Tag Archive for: #article of the week


Editorial: HoLEP is the complete technique for treating BPH

Ten years of experience with holmium laser enucleation of the prostate (HoLEP) are documented by Romero‐Otero et al. [1] and offer valuable insight into the real‐world use of this technique. No information on the 10‐year durability is available, however, as only the 12‐month data are presented, but there is a wealth of other information concerning both peri‐operative outcomes and complications. A particular strength of this paper is that all‐comers were studied, including patients with catheters, those with prostates larger than 100 g and those taking anti‐coagulants, plus there is the addition of the cases the three surgeons performed during their ‘learning curve’, although these are not analysed separately.

The authors’ technique almost certainly evolved over the study period. Personally, I currently find a one‐ or two‐piece enucleation to be more efficient than the three‐lobe technique originally described [2]. Enucleation efficiency of 1–2 g/min, as was achieved in this series (73 g in 40 min), is a good benchmark for tissue removal for those new to the technique and is a good measure of surgical proficiency. Being less aggressive anteriorly seems to have an impact on continence. It is often tempting to completely enucleate circumferentially in one continuous plane which is sometimes well beyond the commissure anteriorly. A more moderate dissection in this area can reduce the transient incontinence sometimes seen [3]. The incontinence rates in the current series of 12.8% at 3 months and 2.3% at 12 months are probably representative [1]. An analysis of the factors predisposing to moderate‐to‐severe incontinence in the six patients in this series would have been useful, particularly regarding prostate size, presence of a catheter and age.

The main contribution of HoLEP to the urological armamentarium is its ability to safely treat large prostates endoscopically [4]. Although robot‐assisted techniques have also decreased the morbidity of open prostatectomy [5], the attraction of the obvious ‘natural orifice’ for access and the use of laser technology for the enucleation with HoLEP is probably the least morbid and most cost‐effective way to treat these patients. Tackling a prostate larger than 100 g involves applying the same principles as for smaller prostates, with a few provisos. Firstly, having a consistent strategy for these large prostates is important and can be reassuring when things become difficult. Secondly, it is even more important to maintain the correct plane religiously as it is easier to get lost in these glands. A good sense of direction is important! Thirdly, stay ahead of the bleeding rather than trying to catch up as it can further compound an already difficult situation. Patience is a virtue.

The learning curve of HoLEP has historically been regarded as a major barrier to the uptake of the technique [6]. This has, of course, been exaggerated by proponents of other techniques, but it is important to emphasize that during this learning phase the excellent outcomes are maintained and that conversion to TURP, if necessary (3.4% in this series), can be safely done, as these authors’ have demonstrated. The length of the learning curve has been variously described as being between 20 and 80 cases and is almost entirely due to the way training is done. A modular mentored approach appears to be the best method and could equally be applied to endoscopic enucleation using any of the other energy sources that have been described [7].

HoLEP and all its progeny are here to stay, but which of these enucleation energy sources will gain ascendancy remains to be seen. Sadly, this will likely be more to do with the depth of the corporate pockets and their commitment to the cause rather than proper scientific appraisal [8].

by Peter Gilling


  1. Romero‐Otero J, Garcia‐Gomez B, Garcia‐Gonzalez L et al. Critical analysis of a multicentric experience with holmium laser enucleation of the prostate for benign prostatic hyperplasia: outcomes and complications of 10 years of routine clinical practice. BJU Int 2020; 126: 177-182
  2. Gilling PJ, Kennett K, Das AK, Thompson D, Fraundorfer MR. Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience. J Endourol 1998; 12: 457– 9
  3. Tunc L, Yalcin S, Kaya E et al. The “Omega Sign”: a novel HoLEP technique that improves continence outcomes after enucleation. World J Urol 2020 https://doi.org/10.1007/s00345-020-03152-9
  4. Gilling PJ, Kennett KM, Fraundorfer MR. Holmium laser enucleation of the prostate for glands larger than 100 g: an endourologic alternative to open prostatectomy. J Endourol 2000; 14: 529– 31
  5. Mourmouris P, Keskin SM, Skolarikos A et al. A prospective comparative analysis of robot‐assisted vs open simple prostatectomy for benign prostatic hyperplasia. BJU Int 2019; 123: 313– 7
  6. Placer J, Gelabert‐Mas A, Vallmanya F et al. Holmium laser enucleation of prostate: outcome and complications of self‐taught learning curve. Urology 2009; 73: 1042– 8
  7. Kuronen‐Stewart C, Ahmed K, Aydin A et al. Holmium Laser Enucleation of the prostate: simulation based training curriculum and validation. Urology 2015; 86: 639– 46.
  8. Herrmann TR. Enucleation is enucleation is enucleation is enucleation. World J Urol 2016; 34: 1353– 5

Editorial: Fake news about benign prostatic hyperplasia on YouTube

YouTube is a widely used video‐sharing and social networking platform. It contains a large volume of content about medical topics, including urological conditions. In this issue of BJUI, Betschart et al. [1] examined the quality of 159 YouTube videos about surgical treatment of BPH with ≥500 views. The median overall quality of videos was poor (2 out of 5 possible points) based on validated criteria for the assessment of consumer health information. Nearly 87% of videos contained some misinformation and 84% had commercial bias.

We previously reported similar findings in the first 150 videos in a YouTube search for prostate cancer [2]. The median overall quality of videos was moderate (3 out of 5 points), and 77% contained biased and/or misinformative content in the video or comments beneath it. Furthermore, videos with lower expert‐rated quality had higher user engagement.

In the study by Betschart et al. [1], most of the YouTube videos about BPH had very good production quality, and 69% were posted by healthcare providers (e.g., doctor, clinic, hospital or university). These attributes might lead health consumers to have more trust in the information that is provided. In fact, they found that two‐thirds of videos with the most views in each topic had a quality score below the median score for videos about that topic.

Unfortunately, these issues are pervasive across many health domains. A recent review article reported on the prevalence of commercial bias and misinformation in social media posts about a variety of urology topics, including female pelvic medicine, endourology, sexual medicine, and infertility [3].

What can be done to combat the large quantity of misinformative urological information circulating online? For BPH on YouTube alone, Betschart et al. [1] reported that there were >12 000 videos as of May 2019. It is not practical for medical experts to manually vet the vast and continually changing repository of online medical information.

One future possibility is the development of computational tools to help evaluate the quality of information. For example, using an annotated dataset of 250 YouTube videos about prostate cancer, we created an automatic classification model for the identification of misinformation with an accuracy of 74% [4]. Further study is warranted to develop and test the use of machine learning to help filter the quality of online content.

As healthcare providers, what can we do to address these problems in the near‐term? We previously reported that USA adults who perceive worse patient‐physician communications are significantly more likely to watch health videos on YouTube [5]. This highlights the importance of shared decision‐making and proactively directing our patients to trusted sources of information. A curated list of reputable sources of online urological health information is presented in a recent review [6]. In addition, healthcare providers should be encouraged to actively participate in social media to flag any content that is inaccurate or dangerous and to help provide accurate information to the public. The BJUI, European Association of Urology, and AUA have all published guidance regarding best practices for social media engagement, which should be incorporated into urological education in the future [7].

In conclusion, social networks have a huge global audience and offer great potential to benefit the care of BPH and other urological conditions. However, to meet this potential and offset the risks will require significant ongoing efforts from the urological community.

by Stacy Loeb


  1. Betschart P, Pratsinis M, Müllhaupt G et al. Information on surgical treatment of benign prostatic hyperplasia on YouTube is highly biased and misleading. BJU Int 2020; 125: 595-601
  2. Loeb S, Sengupta S, Butaney M et al. Dissemination of misinformative and biased information about prostate cancer on YouTube. Eur Urol 2019; 75: 564– 7
  3. Loeb S, Taylor J, Borin JF et al. Fake News: Spread of misinformation about urological conditions on social media. Eur Urol Focus 2019 [Epub ahead of print].
  4. Hou R, Perez‐Rosas V, Loeb S, Mihalcea R. Towards Automatic Detection of Misinformation in Online Medical Videos. International Conference on Multimodal Interaction. Suzhou, Jiangsu, China: ACM, 2019. Available at: https://arxiv.org/abs/1909.01543. Accessed January 2020
  5. Langford A, Loeb S. Perceived patient‐provider communication quality and sociodemographic factors associated with watching health‐related videos on YouTube: a cross‐sectional analysis. J Med Internet Res 2019; 21: e13512. 
  6. Langford AT, Roberts T, Gupta J, Orellana KT, Loeb S. Impact of the internet on patient‐physician communication. Eur Urol Focus 2019: 31582312 [Epub ahead of print].
  7. Taylor J, Loeb S. Guideline of guidelines: social media in urology. BJU Int 2020; 125: 379-382

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