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Rubio-Briones, J. Casanova, F. Martínez, J.L. Domínguez-Escrig, A. Fernández-Serra, R. Dumont, M. Ramírez-Backhaus, A. Gómez-Ferrer, A. Collado, L. Rubio, A. Molina, M. Vanaclocha, D. Sala, J.A. Lopez-Guerrero" "autores" => array:14 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Rubio-Briones" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Casanova" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Martínez" ] 3 => array:2 [ "nombre" => "J.L." "apellidos" => "Domínguez-Escrig" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Fernández-Serra" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Dumont" ] 6 => array:2 [ "nombre" => "M." "apellidos" => "Ramírez-Backhaus" ] 7 => array:2 [ "nombre" => "A." "apellidos" => "Gómez-Ferrer" ] 8 => array:2 [ "nombre" => "A." "apellidos" => "Collado" ] 9 => array:2 [ "nombre" => "L." "apellidos" => "Rubio" ] 10 => array:2 [ "nombre" => "A." "apellidos" => "Molina" ] 11 => array:2 [ "nombre" => "M." "apellidos" => "Vanaclocha" ] 12 => array:2 [ "nombre" => "D." "apellidos" => "Sala" ] 13 => array:2 [ "nombre" => "J.A." "apellidos" => "Lopez-Guerrero" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210480616301991" "doi" => "10.1016/j.acuro.2016.10.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480616301991?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578617300513?idApp=UINPBA00004N" "url" => "/21735786/0000004100000005/v1_201705270112/S2173578617300513/v1_201705270112/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Thulium laser enucleation (ThuLEP) versus transurethral resection of the prostate in saline (TURis): A randomized prospective trial to compare intra and early postoperative outcomes" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "309" "paginaFinal" => "315" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "G. Bozzini, M. Seveso, S. Melegari, O. de Francesco, N.M. Buffi, G. Guazzoni, M. Provenzano, A. Mandressi, G. Taverna" "autores" => array:9 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Bozzini" "email" => array:1 [ 0 => "gioboz@yahoo.it" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Seveso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Melegari" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "O." "apellidos" => "de Francesco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "N.M." "apellidos" => "Buffi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "G." "apellidos" => "Guazzoni" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "M." "apellidos" => "Provenzano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 7 => array:3 [ "nombre" => "A." "apellidos" => "Mandressi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "G." "apellidos" => "Taverna" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Departamento de Urología, Humanitas Mater Domini, Castellanza, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Urología, Humanitas Clinical and Research Center, Rozzano, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Humanitas Clinical and Research Center, Humanitas University, Rozzano, Italy" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enucleación con láser de tulio (ThuLEP) frente a resección transuretral de la próstata en solución salina (TURis): un ensayo prospectivo aleatorizado para comparar resultados intra y postoperatorios tempranos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Approximately 30% of men aged 50–80 suffer from moderate-to-severe lower urinary tract symptoms that are significant enough to reduce the patient's quality of life.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The monopolar transurethral resection of the prostate (TURP) has been used for a long time as an effective and feasible alternative for open prostatectomy (OP) in managing males with medium and large sized prostates and having an indication for surgical intervention. The risk of life threatening complications associated with monoplar TURP especially TUR syndrome and the difficulty in managing large-sized glands shifted the studies toward other alternatives.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> While TURP is still the gold standard to treat BPH, bipolar resection of the prostate was introduced as an alternative to TURP to reduce its complications. The bipolar transurethral resection in saline (TURis) could be performed using saline as an irrigant, avoiding the possibility of TUR syndrome, claiming better haemostasis than the conventional monopolar TURP, with shorter catheterization time and shorter hospital stay.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Among those studied alternatives is holmium laser enucleation of the prostate (HoLEP) that uses the Holmium laser to enucleate the prostatic adenoma from the surgical capsule in a manner similar to open prostatectomy. Advantages of HoLEP include perfect haemostasis, shorter catheterization time, shorter hospital stay, absence of TUR syndrome, and its ability to treat very large prostate glands.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Since the first HoLEP treatment was described by Gilling et al.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> in 1995, various laser treatments of benign prostatic obstruction have been developed and have become potent challengers of the gold standard surgical treatments.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Thulium (Tm:YAG) laser has been introduced into urological soft tissue surgery in 2005. It emits laser energy in a continuous wave fashion at a wavelength of 2013<span class="elsevierStyleHsp" style=""></span>nm. As in the pulsed Ho:YAG, the particular wavelength is close to the absorption peak of water, and thereby, Tm:YAG laser demonstrates a shallow tissue penetration, coagulation zone, and necrotic tissue zone providing high surgical safety. In addition, Tm:YAG laser has an excellent hemostatic and vaporization efficiency that renders it a very versatile and appealing energy source for prostate surgery.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">ThuLEP was introduced in 2010 by Herrmann et al.,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a> and in contrast to the rest of energy-based transurethral enucleating techniques, it is characterized by the blunt/mechanical enucleation of the adenoma without the use of energy (retrogradely separating the adenoma over its surgical capsule with the use of the tip of laserscope), in accordance with the finger preparation of the adenoma during OP. Following blunt dissection, punctual coagulation of capsular bleeding vessels with the use of Tm:YAG laser establishes a bloodless field and a minimum energy exposure on the pericapsular tissue.</p><p id="par0035" class="elsevierStylePara elsevierViewall">ThuLEP literature is still very limited. Based on the available data, the approach is safe and effective, demonstrating favorable outcomes,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a> comparable with the current standard treatment options.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a> Currently, ThuLEP is present inside EAU guidelines to treat BPH.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">This study was planned to discuss the pros and cons of each of the two techniques described (TURis and ThuLEP). The objective is to compare clinical intra and early postoperative outcomes.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0045" class="elsevierStylePara elsevierViewall">This is a prospective randomized study that was carried out between September 2014 and September 2015. The study included patients with benign prostatic hyperplasia (BPH) that required surgical intervention according to EAU guidelines.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a> The study was approved by our local Ethical Committee. ThuLEP was performed by the same surgeon (GB). On the other hand, TURis was carried out by three of the authors (GT, MS, AM) who are all experienced in this technique. Inclusion criteria included all male patients with bothersome lower urinary tract symptoms due to BPH with indications for surgical intervention regardless of the patient age, International Prostate Symptom Score (IPSS), and prostatic size. Exclusion criteria were the following: Patients with mild symptoms (IPSS <8 and/or maximum urinary flow rate ≥15<span class="elsevierStyleHsp" style=""></span>ml/s and postvoid residual urine <50<span class="elsevierStyleHsp" style=""></span>ml), small adenomas <20<span class="elsevierStyleHsp" style=""></span>g measured by transrectal ultrasound, presence of urethral stricture, neurogenic bladder, vesicoureteric reflux, huge retentive bladder diverticulum, previous prostatic surgeries, previous or subsequent diagnosis of prostatic adenocarcinoma, patients receiving anticoagulant drugs due to the fact that holmium can be used safely in patients receiving anticoagulant drugs unlike TURis. The patients were randomized in 2 groups: group A patients were managed by ThuLEP and group B patients were managed by TURis. The mean age, preoperative prostate-specific antigen (PSA), IPSS, maximum urinary flow rates, residual urine, prostate size, operative time, blood loss, resected volume, hemoglobin decrease after 24<span class="elsevierStyleHsp" style=""></span>h, intraoperative and postoperative complications, catheterization time, hospital stay, and costs were compared in both groups with a 3-month follow-up. Prostatic size was measured by transrectal ultrasound that was performed to all patients reserving the biopsy only for patients with abnormal digital rectal examination and/or elevated PSA. Any patient with biopsy-proven prostate cancer was excluded from the study.</p><p id="par0050" class="elsevierStylePara elsevierViewall">All patients included in the study were informed about the procedure chosen for them, and a signed written consent was obtained.</p><p id="par0055" class="elsevierStylePara elsevierViewall">ThuLEP was performed using the high-powered 200-W Cyber TM Thulium Laser Device (Quanta Systems, Solbiate Olona, Varese, Northern Italy). A 800-μm end-firing laser fiber was used. The irrigating fluid used was physiological saline (0.9%). The enucleation technique used was that described by Herrmann et al.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a> A continuous energy was used with a total power of 120<span class="elsevierStyleHsp" style=""></span>W for cutting and a power of 40<span class="elsevierStyleHsp" style=""></span>W for coagulating.</p><p id="par0060" class="elsevierStylePara elsevierViewall">At the end of the procedure, morcellation was done using the tissue morcellator Piranha through the nephroscope taking care to avoid injuring the bladder wall by closing the outflow of the irrigation fluid. A dual-way 22-Ch silicone urethral catheter was inserted at the end of the procedure.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Bipolar resection of the prostate was done using the bipolar resection system (Surgmaster TURis; Olympus, Tokyo, Japan). The irrigating fluid used was physiological saline (0.9%). The technique used was similar to the ordinary monopolar TURP.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a> A copious amount of lubricant was used around the sheath in the urethra to prevent thermal injury to the urethra and later on urethral stricture. At the end of the procedure, careful haemostasis was performed and a dual-way 22-Ch silicone urethral catheter was inserted.</p><p id="par0070" class="elsevierStylePara elsevierViewall">All patients were evaluated intra and early postoperatively with regard to blood loss, catheterization time, irrigation volume, hospital stay, and operative time. At 3 months after surgery, they were also evaluated by International Prostate Symptom Score (IPSS), maximum flow rate (<span class="elsevierStyleItalic">Q</span>max), and postvoid residual urine volume (PVR). Our sample size has an alpha error of 0.05 and beta error of 0.2.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Statistical analysis was done using the SPSS computer program (version 15 Windows). Quantitative data were expressed as the mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation. Comparison between the mean values of the two groups was performed using the Student's <span class="elsevierStyleItalic">t</span>-test, whereas comparison between paired samples was performed using a paired <span class="elsevierStyleItalic">t</span> test. <span class="elsevierStyleItalic">p</span> values ≤ 0.05 were considered statistically significant.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">This study randomized 208 consecutive patients with BPH to ThuLEP (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>102) or TURis (<span class="elsevierStyleItalic">n</span> =106). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes patient's characteristics and preoperative data. Both groups were found to be comparable with no statistically significant difference regarding the preoperative parameters (patient's age, prostatic volume, serum PSA, blood hemoglobin level, preoperative IPSS, preoperative <span class="elsevierStyleItalic">Q</span>max, and the postvoid residual urine). Four patients in the ThuLEP group had stone bladder, and lithotripsy using the holmium laser was performed before enucleation of the prostate. The time employed to fragment and extract the stones was not counted into the operative time to perform the ThuLEP procedure. No patients inside the TURis group had bladder stones.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> underlines intra and early postoperative evidences. Compared with TURis, ThuLEP had same operative time (53.69<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>31.44 vs 61.66<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>18.70<span class="elsevierStyleHsp" style=""></span>minutes, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.123) but resulted in less hemoglobin decrease (0.45 vs 2.83<span class="elsevierStyleHsp" style=""></span>g/dl, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.005). ThuLEP also needed less catheterization time (1.3 vs 4.8 days, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.011), irrigation volume (29.4 vs 69.2<span class="elsevierStyleHsp" style=""></span>l, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002), and hospital stay (1.7 vs 5.2 days, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.016). The mean resected prostatic volume was 51.13 gr. in the ThuLEP group and 48.84 gr. in the bipolar group.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> underlines postoperative complications.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Three patients in the bipolar group required transfusion of one unit of blood. None of the patients in the ThuLEP group required blood transfusion. This was not statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.496).</p><p id="par0100" class="elsevierStylePara elsevierViewall">One patient in group A had a bladder injury during the morcellation procedure, it was coagulated and fixed with Tm:YAG during the procedure and had a catheterization time of three days.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In the ThuLEP group, seven patients could not void after removing the urethral catheter, so recatheterization was conducted. All of them could micturate successfully at the second attempt to remove the catheter after 48<span class="elsevierStyleHsp" style=""></span>h. In the TURis group, twelve patients did not void after catheter removal. Ten of them had clots retention and the catheter stayed for 72<span class="elsevierStyleHsp" style=""></span>h because of hematuria with successful voiding after catheter removal.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Seven patients in the ThuLEP group developed postoperative urge incontinence that disappeared after 3 months (on anticholinergics and pelvic floor exercises). Two patients for each group developed stress incontinence, this disappeared after pelvic floor exercises. This was not statistically significant between both groups (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.119). Five patients in the TURis group developed urge incontinence. Four patients in the TURis group and one patient in the ThuLEP group developed a stricture of the membranous urethra in 3 months that was managed endoscopically.</p><p id="par0115" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> underlines surgical outcome after 3 months. During the 3 months of follow-up, the procedures did not demonstrate a significant difference in <span class="elsevierStyleItalic">Q</span>max, IPSS, PVR, and QOLS.</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">For a long period of time since its introduction, the monopolar TURP has been considered the standard treatment option for patients with BPH. On the other hand, monopolar TURP has been associated with an higher risk of bleeding (2–4.8%) and the more serious TUR syndrome (1.1%).<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> Given this, many other alternatives have been studied. One of the most commonly studied alternatives is TURis.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a> To compare the bipolar TURis with the monopolar TURP, several studies have been published. In these studies, there was a significantly shorter catheterization time in the bipolar group as compared to the monopolar group (mean difference: 17.14<span class="elsevierStyleHsp" style=""></span>min; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>00001) and, consequently, shorter hospital stay (mean difference: 0.79 days; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.003). Despite the fact that there was no statistically significant difference between both techniques in their operative time, there were lower complications rates in the bipolar group if we consider the need for blood transfusion, postoperative clots retention, and overall immediate reoperation rate. No single case of TUR syndrome was reported in the bipolar group. At 12 months, meta-analysis of randomized controlled trials showed no statistically significant differences between both techniques on IPSS, PVR, and prostate volume. The maximum urinary flow rate seemed to be better in the bipolar group.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">One of the most commonly studied alternatives is HoLEP, which proved to be effective with shorter hospital stay, better haemostasis, and lower transfusion rate as compared to monopolar TURP.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a> Recently, another Laser technique has been introduced employing Thulium Laser. ThuLEP is now used in common practice to treat BPH<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a> and entered in EAU guidelines since 2013.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Available cohorts on ThuLEP are still very limited and consisted of only five studies including two prospective cohorts, two short-term-follow-up RCTs and one intermediate-term RCT.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">15–19</span></a> Current experience on ThuLEP indicates that the approach demonstrates favorable results in all prostatic sizes, although small prostatic volumes (<50<span class="elsevierStyleHsp" style=""></span>ml) have been associated with a higher incidence of treatment failure. In addition, age >80 and the presence of comorbidities as indicated by the American Society of Anesthesiologists (ASA) classification have also been identified as predictors of treatment failure.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a> In any case, results derived from the available RCTs define ThuLEP effectiveness as comparable with HoLEP in prostates <80<span class="elsevierStyleHsp" style=""></span>ml and TURP for any prostatic size volumes.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">18,19</span></a> Systematic reviews of the literature acknowledge the lack of evidence in thulium-assisted transurethral procedures. Still, based on current limited data, all thulium-based approaches are regarded as equal to the rest well-established procedures (e.g., monopolar and bipolar TURP, HoLEP, etc.).<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">7,13</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">To our knowledge, this is the first study that compares ThuLEP and TURis.</p><p id="par0140" class="elsevierStylePara elsevierViewall">There was no statistically significant difference between both groups in preoperative data. There was a clear advantage for ThuLEP group considering hemoglobin loss, catheterization time, irrigation volume employed, and length of hospitalization. Even there was no statistical evidence that the need of blood transfusion was higher in group B, only in this group we found patients that needed them.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The post removal catheter clots retention in group A happened mainly in small-sized prostates and the bladder neck edema could be regarded as the cause of the reported complication. Urine remained clear with no evidence of gross haematuria. As the bladder neck edema could be also the reason for urinary retention in group B, the presence of clots and the need for a longer catheterization time (because of the subsequent haematuria) can be regarded as a point that underlines the lower coagulation outcome of TURis.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Previous studies have already stated that the histological features of the enucleated prostate by ThuLEP is similar to the resected one in other techniques<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> and no differences were outlined by our pathologist looking at the specimens coming from the two different groups.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Our results confirmed that the evidence of the published literature on ThuLEP reveals a favorable safety profile for the approach. During the procedure, ThuLEP shares the same general challenges with all transurethral enucleation approaches which are the risk of surgical capsule perforation during enucleation and the chance of bladder wall laceration and/or perforation during the morcellation process. Surgical capsule perforation is generally avoided during ThuLEP, as blunt dissection of adenoma over its capsule not only minimizes such a risk but also ensures proper capsule visualization during enucleation maneuvers.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a> Such a complication has been reported in only one patient throughout ThuLEP literature.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a> Bladder wall injury during morcellation has been reported in up to 5.56% of cases, when a mechanical tissue morcellator was employed.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a> As reported in the literature, if the bladder injury is intraoperatively recognized, it can be easily fixed with Tm:YAG coagulation and does not lead to any postoperative issues.</p><p id="par0160" class="elsevierStylePara elsevierViewall">The excellent haemostasis provided by thulium laser application is evidenced by a limited hemoglobin decrease (0.45<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.23<span class="elsevierStyleHsp" style=""></span>g/dl in our study 0.5–1.27<span class="elsevierStyleHsp" style=""></span>g/dl in the literature) in the vast majority of patients. This is consistent with reports for other Tm:YAG-based techniques.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Our data on early postoperative outcomes underline a good control on hemoglobin loss. This report is confirmed by current literature revealing that ThuLEP resulted in significantly lower blood loss and transfusion rates than TURP (0.95 vs 1.81<span class="elsevierStyleHsp" style=""></span>g/dl and 0 vs 3.85% accordingly) and comparable outcomes with HoLEP.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">18,19</span></a> With our evidence, this can be also the result compared to TURis. This may be attributed to the coagulative necrosis caused by the laser beam that causes less bleeding. Furthermore, the enucleation during ThuLEP occurs at the level of the capsule, thus opening the prostatic vessels only once unlike the bipolar resection that opens the vessels several times during resection.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> This has been also indicated by Carmignani et al.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a> as one of the reasons for the ejaculatory preserving function of ThuLEP.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Re-catheterization rates in the published literature varied significantly among studies (0, 1.4, 2.7 and 6.8%) reflecting the heterogeneity of studied populations.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">15,16,18,19</span></a> However, reported rates are low and at least comparable with the rest of transurethral literature.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Someone can argue that the ThuLEP learning curve is an issue as it is in HoLEP. Actually, the main reported drawback of the HoLEP is the steep learning curve for this procedure which might be attributed to the use of the straight end-firing laser fiber and the resection technique in a retrograde manner; unlike the TURP, both might be the reason for also the relatively longer operative time.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> However, this does not agree with what was published by Ahyai et al.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> who reported a faster enucleation time with holmium comparable to open prostatectomy and better than monopolar TURP. The same conclusion on ThuLEP has been reached by Saredi et al.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">When comparing HoLEP and bipolar TURP, Chen et al.,<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> in their randomized study carried out on 280 patients, showed similar results on IPSS, <span class="elsevierStyleItalic">Q</span>max after a 2-year follow-up with shorter catheterization time, shorter hospital stay, and less bleeding in the bipolar group. Better outcomes with regard to shorter catheterization time, lower economic costs, and a reduced hospital stay were found by Juaneda in his study that compared HoLEP with laparoscopic simple prostatectomy.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">To our knowledge, this is the first study that compares ThuLEP with TURis and we can confirm the same intraoperative outcomes of the previous study on different techniques.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Both techniques are safe, with no relatively longer operative time for ThuLEP.</p><p id="par0195" class="elsevierStylePara elsevierViewall">In this study, we are trying to find out the advantages and disadvantages of each technique over the other. As regard the retrieved prostatic tissue, although the mean retrieved tissues were found more in the ThuLEP group as compared to the TURis group, this was not found statistically significant. This may be attributed to the technique of enucleation we used to separate the adenoma from the capsule which combines both the power of the end-firing laser fiber and the mechanical peeling effect of the sheath leading to a more radical removal of the adenoma as compared to the bipolar resection technique.</p><p id="par0200" class="elsevierStylePara elsevierViewall">On the other hand, mean operative time was found to be statistically similar in the two groups. This disagrees with some other previous study,<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">21,26</span></a> and we believe that this might be attributed to the fact that each surgeon was not in training for the performed procedure. Finally, the time needed for the morcellation did not add additional operative time.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Postoperative urethral stricture was reported in 4 patients in group B and one in the ThuLEP group (group A). Whether this can be attributed to the bipolar resection using the bipolar resection system (Surgmaster TURis; Olympus) or another unknown cause is not clear. However, several studies tried to find out the associated risk of urethral stricture after bipolar resection of the prostate and found no statistically significant difference between bipolar and monopolar resection of the prostate.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">There was no statistically significant difference between both groups regarding the maximum flow rate. This agrees with the results of our previous study analyzing HoLEP versus TURis<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">21,25</span></a> in which the authors did not find any difference between both groups considering the IPSS and <span class="elsevierStyleItalic">Q</span>max.</p><p id="par0215" class="elsevierStylePara elsevierViewall">The limitation of this study included the need for a larger sample size. This will allow to divide the groups according to the prostate size and compare the results of ThuLEP and bipolar resection based on their sizes. Another limitation is the short follow-up time in which the results of the two different approaches seem to provide the same outcomes. This needs to be confirmed in a longer period.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0220" class="elsevierStylePara elsevierViewall">ThuLEP and TURIS both relieve lower urinary tract symptoms equally, with high efficacy and safety. ThuLEP was statistically superior to TURIS in blood loss, catheterization time, irrigation volume, and hospital stay. However, procedures did not differ significantly in <span class="elsevierStyleItalic">Q</span>max, IPSS, PVR, and QOLS through 3 months of follow-up.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">Authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres843915" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec839026" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres843916" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec839027" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack283517" "titulo" => "Acknowledgement" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-04-21" "fechaAceptado" => "2016-06-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec839026" "palabras" => array:3 [ 0 => "Benign prostatic hiperplasia" 1 => "Thulium laser transurethral enucleation of the prostate" 2 => "Transurethral bipolar resection of the prostate" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec839027" "palabras" => array:3 [ 0 => "Hiperplasia benigna de próstata" 1 => "Enucleación transuretral con láser de tulio de la próstata" 2 => "Resección bipolar transuretral de la próstata" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To compare clinical intra and early postoperative outcomes between thulium laser transurethral enucleation of the prostate (ThuLEP) and transurethral bipolar resection of the prostate (TURis) for treating benign prostatic hyperplasia (BPH) in a prospective randomized trial.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The study randomized 208 consecutive patients with BPH to ThuLEP (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>102) or TURis (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>106). For all patients were evaluated preoperatively with regards to blood loss, catheterization time, irrigation volume, hospital stay and operative time. At 3 months after surgery they were also evaluated by International Prostate Symptom Score (IPSS), maximum flow rate (<span class="elsevierStyleItalic">Q</span>max), and postvoid residual urine volume (PVR).</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The patients in each study arm each showed no significant difference in preoperative parameters. Compared with TURIS, ThuLEP had same operative time (53.69<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>31.44 vs 61.66<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>18.70<span class="elsevierStyleHsp" style=""></span>minutes, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.123) but resulted in less hemoglobin decrease (0.45 vs 2.83<span class="elsevierStyleHsp" style=""></span>g/dl, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.005). ThuLEP also needed less catheterization time (1.3 vs 4.8 days, P<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.011), irrigation volume (29.4 vs 69.2<span class="elsevierStyleHsp" style=""></span>l, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.002), and hospital stay (1.7 vs 5.2 days, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.016). During the 3 months of follow-up, the procedures did not demonstrate a significant difference in <span class="elsevierStyleItalic">Q</span>max, IPSS, PVR, and QOLS.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">ThuLEP and TURis both relieve lower urinary tract symptoms equally, with high efficacy and safety. ThuLEP was statistically superior to TURis in blood loss, catheterization time, irrigation volume, and hospital stay. However, procedures did not differ significantly in <span class="elsevierStyleItalic">Q</span>max, IPSS, PVR, and QOLS through 3 months of follow-up.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Comparar los resultados clínicos intra y postoperatorios tempranos entre la enucleación transuretral con láser de tulio de la próstata (ThuLEP) y la resección bipolar transuretral de la próstata (TURis) para el tratamiento de la hiperplasia prostática benigna (HBP) en un ensayo prospectivo aleatorizado.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El estudio aleatorizó a 208 pacientes consecutivos con HBP a ThuLEP (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>102) o TURis (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>106). Para todos los pacientes se evaluaron preoperatoriamente en cuanto a pérdida de sangre, tiempo de cateterización, volumen de irrigación, estancia hospitalaria y tiempo operatorio. A los 3 meses después de la cirugía también fueron evaluados por la <span class="elsevierStyleItalic">International Prostate Symptom Score</span> (IPSS) el flujo máximo (Qmáx) y el volumen de residuo posmiccional (RPM).</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los pacientes en cada brazo de estudio no mostraron diferencias significativas en los parámetros preoperatorios. En comparación con TURis, ThuLEP tuvo el mismo tiempo quirúrgico (53,69<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>31,44 vs 61,66<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>18,70<span class="elsevierStyleHsp" style=""></span>min; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,123), pero resultó en menos disminución de la hemoglobina (0,45 vs 2,83<span class="elsevierStyleHsp" style=""></span>g/dl, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,005). ThuLEP también necesitó menos tiempo de cateterización (1,3 vs 4,8 días, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,011), volumen de irrigación (29,4 vs 69,2<span class="elsevierStyleHsp" style=""></span>l; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,002) y estancia hospitalaria (1,7 vs 5,2 días, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,016). Durante los 3 meses de seguimiento, los procedimientos no demostraron una diferencia significativa en Qmáx, IPSS, RPM y ECDV.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ThuLEP y TURis alivian los síntomas del tracto urinario inferior igualmente, con alta eficacia y seguridad. ThuLEP fue estadísticamente superior a TURis en la pérdida de sangre, el tiempo de cateterización, el volumen de irrigación y la estancia hospitalaria. Sin embargo, los procedimientos no difirieron significativamente en Qmáx, IPSS, RPM y ECDV a través de 3 meses de seguimiento.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bozzini G, Seveso M, Melegari S, de Francesco O, Buffi NM, Guazzoni G, et al. Enucleación con láser de tulio (ThuLEP) frente a resección transuretral de la próstata en solución salina (TURis): un ensayo prospectivo aleatorizado para comparar resultados intra y postoperatorios tempranos. Actas Urol Esp. 2017;41:309–315.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group A \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group B \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">N</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">102 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age yrs (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preoperative prostatic volume ml. (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>45.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>39.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PSA ng/ml (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preoperative Hb g/dl (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IPSS (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Q</span>max ml/s (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postvoid volume ml (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>75.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">112.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>83.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1425410.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient data.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group A \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group B \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Operative time, min (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.69<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>31.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.66<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>18.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.123 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hemoglobin decrease, g/dl. (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.45<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.83<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Catheterization time, days (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.011 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Continuous irrigation volume, l (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>25.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Enucleated/resected prostatic volume, gr. (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.13<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>23.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.84<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>18.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.321 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital stay, days (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.016 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1425409.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Intra and early postoperative outcomes.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group A (no. patients, %) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group B (no. patients, %) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Blood transfusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postvoid urinary retention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (6.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (11.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stress incontinence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urge incontinence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (6.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urethral strictures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bladder injury \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1425408.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Postoperative complications.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group A \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group B \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Q</span>max ml/s (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.14<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.87<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IPSS (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.85<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.78<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postvoid residual, ml (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">QOLS (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1425411.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Postoperative functional outcomes (after 3 months).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0140" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[discussion 264]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines on benign prostatic hyperplasia (BPH). 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