561 HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HOLEP): REALISTIC CONSIDERATIONS AFTER 100 CASES

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Holmium Laser Enucleation of the Prostate (HoLEP): realistic considerations after 100 cases

Holmium laser enucleation of the prostate combined with mechanical morcellation: 3 years of follow-up

Richter M., De Geeter P., Albers P.

Vavassori I., Vismara A., Hurle R., Manzetti A., Valenti S., Dell’Acqua V., Naspro R.

Klinikum Kassel GmbH, Dpt. of Urology, Kassel, Germany

Humanitas-Gavazzeni, Urology, Bergamo, Italy

Introduction & Objectives: Holmium Laser enucleation of the prostate (HoLEP) is still waiting for its break-through as an alternative to conventional transurethral resection (TUR). Although the steep learning curve is a major drawback, potentional technical problems are generally not mentioned.

Introduction & Objectives: To assess safety, efficacy and long term reliability and durability of Holmium Laser enucleation of the Prostate (HoLEP) combined with mechanical morcellation for the treatment of benign prostatic hyperplasia (BPH)-related bladder outlet obstruction.

Material & Methods: Starting in July 2003, 105 patients underwent HoLEP at our institution. Initially we used an 80 W laser (Lisa Laser) with a prototype (Wolf) morcellator. In March 2006 we purchased a 100 W Versapulse (Lumenis) laser and a Versacut morcellator. Surgery was performed with an 26 Fr continuous flow resectoscope (Storz) with a specially adapted nephroscope insert. Maximum power was 80 W or 100 W. Irrigation fluid was 0,9 % saline. In many cases tissue fragmentation was performed by traditional electrocautery loop resection (TUR) of the free flotating devascularized lobes; in addition smaller fragments could be extracted directly with a cold (Gilling) loop. Results: Mean operative time was 92 min. (18 - 254) for a mean prostate volume of 67 cc (15 - 350 cc). Bleeding problems occured in 8 patients (7,6%) with a transfusion rate of 2.8% (3 pts.). Those patients had an incomplete HoLEP and had their surgery completed by TUR. In 4 patients capsular perforation or undermining of the trigone occurred during surgery. This was uneventful in 2 cases, but 2 patients had conversion to open surgery or had postponed TUR. A common intraoperative problem was malfunction of the (sphinx) laser system due to overheating or dysfunction of the tissue morcellator. This occured in 22% of the 27 patients (group A) with smaller (< 40 cc) glands and in 50% of the 76 patients (group B) with larger (> 40cc) glands; in those cases TUR was required to complete the surgery or for tissue fragmentation. Mean operative time varied accordingly: 63 min (group A) and 102 min (group B). Reinterventions for persisting dysuria were necessary in 29,6% of the patients in group A and in 26,3 % of the patients in group B, mostly because of residual tissue at the apex or dorsal bladder neck. Free flotating remaining tissue was another cause in 4 patients with the larger glands. Late problems were caused by urethral stricture formation in 4 patients, adding up to an overall reintervention rate of 26,7%. Conclusions: HoLEP has many benefits over conventional TUR in glands > 40 cc. Enucleation of smaller glands is difficult because of the lack of tissue planes; remaining tissue at the apex or dorsal bladder neck is a frequent cause for persisting voiding problems. On the other hand enucleation of larger glands may be a real challenge due to malfunction of the laser system (overheating) or problems with the morcellator. This means one has to create optimal conditions by using a heavy duty 100 W laser system and a functioning morcellator. A specially adapted endoscopic equipment is equally important. Keeping this in mind will shorten the learning curve dramatically.



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Material & Methods: Between January 2000 and July 2003, at total of 330 consecutive patients suffering from symptomatic bladder outlet obstruction underwent HoLEP at our institution. All patients were pre-operatively assessed with the following examinations: trans-rectal ultrasound gland volume evaluation (TRUS), peak urinary flow rate estimation (Qmax), post-void residual volume, international prostate symptoms score (I-PSS) and the single question quality of life (QOL) score. All procedures were performed using a pulsed high powered 80 watt holmium laser was used (power setting: 2.0 Joules per pulse, 35 pulses per second). Intra, peri and post operative parameters were evaluated and the patients were re-assessed at 1,3,6,12,18,24, and 36 month follow-up with I-PSS, uroflowmetry and with an interview to determine any adverse event or complication. Results: The mean age of the patients was 66±8,1 years, pre-operative prostate volume was 62±34cc, Qmax was 9±3,1 ml/sec, QoL was 5,2 ± 0,8 and I-PSS was 24±5,6. Enucleation time was 45,4±22.9 min, resected weight was 40±27,5 g and morcellation efficiency was 17,3±14,5 g/min. Catheter time was 23±14,7 hours and hospital stay was 48±26 days. Mean hemoglobin and serum sodium levels did not drop significantly from baseline after the procedure. No patient required blood transfusion, bladder mucosal injury was reported in 19 cases(5,7%). A statistically significant improvement occurred in all measured voiding parameters, including in peak flow rates and in symptoms score postoperatively and were conformed at the 3 year follow-up. Furthermore, the patients reported a subjective improved quality of life as a result of surgery starting from 3 months post-operatively. Functional results are detailed in Table 1. When considering overall complications, 93 (28%) of patients complained of irritative urinary symptoms, not associated with low urinary tract infection typically self-limiting after 3 months, transient stress incontinence was reported in 24 cases (7,3%). Nine patients (2,7%) had persistence of bladder outlet obstruction, requiring re-operation for minimal residual tissue in the prostatic fossa. Conclusions: HoLEP combined with mechanical morcellation represents an efficacious surgical intervention for symptomatic bladder obstruction associated with minimal morbidity. The relief of bladder outlet obstruction also proved to be durable after 3 year follow up, therefore the HoLEP technique could became the standard surgical treatment of prostates of virtually any size.



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Photoselective vaporization (PVP) versus transurethral resection of the prostate (TURP) for prostates >80 g: a prospective randomized trial

Laparoscopic extraperitoneal Millin’s adenomectomy versus open retropubic adenomectomy: a prospective comparison

Sarica K., Altay B.

Peltier A., Hoffmann P., Hawaux E., Entezari K., Deneft F., Van Velthoven R.

Istanbul Memorial Hospital, Urology, Istanbul, Turkey

Jules Bordet Institute, Urology, Brussels, Belgium

Introduction & Objectives: To compare the safety and efficacy of photoselective vaporization (PVP) and transurethral resection of the prostate (TURP) for glands larger than 80g in a prospective randomised trial.

Introduction & Objectives: Initially developed to provide urologists with an easy procedure able to reduce the steepness of learning curve for radical prostatectomy, the laparoscopic translation of Millin’s retropubic procedure is considered a routine procedure at many centers. It has now to face the proof of time to become widely accepted in the surgical armamentarium for BPH.

Material & Methods: From April 2004 to September 2005, 60 consecutive patients were randomised for surgical treatment with TURP (n=32) or PVP (n=28). International Prostate Symptom Score (IPSS), maximum flow rates (Qmax), post-void residual volumes (PVR), TRUS volumes were recorded. Complications, operative duration, catheter removal, and hospital stays were recorded. Patients were reassessed at 6 and 12 months. Results: Baseline characteristics of both groups were similar. Mean preoperative TRUS volume was 91.8+/-3.6g (82-135) in the TURP group and 89.1+/-4.0g (83-142) in the PVP group. Operating room time was significantly shorter for the TURP group (68.7+/-17.2 min vs. 99.6+/-19.1 min, p<0.05); catheter removal (4.1+/-1.1 d and 1.6+/-0.8 d, p<0.05) and hospital stay (2.8+/-1.2 d vs. 1.1+/-0.4 d, p<0.05) were shorter in the PVP group. In both groups IPSS, PVR and uroflowmetry findings improved from baseline at the 6-months follow-up, and were comparable. The percentage volume reduction was significantly higher in TURP group at both 6 and 12 months. At 12 months there were significant differences between the two groups with respect to the improvement of IPSS and Qmax values in favour of the TURP group. Late complications were comparable. Conclusions: Early outcomes 6-months after PVP and TURP are comparable. TURP seems to be superior to PVP with respect to the relief of symptoms and urodynamic findings in patients with enlarged prostates >80g after 12 months.

Material & Methods: We registered prospectively parameters of 102 consecutive patients suitable for an adenomectomy: 51 with an open transcapsular retropubic Millin’s technique and 51 with a laparoscopic extraperitoneal adenomectomy, allowing for a “case matched” comparison. Results: Millin Operating time (min) Weight of enucleated tissue (gr) Catheter duration (days) Hospital stay (days) Blood loss (ml) Post-op max flow (ml/sec) Post-op residual vol (ml) Post-op IPSS

Open N = 51 90 40 4 8 500 17,8 23 6

Laparoscopic N = 51 149 46 2 5 100 22 18 3

P value < 0,001 0,67 < 0,001 < 0,001 < 0,001 0,06 0,05 < 0,001

Conclusions: Except for the majoration of operating time due to the specific learning curve, comparative results of laparoscopic adenomectomy are favorable, especially regarding reduction of blood loss, catheter duration and hospital stay. Beyond its feasibility, this technique may provide not only teaching facilities for laparoscopic skills but also reproducible results to treat a common disease of the prostate.

Eur Urol Suppl 2007;6(2):163