Comparison of perioperative and functional outcomes of holmium laser enucleation of prostate with different power: A systematic review and meta-analysis

doi:10.21203/rs.3.rs-3303701/v1

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Comparison of perioperative and functional outcomes of holmium laser enucleation of prostate with different power: A systematic review and meta-analysis

https://doi.org/10.21203/rs.3.rs-3303701/v1

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Objective: The objective is to systematically review the perioperative and prognostic outcome differences between low-power (LP) and high-power (HP) holmium laser enucleation of the Prostate (HoLEP).

Methods: Up to 2023, we systematically searched English databases such as PubMed, EMBASE, Google Scholar, SinoMed, CNKI for related original research literature. Review Manager 5.4 software was used for meta-analysis. Pooled odds ratios (ORs), weight mean differences (WMDs) and standard mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using the fixed-effects or random-effects model. Publication bias was evaluated using funnel plots.

Results: We identified 1026 records in the literature search. After screening titles, abstracts, and full texts, we finally selected and included 5 studies. This meta-analysis (5 trials) showed that in intraoperative variables, HP HoLEP is superior to LP HoLEP in terms of enucleation efficiency, but there was no significant difference in operative time; there was no significant difference in postoperative outcomes (length of hospital stay, postoperative catheterization time), postoperative incontinence rates, and related complications between the two groups. There was no significant difference in postoperative functional outcomes (IPSS; Qmax; QOL; PVR).

Conclusion: Compared to LP HoLEP, HP HoLEP has a certain advantage in terms of enucleation efficiency; there is no significant difference in other aspects; however, LP HoLEP consumes less energy and is more energy-efficient and environmentally friendly. Furthermore, further comparative research is still needed to elevate the level of evidence.

Registration: The study protocol was registered with PROSPERO(CRD42023445989).

BPH

HoLEP

Holmium Laser

Power

Enucleation efficiency

characterized by lower urinary tract symptoms (LUTS)[1], Its incidence increases with age, reaching 50%-75% in men over 50 years old, and exceeds 80% in those over 70 years old[2]. Surgical treatment can be considered in cases where medication is ineffective, moderate to severe LUTS is present, or acute urinary retention occurs[1].

With the development of laser surgery, Holmium Laser Enucleation of the Prostate (HoLEP) was first introduced by Dr. Gilling and his colleagues in 1998[3]. It has been favored by most urologists due to its advantages such as complete removal of the gland, minimal surgical trauma, excellent hemostasis, and fewer postoperative complications[4]. As this technology becomes more widespread, it is expected to replace transurethral resection of the prostate (TURP) as the gold standard for endoscopic surgery of BPH with surgical indications[5, 6]. HoLEP involves vaporizing, cutting, and removing tissue with a laser of a certain power, thereby relieving obstruction[7]. HoLEP usually uses a standard power setting of 80–100 W (2 J, 40–50 Hz)[8, 9]. Thus, it requires a holmium machine with multiple high-power sockets and multiphase connectors capable of emitting high power (HP), leading to higher equipment costs. Coupled with the steep surgical learning curve for clinicians[10–12], this has limited the widespread implementation of HoLEP in clinical practice. However, there have been few reports on performing HoLEP using low power (LP) settings compared to HP settings. Yet, low-power (LP) machines (30-60W) are also being used in clinical practice[13], and compared to HP devices, their lower investment costs and energy consumption, as well as the lack of need for dedicated sockets, are potential advantages. Using the same machine for prostate enlargement surgery as for lithotripsy may be an additional advantage. Furthermore, several studies have shown that HoLEP performed using LP has higher safety and effectiveness compared to standard HoLEP[14, 15]. Therefore, this systematic review aims to compare the perioperative and postoperative functional outcomes of LP and HP HoLEP in the treatment of BPH, explore the potential relative advantages of the two techniques, and provide an evidence base for clinical practice.

Search strategy

This systematic review and meta-analysis were developed and implemented according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Table S1). Two reviewers (LW and SY) conducted a thorough search using electronic databases, including PubMed, EMBASE, Google Scholar, SinoMed, and CNKI. The reference lists of relevant studies were also manually searched. The accuracy and timeliness of this meta-analysis were validated by searching for papers meeting the research criteria before June 25, 2023, and re-searching prior to submission.

The following related terms were searched through intervention and disease: [(benign OR prostate hypertrophy OR prostatic hyperplasia OR prostate adenoma OR BPH OR BPO OR BOO) AND (holmium OR Holmium Lasers) AND (power OR energy OR Watt OR Hz OR Hertz) AND (HoLEP OR Ho-LEP)].

This search process did not impose language restrictions on the content searched. The research protocol has been registered in PROSPERO (CRD42023445989).

Inclusion/exclusion criteria

The PICOS (Patient, Intervention, Comparison, Outcomes, and Study design) method was used to determine eligibility for analysis and to design follow-ups: (P) adult patients who underwent HoLEP surgery for BPH; (I) patients who underwent low-power HoLEP (LP) surgery; (C) patients who underwent high-power HoLEP (HP) surgery; (O) one or more postoperative functional outcome measures (IPSS, QoL, Qmax, PVR), and perioperative measures (OT, Catheterization, LOS, EE, blood transfusion rate, and postoperative complications); (S) prospective comparisons, retrospective studies, or randomized controlled trials (RCT). Based on the power used, patients were divided into two groups. The LP group included surgeries conducted at 30W-60W power; for the HP group, HoLEP was performed at 80-100W. Exclusion criteria were as follows: (1) The article did not have available relevant data or data were not complete; (2) there was no control group in the trial; (3) surgeries performed with devices other than holmium lasers for prostate enucleation were excluded; (4) case reports, expert opinions, reviews, and related animal experiments were also excluded.

Data extraction and quality assessment

Predefined Microsoft Excel was used to extract data from the baseline characteristics of the study population and relevant outcome measures. After initial screening of titles and abstracts, two researchers (LW and SY) independently read the full text and performed data transformation and extraction. Issues were resolved by discussion with a third reviewer (LY) or by reaching a consensus.

If necessary, we also contacted the original authors to obtain complete usable data. At the same time, our staff double-checked the references and data of each study to ensure the completeness and feasibility of the data.

Data extraction included the first author, study type, country, year of publication, average age and number of patients in different groups, prostate volume size, type of enucleation, energy setting, perioperative related information (OT, Catheterization, LOS, EE, blood transfusion rate, and the incidence of postoperative incontinence), and functional outcome measures after prostate hyperplasia surgery (IPSS, QOL, Qmax, PVR).

The Newcastle-Ottawa Scale (NOS) was used to assess the quality of closed cohorts and case-control studies[16]. Each NOS item scored 1 or 2 points, and scores of 5 points or less were considered low quality; 6 to 7 points were medium quality, and 9 points or above were considered almost good quality.

Risk of bias

ROBINS-I (Risk of Bias in Non-randomized Studies of Interventions) was used to assess the potential risk of bias in non-randomized studies included in the meta-analysis[17].

Statistical analysis

The means and standard deviations (SDs) of continuous variables were calculated. However, if the provided raw data were only medians and interquartile ranges (IQRs), or the maximum and minimum values of that range, then transformations were needed. Luo et al. [18]used a conversion table to transform the data to a normal distribution. For non-normally distributed data, the formula provided by McGrath et al.[19] was used for the corresponding conversion. Continuous and binary variables involved in the studies were represented as weighted mean differences (WMD) and odds ratios (OR), along with their corresponding 95% confidence intervals (CIs).

To assess the degree of heterogeneity among the studies, the I² test and chi-square test were used. Statistically significant heterogeneity was defined as p < 0.01, indicating moderate to high heterogeneity (I² > 40%). The Z test was used to determine the statistical significance of the effect size of the combined studies, with statistical significance defined as p < 0.05. If I² > 40%, a random-effects model was chosen according to the principles of Cochrane reviews. In all other cases, a fixed-effects model was applied.

The baseline was compared to determine the statistical variability between the two treatment groups. All statistical analyses were performed using RevMan 5.4 and Stata 17.0. We studied the sensitivity of specific studies with significant heterogeneity using a leave-one-out strategy. A visual assessment of publication bias for the results of the five included studies was conducted using funnel plots and Egger's regression test (p > 0.05)[20, 21].

Baseline Characteristics

The flowchart of literature selection and final inclusion is shown in (Fig. 1). After a thorough evaluation and filtering process, we found 5 studies (304 LP-HoLEP and 281 HP-HoLEP) out of 22 research articles, involving a total of 585 patients. Two of these 5 control studies [14, 22] were retrospective studies, while 3 articles [15, 23, 24] were included in randomized controlled studies. The basic characteristics of patients in all included studies are shown in (Table 1).

Table 1

Baseline characteristics of enrolled trials RCT = randomized controlled trial; W = Watt; J = joule; Hz = Hertz; L = Lp HoLEP; H = Hp HoLEP; LE = level of evidence according to the Oxford Center for Evidence-based Medicine.1 = operative time; 2 = length of stay; 3 = catheterization; 4 = enucleation efficiency; 5 = blood transfusion rate; 6 = urinary incontinence rate;7 = international Prostate Symptom Score; 8 = peak urinary flow rate; 9 = Quality of Life; 10 = Postvoid residual urine.
Study	Country	Type of study	Enrolled patients		Energy setting low power	Energy setting high power	Outcomes	Type of enucleation	LE
			LP	HP
shah 2021	USA	RCT	46	48	(50–60)W (2J × (25–30) Hz)	100W (2 J × 50 Hz)	2,3,4,5,6,7,8,10	2-lobe and 3-lobe	2b
Jiang 2021	China	RCT	79	81	45W (1. 5 J × 30 Hz)	80W (2J × 40 Hz)	1,2,3,4,5,6,7,8,10	2-lobe	2b
fan 2022	China	Retrospective	60	60	60W (1. 5 J × 40 Hz)	100W (2.5 J × 40 Hz)	1,2,3,5,6,7,8,9	2-lobe	2b
Elshal 2018	Egypt	RCT	61	60	50W (2 J × 25Hz)	100W (2J × 50 Hz)	1,2,3,4,5,6,7,8,9,10	2-lobe and 3-lobe	2b
Liu 2019	China	Retrospective	58	32	40W (2 J × 20Hz)	90W (3 J × 30Hz)	1,2,3,5,6,7,9	2-lobe and 3-lobe	2b

Quality Assessment

The study range covered 2018 to 2023, and the ROBINS-I tool showed [17] that the overall bias of the study was moderate or higher (see Table S3 for details). Moreover, we found that according to the NOS score (> 5), all included studies were of medium or better quality. Figure 2 and Table S1 provide specific evidence regarding quality assessment.

Baseline Characteristic Variables

No significant differences were observed in the LP and HP groups in terms of age (p = 0.13) and average prostate volume size (p = 0.67) (Table 2).

Table 2

Comparison of the patient’s baseline characteristics
Baseline characteristic	No. of studies	LP vs. HP	Heterogeneity I²(%)	p-value
Age WMD (95% CI)	5	0.44(-0.64,1.5)	0	0.43
PV WMD (95% CI)	5	-3.09(-8.44,2.27)	51	0.26
LP = LP HoLEP; HP = HP HoLEP; PV = prostate volume; WMD = weight mean difference; CI = confidence interval.

Perioperative Efficacy

3.1.1 Operative Time (OT) (min)

Based on the meta-analysis of 4 included studies (258 cases in LP and 258 cases in HP), this study used a random-effects model with high heterogeneity (I² = 82%, p < 0.0009). There was no significant difference and no statistical significance in operation time between the HP group and the LP group (WMD = 6.75min, 95% CI: -2.33 to 15.83, p = 0.14, Fig. 3A).

3.1.2 Length of Stay (LOS) (day)

Based on the meta-analysis of 5 included studies (304 cases in LP and 281 cases in HP), this study used a random-effects model with high heterogeneity (I² = 61%, p < 0.04). There was no significant difference and no statistical significance in length of stay between the HP group and the LP group (WMD = 0.01days, 95% CI: -2.28 to 0.12, p = 0.90, Fig. 3B).

3.1.3 Catheterization (day)

Based on the meta-analysis of 5 included studies (304 cases in LP and 281 cases in HP), this study used a random-effects model with high heterogeneity (I² = 71%, p < 0.007). There was no significant difference and no statistical significance in catheterization time between the HP group and the LP group (WMD = 0.01days, 95% CI: -0.15 to 0.16, p = 0.94, Fig. 3C).

3.1.4 Enucleation Efficacy (EE) (gm/min)

Based on the meta-analysis of 3 included studies (186 cases in LP and 189 cases in HP), this study used a fixed-effects model with no heterogeneity (I² = 0%, p = 0.73). Compared with the LP group, the enucleation efficacy of the HP group was significantly superior, with statistical significance (WMD = -0.13gm/min, 95% CI: -0.18 to -0.08, p < 0.00001, Fig. 3D).

3.1.5 Blood Transfusion Rate

According to the meta-analysis of 5 included studies (304 cases in LP and 281 cases in HP), this study used a fixed-effects model with no heterogeneity (I² = 0%, p = 0.56). There was no significant difference and no statistical significance in the blood transfusion rate between the HP group and the LP group (RR = 0.38, 95%CI:0.08 to 1.86, p = 0.23, Fig. 3E).

3.1.6 Postoperative Complications (Incontinence Rate)

Based on the meta-analysis of 5 included studies (304 cases in LP and 281 cases in HP), this study used a random-effects model with moderate heterogeneity (I² = 46%, p = 0.13). There was no significant difference and no statistical significance in the rate of postoperative complications between the HP group and the LP group (RR = 1.07, 95%CI:0.58 to 1.99, p = 0.83, Fig. 3F).

Postoperative Functional Outcome Indicators

3.1.7 IPSS

Based on the meta-analysis of 5 trials (304 cases in LP and 281 cases in HP) using a random-effects model, this study used a random-effects model with moderate heterogeneity (I² = 62%, p = 0.03). There was no significant difference and no statistical significance in postoperative IPSS between the LP group and the HP group (WMD = 0.05, 95% CI: -0.70 to -0.80, p = 0.90, Fig. 4A).

3.1.8 Qmax

Based on the meta-analysis of 4 trials (246 cases in LP and 249 cases in HP) using a random-effects model, this study used a fixed-effects model with no heterogeneity (I² = 0%, p = 0.40). There was no significant difference and no statistical significance in postoperative Qmax between the LP group and the HP group (WMD = 0.42, 95% CI: -0.27 to 0.12, p = 0.23, Fig. 4B).

3.1.9 QOL

Based on the meta-analysis of 3 trials (179 cases in LP and 152 cases in HP) using a random-effects model, this study used a random-effects model with moderate heterogeneity (I² = 76%, p = 0.02). There was no significant difference and no statistical significance in postoperative QOL between the LP group and the HP group (WMD =-0.02, 95% CI: -0.27 to 0.22, p = 0.84, Fig. 4C).

3.1.10 PVR

Based on the meta-analysis of 3 trials (179 cases in LP and 152 cases in HP) using a random-effects model, this study used a random-effects model with high heterogeneity (I² = 93%, p = 0.00001). There was no significant difference and no statistical significance in postoperative PVR between the LP group and the HP group (WMD =-3.73, 95% CI: -11.15 to 3.69, p = 0.32, Fig. 4D).

Heterogeneity

Most studies showed low to moderate heterogeneity, but some results, such as OT, Catheterization, and QOL, inevitably showed high heterogeneity (I² > 70%). This should not be ignored when reviewing the results, despite the biases of surgical doctors' preference for different surgical methods and power selections, the span of the studies' durations, and small sample biases.

Analysis of sensitivity and publication bias

It is evident from the NOS scores that most studies are of medium or higher quality. However, we can use sensitivity tests to confirm the validity of a few studies with significant heterogeneity (OT, Catheterization, QOL). After individually removing each trial and recalculating the overall mean difference, we found that the results underwent stable changes (Fig. 5). Despite only five studies being included, the funnel plot is not visually obviously asymmetric (Fig. 6).

This is an evidence-based study comparing different power settings of Laser impact on Perioperative and functional outcomes of Holmium Laser Enucleation of the Prostate. We must investigate the key issues of the study in more depth. In surgical treatment of benign prostatic hyperplasia, the results of this meta-analysis show significant differences between LP and HP in surgical enucleation efficiency, but no significant differences in other perioperative indicators such as OS, LOS, blood transfusion rate and complications. Also, no statistical differences were found in functional outcome indicators including IPSS, Qmax, QOL, and PVR.

Surgical outcomes

The efficiency of the surgery is the most important difference between LP HoLEP and HP. Indeed, surgical experience might be a significant confounding factor in comparing surgical efficiency. Shigemura et al. [25] found that increased surgical experience significantly affected operation time, prostate enucleation time, and incidence of urinary incontinence (UI) after HoLEP (p = 0.0146, p = 0.0216, and p = 0.0405, respectively) in their study statistics. However, surgery-related variables (such as crushing time, prostate resection volume, infectious or non-infectious surgery-related complications, or postoperative urination-related outcomes) did not change significantly (p > 0.05).

In the retrospective study by Minagawa et al. [26], all 44 HoLEP operations performed were set at a power of 30W and were completed by a single surgeon with abundant surgical experience. The authors considered the surgeon's level of expertise and evaluated the results, concluding that when an experienced surgeon performs HoLEP, the enucleation time can be significantly reduced. This illustrates the importance of accumulated surgical experience in enhancing surgical efficiency.

Additionally, due to the stronger energy brought by higher power, the efficiency of prostate enucleation in HP was higher than that in LP. However, the results found that there were no significant differences in total surgery time, surgical efficiency, and other intraoperative indicators between the two, which indicates that the energy of LP does not affect the efficiency of the entire operation compared to HP.

Elshal et al.[23] used a low-power laser with power settings of (50 W, 2 J/25 Hz). They also demonstrated equivalent operative time and efficiency to HP, with average surgical efficiencies of 1.01 ± 0.4 and 1.09 + 0.4gm/min for LP HoLEP and HP HoLEP respectively, (p = 0.6), and no significant statistical difference between the two.

However, in the study by Jiang et al.[15], it was found that for medium and small volume prostates (30ml < V ≤ 80ml), LP HoLEP had no significant differences in operation time, enucleation time, crushing time, prostate quality, and efficiency compared to HP HoLEP. For larger volume prostates (V > 80ml), LP HoLEP had significantly longer operation time (103.43min vs. 86.74 min, P < 0.001) and enucleation time (83.53 min vs. 65.30min, P < 0.01) compared to HP HoLEP. Therefore, these results need further verification from more trials. Furthermore, surgical technique may also impact overall surgical efficiency [22, 27].

Postoperative Functional Outcomes

Normally, postoperative urinary irritative and storage symptoms should significantly improve compared to preoperative conditions. Referring to short-term postoperative functional indicators such as Qmax, IPSS score, QoL, and PVR[28], the study by Jiang et al. [10] observed postoperative follow-up indicators and found that the IPSS and PVR of patients in each group were lower than preoperative levels at 1 and 6 months postoperatively (P < 0.05). The Qmax of the low-power group also increased from 9.03 ± 1.91 mL/s preoperatively to 19.71 ± 5.39 mL/s 6 months postoperatively (P < 0.05) after combining subgroups. This is like the results of the study by Tokatli et al. [29] (7.8 mL/s vs. 28 mL/s, p < 0.001).

Similarly, Becker et al.[30] in their LP HoLEP study, found significant improvements in IPSS, quality of life, Qmax, and PVR at 1 month (p ≤ 0.009) and 6 months of follow-up (p < 0.001). In summary, all functional indicators significantly improved postoperatively compared to baseline. In addition, a randomized trial[23] found no statistically significant differences between LP and HP HoLEP in terms of IPSS scores (3 vs. 4, p = 0.4), QoL (1 vs. 1, p = 0.6), Qmax (12.1 vs. 21.8, p = 0.7), and PVR (29 vs. 22, p = 0.09) at 12 months of follow-up.

In performing apical urethral mucosa disconnection and prostatic fossa hemostasis with low-power holmium laser, there may be potential advantages in reducing thermal damage to surrounding tissues, thereby potentially mitigating postoperative urinary incontinence and early postoperative lower urinary tract symptoms due to the lower laser energy. However, from the analysis of postoperative functional outcome results between high- and low-power groups, it cannot be determined that this is a potential advantage of LP HoLEP, as there are no significant statistical differences in the incidence of irritative and storage symptoms postoperatively between LP and HP HoLEP.

Safety and complications of LP-HoLEP

According to literature reports, the complication rate of LP HoLEP is 7%-24%[31]. Among these, 3.7% are Clavien grade 3a and 5.5% are Clavien 3b[30]. This meta-analysis included a total of 304 patients, with only one patient in the LP group requiring intraoperative blood transfusion, which is fewer than the four patients in the HP group, although there was no significant difference statistically. The study by Becker et al. reported that the blood transfusion rate for their LP HoLEP surgery (1.9%) was comparable to the transfusion rate in the 100W high-power device surgery conducted by Krambeck et al. [28, 30]. One study even found that regardless of the type of laser device used, hemoglobin levels significantly decreased in patients who underwent a prostate biopsy before HoLEP treatment (p = 0.002) [24].

Elshal et al.[23] completed prostate gland nucleation and hemostasis in their trials under a low-power machine, and there were no significant differences in perioperative hemoglobin deficit median (0.9 vs. 0.7, p = 0.6), blood transfusion rate (0% vs. 0%), and other perioperative indicators between LP and HP HoLEP. This fully demonstrates the good coagulation effect and surgical safety of LP-HoLEP. The most common postoperative complication is temporary urinary incontinence, which is relatively rare and usually mild and can recover over time. This is comparable to the prognosis of TURP and other benign prostatic hyperplasia surgeries[12, 32–34]. The cause may be stress reactions due to excessive pulling of the urethral sphincter during surgery, or tissue damage caused by excessive laser energy near the apex of the prostate. Another complication is difficulty urinating caused by urethral stricture or bladder injury[35–37].

In the randomized controlled trial conducted by Liu et al.[22], there was no significant postoperative urinary incontinence, and there was one case (1.7%) of difficulty urinating after LP catheter removal. Elshal et al.[23] reported that the incidence of postoperative incontinence was similar (6.5% vs. 8.3% at one month, P = 0.6), and each group had one patient who had persistent stress urinary incontinence for four months. Shah's study[24] found that although 9.5% of patients had temporary incontinence, all patients' incontinence completely alleviated during the 3–5-month follow-up period. In addition, in this study, there were no significant differences in the length of hospital stay (p = 0.94) and average postoperative catheterization time (p = 0.43) between the two groups. This shows that LP can achieve comparable coagulation effects and better recovery as HP, which strongly proves the effectiveness and safety of LP.

Limitations

Our study has several limitations. First, the quantity of available randomized controlled trials (RCTs) and literature included in our study is limited, comprising only three RCTs and two retrospective studies. This could introduce bias, and more robust clinical data and evidence is necessary for further investigation. Second, our study did not specifically clarify whether patients were given α-blockers or other drugs to treat benign prostatic hyperplasia during the perioperative period. Some of the studies had a small sample size and short follow-up periods, and thus lacked long-term postoperative functional outcome results. Unfortunately, despite sensitivity analyses providing some evidence for more heterogeneous outcomes, confounding factors are inevitable and should be interpreted with caution. Finally, there may be unknown differences among geographical regions, medical institutions, and racial groups, which makes it difficult to generalize the results reported.

In conclusion, our meta-analysis indicates that for adult patients with benign prostatic hyperplasia undergoing HoLEP treatment, HP has a certain advantage in terms of enucleation efficiency compared to LP, but there is no significant difference in overall perioperative advantages (OT, LOS, transfusion rate). However, LP HoLEP consumes less energy, has lower equipment costs, and is more energy-efficient and environmentally friendly. From an economic perspective, it is easier to implement. This article provides evidence of the effectiveness of this technique for surgeons using LP HoLEP machines to perform HoLEP, but further large-scale prospective randomized controlled trials comparing the two are still needed to elevate the level of evidence.

WMD

weighted mean difference

odd ratio

Standard deviation

confidence intervals

RCT

randomized controlled trial

BPH

benign prostatic hyperplasia

BPO

benign prostatic obstruction

HoLEP

holmium laser enucleation of the prostate

low-power holmium laser enucleation of prostate

High-power holmium laser enucleation of prostate

Watt

joule

Hertz

prostate volume

LUTS

lower urinary tract symptoms

IPSS

international Prostate Symptom Score

Qmax

peak urinary flow rate

QoL

quality of life

TURP

transurethral resection of the prostate

operative time

LOS

length of stay

Enucleation Efficacy

BTR

blood transfusion rate

PVR

Postvoid residual urine

Acknowledgment

Thanks to Dr. Li Wang for his support and indications in this research.

Authors' contributions

Conceptualization: Lin Yang and Li Wang, Data curation: Li Wang and Shan Yin, Methodology: Ying Liu and Shan Yin, Software: Li Wang and Lin Yang, Supervision: Shan Yin and Li Wang, Writing – original draft: Lin Yang, Writing – review & editing: Ping-yu Zhu

Funding

None

Data Availability Statement

If necessary, the corresponding raw data can be provided by the corresponding author.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

No conflicts of interest are declared.

Gratzke C, Bachmann A, Descazeaud A, Drake MJ, Madersbacher S, Mamoulakis C, Oelke M, Tikkinen KAO, Gravas S. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. Eur Urol. 2015;67(6):1099–109.
Egan KB. The Epidemiology of Benign Prostatic Hyperplasia Associated with Lower Urinary Tract Symptoms: Prevalence and Incident Rates. Urol Clin North Am. 2016;43(3):289–97.
Gilling PJCC, Malcolm A, et al. Holmium laser resection of the prostate versus neodymium:yttrium-aluminumgarnet visual laser ablation of the prostate: a randomized prospective comparison of two techniques for laser prostatectomy. Urology. 1998;51:573–7.
Ahyai SA, Lehrich K, Kuntz RM. Holmium laser enucleation versus transurethral resection of the prostate: 3-year follow-up results of a randomized clinical trial. Eur Urol. 2007;52(5):1456–63.
Elzayat EA, Habib EI, Elhilali MM. Holmium laser enucleation of the prostate: a size-independent new gold standard. Urology. 2005;66(5 Suppl):108–13.
Ahyai SA, Chun FK, Lehrich K, Dahlem R, Zacharias MS, Fisch MM, Kuntz RM. Transurethral holmium laser enucleation versus transurethral resection of the prostate and simple open prostatectomy–which procedure is faster? J Urol. 2012;187(5):1608–13.
Scoffone CM, Cracco CM. High-power HoLEP: no thanks! World J Urol. 2018;36(5):837–8.
Gilling PJKK, Das AK, et al. Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience. J Endourol. 1998;12:457–9.
Scoffone CMCC. Prostate enucleation, better with low or high-power holmium laser? A systematic review. Arch Esp Urol. 2020;73:745–52.
Elshal AM, Nabeeh H, Eldemerdash Y, Mekkawy R, Laymon M, El-Assmy A, El-Nahas AR. Prospective Assessment of Learning Curve of Holmium Laser Enucleation of the Prostate for Treatment of Benign Prostatic Hyperplasia Using a Multidimensional Approach. J Urol. 2017;197(4):1099–107.
Shah HN, Mahajan AP, Sodha HS, Hegde S, Mohile PD, Bansal MB. Prospective evaluation of the learning curve for holmium laser enucleation of the prostate. J Urol. 2007;177(4):1468–74.
Naspro R, Suardi N, Salonia A, Scattoni V, Guazzoni G, Colombo R, Cestari A, Briganti A, Mazzoccoli B, Rigatti P, et al. Holmium laser enucleation of the prostate versus open prostatectomy for prostates > 70 g: 24-month follow-up. Eur Urol. 2006;50(3):563–8.
Rassweiler J, Roder M, Schulze M, Muschter R. Transurethral enucleation of the prostate with the holmium: YAG laser system: how much power is necessary? Urologe A. 2008;47(4):441–8.
Fan S, Chang B. Clinical Efficacy of 60 W (1. 5 J × 40 Hz) Holmium Laser Enucleation of the Prostate in the Treatment of Benign Prostatic Hyperplasia. Chin J Minim Invasive Surg. 2022;22(4):318–22.
Jiang J, Gu Z, Chen J. Efficacy analysis of high and low-power holmium laser enucleation in the treatment of benign prostatic hyperplasia with different volumes. Chin J Clin Med. 2021;28(5):846–52.
Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–5.
Sterne JA, Hernan MA, Reeves BC, Savovic J, Berkman ND, Viswanathan M, Henry D, Altman DG, Ansari MT, Boutron I, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.
Luo D, Wan X, Liu J, Tong T. Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res. 2018;27(6):1785–805.
McGrath S, Zhao X, Steele R, Thombs BD, Benedetti A, Collaboration DESD. Estimating the sample mean and standard deviation from commonly reported quantiles in meta-analysis. Stat Methods Med Res. 2020;29(9):2520–37.
Lau JIJ, Terrin N, Schmid CH, Olkin I. The case of the misleading funnel plot. BMJ (Clinical research ed). 2006;333(7568):597–600.
Roig M. The case of the misleading funnel plot. BMJ. 2006;333(7568):596–7.
Liu K, Zhang F. Low power seven-step two-lobe holmium laser enucleation of the prostate technique for surgical treat. J Peking University(Health Sciences). 2019;51(06):1159–64.
Elshal AM, El-Nahas AR, Ghazy M, Nabeeh H, Laymon M, Soltan M, Ghobrial FK, El-Kappany HA. Low-Power Vs High-Power Holmium Laser Enucleation of the Prostate: Critical Assessment through Randomized Trial. Urology. 2018;121:58–65.
Shah HN, Etafy MH, Katz JE, Garcia Lopez EA, Shah RH. A randomized controlled trial comparing high and medium power settings for holmium laser enucleation of prostate. World J Urol. 2021;39(8):3005–11.
Shigemura K, Yamamichi F, Kitagawa K, Yamashita M, Oka Y, Tanaka H, Fujisawa M. Does Surgeon Experience Affect Operative Time, Adverse Events and Continence Outcomes in Holmium Laser Enucleation of the Prostate? A Review of More Than 1,000 Cases. J Urol. 2017;198(3):663–70.
Minagawa S, Okada S, Morikawa H. Safety and Effectiveness of Holmium Laser Enucleation of the Prostate Using a Low-power Laser. Urology. 2017;110:51–5.
Liu K, Xiao C, Hao Y, Ma L. Seven-step two-lobe' HoLEP: a modification to gain efficiency of the enucleation applying relatively low-power holmium laser devices. World J Urol. 2021;39(7):2627–33.
Tamalunas A, Schott M, Keller P, Atzler M, Ebner B, Buchner A, Stief CG, Magistro G. How does symptom severity impact clinical outcomes of men with lower urinary tract symptoms after holmium laser enucleation or transurethral resection of the prostate? Cent Eur J Urol. 2022;75(4):387–94.
Tokatli Z, Ferhat M, Ibis MA, Turkmen Sariyildiz G, Elhan A, Sarica K. Does the power of the laser devices matter for a successful HoLEP procedure? A prospective comparative study. Int J Clin Pract. 2021;75(10):e14531.
Becker B, Gross AJ, Netsch C. Safety and efficacy using a low-powered holmium laser for enucleation of the prostate (HoLEP): 12-month results from a prospective low-power HoLEP series. World J Urol. 2018;36(3):441–7.
Cracco CC, Sica G, Ndrevataj A, Scoffone D, MP32-08 IMPACT OF ADENOMA VOLUME ON THE INTRAOPERATIVE FEATURES OF 3 NEWLY DEVELOPED APPROACHES FOR HOLMIUM LASER ENUCLEATION OF THE PROSTATE. J Urol. 2020;203:e487–8.
Zhong J, Feng Z, Peng Y, Liang H. A Systematic Review and Meta-analysis of Efficacy and Safety Following Holmium Laser Enucleation of Prostate and Transurethral Resection of Prostate for Benign Prostatic Hyperplasia. Urology. 2019;131:14–20.
Ahyai SA, Gilling P, Kaplan SA, Kuntz RM, Madersbacher S, Montorsi F, Speakman MJ, Stief CG. Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. Eur Urol. 2010;58(3):384–97.
Gilling PJ, Wilson LC, King CJ, Westenberg AM, Frampton CM, Fraundorfer MR. Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. BJU Int. 2012;109(3):408–11.
Elsaqa M, Risinger J, El Tayeb MM. Urethral Complications Post-Holmium Laser Enucleation of the Prostate: A Seven-Year Experience. J Endourol. 2022;36(12):1575–9.
Shah HN, Mahajan AP, Hegde SS, Bansal MB. Peri-operative complications of holmium laser enucleation of the prostate: experience in the first 280 patients, and a review of literature. BJU Int. 2007;100(1):94–101.
Wei Y, Ke ZB, Xu N, Xue XY. Complications of anatomical endoscopic enucleation of the prostate. Andrologia. 2020;52(8):e13557.

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Comparison of perioperative and functional outcomes of holmium laser enucleation of prostate with different power: A systematic review and meta-analysis

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Abstract

Figures

1 Introduction

2 Evidence acquisitions

3 Results

3.1.1 Operative Time (OT) (min)

3.1.2 Length of Stay (LOS) (day)

3.1.3 Catheterization (day)

3.1.4 Enucleation Efficacy (EE) (gm/min)

3.1.5 Blood Transfusion Rate

3.1.6 Postoperative Complications (Incontinence Rate)

3.1.7 IPSS

3.1.8 Qmax

3.1.9 QOL

3.1.10 PVR

4 Discussion

5 Conclusions

Abbreviations

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Acknowledgment

Authors' contributions

Funding

Data Availability Statement

Ethics approval and consent to participate

Consent for publication

Competing interests

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