3rd Annual Jefferson Urology Symposium: Men’s Health Forum

© The Canadian Journal of Urology TM : International Supplement, August 2020 45 Holmium laser enucleation of the prostate (HoLEP): size-independent gold standard for surgical management of benign prostatic hyperplasia Analysis of these treatment modalities has shown HoLEP to have improved subjective and objective outcomes, including AUA Symptom Score (AUA-SS), postoperative Q max and retreatment rates, when compared to TURP and OSP. 7 Additionally, HoLEP results in reduced immediate complications, decreased length of hospital stay (LOS), shorter catherization times, and decreased blood loss when compared to TURP 8 and OSP. 9 According to current AUA guidelines, laser enucleation techniques are the only recommended size-independent endoscopic surgical option for symptomatic BPH. 3 This review will detail surgical strategies and techniques, outcomes, safety, and long term durability of the HoLEP procedure. Equipment and technique The standard HoLEP technique has been previously described 10 and is performed using a high-power 100-120 W holmium laser (Lumenis, Yokneam, Israel) with an end-firing 550-micron laser fiber. Newer laser systems, with two pedals, offer the ability to alternate between treatment settings – commonly 2.0 J with a frequency of 40-50 Hz and wide pulse width – and hemostasis settings – typically 1.5 J and 30 Hz. The procedure is performed using a 26-Fr continuous flow endoscope with a laser bridge. The laser fiber is delivered through the working channel within a 7 Fr laser catheter, which provides stabilization of the fiber throughout the procedure. The inflow port is connected to two separate 3 liter normal saline irrigation bags, which are left wide open, and the outflow port is left to gravity drainage. The classic, and most commonly used, HoLEP technique is performed by enucleating the median and lateral lobes of the prostate and releasing them into the bladder. Incisions are made at the 5- and 7-o’clock location at the bladder neck and are carried down to the fibers of the prostatic capsule. These incisions are then extended distally and joined proximal to the verumontanum. Starting at this distal location, the median lobe is dissected off of the capsule until it can be released into the bladder. This process can be aided by using the end of the scope to lift the prostatic adenoma while using the laser fiber to develop the dissection plane at the level of the capsule. A similar approach is utilized for the lateral lobes, which are enucleated separately. An additional 12-o’clock incision is made at the bladder neck and again carried distally to the level of the verumontanum, with care to avoid damage to the external urethral sphincter. This incision is again carried down to the level of the prostatic capsule and using similar technique, the lobe is gradually dissected free, as the surgeon works to connect the 12-o’clock incision with the 5-o’clock incision. Once all lobes are enucleated, hemostasis can be achieved by activating the laser on bleeding tissue, but from a further distance than usual. This technique serves to “de-focus” the laser energy and results in tissue blanching and coagulation. Once all three lobes are free-floating within the bladder, the endoscope is exchanged for an offset nephroscope with a straight working channel through which a soft tissue morcellator is placed. It is important to maintain a full bladder during this process, as decompression can lead to bleeding and decreased visualization. A second irrigation channel is placed in order to optimize visualization during morcellation, with the morcellator serving as outflow suction. Suction on the morcellator is activated, which draws the prostatic adenoma onto the blades. Once the adenoma is visualized to be safely away from bladder mucosa, the blades are activated and prostatic tissue is extracted. Under usual circumstances, the surgeon is able to completely morcellate all adenoma tissue, however, there are instances in which this cannot be completed, and remaining tissue must be extracted by other means (i.e. resectoscope or foreign body grasper). After ensuring all tissue has been removed from the bladder, a 24-Fr three-way Foley catheter is placed and continuous bladder irrigation is initiated. The newer techniques and equipment HoLEPmay help improve OR time, shorten the learning curve, and reduce the incidence of transient stress incontinence. NewerHoLEP surgical techniques include the two-lobe and complete en-bloc enucleation of the prostate. 12,13 In a randomized control trial comparing two-lobe technique to the standard three-lobe technique, Xu et al demonstrated reduced incidence of retrograde ejaculation and urinary incontinence. 11 Similarly, studies comparing efficacy and safety of traditional HoLEP and en bloc technique have shown potential advantages toward the latter technique, including decreased enucleation time and total operative time owing to faster identification of the surgical capsule, 13,14 lower risk of major complications, 15 and improvements in quality of life. 15 A study comparing traditional three-lobe, two-lobe, and en bloc techniques done by Tokatli et al, found decreased enucleation time with the two-lobe technique, and also higher rates of transient urinary incontinence in the en bloc group. 16 Varying laser settings have also been studied with results demonstrating that low-powered HoLEP (LP-HoLEP) can be performed feasibly, safely, and effectively. 17,18 A randomized trial by Elshal et al comparing lower power (LP)-HoLEP (2 J, 25 Hz) to