Journal Spotlight: Laser vs. TURP for BPH, The GOLIATH Trial

For men with bothersome lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH), transurethral surgery can improve urinary flow and symptoms for men who are not helped by medications. Transurethral resection of the prostate (TURP) is the traditional method for removing the obstructive tissue of a large, benign prostate. This involves using electrocautery to resect tissue, which is then collected from the bladder and removed from the patient. Historically, TURP is associated with a significant and excellent improvements in LUTS with a complication rate of approximately 10%.[1]

Over the past two decades a number of technologies have emerged to improve TURP including laser vaporization, bipolar TURP or vaporization, and laser enucleation of the prostate. Laser vaporization technologies are the most widely used as they were among the first new technologies introduced, are relatively easy to use and are believed the have less bleeding and improved visualization. However, no rigorous, head-to-head study has evaluated laser technology compared to the gold standard TURP – which has the benefits of being a faster operation with well-established, long-term benefits.

The GOLIATH Trial, a European multicenter, randomized study of laser vaporization versus TURP for BPH was recently published in European Urology and the 12-month update in the Journal of Urology.

Bachmann A, Tubaro A, Barber N, etal. 180-W XPS GreenLight laser vaporisation versus transurethral resection of the prostate for the treatment of benign prostatic obstruction: 6-month safety and efficacy results of a European Multicentre Randomised Trial--the GOLIATH study. Eur Urol. 2014 May;65(5):931-42. doi: 10.1016/j.eururo.2013.10.040. Epub 2013 Nov 11.

Bachmann A, Tubaro A, Barber N, etal. A European Multicenter Randomized Noninferiority Trial Comparing 180 W GreenLight XPS Laser Vaporization and Transurethral Resection of the Prostate for the Treatment of Benign Prostatic Obstruction: 12-Month Results of the GOLIATH Study. J Urol. 2014 Sep 16. pii: S0022-5347(14)04377-8. doi: 10.1016/j.juro.2014.09.001. [Epub ahead of print]

 
Vital statistics of the GOLIATH Study:

• 291 patients
• 29 centers in 9 European countries
• Laser vaporization: 180 Watt Greenlight-XPS™
  
• TURP: monopolar or bipolar (42%) technology

Important results from this trial include:

• No difference between laser vaporization and TURP with regard to urinary outcomes (see table):
  • IPSS (International Prostate Symptom Score)
  • IPSS Quality of life score (IPSS QOL)
  • Maximum flow rate (Qmax)
  • Post-void residual urine
  • Both treatments were associated with short-term dysuria (discomfort with voiding that resolved spontaneously) in approximately 18% of men.
• Decreases in PSA and prostate volume were also similar among treatments.
  • Six men undergoing TURP were found to have prostate cancer; tissue is not analyzed after laser vaporization.
• Outcomes that favored laser vaporization included:
  • Length of stay
  • Catheterization time
  • Return to stable health status
  • Fewer 30-day re-operations
• Adverse events and re-operative rates were similar at 12 months:
  • Laser vaporization patients were more likely to undergo re-operation for bladder neck contractures and urethral strictures
  • TURP patients were more likely to undergo re-operation for bleeding
• No difference between monopolar and bipolar TURP for any outcome.

	Baseline			12 Months
(Mean Value)	GL-XPS	TURP	p Value	GL-XPS	TURP	p Value
I-PSS:	21.2±5.9	21.7±6.4	0.541	7.0±6.0	5.7±5.3	0.079
I-PSS-QOL:	4.6±1.1	4.5±1.4	0.721	1.4±1.4	1.2±1.3	0.287
Qmax (ml/sec):	9.5±3.0	9.9±3.5	0.266	23.0±10.7	24.7±10.1	0.221
PVR (ml):	110.1±88.5	109.8±103.9	0.453	43.0±57.1	33.7±43.8	0.107
PSA (ng/ml):	2.7±2.1	2.6±2.1	0.816	1.3±1.3	1.1±1.0	0.116
Prostate vol (ml):	48.6±19.2	46.2±19.1	0.301	21.9±11.0	21.0±12.8	0.574

 
Proponents of laser technology claim this study as a victory for laser technology given economic and quality of life implications of decreased length of stay, catheterization time, return to stable health and lower, 30-day reoperation rate. However, this should be balanced with a higher rate of urethral stricture disease – which not only requires re-operation but may have serious implications for cost, quality of life and urinary continence with longer follow-up – and inability to diagnose prostate cancer (as tissue is destroyed rather than evaluated) in select patients.

Take-home: Both laser vaporization and TURP are excellent procedures for the management of LUTS due to BPH. Both result in marked improvements in symptoms at 1 year. Both are associated with short-term dysuria. Patients undergoing TURP have a higher likelihood of re-operation within 30 days due to bleeding from surgery. Patients undergoing laser vaporization have a higher likelihood of requiring a secondary procedure for bladder neck contracture or stricture disease. No one surgery is right for all patients and a surgeon may have a preference to the technology they use. The decision on type of surgery should not rely on technology, but should take into account patient characteristics and preferences as well as surgeon experience and skill set.

 
[1] Wasson JH, Reda DJ, Bruskewitz RC, Elinson J, Keller AM, Henderson WG. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. N Engl J Med. 1995 Jan 12;332(2):75-9.