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Holmium laser prostatectomy: current techniques
SURGICAL TECHNIQUES IN UROLOGY
HOLMIUM LASER PROSTATECTOMY: CURRENT TECHNIQUES ANDREW H. H. TAN
AND
PETER J. GILLING
ABSTRACT Introduction. During the past 7 years, holmium laser prostatectomy has evolved into an enucleation procedure, incorporating the use of established surgical planes. Holmium laser enucleation of the prostate (HoLEP) uses the excellent incisional and hemostatic properties of the holmium laser wavelength. Clinical outcomes with this may be superior to transurethral resection of prostate. HoLEP is also a minimally invasive therapy for larger glands that have traditionally been treated by open prostatectomy. Technical Considerations. There are four steps to performing HoLEP: (a) creation of bladder neck incisions, (b) enucleation of the median lobe, (c) enucleation of the lateral lobes off the prostatic capsule, and (d) transurethral morcellation. In most cases, postoperative irrigation is not needed and the catheterization time is less than 24 hours. Conclusions. HoLEP is an emerging technique in the surgical management of benign prostatic hyperplasia. There is a learning curve with this procedure, because the technique is very different from transurethral resection of prostate. UROLOGY 60: 152–156, 2002. © 2002, Elsevier Science Inc.
T
he holmium:yttrium-aluminium-garnet laser is an ideal incisional tool for urologic endoscopic surgery. The holmium wavelength (2140 nm) is strongly absorbed by water, has excellent hemostatic properties, and has an absorption length of only 0.4 mm in tissue. It can be transmitted along flexible quartz fibers of varying diameter (200 to 1000 m), which enables its use in a variety of rigid, semirigid, and flexible endoscopes. It is a pulsed laser with each pulse in the kilowatt range of power. This creates very precise tissue vaporization and makes it an excellent incisional tool for soft tissue. HOLMIUM LASER IN TREATMENT OF BENIGN PROSTATIC HYPERPLASIA Bladder outflow obstruction secondary to benign prostatic hyperplasia (BPH) can be treated with the holmium laser by performing a bladder neck incision, by vaporization with a side firing or end firing P. J. Gilling is a study investigator funded by Lumenis, Inc. From the Department of Urology, Tauranga Hospital, Tauranga, New Zealand Reprint requests: Peter J. Gilling, M.D., Promed Urology Limited, Promed House, Suite 6, 71 Tenth Avenue, P.O. Box 56, Tauranga, New Zealand Submitted: December 4, 2001, accepted (with revisions): February 19, 2002
152
© 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
fiber,1–3 by resecting tissue into fragments, or by enucleating entire lobes. Although a bladder neck incision is still useful in small glands, the vaporization technique has largely been abandoned, because it is inefficient and generates no surgical specimen. The resection technique involves excising the prostatic lobes off the capsule and simultaneously dividing them into fragments small enough to remove with a modified grasping loop. Since the development of the transurethral morcellator in 1996, holmium laser prostatectomy is done entirely by the enucleation technique in our institution, with the lobes dissected intact off the surgical capsule and morcellated while free in the bladder. The three currently used techniques are briefly reviewed. HOLMIUM LASER BLADDER NECK INCISION The simplest BPH procedure to learn and perform using the holmium wavelength is a bladder neck incision. This can be performed bilaterally or with a single incision using the high-powered holmium laser (greater than 60 W). Its use was first described in humans when the initial 69 patients from this institution were reviewed.4 The average prostate volume was 24.4 cm3. No untoward events occurred, and all patients voided spontaneously after removal of their catheters the morning after surgery. The flow rates improved from an av0090-4295/02/$22.00 PII S0090-4295(02)01648-5
erage of 7.9 mL/s preoperatively to 19.0 mL/s at 3 months of follow-up. The American Urological Association (AUA) scores decreased from an average of 22.3 preoperatively to 8.1 at 3 months postoperatively. Cornford et al.5 performed a single incision as a day case in 100 men with prostate glands less than 30 g in size. The AUA scores decreased from a mean of 19.2 preoperatively to 3.7 at 6 weeks and 3.5 at 2 years. The peak flow rates improved from a mean of 9.79 mL/s to 19.23 and 18.27 mL/s at 6 weeks and 2 years, respectively. All the patients were left without a catheter, and only three failed to void postoperatively. HOLMIUM LASER RESECTION OF PROSTATE Holmium laser resection of prostate (HoLRP) was developed as a way to overcome the inefficiencies of laser ablation while using the precise incisional qualities of the holmium wavelength.6 The procedure involves the complete resection of the prostatic adenoma, using a piecemeal incisional technique, down to the surgical capsule, with the creation of a transurethral resection of the prostate (TURP)-like cavity. One of the benefits of the HoLRP technique is that tissue is retrieved for histologic examination. Approximately one third of the resected weight of tissue is retrieved, with the remainder vaporized.7 The quality of tissue available for histologic examination has been shown to be inferior to that retrieved by TURP, however, because of thermal artifacts.8 The postoperative catheter time is consistently less than 24 hours in more than 90% of cases. Patients with urinary retention have been treated, with an overall success rate of 94%.9 More than 1000 cases were performed between 1994 and 1996 at our institution using this technique. The procedure was compared with visual laser ablation of the prostate in a randomized prospective trial and was found to result in a significantly shorter catheter time, lower recatheterization and reoperation rates, and significantly less irritable lower urinary tract symptoms in the early postoperative period. The peak urinary flow rates were significantly higher in the HoLRP group up to 12 months of follow-up, and the degree of bladder outflow obstruction was significantly less in the HoLRP group at 3 months.10 In a large randomized trial comparing HoLRP with TURP with 2 years of follow-up, similar clinical outcomes for both procedures were found in terms of urodynamic findings, symptom assessment, continence, and potency.11 Although the holmium procedure took longer than standard TURP to perform, perioperative factors such as nursing contact time, transfusion rate, catheter time, and hospital stay favored HoLRP. UROLOGY 60 (1), 2002
Other investigators have reported similar experiences with this technique.12–16 HoLRP has also been found to be more cost effective than TURP, because although the clinical outcomes are equivalent to at least 1 year, HoLRP patients experience fewer complications and have a shorter hospital stay and catheter time than do TURP patients. It was calculated that a minimum of 93 cases per year are required to recover the capital and service costs of the holmium:yttriumaluminium-garnet laser, however. 17 The main disadvantage of HoLRP is the longer operative time, which can be up to 20% to 30% longer than for standard TURP. This is primarily because of the time it takes to incise the lateral lobes into fragments small enough to be safely extracted by way of the urethra. This issue was addressed by the development of a transurethral tissue morcellator and the evolution of the enucleation technique. HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HOLEP) The most recent step in the evolution of the holmium laser prostatectomy has been the development of a technique involving the enucleation of entire prostatic lobes using existing surgical tissue planes. Thus, the holmium laser fiber acts much like the index finger of the surgeon during an open prostatectomy in shelling out the adenoma. The lobes are then morcellated in the bladder using a specially built tissue morcellator. The operative time has been shortened considerably compared with HoLRP.18 –20 In our experience with resident training, the procedure is conceptually simpler than HoLRP and TURP and, when properly taught, we have seen satisfactory enucleations by our residents (with little TURP experience) after between 5 and 10 cases. For urologists who are self-taught at least 20 moderate-size prostates should be tackled before proficiency can be expected. HoLEP—SURGICAL TECHNIQUE PREOPERATIVE CONSIDERATIONS Patients are selected on the basis of symptoms, voiding uroflowmetry, and, if indicated, pressure flow urodynamic findings. Although desirable, it is not mandatory for patients taking aspirin or warfarin to discontinue their medication before surgery. The prostate volume is assessed by transrectal or transabdominal ultrasonography, which is also useful for picking up unexpected pathologic features such as bladder stones. There is no upper limit in terms of gland size for surgical treatment, but the difficulty and time of the procedure correlate well with the gland size, which allows for better planning of the operating list.21 It is not neces153
FIGURE 1. Versacut morcellator, including hand piece, blades, and controller box with high suction pump.
sary to cross-match blood for the procedure, and the transfusion rate is less than 0.2% in our institution. Patients with an active urinary tract infection should be deferred until they have been treated with a course of antibiotics. All patients receive intravenous antibiotics (160 mg gentamicin) at the time of anesthesia induction. EQUIPMENT Currently, we use a 100-W Versapulse Holmium Laser (Lumenis, Santa Clara, Calif) with a 550-m end firing fiber. The power setting is 2.0 J at 50 Hz (100 W). The fiber is placed through a protective 6F ureteral catheter (Cook, Spencer, Ind) and secured with a Luer-Lok injection port (Baxter, Deerfield, Ill). HoLEP is performed using a 27F continuous flow resectoscope (Olympus, Hamburg, Germany). The inner sheath is modified by incorporating a laser fiber channel and bridge as a single instrument. A 30° telescope is used. The irrigating solution is 0.9% saline. The morcellator telescope is 26F in caliber (Olympus) and has an offset lens, an oval-shaped sheath, and a 5-mm working channel. Other instrument makers have equipment that can be adapted for use with this procedure; the Olympus equipment has been designed specifically for HoLEP. The Versacut morcellator (Lumenis) (Fig. 1) comprises a handpiece with reciprocating blades, controller box with high suction pump, and a foot pedal. This is currently the only commercially available transurethral morcellator. STEP 1—BLADDER NECK INCISIONS (ANIMATION CLIP 1) Bilateral bladder neck incisions are made at the 5 and 7-o’clock positions, and the depth is increased until all circular fibers have been divided. It is important to identify the surgical capsule of the prostate, which is defined by circular fibers running in 154
a transverse direction. This will be the landmark for the depth of dissection for the rest of the procedure. The incisions are lengthened down just adjacent to the verumontanum. The laser fiber is kept close to the end of the resectoscope so that the resectoscope beak can be used to separate tissue during the dissection. The incisions are widened laterally by undermining the lateral lobes. This helps to define the plane of dissection for the enucleation of these lobes, which comes later, and also allows irrigant to flow more easily along these incisions to improve vision. If the bladder neck is particularly high, with a large median lobe, it is often easier to find the correct plane just proximal to the verumontanum on either side and then connect this incision up with one made at the bladder neck at the 5 or 7-o’clock position. Bothersome bleeding can occur at the apex on either side of the verumontanum, and defocusing the beam by pulling the fiber back slightly can coagulate these vessels effectively. STEP 2—ENUCLEATION OF THE MEDIAN LOBE (ANIMATION CLIP 2) The distal ends of the bladder neck incisions are then joined just proximal to the verumontanum with a transverse incision, and the median lobe is dissected on the capsule in a retrograde fashion toward the bladder neck. The beak of the resectoscope is important during this step, as it manipulates the median lobe up into the bladder, allowing the laser to dissect the adenoma off the capsule. Care must be taken not to go too deeply and undermine the bladder neck. STEP 3—ENUCLEATION OF THE LATERAL LOBES (ANIMATION CLIP 3) The lateral lobes are then undermined on each side by extending the initial bladder neck incision laterally and circumferentially at the apex, working toward the 2 and 10-o’clock positions. The depth of the initial bladder neck incision is used as a guide to the surgical capsule and the plane of dissection. Once found the plane is clearly visible, the lobes strip away easily. The plane is developed from the apex toward the bladder neck. A bladder neck incision is then also made at the 12-o’clock position down to the capsule. A sweeping motion is used to continue the incision circumferentially laterally, as well as distally, until the resectoscope can be partially withdrawn, and the upper and lower resection planes can be visualized and connected. This is probably the most challenging part of the procedure. It is particularly so in large prostates in which it is occasionally difficult to judge how far back to carry the upper incision before sweeping down. Coming down too early leads to creating a new plane of dissection inside the proper UROLOGY 60 (1), 2002
plane, and continuing the upper incision too far runs the risk of injuring the external sphincter. Once each of the lateral lobes has been released from the bladder neck in turn, hemostasis should be attended to with the defocused laser beam. This is important to achieve optimal visibility for the next part of the operation, the morcellation of prostate fragments. STEP 4 —MORCELLATION OF PROSTATE FRAGMENTS Morcellation takes place through a dedicated telescope (see above) or a nephroscope with a 5-mm working channel. The morcellator uses a set of two blades with a hollow inner lumen. One blade fits inside the other. These blades are 5 mm in diameter and are designed to pass down a working channel of similar size. The bladder is distended to its full capacity, and high-powered suction tubing is used to engage the prostate fragments, which are free in the bladder. The operator controls the variable suction using the footpedal to attract and then engage the fragments. The foot pedal can also control the speed of the morcellator blades. The guillotine action of the blades slices off fragments of tissue that pass through the lumen of the hollow inner sheath and out through the suction tubing by way of the roller pump to be collected in a special sock that fits over the end of the tubing. The operator must be careful not to engage the bladder mucosa. If this happens, the foot should be taken off the pedal, and the pump suction released by opening the hinged gate on the roller pump. The injury to the bladder mucosa is generally minor and should not interfere with continuing the procedure. Large, full-thickness injuries can lead to extravasation of irrigant or excessive bleeding, which will hamper visibility. Prostatic tissue can be removed at a rate of up to 10 g/min, but if the prostatic tissue is particularly fibrous, morcellation tends to proceed more slowly. Any smaller fragments that are left can be evacuated with a Toomey syringe by way of the resectoscope sheath. A 20F urethral catheter is then introduced into the bladder and removed the following morning. HoLEP—CLINICAL OUTCOMES A randomized trial comparing HoLEP with TURP for prostates in the range of 40 to 200 g has been conducted in our institution, and the 6-month data have recently been presented.22 This trial demonstrated that the clinical outcomes in terms of relief of obstruction were superior in the HoLEP group compared with the TURP group. The mean catheter time and hospital stay were also significantly shorter in the HoLEP arm, but the mean operative time was longer. Anecdotally, the tissue UROLOGY 60 (1), 2002
quality was equivalent to that after TURP. A costeffectiveness analysis is currently underway comparing the two procedures. Using the HoLEP technique, large glands with ultrasound volumes of more than 100 cm3 in volume are able to be enucleated transurethrally in an efficient and relatively bloodless manner.21 Fortythree patients with prostates greater than 100 g underwent HoLEP and intracavitary morcellation at our institution and were followed up for 6 months. Twelve had urinary retention at the time of surgery. The mean laser time was 66.4 minutes (range 24 to 146). The mean morcellation time was 16.1 minutes (range 4 to 65). The average resected weight was 61.8 g of tissue (range 20 to 152). The mean catheter time was 19.7 hours (range 10 to 44), and mean hospitalization time was 28.4 hours (range 17 to 48). One patient required recatheterization in the immediate postoperative period and four required bladder irrigation because of hematuria. The AUA scores decreased from a mean of 23.5 preoperatively to 2.8 at 6 months postoperatively. The peak urinary flow rate (Qmax) improved from a mean of 9.0 mL/s preoperatively to 24.8 mL/s postoperatively. Moody and Lingeman23 compared 10 patients who underwent HoLEP with 10 patients who underwent open prostatectomy. All patients had BPH with a prostate size greater than 100 g. They found that both groups had a significant decrease in AUA scores after their procedure. No significant difference was found in operating times, but the resected weight of tissue in the holmium group was greater (151 versus 106 g; P ⫽ 0.07). All the holmium patients left the hospital without a catheter after an average stay of 2.1 days. All the open prostatectomy patients left the hospital with an indwelling catheter after an average duration of 6.1 days. Stress incontinence was seen frequently in the holmium-treated group but was short term and self-limiting. They recognized the requirement for considerable operator experience in tackling large adenomas with HoLEP. Kuntz and co-workers24 recently presented the preliminary results of the first prospective randomized trial comparing HoLEP and open prostatectomy at the 2001 American Urological Association meeting in Anaheim, California. They found that the operation time was significantly longer for HoLEP than for open prostatectomy (138.4 versus 90 minutes, respectively), but the hospital stay and catheter times were significantly less in the HoLEP group (48 versus 240 hours and 24 versus 144 hours, respectively). Most importantly, however, the clinical outcomes at all points to 12 months were similar, confirming that HoLEP and open prostatectomy are equivalent in matched patients. 155
CONCLUSIONS The current technique of holmium laser prostatectomy involves the enucleation of entire lobes of the prostate followed by intravesical morcellation (HoLEP). In this way, it is the endourologic equivalent of an open prostatectomy. Compared with TURP, HoLEP leads to similar clinical outcomes but is superior at relieving obstruction by urodynamic comparison. The blood loss is less, the hospital stay is shorter, and the catheter times are decreased compared with those for TURP. When compared with open prostatectomy, the hospital stay, catheter times, and amount of blood loss strongly favor HoLEP, and the improvement in symptoms and flow rates are equivalent between the two groups. There is a learning curve associated with this procedure, although it is certainly easier to learn than other new techniques in urology (eg, laparoscopy). The instrumentation for this technique is continuing to evolve. Although the cost of the equipment is significant, the hospital time and morbidity are decreased and results in ongoing cost savings for the institution in the long term. In addition, the laser can be used for nonBPH procedures such as stones and strictures and urothelial tumors. Holmium laser prostatectomy using the enucleation technique is a serious challenger to the time-honored techniques of TURP and open prostatectomy for the surgical treatment of BPH. REFERENCES 1. Gilling PJ, Cass CB, Malcolm A, et al: Combination holmium and Nd:YAG laser ablation of the prostate: initial clinical experience. J Endourol 9: 151–153, 1995. 2. Razvi HA, Chun SS, Denstedt JD, et al: Soft tissue applications of the holmium:YAG laser in urology. J Endourol 9: 387–390, 1995. 3. Mottet N, Anidjar M, Bourdon O, et al: Randomized comparison of transurethral electroresection and holmium: YAG laser vaporization for symptomatic benign prostatic hyperplasia. J Endourol 13: 127–130, 1999. 4. Gilling PJ, Cass CB, Cresswell MD, et al: The use of the holmium laser in the treatment of benign prostatic hyperplasia. J Endourol 10: 459 – 461, 1996. 5. Cornford PA, Biyani CS, and Powell CS: Transurethral incision of the prostate using the holmium:YAG laser: a catheterless procedure. J Urol 159: 1229 –1231, 1998. 6. Gilling PJ, Cass CB, Cresswell MD, et al: Holmium laser resection of the prostate: preliminary results of a new method for the treatment of benign prostatic hyperplasia. Urology 47: 48 –51, 1996. 7. Gilling PJ, Mackey M, Cresswell M, et al: Holmium laser versus transurethral resection of the prostate: a randomized prospective trial with 1-year follow-up. J Urol 162: 1640 – 1644, 1999.
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8. Das A, Kennett KM, Sutton T, et al: Histologic effects of holmium:YAG laser resection versus transurethral resection of the prostate. J Endourol 14: 459 – 462, 2000. 9. Kabalin JN, Mackey MJ, Cresswell MD, et al: Holmium: YAG resection of the prostate (HoLRP) for patients in urinary retention. J Endourol 11: 293–295, 1997. 10. Gilling PJ, Cass CB, Malcolm A, et al: Holmium laser resection of the prostate versus neodymium:yttrium-aluminium-garnet visual laser ablation of the prostate: a randomized prospective comparison of two techniques for laser prostatectomy. Urology 51: 573–577, 1998. 11. Gilling PJ, Kennett KM, and Fraundorfer MR: Holmium laser resection v transurethral resection of the prostate: results of a randomized trial with 2 years’ follow-up. J Endourol 14: 757–760, 2000. 12. Kabalin JN: Holmium:YAG laser prostatectomy: results of U.S. pilot study. J Endourol 10: 453– 457, 1996. 13. Matsuoka K, Iida S, Tomiyasu K, et al: Holmium laser resection of the prostate. J Endourol 12: 279 –282, 1998. 14. Bukala B, and Denstedt JD: Holmium:YAG laser resection of the prostate. J Endourol 13: 215–218, 1999. 15. Mackey MJ, Chilton CP, Gilling PJ, et al: The results of holmium laser resection of the prostate. Br J Urol 81: 518 – 519, 1998. 16. Kitagawa M, Furuse H, Fukuta K, et al: Holmium:YAG laser resection of the prostate versus visual laser ablation of the prostate and transurethral ultrasound-guided laser induced prostatectomy: a retrospective comparative study. Int J Urol 5: 152–156, 1998. 17. Fraundorfer MR, Gilling PJ, Kennett KM, et al: Holmium laser resection of the prostate is more cost effective than transurethral resection of the prostate: results of a randomised prospective study. Urology 57: 454 – 458, 2001. 18. Gilling PJ, Kennett KM, 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 12: 457– 479, 1998. 19. Fraundorfer MR, and Gilling PJ: Holmium:YAG laser enucleation of the prostate combined with mechanical morcellation: preliminary results. Eur Urol 33: 69 –72, 1998. 20. Moody JA, and Lingeman JE: Holmium laser enucleation of the prostate with tissue morcellation: initial United States experience. J Endourol 14: 219 –223, 2000. 21. Gilling PJ, Kennett KM, and Fraundorfer MR: Holmium laser enucleation of the prostate for gland larger than 100 g: an endourologic alternative to open prostatectomy. J Endourol 14: 529 –531, 2000. 22. Gilling PJ, Kennett K, and Fraundorfer MR: Holmium laser enucleation of the prostate (HoLEP) is superior to TURP for the relief of bladder outflow obstruction (BOO). J Endourol A5–P6: A41, 2001. 23. Moody JA, and Lingeman JE: Holmium laser enucleation for prostate adenoma greater than 100 gm: comparison to open prostatectomy. J Urol 165: 459 – 462, 2001. 24. Kuntz RM, Lehrich K, and Fayad A: Transurethral holmium laser enucleation (HoLEP) versus open transvesical enucleation of prostates larger than 100 grams: the first randomized prospective trial (abstract). J Urol 165: 293, 2001.
A video clip of this procedure can be viewed on the Internet at: http://www.goldjournal. net.
UROLOGY 60 (1), 2002
HOLMIUM LASER PROSTATECTOMY: CURRENT TECHNIQUES ANDREW H. H. TAN
AND
PETER J. GILLING
ABSTRACT Introduction. During the past 7 years, holmium laser prostatectomy has evolved into an enucleation procedure, incorporating the use of established surgical planes. Holmium laser enucleation of the prostate (HoLEP) uses the excellent incisional and hemostatic properties of the holmium laser wavelength. Clinical outcomes with this may be superior to transurethral resection of prostate. HoLEP is also a minimally invasive therapy for larger glands that have traditionally been treated by open prostatectomy. Technical Considerations. There are four steps to performing HoLEP: (a) creation of bladder neck incisions, (b) enucleation of the median lobe, (c) enucleation of the lateral lobes off the prostatic capsule, and (d) transurethral morcellation. In most cases, postoperative irrigation is not needed and the catheterization time is less than 24 hours. Conclusions. HoLEP is an emerging technique in the surgical management of benign prostatic hyperplasia. There is a learning curve with this procedure, because the technique is very different from transurethral resection of prostate. UROLOGY 60: 152–156, 2002. © 2002, Elsevier Science Inc.
T
he holmium:yttrium-aluminium-garnet laser is an ideal incisional tool for urologic endoscopic surgery. The holmium wavelength (2140 nm) is strongly absorbed by water, has excellent hemostatic properties, and has an absorption length of only 0.4 mm in tissue. It can be transmitted along flexible quartz fibers of varying diameter (200 to 1000 m), which enables its use in a variety of rigid, semirigid, and flexible endoscopes. It is a pulsed laser with each pulse in the kilowatt range of power. This creates very precise tissue vaporization and makes it an excellent incisional tool for soft tissue. HOLMIUM LASER IN TREATMENT OF BENIGN PROSTATIC HYPERPLASIA Bladder outflow obstruction secondary to benign prostatic hyperplasia (BPH) can be treated with the holmium laser by performing a bladder neck incision, by vaporization with a side firing or end firing P. J. Gilling is a study investigator funded by Lumenis, Inc. From the Department of Urology, Tauranga Hospital, Tauranga, New Zealand Reprint requests: Peter J. Gilling, M.D., Promed Urology Limited, Promed House, Suite 6, 71 Tenth Avenue, P.O. Box 56, Tauranga, New Zealand Submitted: December 4, 2001, accepted (with revisions): February 19, 2002
152
© 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
fiber,1–3 by resecting tissue into fragments, or by enucleating entire lobes. Although a bladder neck incision is still useful in small glands, the vaporization technique has largely been abandoned, because it is inefficient and generates no surgical specimen. The resection technique involves excising the prostatic lobes off the capsule and simultaneously dividing them into fragments small enough to remove with a modified grasping loop. Since the development of the transurethral morcellator in 1996, holmium laser prostatectomy is done entirely by the enucleation technique in our institution, with the lobes dissected intact off the surgical capsule and morcellated while free in the bladder. The three currently used techniques are briefly reviewed. HOLMIUM LASER BLADDER NECK INCISION The simplest BPH procedure to learn and perform using the holmium wavelength is a bladder neck incision. This can be performed bilaterally or with a single incision using the high-powered holmium laser (greater than 60 W). Its use was first described in humans when the initial 69 patients from this institution were reviewed.4 The average prostate volume was 24.4 cm3. No untoward events occurred, and all patients voided spontaneously after removal of their catheters the morning after surgery. The flow rates improved from an av0090-4295/02/$22.00 PII S0090-4295(02)01648-5
erage of 7.9 mL/s preoperatively to 19.0 mL/s at 3 months of follow-up. The American Urological Association (AUA) scores decreased from an average of 22.3 preoperatively to 8.1 at 3 months postoperatively. Cornford et al.5 performed a single incision as a day case in 100 men with prostate glands less than 30 g in size. The AUA scores decreased from a mean of 19.2 preoperatively to 3.7 at 6 weeks and 3.5 at 2 years. The peak flow rates improved from a mean of 9.79 mL/s to 19.23 and 18.27 mL/s at 6 weeks and 2 years, respectively. All the patients were left without a catheter, and only three failed to void postoperatively. HOLMIUM LASER RESECTION OF PROSTATE Holmium laser resection of prostate (HoLRP) was developed as a way to overcome the inefficiencies of laser ablation while using the precise incisional qualities of the holmium wavelength.6 The procedure involves the complete resection of the prostatic adenoma, using a piecemeal incisional technique, down to the surgical capsule, with the creation of a transurethral resection of the prostate (TURP)-like cavity. One of the benefits of the HoLRP technique is that tissue is retrieved for histologic examination. Approximately one third of the resected weight of tissue is retrieved, with the remainder vaporized.7 The quality of tissue available for histologic examination has been shown to be inferior to that retrieved by TURP, however, because of thermal artifacts.8 The postoperative catheter time is consistently less than 24 hours in more than 90% of cases. Patients with urinary retention have been treated, with an overall success rate of 94%.9 More than 1000 cases were performed between 1994 and 1996 at our institution using this technique. The procedure was compared with visual laser ablation of the prostate in a randomized prospective trial and was found to result in a significantly shorter catheter time, lower recatheterization and reoperation rates, and significantly less irritable lower urinary tract symptoms in the early postoperative period. The peak urinary flow rates were significantly higher in the HoLRP group up to 12 months of follow-up, and the degree of bladder outflow obstruction was significantly less in the HoLRP group at 3 months.10 In a large randomized trial comparing HoLRP with TURP with 2 years of follow-up, similar clinical outcomes for both procedures were found in terms of urodynamic findings, symptom assessment, continence, and potency.11 Although the holmium procedure took longer than standard TURP to perform, perioperative factors such as nursing contact time, transfusion rate, catheter time, and hospital stay favored HoLRP. UROLOGY 60 (1), 2002
Other investigators have reported similar experiences with this technique.12–16 HoLRP has also been found to be more cost effective than TURP, because although the clinical outcomes are equivalent to at least 1 year, HoLRP patients experience fewer complications and have a shorter hospital stay and catheter time than do TURP patients. It was calculated that a minimum of 93 cases per year are required to recover the capital and service costs of the holmium:yttriumaluminium-garnet laser, however. 17 The main disadvantage of HoLRP is the longer operative time, which can be up to 20% to 30% longer than for standard TURP. This is primarily because of the time it takes to incise the lateral lobes into fragments small enough to be safely extracted by way of the urethra. This issue was addressed by the development of a transurethral tissue morcellator and the evolution of the enucleation technique. HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HOLEP) The most recent step in the evolution of the holmium laser prostatectomy has been the development of a technique involving the enucleation of entire prostatic lobes using existing surgical tissue planes. Thus, the holmium laser fiber acts much like the index finger of the surgeon during an open prostatectomy in shelling out the adenoma. The lobes are then morcellated in the bladder using a specially built tissue morcellator. The operative time has been shortened considerably compared with HoLRP.18 –20 In our experience with resident training, the procedure is conceptually simpler than HoLRP and TURP and, when properly taught, we have seen satisfactory enucleations by our residents (with little TURP experience) after between 5 and 10 cases. For urologists who are self-taught at least 20 moderate-size prostates should be tackled before proficiency can be expected. HoLEP—SURGICAL TECHNIQUE PREOPERATIVE CONSIDERATIONS Patients are selected on the basis of symptoms, voiding uroflowmetry, and, if indicated, pressure flow urodynamic findings. Although desirable, it is not mandatory for patients taking aspirin or warfarin to discontinue their medication before surgery. The prostate volume is assessed by transrectal or transabdominal ultrasonography, which is also useful for picking up unexpected pathologic features such as bladder stones. There is no upper limit in terms of gland size for surgical treatment, but the difficulty and time of the procedure correlate well with the gland size, which allows for better planning of the operating list.21 It is not neces153
FIGURE 1. Versacut morcellator, including hand piece, blades, and controller box with high suction pump.
sary to cross-match blood for the procedure, and the transfusion rate is less than 0.2% in our institution. Patients with an active urinary tract infection should be deferred until they have been treated with a course of antibiotics. All patients receive intravenous antibiotics (160 mg gentamicin) at the time of anesthesia induction. EQUIPMENT Currently, we use a 100-W Versapulse Holmium Laser (Lumenis, Santa Clara, Calif) with a 550-m end firing fiber. The power setting is 2.0 J at 50 Hz (100 W). The fiber is placed through a protective 6F ureteral catheter (Cook, Spencer, Ind) and secured with a Luer-Lok injection port (Baxter, Deerfield, Ill). HoLEP is performed using a 27F continuous flow resectoscope (Olympus, Hamburg, Germany). The inner sheath is modified by incorporating a laser fiber channel and bridge as a single instrument. A 30° telescope is used. The irrigating solution is 0.9% saline. The morcellator telescope is 26F in caliber (Olympus) and has an offset lens, an oval-shaped sheath, and a 5-mm working channel. Other instrument makers have equipment that can be adapted for use with this procedure; the Olympus equipment has been designed specifically for HoLEP. The Versacut morcellator (Lumenis) (Fig. 1) comprises a handpiece with reciprocating blades, controller box with high suction pump, and a foot pedal. This is currently the only commercially available transurethral morcellator. STEP 1—BLADDER NECK INCISIONS (ANIMATION CLIP 1) Bilateral bladder neck incisions are made at the 5 and 7-o’clock positions, and the depth is increased until all circular fibers have been divided. It is important to identify the surgical capsule of the prostate, which is defined by circular fibers running in 154
a transverse direction. This will be the landmark for the depth of dissection for the rest of the procedure. The incisions are lengthened down just adjacent to the verumontanum. The laser fiber is kept close to the end of the resectoscope so that the resectoscope beak can be used to separate tissue during the dissection. The incisions are widened laterally by undermining the lateral lobes. This helps to define the plane of dissection for the enucleation of these lobes, which comes later, and also allows irrigant to flow more easily along these incisions to improve vision. If the bladder neck is particularly high, with a large median lobe, it is often easier to find the correct plane just proximal to the verumontanum on either side and then connect this incision up with one made at the bladder neck at the 5 or 7-o’clock position. Bothersome bleeding can occur at the apex on either side of the verumontanum, and defocusing the beam by pulling the fiber back slightly can coagulate these vessels effectively. STEP 2—ENUCLEATION OF THE MEDIAN LOBE (ANIMATION CLIP 2) The distal ends of the bladder neck incisions are then joined just proximal to the verumontanum with a transverse incision, and the median lobe is dissected on the capsule in a retrograde fashion toward the bladder neck. The beak of the resectoscope is important during this step, as it manipulates the median lobe up into the bladder, allowing the laser to dissect the adenoma off the capsule. Care must be taken not to go too deeply and undermine the bladder neck. STEP 3—ENUCLEATION OF THE LATERAL LOBES (ANIMATION CLIP 3) The lateral lobes are then undermined on each side by extending the initial bladder neck incision laterally and circumferentially at the apex, working toward the 2 and 10-o’clock positions. The depth of the initial bladder neck incision is used as a guide to the surgical capsule and the plane of dissection. Once found the plane is clearly visible, the lobes strip away easily. The plane is developed from the apex toward the bladder neck. A bladder neck incision is then also made at the 12-o’clock position down to the capsule. A sweeping motion is used to continue the incision circumferentially laterally, as well as distally, until the resectoscope can be partially withdrawn, and the upper and lower resection planes can be visualized and connected. This is probably the most challenging part of the procedure. It is particularly so in large prostates in which it is occasionally difficult to judge how far back to carry the upper incision before sweeping down. Coming down too early leads to creating a new plane of dissection inside the proper UROLOGY 60 (1), 2002
plane, and continuing the upper incision too far runs the risk of injuring the external sphincter. Once each of the lateral lobes has been released from the bladder neck in turn, hemostasis should be attended to with the defocused laser beam. This is important to achieve optimal visibility for the next part of the operation, the morcellation of prostate fragments. STEP 4 —MORCELLATION OF PROSTATE FRAGMENTS Morcellation takes place through a dedicated telescope (see above) or a nephroscope with a 5-mm working channel. The morcellator uses a set of two blades with a hollow inner lumen. One blade fits inside the other. These blades are 5 mm in diameter and are designed to pass down a working channel of similar size. The bladder is distended to its full capacity, and high-powered suction tubing is used to engage the prostate fragments, which are free in the bladder. The operator controls the variable suction using the footpedal to attract and then engage the fragments. The foot pedal can also control the speed of the morcellator blades. The guillotine action of the blades slices off fragments of tissue that pass through the lumen of the hollow inner sheath and out through the suction tubing by way of the roller pump to be collected in a special sock that fits over the end of the tubing. The operator must be careful not to engage the bladder mucosa. If this happens, the foot should be taken off the pedal, and the pump suction released by opening the hinged gate on the roller pump. The injury to the bladder mucosa is generally minor and should not interfere with continuing the procedure. Large, full-thickness injuries can lead to extravasation of irrigant or excessive bleeding, which will hamper visibility. Prostatic tissue can be removed at a rate of up to 10 g/min, but if the prostatic tissue is particularly fibrous, morcellation tends to proceed more slowly. Any smaller fragments that are left can be evacuated with a Toomey syringe by way of the resectoscope sheath. A 20F urethral catheter is then introduced into the bladder and removed the following morning. HoLEP—CLINICAL OUTCOMES A randomized trial comparing HoLEP with TURP for prostates in the range of 40 to 200 g has been conducted in our institution, and the 6-month data have recently been presented.22 This trial demonstrated that the clinical outcomes in terms of relief of obstruction were superior in the HoLEP group compared with the TURP group. The mean catheter time and hospital stay were also significantly shorter in the HoLEP arm, but the mean operative time was longer. Anecdotally, the tissue UROLOGY 60 (1), 2002
quality was equivalent to that after TURP. A costeffectiveness analysis is currently underway comparing the two procedures. Using the HoLEP technique, large glands with ultrasound volumes of more than 100 cm3 in volume are able to be enucleated transurethrally in an efficient and relatively bloodless manner.21 Fortythree patients with prostates greater than 100 g underwent HoLEP and intracavitary morcellation at our institution and were followed up for 6 months. Twelve had urinary retention at the time of surgery. The mean laser time was 66.4 minutes (range 24 to 146). The mean morcellation time was 16.1 minutes (range 4 to 65). The average resected weight was 61.8 g of tissue (range 20 to 152). The mean catheter time was 19.7 hours (range 10 to 44), and mean hospitalization time was 28.4 hours (range 17 to 48). One patient required recatheterization in the immediate postoperative period and four required bladder irrigation because of hematuria. The AUA scores decreased from a mean of 23.5 preoperatively to 2.8 at 6 months postoperatively. The peak urinary flow rate (Qmax) improved from a mean of 9.0 mL/s preoperatively to 24.8 mL/s postoperatively. Moody and Lingeman23 compared 10 patients who underwent HoLEP with 10 patients who underwent open prostatectomy. All patients had BPH with a prostate size greater than 100 g. They found that both groups had a significant decrease in AUA scores after their procedure. No significant difference was found in operating times, but the resected weight of tissue in the holmium group was greater (151 versus 106 g; P ⫽ 0.07). All the holmium patients left the hospital without a catheter after an average stay of 2.1 days. All the open prostatectomy patients left the hospital with an indwelling catheter after an average duration of 6.1 days. Stress incontinence was seen frequently in the holmium-treated group but was short term and self-limiting. They recognized the requirement for considerable operator experience in tackling large adenomas with HoLEP. Kuntz and co-workers24 recently presented the preliminary results of the first prospective randomized trial comparing HoLEP and open prostatectomy at the 2001 American Urological Association meeting in Anaheim, California. They found that the operation time was significantly longer for HoLEP than for open prostatectomy (138.4 versus 90 minutes, respectively), but the hospital stay and catheter times were significantly less in the HoLEP group (48 versus 240 hours and 24 versus 144 hours, respectively). Most importantly, however, the clinical outcomes at all points to 12 months were similar, confirming that HoLEP and open prostatectomy are equivalent in matched patients. 155
CONCLUSIONS The current technique of holmium laser prostatectomy involves the enucleation of entire lobes of the prostate followed by intravesical morcellation (HoLEP). In this way, it is the endourologic equivalent of an open prostatectomy. Compared with TURP, HoLEP leads to similar clinical outcomes but is superior at relieving obstruction by urodynamic comparison. The blood loss is less, the hospital stay is shorter, and the catheter times are decreased compared with those for TURP. When compared with open prostatectomy, the hospital stay, catheter times, and amount of blood loss strongly favor HoLEP, and the improvement in symptoms and flow rates are equivalent between the two groups. There is a learning curve associated with this procedure, although it is certainly easier to learn than other new techniques in urology (eg, laparoscopy). The instrumentation for this technique is continuing to evolve. Although the cost of the equipment is significant, the hospital time and morbidity are decreased and results in ongoing cost savings for the institution in the long term. In addition, the laser can be used for nonBPH procedures such as stones and strictures and urothelial tumors. Holmium laser prostatectomy using the enucleation technique is a serious challenger to the time-honored techniques of TURP and open prostatectomy for the surgical treatment of BPH. REFERENCES 1. Gilling PJ, Cass CB, Malcolm A, et al: Combination holmium and Nd:YAG laser ablation of the prostate: initial clinical experience. J Endourol 9: 151–153, 1995. 2. Razvi HA, Chun SS, Denstedt JD, et al: Soft tissue applications of the holmium:YAG laser in urology. J Endourol 9: 387–390, 1995. 3. Mottet N, Anidjar M, Bourdon O, et al: Randomized comparison of transurethral electroresection and holmium: YAG laser vaporization for symptomatic benign prostatic hyperplasia. J Endourol 13: 127–130, 1999. 4. Gilling PJ, Cass CB, Cresswell MD, et al: The use of the holmium laser in the treatment of benign prostatic hyperplasia. J Endourol 10: 459 – 461, 1996. 5. Cornford PA, Biyani CS, and Powell CS: Transurethral incision of the prostate using the holmium:YAG laser: a catheterless procedure. J Urol 159: 1229 –1231, 1998. 6. Gilling PJ, Cass CB, Cresswell MD, et al: Holmium laser resection of the prostate: preliminary results of a new method for the treatment of benign prostatic hyperplasia. Urology 47: 48 –51, 1996. 7. Gilling PJ, Mackey M, Cresswell M, et al: Holmium laser versus transurethral resection of the prostate: a randomized prospective trial with 1-year follow-up. J Urol 162: 1640 – 1644, 1999.
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8. Das A, Kennett KM, Sutton T, et al: Histologic effects of holmium:YAG laser resection versus transurethral resection of the prostate. J Endourol 14: 459 – 462, 2000. 9. Kabalin JN, Mackey MJ, Cresswell MD, et al: Holmium: YAG resection of the prostate (HoLRP) for patients in urinary retention. J Endourol 11: 293–295, 1997. 10. Gilling PJ, Cass CB, Malcolm A, et al: Holmium laser resection of the prostate versus neodymium:yttrium-aluminium-garnet visual laser ablation of the prostate: a randomized prospective comparison of two techniques for laser prostatectomy. Urology 51: 573–577, 1998. 11. Gilling PJ, Kennett KM, and Fraundorfer MR: Holmium laser resection v transurethral resection of the prostate: results of a randomized trial with 2 years’ follow-up. J Endourol 14: 757–760, 2000. 12. Kabalin JN: Holmium:YAG laser prostatectomy: results of U.S. pilot study. J Endourol 10: 453– 457, 1996. 13. Matsuoka K, Iida S, Tomiyasu K, et al: Holmium laser resection of the prostate. J Endourol 12: 279 –282, 1998. 14. Bukala B, and Denstedt JD: Holmium:YAG laser resection of the prostate. J Endourol 13: 215–218, 1999. 15. Mackey MJ, Chilton CP, Gilling PJ, et al: The results of holmium laser resection of the prostate. Br J Urol 81: 518 – 519, 1998. 16. Kitagawa M, Furuse H, Fukuta K, et al: Holmium:YAG laser resection of the prostate versus visual laser ablation of the prostate and transurethral ultrasound-guided laser induced prostatectomy: a retrospective comparative study. Int J Urol 5: 152–156, 1998. 17. Fraundorfer MR, Gilling PJ, Kennett KM, et al: Holmium laser resection of the prostate is more cost effective than transurethral resection of the prostate: results of a randomised prospective study. Urology 57: 454 – 458, 2001. 18. Gilling PJ, Kennett KM, 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 12: 457– 479, 1998. 19. Fraundorfer MR, and Gilling PJ: Holmium:YAG laser enucleation of the prostate combined with mechanical morcellation: preliminary results. Eur Urol 33: 69 –72, 1998. 20. Moody JA, and Lingeman JE: Holmium laser enucleation of the prostate with tissue morcellation: initial United States experience. J Endourol 14: 219 –223, 2000. 21. Gilling PJ, Kennett KM, and Fraundorfer MR: Holmium laser enucleation of the prostate for gland larger than 100 g: an endourologic alternative to open prostatectomy. J Endourol 14: 529 –531, 2000. 22. Gilling PJ, Kennett K, and Fraundorfer MR: Holmium laser enucleation of the prostate (HoLEP) is superior to TURP for the relief of bladder outflow obstruction (BOO). J Endourol A5–P6: A41, 2001. 23. Moody JA, and Lingeman JE: Holmium laser enucleation for prostate adenoma greater than 100 gm: comparison to open prostatectomy. J Urol 165: 459 – 462, 2001. 24. Kuntz RM, Lehrich K, and Fayad A: Transurethral holmium laser enucleation (HoLEP) versus open transvesical enucleation of prostates larger than 100 grams: the first randomized prospective trial (abstract). J Urol 165: 293, 2001.
A video clip of this procedure can be viewed on the Internet at: http://www.goldjournal. net.
UROLOGY 60 (1), 2002