Abstract
Since its development in the 1930s, transurethral resection of the prostate has remained the gold standard. Patients with larger glands mainly undergo open adenomectomy. Recently, transurethral enucleation with a holmium laser was the only new technique that had sufficient long-term data to become a standard for larger glands. Yet, the learning curve and the increased costs (high power holmium laser, morcellator) are still a limitation to its widespread use. The technique itself, like the technique used by the authors, combined two other known techniques: Adenomectomy and holmium laser (the so long desired laser on the tip of the finger during open adenomectomy was now available transurethrally).
In the last few years, a tremendous number of new techniques with similar abbreviations appeared on the market: Transurethral resection in saline, transurethral microwave thermotherapy, transurethral needle ablation, thulium laserenucleation of the prostate, thulium vapoenucleation of the prostate, to just name some of the transurethral techniques. Until now, none of these techniques proved to have superior or equal long-term results in comparison with holmium laser enucleation of the prostate or open adenomectomy. There is no new “winner.”
Further on, all these techniques need their specific equipment, and some of them will eventually lead to secondary procedures, as long-term results may be inferior to adenomectomy, be it transurethral or open. Costs will rise.
In some countries, such as Germany, healthcare providers are no longer willing to pay for all the new “toys” of the urologists. They want proof of effectiveness and of long-lasting results. High-quality studies with long follow-up are lacking for most of the new techniques. Thus, to limit the upcoming rise in costs, some of the newer techniques will probably no longer be reimbursed in the near future. Until they prove their effectiveness, they will only be offered to patients in studies.
The technique described by the authors has the advantage of using already existing devices in many urologic departments. Only the mushroom-shaped electrode would have to be acquired. Costs will remain manageable. The learning curve will probably be equal to that of holmium laser (or perhaps a little less steep), which will, to some degree, also remain an obstacle to its widespread use.
As the authors correctly concluded, they need a higher volume of patients and an adequate follow-up to establish their technique as a new standard procedure. This is true for them and for all the other new techniques.
University Hospital Mannheim, Mannheim, Germany.