Stesura Seveso Archivio Italiano di Urologia e Andrologia 2023; 95(4):11629 1 ORIGINAL PAPER is the most invasive and associated with high operative morbidity (1). The rate of open prostatectomy surgeries has been progressively decreasing with the advent of min- imally invasive techniques, including monopolar and bipolar TURP and diferent laser therapies (2). Holmium laser enucleation of the prostate (HoLEP) has shown a com- parable functional outcome to open prostatectomy in treating prostates larger than 80 cc (3). However, due to its steep learning curve and higher cost, HoLEP gained lit- tle popularity, especially in developing countries (4). Transurethral enucleation resection of the prostate (TUERP) incorporated the enucleation technique with standard transurethral resection of the prostate (TURP). It is available in all urology theaters, is cost-effective, and could be con- sidered a treatment option resembling LASER enucle- ation, specifically bipolar TUERP (5). In the present study, we aimed to assess the efficacy and safety of bipolar TUERP compared to retropubic prostate- ctomy in patients with LUTS secondary to benign prosta- tic hyperplasia with prostate volumes larger than 80 cc. PATIENTS AND METHODS A prospective randomized study included all patients amenable to benign prostate hyperplasia (BPH) surgeries to control lower urinary tract symptoms with prostate size over 80 cc at the Urology Department of Al-Azhar University Hospitals between January 2020 to February 2022. We excluded patients with neurogenic bladder dysfunction, previous prostatic or urethral surgeries, urethral stricture or bladder neck contracture, renal impairment, and comor- bidities that render them at high anesthetic risk. The local ethical committee approved our research, and all partici- pants signed informed consent. Patients were randomly allocated into one of the two groups; Group 1 included patients who underwent bipolar TUERP, and Group 2 had retropubic open prostatectomy. A stratified block random- ization method (1:1 ratio) was used for patient allocation. Objectives: To compare the outcomes of bipolar Transurethral Enucleation Resection of the Prostate (TUERP) and simple retropubic prostatectomy in patients with prostate volumes larger than 80 cc. Patients and methods: A prospective randomized study included all patients amenable to surgeries for benign prostate hyperpla- sia (BPH) with prostate size over 80 cc at a tertiary care hospital between January 2020 to February 2022. Bipolar TUERP and Retropubic open prostatectomy techniques were compared regarding patients' demographics, intraoperative parameters, outcomes, and peri-operative complications. Results: Ninety patients were included in our study and random- ly assigned to bipolar TUERP (Group 1 = 45 patients) and retropubic open prostatectomy (Group 2 = 45 patients). The TUERP group demonstrated significantly lower operative time (77 ± 11 minutes vs. 99 ± 14 minutes, p < 0.001), hemoglo- bin drop (median = 1.1 vs. 2.5, p < 0.001), and resected tissue weight (71 ± 6.6 cc vs. 84.5 ± 10.6 cc, p < 0.001). Postoperatively, the TUERP group demonstrated significantly lower catheter time (median = 2 vs. 7 days, p < 0.001) and less hospital stay. IPSS, Qmax, and patient satisfaction were better in the TUERP group within six months of surgery. We reported 90-day complications after TUERP in 13.3% of patients com- pared to 17.8% after retropubic prostatectomy, with a statistical- ly insignificant difference. Urethral stricture predominated after TUERP, while blood transfusion dominated in retropubic prosta- tectomy. Conclusions: The present study found that TUERP had equiva- lent efficacy and safety to open retropubic prostatectomy for patients with BPH and prostate volumes > 80 ml. KEY WORDS: TUERP; Simple retropubic prostatectomy; Complications. Submitted 1 August 2023; Accepted 31 August 2023 INTRODUCTION Open prostatectomy is considered the most durable sur- gical option for large (> 80 gm) prostates. Meanwhile, it Evaluation of bipolar Transurethral Enucleation and Resection of the Prostate in terms of efficiency and patient satisfaction compared to retropubic open prostatectomy in prostates larger than 80 cc. A prospective randomized study Ibrahim Tagreda, Mahmoud Heikal, Adel Elatreisy, Mohamed Fawzy Salman, Ahmed Mohamed Soliman, Ayman Kotb Koritenah, Hesham Abozied, Mohamed Ibrahim Algammal, Ahmed A. Alrefaey, Mohamed Elsalhy, Mohamed Shehab, Mahmoud Mohammed Ali, Aly Gomaa Eid, Abdrabuh M. Abdrabuh, Sayed Eleweedy Urology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt. DOI: 10.4081/aiua.2023.11629 Summary Archivio Italiano di Urologia e Andrologia 2023; 95(4):11629 I. Tagreda, M. Heikal, A. Elatreisy, et al. 2 All recruited patients were assessed through the following regimen: full medical history including International Prostate Symptom Score (IPSS) assessment and internation- al index of erectile function (IIEF); complete clinical exam- ination, including digital rectal examination (DRE) and focused neurological examination; urine analysis, urine culture and sensitivity, serum creatinine, coagulation pro- file, CBC, serum Na and potassium, blood sugar, and prostate specific antigen (PSA). Objective evaluation of LUTS carried out through uroflowmetry with post-void residual urine, transrectal ultrasound for estimation of prostate volume, and pelvic-abdominal ultrasound in cases with recurrent hematuria, infection, loin pain, or high post-void residual urine. TUERP procedure was per- formed using a Plasma kinetic resection using a KLS Martin maximum with Storz Fr 26 resectoscope with plasma kinetic electrode using the bipolar current and normal saline irrigation. The procedure involved the cre- ation of the plane of the surgical capsule at a level close- ly proximal to the verumontanum with vaporization; the adenoma was dissected from the capsule plane by unclenching it using the beak of the resectoscope sheath from one side to the other. The blood vessels to the ade- noma were coagulated at the time of dissection. When the whole adenoma was almost dissected from the capsule, a small proportion of adenoma was allowed to anchor the capsule at the bladder neck, which helped the surgeon to harvest the whole adenoma in pieces with resection. The adenoma slices were evacuated manually. The retropubic open prostatectomy procedure was per- formed following the standard operative technique (6). Intraoperative adverse events, operative time, and enucle- ated prostatic weight were recorded. Similarly, postoper- ative reporting of hemoglobin, hematocrit, serum sodium and potassium (K), hospital stay, catheterization period, and 90-day complications were recorded. Patients were booked for clinic visits after one, three, and six months from surgery for clinical evaluation, including IPSS questionnaire, physical assessment, uroflowmetry, and PVR. The study groups were compared in terms of patient demographics, intraoperative parameters, out- comes, and peri-operative complications. Statistical analysis Statistical analysis was done utilizing the SPSS version 28 (IBM, Armonk, New York, United States). Quantitative data were assessed for normality using the Shapiro-Wilk test and direct data visualization methods. According to nor- mality, quantitative data were summarized as means and standard deviations or medians and ranges. Categorical data were expressed as numbers and percentages. Quantitative data were compared between the studied groups using the independent t-test or Mann-Whitney U test for normally and non-normally distributed quantitative variables. Categorical data were compared using the Chi- square or Fisher’s exact test. All statistical tests were two- sided. P values less than 0.05 were considered significant. RESULTS Ninety patients were included in our study and randomly assigned to bipolar TUERP (Group 1 = 45 patients) and retropubic open prostatectomy (Group 2 = 45 patients). The study groups were comparable regarding the patients’ demographics and preoperative laboratory investigations, as shown in Tables 1 and 2. The TUERP group demon- strated significantly lower operative time (77 ± 11 minutes vs. 99 ±14 minutes, p < 0.001), hemoglobin drop (medi- an = 1.1 vs. 2.5, p < 0.001), resected tissue weight (71 ± 6.6 cc vs. 84.5 ± 10.6 cc, p < 0.001), serum potassium (3.9 ± 0.4 vs. 4.1 ± 0.3, p = 0.002), hematocrit (vs. 29 ± 2 vs. 31 ± 2, p < 0.001), and bleeding (22.2% vs. 57.8%, p < 0.001). No significant difference was observed regarding serum Na (p = 0.948) (Table 3). Postoperatively, the TUERP group demonstrated signifi- cantly lower catheter time (median = 2 vs. 7 days, p < 0.001) and lower serum potassium level (2.9 ±0.3 vs. 4.1 ± 0.3, p < 0.001). Additionally, hospital stay significantly differed between the studied groups (p < 0.001), with 57.8% and 42.2% of the TUERP patients having a hospi- Table 1. Baseline general and clinical characteristics of the study groups. Group 1 Group 2 P-value (n = 45) (n = 45) Age (years), mean ± SD 66 ± 6 66 ± 7 0.7 Co-morbidities, N (%) 31(68.9) 28 (62.2) 0.506 IPSS, median(range) 25 (18-32) 24 (16-35) 0.209 Quality of life, N (%) 0.418 Mostly dissatisfied 8 (17.8) 5 (11.1) Unhappy 14 (31.1) 11 (24.4) Terrible 23 (51.1) 29 (64.4) IEEF, median(range) 7 (5-14) 7 (5-13%) 0.239 Prostate size (cc), mean ± SD 110 ± 8 cc 112 ± 7 cc 0.211 Residual urine (ml), median(range) 195 (90 - 590) 190 (107-240) 0.721 TRUS (TV) (cc), mean ± SD 104 ± 12 cc 108 ± 10 0.085 TZ (cc), mean ± SD 89 ± 8.7 cc 91.4 ± 7.9 0.169 Qmax (ml/sec), mean ± SD 9.4 ± 14 8.9 ± 1.5 0.819 IPSS: International Prostate Symptom Score; IEEF: International index of erectile function; TV: total volume of prostate; TZ: transition zone of prostate. Table 2. Baseline laboratory findings of the study groups. Group 1 Group 2 P-value (n = 45) (n = 45) Pyuria, N (%) 23 (51.1) 28 (62.2) 0.288 Positive urine culture, N (%) 23 (51.1) 28 (62.2) 0.288 Serum creatinine (mg/dl), mean ± SD 1.12 ± 0.34 1.03 ± 0.18 0.114 Hemoglobin (gm/dl), mean ± SD 13.2 ± 1.8 13.6 ± 1 0.235 Hematocrit (%), mean ± SD 40.3 ± 4.7 41.3 ± 2.9 0.199 Serum Na (mEq/l), mean ± SD 136.9 ± 4.2 135.8 ± 1.5 0.081 K (mEq/l), mean ± SD 4.12 ± 0.66 4.05 ± 0.36 0.509 PSA-total (ng/ml), median (range) 4 (1.1-20) 3.8 (1.9-10.9) 0.707 PSA-free (ng/ml), median (range) 1 (0.3-2.3) 0.8 (0.4-1.9) 0.084 INR, mean ± SD 0.99 ± 0.03 0.97 ± 0.04 0.129 Random blood sugar (mg/dl), mean ± SD 107 ± 16 104 ± 15 0.361 K: potassium; PSA; prostate specific antigen; INR; international normalized ratio. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11629 3 Evaluation of bipolar Transurethral Enucleation and Resection of the Prostate in terms of efficiency and patient satisfaction... tal stay of two and three days compared to seven days in patients in the open group. No significant differences were observed regarding serum Na (p = 0.265), hemoglobin (p = 0.243), and hematocrit (p = 0.495) levels (Table 4). After one month from surgery, the TUERP group demon- strated significantly lower IPSS (median = 6 vs. 7, p < 0.001) and pyuria (0% vs. 24.4%, p < 0.001). In contrast, it showed a significantly higher urinary flow (20.1 ± 3.1 ml/sec vs. 17.1 ± 1.9 ml/sec, p < 0.001). Additionally, the quality of life differed between the studied groups, with most TUERP patients being mostly satisfied (75.5%) com- pared to the open group (66.6%). No significant differences were observed regarding IIEF (p = 0.065), dysuria (p = 0.292), and residual urine (p = 0.868) (Table 5). After three months, the TUERP group demonstrated sig- nificantly lower IPSS (median = 4 vs. 5, p = 0.049) and dysuria (0% vs. 15.6%, p = 0.012). In contrast, it showed a significantly higher urinary flow (19.7 ± 2.6 ml/sec vs. 18.5 ± 2.5 ml/sec, p = 0.022) and residual urine (median = 16 ml vs. 10 ml, p = 0.014). Additionally, the quality of life differed between the studied groups, with most TUERP patients being mostly satisfied (95.5%) compared to the open group (88.8%). No significant differences were observed regarding IIEF (p = 0.588) and pyuria (p = 0.242) (Table 6). After six months, the TUERP group demonstrated signifi- cantly higher urinary flow (19.3 ± 2.7 ml/sec vs. 17.7 ± 2.4 ml/sec, p = 0.005) and residual urine (median = 15 ml vs. 0, p < 0.001) compared to the open group. No significant differences were observed regarding IPSS (p = 0.189), QOL (p = 0.523), IIEF (p = 0.361), dysuria (p = 0.242), and pyuria (p = 0.242) (Table 7). As regards the complications in the bipolar TUERP Table 3. Intraoperative findings in the studied groups. Group 1 Group 2 P-value (n = 45) (n = 45) Operative time (min), mean ± SD 77 ± 11 99 ± 14 < 0.001 Hemoglobin drop (gm/dl), median(range) 1.1 (0.2-3.7) 2.5 (0.9-6.5) < 0.001 Resected tissue weight (gm), mean ± SD 71 ± 6.6 84.5 ± 10.6 < 0.001 Na (mEq/l), mean ± SD 132 ± 4 132 ± 2 0.948 K (mEq/l), mean ± SD 3.9 ± 0.4 4.1 ± 0.3 0.002 Hematocrit (%), mean ± SD 29 ± 2 31 ± 2 < 0.001 Bleeding, N (%) 10 (22.2) 26 (57.8) < 0.001 K: potassium. Table 4. Postoperative findings in the studied groups. Group 1 Group 2 P-value (n = 45) (n = 45) Catheter time (days) 2 (2-3) 7 (7-7) < 0.001 Hospital stays (days), N (%) < 0.001 Two days 26 (57.8) 0 Three days 19 (42.2) 0 Seven days 0 45 (100) Na (mEq/l), mean ± SD 134.7 ± 4.2 133.9 ± 2.6 0.265 K (mEq/l), mean ± SD 3.9 ± 0.3 4.1 ± 0.3 < 0.001 Hemoglobin (gm/dl), mean ± SD 10.8 ± 1.3 11.1 ± 0.9 0.243 Hematocrit (%), mean ± SD 30 ± 1.8 29.6 ± 3.3 0.495 K: potassium. Table 5. One-month follow-up in the studied groups. Group 1 Group 2 P-value (n = 45) (n = 45) IPSS, median(range) 6 (5-8) 7 (6-17) < 0.001 Quality of life, N (%) Mostly satisfied 34 (75.5) 30 (66.6) Equivocal 11 (24.4) 11 (24.4) Mostly dissatisfied 0 4 (8.9) IIEF, median(range) 7 (5-13) 6 (5-12) 0.065 Dysuria, N (%) 11 (24.4) 7 (15.6) 0.292 Pyuria, N (%) 0 (0) 11 (24.4) < 0.001 Uroflow (ml/sec), mean ± SD 20.1 ± 3.1 17.1 ± 1.9 < 0.001 Residual urine (ml), median (range) 20 (10-70) 25 (0-120) 0.868 IPSS: International Prostate Symptom Score; IEEF: International index of erectile function. Table 6. Three-month follow-up in the studied groups. Group 1 Group 2 P-value (n = 45) (n = 45) IPSS, median(range) 4 (2-6) 5 (3-18) 0.049 Quality of life, N (%) Mostly satisfied 43 (95.5) 40 (88.8) Equivocal 2 (4.4) 5 (11.1) IIEF, median(range) 7 (5-13) 7 (5-13) 0.588 Dysuria, N (%) 0 (0) 7 (15.6) 0.012 Pyuria, N (%) 0 (0) 3 (6.7) 0.242 Uroflow (ml/sec), mean ± SD 19.7 ± 2.6 18.5 ± 2.5 0.022 Residual urine (ml), median (range) 16 (5-50) 10 (0-140) 0.014 IPSS: International Prostate Symptom Score; IEEF: International index of erectile function. Table 7. Six-month follow-up in the study groups. Group 1 Group 2 P-value (n = 45) (n = 45) IPSS, median(range) 3 (2-5) 3 (2-18) 0.189 Quality of life, N (%) 0.523 Pleased 37 (82.2) 34 (75.6) Mostly satisfied 8 (17.8) 8 (17.8) Equivocal 0 (0) 1 (2.2) Mostly dissatisfied 0 (0) 2 (4.4) IIEF, median(range) 7 (5-13) 7 (5-13) 0.361 Dysuria, N (%) 0 (0) 3 (6.7) 0.242 Pyuria, N (%) 0 (0) 3 (6.7) 0.242 Uroflow (ml/sec), mean ± SD 19.3 ± 2.7 17.7 ± 2.4 0.005 Residual urine (ml), median(range) 15 (4-40) 0 (0-160) < 0.001 IPSS: International Prostate Symptom Score; IEEF: International index of erectile function. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11629 I. Tagreda, M. Heikal, A. Elatreisy, et al. 4 group, two patients developed persistent LUTS postoper- atively and were treated with anticholinergics for one month. One patient was catheterized due to urine reten- tion and needed a re-cystoscopy with resection of rem- nant prostatic tissue. Another patient was hospitalized due to secondary hemorrhage and received IV fluids, antibiotics, and hemostatic drugs for three days without re-catheterization or need for blood transfusion. Two patients developed urethral stenosis, which was treated by visual internal urethrotomy (VIU). In the open group, two patients needed blood transfusion postoperatively. Three patients developed persistent LUTS and were treated with anticholinergics for six weeks. Two patients were hospitalized due to secondary hemorrhage and received IV fluids, antibiotics, and hemostatic drugs for two days without re-catheterization or need for blood transfusion. At the same time, one patient developed bladder neck contracture and was treated by bladder neck incision (BNI). The study groups had no statistically significant differ- ence (Table 8). DISCUSSION BPH is a prevalent condition with substantial costs, lead- ing to increased interest in its management (7). Surgical treatments include resection, enucleation, vaporization, alternative ablative techniques (Aquablation- Prostatic artery embolization- The Rezum System), and non-ablative techniques (Prostatic urethral Lift, Intra-prostatic injections) (8). TUERP is a recently developed procedure in which the prostate is transurethrally enucleated and resected using a bipolar plasma kinetic resectoscope. Many studies suggested that TUERP is a safe and feasible treatment for BPH with few complications (9-11). Although several studies have demonstrated better clini- cal benefits for TUERP than other treatments, this proce- dure has yet to be widely accepted for prostates larger than 60 g (12). Therefore, the current study aimed to compare the safety and efficacy of transurethral enucleation resection of the prostate (TUERP) versus open retropubic prostatectomy in patients with LUTS secondary to benign prostatic hyperplasia with prostate volumes larger than 80 cc. In the current study, the TUERP group demonstrated sig- nificantly lower operative time, smaller drop in serum hemoglobin level, less resected tissue weight, smaller drop in hematocrit concentration, and lower incidence of bleeding. In line with our results, a study by Wei et al. found that TUERP had a better outcome regarding operative time and less tissue removal, which may indicate a more pre- cise and targeted approach to prostate surgery (9). Rao et al. found that TUERP generated a smaller serum hemo- globin level drop than trans-vesical prostatectomy (2). In contrast, Ou et al. found no significant difference in operative time between the two procedures (p = 0.107) (10). The resected adenoma weight harvested in the trans-vesical prostatectomy group was more than that in the TUERP group, but the difference between the groups was insignificant (p = 0.062). Similarly, Wang and Wang found no statistically signifi- cant differences in operative time between both tech- niques (13). Some authors reported no significant differences regard- ing the volume of tissue retrieved and postoperative Hb in both groups (p > 0.05) (13, 14). However, some authors reported shorter operative time in open prostate- ctomy procedures compared to TUERP (2, 14). These findings may be due to variations in the study popula- tions, prostate size, surgical techniques, and outcome measures used in each study. As supported by several authors (9, 10, 13, 14), we have found that TUERP has advantages over simple prostatec- tomy in terms of shorter postoperative catheter time and hospital stay. The current study shows the superiority of the urinary functional outcome of TUERP compared to retropubic prostatectomy. IPSS, Qmax, and patient satisfaction were better in the TUERP group within six months of surgery. However, IPSS and patient satisfaction were similar for both techniques six months after surgery. A study by Wei et al. (9) supports our findings that TUERP is better regarding functional outcomes such as IPSS and Qmax. Conversely, other authors reported no superiority for TUERP regarding postoperative urinary functional out- comes compared to simple open prostatectomy. Giulianelli et al. found no significant differences in the Qmax score, QoL score, PSA, and Post-void residual urine between both techniques (14). The smaller prostate size may explain it compared to the populations in our study. Additionally, differences in the follow-up period can con- tribute to differences in study results. Patients were fol- lowed up for 12 months, whereas our study followed up patients for a shorter period. There were no significant differences in Qmax between TUERP and open prostatectomy during the postoperative 1, 3, 6, 12 months, and two years when followed by Chen et al. (3). Analysis by Geavlete et al. showed no significant differences in QoL or PSA between TUERP and open prostatectomy at each follow-up time point (11). The lack of significant differences in Qmax, QoL, and PSA between TUERP and open prostatectomy at multiple follow-up time points in these studies suggests that the two proce- dures may have similar long-term outcomes in terms of these measures. However, the findings could be affected by patient characteristics, surgical technique, and follow- up period. Table 8. Postoperative complications in the study groups. Group 1 Group 2 P-value (n = 45) (n = 45) Secondary hemorrhage, N (%) 1 (2.2) 2 (4.4) 1.0 Retention, N (%) 1 (2.2) 0 (0) 1.0 Blood transfusion, N (%) 0 (0) 2 (4.4) 0.494 LUTS, N (%) 2 (4.4) 3 (6.7) 1.0 Bladder neck contracture, N (%) 0 (0) 1 (2.2) 1.0 Urethral stenosis, N (%) 2 (4.4) 0 (0) 0.494 Archivio Italiano di Urologia e Andrologia 2023; 95(4):11629 5 Evaluation of bipolar Transurethral Enucleation and Resection of the Prostate in terms of efficiency and patient satisfaction... Other measures, such as operative time, blood loss, and length of hospital stay, may still favor TUERP over open prostatectomy. Therefore, the choice of procedure may depend on various factors, including patient preference and surgeon experience. Similarly, Ou et al. found no significant difference between the groups regarding IPSS and PVR at 3 and 12 months postoperatively. However, the patients in the open prostatectomy group appeared to have a better Qmax at three months, but the difference was insignificant (p = 0.081). Each group's mean postoperative PSA reductions were similar (p = 0.12) (10). In contrast, Giulianelli et al. observed significantly lower IPSS and PVR scores at 12, 24, and 36 months in the TUERP group when compared with the open prostatec- tomy group (p < 0.05) (14). We reported 90-day complications after TUERP in 13.3% of patients compared to 17.8% after retropubic prostate- ctomy with a statistically insignificant difference; urethral stricture predominated after TUERP while blood transfu- sion dominated in retropubic prostatectomy. Giulianelli et al. found that dysuria was the most common Grade I complication in the TUERP group (p < 0.05) and urinary urge incontinence up to 30 days in the open prostatectomy group (p < 0.05). In the Grade II compli- cations, the results favored the TUERP group (postopera- tive acute urinary retention, p < 0.05 and blood transfu- sion requirement, p < 0.05) than the open prostatectomy group. The study favored the TUERP group (capsular perforation and reintervention, p < 0.05) over the open prostatectomy group for Grade III complications (14). Also, Gratzke et al. reported a higher incidence of blood transfusion, stress incontinence, and urethral stricture in a large series of open prostatectomies for large prostates (15). UTI and re-catheterization rates were slightly lower in a study by Tubaro et al. (16). Serretta et al. detected a higher incidence of bleeding, blood transfusions, and sepsis in open prostatectomies. Reinterventions were also higher, mainly due to bladder neck stenosis (17). Also, Wang and Wang (13) and Wei et al. (9) found that the inci- dence of complications in the TUERP group was statisti- cally lower (p < 0.05). Geavlete et al. found no statistical differences between TUERP and open prostatectomy con- cerning transient incontinence, bladder neck contracture, or urethral stricture (11). Limitations of the study Despite being a prospective randomized trial, the current study has some limitations. Firstly, it has a small sample size. Secondly, the follow-up period is short. Additionally, it is essential to note that the study only included patients with prostate volumes larger than 80cc, which may not represent patients with smaller prostate volumes. CONCLUSIONS The number of patients with large prostate volumes undergoing surgical therapy is increasing, and the trend is likely to continue as the population ages. The present study found that TUERP had equivalent efficacy and safe- ty to open retropubic prostatectomy for patients with BPH and prostate volumes > 80 ml. REFERENCES 1. Gravas, SCJN, Cornu JN, Gacci M, et al. Management of non- neurogenic male lower urinary tract symptoms (LUTS), incl. benign prostatic obstruction (BPO). European Association of Urology, 2019. (European Association of Urology. Guidelines). 2. Rao JM, Yang JR, Ren YX, et al. Plasmakinetic enucleation of the prostate versus transvesical open prostatectomy for benign prostatic hyperplasia > 80 mL: 12-month follow-up results of a randomized clinical trial. Urology. 2013; 82:176-81. 3. Chen S, Zhu L, Cai J, et al. Plasmakinetic enucleation of the prostate compared with open prostatectomy for prostates larger than 100 grams: a randomized noninferiority controlled trial with long- term results at 6 years. Eur Urol. 2014; 66:284-291. 4. Elzayat EA, Elhilali MM. Holmium laser enucleation of the prostate (HoLEP): long-term results, reoperation rate, and possible impact of the learning curve. Eur Urol. 2007; 52:1465-1472. 5. Lourenco T, Armstrong N, N’dow J, et al. Systematic review and economic modelling of effectiveness and cost utility of surgical treat- ments for men with benign prostatic enlargement. Health Technol Assess. 2008; 12: 1-146. 6. Millin T. The surgery of prostatic obstructions. Irish Journal of Medical Science (1926-1967). 1947; 22:185-189. 7. Miernik A, Gratzke C. Current treatment for benign prostatic hyperplasia. Deutsches Ärzteblatt International. 2020; 117:843. 8. Hwang EC, Jung JH, Borofsky M, et al. Aquablation of the prostate for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database of Systematic Reviews. 2019; 2. 9. Wei Y, Xu N, Chen SH, et al. Bipolar transurethral enucleation and resection of the prostate versus bipolar resection of the prostate for prostates larger than 60gr: a retrospective study at a single aca- demic tertiary care center. International Braz J Urol. 2016; 42:747- 756. 10. Ou R, Deng X, Yang W, et al. Transurethral enucleation and resection of the prostate vs transvesical prostatectomy for prostate volumes > 80 mL: a prospective randomized study. BJU internation- al. 2013; 112:239-245. 11. Geavlete B, Bulai C, Ene C, et al. Bipolar vaporization, resection, and enucleation versus open prostatectomy: optimal treatment alter- natives in large prostate cases. J Endourol. 2015; 29:323-331. 12. Xu P, Xu A, Chen B, et al. Bipolar transurethral enucleation and resection of the prostate: Whether it is ready to supersede TURP? Asian J Urol. 2018; 5:48-54. 13. Wang Y, Wang X. Comparison of effects of transurethral enucle- ation of prostate and suprapubic prostatectomy in the treatment of massive prostatic hyperplasia. Chinese Journal of Primary Medicine and Pharmacy. 2019; 2467-2470. 14. Giulianelli R, Gentile BC, Mirabile G, et al. Bipolar plasma enu- cleation of the prostate vs. open prostatectomy in large benign pro- static hyperplasia: a single centre 3-year comparison. Prostate Cancer and Prostatic Dis. 2019; 22:110-116. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11629 I. Tagreda, M. Heikal, A. Elatreisy, et al. 6 15. Gratzke C, Schlenker B, Seitz M, et al. Complications and early postoperative outcome after open prostatectomy in patients with benign prostatic enlargement: results of a prospective multicenter study. J Urol. 2007; 177:1419-1422. 16. Tubaro A, Carter S, Hind A, et al. A prospective study of the safe- ty and efficacy of suprapubic transvesical prostatectomy in patients with benign prostatic hyperplasia. J Urol. 2001; 166:172-176. 17. Serretta V, Morgia G, Fondacaro L, et al. Open prostatectomy for benign prostatic enlargement in southern Europe in the late 1990s: a contemporary series of 1800 interventions. Urology. 2002; 60:623-627. Correspondence Ibrahim Tagreda, MD itagreda@yahoo.com Mahmoud Heikal, MD mahheikal1187@gmail.com Adel Elatreisy, MD (Corresponding Author) dr_adelelatreisy@yahoo.com; adel.elatreisy@azhar.edu.eg Mohamed Fawzy Salman, MD prof_mohamed_fawzy@yahoo.com Ahmed Mohamed Soliman, MD a_soliman_1@hotmail.com Ayman Kotb Koritenah, MD dr.ayman.kotb@gmail.com Hesham Abozied, MD aboziedhesham@gmail.com Mohamed Ibrahim Algammal, MD gemykarter2020@gmail.com Ahmed A. Alrefaey, MD a7medrefa3y.ash@gmail.com Mohamed Elsalhy, MD drsalhy2020@gmail.com Mohamed Shehab, MD shehab810@gmail.com Mahmoud Mohammed Ali, MD dr_mahmoud72@hotmail.com Aly Gomaa Eid, MD alygomaa68@yahoo.com Abdrabboh Abdrabboh, MD abdo197871@yahoo.com Sayed Eleweedy, MD seleweedy2002@yahoo.com Urology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Conflict of interest: The authors declare no potential conflict of interest.