Transurethral enucleation procedures for benign prostatic hyperplasia (BPH) can effectively remove large volumes of prostatic tissue comparable to open simple prostatectomy. The most common enucleation procedure is the Holmium Laser Enucleation (HOLEP), but the learning curve is steep and has, thus, not been widely adopted (1). The senior author in this study - a non-fellowship (HOLEP)-trained urologist - was asked to learn HOLEPs, but quickly abandoned them after approximately 6 months and 15 HOLEP procedures when operative times and surgical outcomes were not improving satisfactorily relative to their standard transurethral resection (TURP) experience. Wanting to continue enucleations, however, the enucleation principles were incorporated into more familiar resection bipolar devices, first using the bipolar button (Olympus) electrode and later the plasma button (Olympus). The primary anecdotal advantages expressed by the senior author were 1) immediate familiarity with the instrumentation, 2) ability to use enucleation and traditional resection techniques interchangeably and 3) the ability to perform antegrade and retrograde manipulation of the prostatic tissue during blunt dissection and adenoma enucleation. The purpose of this study is to review our 5-year experience with transurethral bipolar enucleation of the prostate (TUBE). We hypothesized that 1) operative time would decrease and 2) resection volumes would increase over the study period and 3) surgical outcomes would be similar to those reported for standard transurethral resection (TURP) and HOLEP.

This was a retrospective review of a single-surgeon experience with TUBE. From 2015 to 2018, the Olympus PlasmaButton was used for the enucleation. This was switched to the Olympus BandElectrode in early 2019 after negative changes were noted in the durability of the PlasmaButton during the enucleation process (bending/breaking of the electrode). The primary study outcomes included 1) operative time, 2) tissue resection, 3) PSA drop, 4) symptom improvement, 5) maximum flow rate and 6) post-void residual improvement, assessed both as median (range; due to non-normal distributions) and over time (to assess learning curve). Secondary outcomes included rates of 1) de novo stress incontinence, 2) de novo erectile dysfunction, 3) post-operative transfusion, 4) secondary operations for perioperative complications and 5) reoperations for recurrent or persistent obstructive voiding symptoms. Finally, a subanalysis was performed in the cohort of patients that presented in urinary retention requiring either indwelling (n = 68) or intermittent catheterization (n = 22) to see how many became catheter free post-TUBE. All statistical analyses were performed in Excel.

There were 208 patients that underwent a TUBE procedure during the study period, of which 154(74%) were performed with the PlasmaButton and 58 (26%) with the BandElectrode. Prior TUR procedures had been performed in 25 (12%) of the patients (13 TURP, 5 Greenlight Laser, 7 Urolift) by referring providers. Median operative time was 80 minutes (range 3 to 261). The median amount of tissue recovered was 20 grams; 19 grams (range - 2 to 83) with the PlasmaButton and 21 grams (range 1 - 182) with the BandElectrode (p = 0.3). There were no significant changes in either operative time or tissue resection during the study period (Figure 1). Prostate cancer was detected in 13 (6%) patients, of which only 3 (23%) were Grade 3 or higher. The median decline in PSA relative to pre-operative values was 67%.  Perioperative transfusions were required in 3 (1.4%) patients, of which 2 required a secondary procedure for bleeding/clot retention. Four (2%) other patients underwent secondary procedures for acquired bladder neck contracture (n =2), fossa navicularis urethral stricture (n = 1) and prostate regrowth/inadequate initial resection (n = 1) at a median follow time of 1.0 +/- 1.3 months. The median improvement in urinary flow rate was 8.6 mL/sec (range -2.1 to 36.2). The median decrease in post-void residual was 106 mL (range -36 to 869). Of the 93 patients that were catheter dependent pre-operatively, 84 (90%) able to stop catheter use after TUBE. There were 4 (2%) patients that developed de novo stress incontinence (SUI), of which 50% were catheter dependent pre-operatively and none have SUI bothersome enough to require intervention. De novo post-operative PDE-5 prescriptions were provided to 21 (10%) men, though 17 (81%) of these men had an indwelling catheter before surgery with unknown pre-surgical erection status. Of the 166 (80%) of patients that were on prostate/bladder medications pre-operatively, 107 (64%) were off all medications post-operatively, with the majority of those remaining on anticholinergics/muscarinics for persistent urgency/frequency (n = 52; 88%).

TUBE of the prostate can be learned quickly, with minimal learning curve, by urologists already familiar with transurethral resection techniques. Surgical outcomes in this single-surgeon series were favorable and comparable to large HOLEP series (2).

In this single surgeon retrospective study of 208 consecutive TUBE procedures performed by a non-fellowship (HOLEP) trained urologist, comfortable with transurethral procedures, but unable/willing to reach the HOLEP learning curve plateau, surgical outcomes were comparable to HOLEP. While there are likely surgical and perioperative advantages of HOLEP to TUBE that cannot be demonstrated here, this study shows that TUBE may increase the likelihood of incorporating enucleation techniques into clinical practice by those without the necessary technology or the means to endure the HOLEP learning curve (3).

Kampantais S, Dimopoulos P, Tasleem A, Acher P, Gordon K, Young A. Assessing the Learning Curve of Holmium Laser Enucleation of Prostate (HoLEP). A Systematic Review. Urology. 2018 Oct;120:9-22. doi: 10.1016/j.urology.2018.06.012. Epub 2018 Jul 4. PMID: 30403609.
Ibrahim A, Alharbi M, Elhilali MM, Aubé M, Carrier S. 18 Years of Holmium Laser Enucleation of the Prostate: A Single Center Experience. J Urol. 2019 Oct;202(4):795-800. doi: 10.1097/JU.0000000000000280. Epub 2019 Sep 6. PMID: 31009288.
Robles J, Pais V, Miller N. Mind the Gaps: Adoption and Underutilization of Holmium Laser Enucleation of the Prostate in the United States from 2008 to 2014. J Endourol. 2020 Jul;34(7):770-776. doi: 10.1089/end.2019.0603. Epub 2020 Apr 6. PMID: 31880957; PMCID: PMC7404815.