Holmium laser enucleation of the prostate (HoLEP) is safe and effective in patients with high comorbidity burden

Maida, Fabrizio Di; Grosso, Antonio Andrea; Tellini, Riccardo; Nardoni, Samuele; Giudici, Sofia; Cadenar, Anna; Salamone, Vincenzo; Lambertini, Luca; Salvi, Matteo; Minervini, Andrea; Tuccio, Agostino

doi:10.1590/S1677-5538.IBJU.2022.0174

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ORIGINAL ARTICLE • Int. braz j urol 49 (3) • May-Jun 2023 • https://doi.org/10.1590/S1677-5538.IBJU.2022.0174 copy

Holmium laser enucleation of the prostate (HoLEP) is safe and effective in patients with high comorbidity burden

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Introduction

We assessed the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) in patients with high comorbidity burden.

Materials and methods

Data from patients treated with HoLEP at our academic referral center from March 2017 to January 2021 were prospectively collected. Patients were divided according to their CCI (Charlson Comorbidity Index). Perioperative surgical data and 3-month functional outcomes were collected.

Results

Out of 305 patients included, 107 (35.1%) and 198 (64.9%) were classified as CCI ≥ 3 and < 3, respectively. The groups were comparable in terms of baseline prostate size, symptoms severity, post-void residue and Qmax. The amount of energy delivered during HoLEP (141.3 vs. 118.0 KJ, p=0.01) and lasing time (38 vs 31 minutes, p=0.01) were significantly higher in patients with CCI ≥ 3. However, median enucleation, morcellation and overall surgical time were comparable between the two groups (all p>0.05). Intraoperative complications rate (9.3% vs. 9.5%, p=0.77), median time to catheter removal and hospital stay were comparable between the two cohorts. Similarly, early (30 days) and delayed (>30 days) surgical complications rates were not significantly different between the two groups. At 3-month follow up, functional outcomes using validated questionnaires did not differ between the two groups (all p>0.05).

Conclusions

HoLEP represents a safe and effective treatment option for BPH also in patients with high comorbidity burden.

Holmium; Lasers; Prostate

Variables	CCI ≥ 3 patients (n=107; 35.1%)		p-value
Preoperative characteristics
Age (years) (median, IQR)	73 (69 – 77)	63 (61 – 70)	<0.001
BMI (kg/m^2) (median, IQR)	26 (23.7 – 28.1)	26.1 (24.4 – 28.5)	0.73
ASA score (median, IQR)	2 (¹1. Roehrborn CG. Pathology of benign prostatic hyperplasia. Int J Impot Res. 2008;20(Suppl 3):S11-8. 2. Lim KB. Epidemiology of clinical benign prostatic hyperplasia. Asian J Urol. 2017;4:148-51.-³3. Gratzke C, Bachmann A, Descazeaud A, Drake MJ, Madersbacher S, Mamoulakis C, et al. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. Eur Urol. 2015;67:1099-109.)	2 (¹1. Roehrborn CG. Pathology of benign prostatic hyperplasia. Int J Impot Res. 2008;20(Suppl 3):S11-8. 2. Lim KB. Epidemiology of clinical benign prostatic hyperplasia. Asian J Urol. 2017;4:148-51.-³3. Gratzke C, Bachmann A, Descazeaud A, Drake MJ, Madersbacher S, Mamoulakis C, et al. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. Eur Urol. 2015;67:1099-109.)	0.21
AMI (n, %)	36 (33.6)	13 (6.5)	<0.001
Diabetes (n, %)	75 (70.0)	24 (12.1)	<0.001
Peripheral vascular disease (n, %)	21 (19.6)	7 (3.5)	<0.001
CVA (n; %)	26 (24.2)	6 (3.0)	<0.001
ACs/APs therapy at surgery (n, %)	36 (33.6)	17 (8.5)	<0.001
Prostate volume (mL) (median, IQR)	110 (80 – 130)	100 (75 – 130)	0.39
Creatinine serum level (mg/dL) (median, IQR)	1 (0.9-1.2)	0.9 (0.9-1.1)	0.91
HB blood level (g/dL) (median, IQR)	14.1 (13.2-15.0)	14.9 (13.7-15.3)	0.34
Q-max (mL/s) (median, IQR)	8.2 (7.0 – 10.0)	8.7 (7.3 – 10.3)	0.47
PVR volume (mL) (median, IQR)	150 (100 – 280)	130 (100 – 250)	0.11
PSA serum level (ng/mL) (median, IQR)	5.6 (2.8 – 8.7)	4.8 (2.5 – 7.3)	0.25
IPSS score (median, IQR)	24 (21 – 28)	24 (21 – 27)	0.63
IIEF-5 score (median, IQR)	14 (11 – 17)	17 (12 – 21)	0.02
OAB-q score (median, IQR)	42 (26 – 54)	39 (26 – 53)	0.76
ICIQ-sf score (median, IQR)	0 (0 – 0)	0 (0 – 0)	0.42
QoL score (median, IQR)	4 (3 – 5)	4 (4 – 5)	0.34

Variables		CCI ≥ 3 patients (n=107; 35.1%)	CCI < 3 patients (n=198; 64.9%)	p-value
Surgical Outcomes
Enucleation Technique (n, %)	Three-lobes	38 (35.5)	89 (44.9)	0.17
Enucleation Technique (n, %)	En-bloc	69 (64.5)	109 (55.1)	0.17
Overall operative time (min) (median, IQR)		100 (67 - 120)	92 (65 – 115)	0.10
Enucleation time (min) (median, IQR)		51 (41 – 60)	45 (38 – 58)	0.08
Morcellation time (min) (median, IQR)		24 (16 – 35)	23 (16 – 32)	0.17
Lasing time (min) (median, IQR)		38 (32 – 47)	31 (29 – 40)	0.01
Energy delivered (kJ) (median, IQR)		141.3 (103.2 – 162.6)	118.0 (100.9 – 140.3)	0.01
Conversion to TURP (n, %)		0 (0)	0 (0)	-
Conversion to open adenomectomy (n, %)		0 (0)	0 (0)	-
Intraoperative complication (n, %)		10 (9.3)	19 (9.5)	0.77
Capsule perforation		7 (6.5)	13 (6.5)
Bladder mucosal damage		3 (2.8)	7 (3.5)

Variables		CCI ≥ 3 patients (n=107; 35.1%)	CCI < 3 patients (n=198; 64.9%)	p-value
Postoperative and Functional Outcomes
Hospitalization time (days) (median, IQR)		4 (4 - 5)	4 (4 - 4)	0.35
Catheterization time (days) (median, IQR)		3 (3 - 4)	3 (3 - 3)	0.16
Δ decreasing HB (g/dL) (median, IQR)		-0.8 (0.4 - 1.4)	-0.65 (0.4 - 1.2)	0.45
Postoperative complications (n, %)	Early events	18 (16.7)	26 (13.1)	0.51
	CD ≤ 2	16 (14.9)	24 (12.1)
	Blood Transfusion	4 (3.7)	6 (3.0)
	Fever	8 (7.4)	14 (7.0)
	Orchiepididymitis	4 (3.7)	4 (2.2)
	CD >2	2 (1.8)	2 (1.0)
	Clot retention requiring reintervention	2 (1.8)	2 (1.0)
	Late events	2 (1.8)	3 (1.5)	0.69
	CD ≤ 2	0 (0.0)	1 (0.5)
	AUR requiring catheter replacement	0 (0.0)	1 (0.5)
	CD >2	2 (1.8)	2 (1.0)
	Urethral stricture requiring reintervention	2 (1.8)	2 (1.0)
3-mo Q-max (mL/s) (median, IQR)		17 (14 - 21)	19 (16 – 22)	0.05
3-mo PVR volume (mL) (median, IQR)		50 (0 - 90)	40 (0 – 90)	0.68
3-mo PSA (ng/mL) (median, IQR)		0.9 (0.63 – 1.00)	0.9 (0.68 – 1.60)	0.17
3-mo IPSS (median, IQR)		8 (2 – 10)	7 (1 – 9)	0.24
3-mo IIEF-5 (median, IQR)		15 (11 – 17)	17 (12 – 21)	0.04
3-mo OAB-q (median, IQR)		15 (13 – 19)	13 (13 – 16)	0.10
3-mo ICIQ-sf (median, IQR)		0 (0 – 0)	0 (0 – 0)	0.31
3-mo QoL (median, IQR)		1 (0 – 2)	1 (0 – 1)	0.13
UI at 3-mo follow-up (n, %)		8 (7.4)	14 (7.0)	0.22
Follow-up (month) (median, IQR)		18 (9-29)	17 (9-27)	0.35

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[1] Correspondence address: Agostino Tuccio, MD PhD Depart. of Experimental and Clinical Medicine, University of Florence - Unit of Oncologic Minimally Invasive Urology and Andrology, Careggi Hospital, Florence, Italy Largo Brambilla 3, Careggi Hospital, 50134, Florence, Italy Fax: 055 275 8014 E-mail: agostinotuccio@yahoo.it