TURP vs GreenLight Laser vs HoLEP: Which Surgery to Pick?

Subtitle text

Automatic YouTube captions; they may contain errors.

0:07 Doctor, I've been doing some research and there are many options for prostate surgery. Which one's the best? >> I get asked this question all the time and the short answer is that not all techniques are the same.

0:19 But I don't want you to just take my word for it. I want you to see the data. I'm Dr. Fernando Gomez Sancha. I've operated on over 10,000 prostates with lasers. I have experience with the three main techniques we're going to discuss.

0:33 Transurethral Resection, Greenlight Laser Vaporization, and Prostate Laser Enucleation. So, I'm going to compare them based on experience and scientific evidence. Transurethral Resection of the Prostate is the classic technique.

0:50 It recently turned 100 years old. It is or has been considered [music] the gold standard, which means the treatment against which others must be compared. It uses an electric loop that [music] scrapes the prostate tissue from inside the urethra layer by layer. It works well for small and medium prostates up to about 80 g.

1:14 It's a technique that most urologists know and have mastered. The problem is in larger prostates, resection is incomplete by definition, almost by definition, and the 10-year reoperation rate is between 15 and 20%. In other words, for every five or six patients who undergo a transurethral resection, one will need surgery again.

1:37 It also carries a higher risk of bleeding and a problem called absorption syndrome, which has recently been greatly reduced with new bipolar resection instruments, [music] but historically it was a major complication.

1:50 The green laser or green light uses a type of laser that vaporizes the prostate tissue. It evaporates it. It's a technique that [music] became popular. I've used it since 2003 because it causes little bleeding, making it ideal for patients on anticoagulants, and the immediate recovery is good.

2:11 The downsides, [music] first, when vaporizing, you don't get tissue for analysis. If there's a hidden cancer in that prostate, you won't detect it. And secondly, the re-treatment rate is significantly higher than with enucleation.

2:27 Several studies place it much higher than laser enucleation. And thirdly, in large prostates, vaporization is a very slow and inefficient process. Finally, prostate enucleation with holmium laser. I started with the green laser, but then I went back, well, I switched to the holmium laser, and this is a technique I've been performing for many years.

2:54 The laser separates the entire prostatic adenoma from the prostatic capsule, enucleating it completely. >> [music] >> It doesn't cut it into pieces or destroy it. It extracts it whole, as if we were peeling a fruit or an orange, and then taking out the orange segments in very [music] small pieces.

3:15 Why do I consider holmium laser enucleation to be superior? Because of the data. Firstly, it works for any prostate size. There is no limit. [music] I've operated on prostates from 25 to 30 g up to over 500 g using the same technique.

3:32 Secondly, the long-term re-treatment rate is less than 2% compare that to the 15 to 20% for transurethral resection. And thirdly, you obtain tissue for histological analysis. If there is an incidental cancer, we'll detect it.

3:50 Fourthly, patients bleed much less and patients on anticoagulants who nowadays, well, probably half of men over 60 take some kind of anticoagulant medication, can be operated on with much less [music] risk.

4:05 Fifthly, the results are extremely long-lasting. 10 and 15-year studies show that the results of enucleation are maintained. So, why does not everyone do HoLEP? The answer is simple, the learning curve.

4:22 The holmium laser enucleation is technically a bit more demanding than other operations like transurethral resection and green laser. It requires specific training, supervised practice, and [music] many cases to master it. Not all centers have the equipment or trained surgeons.

4:41 This is a reality. That's why I have dedicated a significant part of my career to training other colleagues and the um generalization of the technique. I have taught the technique in over 50 countries, trained more than 600 urologists, and recently published a book on the technique.

5:01 Because I believe patients deserve access to the best technique available regardless of where they live. So, my advice before having surgery, ask your urologist which technique they will use, how many procedures they have done with it, and what their re-treatment rates are.

5:18 Not all HoLEPs are the same just as not all TURPs are the same. The technique matters, but the surgeon's experience matters as much if not more. Subscribe and see you in the next video.