group (3.2%) required pads for de novo incontinence at 12months, similar to the expected rate of stress incontinencefollowing open prostatectomy.19

A drawback of the HoLEP technique is the associated learn-ing curve. It has been estimated that trainees must perform 20to 30 cases on moderate sized glands (50 ml) before they canconsistently reproduce the outcomes that are presented.20 It isprobably not too dissimilar to the initial learning curve forTURP. Anecdotal evidence from urological trainees rotatingthrough our department suggests that learning HoLEP isequivalent to learning TURP because it is a relatively bloodlessprocedure with better visibility than TURP and the correctdissection plane is easier to discern. However, close supervisionand structured training are vital to success.

CONCLUSIONS

Our trial demonstrates certain points. HoLEP is superiorto TURP for relieving urodynamically confirmed BOO sec-ondary to BPH and it removes more tissue than TURP inprostates of similar size by ultrasound. HoLEP results inshorter catheter time and hospital stay compared with TURPand it causes less perioperative bleeding. HoLEP is equiva-lent to TURP in terms of improving peak flow rates, symptomscores and quality of life scores. Overall there were feweradverse events in the HoLEP arm than in the TURP arm.HoLEP has emerged as a serious challenger to TURP as thepreferred surgical treatment for BOO secondary to BPH inlarge glands (40 to 200 ml).

REFERENCES

1. Mebust, W. K., Holtgrewe, H. L., Cockett, A. T. K., Peters, P. C.and Writing Committee: Transurethral prostatectomy: imme-diate and postoperative complications. A cooperative study of13 participating institutions evaluating 3,885 patients. J Urol,141: 243, 1989

2. Olsson, J., Nilsson, A. and Hahn, R. G.: Symptoms of the trans-urethral resection syndrome using glycine as the irrigant.J Urol, 154: 123, 1995

3. Gilling, P. J., Cass, C. B., Malcolm, A. R. and Fraundorfer, M. R.:Combination holmium and Nd:YAG laser ablation of the pros-tate: initial clinical experience. J Endourol, 9: 151, 1995

4. Razvi, H. A., Chun, S. S., Denstedt, J. D. and Sales, J. L.:Soft-tissue applications of the holmium:YAG laser in urology.J Endourol, 9: 387, 1995

5. Mottet, N., Anidjar, M., Bourdon, O., Louis, J. F., Teillac, P., Costa,P. et al: Randomized comparison of transurethral electroresec-tion and holmium:YAG laser vaporization for symptomatic be-nign prostatic hyperplasia. J Endourol, 13: 127, 1999

6. Gilling, P. J., Cass, C. B., Cresswell, M. D., Malcolm, A. R. andFraundorfer, M. R.: The use of the holmium laser in the treat-ment of benign prostatic hyperplasia. J Endourol, 10: 459, 1996

7. Kabalin, J. N.: Holmium:YAG laser prostatectomy: results ofU.S. pilot study. J Endourol, 10: 453, 1996

8. Cornford, P. A., Biyani, C. S. and Powell, C. S.: Transurethralincision of the prostate using the Holmium:YAG laser: a cath-eterless procedure. J Urol, 159: 1229, 1998

9. Gilling, P. J., Kennett, K., Das, A. K., Thompson, D. andFraundorfer, M. R.: Holmium laser enucleation of the prostate(HoLEP) combined with transurethral tissue morcellation: anupdate on the early clinical experience. J Endourol, 12: 457, 1998

10. Gilling, P. J., Mackey, M., Cresswell, M., Kennett, K., Kabalin,J. N. and Fraundorfer, M. R.: Holmium laser versus transure-thral resection of the prostate: a randomized prospective trialwith 1 year followup. J Urol, 162: 1640, 1999

11. Fraundorfer, M. R. and Gilling, P. J.: Holmium:Yag laser enu-cleation of the prostate combined with mechanical morcella-tion: preliminary results. Eur Urol, 33: 69, 1998

12. Moody, J. A. and Lingeman, J. E.: Holmium laser enucleation ofthe prostate with tissue morcellation: initial United Statesexperience. J Endourol, 14: 219, 2000

13. Gilling, P. J., Kennett, K. M. and Fraundorfer, M. R.: Holmiumlaser enucleation of the prostate for glands larger than 100 g:an endourologic alternative to open prostatectomy. J En-dourol, 14: 529, 2000

14. Fraundorfer, M. R. and Gilling, P. J.: Holmium:YAG laser enu-cleation of the prostate (HoLEP) combined with mechanicalmorcellation: preliminary results. Eur Urol, 33: 69, 1998

15. Tan, A. H. H. and Gilling, P. J.: Holmium laser prostatectomy:current techniques. Urology, 60: 152, 2002

16. Moody, J. A. and Lingeman, J. E.: Holmium laser enucleation forprostate adenoma greater than 100 gm. Comparison to openprostatectomy. J Urol, 165: 459, 2001

17. Kuntz, R. M. and Lehrich, K.: Transurethral holmium laserenucleation versus transvesical open enucleation for prostateadenoma greater than 100 gm.: a first randomized prospectivetrial of 120 patients. J Urol, 168: 1465, 2002

18. McConnell, J. D., Barry, M. J., Bruskewitz, R. C., Bueschen, A. J.,Denton, S. E., Holtgrewe, H. L. et al: Clinical Practice Guideline:Benign Prostatic Hyperplasia: Diagnosis and Treatment. Rock-ville, Maryland: Agency for Health Care Policy and Research,Public Health Service, Publication No. 94-0582, 1994

19. Oesterling, J. E.: Retropubic and suprapubic prostatectomy. In:Campbell’s Urology, 7th ed. Edited by P. C. Walsh, A. B. Retik,E. D. Vaughan, Jr. and A. J. Wein. Philadelphia: W. B. Saunders,Co., vol. 2, chapt. 50, pp. 1529–1541, 1998

20. El-Hakim, A. and Elhilali, M. M.: Holmium laser enucleation ofthe prostate can be taught: the first learning experience. BJUInt, 90: 863, 2002

EDITORIAL COMMENT

A positive aspect of clinical investigation in the field of urology hasbeen increasing reliance on randomized clinical trials to evaluatevarious therapies (medical and surgical) for BPH. The AUA BPHguidelines committee, and the Food and Drug Administration shouldbe recognized for their support of this encouraging development(reference 18 in article). The current study adds further high qualitydata to the information that we as clinicians need to make the mostappropriate and intelligent decisions regarding the treatment of ourpatients with BPH, particularly patients with a larger prostate.

This group from Tauranga, New Zealand has previously comparedTURP with HoLRP in a randomized clinical trial (reference 10 inarticle). In that study performed prior to the advent of a practical tissuemorcellator smaller prostates were treated with a mean weight of tissueremoved of than 10 gm. HoLRP produced equivalent outcomes to TURPwith significant decreases in perioperative morbidity, such as bleeding,duration of catheterization and hospital stay. In the current study theauthors extended the application of the Ho laser to considerably largerprostates and evolved from resection to the technique of enucleation,much akin to open simple prostatectomy. Removal of large adenomavolumes from the bladder was not possible until the development of apractical morcellator, which was used in this trial. Again, when HoLEPwith tissue morcellation was compared with TURP, substantial benefitsto the patient accrued with lowered perioperative morbidity, while stillachieving outcomes equivalent to those of TURP. Indeed, in this par-ticular trial at 6 months urodynamic evaluation suggested that HoLEPwith tissue morcellation was more effective than TURP in for de-obstruction, an observation probably related to the larger amount oftissue removed by the enucleation procedure (40.4 gm for HoLEP vs24.7 for TURP, p �0.05).

So why isn’t everybody doing HoLEP? In addition to the need for ahigh power Ho laser and tissue morcellator, the most dauntingimpediment to adopting this attractive technique is the significantlearning curve required, particularly for surgeons who are not in asituation where they can be closely mentored. I agree with the authorassessment that the learning curve for HoLEP with tissue morcel-lation is similar to that for TURP (ie 20 to 30 cases on small tomoderate size glands). It may be more of a learning curve than mosturologists already in practice are willing to bear. Furthermore, it isimportant to realize that there is an additional learning curve tomove from small to moderate sized glands to the larger prostatestreated in the current series. Nevertheless, for surgeons willing tomake the effort HoLEP with tissue morcellation provides uniqueadvantages, in that it is a relatively bloodless procedure associatedwith low perioperative morbidity. There are no practical prostatesizes or configurations that cannot be addressed with this innovativeapproach after the procedure has been mastered. The authors pro-vide an innovative contribution to our urological armamentarium forBPH.

James E. LingemanMethodist Hospital Institute for Kidney Stone DiseaseIndianapolis, Indiana

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