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Keywords:

  • laser surgery;
  • prostate hyperplasia;
  • transurethral surgery;
  • recurrent;
  • residual;
  • HoLEP

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Study Type – Therapy (case series)

Level of Evidence 4

What's known on the subject? and What does the study add?

The major advantage of holmium laser enucleation of the prostate (HoLEP) depends on the ability to use the native anatomical plane between the prostate adenoma and surgical capsule, peeling each prostatic lobe from the capsule. HoLEP is associated with less catheterisation time, hospital stay and blood loss than transurethral resection of the prostate (TURP) or open prostatectomy. Urodynamic relief of obstruction has been reported to be better with HoLEP than TURP. However, surgical treatment of recurrent prostatic obstruction after previous transurethral surgery for symptomatic benign prostatic hyperplasia is more challenging because of loss of anatomical landmarks resulting in either incomplete removal or incontinence.

HoLEP for recurrent symptoms due to residual or re-growing prostatic adenoma seems to be as safe, feasible and efficient as HoLEP for de novo cases. The surgical plane between the adenoma and the surgical capsule was still accessible resulting in a durable long-term outcome with minimal side-effects. Previous transurethral prostatic surgery is not a contraindication for HoLEP.

OBJECTIVE

  • • 
    To assess the technical feasibility, functional outcome and morbidity of holmium laser enucleation of the prostate (HoLEP) for symptomatic benign prostatic hyperplasia (BPH) in patients with previous transurethral prostate surgery. ‘Redo’ surgery for recurrent or residual BPH poses a technical challenge with uncertain outcome as a result of disturbed anatomical landmarks with no clear surgical limits.

PATIENTS AND METHODS

  • • 
    We retrospectively reviewed 1054 patients who underwent HoLEP for symptomatic BPH.
  • • 
    Patients were stratified into two groups, group-I with no previous prostate surgery or primary-HoLEP (978 patients) and group-II with history of previous prostate surgery or secondary-HoLEP (76).
  • • 
    All patients' variables as well as follow-up data were assessed and compared.

RESULTS

  • • 
    There were no significant differences in baseline criteria between the two groups (P > 0.05).
  • • 
    In group-II, HoLEP was done after a median (range) of 66 (13–121) months from previous prostate surgeries, including transurethral resection of the prostate (48 patients), HoLEP (eight), transurethral incision of the prostate (nine), photoselective vaporization of the prostate (four) and other procedures (seven).
  • • 
    In both groups, routine HoLEP technique was adopted, the plane of enucleation could be identified without extra difficulty. However, more energy per gram of prostate tissue was needed in group-II (P < 0.05).
  • • 
    Operative auxiliary procedures were indicated in 1.9% of group-I, and 1.3% of group-II (P > 0.05). There were no operative complications or blood transfusion in group-II. The mean hospital stay and catheter time was similar in both groups. Early and late postoperative complications were not statistically different (P > 0.05).
  • • 
    At 1 month the mean maximum urinary flow rate (Qmax) was 22.3 and 18.8 mL/s, postvoid residual urine volume (PVR) was 46 and 45 mL, International Prostate Symptom Score (IPSS) was 7.04 and 7.08, and the health-related quality of life (HRQL) score was 1.57 and 1.56, in group-I and II, respectively. At 1 year the mean Qmax was 23.4 and 25.9 mL/s, PVR was 32.5 and 24.1 mL, IPSS was 4.5 and 4.4, and the HRQL score was 1.2 and 1.1,) in group-I and II, respectively (P > 0.05).
  • • 
    Reoperation for recurrent obstruction was indicated in 4% in group-I and 5.2% in group-II (P > 0.05).

CONCLUSION

  • • 
    Secondary-HoLEP procedures seem to be safe and technically feasible with comparable functional outcomes as those of primary-HoLEP.

Abbreviations
ASA

American Society of Anesthesiologists

HoLEP

holmium laser enucleation of the prostate

HRQL

health-related quality of life

Qmax

maximum urinary flow rate

PVR

postvoid residual urine volume

(S)UI

(stress) urinary incontinence.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The holmium laser enucleation of the prostate (HoLEP) technique entails the use of an end-firing laser fibre to enter the native anatomical plane between the prostate adenoma and surgical capsule and then to peel each prostatic lobe from the capsule.

High-quality studies have been published comparing HoLEP to the ‘gold standard’ TURP and open prostatectomy). These qualify HOLEP as the most rigorously analysed laser technique to date. Data suggest that catheterisation time, hospital stay and blood loss were significantly lower in HoLEP compared with TURP or open prostatectomy. Furthermore, urodynamic relief of obstruction was reported to be better with HOLEP than with TURP, with at least equal late adverse events to TURP [1–4]. These findings, plus the fact that the HoLEP procedure is prostate-size independent, in contrast to TURP, makes HoLEP a strong competitor for the new reference standard in transurethral surgery for symptomatic BPH. However, most randomised controlled studies tend to exclude patients with previous prostatic surgery with recurrent outflow obstruction secondary to enlarged prostate gland [5–9]. The rationale for that is to keep the treatment arms homogeneous as well as the expected technical difficulty with a potentially unpredictable outcome.

The aim of the present study was to assess the technical feasibility, functional outcome and morbidity of HoLEP for symptomatic BPH in this particular patient population.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

A retrospective review of our prostate centre database for patients who were treated with laser prostate surgery for obstructing BPH was done. Among 1502 laser prostate surgeries, 1054 HoLEP procedures were performed between May 1998 and June 2011 for symptomatic BPH. Patients were stratified into two groups, group-I with no previous prostate surgery (978 patients) and group-II with history of previous prostate surgery (76).

SURGICAL TECHNIQUE

All laser surgeries were performed or supervised by a single surgeon (M.M.E.) where a trainee (senior resident/fellow) was involved in most of cases. The equipment used was: an 100-W holmium: YAG (yttrium aluminium garnet) laser (Versapulse, Lumenis Inc., Santa Clara, CA, USA); a 550-nm end-firing fibre (SlimLineTM 550, Lumenis Inc.); a modified continuous-flow 26-F resectoscope with a distal bridge; a 6-F catheter through the proximal bridge to stabilise the laser fibre; continuous saline irrigation; a rigid indirect nephroscope with a 5-mm working channel; a tissue morcellator (Lumenis Inc.); and a video system. In group-I, HoLEP was performed as described previously [5,10]. Briefly, a plane was created between the adenoma and the surgical capsule early after the first incision of the gland from the bladder neck to the level of the verumontanum. The gland was enucleated in two or three lobes depending on the anatomy and the prominence of the grooves on either side of the middle lobe. The ‘two-lobe’ technique starts with 5- or 7-o'clock position incisions in a groove between the median lobe and one lateral lobe (the deeper groove) with enucleation of one lateral lobe, followed by the median and the remaining lateral lobe as a single unit and deposited into the bladder. The ‘three-lobe’ technique involves 5- and 7-o'clock position incisions with enucleation of the middle lobe and subsequent enucleation of one lateral lobe followed by the other lateral lobe. The ‘one-lobe’ technique was used infrequently in some cases. The procedure is performed at a laser setting of 2 J and 50 Hz for enucleation, and 1.5 J and 30 Hz for apical dissection and to release the lobes from the sphincter. If bleeding is encountered, the laser fibre can be defocused slightly from the bleeding point to achieve haemostasis. Coagulation can be optimised by reducing the laser setting to 1.5 J and 30 Hz. Furosemide is administered (20 mg/h, i.v.) after 1 h of surgery, to correct for any fluid absorption and to enhance urine flow. After haemostasis, the morcellator is introduced and the prostatic lobes are morcellated and removed. A standard 22-F two-way catheter is inserted and connected to straight drainage, unless the degree of haematuria requires bladder irrigation. Intermittent bladder irrigation is delivered through a ‘Y’-connector. On rare occasions, if the haematuria persists despite intermittent irrigation, continuous irrigation was instituted by a three-way catheter. Routinely, the catheter is removed the next morning, and when the patient is able to void adequately, he is discharged home.

In group-II, the technique used the same principle but had to be modified according to the extent and location of the residual or recurrent adenoma.

PREOPERATIVE EVALUATION

Preoperatively, all patients were thoroughly evaluated by medical history and physical examination, DRE, PSA, urine analysis and urine culture, IPSS, health-related quality of life (HRQL), TRUS measurement of prostatic volume, postvoid residual urine volume (PVR) assessment, and maximum urinary flow rate (Qmax).

Preoperative flexible urethrocystoscopy was done when haematuria was the presenting symptom and for all cases in group-II. Urodynamic assessment; cystometrogram and pressure flow studies were performed in patients with indwelling catheters or those where outlet obstruction was unclear.

OUTCOME MEASURES

Postoperative primary outcome measures were the IPSS, HRQL score, Qmax, and PVR at 1, 3 and 12 months, and then at 5 years. Operative parameters, catheterisation time and hospital stay as well as early and late postoperative complications and the need for reoperations were reported and analysed in both groups.

Flexible urethrocystoscopy and/or urodynamic assessments were performed when the postoperative flow parameters were deemed to be poorer than expected.

STATISTICAL ANALYSIS

Baseline characteristics, perioperative data and postoperative outcome parameters in the two groups were compared. Results were given as mean (sd). The two-sided Mann–Whitney test, chi-square, and Fishers' exact tests were used when appropriate. A P < 0.05 was considered to indicate statistical significance.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

BASELINE CHARACTERISTICS

There were no significant differences between the two groups for mean age, American Society of Anesthesiologists (ASA) score and indications for surgery (Table 1). However, the mean preoperative PSA level and TRUS size of the gland was higher in group-I (P < 0.05; Table 1). The mean preoperative Qmax (6.2 and 5.2 mL/s), PVR (300.7 and 152 mL), IPSS (18.5 and 16.9) and HRQL score (3.6 and 3.2) in group-I and -II respectively, were not significantly different.

Table 1. Baseline characteristics
VariableGroup I (Primary)Group II (secondary) P
Number of patients97876 
Age at time of surgery, years70.0772.70.08
Indications, n:  0.09
 Retention39022
 LUTs57548
 Haematuria136
ASA score, n:  0.23
 I70948
 ≥ II26928
Mean preoperative PSA level, ng/mL6.95.410.03
Mean preoperative TRUS, mL94.379.30.04

In group-II, HoLEP was done after a median (range) of 66 (13–121) months from previous prostate surgeries, including 48 TURP, eight HoLEP, nine transurethral incision of the prostate, four photoselective vaporization of the prostate and seven other procedures.

INTRAOPERATIVE AND EARLY POSTOPERATIVE OUTCOMES

In the two groups, the routine HoLEP technical principle was used. In group-I, the ‘three-lobe’ technique was used in 64, ‘two-lobe’ technique in 908 and ‘one-lobe’ technique in six cases. In group-II, the ‘three-lobe’ technique was used in one, ‘two-lobe’ technique in 72 and ‘one-lobe’ technique in three cases. The plane of enucleation could be identified without added difficulty; however, more sharp dissection using laser cutting energy was used to peel the adenoma from the prostate surgical capsule in group-II (P > 0.05; Table 2). Operative auxiliary procedures were necessary in 1.9% of cases in group-I, and 1.3% of group-II (P > 0.05; Table 2). Morcellation was not started until haemostasis was adequate. Nine patients required the use of electrocautery to ensure complete haemostasis, and all were in group-I. Lengthy procedures with large glands may require postponing the morcellation to shorten the anaesthesia time for the patient, this was necessary in seven patients in group-I. Furthermore, with exceptionally large glands the enucleated adenoma may occupy most of the bladder cavity rendering the morcellation process unsafe; in which case an open cystostomy was performed in four cases to extract the enucleated adenoma. Perioperative blood transfusion was indicated in five cases (0.5%), all were on anticoagulant/antiplatelet therapy. There were no operative complications or blood transfusions in group-II.

Table 2. Perioperative data
VariableGroup I (primary)Group II (secondary) P
  1. *TOV, trial of voiding.

Mean:   
 Energy used, KJ186.3226.70.08
 Enucleation time, min91.8760.029
 Morcellation time, min16.916.60.86
 Resected weight, g64.552.60.03
Auxiliary procedures, n:  0.065
 Electrocautery for haemostasis9
 Re-cystoscopy to complete morcellation7
 Open cystostomy to extract the adenoma31
Mean catheterization time, days1.31.60.16
Postoperative catheter irrigation, n:  0.147
 Intermittent bladder irrigation93972
 Continuous bladder irrigation394
Mean hospital stay, days1.21.30.79
Postoperative complications, n (%):  0.053
 Failed TOV*– early retention12 (1.2)2 (2.6)
 Haematuria/cystoscopic haemostasis2 (0.2)1 (1.3)
 Epididymo-orchitis2 (0.2)
 Thromboembolic4 (0.4)

There were no significant differences in hospital stay and time to catheter removal between both groups (Table 2).

At 1 month mean Qmax (22.3 and 18.8 mL/s), PVR (46 and 45 mL), IPSS (7.04 and 7.08), and HRQL score (1.57 and 1.56) were similar in both groups (P > 0.05). Overall early postoperative complications were slightly more in group-II (P > 0.05; Table 2). The need to re-insert a urethral catheter due to early failure of spontaneous voiding was the most frequent postoperative morbidity encountered in 1.2% of patients in group-I and 2.6% in group-II. Significant postoperative haematuria requiring an endoscopic procedure for haemostasis was necessary in two cases in group-I and one in group-II. The degree of postoperative haematuria was reflected by the need of postoperative continuous bladder irrigation required in 4 and 5.2% in group-I and –II, respectively (P > 0.05; Table 2).

DELAYED SURGICAL OUTCOMES

Outcomes in terms of increase in Qmax, decrease in IPSS, HRQL score, and decrease in PVR are shown graphically in Fig. 1A–D. There was dramatic improvement in the four parameters compared with preoperative values and the degree of improvement was comparable in both groups at all time-points of follow-up (P > 0.05). Compared with the preoperative values, there were significant reductions in PSA level after the procedure at all time-points of follow-up. The percentage of reduction in PSA level was significantly higher in group-I (P < 0.05; Fig. 1E). The mean postoperative PSA level at 1 year was 0.96 and 1.1 ng/mL in group-I and –II, respectively (P > 0.05).

image

Figure 1. Outcome parameters; A, Qmax, B, PVR, C, IPSS, D, HRQL score, E, Percentage reduction of PSA level at different points of follow-up. (First year 782 and 73 patients, fifth year; 579 and 61 patients, in group-I and II, respectively).

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Postoperative stress urinary incontinence (SUI) was found in 44 (4.5%) patients in group-I and five (6.5%) in group-II (P < 0.05). Counselling for Kegel's exercise was associated with recovery of most patients after 3 months, with persistent of SUI in five and one patient after 1 year in group-I and –II, respectively (P > 0.05). Total UI was encountered in five patients in group-I where a neurological deficit was the underlying cause. Urge symptoms necessitating anticholinergic medications occurred in 1.3% of patients in group-I. Late postoperative complications are shown in Fig. 2, with no significant difference between the two groups (P > 0.05). Recurrent obstruction occurred in 39 (4%) and four (5.2%) patients; residual/re-growth of adenoma occurred in eight and one, bladder neck contracture in 11 and one and urethral stricture in 20 and two patients in group-I and –II, respectively. All residual/re-growth of adenoma were treated by redo HoLEP.

image

Figure 2. Adverse events.

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DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

A ‘gold standard’ procedure is usually referred to as the best available therapeutic option under reasonable conditions. At other times, the term ‘gold standard’ is used to refer to the most appropriate choice without restrictions. For many years, TURP was referred to as the ‘gold standard’ for BPH surgical treatment. Recently, many procedures claim to challenge this ‘gold standard’ procedure; none of them achieved the definition of ‘gold standard’ having restricted indications or limitations in certain patient population. Previous transurethral surgery for BPH was often considered as an exclusion criterion for studies involving transurethral enucleation procedures. In the present study, we report on our experience with HoLEP in such a group of patients, introducing the term ‘secondary HoLEP’, comparing the outcome of this procedure to a large cohort of HoLEP procedures in patients not operated on previously.

In the present series, all urine flow parameters showed significant comparable improvement in both groups, which was sustained over time. These results seem to be comparable to all the published reports of HoLEP, in different series (Table 3) [5,11–14].

Table 3. Comparison of the outcome parameters between the largest contemporary HoLEP series and the present studied group
 Baseline1 Year+/− Change (%)
  1. n.r., not reported.

Mean Qmax, mL   
 Gupta et al. [11]5·225·1+19.9 (382.6)
 Tan et al. [13]8·421·8+13.4 (159.5)
 Kuntz et al. [5]4·927·9+23 (469.3)
 Montorsi et al. [12]8·225·1+16.9 (206.1)
 Gilling et al. [14]8.2821.3+13 (157.2)
 Our study (secondary HoLEP) 5.2 25.9 +20.7 (398)
Mean PVR, mL   
 Gupta et al. [11]112<20−90 (82.1)
 Tan et al. [13]113n.r
 Kuntz et al. [5]2385.3−232.7 (97.7)
 Montorsi et al. [12]n.rn.r
 Gilling et al. [14]116.14n.r
 Present study (secondary HoLEP) 152 24.1 −127.9 (84.1)
Mean IPSS   
 Gupta et al. [11]23.45.2−18.2 (77.7)
 Tan et al. [13]264.3−21.7 (83.4)
 Kuntz et al. [5]n.rn.r
 Montorsi et al. [12]21.64.1−17.5 (81)
 Gilling et al. [14]26.34.6−21.7 (82.5)
 Present study (secondary HoLEP) 16.9 4.4 −12.5 (73.9)
Mean HRQL score   
 Gupta et al. [11]n.rn.r
 Tan et al. [13]4.81.5−3.3 (68.7)
 Kuntz et al. [5]n.rn.r
 Montorsi et al. [12]4.61.4−3.2 (70)
 Gilling et al. [14]4.791.5−3.29 (68.6)
 Present study (secondary HoLEP) 3.2 1.1 −2.1 (65.6)

When analysing intraoperative parameters during HoLEP, the overall operating time reported in the present series seems to be shorter with secondary HoLEP, which is expected with the relatively smaller glands in this group (mean resected weight 52.6 g). The Enucleation time is a function of the gland size, gland anatomy, the degree of multi-nodularity, as well as the vascularity. Several important factors might influence the efficiency of morcellation. Efficiency of the morcellator blades as well as the consistency of the prostate tissue may vary. In secondary HoLEP group, the mean morcellation rate was 3.16 vs 3.81 g/min for primary cases. Furthermore, more energy per gram of tissue was needed for enucleation in secondary HoLEP group than the de novo cases 4.3 vs 2.9 KJ/g, respectively.

A PubMed® search for HoLEP-related articles revealed many reports on the technique, with long-term results and reports of re-operation for re-growing adenoma; however; the nature of intervention for these cases is often missing [15]. In 2011, Gilling et al. [14] reported in their long-term randomised controlled trial, that three cases in the TURP group had had re-growing adenoma for which HoLEP was done safely.

The durability of outcomes in the present series was maintained with a very low re-operation rate. Occasionally, due to the multi-nodular nature of the BPH, a few nodules may be hidden within the capsule where they might be missed during enucleation, especially during the early phase of learning. Re-growth of these nodules may cause obstruction during follow-up. The need for re-treatment after primary HoLEP for recurring adenoma is low (0.8%). The need for re-treatment after secondary (redo) HoLEP for recurring adenoma is rare occurring only once (1.3%). In this case, the first HoLEP was done for recurrent obstruction after previous TURP; 10 years later, recurrent obstruction necessitated removal of obstructing prostate tissue by secondary HoLEP. It was one of the earliest cases in the present series. The rate of bladder neck contracture and urethral stricture was 1.3 and 2.5%, respectively, which is comparable with that in de novo cases (1.12 and 2.04%, respectively) and with published results (0.6–3% for bladder neck contracture and 0–3.2% for the urethral stricture) [11–15].

Limitations of this work may be its retrospective nature, the disparity in the sample size and the lack of evaluation of sexual function, especially with such repeated transurethral surgery. The latter point would be an interesting subject for a future prospective work, especially with higher relative energy use in secondary HOLEP. However, many strengths of this work may be summarised as exploring an area that was almost always considered as a restricted zone for enucleation procedures. One can argue that it would be more intuitive in the urological community to opt for transurethral resection techniques for such cases rather than resorting to enucleation techniques. However, many cases with recurrent prostatic obstruction are now seen in older patients who are on anticoagulant/antiplatelet therapy or have associated co-morbid cardiovascular factors limiting the use of non-electrolyte solutions. In these settings HoLEP would have a clear advantage and as shown in the present series at no added risk.

In conclusion, secondary HoLEP for recurrent LUTS due to residual or re-growing prostatic adenoma seems to be as safe, feasible and efficient as a primary HoLEP procedure. Proper patient selection, where the recurring LUTS are clearly secondary to BPH, is important to optimise the outcome. Previous transurethral prostatic surgery is not a contraindication for HoLEP, which is a versatile technique following well recognised anatomical landmarks with a durable long-term outcome.

CONFLICT OF INTEREST

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Mostafa M. Elhilali is a Consultant/Advisor for Lumenis.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES
  • 1
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