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Endoscopic Enucleation of the Prostate

It has now been over 20 years since holmium enucleation of the prostate was first described. Since then, several other energy sources have been described to perform endoscopic enucleation and more recently there has been a shift to performing the surgery using an enbloc resection technique instead of individual lobar resection. At the end of the day, it probably doesn’t make a great deal of difference as to which energy source is used to perform endoscopic enucleation of the prostate (EEP) and as to whether tissue removal was by individual lobes or enbloc. They are all achieving the same anatomical removal of tissue and are a basically similar principle of technique.

There have been systematic reviews and meta-analyses evaluating individual energy sources to perform EEP versus transurethral resection of the prostate (TURP). The study by Zhang and colleagues is novel in that for the first time, we have an analysis that takes the stance that all of the EEP techniques are essentially equivalent, and therefore creating a very powerful comparison with TURP.

This study finds the superiority of EEP against TURP. On the basis of this type of analysis, EEP could quite reasonably lay claim to being the new gold standard for the surgical treatment of benign prostatic hyperplasia. But we have to ask the question as to why it is that after over 20 years of EEP techniques being performed that we find little penetration into urological practice? The commonly stated reasons include learning curve and stress incontinence rates and these issues will always fail to be clarified in studies where EEP experts pit their skills against TURP. There may be conjecture as to how we define a gold standard but it appears that clinical data alone may not be enough.


Written by: Henry Woo, MBBS, DMedSc, FRACS. Henry Woo is a urological surgeon who is subspecialized in the treatment of prostatic diseases. He is the Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney. Additionally, he is the Director of Uro-Oncology and Professor of Robotic Cancer Surgery at the Chris O'Brien LifeHouse cancer hospital. He is a Board Director of the Australian and New Zealand Urogenital and Prostate Cancer trials group (ANZUP) and a Board Director of the Australian Urological Foundation (AUF).

Read the Full-Text Article: Efficacy and Safety of Enucleation vs. Resection of Prostate for Treatment of Benign Prostatic Hyperplasia: A Meta-analysis of Randomized Controlled Trials