HOLMIUM LASER ENUCLEATION OF THE PROSTATE: MODIFIED TECHNICAL ASPECTS
Version of Record online: 11 JAN 2010
© 2010 THE AUTHORS. JOURNAL COMPILATION © 2010 BJU INTERNATIONAL
Volume 105, Issue 5, pages 584–585, March 2010
How to Cite
Baazeem, A. S., Elmansy, H. M. and Elhilali, M. M. (2010), HOLMIUM LASER ENUCLEATION OF THE PROSTATE: MODIFIED TECHNICAL ASPECTS. BJU International, 105: 584–585. doi: 10.1111/j.1464-410X.2009.09111.x
- Issue online: 11 FEB 2010
- Version of Record online: 11 JAN 2010
- Accepted for publication 22 October 2009
holmium laser enucleation of the prostate.
There is an increasing interest in holmium laser enucleation of the prostate (HoLEP) as the new standard for the surgical management of BPH of any size, replacing open prostatectomy and TURP . The results of HoLEP, as evidenced by PSA data, TRUS, the weight of tissue resected, urodynamic variables and data from many randomized trials, systematic reviews and meta-analyses, confirmed the effectiveness and durability of this technique [2–7]. HoLEP reproduces the removal of the whole obstructing adenoma (transitional zone) of the prostate by surgical enucleation, similar to the technique of using the index finger in open prostatectomy. HoLEP is equally suitable for small, medium and large prostate glands, with clinical outcomes that are independent of prostate size, and recently it has been proposed as a new standard for treating symptomatic BPH [8,9] HoLEP is also a safe and effective therapy in patients on anticoagulation and with symptomatic BPH refractory to medical therapy .
The adoption of HoLEP has been limited by the steep learning curve, a limitation often stated by urologists . In the associated video recording we describe the two-lobe and three-lobe techniques, with emphasis on some technical aspects and the importance of blunt dissection. This video clearly outlines the four phases of HoLEP and is described in the accompanying narration.
The multimedia description of the technique of HoLEP was recorded using a digital video endoscopic capture system (Stryker Corporation, Kalamazoo, MI, USA). Video clips from operations on two patients (one using the two-lobe technique and the other using the three-lobe technique for prostates of 120 g and 108 g by TRUS, respectively) were selected and saved in MPEG-2 format, and portions were clipped using Apple Final Cut Pro Studio 2, with professional narration added. An 80–100-W Versa Pulse holmium laser (Lumenis Corporation, Yokneam, Israel) with an end-firing 550-µm fibre was used. Fibres were stripped before each use and reused for an average of 20–30 procedures. The ideal power setting was 2 J at 40–50 Hz. The endoscope was a 26 F continuous-flow resectoscope (Storz, Tuttlingen, Germany) with a sheath modified for the laser fibre that was placed in a 7 F stabilizing catheter (Cook Corporation, Bloomington, IN, USA) and viewed through a 30° telescope attached to a video monitoring system. Normal saline was used as the irrigating fluid. After enucleation of the prostate, a Versacut tissue morcellator (Lumenis) was placed through a standard indirect nephroscope with an adapter to fit to the outside of the resectoscope sheath. After the procedure, a 22 F catheter with a 30 mL balloon was inserted, and an optional Y-connector was attached when required for intermittent bladder irrigation.
HoLEP can be divided into four phases: inspection, enucleation, haemostasis and morcellation. All phases are described in details in the accompanying video with emphasis on some new technical details.
Technical modifications and their advantages: HoLEP offers the advantages of less bleeding, decreased irrigation, catheterization and hospitalization times, and can be used to treat glands with no size limitation. It eliminates the risk of TUR syndrome with saline irrigation, and can be used on critically ill patients and those receiving anticoagulation therapy. It has been shown to be more cost effective than open prostatectomy. It also provides tissue for histopathological assessment.
We hope that by understanding the new technical considerations presented in this video, urologists interested in learning HoLEP will do so more quickly. The enucleation procedure has been well described by Gilling et al. in addition to a video article previously published by Fong and Elhilali . However, some technical refinements in the HoLEP technique described in the present video could decrease the operative time and the learning curve. We emphasized the importance of blunt dissection facilitating the early separation of the adenoma near the verumontanum proximal to the external sphincter. Some of the technical details will avoid the early frustrations encountered by most urologists trying to adopt this technique. In general, a two-lobe technique should be attempted whenever there is only a single or no grooves (which is most cases). This would lower the risk of undermining the trigone. The three-lobe technique is used only when there is a large median lobe with deep grooves on both sides. The blunt enucleation is achieved by using the tip of the endoscope, as one would use the finger to separate the adenoma from the surgical capsule in a concept similar to the traditional retropubic prostatectomy but in a retrograde manner. The operator should always use a rotating movement to follow the contour of the prostate, and care must be taken to avoid using excessive force to prevent unnecessary stretching of the external urinary sphincter. Blunt enucleation should be avoided if the tissues are not separating easily. Instead, the laser should be used to cut any attachments. The proper plane can be identified by its appearance as well as by the ease with which the tissues separate. One of the modifications we are proposing is that when the adenoma is separated laterally and the anterior aspect of the prostate is reached, the dissection is extended across the midline to facilitate the separation of the two lobes in the midline anteriorly later on, when we make the 12 o’clock incision, eliminating any guessing about the depth needed and avoiding the creation of multiple planes. Special emphasis is placed on achieving excellent haemostasis before starting morcellation, because the visibility with the indirect nephroscope is not as good as with the cystoscope lens. When coagulating a bleeding vessel, the laser fibre is unfocused but directed end-on towards the bleeding point. A whitening of the tissue around the vessel can often be used as an indicator of adequate coagulation. Morcellation is one of the most critical steps of the procedure and often considered potentially dangerous. To avoid complications, two principles need to be strictly observed. First, the patient’s bladder should be adequately distended. This is achieved by ensuring that the patient’s abdominal muscles are relaxed and by making sure that the irrigation inflow is not interrupted and by closing the outflow channel. Second, the morcellation process should always be done under direct vision. This is achieved by having adequate haemostasis and by keeping the engaged piece directly in front of the lens of the nephroscope, with the nephroscope lowered down to keep the cutting blades in the middle of the bladder. An average of 15–20 cases is needed for the trainee to feel confident with the technique . However, others have reported that an endourologist inexperienced with HoLEP can perform the procedure with reasonable efficiency after about 50 cases, with an outcome comparable to that of the experts . We feel that it is also important that learning the technique is easier if cases follow closely after each other to avoid relearning for every case.
In conclusion, our institutional experience shows that 20 cases on average are required for a trainee to feel comfortable with HoLEP for a moderate size gland. We hope that this video will help to reduce the frustrations encountered when learning HoLEP, by understanding the technical aspects of this procedure used for efficient enucleation of the prostate.
CONFLICT OF INTEREST
Mostafa M Elhilali is a consultant for Lumenis and lecturer on behalf of Lumenis and AMS (Laserscope).
Video. Holmium Laser Enucleation of the Prostate.
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Please note: Wiley Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.