Reply to Xu, P.; Krambeck, A. Comment on “Trotsenko et al. Early Results after Thulium Laser Enucleation of the Prostate in Patients with Urodynamically Proven Detrusor Underactivity. Soc. Int. Urol. J. 2024, 5, 160–168”

We are delighted that this important topic is attracting the attention of the urological community in the global scope and would like to express thanks for the positive comment [1]. One of the main problems is the lack of an accurate guideline for considering surgery in patients with a benign prostatic obstruction (BPO) and concomitant, non-neurogenic detrusor underactivity (DU) or acontractility (DA) [2]. At the same time, the indication for transurethral, anatomic enucleation of the prostate (AEEP) is usually based on the size of the prostate and not on the presence of a disorder like urodynamically proven DU/DA [3,4]. Of course, the clinical suspicion of DU/DA could be a sufficient indication for an AEEP in the future, but, due to evidence requirements, we currently have to rely on urodynamic examinations as the only widely accepted method to confirm the diagnosis In addition, a transurethral resection of the prostate is still considered the gold standard for subvesical desobstruction, and AEEP is not yet fully established as the primary tool for patients with a BPO without additional bladder function problems [2,3,4,5,6].

The certainty of evidence required to support the assumption of the authors of the comment on our study is simply not there yet, although any key opinion leader and user of AEEP would support this on the basis of seeing is believing (Plautus) [7]. However, despite the eminence-based strong support for AEEP as the optimal solution in these cases, the quality of the given studies and, thereby, the certainty of evidence in mainly retrospective cohort studies or case series are low. The European Association of Urology guideline panel for the management of non-neurogenic male lower urinary tract symptoms defined the point at which a treatment could be perceived as “standard”. Currently, the studies range at the lower level of this pyramid and, thereby, do not allow such a firm conclusionTherefore, a key objective is to initiate well-designed, large, multicenter, and pro-/retrospective studies on AEEP in DU/DA, regardless of the energy source used, with adequate length of follow-up to support precision medicine and to facilitate the development of recommendations in high-quality guidelines [3,4,8]. As long as the level of evidence and, thus, the certainty of evidence has not reached a level of 1B, Euclid’s 2300-year-old statement remains as relevant as ever: “Quod gratis asseritur, gratis negatur”—“What has been affirmed without proof can also be denied without proof” [9].