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Elterman et al

       performed due to concomitant pathology, such as large blad-  In the GOLIATH international, multicenter, randomized
       der stones or bladder diverticulum. There are no random-  controlled trial comparing the 180W XPS PVP to TURP for
       ized controlled trials comparing LSP and RASP to OSP or to   prostate volumes 30–80cc, there was a statistically significant
       any other enucleation procedure. The largest retrospective   difference in early adverse events, notably bleeding-related
       series includes both techniques and has shown both to be   one, within the first 30 days favoring XPS PVP. 68,75   Compared
       safe and effective.  A recent systematic review found that   to TURP, PVP has better perioperative safety, shorter catheter-
       RASP showed similar improvements in IPSS, PVR, Qmax,   ization time, and shorter hospitalization.  Multiple studies
       and quality of life, while having similar complication rates   have demonstrated that PVP is safe and effective for elderly
       and estimated blood loss (EBL) to laser vaporization and enu-  men, with significant medical comorbidities,  large median
       cleation of the prostate.  In comparison to OSP, the length   lobes,  and in patients who continue their AC/AP therapy,
       of stay (LOS) and EBL are significantly lower for RASP. 61   with negligible transfusion rates. 79-81  Further to GreenLight
       Finally, catheterization time and LOS are longer with RASP   safety profile, PVP has been shown to be a cost-effective
       compared to laser enucleation of the prostate.        alternative to TURP in the Canadian setting.  There exists no
                                                             size or shape limitation to PVP; only surgeon expertise and
       We	recommend	LSP	or	RASP	as	alternative	surgical	ther-  clinical judgement dictate size limitations.
       apies	for	men	with	moderate-to-severe	LUTS/BPS	and
       enlarged	prostate	volume	>80	cc	in	centers	where	there	  We	recommend	PVP	as	an	alternative	to	M-TURP	or	B-TURP
       are	surgeons	with	high-level	expertise	in	robotics	or	lapa-  in	men	with	moderate-to-severe	LUTS (strong recommen-
       roscopy (conditional recommendation, evidence level B).  dation based on high-quality evidence). We	also	suggest
                                                             GreenLight	PVP	therapy	as	an	alternate	surgical	approach
       2.4.4. AEEP                                           in	men	on	anticoagulation	or	with	a	high	cardiovascular
       AEEP adopts the principle of open prostatectomy (OP) using   risk (conditional recommendation, evidence level B).
       different energy sources and instruments. The holmium laser
       (HoLEP) with or without Moses technology, GreenLight laser   2.4.6. Transurethral incision of the prostate
       (GreenLEP), monopolar enucleation (MonolEP), bipolar   Transurethral incision of the prostate (TUIP) is an appro-
       enucleation (BipolEP), diode laser (DiLEP), thulium laser   priate therapy for men with a small prostate size <30 cc
       (ThuLEP), and thulium fiber laser (ThuFLEP) are among the   without a middle lobe.  Symptoms and voiding parameters
       available energy sources. The efficacy and safety of AEEP,   are improved and the risk of retrograde ejaculation and TUR
       regardless of the energy source used, have been widely   syndrome is reduced (18.2% and 0%, respectively) com-
       demonstrated.                                         pared to TURP; however, the risk of surgical retreatment
         When compared to TURP and OSP, AEEP was associated   for LUTS related to BPH are significantly higher for TUIP
       with greater improvements in IPSS, Qmax, and PVR. AEEP   (18.4%) than after TURP (7.2%).
       resulted in greater prostate tissue removal, reduced hemo-
       globin loss, shorter catheterization time, and shorter LOS.    We	recommend	TUIP	to	treat	moderate-to-severe	LUTS	in
         Recent evidence supports the use of AEEP in patients with   men	with	prostate	volume	<30	cc	without	a	middle	lobe.
       BPH on anticoagulant (AC) or antiplatelet (AP) therapy. 64-66    Patients	should	be	made	aware	of	the	high	retreatment	rate
       AEEP has demonstrated durable results, with a low reoper-  (strong recommendation, evidence level B).
       ation rate of 0–3.7% (attributed to adenoma regrowth) on
       long-term followup of up to 18 years. 67-71  The procedure   2.4.7. Minimally invasive techniques
       requires a steep learning curve (estimated >20–50 cases).
                                                             Transurethral microwave therapy
       We	recommend	AEEP	as	an	alternative	to	TURP	or	OSP	in	  Transurethral microwave therapy (TUMT) is an option for
       men	with	moderate-to-severe	LUTS	and	any	size	prostate	  elderly patients with significant comorbidities or greater
       >30	cc	if	performed	by	an	AEEP-trained	surgeon.	AEEP	can	  anesthesia risks, as this procedure can be performed under
       be	safely	performed	in	patients	on	AC/AP	therapy (strong   local ansthesia. 84,85  Although short-term success for LUTS
       recommendation, evidence level A).                    improvement has been reported, the long-term durability of
                                                             TUMT is limited, with five-year cumulative retreatment rates
       2.4.5. PVP                                            from 42–59%. TUMT should not be performed in patients
       GreenLight-PVP (180W XPS and 120W HPS systems) provides   with a significant median lobe.
       comparable outcomes to TURP in terms of durable improve-
       ments in IPSS and Qmax, with similar overall complication   We	suggest	TUMT	therapy	as	a	consideration	for	treatment
       rate.  Five-year mid-term durability of XPS reported a 1.1%   of	carefully	selected,	well-informed	men (conditional rec-
       retreatment rate in prostates with volumes of an average 80 g.    ommendation, evidence level C).

       250                                       CUAJ • August 2022 • Volume 16, Issue 8
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