From "gold standard" resection to reproducible "future standard" endoscopic enucleation of the prostate: what we know about anatomical enucleation.
BACKGROUND
Open prostatectomy (OP) and transurethral resection of the prostate (TURP) have traditionally been the most common surgical approaches for the treatment of benign prostatic hyperplasia causing bladder outlet obstruction and have certainly passed the test of time. In time, many endoscopic surgical procedures have been described as an alternative mini-invasive treatment. Holmium laser enucleation (HoLEP) guaranteed functional outcomes similar to OP and TURP with lower perioperative complication rates for any prostate size. With the development of different kinds of lasers (such as thulium, "green light" and diode) and bipolar energy, the feasibility of endoscopic enucleation using these energies has been explored.


METHODS
In this paper, recent techniques to perform true prostate enucleation have been reviewed through a search of PubMed and Web of Science, including articles published in the last 20 years in clinical journals. The review is based on a peer-review process of the authors after a structured data search. Search terms included "Thulium prostate enucleation, THULEP, TmLEP/Tm Yag enucleation" OR "Greenlight enucleation/prostate enucleation/vapo-enucleation/KTP prostate enucleation, PVP prostate enucleation, GreenLep/" OR "bipolar prostate enucleation" OR "HoLEP, Holmium prostate enucleation" OR "monopolar prostate enucleation" OR "Diode prostate enucleation" OR "DiLEP" OR "Eraser prostate enucleation" OR "ELEP".


RESULTS
Following the example of HoLEP, many techniques have been described in the literature using a variety of energy sources and instruments either in a pure enucleative or a hybrid (mixed) fashion. However, the levels of evidence are too low and follow-up still too short to offer solid recommendations.


CONCLUSIONS
HoLEP has become the conceptual and practical paradigm for the wide spread of enucleation thanks to the evidence provided by the literature and excellent outcomes. Higher level of evidence is required to assess efficacy of alternative enucleative techniques.
Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy - nasprorichard@gmail.com.
Richard
R
Naspro
Department of Urology and Robotic Surgery, ICUA, Clínica CEMTRO, Madrid, Spain.
Fernando
F
Gomez Sancha
Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy.
Michele
M
Manica
Department of Urology, Azienda Ulss 19, Adria, Rovigo, Italy.
Agostino
A
Meneghini
Department of Urology, University Medical Center Göttingen, Göttingen, Germany.
Sascha
S
Ahyai
Department of Urology, Addenbrooke's Hospital, Hills Road, Cambridge, UK.
Tevita
T
Aho
Department of Urology, A.O.U. San Luigi Gonzaga, Università degli Studi di Torino, Orbassano, Turin, Italy.
Cristian
C
Fiori
Department of Urology, Ospedale Treviglio-Caravaggio, ASST Bergamo Ovest, Bergamo, Italy.
Ivano
I
Vavassori
Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy.
Luigi F
LF
DA Pozzo
Department of Urology, Fondazione Vincenzo Pansadoro, Rome, Italy.
Vito
V
Pansadoro
Department of Urology, Vita-Salute San Raffaele University, Milan, Italy.
Francesco
F
Montorsi
Department of Urology and Urological Oncology, Division of Endourology and Laparoscopy, Hannover Medical School, Hannover, Germany.
Thomas R
TR
Herrmann
D004724:Endoscopy / Q000379:methods*; D006801:Humans; D053685:Laser Therapy; D008297:Male; D011467:Prostate / Q000033:anatomy & histology / Q000601:surgery*; D011468:Prostatectomy / Q000379:methods*; D020728:Transurethral Resection of Prostate