BPH treatment: laser for everyone | Opinion: NO

Benign prostate enlargement (BPE) is a highly prevalent pathology (1). The main consequence of BPE is Bladder Outlet Obstruction (BOO). Patients with BOO may be bothered by voiding lower urinary tract symptoms (LUTS). Those men with BOO and significant LUTS which did not respond to clinical approaches may be candidate to surgical procedures. In patients with prostate volume inferior to 80-100 grams, monopolar transurethral resection of prostate (TURP) has been considered the gold standard for decades. The American Urological Association (AUA) considered TURP as standard treatment for BPH (2) and The European Urological Association considered TURP “the treatment of choice” for prostates sized 30 to 80 cm3 (3). In the past years, a wide range of innovative transurethral procedures have challenged the supremacy of this standard surgical option (4). These alternative transurethral procedures embrace all laser therapies, encompassing the various types of lasers and modalities of prostatic tissue ablation (enucleation, vaporization, and resection) and bipolar devices permitting bipolar TURP (5-7). Many of the “innovative” techniques at their time, such as trans-rectal high intensity focused ultrasound, visual laser ablation and transurethral needle ablation, claimed good results and did not survive to test of the time (8, 9). TURP has been shown to be cost-effective, efficient, durable and with well-defined long-term complications and re-treatment rates (10). A large prospective multicenter study, including 10,654 men, who underwent TURP described a mortality rate of 0.10% and the cumulative short-term morbidity rate of 11.1% (11). Complications of TURP include failure to void (4.5% to 5.8%), surgical revision (1.1% to 5.6%), urinary tract infection (3.6% to 4.2%), bleeding which requires transfusions (2.0% to 2.9%) and TUR syndrome (0.8% to 1.4%) (11, 12). By using bipolar TURP, TUR syndrome has been overpassed. The bipolar TURP is performed with saline solution, which has improved safety, allow longer resection time and can reduce TUR syndrome, catheter time and length of hospital stay (13). Furthermore, in skilled hands bipolar TURP can be performed in prostate glands bigger than 80-100 grams. Many endoscopic technologies have been proposed to replace TURP as the new standard reference. There has been a rise in the use of minimally invasive surgical therapy (14). Emerging laser treatments that deserve consideration in this debate are Holmium laser enucleation of the prostate (HoLEP) and photoselective laser vaporization of the prostate (PVP). There are some trials comparing HoLEP and TURP (15-18). With mean follow-up range of 1 to 3 years, HoLEP demonstrated similar functional results to TURP when considering International Prostate Symptom Score [IPSS], quality of life score [QOL], and DIffERENCE Of OPINION Vol. 44 (1): 215-218, March Abril, 2018