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Pulsed-Wave vs Continuous-Wave Thulium Fiber Laser Enucleation of the Prostate (ThuFLEP): A Comparison of Perioperative Outcomes - Beyond the Abstract

Endoscopic laser enucleation of the prostate (EEP) has spread worldwide over the last decades, eventually becoming a recommended alternative to standard transurethral resection of the prostate (TURP) by international guidelines, also for the treatment of large prostates.1 

At the same time, thulium laser has been proven to be safe and effective, with no significant differences concerning functional outcomes and perioperative complications.2-6 Two types of thulium-based lasers are available, with differences regarding functioning mechanism and wavelength: the thulium: yttrium–aluminum–garnet laser (Tm:YAG, 2010 nm wavelength) and the thulium fiber laser (TFL, 1940 wavelength). The shorter wavelength of the latter closely matches the absorption coefficient peak in water, thus maximizing the vaporization of tissues and reducing penetration depth to around 0.1 mm.7 However, while Tm:YAG is a continuous laser, the TFL can be set to function in a pulsed-wave (PW) or a continuous-wave (CW) mode.

Theoretical advantages of the TFL, like shallower penetration depth and improved vaporization, did not translate into relevant perioperative outcomes when comparing thulium laser enucleation of the prostate with Tm:YAG laser (ThuLEP) versus enucleation with TFL set in a CW-mode (CW-ThuFLEP).8 In our study, instead, we compared outcomes between TFL enucleation of the prostate set in a PW (PW-ThuFLEP) vs CW (CW-ThuFLEP) mode within a cohort of 238 patients.9 All surgeries were performed by the same urologist using the 60 W Fiber Dust TFL generator (Quanta System, Samarate, Italy). The TFL was set in PW mode (energy 2 J, frequency 30 Hz) for patients in Group A and in CW mode (60 W for cutting and 35 W for coagulation) for patients in Group B.

According to our results, CW-ThuFLEP showed a shorter operative time (61.5 vs 67.4, p = 0.04). Enucleation time (50.2 vs 53.3 min) and enucleation efficiency (0.8 vs 0.7 g/min) were comparable between PWThuFLEP and CW-ThuFLEP and no significant difference in complication rate was observed. Three months after surgery functional outcomes resulted in a mean decrease in IPSS score of 14.3 vs. 13.1, mean increase in Qmax of 12.3 vs. 11.2 ml/s, and mean decrease in PVR of 104.8 vs. 102.9 ml with PW-ThuFLEP vs. CW-ThuFLEP, respectively.

Our study confirms the role of ThuFLEP as a safe and effective surgical treatment for benign prostatic hyperplasia independently from the wave output employed (pulsed vs. continuous). Only operative time was significantly different in favour of CW-ThuFLEP, however, the difference was of low entity, with a mean decrease in total operative time of 5.9 minutes. Interestingly, the
use of a continuous-wave output did not result in a significant difference in perioperative bleeding and the rate of postoperative urge incontinence did not differ between groups, suggesting that the risk of irritative symptoms is independent from the output setting. Therefore, data currently available seem to suggest that the choice to perform ThuLEP vs. CW-ThuFLEP vs. PW-ThuFLEP basically depends on the surgeon’s preference, with no significant differences demonstrated on efficacy and safety profile.

Written by: Davide Perri & Giorgio Bozzini, Department of Urology, Sant'Anna Hospital, San Fermo della Battaglia, Italy

References:

  1. Cornu JN, Gacci M, Hashim H, Herrmann TRW, Malde S, Netsch C, et al. EAU Guidelines on the Non-neurogenic Male Lower Urinary Tract Symptoms (LUTS) including Benign Prostatic Obstruction (BPO). EAU Guidelines. Edn. presented at the EAU Annual Congress Milan March 2023.
  2. Wani MM, Sriprasad S, Bhat T, Madaan S. Is Thulium laser enucleation of prostate an alternative to Holmium and TURP surgeries - A systematic review? Turk J Urol 2020;46:419–26.
  3. Huang S-W, Tsai C-Y, Tseng C-S, Shih M-C, Yeh Y-C, Chien K-L, et al. Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: systematic review and network meta-analysis. BMJ 2019;367:l5919.
  4. Zhang Y, Yuan P, Ma D, Gao X, Wei C, Liu Z, et al. Efficacy and safety of enucleation vs. resection of prostate for treatment of benign prostatic hyperplasia: a meta-analysis of randomized controlled trials. Prostate Cancer Prostatic Dis 2019;22:493–508.
  5. Hartung FO, Kowalewski K-F, von Hardenberg J, Worst TS, Kriegmair MC, Nuhn P, et al. Holmium Versus Thulium Laser Enucleation of the Prostate: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Eur Urol Focus 2022;8:545–54.
  6. Zhang F, Shao Q, Herrmann TRW, Tian Y, Zhang Y. Thulium laser versus holmium laser transurethral enucleation of the prostate: 18-month follow-up data of a single center. Urology 2012;79:869–74.
  7. Kronenberg P, Traxer O. The laser of the future: reality and expectations about the new thulium fiber laser-a systematic review. Transl Androl Urol 2019;8:S398–417.
  8. Bozzini G, Berti L, Maltagliati M, Besana U, Micali S, Roche JB, et al. Thulium: YAG vs continuous-wave thulium fiber laser enucleation of the prostate: do potential advantages of thulium fiber lasers translate into relevant clinical differences? World J Urol 2022.
  9. Perri D, Mazzoleni F, Besana U, Pacchetti A, Morini E, Berti L, et al. Pulsed-wave vs Continuous-wave Thulium Fiber Laser Enucleation of the Prostate (ThuFLEP): a comparison of perioperative outcomes. Urology 2023:S0090-4295(23)00449-1.
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