ThuLEP: Laser Treatment for Benign Prostatic Hyperplasia Offers New Standard of Care at University Health System

By Josh Garcia
Thursday, June 14, 2018
Specialty: 

No matter the size of the gland, thulium laser enucleation of the prostate (ThuLEP) offers next-day resolution of benign prostatic hyperplasia (BPH) symptoms without the need for extended hospital stays or invasive surgery.


Ahmed Mansour, MD, MRCS, Assistant Professor of Urology at UT Health San Antonio

Transurethral resection of the prostate (TURP) has traditionally served as the gold standard surgical treatment for urinary symptoms due to BPH, but laser treatments such as holmium laser enucleation of the prostate (HoLEP) and ThuLEP are more deserving of the title, according to Ahmed Mansour, MD, MRCS, Assistant Professor of Urology at UT Health San Antonio.

“Studies have shown that laser enucleation is more efficient and equally — if not more — effective than TURP” Dr. Mansour says. “In the case of larger prostate glands, it is also an ideal, minimally invasive alternative to open or robotic prostatectomy.”

While most healthcare institutions do not offer laser enucleation procedures such as HoLEP or ThuLEP, the benefits of laser enucleation have been exhibited in several randomized trials and have been endorsed by society guidelines.

“TURP involves taking multiple snips of enlarged prostate tissue using a hot wire,” Dr. Mansour says. “With each snip, bleeding has to be controlled before the next snip can be taken. Enucleation is a different concept entirely.

“Patients who undergo laser enucleation show a greater improvement in subjective symptoms and a lower rate of reoperation at five and 10 years when compared to other procedures”

Laser Enucleation: a Newer Technique to Treat BPH

During laser enucleation, a cystoscope is passed through the urethra to the enlarged prostate. The laser is introduced through the cystoscope and instead of cutting the prostate in pieces, the laser is used to separate the enlarged part of the gland tissue from the prostate’s outer capsule.


University Hospital

“The process of laser enucleation is similar to peeling an orange but leaving the peel behind,” Dr. Mansour says.

The removed tissue is then pushed into the bladder in a single piece. Once the prostate tissue has been relocated to the bladder, a morcellator is introduced through the cystoscope. The morcellator grinds up the excised prostate tissue and suctions it out of the body, where it can be examined for cancer and other conditions.

The entire laser enucleation procedure takes 90 to 150 minutes to complete and requires general or spinal anesthesia. No abdominal incisions are made, and after a 23-hour period of observation with a catheter in place, patients are usually free to leave the hospital. In comparison, procedures such as open or robotic prostatectomy can require three to four days of hospitalization and up to a week of catheterization.

Replacing Open Prostatectomy


Robotic surgery

Due to the aging population, more patients are presenting with larger prostate glands simply as a result of longevity. Furthermore, the success of medical treatment in improving symptoms typically delays the time of surgery by 10 years or more.

“As a result, we have to operate on bigger prostates in comorbid patients,” Dr. Mansour says.

Traditionally, enlarged prostate glands that are over 100 grams in weight require open or robotic prostatectomy for removal. Because laser enucleation is a size-independent procedure, ThuLEP has been used to successfully remove up to 300 grams of enlarged prostate tissue — potentially allowing patients who might not be eligible for open surgery to find relief from BPH symptoms.

“The procedure can also be used in patients who are maintained on blood thinners and anticoagulants,” Dr. Mansour says.

ThuLEP vs. HoLEP

The only major difference between ThuLEP and HoLEP lies in the type of laser that is used for the procedure. Holmium and thulium lasers have different wavelengths and are thus absorbed by different substances in the body. Holmium lasers are mainly absorbed by hemoglobin, while thulium lasers are mostly taken in by water. Holmium lasers are pulsed lasers; thulium lasers are continuous.

“Thulium provides a knife-like action as opposed to holmium’s pulse laser,” Dr. Mansour says. “Theoretically, thulium lasers are associated with improved hemostasis and control of blood vessels, and while we’ve personally perceived these improvements, ongoing clinical trials will shed light on the clinical significance.”


Michael Liss, MD, Director of Clinical Research at University Hospital and Assistant Professor of Urology at UT Health San Antonio. Dr. Liss offers fusion-guided prostate biopsy.

Adoption of Laser Enucleation Procedures

Despite the effectiveness and efficiency of laser enucleation, University Health System is just one of a handful of medical institutions in the country that offer procedures such as ThuLEP. Due to a lack of training opportunities for current and soon-to-be surgeons, laser enucleation has yet to receive widespread adoption by the medical community. University Health System hopes to reverse this trend by providing training programs in laser enucleation for surgeons both within and outside of the organization.

“Laser enucleation is perceived as a difficult procedure to learn, but that’s not well-supported in the literature,” Dr. Mansour says. “We are one of the few centers in which HoLEP and ThuLEP training is being incorporated in our residency program with objective assessments tools for performance metrics. We are in the process of developing a program where visiting surgeons can observe and be trained in these new procedures as well.”

Steps have also been taken to ensure that patients in the area can be easily referred to University Health System for laser enucleation, especially if they have large prostates that would require open prostatectomy were it not for University Health System’s ThuLEP capabilities.

“It’s important for widespread implementation of laser enucleation to be realized,” Dr. Mansour says. “Until then, we have a dedicated team that can manage physician referrals to make the process easier for doctors.”

BPH is the most prevalent prostate problem for men older than 50, affecting almost half of all men between 51 and 60 years old. Enlarged prostates can apply excessive pressure to the urethra and cause issues such as acute urinary retention, bladder and kidney damage, and urinary tract infections.


For more information about ThuLEP or other urology programs at University Health System, please visit universityhealthsystem.com/services/urology or call 210-450-9600.

Diagnostic and Therapeutic Options for Prostate Cancer

University Health System is utilizing new diagnostic and therapeutic techniques and technologies to improve prostate cancer care for its patients.


Michael Liss, MD, Director of Clinical Research at University Hospital and Assistant Professor of Urology at UT Health San Antonio

Fusion-guided biopsy has been offered at University Health System since 2016 and offers a more precise method of examining the prostate for biopsy sites. This method merges MRI and ultrasound imaging to create more detailed images of the prostate than either method alone. These images help specialists identify abnormal cells. Biopsies can then be performed in those areas where prostate cancer is more likely to occur.

Traditionally, prostate biopsies are performed based on a template model, but the new fusion-guided method allows for the identification of possible cancer in areas that would not normally be located on the template.

“The prostate is one of the only organs where biopsies are performed in this way,” says Michael Liss, MD, Director of Clinical Research at University Hospital and Assistant Professor of Urology at UT Health San Antonio. “The traditional method is similar to playing Battleship and choosing to biopsy areas where we think cancer may be present. With fusion-guided biopsy, we can better choose our biopsy targets — we can see where the ‘ships’ are.”

Recommended patients for fusion-guided biopsy include patients who are undergoing active surveillance for low-grade prostate cancer and those who are suspected of having prostate cancer despite a negative result from a traditional biopsy.

“We’re doing a study with the National Cancer Institute to determine if fusion-guided biopsy is appropriate for a wider range of patients,” Dr. Liss says. “We want to be sure we don’t increase the number of false positive findings for prostate cancer.”

University Health System is involved in many other studies as well, including clinical trials that can provide additional therapy options to patients who have exhausted current treatment modalities. University Health System’s emphasis on research extends to every aspect of care, and patients are encouraged to participate in whatever way they can.

“Patients don’t need to be in a randomized clinical trial to help,” Dr. Liss explains. “For example, they can donate blood or tissue samples to projects that advance cancer research.”

Regardless of what procedures or studies patients undergo, specialists from both University Health System and Mays Cancer Center UT Health San Antonio have synergized with MD Anderson Cancer Center to ensure every aspect of a patient’s care is vetted from multiple viewpoints. This multidisciplinary approach involves urologists, radiation oncologists, hematologists, radiologists, pathologists, residents and more.

“We have tumor boards every two weeks to go over patient cases,” Dr. Liss says. “It helps to have multiple eyes examine a case. No single one of us is as smart as all of us combined.”

Open communication between members of University Health System and UT Health San Antonio ensure patients receive the care they need as soon as possible. Specialists have excellent communication with each other through various means that include the medical health record to a simple phone call, which expedites test orders and access to urgent care.

Should patients require surgery for prostate cancer, University Health System surgeons perform a high volume of robotic surgeries using the latest da Vinci Surgical System, the da Vinci Xi. This model allows for greater visualization through the use of HD imaging and tenfold magnification capabilities.

“The newest robot allows us better visualization and improved focus on the procedure with less troubleshooting the equipment,” Dr. Liss says. “We can operate with minimal incisions, and the patient can go home the next day. Our robotic experience with complex cancer cases is exponentially growing.”

For patients who cannot undergo laparoscopic surgery due to a previous procedure or wound, surgeons at University Health System are also proficient in traditional open surgery.