Newer technology enhances efficiency of holmium laser enucleation of the prostate

Use of newer laser technology optimized for holmium laser enucleation of the prostate (HoLEP) provides significant benefits compared with an earlier system, according to the results of a recently published prospective, randomized, double-blind trial.¹

The study, conducted at the Mayo Clinic in Phoenix, Arizona, included 27 men who underwent HoLEP using a holmium:YAG laser platform (Lumenis Pulse 120H) with a dedicated 550-nm end-fire laser fiber. The patients were randomized to undergo right or left lobe enucleation using Moses 2.0 technology. HoLEP in the opposite lobe was performed without Moses technology.

Of the 27 procedures, 11 were done by 2 urologists experienced with HoLEP. Two trainees did the remaining procedures, and neither was experienced with HoLEP.

The primary outcome of the study was lobe enucleation efficiency, and in the hands of the expert surgeons, it was significantly better using Moses compared with the non-Moses technology (mean, 1.75 g/min vs 1.05 g/min). Compared with the non-Moses procedures, Moses 2.0 was also associated with statistically significant reductions in mean fiber degradation in analyses for both the expert (3.45 mm vs 19.9 mm) and trainee (1.1 mm vs 34.6 mm) subgroups. Considering the procedures done by the trainees, Moses also resulted in a significant reduction in mean hemostasis laser time (4.1 min vs 9.0 min).

“Our study is novel in that it was designed to have patients serve as their own controls,” said Amihay Nevo, MD. “This methodology accounts for confounding that can occur because of interpatient variations in prostate tissue properties and vascularity and allowed us to compare the 2 technologies using a smaller patient population.”

“To our knowledge, ours is the first study demonstrating that the Moses 2.0 technology dramatically improves clinical outcomes for HoLEP,” Nevo continued.. “Although HoLEP is unique among treatments for BPH [benign prostatic hyperplasia] in having a long and steep learning curve, we believe that the documented benefits of using the optimized technology may make HoLEP more accessible to urologists and their patients.”

Nevo is lead author of the published paper reporting the results of the study. He participated in the investigation as an endourology fellow at the Mayo Clinic, and is now chief of endourology for University Hospitals, Cleveland, Ohio.

Subjective ratings also recorded for each procedure

In addition to the objective outcome measures, the study end points included a subjective rating of each laser procedure. Because the operators were able to identify which technology was used, the ratings were done by 2 independent reviewers based on intraoperative video review.

The performance parameters graded were incision sharpness, fiber control, tissue separation, tissue damage, hemostasis, visibility, and char. Statistically, significant differences favoring Moses 2.0 over non-Moses were achieved for all 7 of the subjective outcome measures.

“HoLEP with Moses 2.0 is smoother surgery. Because it is associated with less bleeding, less charring, and better tissue separation, trainees will be better able to focus on recognizing the anatomy and learning the procedure’s steps,” said Nevo.

Nevo told Urology Times® that planning is under way for a study comparing Moses 2.0 and non-Moses HoLEP to test the hypothesis that the optimized technology shortens the learning curve for the laser procedure.

“Our study was not designed to compare the learning curve of the 2 technologies, and the trainees who were involved were doing their first HoLEP procedures,” Nevo said. “Therefore, it is likely that the outcomes in their hands do not accurately reflect the potential benefit of Moses 2.0 versus non-Moses in trainees. I am certain, however, we will find in our next study that Moses 2.0 shortens the learning time.”

Reference

1. Nevo A, Faraj KS, Cheney SM, et al. Holmium laser enucleation of the prostate using Moses 2.0 vs non‐Moses: a randomised controlled trial. BJU Int. Published online October 7, 2020. doi:10.1111/bju.15265