"Double rings" En-bloc technique with early anatomical apical release in thuflep for the patients with large glands (≥ 80 mL): the outcomes from single center.

Background and purpose: We aimed to describe the technique and outcomes of "Double Rings" En-bloc thulium fiber laser enucleation of the prostate (ThuFLEP) with early anatomical apical release in benign prostatic hyperplasia (BPH) with large glands (≥ 80 mL).

Patients and methods: A total of 68 BPH patients with large glands (≥ 80 mL) who received our technique performed by a single surgeon were enrolled between January 2021 and January 2022. The parameter set of thulium fiber laser was 1.5 J/40 Hz (60 W). Enucleation was performed using the "Double Rings" technique. The first ring was created by circumferentially incising the urethral mucosa around the adenoma at the apex. The second ring was formed by dissecting the bladder neck at 12 o'clock position, which served as a landmark for guiding further dissection. The adenoma was then pushed into the bladder, and the bleeding points of the prostatic fossa were coagulated with a thulium fiber laser to ensure hemostasis. We analyzed patient demographic, perioperative and two-year follow-up data.

Results: Mean preoperative prostate volume was 135 ml (range, 80-275). Mean preoperative International Prostate Symptom Score (IPSS) was 21.1 (range, 17.8-29.6). Mean preoperative quality of life (QoL) score was 4.7 (range, 3-5). Mean operative time was 88.6 min (range, 40-199). Mean enucleated tissue weight was 70.8 g (range, 30-162). The rate of postoperative complication was 11.8% (2 fevers and 6 urinary tract infections), which were manageable. No blood transfusion. IPSS, QoL score, peak urinary flow rate, and postvoid residual urine volume were all significantly improved (p < 0.01). Six patients had transient early stress urinary incontinence (SUI), but all recovered in 3 months. Over a follow-up of 38.2 months (range: 28-45 months), no urethral stricture or bladder neck contracture were detected. No patient developed permanent SUI.

Conclusions: "Double Rings" En-bloc technique with early anatomical apical release in ThuFLEP seems to be a safe and effective approach for BPH patients with large glands. However, multi-center and large sample studies are still needed.