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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
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safe and effective. A recent systematic review found that to TURP, PVP has better perioperative safety, shorter catheter-
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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
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cleation of the prostate. In comparison to OSP, the length lobes, and in patients who continue their AC/AP therapy,
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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
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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
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(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-
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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
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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).
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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
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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-
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retreatment rate in prostates with volumes of an average 80 g. ommendation, evidence level C).
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250 CUAJ • August 2022 • Volume 16, Issue 8