Background and Objectives: In the surgical treatment of benign prostatic hyperplasia (BPH), laser enucleation of the prostate is recommended as an alternative to transurethral resection (TURP) and open prostatectomy (OP). The thulium fiber laser, with its superficial penetration depth, can offer a rapid learning process by causing less heat injury and capsule damage. This study compares the first 60 cases of an endourologist performing thulium fiber enucleation of the prostate (ThuFLEP) without a mentor to the results of OP and TURP performed by experienced surgeons. It also identifies the case number at which the operation time for ThuFLEP starts to plateau. Materials and Methods: Between 1 November 2021 and 1 November 2023, the initial 60 ThuFLEP cases of an endourologist with no prior enucleation experience were compared with TURP and OP operations performed by experienced surgeons. Since the first 60 ThuFLEP cases involved 80-120 cc prostates, TURP and OP operations within this size range performed during the same period were included in the study. The groups were assessed for age, preoperative and postoperative prostate volume, PSA levels, the IPSS, the IPSS Quality of Life (QoL), and maximum urinary flow (Qmax). The 60 consecutive ThuFLEP cases were divided into three groups of 20 (Groups 1, 2, and 3) and compared for operation time, IPSS, and Qmax. Results: The operation time for TURP was shorter than for ThuFLEP and OP (p < 0.001). There was no significant difference between ThuFLEP and OP in postoperative Qmax and IPSS, while TURP had lower values than the other two methods. For ThuFLEP, the operation time was longer in the first 20 cases but plateaued in groups 2 and 3 (p < 0.001). Postoperative Qmax and IPSS values showed no significant differences among the three ThuFLEP groups (p > 0.05). Conclusions: For large prostates, ThuFLEP provides better postoperative results than TURP and offers shorter catheterization and hospital stay times than OP. Its short learning curve makes it a preferable method for treating BPH compared to other laser techniques.

OBJECTIVE: To evaluate the stone ablation rate and direct thermal damage from thulium fiber laser (TFL) lithotripsy using continuous (C) and burst (B) lasing techniques on an in vitro ureteral model.
METHODS: The TFL Drive (Coloplast, Humlebaek, Denmark) was used in an in vitro saline-submerged ureteral model. Ten participants, including five junior and five experienced urologists, conducted the experimental setup with 7 different settings comparing two lasing techniques: steady-state lasing (0.5 J/10 Hz = 5W for 300 s and 0.5 J/20 Hz = 10W for 150 s) and burst, intermittent 5 s on/off lasing (0.5 J/20 Hz, 0.5 J/30 Hz, 0.5 J/60 Hz, 0.1 J/200 Hz, and 0.05 J/400 Hz) with a target cumulative energy of 1500 J using cubic 125 mm3 phantom BegoStonesTM. Ureteral damage was graded 1-3 based on the severity of burns and holes observed on the surface of the ureteral model.
RESULTS: The were no significant differences in stone ablation mass neither between C and B lasing techniques, nor between expertise levels. At C lasing technique had only mild ureteral lesions with no significant differences between expertise levels (p: 0.97) or laser settings (p: 0.71). At B lasing technique, different types of thermal lesions were found with no expertise (p: 0.11) or setting (p: 0.83) differences. However, B laser setting had higher grade direct thermal lesions than C (p: 0.048).
CONCLUSIONS: Regarding efficacy, C and B lasing techniques achieve comparable stone ablation rates. Safety-wise, B lasing mode showed higher grade of direct thermal lesions. These results should be further investigated to verify which of the lasing mode is the safest in vivo. Until then and unless proven otherwise, a C mode with low frequency should be recommended to avoid ureteral wall lesions.

UNASSIGNED: To compare the efficacy and safety of thulium fiber laser (TFL) and holmium:yttrium-aluminum-garnet (Ho:YAG) laser for ureteric stone management with semi-rigid ureteroscopy.
UNASSIGNED: In a prospective study from January 2020 to December 2021, we compared 40 patients in each group who underwent semi-rigid ureteroscopic lithotripsy with TFL and that with Ho:YAG laser. Stone volume, stone density, stone fragmentation rates, total lasing time, total operative time, endoscopic vision, retropulsion and stone free rates were analyzed in both groups and compared.
UNASSIGNED: Mean stone volume was comparable in the TFL group and the Ho:YAG laser group (282.45 [standard deviation, SD 139.79] mm3 vs. 279.49 [SD 312.52] mm3; p=0.964). Mean stone density was also comparable in the TFL group and the Ho:YAG laser group (1135.30 [SD 317.04] Hounsfield unit vs. 1131.75 [SD 283.03] Hounsfield unit; p=0.959). The mean stone fragmentation rates calculated as stone volume divided by lasing time were 25.85 (SD 10.61) mm3/min and 21.37 (SD 14.13) mm3/min in the TFL group and the Ho:YAG laser group, respectively (p=0.113). The mean total lasing time (10.15 [SD] 4.69 min vs. 11.43 [SD 4.56] min; p=0.222), mean operative time (25.13 [SD 9.51] min vs. 25.54 [SD 10.32] min; p=0.866), and mean total hospital stay (2.62 [SD 0.77] days vs. 2.61 [SD 0.84] days; p=0.893) were comparable in the TFL group and in the Ho:YAG group. The vision was better and retropulsion was less in the TFL group. The stone-free rate at 1 month postoperatively was slightly better in the TFL group (100% vs. 90%; p=0.095).
UNASSIGNED: TFL technology was associated with the comparable total surgical time, total lasing time, and stone fragmentation rate with Ho:YAG laser. However, TFL had better endoscopic vision, lesser stone retropulsion, and slightly better stone-free rates.

OBJECTIVE: The solid-state Thulium laser (Tm: YAG) is a novel alternative to the widely used Holmium laser for endoscopic enucleation of the prostate (EEP) due to its relatively high peak power. The aim of this study was to examine the efficacy and safety of a new pulsed Tm: YAG laser in its first application in humans.
METHODS: Data were retrospectively collected for the first 103 patients who underwent EEP with a new pulsed solid-state Tm: YAG laser (Thulio®, Dornier MedTech Systems GmbH, Weßling, Germany). Peri- and postoperative data were assessed. Procedure-specific complications were graded using Clavien-Dindo Classifications (CDC). Patients were interviewed 15 months after the surgery to evaluate functional and long-term outcomes. Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS®).
RESULTS: The mean preoperative prostate volume was 105.6 ± 55.0 ml. Median enucleation speed was 4.1 g per minute (range 1.1-9.7). Short-term postoperative complications occurred in 21 patients (20.4%), but no high-grade complications (CDC ≥ IV) were observed. Five patients suffered gross haematuria and required reintervention (CDC IIIb; 4.9%). After 15 months, 76 patients (73.8%) participated in the follow-up interview, where seven patients (9.2%) reported complications, including two reinterventions for urethral strictures (CDC IIIb; 2.6%). Most patients reported an improvement in continence (54.0%) and urine stream (93.4%), but no difference in erectile function (81.6%). No persistent dysuria was reported. Patient satisfaction with the surgery results was very high (96.1%).
CONCLUSIONS: Endoscopic enucleation of the prostate with the new pulsed solid-state Tm: YAG laser is a safe and effective option for surgical BPH treatment.
BACKGROUND: German Clinical Trials Register number: DRKS00031676. Registration date: 10 May 2023, retrospectively registered.

OBJECTIVE: This study compares the peri-operative and functional outcomes of three distinct surgical techniques in Thulium Laser Enucleation of the Prostate (ThuLEP) for benign prostatic hyperplasia (BPH). The main aim is to assess whether the En-bloc, Three-lobe, and Two-lobe techniques have differential effects on surgical efficacy and patient outcomes.
METHODS: A retrospective analysis was conducted on patients undergoing ThuLEP for BPH between January 2019 and January 2024 at two tertiary centers. Propensity score matching was utilized to balance baseline characteristics among patients undergoing the different techniques. Surgical parameters, including operative time, enucleation time, morcellation time, energy consumption, and postoperative outcomes, were compared among the groups.
RESULTS: Following propensity score matching, 213 patients were included in the analysis. Intraoperative analysis revealed significantly shorter enucleation, laser enucleation, morcellation and operative times and total energy delivered in the En-bloc and Two-lobe groups compared to the Three-lobe group. No significant differences were observed among the groups in terms of intraoperative and postoperative complications. There were no significant differences in functional outcomes at the 3-month follow-up among the groups.
CONCLUSIONS: The findings of this study suggest that while the En-bloc and Two-lobe techniques may offer efficiency benefits and could be considered safe alternatives in ThuLEP procedures, the reduction in laser enucleation time and energy delivered did not necessarily translate into improvements in post operative storage symptoms or other functional outcomes for the patients. Surgeon preference and proficiency may play a crucial role in selecting the most suitable technique for individual patients. Future research should focus on larger-scale prospective studies to further validate these findings and explore potential factors influencing surgical outcomes.

New minimally invasive procedures to treat benign prostatic hyperplasia (BPH) have been developed in the last 20 years. With the introduction of laser enucleation techniques in prostate surgery, previous standard surgical procedures (open retropubic or transvesical adenectomy and transurethral resection of the prostate) have become less relevant, especially in case of very large prostates. The objective of this paper is to describe the experience and results of thulium:YAG laser application in BPH treatment in our department. In the last five years, 246 patients underwent thulium:YAG laser enucleation of the prostate (ThuLEP) due to BPH or lower urinary tract symptoms following complete urologic evaluation. The mean age of our patients was 73 (range 51-95) years and mean duration of surgery was 92 minutes. The mean weight of enucleated tissue was 73 grams. A low rate of intraoperative and early postoperative complications and short length of stay proved minimal invasiveness of this procedure, which results in significant improvements in urodynamic parameters and substantially reduces the post-void residual urine volume. The most important surgical and technical characteristics (enucleation and low-power laser application) make ThuLEP a safe and efficient surgical method not limited by the prostate volume. ThuLEP has a potential to displace the current standard surgical procedures to treat BPH.

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UNASSIGNED: We aimed to study whether using 30 W versus 60 W thulium enucleation of the prostate (ThuLEP) would affect postoperative outcomes in patients with benign prostatic hyperplasia (BPH).
UNASSIGNED: We prospectively identified male patients with moderate or severe lower urinary tract symptoms due to BPH. We randomized patients into 30 W (Group 1) or 60 W (Group 2) thulium yag laser with a 550 μm laser fiber and a 26 Fr continuous flow resectoscope. We collected data related to prostate size, enucleation time, morcellation time, laser time, perioperative complications, and 1-year functional outcomes.
UNASSIGNED: A total of 120 patients were included, with a mean age of 67 years and a mean prostate size of 105 g. The preoperative characteristics were similar across both groups. The mean operative time was shorter in the 60 W group, 74 ± 27 vs. 91 ± 33 min in the 30 W group (P = 0.001), and the mean laser time was 55 ± 20 in 60 W versus 71 ± 25 in 30 W (P = 0.0001). The mean hospital stay was 1 day in both groups and at 1-year follow-up; there was a similar improvement in mean Qmax and International Prostate Symptom Score symptom scores.
UNASSIGNED: Both 30 and 60 W ThuLEP provided a safe and comparable outcome with a relatively shorter operative time for the 60 W groups. Perhaps using a 30-W setting would be beneficial in the early learning curve or cases with more bleeding capsular perforators; besides, the financial benefit of manufacturing low-cost low-power devices that may help in the widespread of AEEP.

Thulium laser enucleation of the prostate (ThuLEP) is a highly effective approach to the treatment of benign prostatic hyperplasia. We present here a description of the \"ARTh Technique\" and the benefits it offers in terms of improved visualization, short operation times, and easy recognition of the dissection plane, describing specifically the anterior release (AR) technique using ThuLEP(Th). Included in this retrospective study were 32 consecutive patients operated on between January 2022-November 2022. Parameters were measured before and after the procedure: the International Prostate Symptom Score(IPSS), maximum flow rate(Qmax), post-void residual urine(PVR) prostate-specific antigen(PSA), prostate volume, operation-time, morcellation-time, catheterization-time and presence of transient urinary incontinence, and compared. The median age of patients undergoing enucleation of the prostate using the ARTh technique was 64 years (range: 44-83). The median prostate volume of the patients was 83.5 ml(50-128 ml), preoperative-IPSS was 24.8(15-33), postoperative-IPSS was 7(5-11), preoperative-Qmax was 8.1 ml/Sects. (5-11.5 ml/sec), postoperative-Qmax was 26.9 ml/Sect. (20.8-34 ml/sec), preoperative-PVR was 145 ml(75-258 ml), postoperative-PVR was 36.2 ml(0-66 ml), total operation time was 51.4 min(28-82 min), enucleation time was 36.9 min(19-51 min) and morcellation time was 15.3 min(8-27 min). The ARTh technique is a safe procedure that allows the surgeon to easily recognize and adhere to the defined dissection plane, thus decreasing operation times, significantly reducing the rate of postoperative transient urinary incontinence (TUI).

OBJECTIVE: To compare the perioperative and functional outcomes of low-power and high-power thulium:YAG VapoEnucleation (ThuVEP) of the prostate for the treatment of large-volume benign prostatic hyperplasia (BPH) (> 80 ml).
METHODS: A prospective analysis of 80 patients with symptomatic BPO and prostatic enlargement (more than 80 ml) was conducted. They were divided randomly into two groups (40 patients in each group). One group was treated with low-power ThuVEP, and the other group was treated with high-power ThuVEP. All patients were assessed preoperatively and early postoperatively, and 12-month follow-up data were analyzed. The complications were noted and classified according to the modified Clavien classification system.
RESULTS: The mean age at surgery was 68 (± 6.1) years, and the mean prostate volume was 112 (± 20.1) cc, and there were no differences between the groups (p = 0.457). The mean operative time was 88.4 ± 11.79 min for group A and 93.4 ± 16.34 min for group B, while the mean enucleation time was 59.68 ± 7.24 min for group A and 63.13 ± 10.75 min for group B. There were no significant differences between the groups regarding catheterization time and postoperative stay. The quality of life (QoL), International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), postvoiding residual urine (PVR), and prostate volume improved significantly after treatment and were not significantly different between those treated with the different energies. The incidence of complications was low and did not differ between both the groups.
CONCLUSIONS: Low-power ThuVEP is feasible, safe, and effective with comparable results with high-power ThuVEP in the treatment of BPO.