 12) p value 0.38 0.83 0.64 0.46 QoL TmLRP-TT 4.7 0.9 (3 6) 1.6 1.4 (0 5) 1.1 1.1 (0 4) 1.0 0.9 (0 3) TURP 4.5 1.1 (3 6) 1.5 1.2 (0 5) 0.9 1.0 (0 4) 0.9 0.8 (0 4) p value 0.32 0.89 0.40 0.48 Q max (ml/s) TmLRP-TT 8.0 2.8 (3.2 14) 23.8 8.6 (6.4 45.3) 24.5 9.2 (7.8 48.7) 23.7 6.0 (10.3 40.4) TURP 8.3 3.0 (3.3 14) 22.5 10.0 (6.7 43.7) 23.3 10.5 (6.2 47.7) 24.1 6.4 (9.5 34.1) p value 0.63 0.47 0.54 0.77 PVR vol (ml) TmLRP-TT 93.1 32.1 (30 150) 9.7 9.1 (0 40) 7.1 6.6 (0 35) 5.2 4.8 (0 27) TURP 85.0 36.7 (25 150) 10.4 10.1 (0 36) 6.7 6.3 (0 25) 6.1 5.6 (0 25) p value 0.24 0.72 0.76 0.41 Preop, preoperative; postop, postoperative; SD, standard deviation; IPSS, International Prostate Symptom Score; TmLRP-TT, thulium laser resection of the prostate-tangerine technique; TURP, transurethral resection of the prostate; QoL, quality of life; Q max, maximum flow rate; PVR, postvoid residual; vol, volume..

european urology 53 (2008) 382 390 387 Table 4 Urodynamic findings Mean preop SD (range) Mean 12 mo postop SD (range) p value PdetQ max (cm H 2 O) TmLRP-TT 85.9 29.3 (44 138.3) 38.1 17.5 (20.4 95.5) <0.0001 TURP 83.4 33.3 (40.5 197.8) 38.9 17.3 (18.8 75.7) <0.0001 p value 0.69 0.80 Schäfer grade TmLRP-TT 3.8 1.1 (2 6) 0.71 0.67 (0 2) <0.0001 TURP 3.6 1.2 (2 6) 0.79 0.77 (0 2) <0.0001 p value 0.48 0.58 Preop, preoperative; SD, standard deviation; postop, postoperative; PdetQ max, detrusor pressure at maximum flow rate; TmLRP-TT, thulium laser resection of the prostate-tangerine technique; TURP, transurethral resection of the prostate. Table 5 IIEF-5 scores: TmLRP-TT versus TURP Domains Mean TmLRP-TT SD Mean TURP SD p value Preop 19.3 6.1 (7 25) 20.0 5.2 (7 25) 0.54 6 mo 20.4 6.0 (7 25) 21.7 4.8 (7 25) 0.25 12 mo 21.0 5.8 (8 25) 21.4 5.3 (7 25) 0.67 IIEF-5, International Index of Erectile Function-5-item version; TmLRP-TT, thulium laser resection of the prostate-tangerine technique; SD, standard deviation; TURP, transurethral resection of the prostate; preop, preoperative. irritative symptoms released after the antibiotics were used. No episode of acute urine retention after catheter removal was noted in either group. Of sexually active patients, retrograde ejaculation postoperatively was reported in 18 of 33 (55%) in the TmLRP-TT group and 20 of 31 (65%) in the TURP group. At the 12-mo follow-up, only one case of urethral stricture was observed in the TmLRP-TT group compared with three cases (6.3%) in the TURP group. All bladder-neck contractures and urethral strictures requiring precise cutting were successfully incised with the thulium laser in pulsed mode. Table 6 Adverse events No. of TmLRP TT No. of TURP p value Perioperative and first follow-up Blood transfusion 0 2 (4.2%) 0.23 Transurethral resection 0 1 (2.1%) 0.48 syndrome Urinary tract infection 2 (3.9%) 4 (8.3%) 0.42 Recatheterization 0 0 Transitory urge incontinence 12 (23.1%) 15 (31.3%) 0.36 6 12 mo postoperative Retrograde ejaculation 18/33 (55%) 20/31 (65%) 0.42 Urethral stricture 1 (1.9%) 3 (6.3%) 0.35 Stress incontinence 0 1 (2.1%) 0.48 TmLRP-TT, thulium laser resection of the prostate-tangerine technique; TURP, transurethral resection of the prostate. 4. Discussion Thulium laser is a new type of surgical laser, which recently has been applied in urology. Its first advantage is that the center wavelength of the laser is tunable between 1.75 mm and 2.22 mm, allowing the wavelength to exactly match the 1.92-mm water absorption peak in tissue. Higher absorption of the laser radiation at the thulium wavelength results in more efficient and rapid tissue cutting. At the same time, it theoretically causes a smaller thermal damage zone in the tissue. A thin layer of carbonized tissue measuring approximately 50 mm was observed at the surface in the hematoxylineosin-stained histological cross-sections [8]. Second, the thulium laser can be operated in both continuous wave mode and pulsed mode. Continuous wave mode, which can provide maximum hemostasis and coagulation, is used for prostate procedures to perform a smooth incision or vaporization. Pulsed mode is used for applications requiring precision cutting such as bladder-neck contractures and urethral strictures, and is also used for lithotrity [10]. This versatility makes the thulium fiber laser especially attractive for the wide medical field. We designed the tangerine technique and proved that it is a suitable procedure for thulium laser in the treatment of BPH. We joined the incision by making a transverse cut from the level of the verumontanum to the bilateral bladder neck, made the resection deep enough to the surgical capsule, and resected the prostate into small pieces, just like peeling a tangerine. As we resected the prostate, the pieces of the prostate were vaporized small enough to evacuate through the resectoscope sheath, and use of the mechanical tissue morcellator was not required. It was reported that a continuous-wave, 50-W thulium fiber laser operating at a wavelength of 1.91 um vaporized prostate tissue at a rate of 0.45 g/min [8]. In our trial, the tissue amount

388 european urology 53 (2008) 382 390 Fig. 6 resected and vaporized is close to 1:1 for TmLRP-TT, achieving a significant increase in the speed of the procedure. This procedure, which needs less operative time, possesses high safety, and combines efficient cutting and rapid organic vaporization, shows the great superiority of the thulium fiber laser in the treatment of BPH (Fig. 6). It has been proved that a large, variable thermal coagulation zone is observed, which ranged from 500 to 2000 mm across the prostate samples. It shows that the thulium laser may provide sufficient hemostasis during clinical treatment of BPH [8]. The excellent hemostasis of thulium laser ensured the safety of TmLRP-TT. Surprisingly clear visions in the procedure make sure that the adenomatous tissue is precisely dissected off the surgical capsule of the prostate in a retrograde fashion, starting at the apex of the prostate and continuing toward the bladder neck. Having almost no adenomatous tissue residual results in decreased bleeding postoperatively. The following reflect the potency of TmLRP-TT: less blood loss, high safety, and quick recovery. First, there is no significant difference between preoperative and postoperative hemoglobin. Second, the urine is so clear postoperatively that no bladder irrigation is needed. Third, the catheters were removed 1 2 d postoperation and the postoperative hospital stay was decreased to 4 5 d. Fourth, saline irrigation is used intraoperatively, thus decreasing the risk of transurethral resection syndrome (TURS). In our experience, operative time of TmLRP-TT is shorter compared with standard TURP, but we could not find significant difference between them, which probably seems to be the learning curve needed [11,12]. We had a research and training stage at the initial stage of developing TmLRP-TT. We were very encouraged that all doctors who took part in the trial had previous endoscopic experiences with HoLEP and TURP, so this new procedure seemed easier to grasp. The hospital stay of our patients after the operation was much longer than that reported in the literature for HoLEP and TURP. The first reason was that we wanted to observe the safety and efficacy of this new technique, so the policy of keeping the patient in the hospital for 3 d after catheter removal was also used in the control group (TURP group). Second, in China most patients do not leave the hospital until they can return to normal activities; thus, their hospital stay time was much longer and was very close to the interval to return to normal activities. So when comparing our hospital stay data with other reported series, we must keep this special reason in mind. Intraoperative and perioperative complications were less frequent in the thulium group. Two patients in the TURP group underwent blood transfusion, which was not necessary in the TmLRP-TT group. Another important fact is that the thulium laser wavelength is excellent for controlling bleeding intraoperatively. Decreasing theriskoftursmadetmlrp-ttasafechoicefor patients with heart diseases. The rate of urinary tract infection at 1 mo postoperative was significantly less in the TmLRP-TT group (4%) than in the TURP group (8%), whereas Westenberg et al [13] reported a 10% rate in a HoLEP group and an 11.6% rate in a TURP group who still endured urinary tract infection 48 mo postoperatively [13]. Inourexperience, keeping the patients in hospital 3 d after catheters are removed to observe the temperature and using levofloxacin routinely may reduce the rate of postoperative urinary tract infection; meanwhile, it may be one reason why no patient need recatheterization. It has been reported that a certain degree of subjective burning and urge incontinence was recorded more frequently after HoLEP than after TURP (48% vs. 38%) [14], which was probably due to the high energy applied to the capsule during the procedure [15]. Inourtrial,12patients(23%) in TmLRP-TT and 15 patients (31%) in TURP had short-term and self-limiting transitory urge incontinence after catheter removal. Postoperatively, retrograde ejaculation was common in both groups, which did not differ within the groups. For most patients, their satisfaction with their orgasm

european urology 53 (2008) 382 390 389 remained unchanged, and retrograde ejaculation seemed acceptable if they had been informed preoperatively. Comparing complications in our series with other procedures, urethral stricture was lower in the TmLRP-TT group (1.9%) than in the literature for HoLEP (3.2%) [16]. Minimizing thermal damage may be important in reducing scar formation and stricture recurrence after laser incision [8]. We urge urologists to perform urethral sounding for every patient 1 mo postoperative, which may reduce the rate of urethral stricture effectually. We hope this procedure will help us prevent and detect urethral stricture in the early period when it forms easily. Because the policy of urethral sounding has been used in only our center and is the regular practice in our center, its effects must be confirmed through a randomized prospective study. Stress incontinence was noticed in only one patient in the TURP group at the 12-mo followup. TmLRP-TT shows great predominance when we deal with the apex of the prostate. The optical fiber was used in the noncontact mode at a distance of 5 mm from the prostate, maintaining a laser spot diameter of approximately 1.1 mm. The exact cutting results provide less opportunity of sphincter of urethra damage. 5. Conclusion The tangerine technique is almost a bloodless procedure with high efficacy for treating symptomatic BPH, with little perioperative morbidity. TmLRP-TT is superior to TURP in safety, is as efficacious as TURP, and is a promising technology in the clinical practice field. The 1-yr follow-up results are encouraging, and longer-term follow-up is needed to evaluate the procedure s durability. Conflicts of interest The authors have nothing to disclose. References [1] Wasson JH, Reda DJ, Bruskewitz RC, Elinson J, Keller AM, Henderson WG. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. N Engl J Med 1995;332:75 9. [2] Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP) incidence, management, and prevention. Eur Urol 2006; 50:969 80. [3] De la Rosette J, Alivizatos G. Lasers for the treatment of bladder outlet obstruction: are they challenging conventional treatment modalities? Eur Urol 2006;50:418 20. [4] Kuntz RM. Current role of lasers in the treatment of benign prostatic hyperplasia (BPH). Eur Urol 2006;49: 961 9. [5] Elzayat EA, Elhilali MM. Holmium laser enucleation of the prostate (HoLEP): the endourologic alternative to open prostatectomy. Eur Urol 2006;49:87 91. [6] Reich O, Gratzke C, Stief CG. Techniques and long-term results of surgical procedures for BPH. Eur Urol 2006;49: 970 8. [7] Fried NM, Murray KE. High-power thulium fiber laser ablation of urinary tissues at 1.94 mm. J Endourol 2005; 19:25 31. [8] Fried NM. High-power laser vaporization of the canine prostate using a 110 W thulium fiber laser at 1.91 mm. Lasers Surg Med 2005;36:52 6. [9] Xia SJ, Zhang YN, Lu J, et al. Thulium laser resection of prostate-tangerine technique in treatment of benign prostate hyperplasia [in Chinese]. Zhonghua Yi Xue Za Zhi 2005;85:3225 8. [10] Fried NM. Thulium fiber laser lithotripsy: An in vitro analysis of stone fragmentation using a modulated 110- watt thulium fiber laser at 1.94 micron. Lasers Surg Med 2005;37:53 8. [11] Xia SJ, Zhu J, Lu J, et al. The treatment of benign prostatic hyperplasia by means of transurethral holmium laser enucleation [in Chinese]. Zhonghua Nan Ke Xue 2003;9:257 9. [12] Seki N, Mochida O, Kinukawa N, Sagiyama K, Naito S. Holmium laser enucleation for prostatic adenoma: analysis of learning curve over the course of 70 consecutive cases. J Urol 2003;170:1847 50. [13] Westenberg A, Gilling P, Kennett K, Frampton C, Fraundorfer M. Holmium laser resection of the prostate versus transurethral resection of the prostate: results of a randomized trial with 4-year minimum long-term followup. J Urol 2004;172:616 9. [14] Wilson LC, Gilling PJ, Williams A, et al. A randomised trial comparing holmium laser enucleation versus transurethral resection in the treatment of prostates larger than 40 grams: results at 2 years. Eur Urol 2006;50: 569 73. [15] Montorsi F, Naspro R, Salonia A, et al. Holmium laser enucleation versus trans-urethral resection of the prostate: results from a two-centre prospective randomized trial in patients with obstructive benign prostatic hyperplasia. J Urol 2004;172:1926 9. [16] Kuntz RM, Ahyai S, Lehrich K, Fayad A. Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. J Urol 2004; 172:1012 6.

390 european urology 53 (2008) 382 390 Editorial Comment on: Thulium Laser versus Standard Transurethral Resection of the Prostate: A Randomized Prospective Trial Michael Seitz Department of Urology, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany Michael.Seitz@med.uni-muenchen.de Although transurethral resection of the prostate (TURP) is still regarded as the gold standard in the treatment of patients with benign prostatic hyperplasia (BPH), it is associated with significant morbidity rates. Therefore, in recent decades various alternative laser treatment options have been developed. Although neodymium:yttriumaluminum-garnet (Nd:YAG) laser therapy has been associated with less morbidity than TURP due to excellent hemostatic characteristics, the remaining necrotic tissue caused bladder outlet obstruction (BOO) and BOO-related symptoms for several weeks after treatment. Immediate tissue ablation was accomplished when Malek et al [1] introduced a 60-W potassium-titanyl-phosphate laser vaporization (KTP laser = kalium-titanylphosphate laser) and Fraundorfer et al [2] introduced holmium laser enucleation of the prostate (HoLEP). Although, KTP laser vaporization of the prostate is meanwhile a widely excepted treatment option in patients with BPH, to date only one prospective randomized trial (KTP vs. TURP) has been carried out comparing perioperative complications and early functional outcome; it demonstrated similar outcomes with both techniques after (!) 6 mo [3]. In contrast, HoLEP proved to be safe and effective in several trials with long-term follow-up periods and thus is considered to be an alternative to TURP and also to open surgery [4]. In the present article, Xia et al [5] report a series of 52 thulium laser resections of the prostate (TmLRP) at a single institution with a follow-up of 12 mo. This first report of a prospective, randomized study comparing TmLRP to standard TURP for symptomatic BPH documented remarkable outcomes. Although the restricted time of follow-up has to be considered, TmLRP seems to be a safe and durable procedure and by all means to be comparable to TURP in quickly relieving BOO in this study. TmLRP retrieves tissue for histologic analysis, which is an advantage over KTP laser vaporization. At the same time TmLRP is a user-friendly TURPlike technique requiring less expertise compared to HoLEP. In the light of these excellent results, it will be interesting to see whether these data can be confirmed in large-scale studies by other institutions. To reduce the overall costs of laser procedures, it is possible that alternative laser therapies such as TmLRP will push onto the market. References [1] Malek RS, Barrett DM, Kuntzman RS. High-power potassium-titanyl-phosphate (KTP/532) laser vaporization prostatectomy: 24 hours later. Urology 1998;51:254 6. [2] Fraundorfer MR, Gilling PJ. Holmium:YAG laser enucleation of the prostate combined with mechanical morcellation: preliminary results. Eur Urol 1998;33: 69 72. [3] Bachmann A, Schürch L, Ruszat R, et al. Photoselective vaporization (PVP) versus transurethral resection of the prostate (TURP): a prospective bi-centre study of perioperative morbidity and early functional outcome. Eur Urol 2005;48:965 72. [4] Kuntz RM. Current role of lasers in the treatment of benign prostatic hyperplasia (BPH). Eur Urol 2006;49: 961 9. [5] Xia S-J, Zhuo J, Sun X-W, Han B-M, Shao Y, Zhang Y-N. Thulium laser versus standard transurethral resection of the prostate: a randomized prospective trial. Eur Urol 2008;53:382 90. DOI: 10.1016/j.eururo.2007.05.020 DOI of original article: 10.1016/j.eururo.2007.05.019