Platinum Priority – Editorial and Reply from Authors Referring to the article published on pp. 859–867 of this issue Laser Enucleation Is Increasingly Becoming the Standard of Care for Treatment of Benign Prostatic Hyperplasia of All Sizes Peter J. Gilling * Department of Urology, Tauranga Hospital, Tauranga, New Zealand Laser technologies for benign prostatic hyperplasia (BPH) have steadily replaced transurethral resection of the prostate (TURP) over the past 10 yr in many parts of the world [1]. For example, the rate of TURP performance declined 47.6% in a US Medicare population between 2000 and 2008 [2]. Techniques for laser prostatectomy used in each country vary, with enucleation preferred in some countries [3] and vaporisation preferred in others [2]. The European Association of Urology and the American Uro- logical Association BPH guidelines panels consider both holmium laser enucleation of the prostate (HoLEP) and photoselective vaporisation of the prostate to be equivalent to TURP, with long-term data favouring HoLEP; however, there are now a plethora of ‘‘me too’’ technologies (both electrosurgical and laser) that need to be considered, with a bewildering array of acronyms, now described [4]. The Thulium:Yttrium-Aluminium-Garnet (YAG) laser (2014 nm wavelength) is one of four contemporary groups of laser systems used for BPH treatment. Holmium:YAG (2140 nm wavelength), 532-nm lasers, and diode systems (a variety of wavelengths) are the others [4]. Thulium laser techniques have followed the development of holmium laser prostatectomy, which evolved from a modality used initially for ablation and resection to enucleation more than 15 years ago [5]. Currently, four distinct procedures utilise the thulium laser: vaporisation (ThuVAP), vaporesection (ThuVARP), vapoenucleation (ThuVEP), and enucleation (ThuLEP). Each is described by different authors [6]. In this edition of the journal, Gross and colleagues, who are pioneers with this wavelength, describe a series of 1080 patients who underwent ThuVEP at their institution [7]. They comprehensively document the peri- and early postoperative outcomes and complications in this prospective study. A variety of lasers were used over the 4-yr period, from 70 W to 200 W, reflecting the evolution of the technology over this time. A mechanical morcellator was used, and the data of 11 different surgeons were included. By department protocol, bladder irrigation was used overnight in all cases, and the catheter was removed on the second day. Complications were classified using the modified Clavien system, and rates were compared for differently sized prostates and different phases of the learning curve. The authors found that a median of 30 g of tissue was retrieved from their patients (median preoperative trans- rectal ultrasound volume: 51 ml), and incidental prostatic carcinoma was found in 5.5% of these patients [7]. These values are similar to those found in a large unselected series of patients undergoing HoLEP [8]. Minor complications not requiring intervention (Clavien 1 and 2) occurred in 24.6% of patients. These included recatheterisation in 9%, prolonged irrigation in 3.5%, and transfusion in 1.7%. More important, major complications requiring reintervention (Clavien 3a, 3b, and 4a) occurred in 6.6% of patients, including incomplete morcellation (1.7%), residual apical tissue (2.7%), and coagulation of the prostate fossa for bleeding (2%). A decrease in complications was noted as the series progressed. Since laser enucleation (HoLEP) was first described in large prostates [9], the claim of being a size-independent procedure has been made for HoLEP by a number of authors. Gross and colleagues assessed complications and outcomes by prostate size for ThuVEP [7]. They found that there were no differences in transfusion rates or for any other complication, for that matter, in patients following ThuVEP when these were analysed by prostate size EUROPEAN UROLOGY 63 (2013) 868–871 available at www.sciencedirect.com journal homepage: www.europeanurology.com DOI of original article: http://dx.doi.org/10.1016/j.eururo.2012.11.048. * P.O. Box 56, Tauranga 3140, New Zealand. Tel. +64 7 5790466; Fax: +64 7 5790468. E-mail address: peter@urobop.co.nz. 0302-2838/$ – see back matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.