Holmium Laser Enucleation of Prostate(HOLEP) vs Greenlight(XPS) Laser Photoselective Vapo-Enucleation of Prostate(PVEP)
Holmium Laser Enucleation of Prostate(HOLEP) vs Greenlight(XPS) Laser Photoselective Vapo-Enucleation of Prostate(PVEP)
The investigators are now proposing to compare two laser techniques for treating Benign
 prostate hyperplasia (BPH); Holmium Laser Enucleation of the Prostate (HOLEP) versus
 (greenlight) XPS which is a recently available technology in our center and is more efficient
 hence our choice to include patients with any size prostate. This will confirm whether the
 two techniques are equivalent in efficacy and safety independent of size as well as cost. The
 two techniques are available world wide as standard of care
Patients with lower urinary tract symptoms (LUTS) secondary to bladder outlet obstruction
 from BPH seen through the outpatient clinic in the urology department will be assessed to see
 if the patient satisfies all inclusion and exclusion criteria. Patients who are meeting these
 criteria will be asked to participate in this randomized comparison study. If they agree they
 will be provided with an informed consent form which they can take home with them. The
 randomization process will be performed using computer-generated simple random tables in a
 1:1 ratio. Study participants will be enrolled randomized, and the appropriate surgery
 scheduled. Procedures will be performed on an outpatient basis whenever possible.

 All surgeries will be performed under a spinal or general anaesthesia. In case of coexisting
 vesical stone, Holmium laser cystolithotripsy will be done first regardless the type of next
 procedure for the prostate. Both HOLEP and greenLight (XPS) laser vaporization of the
 prostate begins with the insertion of a resectoscope transurethrally. Examination of the
 lower urinary tract is performed and holmium laser fiber is used to enucleate (HOLEP) or to
 vaporize [greenLight (XPS)] the obstructing prostatic tissue using the Moxy fibre until the
 surgical capsule is reached. After treatment, the prostatic fossa will be examined for
 hemostasis and if adequate, a 22 french Foley catheter will be inserted. Patients will then
 be sent to the post-anaesthetic recovery room.

 Once awake, the patient could have the catheter removed with a voiding trial if the urine is
 judged to be sufficiently clear and the surgeon is comfortable about early catheter removal.
 Those patients able to void will be sent home without catheter. Those patients unable to void
 or the surgeon decides to keep the catheter for 24 hours will be either sent home with a
 catheter to be removed the next day or hospitalized overnight.

 Finally, those patients with multiple medical problems or with postoperative bleeding
 requiring bladder irrigation will be kept overnight with a trial of voiding attempted the
 next morning if the urine is clear.

 Intraoperative and early postoperative parameters of interest will be recorded and compared
 between groups. These parameters include the total procedure time, total laser energy used,
 cost of disposables including the number of laser fibers per case, number of bags of irrigant
 per case, urethral catheterization time, length of hospital stay, subjective assessment of
 hemostasis during each laser procedure, objective assessment of changes in serum electrolytes
 and hematocrit and thorough recording of all complications.

 Patients will be seen in follow-up at 2 weeks, 1, 3, 6, and 12 months. The parameters to be
 assessed at each time point are listed below. As can be seen from the table, the most
 important parameters will be changes in voiding symptoms and uroflowmetry over time. Some
 validated questionnaires will be utilized to assess the patients' sexual function both at
 base line and at different follow-up visits. Different aspects of the sexual function will be
 analysed, partner's feedback will be addressed by a special questionnaire.
Inclusion Criteria:

 1. Ability to give informed consent.

 2. Lower urinary symptoms (LUTS) secondary to bladder outlet obstruction from BPH.

 3. Failed medical treatment of BPH.

 4. International prostate symptom scores (IPSS) > 15.

 5. Peak urinary flow rate (Qmax) < 15 ml/sec.

 6. Preoperative TRUS (transrectal ultrasound) size of the gland (from 40 to 150 cc).

 7. Patients in retention secondary to BPH (with cystometrogram (CMG) confirming adequate
 detrusor pressure if the bladder capacity at time of catheterization is in excess of
 1000 ml).

 Exclusion Criteria:

 1. Inability to give informed consent.

 2. Patient who have a neurological disorder which might affect bladder function as
 cerebrovascular stroke, Parkinson disease.

 3. Active urinary tract infection.

 4. Presence of active bladder cancer (within the last 2 years).

 5. Known cancer prostate patients will be excluded preoperatively on the basis of digital
 rectal examination, prostate specific antigen level, and TRUS imaging followed by
 prostate biopsies if necessary.