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Holmium Laser Enucleation of the Prostate: A Modified Enucleation Technique and Initial Results
Holmium Laser Enucleation of the Prostate: A Modified Enucleation Technique and Initial Results Yong-Guang Gong,* Da-Lin He,* Ming-Zhu Wang, Xu-Dong Li, Guo-Dong Zhu, Zhi-Hu Zheng, Yue-Feng Du, Luke S. Chang and Xun-Yi Nan From the Department of Urology, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
Abbreviations and Acronyms BPH ⫽ benign prostatic hyperplasia HoLEP ⫽ holmium laser enucleation of the prostate I-PSS ⫽ International Prostate Symptom Score PVR ⫽ post-void residual urine Qmax ⫽ maximal flow rate QOL ⫽ quality of life Submitted for publication July 26, 2011. * Correspondence: Department of Urology, the First Affiliated Hospital of Xi’an Jiaotong University, West Yanta Rd. 277, Xi’an, China 710061 (YongGuang Gong—telephone: ⫹86 15991748706; FAX: ⫹86 29 85323661; e-mail: [email protected]; DaLin He—telephone: ⫹86 13991288221; FAX: ⫹86 29 85323661; e-mail: [email protected]).
Purpose: Although holmium laser enucleation of the prostate has been proven to be an excellent technique for the treatment of benign prostatic hyperplasia, it has not been widely applied due to technical difficulties and longer operative time. We modified the current technique of enucleation and present our initial experience. Materials and Methods: A total of 189 patients with benign prostatic hyperplasia underwent prostatectomy with our modified technique for holmium laser enucleation of the prostate. Intraoperative and postoperative data were prospectively collected. For followup International Prostate Symptom Score, quality of life, maximal flow rate and post-void residual urine were recorded. Results: Mean ⫾ SD preoperative prostate volume was 78.1 ⫾ 24.3 cc and 60.9 ⫾ 39.2 gm tissue were enucleated. Mean operative and enucleation times were 54.7 ⫾ 21.1 and 36.5 ⫾ 16.3 minutes, respectively. Mean serum hemoglobin decrease was 0.98 ⫾ 0.72 gm/dl. Mean catheter time was 1.2 ⫾ 0.5 days and mean postoperative hospital stay was 4.9 ⫾ 3.4 days. Serious complications were not observed. Three patients complained of transient stress incontinence which resolved within 3 months. Significant improvement occurred in International Prostate Symptom Score, quality of life, maximal flow rate and post-void residual urine volume at 3 and 6-month followup compared with the preoperative baseline. Conclusions: The modified holmium laser enucleation of the prostate technique is effective and safe when treating benign prostatic hyperplasia. Key Words: prostate, laser therapy, prostatic hyperplasia, prostatectomy
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HOLMIUM laser enucleation of the prostate has been proven to be a safe and efficient therapeutic option for BPH since its introduction into clinical practice by Gilling et al in 1998.1 Compared to transurethral resection of the prostate, this new modality not only has a low reoperation rate, but is also associated with a significant reduction of perioperative morbidity, catheter time and hospital stay.2–5 Moreover it is equally suitable for small and large prostate glands with clinical outcomes comparable to those of open prostatectomy.6,7 Thus, HoLEP has been pro-
posed as a potential new gold standard for the treatment of BPH. However, despite these advantages, HoLEP is still limited to expert teams at high volume centers.8 Many surgeons often find HoLEP difficult to perform and worry about causing harm to patients. In addition, the operative time for HoLEP is longer than for transurethral resection of the prostate.3,9 Thus, some urologists prefer more invasive and expensive options (such as robotic simple prostatectomy) to treat a large prostate instead of HoLEP.10 To make HoLEP easier to perform and to de-
0022-5347/12/1874-1336/0 THE JOURNAL OF UROLOGY® © 2012 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
Vol. 187, 1336-1340, April 2012 Printed in U.S.A. DOI:10.1016/j.juro.2011.11.093
AND
RESEARCH, INC.
MODIFIED HOLMIUM LASER PROSTATE ENUCLEATION
crease operative time, we modified the enucleation technique and present the initial outcomes.
MATERIALS AND METHODS Patient Selection From November 2009 to December 2010, 189 consecutive patients diagnosed with BPH underwent modified HoLEP at our department. The choice of surgery was based on clinical assessment. Inclusion criteria were self-administered I-PSS 8 or greater, QOL score 3 or greater, Qmax 15 ml per second or less, or post-void residual urine volume 50 ml or greater. Patients were excluded from study if they had prostate cancer or voiding disorders not related to BPH. All procedures were performed by a single surgeon. Recorded perioperative data included total operating time, enucleation time, serum hemoglobin decrease, resected tissue weight, catheter time, postoperative hospital stay and complications. I-PSS, QOL score, Qmax and PVR were reassessed at 3 and 6-month followup. The mean values of the parameters were compared using the paired Student’s t test with p ⬍0.05 considered significant.
Technique The equipment used was a 100 W holmium laser (VersaPulse®), a 550 mm end-firing fiber (SlimLine™ 550), and a modified continuous flow 26Fr Olympus resectoscope and video system. The enucleated prostatic tissues were morcellated by a Lumenis morcellator. The laser energy was set at 0.6 J ⫻ 50 HZ (30 watts) for apical incision and at 2 J ⫻ 50 HZ for other positions. Exposing the posterior surgical capsule of the left lateral lobe at the apex. Enucleation begins at the apex. A short horizontal incision near but not exceeding the proximal verumontanum is made along the borderline between the left lateral lobe and the urethra, and is circumferentially extended up to 3 o’clock by rotating the resectoscope (part A of figure). The beak of the resectoscope is then used to bluntly leverage up the left lateral lobe off the surgical capsule and the external sphincter, with the operating plane developed (part B of figure). Exposing the posterior surgical capsule of the median and right lateral lobes. The prostatic tissues before the verumontanum are transected (part C of figure). By moving the resectoscope beak from left to right (transversely) along the already exposed capsule, the median lobe and partially the right lateral lobe are elevated off the posterior surgical capsule (part D of figure). An apical incision is further performed from 7 to 9 o’clock along the lower margin of the right lateral lobe (part E of figure), and pushes this lobe off the prostatic wall and the external sphincter (part F of figure). The median lobe is leveraged up proximally to the bladder neck (part G of figure). After widening the bladder neck, the posterior half surface of the prostate (between 3, 6 and 9 o’clock) is freed inferolaterally from the capsular floor (part H of figure). The left lateral lobe is separated from the median lobe by a 5 o’clock incision, or separated from the right lateral lobe by an incision at 6 o’clock when there is a nonexistent median lobe (part I of figure). Freeing the left lateral lobe from the anterior surgical capsule and enucleating it. The resectoscope beak is retracted back to the verumontanum. The initial apical in-
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cision of the left lateral lobe is extended up from 3 to 11 o’clock along the exposed surgical capsule (part J of figure). Once the incision is completed, the anterior aspect of the left lateral lobe can be easily pushed off the surgical capsule with the operating plane developed (part K of figure). Along this plane the strip of urethral mucosa between 1 and 12 o’clock over the verumontanum is dissected under direct vision (part L of figure), and the left lateral lobe is freed from the anterior capsule toward the bladder neck (part M of figure). When this lobe has fallen totally from the anterior lateral prostatic wall, a 12 o’clock incision is made retrograde to separate it from the right lateral lobe (part N of figure), with the left lateral lobe enucleated. Freeing the right lateral lobe from the anterior surgical capsule to enucleate it. The right lateral lobe enucleation is performed in a way similar to that of the left lateral lobe. The left apical incision is continued up from 9 to 11 o’clock, and the strip of the urethra between 11 and 12 o’clock is dissected (part O of figure). The right lateral lobe is pushed off the surgical capsule with the operating plane developed (part P of figure), further freed away from the anterior prostatic wall, and thereby enucleated with the median lobe (part Q of figure). The morcellator is then inserted into the bladder to morcellate the enucleated prostatic tissue (part R of figure).
RESULTS Mean patient age was 74.2 ⫾ 9.6 years (range 52 to 89) and mean preoperative transrectal ultrasound prostate volume was 78.1 ⫾ 34.2 cc (range 35 to 288). Of the patients 32 had a history of urinary retention. Perioperative and complication data are reported in table 1, including a mean operative time of 54.7 ⫾ 21.1 minutes and a mean enucleation time of 36.5 ⫾ 16.3 minutes. Mean enucleated tissue weight was 60.9 ⫾ 39.2 gm. Mean hemoglobin decrease was 0.98 ⫾ 0.72 gm/dl. Postoperative irrigation was unnecessary for most patients and only some required intermittent irrigation. Mean catheter time was 1.2 ⫾ 0.5 days and mean postoperative hospital stay was 4.9 ⫾ 3.4 days. Of the 189 patients none required blood transfusion. Other intraoperative complications such as capsular perforation and ureteral orifice injury did not occur in all of the patients. Superficial bladder mucosal injury was encountered in 2 patients during morcellation. Transient stress incontinence occurred in 3 patients but spontaneously resolved in all within 3 months after surgery. Recatheterization was required in 4 patients due to urethral edema and the catheter was removed after 1 week. External orifice stricture was found in 2 patients who underwent urethral dilation. All patients were followed for 3 and 6 months, and the data are shown in table 2. I-PSS, QOL score, Qmax and PVR were significantly improved at 3 and 6 months after the operation compared to preoperative data (p ⬍0.0001).
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MODIFIED HOLMIUM LASER PROSTATE ENUCLEATION
Illustrations of modified HoLEP procedure
MODIFIED HOLMIUM LASER PROSTATE ENUCLEATION
Table 1. Perioperative and complication data Mean ⫾ SD operative mins (range) Mean ⫾ SD mins enucleation (range) Mean ⫾ SD gm enucleated tissue wt (range) Mean ⫾ SD gm/dl Hb decrease (range) Mean ⫾ SD days catheter time (range) Mean ⫾ SD days postop hospital stay (range) No. complications (%): Blood transfusion Capsular perforation Superficial bladder mucosal injury Ureteral orifice injury Stress incontinence Urethral stricture Recatheterization
54.7 ⫾ 21.1 (28–86) 36.5 ⫾ 16.3 (19–64) 60.9 ⫾ 39.2 (21–240) 0.98 ⫾ 0.72 (0.20–1.87) 1.2 ⫾ 0.5 (0.5–3) 4.9 ⫾ 3.4 (3–7) 0 0 2 0 3 2 4
(1.0) (1.5) (1.0) (2.1)
DISSCUSSION In HoLEP it is of paramount importance to find the right layer promptly at the beginning of the enucleation. According to all of the methods known to date the surgical capsule is exposed by 1 or 2 posterior grooves deepened to the prostatic wall.11–13 In theory the surgical capsule has an appearance distinct from the prostatic tissues and the incision depth seems easy to decide. However, in clinical practice it becomes difficult, even for an experienced operator, to discern the surgical capsule when the lobes are small, when the prostatic tissues are adherent to the surgical capsule and/or when there is much bleeding.14 Moreover a common mistake of deviating laterally and incising the inferior aspect of the lateral lobe often occurs with novice surgeons.15 To solve these problems we begin enucleation at the apex by incising the lower margin of the left lateral lobe, and further bluntly pushing it up off the surgical capsule and the external sphincter with the operating plane developed. According to our experience exposing the surgical capsule this way can be easily performed even by a beginner within 1 to 2 minutes. Moreover as the incision is superficial and parallel to the capsule, the risks of capsular perforation and injury to the sphincter are also averted. Of the 189 cases we have performed, this no groove approach to exposing the capsule has a 100% success rate despite prostate size and significantly decreases enucleation time. Anatomically the median lobe is anchored by the prostatic tissues before the verumontanum. We found that once the prostatic tissues here are dissected, the median lobe, often together with the right lateral lobe, can be easily pushed up off the surgical capsule by the resectoscope beak moving transversely along the already exposed capsule of the left lateral lobe, making it significantly less time-consuming and easier to further free the posterior half of the prostate proximally toward the bladder neck. To facilitate enucleation Krambeck11 and Baazeem12 et al proposed a 2-lobe technique. We also enucleated the prostate into 2 parts (the left lateral lobe
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and the median incorporated into the right lateral lobes) but in a different way. When the posterior half surface of the prostate has been freed, we incise the prostatic tissues at 5 or 6 o’clock to separate the left lateral lobe from its adjacent lobe. Unlike the traditional technique in which a 12 o’clock groove is first performed to enucleate the lateral lobes,13 we extend the initial incision of the left lateral lobe from 3 o’clock up to 11 o’clock and bluntly push its anterior lateral surface off the surgical capsule with the operating plane developed. Thus, any guessing about the depth needed and creating multiple planes are avoided. Subsequent enucleation of the lateral lobe becomes easier and is facilitated. Moreover once the operating plane has been developed, the strip of urethral mucosa between 1 and 12 o’clock can be easily identified and dissected, thereby eliminating the risk of injury to the external sphincter. The left lateral lobe can be enucleated quickly when it is freed from the anterior lateral capsule along the already developed plane and a subsequent 12 o’clock incision is performed. In a similar way the right lateral and median lobes are enucleated in a unit without any difficulty. In our method blunt enucleation is applied most of the time and sharp dissection with a laser fiber is used when necessary, which is helpful in facilitating enucleation as emphasized by Baazeem et al.12 In HoLEP it is important to stay in the right layer. We propose exposing the surgical capsule of the left lateral lobe first and then extending the already developed plane sequentially around the prostate, thus averting the possibility of losing orientation during enucleation. To assess the efficiency of our technique for HoLEP the operative parameters were evaluated. For the 189 patients who underwent our new HoLEP, mean operative time and enucleating time was 54 and 36 minutes, respectively, both significantly shorter than those previously published.1,5,16 –19 We believe these technical modifications in our approach facilitate enucleation and decrease operative time. Capsular perforation is one of the major complications of HoLEP. No such complication occurred in the patients treated with our technique. This is mainly due to the technical improvement in enucleating, which eliminates any guessing about the inTable 2. Followup data Mean ⫾ SD Preop Mean ⫾ SD 3 Mos Mean ⫾ SD 6 Mos I-PSS QOL score Qmax (ml/sec) PVR (ml)
21.9 ⫾ 5.1 5.2 ⫾ 0.8 4.7 ⫾ 1.6 146.3 ⫾ 80.2
All values p ⫽ 0.0001.
4.3 ⫾ 2.4 1.1 ⫾ 0.5 22.5 ⫾ 6.0 34.4 ⫾ 23.8
3.8 ⫾ 1.7 1.2 ⫾ 0.9 23.4 ⫾ 5.7 28.1 ⫾ 14.4
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MODIFIED HOLMIUM LASER PROSTATE ENUCLEATION
cision depth needed and allows the surgical capsule to be visible for the entire procedure. It has been reported that early transient incontinence occurred in 1.4% to 44% of patients who underwent this procedure.6,20,21 In our group the incidence of transient incontinence was 2%, and all the cases resolved spontaneously within 1 to 3 months after surgery, suggesting that our technique is efficient in terms of preserving the external sphincter. In our patients the mean hemoglobin decrease was 0.98 ⫾ 0.72 gm/dl, comparable to that in most of the literature.16 –19 No blood transfusion was needed in our practice. Mean catheter time at our center was 1.2 days, which was almost the same as that previously reported.16 –19 As the majority of our patients were admitted to the hospital after initial evaluation at the outpatient department, it often takes several days or even longer to complete further preoperative evaluation. Therefore, postoperative hospital stay was recorded in our study. The parameter for our patients was 4.9 days, which is longer than some of those previously reported.5,16 –19 As our many patients were from the countryside where medical conditions are poor, they often require a longer hospital stay, which prolongs the hos-
pital length of stay and is not associated with the operative technique itself. To evaluate the outcome of our HoLEP technique we followed our patients for 3 and 6 months. At 3 and 6 months postoperatively the mean peak urinary flow rate increased approximately fourfold compared to the preoperative level, and mean I-PSS score, median QOL score and PVR decreased significantly. These results, similar to those previously published,2,5,16 demonstrate that our new HoLEP technique is efficient in the treatment of BPH. As previously mentioned in this report our focus was to describe technical aspects and initial results. However, certain limitations of the study must be recognized. The learning curve for novice surgeons will be evaluated in a prospective study, and data on intermediate and long-term outcomes will be the subject of future communications.
CONCLUSIONS A modified technique for HoLEP has been presented and the initial results are encouraging. This technique makes HoLEP easier to perform and decreases the operative time. Further experience and long-term evaluation are required.
REFERENCES 1. Gilling PJ, Kennett K, Das AK et al: Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience. J Endourol 1998; 12: 457. 2. Gilling PJ, Aho TF, Frampton CM et al: Holmium laser enucleation of the prostate: results at 6 years. Eur Urol 2008; 53: 744. 3. Tan AH, Gilling PJ, Kennett KM et al: A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). J Urol 2003; 170: 1270. 4. Kuntz RM and Lehrich K: Transurethral holmium laser enucleation versus transvesical open enucleation for prostate adenoma greater than 100 gm: a randomized prospective trial of 120 patients. J Urol 2002; 168: 1465. 5. Elzayat EA and Elhilali MM: Holmium laser enucleation of the prostate (HoLEP): the endourologic alternative to open prostatectomy. Eur Urol 2006; 49: 87. 6. Kuntz RM, Lehrich K and Ahyai S: Does perioperative outcome of transurethral holmium laser enucleation of the prostate depend on prostate size? J Endourol 2004; 18: 183.
7. Elzayat EA, Habib EI and Elhilali MM: Holmium laser enucleation of the prostate: a size-independent new “gold standard”. Urology 2005; 66: 108. 8. Shah HN, Mahajan AP, Sodha HS et al: Prospective evaluation of the learning curve for holmium laser enucleation of the prostate. J Urol 2007; 177: 1468. 9. Kuntz RM: Current role of lasers in the treatment of benign prostatic hyperplasia (BPH). Eur Urol 2006; 49: 961. 10. Sotelo R, Clavijo R, Carmona O et al: Robotic simple prostatectomy. J Urol 2008; 179: 513. 11. Krambeck AE, Handa SE and Lingeman JE: Experience with more than 1,000 holmium laser prostate enucleations for benign prostatic hyperplasia. J Urol 2010; 183: 1105. 12. Baazeem AS, Elmansy HM and Elhilali MM: Holmium laser enucleation of the prostate: modified technical aspects. BJU Int 2010; 105: 584. 13. Gilling P: Holmium laser enucleation of the prostate (HoLEP). BJU Int 2008; 101: 131. 14. Kuo RL, Paterson RF, Kim SC et al: Holmium laser enucleation of the prostate (HoLEP): a technical update. World J Surg Oncol 2003; 1: 6. 15. El-Hakim A and Elhilali MM: Holmium laser enucleation of the prostate can be taught: the first learning experience. BJU Int 2002; 90: 863.
16. Vavassori I, Valenti S, Naspro R et al: Three-year outcome following holmium laser enucleation of the prostate combined with mechanical morcellation in 330 consecutive patients. Eur Urol 2008; 53: 599. 17. Seki N, Tatsugami K and Naito S: Holmium laser enucleation of the prostate: comparison of outcomes according to prostate size in 97 Japanese patients. J Endourol 2007; 21: 192. 18. Abdel-Hakim AM, Habib EI, El-Feel AS et al: Holmium laser enucleation of the prostate: initial report of the first 230 Egyptian cases performed in a single center. Urology 2010; 76: 448. 19. Placer J, Gelabert-Mas A, Vallmanya F et al: Holmium laser enucleation of prostate: outcome and complications of self-taught learning curve. Urology 2009; 73: 1042. 20. Montorsi F, Naspro R, Salonia A et al: Holmium laser enucleation versus transurethral resection of the prostate: results from a 2-center, prospective, randomized trial in patients with obstructive benign prostatic hyperplasia. J Urol 2004; 172: 1926. 21. Shah HN, Mahajan AP, Hegde SS et al: Perioperative complications of holmium laser enucleation of the prostate: experience in the first 280 patients, and a review of literature. BJU Int 2007; 100: 94.
Abbreviations and Acronyms BPH ⫽ benign prostatic hyperplasia HoLEP ⫽ holmium laser enucleation of the prostate I-PSS ⫽ International Prostate Symptom Score PVR ⫽ post-void residual urine Qmax ⫽ maximal flow rate QOL ⫽ quality of life Submitted for publication July 26, 2011. * Correspondence: Department of Urology, the First Affiliated Hospital of Xi’an Jiaotong University, West Yanta Rd. 277, Xi’an, China 710061 (YongGuang Gong—telephone: ⫹86 15991748706; FAX: ⫹86 29 85323661; e-mail: [email protected]; DaLin He—telephone: ⫹86 13991288221; FAX: ⫹86 29 85323661; e-mail: [email protected]).
Purpose: Although holmium laser enucleation of the prostate has been proven to be an excellent technique for the treatment of benign prostatic hyperplasia, it has not been widely applied due to technical difficulties and longer operative time. We modified the current technique of enucleation and present our initial experience. Materials and Methods: A total of 189 patients with benign prostatic hyperplasia underwent prostatectomy with our modified technique for holmium laser enucleation of the prostate. Intraoperative and postoperative data were prospectively collected. For followup International Prostate Symptom Score, quality of life, maximal flow rate and post-void residual urine were recorded. Results: Mean ⫾ SD preoperative prostate volume was 78.1 ⫾ 24.3 cc and 60.9 ⫾ 39.2 gm tissue were enucleated. Mean operative and enucleation times were 54.7 ⫾ 21.1 and 36.5 ⫾ 16.3 minutes, respectively. Mean serum hemoglobin decrease was 0.98 ⫾ 0.72 gm/dl. Mean catheter time was 1.2 ⫾ 0.5 days and mean postoperative hospital stay was 4.9 ⫾ 3.4 days. Serious complications were not observed. Three patients complained of transient stress incontinence which resolved within 3 months. Significant improvement occurred in International Prostate Symptom Score, quality of life, maximal flow rate and post-void residual urine volume at 3 and 6-month followup compared with the preoperative baseline. Conclusions: The modified holmium laser enucleation of the prostate technique is effective and safe when treating benign prostatic hyperplasia. Key Words: prostate, laser therapy, prostatic hyperplasia, prostatectomy
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HOLMIUM laser enucleation of the prostate has been proven to be a safe and efficient therapeutic option for BPH since its introduction into clinical practice by Gilling et al in 1998.1 Compared to transurethral resection of the prostate, this new modality not only has a low reoperation rate, but is also associated with a significant reduction of perioperative morbidity, catheter time and hospital stay.2–5 Moreover it is equally suitable for small and large prostate glands with clinical outcomes comparable to those of open prostatectomy.6,7 Thus, HoLEP has been pro-
posed as a potential new gold standard for the treatment of BPH. However, despite these advantages, HoLEP is still limited to expert teams at high volume centers.8 Many surgeons often find HoLEP difficult to perform and worry about causing harm to patients. In addition, the operative time for HoLEP is longer than for transurethral resection of the prostate.3,9 Thus, some urologists prefer more invasive and expensive options (such as robotic simple prostatectomy) to treat a large prostate instead of HoLEP.10 To make HoLEP easier to perform and to de-
0022-5347/12/1874-1336/0 THE JOURNAL OF UROLOGY® © 2012 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
Vol. 187, 1336-1340, April 2012 Printed in U.S.A. DOI:10.1016/j.juro.2011.11.093
AND
RESEARCH, INC.
MODIFIED HOLMIUM LASER PROSTATE ENUCLEATION
crease operative time, we modified the enucleation technique and present the initial outcomes.
MATERIALS AND METHODS Patient Selection From November 2009 to December 2010, 189 consecutive patients diagnosed with BPH underwent modified HoLEP at our department. The choice of surgery was based on clinical assessment. Inclusion criteria were self-administered I-PSS 8 or greater, QOL score 3 or greater, Qmax 15 ml per second or less, or post-void residual urine volume 50 ml or greater. Patients were excluded from study if they had prostate cancer or voiding disorders not related to BPH. All procedures were performed by a single surgeon. Recorded perioperative data included total operating time, enucleation time, serum hemoglobin decrease, resected tissue weight, catheter time, postoperative hospital stay and complications. I-PSS, QOL score, Qmax and PVR were reassessed at 3 and 6-month followup. The mean values of the parameters were compared using the paired Student’s t test with p ⬍0.05 considered significant.
Technique The equipment used was a 100 W holmium laser (VersaPulse®), a 550 mm end-firing fiber (SlimLine™ 550), and a modified continuous flow 26Fr Olympus resectoscope and video system. The enucleated prostatic tissues were morcellated by a Lumenis morcellator. The laser energy was set at 0.6 J ⫻ 50 HZ (30 watts) for apical incision and at 2 J ⫻ 50 HZ for other positions. Exposing the posterior surgical capsule of the left lateral lobe at the apex. Enucleation begins at the apex. A short horizontal incision near but not exceeding the proximal verumontanum is made along the borderline between the left lateral lobe and the urethra, and is circumferentially extended up to 3 o’clock by rotating the resectoscope (part A of figure). The beak of the resectoscope is then used to bluntly leverage up the left lateral lobe off the surgical capsule and the external sphincter, with the operating plane developed (part B of figure). Exposing the posterior surgical capsule of the median and right lateral lobes. The prostatic tissues before the verumontanum are transected (part C of figure). By moving the resectoscope beak from left to right (transversely) along the already exposed capsule, the median lobe and partially the right lateral lobe are elevated off the posterior surgical capsule (part D of figure). An apical incision is further performed from 7 to 9 o’clock along the lower margin of the right lateral lobe (part E of figure), and pushes this lobe off the prostatic wall and the external sphincter (part F of figure). The median lobe is leveraged up proximally to the bladder neck (part G of figure). After widening the bladder neck, the posterior half surface of the prostate (between 3, 6 and 9 o’clock) is freed inferolaterally from the capsular floor (part H of figure). The left lateral lobe is separated from the median lobe by a 5 o’clock incision, or separated from the right lateral lobe by an incision at 6 o’clock when there is a nonexistent median lobe (part I of figure). Freeing the left lateral lobe from the anterior surgical capsule and enucleating it. The resectoscope beak is retracted back to the verumontanum. The initial apical in-
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cision of the left lateral lobe is extended up from 3 to 11 o’clock along the exposed surgical capsule (part J of figure). Once the incision is completed, the anterior aspect of the left lateral lobe can be easily pushed off the surgical capsule with the operating plane developed (part K of figure). Along this plane the strip of urethral mucosa between 1 and 12 o’clock over the verumontanum is dissected under direct vision (part L of figure), and the left lateral lobe is freed from the anterior capsule toward the bladder neck (part M of figure). When this lobe has fallen totally from the anterior lateral prostatic wall, a 12 o’clock incision is made retrograde to separate it from the right lateral lobe (part N of figure), with the left lateral lobe enucleated. Freeing the right lateral lobe from the anterior surgical capsule to enucleate it. The right lateral lobe enucleation is performed in a way similar to that of the left lateral lobe. The left apical incision is continued up from 9 to 11 o’clock, and the strip of the urethra between 11 and 12 o’clock is dissected (part O of figure). The right lateral lobe is pushed off the surgical capsule with the operating plane developed (part P of figure), further freed away from the anterior prostatic wall, and thereby enucleated with the median lobe (part Q of figure). The morcellator is then inserted into the bladder to morcellate the enucleated prostatic tissue (part R of figure).
RESULTS Mean patient age was 74.2 ⫾ 9.6 years (range 52 to 89) and mean preoperative transrectal ultrasound prostate volume was 78.1 ⫾ 34.2 cc (range 35 to 288). Of the patients 32 had a history of urinary retention. Perioperative and complication data are reported in table 1, including a mean operative time of 54.7 ⫾ 21.1 minutes and a mean enucleation time of 36.5 ⫾ 16.3 minutes. Mean enucleated tissue weight was 60.9 ⫾ 39.2 gm. Mean hemoglobin decrease was 0.98 ⫾ 0.72 gm/dl. Postoperative irrigation was unnecessary for most patients and only some required intermittent irrigation. Mean catheter time was 1.2 ⫾ 0.5 days and mean postoperative hospital stay was 4.9 ⫾ 3.4 days. Of the 189 patients none required blood transfusion. Other intraoperative complications such as capsular perforation and ureteral orifice injury did not occur in all of the patients. Superficial bladder mucosal injury was encountered in 2 patients during morcellation. Transient stress incontinence occurred in 3 patients but spontaneously resolved in all within 3 months after surgery. Recatheterization was required in 4 patients due to urethral edema and the catheter was removed after 1 week. External orifice stricture was found in 2 patients who underwent urethral dilation. All patients were followed for 3 and 6 months, and the data are shown in table 2. I-PSS, QOL score, Qmax and PVR were significantly improved at 3 and 6 months after the operation compared to preoperative data (p ⬍0.0001).
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MODIFIED HOLMIUM LASER PROSTATE ENUCLEATION
Illustrations of modified HoLEP procedure
MODIFIED HOLMIUM LASER PROSTATE ENUCLEATION
Table 1. Perioperative and complication data Mean ⫾ SD operative mins (range) Mean ⫾ SD mins enucleation (range) Mean ⫾ SD gm enucleated tissue wt (range) Mean ⫾ SD gm/dl Hb decrease (range) Mean ⫾ SD days catheter time (range) Mean ⫾ SD days postop hospital stay (range) No. complications (%): Blood transfusion Capsular perforation Superficial bladder mucosal injury Ureteral orifice injury Stress incontinence Urethral stricture Recatheterization
54.7 ⫾ 21.1 (28–86) 36.5 ⫾ 16.3 (19–64) 60.9 ⫾ 39.2 (21–240) 0.98 ⫾ 0.72 (0.20–1.87) 1.2 ⫾ 0.5 (0.5–3) 4.9 ⫾ 3.4 (3–7) 0 0 2 0 3 2 4
(1.0) (1.5) (1.0) (2.1)
DISSCUSSION In HoLEP it is of paramount importance to find the right layer promptly at the beginning of the enucleation. According to all of the methods known to date the surgical capsule is exposed by 1 or 2 posterior grooves deepened to the prostatic wall.11–13 In theory the surgical capsule has an appearance distinct from the prostatic tissues and the incision depth seems easy to decide. However, in clinical practice it becomes difficult, even for an experienced operator, to discern the surgical capsule when the lobes are small, when the prostatic tissues are adherent to the surgical capsule and/or when there is much bleeding.14 Moreover a common mistake of deviating laterally and incising the inferior aspect of the lateral lobe often occurs with novice surgeons.15 To solve these problems we begin enucleation at the apex by incising the lower margin of the left lateral lobe, and further bluntly pushing it up off the surgical capsule and the external sphincter with the operating plane developed. According to our experience exposing the surgical capsule this way can be easily performed even by a beginner within 1 to 2 minutes. Moreover as the incision is superficial and parallel to the capsule, the risks of capsular perforation and injury to the sphincter are also averted. Of the 189 cases we have performed, this no groove approach to exposing the capsule has a 100% success rate despite prostate size and significantly decreases enucleation time. Anatomically the median lobe is anchored by the prostatic tissues before the verumontanum. We found that once the prostatic tissues here are dissected, the median lobe, often together with the right lateral lobe, can be easily pushed up off the surgical capsule by the resectoscope beak moving transversely along the already exposed capsule of the left lateral lobe, making it significantly less time-consuming and easier to further free the posterior half of the prostate proximally toward the bladder neck. To facilitate enucleation Krambeck11 and Baazeem12 et al proposed a 2-lobe technique. We also enucleated the prostate into 2 parts (the left lateral lobe
1339
and the median incorporated into the right lateral lobes) but in a different way. When the posterior half surface of the prostate has been freed, we incise the prostatic tissues at 5 or 6 o’clock to separate the left lateral lobe from its adjacent lobe. Unlike the traditional technique in which a 12 o’clock groove is first performed to enucleate the lateral lobes,13 we extend the initial incision of the left lateral lobe from 3 o’clock up to 11 o’clock and bluntly push its anterior lateral surface off the surgical capsule with the operating plane developed. Thus, any guessing about the depth needed and creating multiple planes are avoided. Subsequent enucleation of the lateral lobe becomes easier and is facilitated. Moreover once the operating plane has been developed, the strip of urethral mucosa between 1 and 12 o’clock can be easily identified and dissected, thereby eliminating the risk of injury to the external sphincter. The left lateral lobe can be enucleated quickly when it is freed from the anterior lateral capsule along the already developed plane and a subsequent 12 o’clock incision is performed. In a similar way the right lateral and median lobes are enucleated in a unit without any difficulty. In our method blunt enucleation is applied most of the time and sharp dissection with a laser fiber is used when necessary, which is helpful in facilitating enucleation as emphasized by Baazeem et al.12 In HoLEP it is important to stay in the right layer. We propose exposing the surgical capsule of the left lateral lobe first and then extending the already developed plane sequentially around the prostate, thus averting the possibility of losing orientation during enucleation. To assess the efficiency of our technique for HoLEP the operative parameters were evaluated. For the 189 patients who underwent our new HoLEP, mean operative time and enucleating time was 54 and 36 minutes, respectively, both significantly shorter than those previously published.1,5,16 –19 We believe these technical modifications in our approach facilitate enucleation and decrease operative time. Capsular perforation is one of the major complications of HoLEP. No such complication occurred in the patients treated with our technique. This is mainly due to the technical improvement in enucleating, which eliminates any guessing about the inTable 2. Followup data Mean ⫾ SD Preop Mean ⫾ SD 3 Mos Mean ⫾ SD 6 Mos I-PSS QOL score Qmax (ml/sec) PVR (ml)
21.9 ⫾ 5.1 5.2 ⫾ 0.8 4.7 ⫾ 1.6 146.3 ⫾ 80.2
All values p ⫽ 0.0001.
4.3 ⫾ 2.4 1.1 ⫾ 0.5 22.5 ⫾ 6.0 34.4 ⫾ 23.8
3.8 ⫾ 1.7 1.2 ⫾ 0.9 23.4 ⫾ 5.7 28.1 ⫾ 14.4
1340
MODIFIED HOLMIUM LASER PROSTATE ENUCLEATION
cision depth needed and allows the surgical capsule to be visible for the entire procedure. It has been reported that early transient incontinence occurred in 1.4% to 44% of patients who underwent this procedure.6,20,21 In our group the incidence of transient incontinence was 2%, and all the cases resolved spontaneously within 1 to 3 months after surgery, suggesting that our technique is efficient in terms of preserving the external sphincter. In our patients the mean hemoglobin decrease was 0.98 ⫾ 0.72 gm/dl, comparable to that in most of the literature.16 –19 No blood transfusion was needed in our practice. Mean catheter time at our center was 1.2 days, which was almost the same as that previously reported.16 –19 As the majority of our patients were admitted to the hospital after initial evaluation at the outpatient department, it often takes several days or even longer to complete further preoperative evaluation. Therefore, postoperative hospital stay was recorded in our study. The parameter for our patients was 4.9 days, which is longer than some of those previously reported.5,16 –19 As our many patients were from the countryside where medical conditions are poor, they often require a longer hospital stay, which prolongs the hos-
pital length of stay and is not associated with the operative technique itself. To evaluate the outcome of our HoLEP technique we followed our patients for 3 and 6 months. At 3 and 6 months postoperatively the mean peak urinary flow rate increased approximately fourfold compared to the preoperative level, and mean I-PSS score, median QOL score and PVR decreased significantly. These results, similar to those previously published,2,5,16 demonstrate that our new HoLEP technique is efficient in the treatment of BPH. As previously mentioned in this report our focus was to describe technical aspects and initial results. However, certain limitations of the study must be recognized. The learning curve for novice surgeons will be evaluated in a prospective study, and data on intermediate and long-term outcomes will be the subject of future communications.
CONCLUSIONS A modified technique for HoLEP has been presented and the initial results are encouraging. This technique makes HoLEP easier to perform and decreases the operative time. Further experience and long-term evaluation are required.
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7. Elzayat EA, Habib EI and Elhilali MM: Holmium laser enucleation of the prostate: a size-independent new “gold standard”. Urology 2005; 66: 108. 8. Shah HN, Mahajan AP, Sodha HS et al: Prospective evaluation of the learning curve for holmium laser enucleation of the prostate. J Urol 2007; 177: 1468. 9. Kuntz RM: Current role of lasers in the treatment of benign prostatic hyperplasia (BPH). Eur Urol 2006; 49: 961. 10. Sotelo R, Clavijo R, Carmona O et al: Robotic simple prostatectomy. J Urol 2008; 179: 513. 11. Krambeck AE, Handa SE and Lingeman JE: Experience with more than 1,000 holmium laser prostate enucleations for benign prostatic hyperplasia. J Urol 2010; 183: 1105. 12. Baazeem AS, Elmansy HM and Elhilali MM: Holmium laser enucleation of the prostate: modified technical aspects. BJU Int 2010; 105: 584. 13. Gilling P: Holmium laser enucleation of the prostate (HoLEP). BJU Int 2008; 101: 131. 14. Kuo RL, Paterson RF, Kim SC et al: Holmium laser enucleation of the prostate (HoLEP): a technical update. World J Surg Oncol 2003; 1: 6. 15. El-Hakim A and Elhilali MM: Holmium laser enucleation of the prostate can be taught: the first learning experience. BJU Int 2002; 90: 863.
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