Anatomical endoscopic enucleation of the prostate: The next gold standard? No! (or not yet!)

Abstract

Most cases of lower urinary tract symptoms due to benign prostatic hyperplasia are initially managed through medical therapy. In cases that surgery is indicated, the anatomical endoscopic enucleation of the prostate (aEEP), first described in 1983, allegedly presents the same safety profile as the best endoscopic non-enucleating procedures and the same long-term functional outcomes as simple prostatectomy. Thus, why aEEP has not yet been consolidated as the gold-standard BPH surgical treatment? The main reasons are as follows: (a) Multiple energy sources and techniques; (b) High costs; (c) Steep learning curve; (d) Rare in-residency training; (e) Reimbursement issues; (f) Outcomes and (g) Complications. We do believe aEEP is an important advance and a "practice-changing" procedure that will play an important role in the BPH surgical options arsenal, especially for larger prostates. However, there is a need to start an in-residency training program, with a mentor guidance, and, over time, the cost will likely be reduced due to greater competition between companies and greater support from health insurers. Considering these points, in the future, EEP may be considered the gold-standard treatment for BPH… but not yet. K E Y W O R D S endoscopic surgical procedure, prostate, prostatic hyperplasia, standard of care, urologic surgical procedures How to cite this article: Wroclawski ML, Teles SB, Carneiro A. Anatomical endoscopic enucleation of the prostate: The next gold standard? No! (or not yet!). Andrologia.

Anatomical endoscopic enucleation of the prostate for bladder outlet obstruction: a narrative review

“…AEEP not yet been accepted as the gold standard surgical modality of BPH despite having the aforementioned advantages and being introduced for almost 40 years [26]? A gold standard procedure must be safe, efficient, reproducible, and cost-effective compared to the current best choice of management.…”

“…Some of them apply retrograde blunt dissection during the operation along the prostate capsule plane whereas others apply the energy source to dissect. Specimen removal can also be performed in multiple methods, with the mushroom technique or with various morcellators [26]. The absence of superiority in these options over another and the lack of standardization makes it difficult to launch an enucleation program and choose among the multiple surgical techniques and energy sources.…”

“…The requirement for laser fibers, high-power laser generators, and morcellators is a hurdle to the widespread achievement of AEEP [28]. It has been demonstrated that HoLEP is related with a 9.6%-24.5% hospital net cost savings as compared to SP due to the shorter hospital stay related with it [26,29]. However, the initial investment for procuring its equipment can be a significant obstacle mainly because the cost of initial hospitalization is at most comparable between TURP and HoLEP [29].…”

“…Another limitation for the widespread performance of AEEP is that most residents complete their training period without grasping this surgical technique. Thus, urologists who purpose to start AEEP must experience a fellowship or at least devote money and time in observerships and hands-on courses [26].…”

Quest for the best—A move to Anatomical Endoscopic Enucleation of the Prostate

“…Following the introduction from the historical and anatomical perspective (Reddy, Utley, & Gilling, 2020; Oh & Shitara, 2020), different techniques of AEEP by different energy source are illustrated (Ryang, Ly, Tran, Oh, & Cho, 2020; de Figueiredo, Cracco, de Marins, & Scoffone, 2020; Herrmann & Wolters, 2020; Rijo & Misrai, 2020). The surgical outcomes, with emphasis on postoperative continence and sexual functions, and complications of AEEP are summarised in the following chapters (Chen, Chung, Chu, Chen, & Ho, 2020; Lee, Cho, Juan, & Teoh, 2020; Cheng, Li, & Yu, 2020; Wei, Ke, Xu, & Xue, 2020) before a debate on AEEP as the next gold standard treatment for benign prostatic obstruction (Aho, Armitage, & Kastner, 2020; Wroclawski, Teles, & Carneiro, 2020). Finally, this Special Issue is rounded up by a discussion on surgical training (Teoh et al, 2020) and a survey on AEEP from urologists worldwide (Gudaru et al, 2020).…”