- Email: [email protected]
Re: Holmium Laser Enucleation of the Prostate: A Modified Enucleation Technique and Initial Results
LETTERS TO THE EDITOR/ERRATA
395
Angeles Prostate Cancer Index and found that in addition to age, ethnicity, baseline urinary function and comorbidity count were independent predictors of post-prostatectomy urinary function. The metabolic syndrome, the most common comorbidity of elderly men, has been shown to be associated with benign prostatic hyperplasia and lower urinary tract symptoms.2 On the other hand, the time course after RP represents the natural history of lower urinary tract symptoms in the absence of a prostate.3 Thus, it is conceivable that patients with more medical comorbidities are at higher risk for adverse urinary function outcome. Identifying patients at high risk for adverse urinary function outcome is pivotal and facilitates medical decision making. The present study and our series suggest providing a validated, broadly applicable framework to predict the probability of posttreatment urinary control for individual patients. Although urinary control postoperatively remained relatively stable for the entire study cohort, deterioration of urinary continence was observed in a significant proportion of patients at 2 to 5 years following radical prostatectomy.4 This finding raises another important issue. If baseline comorbid disease affects quality of life outcomes, how do comorbid conditions that are diagnosed after treatment impact these outcomes? Patients with localized prostate cancer now routinely live more than 10 years after diagnosis,5 giving them a long opportunity for additional comorbid conditions to develop that may influence quality of life. Future studies must address these important questions. Respectfully, Shunichi Namiki and Yoichi Arai Department of Urology Tohoku University Graduate School of Medicine Sendai, Japan e-mail: [email protected] 1. Namiki S, Kwan L, Kagawa-Singer M et al: Urinary quality of life after prostatectomy or radiation for localized prostate cancer: a prospective longitudinal cross-cultural study between Japanese and U.S. men. Urology 2008; 7: 1103. 2. Hammarsten J and Peeker R: Urological aspects of the metabolic syndrome. Nat Rev Urol 2011; 8: 483.
4. Naselli A, Simone G, Papalia R et al: Late-onset incontinence in a cohort of radical prostatectomy patients. Int J Urol 2011; 18: 76. 5. Albertsen PC, Hanley JA, Penson DF et al: 13-Year outcomes following treatment for clinically localized prostate cancer in a population based cohort. J Urol 2007; 177: 932.
3. Namiki S, Ishidoya S, Saito S et al: Natural history of voiding function after radical retropubic prostatectomy. Urology 2006; 68: 142.
Reply by Authors: We acknowledge the study by Namiki et al and believe their findings are complementary to ours. The body of literature on urinary function after treatment for prostate cancer is substantial, and there are many interesting studies that we were not able to cite in our article. However, while Namiki et al, like many others, identified a single longitudinal trend among all patients, we used a novel method to identify distinct patterns of urinary function recovery within our longitudinal data set. We believe this is a more powerful technique for detecting trends in longitudinal data and identifying patient variables associated with specific outcomes. Now that age and number of medical comorbidities are known to be associated with recovery of urinary function after radical prostatectomy for men within and outside the United States, we should continue to focus our efforts on preoperative counseling and setting reasonable patient expectations.
Re: Holmium Laser Enucleation of the Prostate: A Modified Enucleation Technique and Initial Results Y. G. Gong, D. L. He, M. Z. Wang, X. D. Li, G. D. Zhu, Z. H. Zheng, Y. F. Du, L. S. Chang and X. Y. Nan J Urol 2012; 187: 1336 –1340
To the Editor: Holmium laser enucleation of the prostate has been a routine surgical modality for treatment of benign prostatic hyperplasia (BPH), although a standardized surgical method has yet to be determined. The modified procedure described by Gong et al indicates that enlarged adenomas (mean ⫾ SD 60.9 ⫾ 39.2 gm) can be enucleated with shorter operative times (54.7 ⫾ 21.1 minutes) and with less hemoglobin decrease (0.98 ⫾ 0.72 gm/dl) compared to previously published data.
396
LETTERS TO THE EDITOR/ERRATA
Furthermore, this procedure resulted in transient incontinence in only 3 cases among 189. To promote wider use of this excellent method, the following points should be considered. The reported enucleation time was remarkably short, at a mean of 36.5 minutes. The longest reported time was 64 minutes for enucleation of extremely large adenomas (up to 240 gm). Separation of the median lobe from the surgical capsule was performed before division of the median and lateral lobes. To ensure optimal success, this step must be performed in a time efficient manner. However, in cases of extremely large BPH the prostatic bed is fully occupied by enlarged lateral adenomas as well as a middle lobe, which is in perpendicular contact with the surgical capsule. The limited space and the starkly perpendicular contact make it exceedingly difficult to maneuver the endoscope shaft into proper position to reach the bladder neck. Furthermore, this area of surgical capsule, which consists of not only the peripheral zone, but also the softer central zone, is thought to be a fragile and easily penetrable point. Therefore, we believe that 3-lobe techniques, including our anteroposterior method,1 offer a distinct operative advantage. In addition, the high efficacy of reported morcellation is noteworthy. Ishikawa et al reported a morcellation rate of 6.7 gm per minute in 140 cases.2 This efficacy rate is worsened in larger adenomas (greater than 80 gm). In my experience a 320 gm adenoma requires more than 3 hours to morcellate adequately. Also large adenomas are typically heterogeneous rather than homogeneous. A dense “beach ball” like nodule in a large adenoma will likely decrease the morcellation efficacy. Gong et al report a maximum total operation time, including cases of extremely large BPH, of just 86 minutes, suggesting that they achieved an excellent morcellation rate in all cases. Operative details contributing to their excellent morcellation efficacy should be described. Respectfully, Fumiyasu Endo Department of Urology St. Luke’s International Hospital Tokyo, Japan 1. Endo F, Shiga Y, Minagawa S et al: Anteroposterior dissection HoLEP: a modification to prevent transient stress urinary incontinence. Urology 2010; 76: 1451. 2. Ishikawa R, Shitara T, Wakatabe Y et al: Relationship between morcellation efficiency and enucleated tissue weight in holmium laser enucleation of the prostate (HoLEP) for patients with benign prostatic hyperplasia. Nihon Hinyokika Gakkai Zasshi 2011; 102: 675.
Reply by Authors: For holmium laser enucleation of the prostate one of the principal pitfalls of the traditional 3-lobe method is difficulty in recognizing the level of surgical capsule of the median lobe when cutting through the prostatic tissues down to the posterior prostatic wall. Using our technique, the distal posterior surgical capsule of the median and lateral lobes can be exposed quickly and safely, as described. Once the distal plane is developed, the median and lateral lobes are leveraged up off the posterior surgical capsule step by step toward the bladder neck, with enough operating space created. In our experience the contact between the adenoma and the surgical capsule is often loose and can be separated easily by the endoscope beak. If the prostate is adherent to the surgical capsule and not easy to bluntly lift up, it is also safe to dissect the adherent tissues along the exposed capsule. Sometimes the prostatic tissues near the bladder neck are difficult to separate from the capsule, and we will then incise the prostatic tissues at the 5 o’clock position from the apex to the bladder neck along the already developed plane, with the surgical capsule of the bladder neck exposed and freed. To avoid penetrating the surgical capsule of the median lobe, the operator should always perform the procedure along the exposed capsule and move the endoscope beak forward following the adjacent prostatic tissues already leveraged up. Of course, the operator should also have a good idea of the contour of the prostate. It is often time consuming to morcellate a large adenoma with dense “beach ball” like nodules. To solve this problem, we turn the window at the morcellator tip to the 6 o’clock position, and with it press the prostatic tissue block against the bladder wall to morcellate it. In this way the tissue block does not easily get away and is pressed into the window, thereby significantly increasing morcellating efficacy. This method is safe only if the bladder is distended and the morcellating technique is changed to the traditional one when the tissue block size has become small enough.
395
Angeles Prostate Cancer Index and found that in addition to age, ethnicity, baseline urinary function and comorbidity count were independent predictors of post-prostatectomy urinary function. The metabolic syndrome, the most common comorbidity of elderly men, has been shown to be associated with benign prostatic hyperplasia and lower urinary tract symptoms.2 On the other hand, the time course after RP represents the natural history of lower urinary tract symptoms in the absence of a prostate.3 Thus, it is conceivable that patients with more medical comorbidities are at higher risk for adverse urinary function outcome. Identifying patients at high risk for adverse urinary function outcome is pivotal and facilitates medical decision making. The present study and our series suggest providing a validated, broadly applicable framework to predict the probability of posttreatment urinary control for individual patients. Although urinary control postoperatively remained relatively stable for the entire study cohort, deterioration of urinary continence was observed in a significant proportion of patients at 2 to 5 years following radical prostatectomy.4 This finding raises another important issue. If baseline comorbid disease affects quality of life outcomes, how do comorbid conditions that are diagnosed after treatment impact these outcomes? Patients with localized prostate cancer now routinely live more than 10 years after diagnosis,5 giving them a long opportunity for additional comorbid conditions to develop that may influence quality of life. Future studies must address these important questions. Respectfully, Shunichi Namiki and Yoichi Arai Department of Urology Tohoku University Graduate School of Medicine Sendai, Japan e-mail: [email protected] 1. Namiki S, Kwan L, Kagawa-Singer M et al: Urinary quality of life after prostatectomy or radiation for localized prostate cancer: a prospective longitudinal cross-cultural study between Japanese and U.S. men. Urology 2008; 7: 1103. 2. Hammarsten J and Peeker R: Urological aspects of the metabolic syndrome. Nat Rev Urol 2011; 8: 483.
4. Naselli A, Simone G, Papalia R et al: Late-onset incontinence in a cohort of radical prostatectomy patients. Int J Urol 2011; 18: 76. 5. Albertsen PC, Hanley JA, Penson DF et al: 13-Year outcomes following treatment for clinically localized prostate cancer in a population based cohort. J Urol 2007; 177: 932.
3. Namiki S, Ishidoya S, Saito S et al: Natural history of voiding function after radical retropubic prostatectomy. Urology 2006; 68: 142.
Reply by Authors: We acknowledge the study by Namiki et al and believe their findings are complementary to ours. The body of literature on urinary function after treatment for prostate cancer is substantial, and there are many interesting studies that we were not able to cite in our article. However, while Namiki et al, like many others, identified a single longitudinal trend among all patients, we used a novel method to identify distinct patterns of urinary function recovery within our longitudinal data set. We believe this is a more powerful technique for detecting trends in longitudinal data and identifying patient variables associated with specific outcomes. Now that age and number of medical comorbidities are known to be associated with recovery of urinary function after radical prostatectomy for men within and outside the United States, we should continue to focus our efforts on preoperative counseling and setting reasonable patient expectations.
Re: Holmium Laser Enucleation of the Prostate: A Modified Enucleation Technique and Initial Results Y. G. Gong, D. L. He, M. Z. Wang, X. D. Li, G. D. Zhu, Z. H. Zheng, Y. F. Du, L. S. Chang and X. Y. Nan J Urol 2012; 187: 1336 –1340
To the Editor: Holmium laser enucleation of the prostate has been a routine surgical modality for treatment of benign prostatic hyperplasia (BPH), although a standardized surgical method has yet to be determined. The modified procedure described by Gong et al indicates that enlarged adenomas (mean ⫾ SD 60.9 ⫾ 39.2 gm) can be enucleated with shorter operative times (54.7 ⫾ 21.1 minutes) and with less hemoglobin decrease (0.98 ⫾ 0.72 gm/dl) compared to previously published data.
396
LETTERS TO THE EDITOR/ERRATA
Furthermore, this procedure resulted in transient incontinence in only 3 cases among 189. To promote wider use of this excellent method, the following points should be considered. The reported enucleation time was remarkably short, at a mean of 36.5 minutes. The longest reported time was 64 minutes for enucleation of extremely large adenomas (up to 240 gm). Separation of the median lobe from the surgical capsule was performed before division of the median and lateral lobes. To ensure optimal success, this step must be performed in a time efficient manner. However, in cases of extremely large BPH the prostatic bed is fully occupied by enlarged lateral adenomas as well as a middle lobe, which is in perpendicular contact with the surgical capsule. The limited space and the starkly perpendicular contact make it exceedingly difficult to maneuver the endoscope shaft into proper position to reach the bladder neck. Furthermore, this area of surgical capsule, which consists of not only the peripheral zone, but also the softer central zone, is thought to be a fragile and easily penetrable point. Therefore, we believe that 3-lobe techniques, including our anteroposterior method,1 offer a distinct operative advantage. In addition, the high efficacy of reported morcellation is noteworthy. Ishikawa et al reported a morcellation rate of 6.7 gm per minute in 140 cases.2 This efficacy rate is worsened in larger adenomas (greater than 80 gm). In my experience a 320 gm adenoma requires more than 3 hours to morcellate adequately. Also large adenomas are typically heterogeneous rather than homogeneous. A dense “beach ball” like nodule in a large adenoma will likely decrease the morcellation efficacy. Gong et al report a maximum total operation time, including cases of extremely large BPH, of just 86 minutes, suggesting that they achieved an excellent morcellation rate in all cases. Operative details contributing to their excellent morcellation efficacy should be described. Respectfully, Fumiyasu Endo Department of Urology St. Luke’s International Hospital Tokyo, Japan 1. Endo F, Shiga Y, Minagawa S et al: Anteroposterior dissection HoLEP: a modification to prevent transient stress urinary incontinence. Urology 2010; 76: 1451. 2. Ishikawa R, Shitara T, Wakatabe Y et al: Relationship between morcellation efficiency and enucleated tissue weight in holmium laser enucleation of the prostate (HoLEP) for patients with benign prostatic hyperplasia. Nihon Hinyokika Gakkai Zasshi 2011; 102: 675.
Reply by Authors: For holmium laser enucleation of the prostate one of the principal pitfalls of the traditional 3-lobe method is difficulty in recognizing the level of surgical capsule of the median lobe when cutting through the prostatic tissues down to the posterior prostatic wall. Using our technique, the distal posterior surgical capsule of the median and lateral lobes can be exposed quickly and safely, as described. Once the distal plane is developed, the median and lateral lobes are leveraged up off the posterior surgical capsule step by step toward the bladder neck, with enough operating space created. In our experience the contact between the adenoma and the surgical capsule is often loose and can be separated easily by the endoscope beak. If the prostate is adherent to the surgical capsule and not easy to bluntly lift up, it is also safe to dissect the adherent tissues along the exposed capsule. Sometimes the prostatic tissues near the bladder neck are difficult to separate from the capsule, and we will then incise the prostatic tissues at the 5 o’clock position from the apex to the bladder neck along the already developed plane, with the surgical capsule of the bladder neck exposed and freed. To avoid penetrating the surgical capsule of the median lobe, the operator should always perform the procedure along the exposed capsule and move the endoscope beak forward following the adjacent prostatic tissues already leveraged up. Of course, the operator should also have a good idea of the contour of the prostate. It is often time consuming to morcellate a large adenoma with dense “beach ball” like nodules. To solve this problem, we turn the window at the morcellator tip to the 6 o’clock position, and with it press the prostatic tissue block against the bladder wall to morcellate it. In this way the tissue block does not easily get away and is pressed into the window, thereby significantly increasing morcellating efficacy. This method is safe only if the bladder is distended and the morcellating technique is changed to the traditional one when the tissue block size has become small enough.