Kavoussi NL, Nimmagadda N, Robles J et al: MOSES™ technology for holmium laser enucleation of the prostate: a prospective double-blind randomized controlled trial. J Urol 2021; 206: 104.

The American Urological Association guidelines support laser enucleation of the prostate as a durable and safe size-independent technique for treating lower urinary tract symptoms (LUTS) attributed to benign prostatic hypertrophy (BPH).¹ However, holmium laser enucleation of the prostate (HoLEP) remains underutilized throughout the United States. This is likely due to a relatively steep learning curve and lack of training opportunities compared to other surgical techniques for BPH.²

Figure. Flow diagram of study.

Novel advances in laser technologies may improve energy delivery, providing for better visibility during surgery due to more efficient hemostasis and decreasing operative time. These factors could further the adoption of the technique as well as facilitate the transition of HoLEP to an outpatient surgical setting. One such novel laser system is the MOSES™ holmium laser platform developed by Lumenis (Yokneam, Israel). The system divides the laser pulse into 2 peaks: one separating the water at the tip of the laser (ie bubble formation) and the second for delivering energy to the target, improving energy efficiency. The technical advantages of the technology have already been demonstrated for stone disease.³ We sought to evaluate MOSES technology during HoLEP for the surgical treatment for BPH.

In a double-blind, randomized controlled trial, we compared MOSES enucleation of the prostate (M-HoLEP) to traditional HoLEP.⁴ We included all patients with prostate sizes >80 ccs who sought HoLEP for surgical management of BPH. Patients were randomized in a 1:1 ratio and blinded to their assignment. Assignments were concealed in envelopes and opened by a laser technician, who would activate MOSES or traditional settings without informing the surgeon (see figure). The primary outcome was change in total operative time, with secondary outcomes including blood loss, perioperative outcomes and functional outcomes (via International Prostate Symptom Score [IPSS] and International Index of Erectile Function [IIEF-5]) at 6 weeks.

In the 60 patients analyzed in our study (30 per group), a shorter total operative time was seen in the M-HoLEP group compared to the traditional HoLEP group (101 vs 126 min, p<0.01). This difference remained significant on multiple linear regression, controlling for age, Charlson comorbidity index, change in hematocrit and total size of the prostate enucleated (−17.4, p<0.01). The MOSES^™ technology seemed to have improved enucleation (68 vs 80 min, p=0.03) and hemostasis times (18 vs 29 min, p<0.01), accounting for this improvement, as morcellation time remained unchanged using the technology. Additionally, using the MOSES settings seemed to improve hemostasis in a comparison of change in hematocrit (−6.4 vs −9.0, p=0.03). There was no difference in complications or functional outcomes between the groups (see table).

Our results highlight the benefit of MOSES technology for HoLEP. Although the study had a short followup period (6 weeks) and was limited by all cases being performed at a single institution, the results are consistent with other studies evaluating the utility of the MOSES settings for BPH surgery.^5,6 Further work is required to assess long-term outcomes of MOSES laser technology during HoLEP, as well as its impact on training and adoption of the technique. Additionally, a cost analysis, incorporating operative times and the ability of the technology to facilitate outpatient surgery, requires further investigation. For now, the MOSES laser technology shows improvements in operative times and hemostasis, with similar function and safety outcomes as traditional HoLEP.