World Journal of Urology

https://doi.org/10.1007/s00345-019-02757-z

ORIGINAL ARTICLE

Monopolar enucleation versus transurethral resection of the prostate

for small‑ and medium‑sized (< 80 cc) benign prostate hyperplasia:
a prospective analysis
Dmitry Enikeev1   · Leonid Rapoport1 · Magomed Gazimiev1 · Sergey Allenov1 · Jasur Inoyatov1 · Mark Taratkin1 ·
Ekaterina Laukhtina1 · John M. Sung2 · Zhamshid Okhunov2 · Petr Glybochko1

Received: 8 February 2019 / Accepted: 2 April 2019

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Aim  To assess efficacy and safety of monopolar enucleation of the prostate (MEP) and to compare it with the current treat-
ment standard for medium-sized prostates, < 80 cc, transurethral resection of the prostate (TURP).
Methods  A prospective analysis patients undergoing a surgical procedure for their diagnosis of BPH (benign prostatic
hyperplasia) (IPSS > 20, Qmax < 10; prostate volume < 80 cc) was performed. IPSS, Qmax were assessed preoperatively, at 6
and 12 months postoperatively. The complications were classified according to the modified Clavien–Dindo grading system.
Results  A total of 134 patients were included in the study: 70 underwent MEP and 64 - TURP for BPH (mean prostate
volumes were comparable with p = 0.163). The mean surgery time was 44 min in the TURP group and 48.2 min in the MEP
group, (p = 0.026). Catheterization time for MEP was 1.7 and 3.2 days for TURP (p < 0.001). Hospital stay for MEP was
3.2 days vs. 4.8 days for TURP (p < 0.001). Both techniques shown comparable efficiency in benign prostatic obstruction
relief with IPSS drop in MEP from 23.1 to 5.9 and in TURP group from 22.8 to 7.3, whereas Qmax increased from 8.2 to 20.5
after MEP and from 8.3 and 19.9 after TURP. Urinary incontinence rate after catheter removal in TURP group was 9.0% and
7.8% in MEP group, at 1 year follow-up, it was 1.4% and 3.1% in MEP and TURP, respectively (p = 0.466).
Conclusions  Our experience demonstrated that MEP is an effective and safe BPH treatment option combining the efficacy
of endoscopic enucleation techniques and accessibility of conventional TURP.

Keywords  BPH · Monopolar · Endoscopic enucleation of the prostate · EEP · MEP · TURP

Introduction retentions, urinary tract infections, and retreatment rates,

Transurethral resection of the prostate (TURP) is the treat-
ment of choice for relatively small prostate glands impli-
cated in benign prostatic hyperplasia (BPH) [1]. According
to recent meta-analysis, TURP remains a viable and equiva-
lent to other contemporary BPH treatment techniques [2].
However, the procedure is still stricken with complications
including bleeding necessitating blood transfusions, clot
* Dmitry Enikeev
dvenikeev@gmail.com
1 with monopolar electrosurgery, which is more accessible
Institute for Urology and Reproductive Health, Sechenov
University, 2/1 Bolshaya Pirogovskaya St, Moscow 119991,
Russian Federation
2
Department of Urology, University of California, Irvine,
USA
among others [3]. According to the latest European Asso-
ciation of Urology (EAU) guidelines, endoscopic enuclea-
tion of the prostate (EEP) is recommended as an alternative
treatment modality for men with lower urinary tract symp-
toms (LUTS) due to BPH [4]. For glands larger than 80 cc,
holmium laser enucleation of the prostate (HoLEP) seems
to have gained popularity among urological surgeons due
to known advantages [5]. HoLEP is one of many EEP pro-
cedures that requires laser technologies such as holmium
and thulium lasers. Unfortunately, lasers are not universally
accessible, thus, enucleation often cannot be offered by all
health providers. However, enucleation can be performed
among various providers. Monopolar enucleation of the
prostate (MEP) utilizes electrosurgery rather than lasers to
enucleate the prostate.

13
Vol.:(0123456789)

The first enucleation with monopolar surgery was per-
formed by Hiraoka and colleagues in 1986. However, vari-
ous enucleation techniques only became popular in the late
1990s when HoLEP was introduced [6]. Despite the ability
to completely enucleate entire adenoma lobes, the technique
harbored a serious disadvantage, which was that enucle-
ated lobes had to be cut into pieces before evacuation. The
advent of morcellators and the introduction of the HoLEP
technique in 1998 rolled out the red carpet for transurethral
endoscopic enucleation of the prostate [7]. Currently, MEP
is rarely employed for BPH management as it became over-
shadowed by the emergence of the newer laser enucleation
technologies. Many centers began performing EEP with the
holmium laser, and more recently, interest in thulium-fiber
laser enucleation has emerged. At our center, with substan-
tial experience of more than 1500 cases of laser EEP we
began a search for other possible approaches to EEP. We
wanted to revisit the original modality of EEP, MEP, as it
seems to be the most accessible EEP technique as it does
not require laser equipment. To be sure, MEP only requires
standard monopolar instruments that is widely available in
many centers across the world and may be more cost effec-
tive. A second advantage is that MEP delivers anatomically
correct endoscopic enucleation of the prostate gland, which
can ameliorate common problems otherwise associated
with the TURP procedure that utilizes a non-anatomical
approach to the prostatic tissue. During a TURP, it can be
difficult to determine the correct enucleation plane and can
lead to a higher risk of capsular perforation and need for
retreatment [17]. It has already been studied that MEP is at
least equivalent to other enucleation procedures in regard to
post-surgery IPSS (International Prostate Symptom Score)
and QoL (Quality of Life) scores. We hypothesized that all
these factors may also facilitate enucleation adoption as the
first treatment option in medium-sized prostates (< 80cc).
The aim of the current trial was to assess the efficacy and
safety of MEP and to compare it with the current treatment
standard (TURP).
Materials and methods
This prospective study included patients diagnosed with
benign prostatic obstruction (IPSS > 20, Qmax < 10) that had
prostate volumes < 80  cc undergoing surgical treatment.
Patients were excluded from the study if they had any prior
prostate surgery, a diagnosis of prostate cancer, ongoing anti-
platelet or anticoagulant therapy, or any urethral strictures or
bladder stones. The patients were prospectively randomized
into two groups: TURP and MEP. Each technique—enuclea-
tion and TURP—was performed by a single surgeon highly
experienced in lower urinary tract surgery (DE and LM,
13
World Journal of Urology
respectively). Randomization was carried out with a rand-
omization list.
Surgical Techniques
All surgeries were performed using a ­12o, 26 Fr. resecto-
scope (Richard Wolf, Germany), hook-electrode, and straight
loops. A Valleylab electrical current generator (Force FX,
Boulder, CO) was used for cutting (160 W) and coagulation
(80 W). MEP was performed using the two lobe technique, as
described in other existing literature [4, 7]. Enucleation starts
with an incision at the 5 o’clock position from the bladder
neck to the verumontanum. At the verumontanum, the inci-
sion is widened and continued counterclockwise, laterally to
the 1 o’clock position, toward the bladder neck. Then, an inci-
sion is made at the 12 o’clock position from the bladder neck
toward the verumontanum. The incisions are connected, and
the enucleated left lobe is released into the bladder. The right
lobe is enucleated in a similar manner. The enucleated prostate
tissue is removed with a ­Piranha® mechanical tissue morcel-
lator (Richard Wolf, Knittlingen, Germany). The surgery is
finished with coagulation of any bleeding vessels with a stand-
ard loop if necessary. Monopolar TURP is performed using
the standard technique (loop electrode, cutting ball) without
special modifications. Tissue retrieval after TURP is done with
an Ellik evacuator. In all cases (MEP and TURP), the adenoma
tissue is sent for pathology.
After surgery, a 21 F three-way Foley catheter was inserted
for continuous bladder irrigation with normal saline. Bladder
irrigation was terminated on the first postoperative day. The
catheter was removed when the urine was clear. Patients were
discharged after removal of the catheter and after they began
to void adequately. All perioperative medical and surgical
complications were recorded and classified according to the
modified Clavien–Dindo grading system [2]. The follow-up
period was 12 months. At 3, 6, and 12 months, PSA, TRUS
prostate volume, IPSS, Qmax, and IPSS-QoL were evaluated.
Statistical analysis
For statistical analysis, we used SPSS Statistics 23.0 (IBM,
USA). Patient data were expressed as mean ± standard devia-
tion (SD). Continuous variables were compared by one-way
ANOVA test. Categorical variables were compared by Chi-
square test. The level of statistical significance was taken
as p < 0.05.
Results
This trial included a total of 134 patients; of these, 70
patients underwent MEP and 64 received TURP. Six of 70
initially included TURP patients were excluded from the
World Journal of Urology

study due to inability to present for follow-up. The preop-
erative mean prostate volumes measured with TRUS were
comparable between the two groups (62.3 cc and 59.0cc,
respectively) (p = 0.163). The mean age in the TURP group
was 68 years with a total PSA level of 4.0 ng/mL; and, the
mean age of the patients who underwent MEP was 67 years
with an average PSA level of 3.6 g/mL. There were no inter-
group differences in any preoperative data (IPSS, QoL-IPSS,
Qmax) (Table 1). In addition, none of the patients had any
preoperative urinary incontinence.
The mean surgery time was slightly, yet significantly,
shorter in the TURP group than in the MEP group (44 min
vs. 48.2  min, p = 0.026). Mean mass of removed tissue
was greater after MEP than after TURP (49.0 g vs. 43.6 g,
p = 0.006). Mean catheterization time after MEP was signifi-
cantly shorter than after TURP (1.7 vs 3.2 days, p < 0.001).
The same was true for mean hospital stay (3.2 vs 4.8 days,
p < 0.001) (Table 1).
Regarding surgical complications, the most severe was
bladder tamponade that required repeat surgery under local
anesthesia in one patient after TURP (Clavien–Dindo IIIa).
All other complications were classified as Clavien–Dindo
I–II. No TURP-syndrome or blood loss necessitating blood-
transfusion was encountered (Table 2).
At 12-month follow-up after surgery, all the patients
had substantial improvement in the IPSS scores, QoL, and
Qmax regardless of the procedure they received(p < 0.001)
(Table 3). However, mean residual prostate volume after
MEP group was less than after TURP (13.8 vs 18.1cc,
p < 0.001) (Table 1).
The de novo, transient urinary incontinence rate after
catheter removal in the MEP group was 10% (8.6%—
mild; 1.4%—moderate), and 7.7% in the TURP group
(3.1%—mild; 4.7%—moderate) (p = 0.446). During follow-
up, this rate decreased to 1.4% at 12 months in MEP and to
3.1% in TURP group (p = 0.466) (Table 2).
Discussion
Monopolar TURP was first introduced about a century ago.
It remains one the most effective and frequently used pro-
cedures in endourology. While a lot of different techniques
have attempted to replace it as the treatment standard, TURP
still holds its crown for treatment of certain types of BPH
[8–10]. However, the introduction of EEP led to a paradigm
shift, when international associations (EAU and AUA)
started recommending enucleation as an alternative to con-
ventional TURP.
The first enucleation was performed in 1986 by Hiraoka
et al. with monopolar electrosurgery [6]. The technique
mimicked the movements of a surgeon’s finger during
open prostatectomy, and was anatomically correct allowing
complete removal of adenomas up to the surgical capsule
[11, 12]. Unfortunately, the procedure had a steep learning
curve and outcomes were only equivalent to TURP; there-
fore, MEP failed to gain significant traction. In addition, the
need for a cutting loop electrode to remove the enucleated
tissue (the “mushroom” technique) hindered the widespread
adoption of this surgical method as this additional step sig-
nificantly prolonged surgery and made it more complicated
[13].
An important improvement on the technique was the
introduction of a morcellator that enabled safe and effec-
tive removal of adenomatous tissue of any size (even those
over 200cc) and significantly shortened surgery [14]. The

Table 1  Perioperative Parameter MEP M-TURP p

parameters
Number of patients (n) 70 64
Age (years) 67.3 ± 6.0 (52–80) 68.8 ± 5.3 (58–82) 0.129
Prostate volume (ml) 62.3 ± 13.0 (32–80) 59.0 ± 14.3 (31–80) 0.163
Prostate volume (ml) 12 months after operation 13.8 ± 4.1 (7–22) 18.1 ± 5.2 (8–29) < 0.001*
Surgery time (min) 48.2 ± 10.9 (32–77) 43.9 ± 11.0 (20–67) 0.026*
Surgery efficiency (g/min) 1.0 ± 0.2 (0.6–1.9) 1.0 ± 0.2 (0.7–1.9) 0.489
Removed tissue (g) 49.0 ± 11.1 (20–72) 43.6 ± 11.8 (17–63) 0.006*
Residual volume (cc) 13.8 ± 4.1 (7–22) 18.1 ± 5.2 (7–30) < 0.001*
Catheterization time (days) 1.7 ± 0.8 (1–3) 3.2 ± 0.8 (2–5) < 0.001*
Hospital stay (days) 3.2 ± 0.9 (2–5) 4.8 ± 0.9 (3–6) < 0.001*
Hemoglobin decrease (g/L) 16.6 ± 8.9 (0–30) 17.9 ± 8.0 (2–30) 0.128
Sodium decrease (mmol/L) 3.9 ± 1.7 (0–6) 4.1 ± 1.1 (1–7) 0.743
PSA (ng/ml) pre-op 3.6 ± 2.0 (0.1–11.0) 4.0 ± 2.4 (0.3–14.3) 0.359
PSA (ng/ml) 12 months after operation 0.3 ± 0.2 (0.1–0.9) 0.6 ± 0.4 (0.1–2.1) < 0.001*

Data indicated as mean ± SD (range)

*Statistically significant difference

13
 World Journal of Urology

Table 2  Early and late postoperative complications

Complications Clavien–dindo group MEP (n = 70) M-TURP (n = 64) p

Early postoperative complications

 Short-term stress urinary incontinence (after catheter-removal), n (%)
  I grade I 5 (7.1) 4 (6.3) 0.556
  II grade I 3 (4.3) 2 (3.1) 0.542
 Prolonged bladder irrigation (due to bleed- I 5 (7.1) 5 (7.8) 0.569
ing), n (%)
 Clot retention, n (%) I 7 (10.0) 9 (14.0) 0.473
 Urinary tract infection, n (%) II 5 (7.1) 4 (6.3) 0.556
 Acute urinary retention, n (%) II 2 (2.8) 3 (4.7) 0.457
 Bladder tamponade, n (%) IIIa 2 (2.8) 3 (4.7) 0.457
Complications Follow up MEP (n = 70) M-TURP (n = 64) p

Late postoperative complications (up to 12 months)

 Stress urinary incontinence, n (%) 1 months Mild 6 (8.6) 2 (3.1) 0.168
Moderate 1 (1.4) 3 (4.7) 0.084
3 months Mild 3 (4.3) 3 (4.7) 0.616
Moderate – – –
6 months Mild 2 (2.8) 2 (3.1) 0.655
12 months Mild 1 (1.4) 2 (3.1) 0.466
 Urethral stricture, n (%) 6 months – – –
12 months 1 (1.4) 2 (3.1) 0.466
 Bladder neck sclerosis, n (%) 6 months 1 (1.4) – –
12 months 1 (1.4) 1 (1.5) 0.729

Table 3  Postoperative Parameter Follow up MEP M-TURP p

parameters
IPSS (score) Preoperative 23.1 ± 2.2 (20–28) 22.8 ± 2.4 (20–32) 0.449
12 months 5.9 ± 2.1 (3–9) 7.3 ± 3.5 (3–9) 0.450
p (Preop vs 12 months) < 0.001 < 0.001
QoL (score) Preoperative 4.3 ± 0.9 (3–6) 4.2 ± 1.0 (3–6) 0.573
12 months 1.7 ± 0.7 (1–3) 1.8 ± 0.7 (1–3) 0.951
p (Preop vs 12 months) < 0.001 < 0.001
Qmax (mL/s) Preoperative 8.2 ± 1.9 (1–12) 8.3 ± 1.7 (5–11) 0.755
12 months 20.5 ± 3.0 (12–28) 19.9 ± 2.4 (15–24) 0.251
p (Preop vs 12 months) < 0.001 < 0.001
PVR (mL) Preoperative 62.5 ± 23.4 (20–180) 63.0 ± 20.8 (20–150) 0.887
12 months 11.6 ± 9.7 (0–35) 9.5 ± 7.6 (0–20) 0.167
p (Preop vs 12 months) < 0.001 < 0.001
PVR (mL) Preoperative 0.887
12 months 0.167
p (Preop vs 12 months) < 0.001 < 0.001

Data as mean ± SD (ranges)

morcellator device was invented during the same time as
the development of the widely -known HoLEP enuclea-
tion technique [15]. Therefore, by the time the morcella-
tor device came out to significantly improve EEP surgical
technique, HoLEP had come into play to overshadow MEP.
With all the recent growing interest in EEP surgery, we
wanted to revisit the original monopolar enucleation with
morcellation as it seems to be a feasible approach to BPH
surgery. As standard monopolar urological equipment is
more widely available across various centers, we believed

13
World Journal of Urology
such accessibility would be crucial and even potentially
more cost-effective compared to laser-requiring enuclea-
tion. Currently in our practice, we use holmium/YAG and
thulium fiber lasers for EEP, and monopolar enucleation is
used as often as the other techniques. Within the past few
years, a number of trials on this strategy’s effectiveness
began. Pansadoro et al. reported on 47 patients who under-
went MEP [16]. They found that this technique allowed
for significant improvement in voiding in all patients who
underwent this procedure. As for complications, the urinary
incontinence rate was 2%, which was similar to our own
findings. However, the authors reported 14 postoperative
complications out of 47 total patients: 13 (93%) were Cla-
vien–Dindo Grade I–II, and 1 (7%)—Grade IIIb. Like in this
study, the majority of complications we encountered were
Clavien–Dindo Grade I–II.
Ajib et al. also studied the feasibility of monopolar enu-
cleation [17]. The authors of that study compared enucleore-
section and HoLEP efficiency. In their study, both techniques
were effective and comparable in terms of postoperative out-
comes and complications. One patient in the enucleoresec-
tion group needed blood transfusion due to severe intra- and
postoperative blood loss.
It should be noted that both Pansadoro et al. and Ajib et al.
performed their trials on medium-sized glands (< 80cc). Our
previous retrospective trial on HoLEP, ThuFLEP and MEP
allowed us to suggest that such volume is ideal for these
procedures [18]. In larger prostates, we faced complications
such as TURP-syndrome and extensive bleeding; therefore,
we concluded that MEP, like TURP, is a technique most
suitable for only moderately enlarged glands. Nevertheless,
the maximum volume appropriate for monopolar enucleation
highly depends on the surgeon’s expertise. Volume issues
Fig. 1  Patient’s distribution
depending on postoperative
(12 months) prostate volume.
X-axis—percent of patients;
Y-axis—postoperative volume
(cc); bar—standard deviation
can be mitigated with bipolar enucleation. Geavlete et al.
showed that bipolar enucleation is highly effective in large
prostates (> 80cc) with minor complications [19]. However,
as it was previously mentioned, monopolar surgery is the
most commonly used approach to BPH treatment, and in our
study, we aimed to show that enucleation is possible even
with the most basic instruments available to every urologist.
In our previous works, we also compared the learning curves
associated with laser and electroenucleation [20]. We found
that laser techniques can be taught faster than monopolar
enucleation. Nevertheless, we can conclude that MEP is
a relatively safe technique, even during the initial steps of
training because we did not encounter any serious complica-
tions among patients undergoing MEP.
We found that one major advantage of monopolar enu-
cleation over TURP was more complete removal of the
adenoma. At 12 months of follow-up, residual prostate vol-
ume in MEP patients did not exceed 25 cc, whereas over
12% of TURP patients had residual volumes of 25–30 cc
(Fig. 1). Moreover, MEP with its advantage of more thor-
ough adenoma removal had a more significant drop of PSA
levels after surgery. To be sure, this drop in PSA level was
more pronounced in patients after MEP than after M-TURP
(p < 0.001). Removal of adenomas up to the mostly avascular
surgical plane with MEP can reduce blood loss compared
to TURP because in the latter procedure, resection of surgi-
cal capsule and prostatic parenchyma is usually unavoid-
able [21]. Some suggest that EEP can reduce the number of
reinterventions for BPH relapse [22].
Several studies have demonstrated that MEP is a safe pro-
cedure [16, 17]. In our trial, similarly, we detected a lower
rate of complications in the MEP group compared to the
TURP group. Postoperative transient incontinence, which
13

we defined as any type of urine leakage, occurred after MEP
and TURP in some patients, most of whom recovered to
normal continence within 3 months. At 12-month follow-
up after surgery, incontinence rates were about 1.5% after
MEP and 3.1% after TURP (p = 0.466), which is a similar
rate found in other studies.
Out study has several limitations including a small num-
ber of patients. Possible field for further investigation can
be cost efficiency analysis, which was not present in current
trial. However, given the fact that all patients were treated
similarly, surgery time and prescribed medications were
comparable, and the only differences were catheterization
and hospital stay times, MEP might be superior to TURP
in terms of cost efficiency. One specific limitation of MEP
is that it still requires a morcellator for fast removal of ade-
nomatous tissue from the bladder. A potential alternative,
albeit time-consuming, the mushroom technique, was not
included in our trial.
Conclusions
MEP is an effective and safe BPH treatment option con-
sidering the efficacy of endoscopic enucleation techniques.
MEP harbors the same complications as TURP, yet it allows
for more complete removal of adenomas. We consider this
technique a viable and widely accessible TURP alternative.
Author contributions  DE—manuscript writing/editing; protocol/pro-
ject development; LR—protocol/project development; MG—protocol/
project development; SA—data collection and management; JI—data
collection and management; MT—manuscript writing/editing; proto-
col/project development; data collection and analysis; EL—manuscript
writing/editing; data collection and analysis; JMS—manuscript writ-
ing/editing; ZO—manuscript writing/editing; PG—protocol/project
development.
Compliance with ethical standards  prostate (EEP). World J Urol 35(10):1629–1630. https​://doi.
Conflict of interest  All authors state that they have no conflict of inter-
est that might potentially bias they work.
Ethical approval  The study was approved by the Sechenov University
(Moscow, Russia) Institutional Review Board.
Informed consent  Informed consent was obtained from all individual
participants included in the study.
References
1. Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S,
Michel MC, N’Dow J, Nordling J, de la Rosette JJ, European
Association of U (2013) EAU guidelines on the treatment and
follow-up of non-neurogenic male lower urinary tract symptoms
13
World Journal of Urology
including benign prostatic obstruction. Eur Urol 64(1):118–140.
https​://doi.org/10.1016/j.eurur​o.2013.03.004
2. Peyronnet B, Pradere B, Brichart N, Bodin T, Bertrand P, Mem-
bers of French Group of GreenLight U, Bruyere F (2014) Com-
plications associated with photoselective vaporization of the pros-
tate: categorization by a panel of green light users according to
Clavien score and report of a single-center experience. Urology
84(3):657–664. https​://doi.org/10.1016/j.urolo​gy.2014.05.028
3. Mamoulakis C, de la Rosette JJ (2015) Bipolar transurethral resec-
tion of the prostate: darwinian evolution of an instrumental tech-
nique. Urology 85(5):1143–1150. https​://doi.org/10.1016/j.urolo​
gy.2015.01.003
4. Gravas S, Bach T, Bachmann A, Drake M, Gacci M, Gratzke
C (2016) Management of non-neurogenic male lower urinary
tract symptoms (LUTS), incl. Eur Assoc Urol, Benign Prostatic
Obstruction (BPO) EAU Guidelines on
5. Li S, Zeng XT, Ruan XL, Weng H, Liu TZ, Wang X, Zhang C,
Meng Z, Wang XH (2014) Holmium laser enucleation versus tran-
surethral resection in patients with benign prostate hyperplasia: an
updated systematic review with meta-analysis and trial sequential
analysis. PLoS One 9(7):e101615. https​://doi.org/10.1371/journ​
al.pone.01016​15
6. Hiraoka Y, Lin T, Tsuboi N, Nakagami Y (1986) Transurethral
enucleation of benign prostatic hyperplasia. Nihon Ika Daigaku
Zasshi 53(2):212–215
7. Herrmann TR (2016) Enucleation is enucleation is enucleation
is enucleation. World J Urol 34(10):1353–1355. https​://doi.
org/10.1007/s0034​5-016-1922-3
8. Cornu JN, Ahyai S, Bachmann A, de la Rosette J, Gilling P,
Gratzke C, McVary K, Novara G, Woo H, Madersbacher S (2015)
A systematic review and meta-analysis of functional outcomes and
complications following transurethral procedures for lower uri-
nary tract symptoms resulting from benign prostatic obstruction:
an update. Eur Urol 67(6):1066–1096. https​://doi.org/10.1016/j.
eurur​o.2014.06.017
9. Mamoulakis C, de la Rosette J (2015) Bipolar transurethral resec-
tion of the prostate: darwinian evolution of an instrumental tech-
nique. Urology 85(5):1143–1150. https​://doi.org/10.1016/j.urolo​
gy.2015.01.003
10. Rassweiler J, Teber D, Kuntz R, Hofmann R (2006) Complica-
tions of transurethral resection of the prostate (TURP)–incidence,
management, and prevention. Eur Urol 50(5):969–979. https:​ //doi.
org/10.1016/j.eurur​o.2005.12.042
11. Hiraoka Y, Akimoto M (1989) Transurethral enucleation of benign
prostatic hyperplasia. J Urol 142(5):1247–1250
12. Hiraoka Y (2017) Transurethral endoscopic enucleation of the
org/10.1007/s0034​5-017-2019-3
13. Glybochko PV, Alyaev YG, Rapoport LM, Enikeev DV, Okhu-
nov Z, Netsch C, Spivak LG, Taratkin MS (2018) Endoscopic
enucleation of the prostate: a short term trend or a new treatment
standard? Urologiia 2:130–133
14. Ahyai SA, Gilling P, Kaplan SA, Kuntz RM, Madersbacher S,
Montorsi F, Speakman MJ, Stief CG (2010) Meta-analysis of
functional outcomes and complications following transurethral
procedures for lower urinary tract symptoms resulting from
benign prostatic enlargement. Eur Urol 58(3):384–397. https​://
doi.org/10.1016/j.eurur​o.2010.06.005
15. Gilling PJ, Kennett K, Das AK, Thompson D, Fraundorfer MR
(1998) Holmium laser enucleation of the prostate (HoLEP) com-
bined with transurethral tissue morcellation: an update on the
early clinical experience. J Endourol 12(5):457–459. https​://doi.
org/10.1089/end.1998.12.457
16. Pansadoro V, Emiliozzi P, Del Vecchio G, Martini M, Scar-
pone P, Del Giudice F, Veneziano D, Brassetti A, Assenmacher
C (2017) Monopolar transurethral enucleation of prostatic
World Journal of Urology
adenoma: preliminary report. Urology 102:252–257. https​://doi.
org/10.1016/j.urolo​gy.2016.12.024
17. Ajib K, Zgheib J, Salibi N, Zanaty M, Mansour M, Alenizi A,
El-Hakim A (2018) Monopolar transurethral enucleo-resection
of the prostate versus holmium laser enucleation of the prostate:
a canadian novel experience. J Endourol 32(6):509–515. https​://
doi.org/10.1089/end.2017.0853
18. Enikeev DV, Glybochko PV, Okhunov Z, Alyaev YG, Rapoport
LM, Tsarichenko D, Enikeev ME, Sorokin NI, Dymov AM, Tarat-
kin MS (2018) Retrospective analysis of short-term outcomes
after monopolar versus laser endoscopic enucleation of the pros-
tate: a single center experience. J Endourol 32:417–423. https​://
doi.org/10.1089/end.2017.0898
19. Geavlete B, Stanescu F, Iacoboaie C, Geavlete P (2013) Bipolar
plasma enucleation of the prostate vs open prostatectomy in large
benign prostatic hyperplasia cases—a medium term, prospective,
randomized comparison. BJU Int 111(5):793–803. https​://doi.
org/10.1111/j.1464-410X.2012.11730​.x
20. Enikeev D, Glybochko P, Rapoport L, Gahan J, Gazimiev M,
Spivak L, Enikeev M, Taratkin M (2018) A randomized trial
comparing the learning curve of 3 endoscopic enucleation tech-
niques (HoLEP, ThuFLEP, and MEP) for BPH using mentor-
ing approach-initial results. Urology 121:51–57. https​://doi.
org/10.1016/j.urolo​gy.2018.06.045
21. Choo MS, Lee HE, Bae J, Cho SY, Oh SJ (2014) Transurethral
surgical anatomy of the arterial bleeder in the enucleated cap-
sular plane of enlarged prostates during holmium laser enuclea-
tion of the prostate. Int Neurourol J 18(3):138–144. https​://doi.
org/10.5213/inj.2014.18.3.138
2 2. Shimizu Y, Hiraoka Y, Iwamoto K, Takahashi H, Abe H (2005)
Measurement of residual adenoma after transurethral resection
of the prostate by transurethral enucleation technique. Urol Int
74(2):102–107. https​://doi.org/10.1159/00008​3278
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
13