Towards optimizing prostate tissue retrieval following holmium laser enucleation of the prostate (HoLEP): assessment of two morcellators and review of literature.
With advancements in the treatment of benign prostatic hyperplasia (BPH), patients are now older and have larger prostates at surgery. In these patients, transurethral enucleation is superior to other techniques. (1)
Different kinds of energy have been used in the enucleation procedure, including holmium YAG, (2) thulium, (3) Greenlight laser (532 nm), (4) and plasma kinetic energy, (5) ending by completely or partially detaching the intravesical adenoma. However, the techniques of prostate tissue retrieval, particularly intravesical morcellation of prostatic adenoma, are poorly evaluated.
The transurethral morcellation of intravesical prostate adenoma is a tedious procedure. Many difficulties could be encountered, such as impaired visibility with minor bleeding, variable consistency of the adenoma, and malfunction of reusable blades, especially with large prostates. Furthermore, the morcellation process might come after lengthy enucleation procedure that might oblige the surgeon to postpone it to another session (secondary morcellation). (6)
Transurethral enucleation of the prostate adenoma using holmium laser (HoLEP) has been extensively studied over the past 15 years. However, safety and efficacy of different approaches used to retrieve the enucleated adenoma have not been studied. Since the invention of the mechanical tissue morcellator in 1996, (7) tissue morcellators for different endoscopic surgical procedures have significantly evolved, including those used for transurethral morcellation of intravesical prostate adenoma. There are two popular tissue morcellators. The main differences between them are the type of movement of the cutting blades (guillotine vs. oscillation) and shape of the blade (non-toothed vs. toothed) in the VersaCut (Lumenis Inc.) and Piranha (Wolf Inc., Knittlingen, Germany) morcellators, respectively. Alternatives to tissue morcellators are the mushroom technique (8) and mini-laparotomy suprapubic extraction of the enucleated adenoma. (9)
In this study, we used the Versacut and Piranha morcellators for prostate tissue retrieval during HoLEP. We also reviewed the relevant literature.
After obtaining institutional review board approval, we reviewed the data of 122 consecutive HoLEP procedures to assess tissue retrieval between November 2013 and October 2014. A single surgeon (AME), with experience in the HoLEP procedure with at least 30 procedures of morcellation using either morcellator, performed the procedures. This comparative study was initiated based on local administrative request to purchase another morcellator.
Patients were admitted for BPH surgery when they had refractory lower urinary tract symptoms and failed medical treatment or if they had an indwelling catheter due to urine retention and failed trial of voiding without a catheter. Patients with a history of previous prostate surgery or with diagnosed prostate cancer were not included in the analysis.
A 100W Holmium: YAG laser (Versapulse, Lumenis Inc., Santa Clara, CA) and a 550-um end-firing flexible fibre (SlimLineTM 550, Lumenis Inc.) were used. Continuous flow 26Fr resectoscope (Karl Storz, Tuebingen, Germany) was used for all procedures; a connecting piece was used to adapt a rigid indirect long nephroscope (Karl Storz) with a 5-mm working channel through which the morcellator blade passed. Double irrigation sets were used connected to both inflow and outflow channels of the scope. The enucleation phase of HoLEP was performed as previously described. (2) Retrieval of the prostate adenoma was performed by trans-urethral morcellation using either Piranha morcellator (Fig. 1, parts A and C) or the VersaCut (Fig. 1, parts B and D). The morcellator blade was introduced just inside the bladder neck with the blades facing up; the initial suction brings the adenoma over the tip of the blades after which the cutting starts. The blades and the adenoma are kept away from the bladder mucosa to avoid any laceration.
Between November 2013 and March 2014, we consecutively performed 55 procedures with the VersaCut morcellator, during which 3 new reusable blades were consumed. Between April 2014 and October 2014, we consecutively performed 67 procedures with the Piranha morcellator, during which 3 new reusable blades were consumed. We tallied every case and marked every single blade. Moreover, all peri-procedural parameters were recorded and the surgeon determined whether any blades were non-usable.
All morcellation auxiliary procedures were recorded. Auxiliary procedures included the use of a crown loop (toothed cold loop, Fig. 1, parts E and F) to extract non-morcellated pieces or the use of a laser to score hardly bitten adenomas by the blade. Postoperatively, a 22Fr tri-way urethral catheter was fixed. Most patients were discharged the next day.
Primary outcome measures
Operative efficacy parameters were reported and compared. Efficacy parameters included the time and rate of tissue retrieval procedure, weight of the tissue retrieved and overall operative time. Time of tissue retrieval was defined as the time from introduction of the morcellator blade to the bladder until extraction of the last piece of the prostatic adenoma. The rate of retrieval was calculated by dividing the weight of the prostate specimen by the time needed for retrieval.
Secondary outcome measures
Perioperative complications (safety) were reported and compared. Morcellation-related complications, namely bladder injury and peri-procedural bleeding, were compared. Hospital stay and catheter time were recorded and compared.
Data analysis was conducted using the commercially available Statistical Package for Social Sciences (SPSS 20 for Mac, SAS Institute, Cary, NC). Results were compared between study groups using the Chi-square and Fisher's exact tests for categorical variables and the independent samples t-test and Mann-Whitney U-test for quantitative variables as appropriate. Using post-hoc analysis for the studied sample, considering type 1 statistical error less than 0.05, effect size of 0.6 for the tissue retrieval rate and two-tailed significance, we achieved a computed power of 90%.
Review of literature
We searched PubMed-MEDLINE for English-based literature using medical subject headings including benign prostatic hyperplasia (BPH), enlargement (BPE), and obstruction (BPO); minimal invasive surgery; and the specific MIST and TURP name looking for all transurethral prostate enucleation techniques. Reference lists of all depicted articles were reviewed for relevant reports. Different articles based on the same patient cohort with different follow-up duration and/or outcome measures were considered a single study, and all relevant data regarding methods of prostate tissue retrieval were extracted.
Following Holmium laser-assisted enucleation of the prostate adenoma, the Piranha morcellator was used in 67 procedures and the VersaCut morcellator in 55 procedures. The preoperative prostate size was similar in both morcellators (median [range] transurethral resection of the prostate estimated prostate size was 130 [ranage: 59-295] and 114 [range: 46-345] mL with Piranha and VersaCut morcellators, respectively, p = 0.1). Histopathologic findings of the retrieved prostate tissues were not different between the two morcellators. Significantly more prostate tissue retrieval time and need of morcellation auxiliary procedures were reported with the VersaCut morcellator (Table 1).
The median tissue retrieval rate was 6.2 (range: 2.8-12) and 2.13 (0.46-7) g/min with the Piranha and VersaCut morcellators, respectively (p = 0.001). Similar retrieved tissue weight and catheter time were reported in both morcellators (Table 1).
The median number of procedures done per blade was 22 (range: 20-25) and 18 (17-20) with the Piranha and VersaCut morcellators, respectively (p = 0.01). The median number of grams of prostate tissue retrieved per blade was 1499 (range: 1388-1539) and 943 (833-1248) with the Piranha and VersaCut morcellators, respectively (p = 0.04).
There was no significant difference between the two morcellators regarding perioperative biochemical changes and complications, apart from 5 bladder mucosal injuries in the VersaCut group (9%) (Table 2).
Table 3 summarizes the tissue retrieval approaches used in contemporary series of different transurethral enucleation procedures. Data on preoperative prostate size, retrieved prostate weight, rate of tissue retrieval and possible complications related to the procedure of retrieval namely bleeding and bladder injury were tallied. Furthermore, findings of incidental prostate cancer and history of prior prostate surgery were depicted for possible impact on prostate tissue consistency. (3-6,8,10-27)
The transurethral enucleation of prostate adenoma carries the advantage of doing an anatomical based de-obstruction, which further to being complete is safer by tackling the vascular supply once it goes to the adenoma. Many competing techniques using different energy sources (electric and different lasers) to accomplish the enucleation procedure have been reported. (2-5) However, retrieval of the adenoma after transurethral enucleation remains poorly evaluated. Transurethral resection of partially detached adenoma is not advantageous as it can induce more risk of bleeding, impaired visibility and is time consuming, especially for large prostates where the transurethral enucleation is superior to other minimally invasive surgeries.
Morcellation of intravesical adenoma is currently the standard procedure following most transurethral enucleation procedures; however it is poorly evaluated. It is not complication-free and might require the surgeon to stage the procedure (secondary morcellation due to bleeding or blade malfunction). (6)
In our current study, we presented the current viable approaches used to retrieve the enucleated prostate adenoma following holmium laser enucleation. We compared safety and efficacy of two commercially available morcellators that have not been previously clinically compared. A single surgeon, with HoLEP experience with at least 30 morcellations using either morcellator, performed the procedures. A minimum of 20 cases are required to achieve morcellation efficiency. (28)
In an ex-vivo study, the efficiency of different morcellators were assessed. The Piranha morcellated 20 (range: 19.3-21.4) g/min, the VersaCut 10.8 (range: 8.2-13.1) g/min, Karl Storz prototype 9.8 (range: 7.9-10.76) g/min, and another Wolf prototype 38.6 (35.3-42.9) g/min. (29) Another ex-vivo study looking at different efficiency parameters of the Piranha and VersaCut morcellators revealed similar suction power parameters (20.4 and 22.2 mL/s, respectively). Morcellating powers were (example with baked chicken meat) 2.5 and 6 g/min with Piranha and VersaCut, respectively. (30)
In the current study, the median rate of tissue retrieval was 6.2 (range: 2.8-12) and 2.13 (range: 0.46-7) g/min with Piranha and VersaCut morcellators, respectively. The literature demonstrated tissue retrieval rates of 2.6 to 6.5 and 1.9 to 11 g/min with Piranha and VersaCut morcellators, respectively (Table 3); however, there is little data on the details of morcellation in clinical reports of transurethral enucleation procedures. The safety of morcellator is a crucial part of the assessment in our current study; superficial bladder mucosal injury was reported in 9% of procedures with the VersaCut morcellator. Superficial bladder mucosal injury was reported in 1.4% and 0.7 to 5.7% with Piranha and VersaCut morcellators, respectively; there were bladder perforations with the VersaCut morcellator (range: 0.1-1.5%) (Table 3). In their ex-vivo study, Cornu and colleagues showed that the blade of the Pirhana morcellator was under visual control, whereas the distal part of the cutting blade was out of vision control with the VersaCut. (30)
The efficiency of tissue retrieval by a morcellator is a sum of multiple variables, including prostate tissue consistency, suction power, and morcellator blade. Prior prostate surgery and histopathological features of the adenoma probably affect prostate tissue consistency.
Other non-morcellation approaches have been used in many of the reported transurethral enucleation techniques, as a routine practice (like using mushroom technique after most bipolar enucleation techniques (5,23,26) and, to a lesser extent, after HoLEP (8,16,17)) or occasional in cases of morcellator malfunction or for exceptionally huge adenomas where some surgeons perform an open cystostomy for adenoma extraction. (10)
The morcellator action is to cut and suck. Most of mechanical problems reported in this study were related to suction. In the Piranha morcellator, suction depends on creating negative pressure within a vacuum bottle. Problems occurred secondary to leak of negative pressure from the vacuum bottle/ tubing set. This requires the surgeon to stop to recreate the required negative pressure. In the VersaCut morcellator, suction depends on a high-suction roller pump; obstruction of the tubing set with large tissue piece causes malfunction of the pump and significantly reduces suction power. This also requires the surgeon to stop and reverse direction of flow for a while to clean the tubing set.
Lastly, regarding the technique of transurethral morcellation, we used the conventional upward technique. A modification of the technique to increase morcellation efficiency and to lessen the incidence of bladder injury is called "the inverse technique." (27) It entails sucking the adenoma toward the blades then inversely rotating the nephroscope and the blades, with the blade openings pointing inferior toward the bladder and superior to the prostate tissue. Lee and colleagues reported a higher rate of tissue retrieval with their technique using the VersaCut morcellator. (27) Superficial (7.1% and 0.9%) and deep bladder injuries in (5.9% and 0.3%) were reported in conventional and inverse techniques, respectively (Table 3).
Our study has its limitations. In terms of evidence, this study lacks randomization. However, we found that randomization was not practical for an in depth evaluation of all aspects of morcellation, including reusable blade efficiency (e.g., surgeons prefer using new or minimally used blades when tackling significantly large glands). So, we assigned 3 blades for each morcellator group for the study, with careful reporting of all peri-procedure parameters.
Morcellation with the Piranha morcellator was the most efficient and safe way to retrieve tissue following transurethral enucleation of prostate adenoma during BPH treatment. Detailed reporting of the morcellation step is recommended in any report of a transurethral enucleation technique.
Published online September 9, 2015.
Competing interests: The authors declare no competing financial or personal interests.
This paper has been peer-reviewed.
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Correspondence: Dr. Ahmed M. Elshal, Urology and Nephrology Center, Mansoura University, Mansoura, Dakahlia Governorate, Egypt; firstname.lastname@example.org
Caption: Fig. 1a. Blade of pirnha morcellator.
Caption: Fig. 1b. Blade of versacut morcellator.
Caption: Fig. 1c. Blade of pirnha morcellator in action.
Caption: Fig. 1d. Blade of versacut morcellator in action.
Caption: Fig. 1e. Crown loop.
Caption: Fig. 1f. Crown loop in the bladder to extract non morcellated adenomas.
Ahmed M. Elshal, MD; Ramy Mekkawy, MD; Mahmoud Laymon, MD; Ahmed El-Assmy, MD; Ahmed R. El-Nahas, MD
Urology and Nephrology Center, Mansoura University, Mansoura, Dakahlia Governorate, Egypt
Table 1. Efficacy assessment Piranha VersaCut p value ([yen]) ([dagger]) No. procedures 67 55 Median, range tissue 20 (5:30) 25 (5:70) 0.04 retrieval time (min) Histopathology; median, 67 (23:230) 62 (14:189) 0.07 range of weight of specimen (g) BPH (%) 65 (97) 50 (92) 0.34 BPH with prostatitis (%) -- 2 (3.6) BPH with focal prostate 2 (3) 3 (5.4) cancer (%) Median, range of tissue 6.2 (2.8:12) 2.13 (0.46:7) 0.00 retrieval rate (g/min) [specimen weight/retrieval time] Use of crown loop* 4 (5.9) 17 (30.9) 0.00 for extraction of non- morcellated parts (%) Laser scoring of the -- 7 0.00 adenoma to ease bite by the blade (%) Intraoperative morcellator 7 (10.4) 2 (3.6) 0.2 mechanical problems (%) Median, range of 1 (1:5) 1 (1:3) 0.3 catheterization time (days) Median, range of Hospital 1 (1:3) 1 (1:4) 0.08 stay (days) * Crown loop; toothed cold loop. BPH: benign prostatic hyperplasia; NA: not applicable. ([yen]) Piranha, Wolf Inc., Knittlingen, Germany; ([dagger]) VersaCut, Lumenis. Table 2. Peri-procedure safety profile Piranha VersaCut p value ([yen]) ([dagger]) No. procedures 67 55 Bleeding necessitating post 1(1.4) 5(9) 0.06 retrieval hemostasis (%) Median, range of 1.2 1.5 (0.1:3.7) 0.2 Hemoglobin deficit * (g/dL) (0.1:4.8) Median, range of Hematocrit 4.3 4.3 0.8 value deficit * (%) (-1.6:14.7) (-7.9:20.2) Median, range of Blood 1.5 (1:2.1) 3 (-8.7:11.6) 0.7 sodium deficit * (mmol/L) Bladder injury (%) Bladder mucosal injury -- 5 (9) 0.01 Bladder perforation -- -- Postoperative hematuria (%) 4 (2.9) 2 (3.6) 0.19 * Preoperative minus immediate postoperative value. ([yen]) Piranha, Wolf Inc., Knittlingen, Germany; ([dagger]) VersaCut, Lumenis. Table 3. Critical evaluation of prostate tissue retrieval approaches following different transurethral enucleation techniques in the contemporary series Study (RCT/CS) Procedure Prostate size (mean [+ or -] SD [range] mL) Hochreiter et al HoLEP 38 [20-70] 2002 (8) (CS) Elshal et al (10) G1 (HoLEP) G1; 94.3 2012 (CS) G2 (2ry HoLEP) G2; 79.3 Jaeger et al (11) G1 (2ry HoLEP) G1; 93 [+ or -] 47 2013 (CS) G2 (HoLEP) G2; 96 [+ or -] 46 Wisenbaugh et HoLEP B; 88.1 al 2013 (13) (CS) B and T T; 100.4 Placer et al HoLEP 75.8 [+ or -] 29.7 2009 (14) (CS) Krambeck et al HoLEP NR 201012 (CS) Abdel-Hakim et HoLEP 86.5 [+ or -] 65.4 al 2010 (15) (CS) [20-350] Kuntz et al 2002 HoLEP 114.6[+ or -] 21 (16)(RCT) [100-230] Kuntz et al 2004 HoLEP 53.5 [+ or -] 20 (17)(RCT) [20-95] Vavassori et al HoLEP 62 [+ or -]34 2008 (18) (CS) Lee et al 2012 HoLEP "up [U] 8t U; 54 [+ or -]22 (27)(CS) Inverse tech [I]" I; 53.6[+ or -]20 Zhang et al HoLEP 43.5 [+ or -] 23 2012 (19) (RCT) [37.3-76.4] Zhang et al ThulEP 46.6 [+ or -] 25.2 2012 (19) (RCT) [34.2-79.6] Rausch et al ThulEP 84.8 [+ or -] 34.9 2015 (3) (RCT) Gross et al 2013 ThulEP 51 (36-78) (6)(CS) Hruby et al ELEP 59.9 [+ or -] 15.4 2013 (20) (CS) [34-89] Brunken et al Greenlight 75 [+ or -]38 2011(4)(CS) LEP Liao et al 2012 PKEP 77.3 (26)(CS) [56-95] Luo et al 2014 PKEP 61.8 [+ or -] 18.7 (22)(CS) Zhao et al 2010 PKEP 69.2 [+ or -] 13.5 (24)(RCT) [35-158] Geavlete et al PKEP 132.6 [80-280] 2013(5)(RCT) Zhu et al 2013 PKEP 113.8 [+ or -] 32 (25)(RCT) Chen et al 2014 PKEP 110 [102-130] (21)(RCT) Rao et al 2013 PKEP 116.2 [+ or -] 32 (23)(RCT) Study (RCT/CS) Tissue Retrieved retrieval tissue weight approach (mean + SD [range] g) Hochreiter et al Unipolar NR 2002 (8) (CS) Mushroom Elshal et al (10) VersaCut G1: 64.5 2012 (CS) morcellator G2: 52.6 OC 0.3% Jaeger et al (11) VersaCut G1: 61.7 [+ or -] 40 2013 (CS) morcellator G2: 63.9 [+ or -] 42 Wisenbaugh et VersaCut B: 50 [+ or -] 49.5 al 2013 (13) (CS) morcellator T: 56 [+ or -] 41.8 Placer et al VersaCut 46.7 [+ or -] 27 2009 (14) (CS) morcellator [7-152] Krambeck et al VersaCut 76 [0.4- 201012 (CS) morcellator 532.2] OC 0.2% Abdel-Hakim et VersaCut 78.6 [+ or -] 61.3 al 2010 (15) (CS) morcellator [10-350] OC 0.1% Kuntz et al 2002 Unipolar 83.9 [+ or -] 21.9 (16)(RCT) Mushroom 83% [52-200] VersaCut morcellator 17% Kuntz et al 2004 Unipolar 32.6 [+ or -] 15.0 (17)(RCT) Mushroom [10-80] Vavassori et al VersaCut 40 [+ or -] 27.5 2008 (18) (CS) morcellator Lee et al 2012 VersaCut NR (27)(CS) morcellator Zhang et al Unipolar 40.4 [+ or -] 10.6 2012 (19) (RCT) Mushroom Zhang et al Unipolar 37.6 [+ or -] 12.1 2012 (19) (RCT) Mushroom Rausch et al Piranha 53.68 [+ or -] 29.9 2015 (3) (RCT) morcellator [5-147] Gross et al 2013 Piranha 30 (16-51.25) (6)(CS) morcellator Hruby et al Piranha 32.20 [+ or -] 9.36 2013 (20) (CS) morcellator Brunken et al Morcellator 35 [+ or -] 22 2011(4)(CS) (NR) Liao et al 2012 Bipolar 51 [+ or -] 14.3 (26)(CS) Mushroom Luo et al 2014 Bipolar 46.2 [+ or -] 19.1 (22)(CS) Mushroom Zhao et al 2010 Bipolar 56.4 [+ or -] 1 2.8 (24)(RCT) Mushroom [32-102] Geavlete et al Piranha 108 [58-241] 2013(5)(RCT) morcellator Zhu et al 2013 Bipolar 64.2 [+ or -] 19.0 (25)(RCT) Mushroom Chen et al 2014 Bipolar 118.2 [+ or -]22.0 (21)(RCT) Mushroom Rao et al 2013 Bipolar 65.9 [+ or -] 20.8 (23)(RCT) Mushroom Study (RCT/CS) Retrieval Retrieval time rate (mean (mean + SD [+ or -] SD [range] min) [range] g/min) Hochreiter et al NR NR 2002 (8) (CS) Elshal et al (10) G1: 16.9 G1: 3.81 2012 (CS) G2: 16.6 G2: 3.16 Jaeger et al (11) G1: 19.8 [+ or -] 20 G1: 4 [+ or -] 2 2013 (CS) G2: 14.9 [+ or -] 11 G2: 5 [+ or -] 2.5 Wisenbaugh et B: 4.8 + 2 B: 10.4 + 24 al 2013 (13) (CS) T: 5 [+ or -] 3.6 T: 11.2 [+ or -] 11 Placer et al 17.6 [+ or -] 9.7 2.8[+ or -] 1 [0.9- 2009 (14) (CS) [5-65] 10.1] Krambeck et al NR NR 201012 (CS) Abdel-Hakim et 19.3 [+ or -] 10.1 4.07 [+ or -] 3.2 al 2010 (15) (CS) [4-45] Kuntz et al 2002 NR NR (16)(RCT) Kuntz et al 2004 NR NR (17)(RCT) Vavassori et al 17.3 [+ or -] 14.5 2.3 [+ or -] 1.5 2008 (18) (CS) Lee et al 2012 U: 14.3 [+ or -] 8.6 U: 1.93 [+ or -] 1.1 (27)(CS) I: 6.4 [+ or -] 7.2 I: 4.03 [+ or -] 0.89 Zhang et al NR NR 2012 (19) (RCT) Zhang et al NR NR 2012 (19) (RCT) Rausch et al NR NR 2015 (3) (RCT) Gross et al 2013 11 (8-20) 2.6 (1.7-4) (6)(CS) Hruby et al 20.31 [+ or -] 6.62 NR 2013 (20) (CS) Brunken et al NR NR 2011(4)(CS) Liao et al 2012 NR NR (26)(CS) Luo et al 2014 NR NR (22)(CS) Zhao et al 2010 NR NR (24)(RCT) Geavlete et al 16.5 6.56 2013(5)(RCT) Zhu et al 2013 NR NR (25)(RCT) Chen et al 2014 NR NR (21)(RCT) Rao et al 2013 NR NR (23)(RCT) Study (RCT/CS) Retrieval approach related Complication T1a-b PCa Bleeding Bladder injury (%) Hochreiter et al NR NR 3.2% 2002 (8) (CS) Elshal et al (10) G1: 0.2% 0.7% (Mucosal) NR 2012 (CS) G2: 1.3 Jaeger et al (11) G1: 2.7% NR NR 2013 (CS) Wisenbaugh et 1.3% 0.3% (Perforation) NR al 2013 (13) (CS) Placer et al 0.8% 4% (Mucosal) 4.8% 2009 (14) (CS) Krambeck et al 0.6% 0.1% (Perforation) 10% 201012 (CS) Abdel-Hakim et 4.4% NR 1.7% al 2010 (15) (CS) Kuntz et al 2002 5% NR 5% (16)(RCT) Kuntz et al 2004 NR NR 3% (17)(RCT) Vavassori et al 2.4% 5.7% (Mucosal) 3.6% 2008 (18) (CS) Lee et al 2012 NR 2.3% (Mucosal) NR (27)(CS) 1.5% (Perforation) Zhang et al NR NR NR 2012 (19) (RCT) Zhang et al NR NR NR 2012 (19) (RCT) Rausch et al 6.9% NR 14.1% 2015 (3) (RCT) Gross et al 2013 1.5% 1.4% 5.5% (6)(CS) (Mucosal) Hruby et al NR NR Zero 2013 (20) (CS) Brunken et al NR NR 2011(4)(CS) Liao et al 2012 NR Zero (26)(CS) Luo et al 2014 NR NR (22)(CS) Zhao et al 2010 NR NR (24)(RCT) Geavlete et al 2.9% NR 2.8% 2013(5)(RCT) Zhu et al 2013 NR NR (25)(RCT) Chen et al 2014 NR 1.25% (21)(RCT) Rao et al 2013 NR NR (23)(RCT) RCT; randomized clinical trials, CS; case series, HoLEP; Holmium laser enucleation of the prostate, 2ndry HoLEP; after previous prostate surgery, ThulEP; Thulium laser enucleation of the prostate, Greenlight LEP; Greenlight laser enucleation of the prostate, ELEP; Eraser laser enucleation of the prostate, PKEP; Plasma kinetic enucleation of the prostate, NS; not specified, NR; not reported, NA; not applicable, PCa; prostate cancer, OC; open cystostomy; B: bilop; T: trilob; Piranha, Wolf Inc., Knittlingen, Germany; tVersaCut, Lumenis.
Please note: Illustration(s) are not available due to copyright restrictions.
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|Title Annotation:||ORIGINAL RESEARCH|
|Author:||Elshal, Ahmed M.; Mekkawy, Ramy; Laymon, Mahmoud; Assmy, Ahmed El-; Nahas, Ahmed R. El-|
|Publication:||Canadian Urological Association Journal (CUAJ)|
|Date:||Sep 1, 2015|
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