ArticlePublisher preview available

Ejaculation-sparing enucleation of the prostate with Thulium: Yag laser (ES-ThuLEP) versus Thulium Fiber laser (ES-ThuFLEP): outcomes on sexual function

Authors:
Davide Perri at Azienda Ospedaliera Sant'Anna di Como
Davide Perri
Umberto Besana
Umberto Besana
Umberto Besana
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Federica Mazzoleni
Federica Mazzoleni
Federica Mazzoleni
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Andrea Pacchetti at Azienda Ospedaliera Universitaria San Martino di Genova
Andrea Pacchetti
Show all 13 authorsHide
Read publisher preview
Download citation
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Purpose To compare the effect on sexual function of ejaculation-sparing enucleation of the prostate using Thulium: YAG laser (ES-ThuLEP) versus continuous-wave Thulium Fiber Laser (ES-ThuFLEP). Methods 112 patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia who wished to preserve ejaculation were treated. 58 patients underwent ES-ThuLEP (Group A) using the Cyber TM generator. 54 patients underwent ES-ThuFLEP (Group B) using the Fiber Dust generator. Sexual function was evaluated through the International Index of Erectile Function 5 (IIEF-5) score, the four-item Male Sexual Health Questionnaire (MSHQ-EjD), personal satisfaction and the occurrence of haemospermia and painful ejaculation 3 and 6 months after surgery. Results Mean age of patients was 65.8 years in Group A and 66.7 years in Group B. Groups were comparable according to preoperative features. Mean preoperative IIEF-5 score was 18.8 in Group A and 17.9 in Group B (p = 0.14). In all cases an ejaculation-sparing procedure was performed sparing the tissue around the veru montanum and near the prostate apex. Three months after surgery mean IIEF-5 score was 19.3 in Group A and 18.0 in Group B (p = 0.12). Six months after surgery mean IIEF-5 score was 17.8 in Group A and 18.1 in Group B (p = 0.09). No significant differences were observed according to anterograde ejaculation (81.0% vs. 81.5%, p = 0.07), subjective satisfaction (72.4% vs. 74.1%, p = 0.10), painful ejaculation (10.3% vs. 11.1%, p = 0.14) and haemosparmia rate (12.1% vs. 14.8%, p = 0.08). Ejaculation and satisfaction rate were significantly higher with prostates ≥ 80 ml in both groups. Conclusion Ejaculation-sparing enucleation of the prostate effectively preserved sexual function in the majority of patients, with high rate of anterograde ejaculation and subjective satisfaction, low rates of painful ejaculation and haemospermia and no significant differences between Thulium: YAG and Thulium Fiber Laser. Preservation of ejaculation and personal satisfaction were significantly higher with prostates ≥ 80 ml compared to smaller ones.
A preview of this full-text is provided by Springer Nature.
Learn more
Content available from World Journal of Urology
This content is subject to copyright. Terms and conditions apply.
RESEARCH
World Journal of Urology (2025) 43:92
https://doi.org/10.1007/s00345-025-05483-x
Davide Perri
perri.davide90@gmail.com
1 Department of Urology, Azienda Socio Sanitaria Territoriale
Lariana, Como, Italy
2 Department of Urology, ROC Clinic and HM Hospitales,
Madrid, Spain
3 Department of Urology, Clinique Saint Augustin, Bordeaux,
France
4 Department of Urology, Moscow State University of
Medicine and Dentistry, Moscow, Russian Federation
5 Department of Urology, Sapienza University, Rome, Italy
6 Department of Urology, ASST Santi Paolo e Carlo, Milan,
Italy
7 Division of Urology, Sant’Anna Hospital, Via Ravona 20,
San Fermo della Battaglia 22042, Italy
Abstract
Purpose To compare the eect on sexual function of ejaculation-sparing enucleation of the prostate using Thulium: YAG
laser (ES-ThuLEP) versus continuous-wave Thulium Fiber Laser (ES-ThuFLEP).
Methods 112 patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia who wished to preserve
ejaculation were treated. 58 patients underwent ES-ThuLEP (Group A) using the Cyber TM generator. 54 patients underwent
ES-ThuFLEP (Group B) using the Fiber Dust generator. Sexual function was evaluated through the International Index of
Erectile Function 5 (IIEF-5) score, the four-item Male Sexual Health Questionnaire (MSHQ-EjD), personal satisfaction and
the occurrence of haemospermia and painful ejaculation 3 and 6 months after surgery.
Results Mean age of patients was 65.8 years in Group A and 66.7 years in Group B. Groups were comparable according
to preoperative features. Mean preoperative IIEF-5 score was 18.8 in Group A and 17.9 in Group B (p = 0.14). In all cases
an ejaculation-sparing procedure was performed sparing the tissue around the veru montanum and near the prostate apex.
Three months after surgery mean IIEF-5 score was 19.3 in Group A and 18.0 in Group B (p = 0.12). Six months after surgery
mean IIEF-5 score was 17.8 in Group A and 18.1 in Group B (p = 0.09). No signicant dierences were observed according
to anterograde ejaculation (81.0% vs. 81.5%, p = 0.07), subjective satisfaction (72.4% vs. 74.1%, p = 0.10), painful ejacula-
tion (10.3% vs. 11.1%, p = 0.14) and haemosparmia rate (12.1% vs. 14.8%, p = 0.08). Ejaculation and satisfaction rate were
signicantly higher with prostates ≥ 80 ml in both groups.
Conclusion Ejaculation-sparing enucleation of the prostate eectively preserved sexual function in the majority of patients,
with high rate of anterograde ejaculation and subjective satisfaction, low rates of painful ejaculation and haemospermia and
no signicant dierences between Thulium: YAG and Thulium Fiber Laser. Preservation of ejaculation and personal satis-
faction were signicantly higher with prostates ≥ 80 ml compared to smaller ones.
Keywords Ejaculation · Prostate enucleation · Sexual outcomes · Tm:YAG laser · Thulium Fiber laser
Received: 21 September 2024 / Accepted: 23 January 2025
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2025
Ejaculation-sparing enucleation of the prostate with Thulium: Yag
laser (ES-ThuLEP) versus Thulium Fiber laser (ES-ThuFLEP): outcomes
on sexual function
DavidePerri1,7· UmbertoBesana1· FedericaMazzoleni1· AndreaPacchetti1· TommasoCalcagnile1·
JavierRomero-Otero2· Jean-BaptisteRoche3· AlexanderGovorov4· DmitryPushkar4· Antonio LuigiPastore5·
Maria ChiaraSighinol6· BernardoRocco6· GiorgioBozzini1
1 3
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
ResearchGate has not been able to resolve any citations for this publication.
Evaluation of the learning curve for Thulium laser enucleation of the prostate in a contemporary cohort
Article
Full-text available
  • Apr 2024
  • WORLD J UROL
Purpose To assess the learning curve of Thulium laser enucleation of the prostate (ThuLEP) of a single surgeon. Methods Hundred patients suffering from benign prostatic hyperplasia were treated by the same surgeon. In all cases, a well-trained urologist was present in the operating room. Patients urinary function was assessed preoperatively using the International Prostate Symptoms Score (IPSS), maximum flow rate and Post-Void Residual volume. Preoperative prostate volume was recorded. Enucleation and morcellation efficiency and complication rate were evaluated. Patients were divided into 5 cohorts of 20 consecutive cases to assess changes in outcomes through time. Results Mean age of patients was 73.1 years (SD 17.5) and mean prostate volume was 89.7 ml (SD 55.1). Overall, mean enucleation and morcellation efficiency were 1.7 (SD 2.9) and 5.1 (SD 2.7) g/min. A statistically significant increase in enucleation efficiency was observed when comparing cohort 1 vs 2 (0.9 vs 1.3 g/min, p = 0.03) and cohort 2 vs 3 (1.3 vs 1.7 g/min, p = 0.02). A statistically significant increase in morcellation efficiency was observed when comparing cohort 1 vs 2 (2.8 vs 3.7 g/min, p = 0.02) and cohort 2 vs 3 (3.7 vs 4.9 g/min, p = 0.03). In both cases, no significant differences were observed when comparing the following cohorts. Complication rate showed no significant differences throughout the caseload. Conclusions In our single-surgeon experience, we observed a learning curve of nearly 60 cases for the ThuLEP procedure in presence of a well-trained surgeon. Complication rate was low from the beginning of surgical experience.
View
View
Ejaculation-sparing thulium laser enucleation of the prostate (ES-ThuLEP): outcomes on a large cohort
Article
Full-text available
  • Jun 2021
  • WORLD J UROL
Purpose: To assess the effects of a new ejaculation-sparing thulium laser enucleation of the prostate (ES-ThuLEP) technique on sexual functions and micturition, in patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH) and to evaluate how the surgical technique of ES-ThuLEP can lead to ejaculation preservation. Methods: A prospective study was carried out between January 2015 and January 2018 on patients with surgical indication for BPH, who wished to preserve ejaculation. The patients were treated with ES-ThuLEP and were evaluated before and 3 and 6 months after surgery. Three validated questionnaires (ICIQ-MLUTSsex, IIEF-5 and IPSS) were used to assess changes in ejaculation, erectile function and urinary symptoms. Uroflowmetry (Qmax and Qavg), post-void residual volume and voided volume were also evaluated, to assess micturition improvement. Patients with moderate to severe erectile dysfunction were excluded. Statistical analysis was performed with the Student's t test, Chi-square test and logistic regression analysis. Results: Two hundred and eighty three patients were enrolled. Ejaculation was spared in 203 and 219 patients at 3 and 6 months after surgery. No significant differences were observed between erectile function before and after surgery: baseline IIEF-5 = 16.2 ± 4.47 vs 16.7 ± 2.9 (p = 0.419) and 17.7 ± 3.2 (p = 0.410) at 3 and 6 months. Significant improvement in urinary symptoms was achieved: baseline IPSS = 19.4 ± 7.24 vs 5.8 ± 4.3 (p = 0.032) and 3.9 ± 4.1 (p = 0.029) at 3 and 6 months. Conclusion: ES-ThuLEP effectively preserved ejaculation in over two thirds of the patients without compromising micturition improvement or erectile function. ES-ThuLEP could be a valid treatment option for BPH in young and sexually active men.
View
Efficacy and safety profile of a novel technique, ThuLEP (Thulium laser enucleation of the prostate) for the treatment of benign prostate hypertrophy. Our experience on 148 patients
Article
Full-text available
  • Nov 2012
  • BMC Surg
Over the past years laser technology has played a predominant role in prostate surgery, for the treatment of benign prostate hypertrophy (BPH). Various laser devices have been introduced in clinical practice, showing good results in terms of complications and urodynamic outcomes efficacy compared with TURP and Open Prostatectomy.In this study we describe the efficacy and the safety profile of a novel laser technique, ThuLEP (Thulium Laser Enucleation of Prostate) that permits a complete anatomical endoscopic enucleation of prostatic adenoma independently to prostate size. 148 patients with a mean age of 68.2 years were enrolled between September 2009 and March 2012 (36 months), and treated for BPH with ThuLEP. Every patient was evaluated at base line according to: Digital Rectal Examination (DRE), prostate volume, Post-Voided volume (PVR), International Prostate Symptoms Score (I-PSS), International Index of Erectile Function-5 (IIEF-5), Quality of Life (QoL), PSA values, urine analysis and urine culture, uroflowmetry. The same evaluation was conducted after a 12 month follow-up. ThuLEP was performed by 2 expert surgeons. Our data showed a better post-operative outcome in terms of catheter removal, blood loss, TURP syndrome, clot retention and residual tissue compared to large series of TURP and OP. Only 1.3% of patients had bladder wall injury during morcellation. I-PSS, Qmax, Prostate Volume, QoL and PVR showed a highly significant improvement at 12 month follow-up in comparison to preoperative assessment. ThuLEP represent an innovative option in patients with BPH. It is a size independent surgical endoscopic technique and it can be considered the real alternative, at this time, to TURP and even more to Open Prostatectomy for large prostate, with a complete removal of adenoma and with a low complication rate.
View
Prognostic Factors Predicting Bleeding After Discharge Requiring Readmission After Thulium Laser Enucleation of the Prostate (ThuLEP)
Article
  • Sep 2023
Objectives Postoperative haematuria is a feared complication following prostate enucleation, and it may occur even weeks after discharge. We evaluated the risk of bleeding after discharge and its predictive factors in patients who underwent Thulium laser enucleation of the prostate (ThuLEP).Methods Between January 2015 and December 2018, patients with surgical indication for benign prostatic hyperplasia underwent ThuLEP in 4 urology departments. All procedures were performed by experienced urologists. Postoperative haematuria was defined as macroscopic haematuria occurring 7 days after discharge. Readmission rate due to macroscopic haematuria was assessed. Logistic regression models tested for predictors of postoperative bleeding requiring readmission.ResultsOverall, 748 patients were included, and 52 (6.9%) of them were readmitted after discharge because of macroscopic haematuria. No cases of deep venous thrombosis or pulmonary embolism were diagnosed. Mean length of stay for surgical treatment was 2.1 days, and mean hospitalization for readmission was 5.6 days. None of the readmitted patients required reintervention, while 46.1% of them required blood transfusions. Diabetes mellitus (P < 0.05), a long bridge of oral anticoagulant drugs with low molecular weight heparin (LMWH) (P < 0.05) and history of constipation (P < 0.05) were significant predictors of readmission after discharge due to macroscopic haematuria.Conclusions Patients with a clinical history of diabetes mellitus or constipation and patients who undergo a long bridge of oral anticoagulant therapy with LMWH are at higher risk of bleeding requiring readmission after ThuLEP.
View
Enucleación con láser de tulio (ThuLEP) frente a resección transuretral de la próstata en solución salina (TURis): un ensayo prospectivo aleatorizado para comparar resultados intra y postoperatorios tempranos
Article
  • Jan 2017
Objective: To compare clinical intra and early postoperative outcomes between thulium laser transurethral enucleation of the prostate (ThuLEP) and transurethral bipolar resection of the prostate (TURis) for treating benign prostatic hyperplasia (BPH) in a prospective randomized trial. Methods: The study randomized 208 consecutive patients with BPH to ThuLEP (n=102) or TURis (n=106). For all patients were evaluated preoperatively with regards to blood loss, catheterization time, irrigation volume, hospital stay and operative time. At 3 months after surgery they were also evaluated by International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and postvoid residual urine volume (PVR). Results: The patients in each study arm each showed no significant difference in preoperative parameters. Compared with TURIS, ThuLEP had same operative time (53.69±31.44 vs 61.66±18.70minutes, P=.123) but resulted in less hemoglobin decrease (0.45 vs 2.83g/dL, P=.005). ThuLEP also needed less catheterization time (1.3 vs 4.8 days, P=.011), irrigation volume (29.4 vs 69.2 L, P=.002), and hospital stay (1.7 vs 5.2 days, P=.016). During the 3 months of follow-up, the procedures did not demonstrate a significant difference in Qmax, IPSS, PVR, and QOLS. Conclusion: ThuLEP and TURis both relieve lower urinary tract symptoms equally, with high efficacy and safety. ThuLEP was statistically superior to TURis in blood loss, catheterization time, irrigation volume, and hospital stay. However, procedures did not differ significantly in Qmax, IPSS, PVR, and QOLS through 3 months of follow-up.
View
Ejaculatory Dysfunction After Treatment for Lower Urinary Tract Symptoms: Retrograde Ejaculation or Retrograde Thinking?
Article
For years the wisdom passed down through urological generations, as if from father to son, has been that a dry orgasm following TURP was pretty much inevitable, and dueto "retrograde ejaculation." Perhaps due to this perceived inevitability, men were warned of the risk of dry orgasms, and were expected to live with it ("at least you won’t have to sleep on the wet patch."). Bladder neck incision has been accepted to have a much lower incidence of ejaculatory dysfunction, raising the paradox that one operation (BNI) had a lower rate of retrograde ejaculation than one which also destroyed bladder neck integrity (TURP). Alpha blockers cause ejaculatory dysfunction in many men. Patients were initially told this was also due to semen passing backwards into the bladder. We now know this to be anejaculation due to a central inhibitory effect. Ejaculatory dysfunction associated with tamsulosin is dose dependent. At 0.8mg up to 90% of subjects in one study experienced a reduction in ejaculate volume and over a third reported anejaculation with no significant difference in post-ejaculatory urine sperm concentrations compared to those of men taking alfuzosin or placebo. [1] Clearly, not all α-blockers are equal. Silodosin, a new α1A-adrenoceptor-selective antagonist is associated with a greater risk of anejaculation compared to tamsulosin, which is itself associated with more ejaculatory dysfunction than alfuzosin. [2] This is explained further in animal studies. Both serotonin and dopaminergic receptors play an integral role in the central control of ejaculation: tamsulosin has a binding affinity for 5-HT1a and D2-like receptors almost 10,000 times greater than other α-blockers. Systemic administration of tamsulosin has been shown to significantly reduce bulbospongiosus contractions mediated by 8-OH-DPAT, a 5HT1a and D2-like receptor agonist, in male rats. [3] The 1994 BJU paper, and subsequent excellent video, by Gil Vernet’s group clearly shows that bladder neck contraction is not necessary for antegrade ejaculation [4] Using live transrectal ultrasound, the bladder neck and prostate as far as the bulbar urethra was visualised during masturbation in 30 subjects. Analysis of recorded ultrasound video footage during ejaculation shows that semen emitted from the ejaculatory ducts is directed distally by a coordinated contraction of the external sphincter and bulbar urethra, demonstrating the importance of the muscular tissue proximal to and around the verumontanum (what might be called “the high pressure ejaculatory zone”) for outward ejaculation, rather than closure of the bladder neck. One might infer that, as long as this tissue is not disrupted, ejaculation should still occur even with an open bladder neck.
View
The smooth sphincter of the vesical neck, a genital organ
  • Jan 1972
  • UROL INT
  • 341-354
  • P Gallizia
Gallizia P (1972) The smooth sphincter of the vesical neck, a genital organ. Urol Int 27:341-354. https:/ /doi.or g/10.11 59/00