At present, TURP is still the mainstream surgical treatment for BPH, owing to its fast postoperative recovery and low mortality[11, 12]. However, the traditional monopolar TURP still triggers some complications. To reduce the complications of TURP, various minimally invasive approaches have been developed, including the improvement of surgical method, such as enucleation, and the research and development of surgical equipment, such as holmium laser, green light laser, thulium laser, etc. By dissecting along the surgical capsule to remove more glands, endoscopic prostatic enucleation enables anatomic enucleation of entire prostate lobes in the same way that a surgeon’s finger does during open prostatectomy (OP). Recently, PKEP has been reported to be an attractive, minimally invasive alternative to OP, with comparable functional results, fewer complications and requiring no additional equipment[13, 14]. PKEP, the Gyrus bipolar PlasmaKinetic System combined with transurethral enucleation of the prostate, is an improved surgery for PKRP. The efficacy and safety of PKEP has been demonstrated by urologists, it has the characteristics of complete gland resection, short operation time, less bleeding, and fewer complications[9, 15], even in treating large prostates[10, 16].
Our results showed that the 2 surgical methods, PKEP and PKRP could effectively solve the clinical symptoms caused by BPH, and had significant improvement in IPSS, QOL, and Qmax, and decrease in RUV. There were no significant differences among the 3 groups in postoperative 3-month IPSS, QOL, Qmax and RUV. And the irrigation time, catheterization period, postoperative hospitalization day, were not comparable in the 3 groups. In both the PKEP1 and PKEP2 groups, the hemoglobin change was higher than that in PKRP, but there was no statistical difference between PKEP2 and PKRP. Compared with the results of other researchers, the hemoglobin change in our PKEP group was less, such as the first PRT comparing PKEP with TURP conducted by Zhao, they reported a 15.5 ± 1.7 g/L hemoglobin decrease in the PKEP group. In addition, we found that compared with the PKEP1 group, the hemoglobin change in the PKEP2 was less, which was associated with an increase in the number of cases performed and a greater skill level. Like most other studies, the quality of surgically removed glands in the PKEP group was more, and that's the biggest advantage of enucleation. PKEP can retrogradely and bluntly strip the prostate gland along the surgical envelope interface, and can maximally remove the gland, basically achieving the effect of open surgical anatomical enucleation. It can effectively ameliorate the symptoms of BPH shortly after surgery, especially for patients with a large prostate.
In terms of operation time, PKEP1 had little comparative advantage with PKRP, but PKEP2 was shorter than PKRP significantly. One possible explanation is that after making a circular incision with a cutting loop, the tip of the resectoscope sheath was used to dissect the prostatic lobes in a retrograde fashion and to establish the tissue planes off the capsule. During these steps, no vaporisation bubbles were generated at the point of contact, and clear vision was provided. The other explanation could be that the subtotally enucleated and devascularised lobes were then resected in a nearly bloodless field, without needing to stop frequently to check the position. In addition, the operation time of the PKEP2 group was significantly shorter than that of the PKEP1. Due to the difference in prostate volume of each patient, it is impossible to directly compare the changes in operation time with the increase in the number of cases undergoing surgery. Therefore, we calculated the ratio of operation time to prostate volume and resection mass respectively, and used the difference of ratio to represent the change of operation time with the increase of operation cases. We finally concluded that as the number of cases increased, the duration of surgery decreased.
Although the incidence of overall postoperative complications was not comparable in the 3 groups, there were 2 cases in the PKEP and 0 cases in the PKRP group in terms of UI. It was consistent with the results reported by Luo that the incidence of transient incontinence after PKEP was higher than PKRP. UI is a common major complication of endoscopic prostatic enucleation, the incidence of UI after Holmium laser enucleation of the prostate (HoLEP) and PKEP has been reported to be 1.3–40.7%[18, 19] and 3.5–18.9%, respectively. Studies have found that a large prostate volume(≥ 90 mL) and age ≥ 70 years was significantly associated with UI[20, 21]. More meticulous and gentle enucleation can be done during surgery to reduce postoperative incontinence. Furthermore, some selected patients can be treated by conventional PKRP.