1. Hywel Dda University Health Board, UK
Meta-analysis of Holmium Laser Enucleation versus Transurethral Resection of Prostate for Patients with Benign Prostatic Obstruction
Omar Naser et al, 2015
Hywel Dda University Health Board, UK

2. Introduction Advantages
Holmium:YAG laser enucleation of the prostate (HoLEP) was originally described by Gilling et al, 1996.
Advantages
Hemostatic; may be used on anticoagulated patients.
Normal saline as irrigating fluid.
No prostatic size limit.
Gilling et al. Holmimum laser enucleation of the prostate. Preliminary results of a new method for BPH. Urology 1996;47-48.

3. Disadvantages Increased time for resection. Initial cost.
Some tissue lost as thermal artifact.
Steep learning curve.

4. Aim
This meta-analysis aims at comparing Holmium laser enucleation (HoLEP) versus transurethral resection of prostate (TURP) for patients with benign prostatic obstruction.

5. Method
PubMed was searched for RCTs comparing HoLEP versus TURP using relevant search terms.
Data extracted from eligible studies and were analyzed using RevMan 5.3 for windows.

6. Results
Nine RCTs (871 patients) were included in the final analysis. Follow up ranged from 6 to 92 months.

7. Gilling et al, 2011 61/14 Holep, 17 Turp 40 -200 ml. 7.6 yrs.
Study
Population
Prostate volume
Mean duration of follow up
Gilling et al, 2011
61/14 Holep, Turp
ml.
7.6 yrs.
Fayad et al, 2011 60
ml.
6 month.
Eltabey et al, 2010 80
30-92 ml
12 month.
Mavuduru et al,2009 30
36.33+/-11.4 ml
9 month.
Ahyai et al,2007
200
20-99 ml
36 month
Rigatti et al,2006
100 ml
12 month
Guupta et al,2005 ml
Kuntz et al, 2004
12 momth
Westenberg et al,2004
120
47-80 ml
48 month.

8. Perioperative outcomes
Hb loss. Blood transfusion. Holep superior to Turp.

9. Fig.1: 95% CI of SMD in Hb loss between the two groups

10. postoperative outcomes
Maximum flow rate.
Post-void residual volume.
Holep superior to Turp.

11. Fig.2: 95% CI of SMD in Qmax between the two groups

12. Fig.3: 95% CI of SMD in Post-void residual volume
22 RCC.
1 Oncocytoma.
1 Angiomyolipoma.
2 cases of partial nephrectomy for non functioning upper moiety.

13. Fig.4: 95% CI of SMD in IPSS score
22 RCC.
1 Oncocytoma.
1 Angiomyolipoma.
2 cases of partial nephrectomy for non functioning upper moiety.

14. Fig.5: 95% CI of SMD in AUA symptom score
22 RCC.
1 Oncocytoma.
1 Angiomyolipoma.
2 cases of partial nephrectomy for non functioning upper moiety.

15. Fig.6: 95% CI of SMD in QoL 22 RCC. 1 Oncocytoma. 1 Angiomyolipoma.
2 cases of partial nephrectomy for non functioning upper moiety.

16. Conclusion
HoLEP achieved better changes in Qmax and PVR than TURP. Hb loss and perioperative blood transfusion were less in HoLEP than TURP.

17. Which Modality
For Which Patient

18. TURP for “TURPable” prostates and HOLEP for larger prostates.

19. Refrences
[1] R. M. Kuntz, S. Ahyai, K. Lehrich, and A. Fayad, “Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients.,” J. Urol., vol. 172, no. 3, pp. 1012–6, Sep
[2] A. Westenberg, P. Gilling, K. Kennett, C. Frampton, and M. Fraundorfer, “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., vol. 172, no. 2, pp. 616–9, Aug
[3] L. Rigatti, R. Naspro, A. Salonia, A. Centemero, M. Ghezzi, G. Guazzoni, A. Briganti, P. Rigatti, and F. Montorsi, “Urodynamics after TURP and HoLEP in urodynamically obstructed patients: are there any differences at 1 year of follow-up?,” Urology, vol. 67, no. 6, pp. 1193–8, Jun
[4] A. Briganti, R. Naspro, A. Gallina, A. Salonia, I. Vavassori, R. Hurle, E. Scattoni, P. Rigatti, and F. Montorsi, “Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate: results of a prospective, 2-center, randomized trial.,” J. Urol., vol. 175, no. 5, pp. 1817–21, May 2006.
[5] N. Gupta, Sivaramakrishna, R. Kumar, P. N. Dogra, and A. Seth, “Comparison of standard transurethral resection, transurethral vapour resection and holmium laser enucleation of the prostate for managing benign prostatic hyperplasia of >40 g.,” BJU Int., vol. 97, no. 1, pp. 85–9, Jan
[6] S. a Ahyai, K. Lehrich, and R. M. Kuntz, “Holmium laser enucleation versus transurethral resection of the prostate: 3-year follow-up results of a randomized clinical trial.,” Eur. Urol., vol. 52, no. 5, pp. 1456–63, Nov
[7] R. M. Mavuduru, a K. Mandal, S. K. Singh, N. Acharya, M. Agarwal, S. Garg, and S. Kumar, “Comparison of HoLEP and TURP in terms of efficacy in the early postoperative period and perioperative morbidity.,” Urol. Int., vol. 82, no. 2, pp. 130–5, Jan
[8] M. A. Eltabey, H. Sherif, and A. A. Hussein, “Holmium laser enucleation versus transurethral resection of the prostate,” vol. 17, no. December, pp. 5447–5452, 2010.
[9] A. S. Fayad, M. G. El Sheikh, T. Zakaria, H. a Elfottoh, and R. Alsergany, “Holmium laser enucleation versus bipolar resection of the prostate: a prospective randomized study. Which to choose?,” J. Endourol., vol. 25, no. 8, pp. 1347–52, Aug
[10] P. J. Gilling, L. C. Wilson, C. J. King, A. M. Westenberg, C. M. Frampton, and M. R. Fraundorfer, “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., vol. 109, no. 3, pp. 408–11, Feb

20. [ 3]. L. Rigatti, R. Naspro, A. Salonia, A. Centemero, M. Ghezzi, G
[ 3] L. Rigatti, R. Naspro, A. Salonia, A. Centemero, M. Ghezzi, G. Guazzoni, A. Briganti, P. Rigatti, and F. Montorsi, “Urodynamics after TURP and HoLEP in urodynamically obstructed patients: are there any differences at 1 year of follow-up?,” Urology, vol. 67, no. 6, pp. 1193–8, Jun
[4] A. Briganti, R. Naspro, A. Gallina, A. Salonia, I. Vavassori, R. Hurle, E. Scattoni, P. Rigatti, and F. Montorsi, “Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate: results of a prospective, 2-center, randomized trial.,” J. Urol., vol. 175, no. 5, pp. 1817–21, May 2006.

21. [5]. N. Gupta, Sivaramakrishna, R. Kumar, P. N. Dogra, and A
[5] N. Gupta, Sivaramakrishna, R. Kumar, P. N. Dogra, and A. Seth, “Comparison of standard transurethral resection, transurethral vapour resection and holmium laser enucleation of the prostate for managing benign prostatic hyperplasia of >40 g.,” BJU Int., vol. 97, no. 1, pp. 85–9, Jan
[6] S. a Ahyai, K. Lehrich, and R. M. Kuntz, “Holmium laser enucleation versus transurethral resection of the prostate: 3-year follow-up results of a randomized clinical trial.,” Eur. Urol., vol. 52, no. 5, pp. 1456–63, Nov
[7] R. M. Mavuduru, a K. Mandal, S. K. Singh, N. Acharya, M. Agarwal, S. Garg, and S. Kumar, “Comparison of HoLEP and TURP in terms of efficacy in the early postoperative period and perioperative morbidity.,” Urol. Int., vol. 82, no. 2, pp. 130–5, Jan

22. [8]. M. A. Eltabey, H. Sherif, and A. A
[8] M. A. Eltabey, H. Sherif, and A. A. Hussein, “Holmium laser enucleation versus transurethral resection of the prostate,” vol. 17, no. December , pp. 5447–5452, 2010.
[9] A. S. Fayad, M. G. El Sheikh, T. Zakaria, H. a Elfottoh, and R. Alsergany, “Holmium laser enucleation versus bipolar resection of the prostate: a prospective randomized study. Which to choose?,” J. Endourol., vol. 25, no. 8, pp. 1347–52, Aug
[10] P. J. Gilling, L. C. Wilson, C. J. King, A. M. Westenberg, C. M. Frampton, and M. R. Fraundorfer, “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., vol. 109, no. 3, pp. 408–11, Feb

23. Thank you