4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 American Urological Association (AUA) guidelines, is a size-independent procedure for prostatic size reduction. This technique can be employed for the treatment of large prostates over 80 grams. Traditional endoscopic procedures like transurethral resection of the prostate (TURP) are limited to glands under 80 grams due to the absorption of hypotonic fluid used for irrigation during the procedure which can lead to TUR syndrome. 7,8 Patients with large prostates, greater than 80 grams, often require a simple prostatectomy involving a skin incision and longer catheter times due to the cystotomy. HoLEP has several advantages over TURP, such as the absence of potentially fatal TUR syndrome (which was reported to occur in 1.4% of TURP cases), ability to operate on antithrombotic medication with fewer complications, more efficient tissue removal, improved functional outcomes, etc. 9-11 HoLEP has been previously described as the endoscopic equivalent to open prostatectomy (OP) in which the endoscope during the HoLEP procedure functions as the “surgeon’s finger” during blunt enucleation during OP. 12,13 Compared to OP, HoLEP avoids a lower abdominal incision and has shorter recovery time, hospital stay, and catheterization time, as well as a lower complication rate. 14 In total, HoLEP does not seem to add any cost to a traditional TURP, and has significantly reduced cost compared to OP. 15,16 But, HoLEP also has some disadvantages including a higher initial cost of surgical equipment (laser generator, laser fiber, and endoscopic soft-tissue morcellator), longer duration of the procedure (especially at the beginning of the learning curve), andmost importantly, a longer learning curve of 20-50 cases. 17,18 The relatively long learning curve and the resultant lack of teaching opportunities present an obstacle and ultimately prevent HoLEP from being adopted by many urologists. Here, we present our experience in performing HoLEP in a teaching university hospital, with an emphasis on the surgical technique. Surgical technique Holmium laser prostatectomy can refer to any of the following procedures – holmium laser ablation of the prostate (HoLAP), 19 holmium laser resection of the prostate (HoLRP), 20 holmium laser incision of the prostate (HoIP), and HoLEP. HoLEP is the most equipment intensive out of these procedures, and it is imperative that the surgeon is familiar with the specialized equipment while having access to all the proper tools to finish the procedure. There are other variations of holmium enucleation procedures that utilize the same equipment. These procedures include median-lobe-only enucleation, hybrid procedures such as HoLEP combined with open cystotomy for lobe extraction, distal HoLEP combined with open/ robotic prostatectomy, HoLEP combined with robotic diverticulectomy, or lateral lobe prostatic urethral lift combined with median-lobe only HoLEP. The choices of holmium enucleation techniques enable the surgeon to tailor the right procedure for the individual patient. For example, in the case of an extremely large prostate, a combinedHoLEP/OP can be considered, or in the situation with a patient who desires to preserve antegrade ejaculation – aHoIP or amedian lobeHoLEP may be considered if the anatomy is favorable. There are several variations ofHoLEP that have been described in the literature and include classic 3-lobe, modified 2-lobe, and en-bloc enucleation techniques. The choice for the specific technique is dependent on several factors. The first and most important is the comfort level and experience of the surgeon with a specific technique. This can be an important factor in large teaching university centers; frequently residents perform portions of the procedure. In our experience, it has proven easier for a less-experienced surgeon to start with enucleation of the median lobe and go on to the 3-lobe technique. Second, there is always a concern about residual adenoma tissue that has not been completely resected. This factor is dependent on the recognition of the surgical plane between the adenoma and the prostate, which may be challenging at times, especially for larger glands. And third, the technique used in the distal dissection may impact the possibility of transient stress incontinence (SUI) after surgery. To reduce transient SUI, the beak of the endsoscope is always proximal to the sphincter and the external sphincter is minimally manipulated during the enucleation. 21 Several HoLEP techniques have been introduced to address these issues. The enucleation techniques differ from one another in the incisions that are made in the urethral mucosa and down to the surgical capsule, as well as in the direction of dissection. Here, we will describe the classic 3-lobe technique, the modified 2-lobe technique, en-block technique, and bladder neck preserving techniques. 3-lobe technique The classic technique described previously by Gilling et al is referred to as the “3-lobe technique”. 22 Briefly, in this technique, two mucosal incisions are made and carried down to the fibers of the prostatic capsule at 5 and 7 o’clock, and then these are carried distally to the level of the verumontanum on each side. The distal incisions are connected proximal to the verumontanum 12 Shvero ET AL.