Holmium Laser Ablation Versus Photoselective Vaporization of Prostate Less Than 60 cc: Long-Term Results of a Ran omize Trial

Hazem M. Elmansy, Ehab Elzayat and Mostafa M. Elhilali*,

From the Division of Urology, Department of Surgery, Faculty of Medicine, McGill University, Montreal, Quebec, Canada

Purpose: We evaluated the long-term results and durability of photoselective vaporization and holmium laser ablation as surgical treatment of small to medium prostates in a prospective, randomized study in men ith obstructive benign prostatic hyperplasia. !aterials an !etho s: !rom March "##$ to %pril "##& e randomly allocated '#( patients ith a prostate gland of less than )# cc to prostate photoselective vaporization *$"+ or holmium laser ablation *$&+ and evaluated them ', " and , years postoperatively. !unctional follo up included measurement of ma-imum urinary flo rate, post-void residual urine, .nternational /rostate 0ymptom 0core, 1uality of life, .nternational .nde- of Erectile !unction and prostate specific antigen. Results: Mean 02 preoperative prostate volume as ,,.' '3.$ and ,&., ',.) in the laser ablation and vaporization groups, respectively. %ll functional parameters improved significantly compared to baseline values in each group. 4here as no difference in .nternational /rostate 0ymptom 0core, 1uality of life, ma-imum urinary flo rate, post-void residual urine or percent of prostate specific antigen decrease bet een the " groups ', " and , years postoperatively. %t ,-year follo up .nternational /rostate 0ymptom 0core had improved by &#.$5, 1uality of life had improved by )(.35, ma-imum urinary flo rate had increased by ')35 and post-void residual urine had decreased by 6'5 in the holmium laser ablation group. .n the photoselective vaporization group .nternational /rostate 0ymptom 0core improved by )3.'5, 1uality of life improved by )$.$5, ma-imum urinary flo rate increased by '6(5 and post-void residual urine decreased by &(.$5. 4he overall re-treatment rate as '$.65 for holmium laser ablation vs '(.,5 for photoselective vaporization. "onclusions: /rostate photoselective vaporization and holmium laser ablation are effective surgical treatments for benign prostatic hyperplasia. /ostoperative functional improvements ere significant and durable, and e1uivalent in the " groups. 4he " techni1ues have a similar complication rate.

Abbreviations an Acron#ms 7/H benign prostatic hyperplasia Ho8%/ holmium laser ablation of prostate Ho8E/ holmium laser enucleation of prostate ..E! .nternational .nde- of Erectile !unction .-/00 .nternational /rostate 0ymptom 0core 8940 lo er urinary tract symptoms /0% prostatic specific antigen /:/ photoselective vaporization of prostate /:; post-void residual urine volume <ma<=8 ma-imal flo rate 1uality of life

49;/ transurethral resection of the prostate

0ubmitted for publication !ebruary '(, "#'#. 0tudy received hospital ethics committee approval. * >orrespondence? 9rology 2ivision, 2epartment of 0urgery, ;oyal :ictoria Hospital, Montreal @eneral Hospital, )6& /ine %ve. West, ;oom 0).($, H,% '%', Montreal, <uebec, >anada *tele- phone? $'3-63,-'$')A !%B? $'3-63,-'$$"A e-mail? mostafa.elhilaliCmuhc.mcgill.ca+. !inancial interest andDor other relationship ith 8umenis and 8aserscope *%merican Medical 0ystems+.

$e# %or s: prostateA prostatic hyperplasiaA laser therapyA surgical procedures, minimally invasiveA prostatectomy

0E:E;%8 randomized trials suggest that minimally invasive procedures have short-term efficacy similar to that of 49;/ to improve symptom outcomes and the urinary flo rate.'E, .n the last
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decade many efforts have been made to identify alternative surgical techni1ues providing functional results comparable to those of 49;/ but ith less morbidity and higher perioperative safety.3
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Ho ever, the most concerning aspect about minimally invasive techni1ues is the possible high recurrence rate and the need for re-treatment due to treatment $ failure ith time. ;ecently ongoing advances in laser technology have resulted in ne technical refinements and devices, and their effective application for surgical ) treatment of symptomatic 7/H. 9se of the M4/ laser ith a avelength of $," nm to vaporize prostatic adenoma is referred to as /:/. 2oubling the fre1uency of pulsed Fd?H%@ laser energy ith a M4/ crystal led to the production of a $," nm avelength laser, hich is selectively absorbed by hemoglobin, leading to rapid tissue vaporization ith only a ' to " mm rim of coagulation using optimal tech& ni1ue. /:/ leads to immediate, sustained improvement in subKective and obKective voiding parameters. 4he late complication rate is comparable to that of 6,( 49;/. /:/ provides durable results ith durable improvements in functional outcome parameters. Ho ever, the clinical functional outcome in smaller or larger prostates treated ith /:/ may be dispro6 portionate. 8ong-term data on the durability of /:/ ( for 8940 secondary to 7/H are still sparse. 4he most favorable aspect of /:/ is safe, effective application in patients on anticoagulation, eg arfarin, and antiplatelet agents, eg aspirin and clopidogrel, hile con'# tinuing medication mostly in an outpatient setting. 4he Ho?H%@ laser is a pulsed solid-state laser ith a ",'3# nm avelength. 4his produces vaporization ithout deep coagulation hen used ith a side firing fiber, and provides the striNing surgical effect of a precise incision and enucleation hile maintaining hemostasis hen used ith an end '' firing fiber. Ho8%/ as the first procedure using the holmium avelength alone for laser prostatec'" tomy. Ho8%/ and /:/ are easy to learn but Ho8%/ ', re1uires longer operative time. /:/ and Ho8%/ are best suited to small or medium prostates since other ise they re1uire much longer operative time and more than ' fiber ith reoperation needed in more patients. 4his may raise concern about the economic aspect of these procedures compared '3,'$ ith standard 49;/. % controversial aspect concerning /:/ and Ho8%/ compared to 49;/ is the lacN of tissue for histopathological e-amination ith the risN of missing the diagnosis of prostatic carcinoma. 4hus, it is mandatory to thoroughly evaluate patients ith increased /0% or abnormal digital rectal e-amination necessitating transrectal ultrasound guided biopsy before the intervention, hen indicated. .t is also mandatory to continue postoperative /0% and digi-

tal rectal e-amination surveillance.

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!rom March "##$ to %pril "##& e randomly allocated '#( patients ith lo er urinary tract symptoms secondary to 7/H ith a prostate gland of less than )# cc to /:/ *$"+ or Ho8%/ *$&+. 4he hospital ethics committee approved the protocol. %ll patients ere treated or supervised by ' surgeon *MME+ at the 2ivision of 9rology, 2epartment of 0urgery, Mc@ill 9niversity Health >enter. 0hort-term results, instruments and surgical techni1ues ere previously described.', 8ong-term follo up as done ', " and , years postoperatively. /atients presenting for follo up ere re1uested to complete the .-/00E<=8 1uestionnaire and ..E!. <ma-, /:; and /0% ere determined. We recorded the mean 02 of all continuous measures and scores at baseline and at all follo up visits. >ontinu- ous variables ere compared bet een the treatment groups using 0tudentOs t test ith p #.#$ considered significant. >hanges in preoperative and postoperative outcome parameters ere compared using the paired 0tu- dent t test. =utcome parameters in each group ere com- pared using the unpaired 0tudent t test. 4he complication rate in the groups as compared ith the "-tailed chi- s1uare or !isher e-act test.

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We noted no statistical difference in baseline characteristics bet een the " groups *table '+. Mean preoperative prostate volume as ,,.' '3.$ and ,&., ',.) in the Ho8%/ and /:/ groups, and mean follo up as 3#.#& 6.33 and 3"., &.& months, respectively. -ata Operative. 4able ' lists the main operative data. Ho8%/ re1uired '3 minutes more operative time than /:/, hich as significantly different *p #.##6+. Outcome and followup. :oiding parameters significantly improved immediately after surgery and continued to do so during follo up in each group *table "+. %t ', " and ,-year follo up e had data on $, and $', $" and $', and $' and $# patients in the Ho8%/ and /:/ groups, respectively. %t 3-year follo up '& patients *,#5+ ith Ho8%/ and ", *335+ ith /:/ ere available for evaluation. %t ,-year follo up in the Ho8%/ vs the /:/ group mean .-/00 had improved from "# to $.( *&#.$5+ vs from '6.3 to ).) *)3.'5+, mean <=8 had improved from ,.6 to '.') *)(.35+ vs from ,.) to '."3 *)$.$5+, mean <ma- had increased from ).& to '&.& ml per second *')35+ vs from ).3 to '6.$ *'6(5+ and mean /:; had decreased from "#$ to ,6.6 ml *6'5+ vs from "'$ to 3,.( *&(.$5+. We noted no significant difference in subKective *.-/00E<=8+ or obKective *<ma--/:;+ outcomes bet een the " groups at each time point during follo up. /0% decreased significantly in each group postoperatively and the decrease as sustained during

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Table 12 "aseline preoperative characteristics and operative data on patients with #o$%& and &'& :ariable Mean 02 age *range+ Fo. indication *5+? 8940 failed medical treatment 9rinary retention Hematuria Fo. anticoagulant *5+ Fo. anticoagulant indication *5+? >hronic atrial fibrillation /rosthetic heart valves Myocardial infarction 2eep venous thrombosis %ortic aneurysm Hemophilia Mean 02 cc transrectal ultrasound vol *range+ Mean 02 ngDml /0% *range+ Mean 02 .-/00 *range+ Mean 02 <=8 *range+ Mean 02 mlDsec <ma- *range+ Mean 02 ml /:; *range+ Mean 02 mins laser time *range+ Mean 02 NG total energy *range+ Fo. " fibers needed *5+ Fo. straight drainage *5+ Fo. irrigation *5+? .ntermittent >ontinuous Mean 02 days catheterization *range+ Mean 02 days hospital stay *range+ &".& 3) '' # & , ' " # ' # ,,.' ".6 "# ,.6 ).& "#$ )(.6 "#3 " '3 3# , ".' #.6& Ho8%/ '#., *$'E('+ *6#.&+ *'(.,+ *'"."+ &'.) 3" 6 " 6 " # 3 ' # ' ,&., ".' '6.3 ,.) ).3 "'$ $$.$ ')" " "3 "$ , '.)$ #.() /:/ '#., *$'E66+ *6#.&+ *'$.,+ *3+ *'$.,+ p :alue #.$) #.36 #."" #."# #."#

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follo up. %t ,-year follo up /0% had decreased 3&.35 and "&.)5 in the Ho8%/ and /:/ groups, respectively. 4here as no significant difference bet een the " groups in the /0% decrease at each time point. Late Postoperative "omplications >omplication rates in the " groups ere comparable *table ,+. 8ate complications ere diagnosed subKectively based on patient symptoms, and obKectively based on <ma--/:; and cystoscopy. ;e-treatment as done for urethral stricture, bladder necN obstruction and bladder outlet obstruction caused by residual adenoma. .n the Ho8%/ group urethral stricture developed in " patients *,.$5+, including in ' each 3 and '3 months postoperatively, respectively. .n the /:/ group urethral stricture developed in , patients *$.65+ and as diagnosed ithin the first ) months. !our patients in the Ho8%/ and /:/ groups re1uired urethrotomy. .n the Ho8%/ group , patients *$.,5+ had bladder necN contracture ", '" and ') months postoperatively, respectively, compared ith 3 *&.&5+ in the /:/ group ithin follo up year '. 7ladder necN contracture in each group as treated successfully ith holmium laser incision of the bladder necN. !our patients *&5+ ith Ho8%/ re1uired reoperation for refractory symptoms caused by bladder outlet obstruction due to residual adenoma, including "

diagnosed ithin " months postoperatively and " diagnosed at '3 and ') months, respectively. .n the /:/ group , patients *$.65+ re1uired reoperation for refractory symptoms and residual adenoma at ", '3 and ,) months, respectively. %t the last follo up ' patient *'.65+ ith Ho8%/ vs " *,.65+ ith /:/ had urgency and urge incontinence that did not resolve ith anticholinergic therapy. 4here as no significant difference in postoperative complications in the " groups. 4he overall re-treatment rate as '$.65 for Ho8%/ vs '(.,5 for /:/. 8ocalized prostate cancer as diagnosed during follo up in ' patient *'.65+ in the Ho8%/ group and in " *,.65+ in the /:/ group, hich as not significantly different. .n the Ho8%/ group ,, patients ere se-ually active, as ere ,# in the /:/ group. Erectile function measured by the erectile function domain sho ed no significant improvement ith no significant difference bet een the " groups *table "+. =f se-ually active patients '" of ,, *,).,5+ ith Ho8%/ vs ', of ,# *3,.,5+ ith /:/ e-perienced retrograde eKaculation. 4here as no significant difference bet een preoperative and postoperative se-ual function in terms of orgasmic function, se-ual desire, or intercourse or overall satisfaction ith no significant difference bet een the "

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Table &2 &retreatment and posttreatment sub!ective and ob!ective voiding parameters, and (()F domain changes in #o$%& and &'& groups Mean .-/00? Ho8%/ /:/ p :alue <=8? Ho8%/ /:/ p :alue <ma-? Ho8%/ /:/ ,3.3+ p :alue /:;?* Ho8%/ /:/ ,#$+ p :alue /0%? Ho8%/ /:/ p :alue Erectile function? Ho8%/ /:/ p :alue =rgasmic function? Ho8%/ /:/ p :alue 2esire function? Ho8%/ /:/ p :alue .ntercourse satisfaction? Ho8%/ /:/ p :alue =verall satisfaction? Ho8%/ /:/ p :alue 02 /reop *range+ Mean 02 ' Hr *range+ Mean 02 " Hrs *range+ Mean 02 , Hrs *range+ p :alue #.###' "# '6.3 #.,) ,.6 ,.) #.)) ).& ).3 #.&3 "#$ "'$ #.&, ".6 ".' #.'' "." *#.36E6.(+ '.6 *#."$E(.$+ ).6 ).) *6E,$+ *6E,,+ &.' 6.' #., '.& '.$ #.,) '6., '6.&) #.&& '(& *'#E(##+ )6.'" "#6 *',E',###+ &&.6 #.)$ '.& '.3$ #.3( "." '." *#.,E'"+ *#.,E)+ &".$ ',".' 3.& ).#, *#E"#+ *#E")+ ).# &., #." '." '.,, #.$$ $.) $." *#E"6+ *#E"$+ $.( ).) #.33 '.') '."3 #.$( '&.& '6.$ #.(& #.###' *#E"6(+ 33.( *#E&##+ &$ #.'' '.)( ".) '." *#.,E'3+ *#."E).$+ &6.3 '#,., *#E,$#+ *#E$""+ ,6.6 3,.( #.)" '.3& '.$" #.(3 '."3 *#."(E&.'+ '.3, *#.,E&.$+ #.#' at ' " Hrs, #.##' at , yrs #.#' $).( $6.3 *#E,3#+ *#E $.' $." *#E"#+ *#E"3+ #.###' '.$ '.3 *'E)+ *'E)+ '." '., *#E3+ *#E$+ '.' '.", *#E$+ *#E$+ '."# '."& *#E)+ *#E$+ #.###' ,.( ,.( *#E'$+ *#E'3+ &.$ *3.&E,&."+ '&., 6.( *,E3$+ '&., #.(& ).6 *3.3E,3.6+ ).' *).&E,3.3+ ).& *$.3E3".6+ $.& *&.,E

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* .ncluding patients in urinary retention.

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0everal minimally invasive procedures, including laser techni1ues, are available to treat 8940 secondary to 7/H. Early results for some techni1ues are promising but long-term durability is still uncertain.
Table '2 &ostoperative complications and malignancy detection in #o$%& and &'& groups :ariable :alue 9rge incontinence 9rethral stricture 7ladder necN contracture ;eoperation /rostate >a Fo. Ho8%/ *5+ ' *'.65+ " *,.$5+ , *$.,5+ 3 *&5+ ' *'.65+ Fo. /:/ *5+ " *,.65+ , *$.65+ 3 *&.&5+ , *$.65+ " *,.65+ p #.$# #.$& #.)# #.6# #.$#

We report on '#( patients ho ere randomly assigned to Ho8%/ or /:/ ith up to 3-year follo up. %t ,-year follo up mean .-/00 had improved by &#.$5 and )3.'5, and mean <ma- had increased by ')35 and '6(5 in the Ho8%/ and /:/ groups, respectively. % multicenter study in ',( patients ho underent 6# W /:/ and ere follo ed for , years sho ed that the improvement achieved by /:/ as 6 positive and durable out to , years. %t ,-year follo up the mean improvement in the %merican 9rological %ssociation symptom inde- and <ma- as 6$5 and '&(5, respectively. ;uszat et al reported long-term results of /:/ after $## procedures.( ;esults sho ed that

/:/ leads to immediate, sustained improvement in sub-

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Kective and obKective voiding parameters that lasts up to $ years. .n different prostate size subgroups *less than 3# and 3# to 6# ml+ .-/00 improved by )35 and $&5, and <ma- improved by '#35 and '#'5, respectively. %s reported by 4an et al, longterm Ho8%/ results sho ed that the mean symptom score and flo rate at &-year follo up ere improved by 3&5 and 6,5, respectively.'6 =ther studies have confirmed the long lasting effect of /:/.'(,"# We also found a trend to ard more urethral stricture and bladder necN contracture after /:/ than after Ho8%/ *$.65 vs ,.$5 and &.&5 vs $.,5, respectively+ but this as not statistically significant. ;esectoscope size is less liNely to have been the cause of urethral stricture since it as used in each procedure and operative time as longer for Ho8%/. 4he urethral stricture incidence in patients ho under ent Ho8E/ as reported to be '.35 to 3.'5, although the procedure as done for large glands ith longer operative times."',"" 7achmann et al reported a &.65 incidence of urethral stricture after /:/., ;uszat et al reported a &.65 incidence of bladder necN contracture and urethral ( stricture after /:/ for prostates less than 3# ml. Ho ever, the stricture rate decreased after using a smaller "".$!r laserscope. 4hey also noted a lo er bladder necN contracture rate for larger prostates. We observed that /0% decreased significantly in each group postoperatively and the decrease as sustained during follo up. %t ,-year follo up /0% had decreased 3&.35 and "&.)5 in the Ho8%/ and /:/ groups, respectively, ith no significant difference bet een the groups. ;uszat et al reported an average 3&5 /0% decrease for small to medium prostates at $-year follo up.( 4e et al noted a '&5 decrease in /0% at ,-year follo up after /:/.6 % lesser decrease in /0% reflects incomplete removal of adenomatous tissue. Elmansy et al found that Ho8E/ resulted in significantly decreased /0% *&)5+, hich remained lo er for up to & years of follo up.", 4his suggests that the glandular size decrease after Ho8E/ is durable and more complete, hich may e-plain the lo er '.35 to $.35 reoperation rate previously reported for residual tissue."","3,"$ %lso, the enucleation techni1ue and the release of energy at the capsular plane may e-plain the lo incidence of bladder necN contracture.") .n our study the overall re-treatment rate for urethral stricture, bladder necN obstruction and refractory symptoms most liNely caused by residual adenoma as '$.65 for Ho8%/ vs '(.,5 for /:/. ;ecent reports sho a '$5 to ",5 overall re-treat-

ment rate after /:/ ith a ).65 to '&.(5 reoperation rate for residual adenoma.3,"& 4an et al reported a '$5 overall re-treatment rate after Ho8%/.'6 4he 1uestion of ho large a prostate can be treated ith laser vaporization techni1ues is a ne challenge. 4e et al reported significant differences in /:/ efficacy according to prostate size.6 .n patients ith large glands .-/00 and <ma- improved by only ),5 and ',(5, respectively, ith higher re-treatment rates. %t '-year follo up /fitzenmaier et al observed that the reoperation rate related to insufficient tissue removal as higher in men ith a large prostate *greater than 6# ml+ than in men ith a prostate of less than 6# ml *",.'5 vs '#.35+."6 Mumar reported on '& patients ith prostate volume greater than 6# cc ho ere treated ith a '## W holmium laser.'3 4he mean improvement in the %merican 9rological %ssociation symptom inde- and <maas &#5 and "'&5, respectively, ith a $$5 percent decrease in prostate volume. %lso, the incidence of bladder necN contracture as $5 ith no reported urethral stricture. ;esults ere limited by the small number of patients. Ho ever, other series sho ed that large prostates could be treated successfully.'$ 0e-ual function after laser vaporization has been rarely described. /aicN et al reported improvement in the erectile function domain at )-month follo up *from ''., to '3.&, p #.#'+."( We found no significant improvement in the erectile function domain ith no significant difference bet een the " groups at follo up out to , years. Ho ever, there as no significant difference bet een preoperative and postoperative se-ual function in terms of orgasmic function, se-ual desire, or intercourse or overall satisfaction. % study limitation is that mean prostate size as ,, to ,& gm, hich is considered small. 4his reflects daily practice, in hich most prostates are ithin this range. Ho ever, lately e have noted a trend to ard larger prostate size, reflecting the longer duration that patients remain on medical therapy before surgery.

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/:/ and Ho8%/ are effective surgical treatments for 7/H in small to medium prostates. 4he " techni1ues have similar functional outcomes and complication rates. 0ubKective and obKective voiding pa- rameters sho ed significant improvement lasting for up to , years, confirming the long lasting, dura- ble effects of each techni1ue. !urther studies are needed to assess the effectiveness, safety and dura- bility of these techni1ues for managing large pros- tates.

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'. Wilson 8>, @illing /G, Williams % et al? % ran- domized trial comparing holmium laser enucle- ation versus transurethral resection in the treat- ment of prostate larger than 3# grams? results at " years. Eur 9rol "##)A 00: $)(. ". Mottet F, %nidKar M, 7ourdon = et al? ;andom- ized comparison of transurethral electrosection and holmium?H%@ laser vaporization for symp- tomatic benign prostatic hyperplasia. G Endourol '(((A 1': '"&. ,. 7achmann %, 0church 8, ;uszat ; et al? /hoto- selective vaporization */:/+ versus transurethral resection of the prostate *49;/+? a prospective bi-center study of perioperative morbidity and early functional outcome. Eur 9rol "##$A (4: ()$. 3. ;uszat ;, Wyler 0!, 0eitz M et al? >omparison of potassium-titanyl-phosphate laser vaporization of the prostate and transurethral resection of the prostate? update of a prospective nonrandomized t o-centre study. 7G9 .nt "##6A 10&: '3,". $. ;eich =, @ratzNe > and 0tief >@? 4echni1ues and long-term results of surgical procedures for 7/H. Eur 9rol "##)A (6: (&#. ). 4e %E? 4he ne-t generation in laser treatment and the role of the green light high performance system laser. ;ev 9rol "##)A 4: "3. &. 8ee ;, @onzalez ;; and 4e %E? 4he evolution of photoselective vaporization prostatectomy */:/+? advancing the surgical treatment of benign pros- tatic hyperplasia. World G 9rol "##)A &(: 3#$. 6. 4e %E, Malloy 4;, 0tein 70 et al? .mpact of prostate-specific antigen level and prostate vol- ume as predictors of efficacy in photoselective vaporization prostatectomy? analysis and results of an ongoing prospective multi-center study at , years. 7G9 .nt "##)A 63: '""(. (. ;uszat ;, 0eitzb M, Wylera 0! et al? @reen8ight laser vaporization of the prostate? single-center e-perience and long-term results after $## pro- cedures. Eur 9rol "##6A 0(: 6(,. '#. ;uszat ;, Wyler 0, !orster 4 et al? 0afety and effectiveness of photoselective vaporization of the prostate */:/+ in patients on ongoing oral anticoagulation. Eur 9rol "##&A 01: '#,'. ''. Muntz ;M? >urrent role of lasers in the treatment of 7/H. Eur 9rol "##)A (6: (,(. '". @illing /G, >ass >7, Malcolm %; et al? >ombina- tion holmium and Fd?H%@ laser ablation of the prostate? initial clinical e-perience. G Endourol '(($A 6: '$'. ',. Elzayat E, %l-Mandil M0, Mhalaf . et al? Holmium laser ablation of the prostate versus photoselective vaporization of prostate )# cc or less? short- term results of a prospective randomized trial. G 9rol "##(A 14&: ',,. '3. Mumar 0M? ;apid communication? holmium laser ablation of large prostate glands? an endourologic alternative to open prostatectomy. G Endo 9rol "##&A &1: )$(. '$. 0andhu G0, Fg >, :anderbrinN 7% et al? High- po er potassium-titanyl-phosphate photoselec- tive laser vaporization of prostate for treatment of benign prostatic hyperplasia in men ith large prostates. 9rology "##3A 6(: ''$$. '). 7achmann %, ;uszat ;, Wyler 0 et al? /hoto- selective vaporization of the prostate? the basal e-perience after '#6 procedures. Eur 9rol "##$A (3: &(6. '&. 0arica M, %lNan E, 8uleci H et al? /hotoselective vaporization of the enlarged prostate ith M4/ laser? long term results in "3# patients. G Endourol "##$A 16: ''((. '6. 4an %H, @illing /G, Mennett MM et al? 8ongterm results of high-po er holmium laser vaporization *ablation+ of the prostate. 7G9 .nt "##,A 6&: &#&. '(. 4ugcu :, 4asci %., 0ahin 0 et al? >omparison of photoselective vaporization of the prostate and transurethral resection of the prostate? a prospec- tive nonrandomized bicenter trial ith "year fol- lo -up. G Endourol "##6A &&: '$'(. "#. 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