For managing lower urinary tract symptoms (LUTS) caused by benign prostatic enlargement (BPE), patients are initially treated with medical therapy, and if this treatment failed they were advised to undergo surgery1. Prostate size is a major factor to consider when various treatments for BPE are evaluated2. However, it is difficult to medical or surgical treatment considering treatment efficacy and safety, especially in patient with small prostate. Therefore, this study compared the efficacy of holmium laser enucleation of prostate (HOLEP) and medication for LUTS with a prostate smaller than 40gm.

We retrospectively reviewed and compared the medical records of patients ≥ 40 years old suffering with LUTS who were treated with medication and had undergone HOLEP procedure. For LUTS, the patients were assessed by International Prostate Symptom Score (IPSS), serum PSA, prostate volume measured via transrectal ultrasound, uroflowmetry and post-void residual urine. At first, the patients with LUTS were treated with alpha-blockers. After medical treatment for a month, we discussed about the efficacy and safety for medical treatment and decided whether to continue the medical treatment or to do surgical treatment. We excluded the patients with a history of taking a medication for LUTS (including α-blockers, 5-α-reductase inhibitors or anticholinergics) or other urological condition (cancer, urologic surgery, neurogenic bladder, urinary tract infection). We compared the efficacy using IPSS, maximum urinary flow rate and post-void residual at treatment 3 months between the medical treatment and surgical treatment and analyzed the predictors of progression to surgery.

We enrolled 90 patients with medication continuation and 151 patients with progression to HOLEP, a surgical treatment for BPE. After treatment 3 months, there was no significant difference in total IPSS score. However, voiding score and QOL score in IPSS were improved in HOLEP group compared medication continuation group (4.7±3.9 vs. 5.9±5.2, p=0.013, 2.5±1.5 vs. 3.1±1.4, p=0.004, respectively). And maximum flow rate was improved in HOLEP group compared medication continuation group (19.1±10.5ml/s vs. 15.4±7.6ml/s, p=0.018). On multivariate analysis, older age (odds ratio 0.895, CI: 0.850-0.944, p <0.001), higher QOL score in IPSS (odds ratio 0.695, CI: 0.523-0.922, p=0.012), and larger post-void residual (odds ratio 0.983, CI: 0.971-0.994, p=0.002) were the independent factors for predicting a progression to surgery for LUTS.

For men with LUTS caused by small prostate, HOLEP is more effective than medical treatment in improving symptom and QOL.

For men with LUTS caused by small prostate, HOLEP is more effective than medical treatment in improving symptom and QOL.

Issa MM. The evolution of laser therapy in the treatment of benign prostatic hyperplasia. Rev Urol 2005;7:S15-22
Kuntz RM, Lehrich K, Ahyai S. Does perioperative outcome of transurethral holmium laser enucleation of the prostate depend on prostate size? J Endourol 2004;18: 183–8