Editorial Comment on: 1470 nm Diode Laser Enucleation vs Plasmakinetic Bipolar Resection of the Prostate for Benign Prostatic Hyperplasia: A Randomized Study by Zhang et al . (From: Zhang J,Wang X,Zhang Y,et al. J Endourol 2019;33:211–217;DOI: 10.1089/end.2018.0499)

In this article, Zhang et al. prospectively randomized 157 men with bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), mean size 55–56 mL, to two endoscopic surgical techniques, plasmakinetic bipolar resection of the prostate (PKRP) and 1470 nm diode laser enucleation of the prostate (DiLEP), between January 2016 and March 2017. Overall, 152 patients had complete data and were included in the analysis. All patients had routine preoperative work-up, including hemoglobin and sodium levels, and prostate size measurements were performed using transrectal ultrasonography sizing. Surgical details were collected, and postoperative data such as serum blood measurements, flow parameters (Qmax), postvoid residuals (PVRs), and patient questionnaires (International Prostate Symptom Score [IPSS] and quality of life [QoL]) were tabulated at 3, 6, and 12 months.

Overall, in this subset of patients with mild to moderate enlargement of the prostate, the authors report similar resected prostate weights, improvements in Qmax, and reductions in PVR and IPSS/QoL scores with both interventions. PKRP was, however, associated with longer bladder irrigation and catheterization times, as well as longer hospital stays. And although there was a more marked hemoglobin decrease in the PKRP group, this did not translate into higher intraoperative transfusion (0%) or postoperative bleeding (1%–2%) rates. Of note, other complication rates were low and comparable with other endoscopic BPH procedures.

One of the limitations of this study is the single-blinded nature of the study with associated bias. Another limitation is the unusually long hospitalization times: 7.9 and 9.5 days for DiLEP and PKRP, respectively, much longer than would be expected for prostates around 50–60 mL in size with most, if not all, BPH interventions. Furthermore, although the presence of resected weight does present a surrogate of resected volume, it would have been of great benefit if postoperative prostate size measurements had been performed as well. Finally, there was no cost-benefit analysis performed to assess the health care economics related to these interventions.

Despite the study limitations, both DiLEP and PRKP seem to be valid options for men with mild-to-moderately enlarged prostates with outcomes and complication rates comparable with other endoscopic BPH procedures. And, as endoscopic BPH options continue to multiply, it remains incumbent on surgeons to offer patients the surgical options they are most comfortable with to offer best possible outcomes.