After performing holmium laser enucleation of the prostate (HoLEP) to treat benign prostatic hyperplasia (BPH) for 14 years with the same technology, I was excited when Lumenis launched MOSES laser technology, which showed the potential for significant improvement. MOSES is a pulse delivery technology that combines holmium lasers and fibers to optimize holmium energy transmission using a unique pulse modulation, which makes BPH treatment more efficient compared to standard holmium lasers.

Within a year of the launch, nine studies were released showing the disruptive value this technology has for treatment of BPH. However, there were no randomized controlled trials comparing traditional HoLEP to HoLEP with MOSES (M-HoLEP). Therefore, we designed and conducted the first prospective double-blind randomized controlled trial in 60 patients to properly evaluate MOSES for prostate enucleation.1 The results demonstrated several advantages of M-HoLEP, including procedure time shortened by 20%, faster enucleation and decreased bleeding.1 These improvements allow us to increase the number of surgical procedures we can perform per day and have made M-HoLEP largely an outpatient procedure at our institution.

Study Shows Clear Advantages

The study’s primary endpoint was the difference in operative time between HoLEP and M-HoLEP, with secondary endpoints for enucleation, morcellation, hemostasis time, blood loss, functional outcomes and complications at 6 weeks. Half of the patients had traditional HoLEP and half had M-HoLEP.

To reduce the risk of inherent bias, a MOSES 550-micron fiber was used for every patient, but the surgeon was blinded to the laser randomization. The laser technician was the only person in the operative case informed of the randomization group. The blinding of the patient and the surgeon remained in place until all follow up visits were complete. In addition, we felt it was important for the study to mirror real-world experience rather than just that of HoLEP experts, so in each case, an expert performed the procedure along with an endourology fellow. Each procedure was conducted with consistent technique and defined portions of the case for the expert and the novice in order to ensure consistency.

Impressively, the mean operative time for M-HoLEP was 25 minutes—20% shorter than traditional HoLEP (101 vs. 126 minutes). Other sentinel findings for M-HoLEP were 15% faster enucleation time (68 vs. 80 minutes) and 38% lower hemostasis time (18 vs. 29 minutes), as well as 30% less blood loss (-6.3% vs. -9.0%).1 Functional and safety outcomes were the same 6 months after surgery. The technology showed equal benefit for novice and expert HoLEP surgeon.1

 

The Study Changed Our Practice

One key advantage of the data was clear: Because MOSES allows for better hemostasis, reducing blood loss by 30%, patients feel much better and are less likely to require extended postoperative bladder irrigation.1 As a result, we have largely made M-HoLEP a same-day procedure instead of having a 23-hour hospital stay. Coincidentally, at the time of this study, we were planning an outpatient facility and deciding which cases would be shifted away from the hospital. Access to a MOSES 2.0 laser has allowed us to perform a significant number of our M-HoLEP procedures at the new outpatient location. In my opinion, this would not be possible without MOSES technology.

The financial benefits of MOSES seem clear—20% less OR time, more patients treated per day and fewer overnight stays can certainly add up quickly in dollars and cents that increase profitability.1 We do not have objective data on the financial impact of M-HoLEP, so we are now conducting a cost analysis study to compare traditional HoLEP to M-HoLEP.

I have performed more than 2,500 HoLEP procedures at my institution over the past 14 years, and I believe MOSES is a game changer. When I talk to my friends and colleagues who do a lot of HoLEP, they say the exact same thing. Beyond the numbers, we all appreciate how MOSES improves the HoLEP learning curve with less bleeding, better visualization and less fiber movement for greater accuracy.2 Ultimately, I hope the new learning curve, the switch to outpatient treatment and the ability to treat more patients per day will make M-HoLEP surgery accessible to more patients with BPH.

References:
1.  Kavoussi NL, Nimmagadda N, Robles J, Forbes C, Wang A, Stone B, Miller NL. MOSESTM Technology for Holmium Laser Enucleation of the Prostate: A Prospective Double-Blind Randomized Controlled Trial. J Urol. 2021 Jul;206(1):104-108.

2.  Nevo A, Faraj KD, Cheney SM, et al. Holmium laser enucleation of the prostate using Moses 2.0 vs non-Moses: a randomised controlled trial. BJU Int. 2021 May;127(5):553-559.

*Risk information and laser safety label are available at Lumenis website, operator’s manual and brochure.

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