Stesura Seveso Archivio Italiano di Urologia e Andrologia 2022; 94, 2180 ORIGINAL PAPER No conflict of interest declared. and effective treatment option for patients experiencing symptoms of an enlarged prostate. The HoLEP procedure has comparable results to transurethral resection of the prostate (TURP) and OP, with a low morbidity rate and shorter hospital stay (2-6). HoLEP also demonstrated an acceptable steep learning curve (7). Improvements in out- come parameters following HoLEP are durable, and the late complications and reoperation rates reported are very low, up to 18 years (8). Recent evidence suggests that MOSES- TM technology has further revolutionized HoLEP with mod- ulated pulsed energy transmission (9). Enhanced energy delivery is believed to increase efficiency during HoLEP and reduce the operative and catheterization times, as well as blood loss (10). HoLEP performed using MOSESTM tech- nology has been shown to provide faster hemostasis than HoLEP with a standard 100-W holmium laser (9). Thulium fiber laser enucleation of the prostate (ThuFLEP) is an emerging technology for endoscopic prostate enucle- ation. One of the advantages of the thulium fiber laser (TFL) is its wavelength (1940 nm), which has a pho- tothermal effect and a more shallow penetration depth. This allows for precise tissue cutting and reduces the car- bonization effects associated with Thulium:YAG lasers (11-13). Recent data demonstrate that ThuFLEP is an effective minimally-invasive technique for the surgical manage- ment of benign prostatiec hyperplasia (BPH), with treat- ment outcomes comparable to TURP and OP (13, 14). The objective of this study was to assess the safety and efficacy of TFL in patients who underwent ThuFLEP compared to those that underwent MOSESTM HoLEP at our institution. PATIENTS AND METHODS After obtaining Research Ethics Board approval, we con- ducted a retrospective review of prospectively collected data of eighty-two patients who underwent transurethral enucleation of the prostate at our institution from August 2020 to September 2021. Patients were dichotomized depending on whether they underwent enucleation of the prostate using a 120-W MOSESTM (Lumenis, Yoknaem, Introduction: Novel laser technologies have been developed for the minimally invasive surgical management of benign prostatic hyperplasia (BPH). The objective of this study was to assess the safety and efficacy of MOSESTM technology versus the thulium fiber laser (TFL) in patients with BPH undergoing transurethral enucleation of the prostate. Methods: We conducted a retrospective review of prospectively collected data of eighty-two patients who underwent transurethral enucleation of the prostate using MOSESTM or TFL technologies from August 2020 to September 2021. Preoperative and intraoperative parameters, in addition to post- operative outcomes, were collected and analyzed. Results: Twenty patients underwent transurethral enucleation of the prostate with TFL, while 62 had MOSESTM HoLEP. No statistically significant difference in preoperative character- istics was observed between the groups. Patients in the TFL group had longer median enucleation, hemostasis, and morcella- tion times (p < 0.001) than those in the MOSESTM cohort. The longer morcellation time of TFL is mostly related to less visibility. The postoperative outcomes IPSS, QoL, Qmax, and post void residual (PVR), were comparable between the groups at 1, 3 and 6 months. The incidence of urge urinary incontinence (p = 0.79), stress urinary incontinence (p = 0.97), and hospital readmission rates (p = 0.1) were comparable between the two groups. Conclusions: A satisfactory safety and efficacy profile with comparable postoperative outcomes was demonstrated for both techniques; though, MOSESTM technology was superior to TFL in terms of shorter overall operative time. KEY WORDS: Benign Prostatic Hyperplasia; Laser; Enucleation. Submitted 23 March 2022; Accepted 25 April 2022 INTRODUCTION A wide range of laser technologies have been developed for anatomical endoscopic enucleation of the prostate (AEEP), which adopts the principle of open prostatectomy (OP). The efficacy and safety of AEEP have been widely demon- strated, regardless of the energy source utilized (1). Holmium laser enucleation of the prostate (HoLEP) is a safe Comparative analysis of MOSESTM technology versus novel thulium fiber laser (TFL) for transurethral enucleation of the prostate: A single-institutional study Hazem Elmansy 1, Amr Hodhod 1, Ahmed Elshafei 1, Yasser A Noureldin 1, 2, Vahid Mehrnoush 1, Ahmed S. Zakaria 1, Ruba Abdul Hadi 1, Moustafa Fathy 1, 3, Loay Abbas 1, Ahmed Kotb 1, Walid Shahrour 1 1 Urology Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada; 2 Urology Department, Benha University, Benha, Egypt; 3 Urology Department, Menoufia University, Shebin Elkom, Egypt. DOI: 10.4081/aiua.2022.2.180 Summary 181Archivio Italiano di Urologia e Andrologia 2022; 94, 2 MOSESTM vs. TFL enucleation of prostate Israel) or TFL (Soltive Premium, Olympus, USA). A 550-μm laser fiber and a 28-F continuous flow resectoscope (Karl Storz SE & Co. KG, Tuttlingen, Germany) were used for both procedures. We included patients with a prostate size > 80 g that presented with severe lower urinary tract obstruction that did not respond to medical treatment, refractory urinary retention, refractory hematuria due to prostate enlargement, and bladder stones secondary to BPH. Preoperative evaluation included patient demographics, a complete medical history, physical examination includ- ing a digital rectal exam (DRE), the use of antiplatelets and anticoagulants, history of urinary retention, and previous prostate surgery. Symptom assessment was completed using the International Prostate Symptom Score (IPSS) and quality of life (QoL) questionnaires. Patients underwent prostate-specific antigen (PSA) testing, uroflowmetry, a post-void residual (PVR) bladder scan, and a transrectal ultrasound for prostate volume estimation. Patients with PSA values above normal or those with abnormal DRE findings underwent a preoperative biopsy to exclude prostate cancer. A preoperative cystoscopy was performed in individuals who previously underwent TURP to exclude urethral strictures and bladder neck (BN) contracture. Surgical parameters including enucleation time, enucleation efficiency, morcellation time, laser energy, resected weight, intraoperative complications, and the need for blood transfusion were recorded. Enucleation efficiency is defined as the weight of enucle- ated prostatic tissue (grams) divided by the enucleation time (minute). Early postoperative complications included clot reten- tion, a failed trial of void (TOV) and hospital readmission. Preoperative and postoperative hemoglobin levels were measured. Late postoperative complications included urge urinary incontinence (UUI), stress urinary incontinence (SUI), urethral strictures, and BN contraction. SUI was evaluated with a detailed history regarding the involun- tary passage of urine while coughing or sneezing or the use of pads to avoid wetting. Clinical evaluation of SUI was conducted by asking the patient, with a full bladder, to cough and by observing the passage of any urine. All patients had postoperative follow-ups at 1, 3, 6 and 12 months. Our evaluation included IPSS, QoL, Qmax, and PVR. PSA levels were measured at three months postop- erative. Surgical technique Our top-down enucleation techniques using the holmi- um laser or TFL were reported in previous publications (15, 16). Postoperative care Until August 2020, we performed standard 100-W HoLEP, and our practice was an overnight hospital admission with a next-day TOV (< 24 hours). After acquiring MOSESTM technology in December 2020, we implemented same-day discharge and same-day TOV for patients that underwent MOSESTM HoLEP. The standard practice for TFL prostate enucleation was an overnight admission and next-day TOV (< 24 hours). Patients who met predetermined discharge criteria following an assess- ment by the surgeon were offered same-day catheter removal 3 hours postoperatively. They were informed that our standard practice was an overnight admission or same-day discharge with outpatient catheter removal on postoperative day one (POD1). Patients with an unfit med- ical condition (e.g., uncontrolled cardiovascular disease, cognitive disorder, and anticoagulant or antiplatelet ther- apy) were excluded from early discharge. Those without a caregiver or residing beyond city limits were also excluded. Patients were not excluded based on PVR, the presence of an indwelling catheter or other subjective cri- teria. All patients were counselled regarding the option to decline same-day catheter removal and discharge if they felt uncomfortable. If medically feasible, patients were instructed to temporarily hold their antiplatelet and anti- coagulant medications before surgery for 7 and 3 days, respectively. A same-day TOV was not offered to patients who could not withhold their antiplatelet or anticoagu- lant therapy. All patients had a three-way Foley catheter (22 F, with 75 ml of sterile water in the balloon) inserted postoperative- ly and were kept on mild traction with continuous bladder irrigation (CBI). The cases were postoperatively trans- ferred to the Post Anesthesia Care Unit (PACU) for obser- vation. For MOSESTM patients, CBI was continued for 2 hours and was then stopped for an additional hour to evaluate the degree of hematuria. While patients who underwent TFL were admitted overnight with CBI. Routine blood testing, including a complete blood count and basic metabolic profile, were conducted in the PACU. Voiding trials were performed 3 hours postoperatively for MOSESTM patients and next day for the TFL group. Following TOV, all patients were assessed by the urolo- gist for suitability for discharge. A TOV was performed by filling the catheter with 300- 500 mL of saline or until the patient felt the urge to uri- nate. The urine colour, volume voided, and PVR were assessed to ensure there was no concern for hematuria or possible clot retention. Predetermined discharge criteria included: if the patient was deemed medically fit, was not on anticoagulants or antiplatelets, had a caregiver, and met discharge criteria (17). Patients with a minimum score of 9 on the modified Post Anaesthetic Discharge Scoring System were considered ready for discharge. A score of ≥ 2 was required for vital signs, pain and surgical bleeding criteria, whereas a min- imum score of 1 was required for all other criteria. Before discharge, patients were also required to have acceptable laboratory results, hematuria scores (without CBI or the presence of clots) (18), tolerate diet, and ambulate independently. A TOV was considered success- ful if the patient had a PVR < 300 and if the residual vol- ume was less than half the voided volume, and there was no concern for hematuria or possible clot retention. Statistical analyses Data collection and statistical analyses were performed using Statistical Package for the Social Sciences (SPSS®) ver- sion 26.0 (Chicago, IL, USA) and JMP® Pro16 software (SAS Institute Inc., Cary, NC). Continuous data were pre- sented using medians and interquartile ranges (IQR) and compared with the Mann-Whitney U Test. Numbers and Archivio Italiano di Urologia e Andrologia 2022; 94, 2 H. Elmansy, A. Hodhod, A. Elshafei, et al. 182 percentages were used to describe categorical data, which was compared using the Chi-Square test. The p-value was considered statistically significant if p < 0.05. RESULTS Of the 82 patients included in the study, 62 underwent MOSESTM HoLEP, and 20 had transurethral enucleation of the prostate with TFL. The preoperative characteristics of the two groups are listed in Table 1. There was no difference between treatment modalities in terms of compared preoperative parameters. Patients who underwent TFL prostate enucleation had longer median enucleation, hemostasis, and morcellation times (p < 0.001) compared to MOSESTM (Table 2). Moreover, the enucleation efficiency was significantly higher using MOSESTM technology (p = 0.006). No intraoperative complications were recorded for both technologies. Two patients (10%) in the TFL cohort required hospital readmission compared to one (1.6%) in the MOSESTM group (p = 0.1). All three cases of hospital readmission were due to hematuria. All patients in our study had their catheters removed postoperatively and were discharged from the hospital within 24 hours; though, patients who underwent MOSESTM HoLEP had their catheters removed within 3 hours postoperatively with a hospital stay ≤ 6 hours. Patients who underwent TFL enucleation of the prostate had their catheters removed within 24 hours and had a hospital stay of ≤ 24 hours. None of the patients in our study required postoperative blood transfusion. Following catheter removal, one patient (5%) in the TFL group and 3 individuals (4.8%) in the MOSESTM group experienced SUI (p = 0.97). The incidence of UUI post-catheter removal was 10% (2 patients) and 8.1% (5 patients) in the TFL and MOSES TM groups, respectively (p = 0.79). All cases of SUI and UUI were resolved at 3-months follow-up. The postoperative functional outcomes were comparable between the two groups including median Qmax at 1, 3 and 6 months (p = 0.55, p = 0.32, p = 0.82), respective- ly and median PVR at 1, 3, and 6 months (p = 0.88, p = 0.92, p = 0.31), respectively. The median IPSS at 1, 3 and 6 months (p = 0.6, p = 0.26, p = 0.11), respectively and median QoL at 1, 3 and 6 months (p = 0.6, p = 0.32, p = 0.71), respectively were also comparable between the groups (Figure 1). At 6-months follow-up (Figure 2), there were no differ- ences between the groups in terms of improvement in percentages of IPSS (p = 0.38), QoL (p = 0.77), Qmax (p = 0.84), and PVR (p = 0.33). DISCUSSION Over the last few years, emerging laser technologies have been introduced for BPH management. This study com- pared two well-known technologies: MOSESTM and the novel TFL. Both modalities demonstrated promising results in the management of primary and recurrent enu- cleation of BPH (19). Though MOSES TM and TFL were individually studied with other modalities in the literature, the two technolo- gies were not previously compared. MOSESTM technolo- gy was associated with a shorter operative time compared to conventional HoLEP. This may be due to the enhanced hemostatic properties of MOSESTM (9, 10, 20). Compared to OP, TFL was associated with a shorter hos- pital stay and earlier return to normal activities (14). Moreover, TFL was comparable to conventional monopo- lar TURP in the management of moderate-sized prostates (< 80 cc). At 12-months follow-up, TFL was associated with a greater reduction in PSA levels, indicating enhanced removal of the prostatic adenoma (13). In the current study, MOSESTM HoLEP was associated with significantly less enucleation and hemostasis times than TFL. This could be explained by better hemostasis achieved with MOSESTM technology than TFL. Doizi and colleagues found incision depth and coagulation areas were greater with the holmium laser than TFL. Moreover, they noticed that the holmium laser had no carbonization zone while it was constant with the TFL (21). In this study, MOSESTM technology had better enucle- ation efficiency than TFL (1.6 vs 1.4 g/min, p = 0.006). Our reported TFL enucleation efficiency is comparable to other studies. Enikeev et al. had an enucleation efficiency of 1.04 g/min using TFL (14). Nevo and colleagues report- ed a mean enucleation efficiency of 1.7 g/min with MOSESTM 2.0 technology (10). We found that morcellation time was shorter in the Table 1. Preoperative characteristics of both groups. MOSESTM TFL P-value (62 patients) (20 patients) Age at surgery (median/IQR) yrs 71.4 (64.5-80.1) 73.8 (66.2-82.6) 0.2 Indication Urine retention n (%) 12 (19.4) 7 (35) 0.15 LUTS/hematuria n (%) 50 (80.6) 13 (65) Comorbidities n (%) 51 (82.3) 13 (65) 0.1 Prostate volume (median/IQR) cc 109 (87-122) 102 (91.5-118.75) 0.97 Preoperative IPSS (median/IQR) 25 (22-28) 25.5 (23.3-28.5) 0.55 Preoperative QoL (median/IQR) 5 (4-5.25) 5 (4.25-6) 0.34 Preoperative Qmax (median/IQR) ml/min 7.7 (5.7-10.6) 7.95 (6.4-11) 0.74 Preoperative PVR (median/IQR) ml 223 (130-323) 234 (99.5-440) 0.82 Preoperative PSA (median/IQR) ng/dl 4.8 (3.6-7.4) 4.8 (4.2-5.5) 0.89 Preoperative hemoglobin (median/IQR) g/L 145 (140-151) 139 (131.3-143) 0.052 Table 2. Operative parameters comparing MOSESTM to TFL technologies in prostate enucleation. MOSESTM TFL P-value (62 patients) (20 patients) Enucleation time (median/IQR) min 46.5 (40-54) 61.5 (55-68.7) < 0.001 Hemostasis time (median/IQR) min 3 (2-4) 5 (5-6.7) < 0.001 Morcellation time (median/IQR) min 10 (6.7-12) 15 (10.2-22.7) < 0.001 Laser energy (median/IQR) KJ 79.7 (65.4-99.7) 78.4 (67.8-95.3) 0.75 Prostate enucleated weight (median/IQR) g 70 (60-90) 79 (58.5-90.8) 0.51 Hemoglobin drop (median/IQR) g/L 10 (7-14) 10.5 (7.3-14) 0.6 Enucleation efficiency (median/IQR) g/min 1.6 (1.3-2) 1.4 (1-1.6) 0.006 Readmissions n (%) 1 (1.6) 2 (10) 0.1 183Archivio Italiano di Urologia e Andrologia 2022; 94, 2 MOSESTM vs. TFL enucleation of prostate MOSESTM group compared to the TFL cohort, 10 vs 15 minutes, respectively (p < 0.001). We observed a higher clarity of vision with MOSESTM due to better hemostasis that facilitated faster morcellation of the adenoma. Our morcellation time is similar to that of Large and col- leagues (mean time = 10.4 min) (9). The morcellation time following TFL prostate enucleation is not well docu- mented in the literature. We cannot compare TOV for MOSESTM and TFL because we adopted a same-day TOV for the MOSESTM cohort, whereas patients who underwent TFL were kept overnight. Similarly, the hospital stay cannot be com- pared as TFL patients were routinely admitted and dis- charged the following day. In the current study, same-day TOV following MOSESTM enucleation was successful in about 93.5% of patients. Figure 1. Functional outcomes comparing MOSESTM to TFL technologies for prostate enucleation. Archivio Italiano di Urologia e Andrologia 2022; 94, 2 H. Elmansy, A. Hodhod, A. Elshafei, et al. 184 This result seems promising if we compare it with the 88% successful same-day TOV rate, reported by Slade et al., following conventional HoLEP (22). Although the intraoperative enucleation parameters were better with MOSESTM technology, both TFL and MOSES- TM had comparable postoperative outcomes at 6 months follow-up (Figures 1, 2). Other studies reported similar results for both laser tech- nologies (9, 10, 13, 14). Our study has some limitations, including its retrospec- tive nature, though it is a retrospective analysis of prospectively collected data. A second limitation is the small number of patients in the TFL group. A similar number of procedures were used to evaluate laser enu- cleation of the prostate in other studies (10). Moreover, the hospital stay and same-day TOV of both technologies could not be compared. Our study has a relatively short follow-up period; how- ever, similar follow-up intervals were used in the litera- ture (9, 14). Additional studies with larger sample sizes and more extended follow-up periods are warranted. CONCLUSIONS To the extent of our knowledge, this is the first study com- paring MOSESTM and TFL technologies for transurethral prostate enucleation. A satisfactory safety and efficacy pro- file with comparable postoperative outcomes was demon- strated for both techniques; though, MOSESTM technology was superior to TFL in terms of shorter overall operative time. REFERENCES 1. Herrmann TR. Enucleation is enucleation is enucleation is enucle- ation. World J Urol 2016; 34:1353-5. 2. Kuntz RM, Ahyai S, Lehrich K, Fayad A. Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. J Urol 2004; 172:1012-6. 3. Li S, Zeng XT, Ruan XL, Weng H, Liu TZ, Wang X, et al. Holmium laser enucleation versus transurethral resection in patients with benign prostate hyperplasia: an updated systematic review with meta-analysis and trial sequential analysis. PLoS One 2014; 9:e101615. 4. 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Comparison of Holmium:YAG and Thulium fiber lasers on soft tis- sue: an ex vivo study. J Endourol. 2022; 36:251-258. 22. Slade A, Agarwal D, Large T, Sahm E, Schmidt J, Rivera ME. Expanded criteria same day catheter removal following Holmium laser enucleation of the prostate (HoLEP). J Endourol 2022. doi: 10.1089/end.2022.0007. Epub ahead of print. Correspondence Hazem Elmansy, MD, MSc, FRCSC hazem.mansy@rocketmail.com Associate Professor & Program Director of the Minimally Invasive Urologic Surgery Fellowship Program, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada 146 Court Street South, Thunder Bay, ON, P7B 2X6 Amr Hodhod, MD Ahmed Elshafei, MD Yasser A Noureldin, MD Vahid Mehrnoush, MD Ahmed S Zakaria, MD Ruba Abdul Hadi, RD Moustafa Fathy, MD Loay Abbas, MD Ahmed Kotb, MD Walid Shahrour, MD Urology Department, Northern Ontario School of Medicine, Thunder Bay, Ontario (Canada)