The National Institute for Clinical Excellence is examining holmium laser prostatectomy and will publish guidance on its safety and efficacy to the NHS in England and Wales. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about holmium laser prostatectomy.

This document has been prepared for public consultation. It summarises the procedure and sets out the provisional recommendation made by the Advisory Committee.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows:

• The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
• The Advisory Committee will then prepare the Final Interventional Procedures Document (FIPD) and submit it to the Institute.
• The FIPD may be used as the basis for the Institute's guidance on the use of the procedure in the NHS in England and Wales.

For further details, see the Interim Guide to the Interventional Procedures Programme, which is available from the Institute's website (www.nice.org.uk/ip).

Closing date for comments: 22 July 2003

Target date for publication of guidance: 24 December 2003

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

Current evidence on the safety and efficacy of holmium laser prostatectomy appears adequate to support the use of the procedure, provided that normal arrangements are in place for consent, audit and clinical governance.

This procedure requires specialist training before it is undertaken. The British Association of Urological Surgeons have agreed to produce training standards.

Benign prostatic hyperplasia (BPH), a non-malignant enlargement of the prostate, is a common cause of bladder outlet obstruction and lower urinary tract symptoms in men over 40 years of age. Holmium laser prostatectomy is used to treat BPH. The procedure is used both for resection (HoLRP) and enucleation (HoLEP) of prostatic tissue.

BPH can be managed medically or surgically. The standard surgical treatment of BPH is transurethral resection of the prostate (TURP). However, relatively high morbidity associated with TURP has led to the development of a range of minimally invasive techniques, some of which use thermal energy. One such minimally invasive technique is the use of a holmium: yttrium-aluminium-garnet (YAG) laser.

HoLRP uses the holmium laser and is performed with a modified continuous flow resectoscope that has a circular fibre guide in the tip of the scope. An end-firing laser fibre is used as a precise cutting instrument to resect large pieces of prostate. The laser is then used to cut the resected tissue into smaller pieces before their removal.

A further evolution of the HoLRP procedure is holmium laser enucleation of the prostate (HoLEP) in which the intact prostatic lobes are removed with the holmium laser and then passed into the bladder where they are cut into smaller pieces before removal.

The studies reviewed showed that holmium laser prostatectomy is at least as effective as TURP at improving bladder neck obstruction, symptom scores and quality of life. Duration of catheterisation and hospital stay were reported to be shorter than for TURP. However, the studies were characterised by short follow-up periods and small sample sizes. For more details refer to the overview (see below).

Specialist Advisors considered holmium laser prostatectomy to be established practice and preferable in many cases to TURP and requires a shorter stay in hospital. Some Specialist Advisors were concerned about the completeness of evacuation of debris from the bladder after the procedure.

The studies revealed no significant differences in safety between holmium laser prostatectomy and TURP. Blood loss was reported to be lower with holmium laser prostatectomy than with TURP. For more details refer to the overview (see below)

Specialist Advisors had few concerns about the safety of holmium laser prostatectomy, although one expressed concerned about damage to the bladder. The Specialist Advisors also noted that there was less blood loss with this procedure than with TURP.

The Specialist Advisors commented on the need for special training for this procedure and recommended the introduction of a formal training programme.

The following source of evidence was considered by the Interventional Procedures Advisory Committee.

• Interventional Procedure Overview of Holmium Laser Prostatectomy, April 2003