4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 Shvero ET AL. Enucleation is performed using the 2-lobe, 3-lobe, or en-bloc techniques, depending on the specific anatomy of the patient. After the urethral mucosa is incised, the plane between the adenoma and the surgical capsule is identified and developed using blunt dissection. The laser is used to assist tissue release and hemostasis. All efforts are made to preserve the bladder neck and avoid using high energy in proximity to the external sphincter. After enucleation, tissue morcellation is performed using a soft-tissue morcellator introduced through an offset nephroscope, followed by insertion of a 24Fr 3-way catheter with postoperative continuous bladder irrigation. The catheter is usually removed the morning after surgery and the patient is discharged after a successful voiding trial on postoperative day 1. What does HoLEP bring to the table? HoLEP is considered the endoscopic equivalent to OP as it follows the plane between the adenoma and the surgical capsule similar to the surgeon’s finger during OP, which can explain the excellent volume of tissue removal using this modality. 16 In a study comparing results of HoLEP for prostates smaller than 75 mL, between 75 mL and 125 mL, and larger than 125 mL – there was no difference in the need for blood transfusion or incontinence rates between the groups, providing strong evidence of the size- independent efficacious application of HoLEP. 17 In a large retrospective study of 1,065 patients who underwent HoLEP, de-novo incontinence rates were very low at 1.4%, periop complications rate was 2.3%, and an improvement by almost 23 mL/sec in Qmax after 12 months was observed. 18 In addition to the functional outcomes and safety profile of the procedure, it is important to look at the patient’s perspective on the procedure. Abdul- Muhsin et al 19 conducted a prospective study using a third-party administered survey among patients who underwent surgical treatment for BPH – HoLEP, TURP, photoselective vaporization of the prostate (PVP), transurethral incision of the prostate (TUIP), OP, and HoLAP, aiming to assess subjective quality of life impact among patients post-procedure. Mean IPSS score was lowest for HoLEP, and responses involving quality of life impact and lack of regret significantly favored HoLEP versus all other treatment modalities. HoLEP was also shown to be durable. Elmansy et al 20 conducted a retrospective study looking at the durability of HoLEP among 949 patients with a mean follow up time of 62 months, with 89 patients that had been followed up on for 10 years or more. Total re-operation rate was 0.7%. At 10 years of follow up, IPSSwas 3.6, Qmaxwas 27mL/sec, and PSAreduction was stable at 84%, which implicates the large amount of tissue that is removed, and demonstrates the complete treatment of the bladder outlet obstruction that this modality offers. HoLEPwas also shown to be effective for very large prostates. In a retrospective study of 88 patients with prostates over 200 mL, only 10 patients (11.4%) required a conversion to an OP or required a cystotomy for tissue extraction. Enucleation time was 78 minutes and morcellation time was 49.7 minutes. Only 3 patients (3.9%) needed continence surgery 1 year out of the HoLEP. 21 Recently, papers have been published about the feasibility of removal of the catheter the same day of HoLEP. Agarwal et al conducted a retrospective analysis of 30 patients undergoing HoLEP with same- day catheter removal. Mean prostate size was 81 mL. In order to facilitate same-day catheter removal, a laryngeal mask was used for ventilation (instead of endotracheal tube), no neuromuscular paralysis was used, opiate use was reduced, and early ambulation before catheter removal was encouraged. Same-day voiding trial was done after a mean of 4.9 hours, and was successful in 90% of patients. 22 Another study by Comat et al looked at not only same-day catheter removal, but also same-day discharge. 23 Among 90 patients, same-day discharge was successful in approximately 80% of patients, with the remaining 20% requiring continuous bladder irrigation at least overnight. In an attempt to stratify which of the patients were eligible for same-day discharge, Abdul-Muhsin et al conducted a prospective trial of 47 patients with prostates smaller than 200 mL. 24 Per- protocol, continuous bladder irrigationwas performed for 2 hours post-surgery, then stopped for 2 hours. Urine color was documented and graded according to a hematuria grading scale. For discharge, hematuria grade 4 or less had to be present. Using this method, 59.5% of patients were able to be discharged the same- day of surgery. Twenty-four same-day discharged patients were compared to 19 patients that could not be discharged the same day. Four hr. urine color (hematuria grade) was found to be associated with same-day discharge. Guidelines AUAguidelines onmanagement of BPHwas published in 2018, and was amended in 2019, and 2020. 6 HoLEP was recommended as a size-independent option for surgical management of BPH. For larger prostates, open, lap, or robotic assisted prostatectomy is recommended, depending on the expertise of the 8