ThuFLEP: An emerging choice for AEEP

Dr Ashish Saini

Excel Advanced Urology Center, New Delhi

Anatomic endoscopic enucleation of the prostate (AEEP), first described by Hirahoka in 1983, is included in the EAU, as well as, the AUA guidelines for management of BPH.(1) AEEP is as effective as open prostatectomy with less morbidity for prostates >80ml, and is superior to ‘’standard’’ TURP in terms of lower blood loss and shorter catheterization time.(2) After Fraundorfer and Gilling  successfully introduced holmium laser enucleation of the prostate (HoLEP) in 1998, different laser energy sources have been developed, the most notable being thulium:YAG laser, introduced in 2010 by Herrman and colleagues.(3,4) HoLEP is performed at both high-power (HP; 50–100 W) and low-power (LP; 20–50 W) settings. A recent meta analysis by Pirola and colleagues revealed that HP-HoLEP and LP-HoLEP have comparable surgical times and safety profiles, with similar operative and functional outcomes.(5) Thulium fiber laser (TFL), a woven silica fiber doped with thulium ions, has a shorter wavelength and higher water absorption coefficient in comparison to holmium laser, leading to higher energy density at the tip, which translates into deeper ablation and coagulation abilities. We have seen similar outcomes in our patient series and as seen in the figure 1 where a nice fossa is seen and the sphincter as shown in fig 2 is intact. Our approach of early apical release has shown promising results with no stress urinary incontinence reported in our patient subsets. TFL enucleation of the prostate (ThuFLEP) achieved similar efficacy and efficiency to HoLEP in both a single-center registry and randomized controlled trials across the world and both are considered efficient energy sources for AEEP.(6,7) A comparison of TURP and HoLEP revealed that a longer operative time and a larger prostate volume were risk factors for urethral stricture and bladder neck stenosis with TURP, and that HP-HoLEP was a better alternative.(8) A meta-analysis  revealed that the pooled incidence of bladder neck stenosis was 1.3% after TURP and 0.66% after enucleation.(9) While it may be premature to say that TFL is the next-best laser energy, the evidence suggests that TFL is safe and effective and in no way inferior to HoLEP. In a price conscious economy like India the usability and serviceability are its biggest advantages, and are likely to make TFL more popular (Table 1).

Table 1: TFL: advantages over holmium

TFL: Advantages Over Holmium

4x depth of optical penetration- better Hemostasis

Higher water absorption coefficient- lower power requirements

Greater Mobility

10x lower pulse energy

Figure 1: fossa after enucleation (left); Ext Sphincter after ThuFLEP (right)