4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 and enucleation of the median lobe is performed from distal to proximal fashion and the lobe is released it into the bladder. Next, the12 o’clock bladder neck incision ismade from the bladder neck to the level of the verumontanum. This incision is then connected distally to the posterior incisions on both sides. Enucleation of the lateral lobes are done one at a time. The 3-lobe technique is possibly the easiest to learn and is helpful since the lateral lobes can either be enucleated or during the process of learning the technique, the lateral lobes can be addressed with a TUR loop. Another factor of the 3-lobe technique that is helpful for surgeon’s learning this technique is the irrigation flow improves as the incisions arewidened and endoscopic visibility is improved. In addition, the surgeonwill get comfortable using the endoscope beak to lift the adenoma off the capsule, an essential part of advancing the surgeon’s skills for true anatomic enucleation. Lastly, the surgeon becomes familiar with the rotating movement of the endoscope and allows the surgeon to follow the contour of the prostatic lobes and identify the point of enucleation, and avoid pushing against the external sphincter. After enucleation, meticulous hemostasis is achieved by activating the laser from a distance on the tissue (usually with “coagulation” setting 2J at 30Hz). Finally, tissue morcellation, to be described in depth later, is performed using a soft-tissuemorcellator introduced through an offset nephroscope. A24 French 3-way Foley catheter is inserted and continuous bladder irrigation is initiated. Froma teaching standpoint, the three-lobe technique provides easy division of the case. Trainees can begin learning the nuances of the procedure with enucleation of themedian lobe, which is considered less challenging than the lateral lobes. Modified 2-lobe technique In this technique, only one posterior incision is needed at either the 5 or the 7 o’clock position, depending on the configuration of the specific prostate, as well as surgeon’s preference. In cases where only one sulcus can be identified this approach can prevent undermining of the trigone. The incision is carried proximal to distal fashion and taken to the level of the verumontanum. Next, the incision divides the adenoma into a lateral lobe on one side, and themedian lobe en-bloc with the other lateral lobe. The 12 o’clock incision is the same as in the 3-lobe technique and the posterior and anterior incisions are connected on both sides distally. Enucleation is then completed, followed by tissuemorcellation. The advantage of this technique includes only one posterior bladder neck incision, which saves time. In a prospective study comparing HoLEPwith the 3-lobe, 2-lobe, and en-bloc techniques, enucleation time was significantly longer for the 3-lobe technique by almost 20%, comparedwith the other two techniques, with no difference in functional outcome. 23 The 2-lobe technique represents a natural progression from the 3-lobe technique. Nonetheless, it adds complexity as it makes identification of the surgical plane more difficult, and so should be performed by an experienced HoLEP surgeon. En-bloc technique This technique involves complete detachment of all 3 prostatic lobes in a distal-to-proximal approach. 21,24 There are several en-bloc techniques described in the literature. The techniques differ in the incisions of the urethral mucosa, but all follow the same principle. The procedure starts with the identification of the distal landmarks - external sphincter, distal border of the lateral lobes and the median lobe, and the verumontanum. Two circular incisions are made from both sides of the verumontanum and laterally around the lateral lobes, to meet at 12 o’clock. The two incisions are connected posteriorly just proximal to the verumontanum, to complete a circumferential incision. These incisions are deepened down to the surgical capsule between the adenoma and the prostate and carried proximally in a circumferential fashion towards the bladder neck while using the beak of the scope and the irrigation for blunt dissection together with the laser fiber for hemostasis and delicate dissection. The adenoma is then released to the bladder and tissue morcellation is performed. 25 In a retrospective study that reviewed 1,115 patients who underwent en-bloc or 2-lobe HoLEP, there was no difference in enucleation time or 6-month functional outcome, but morcellation was more efficient in the 2-lobe approach for prostates > 150 cc by about 30%. 26 Others found en-bloc enucleation to be more time-efficient than other techniques by as much as 30%. 27 The surgeon’s preference is the main factor in determining the technique to be used. Bladder neck preservation techniques One of the most common side effects of HoLEP is retrograde ejaculation occurring in 70%-80% of cases. 28 In young and sexually active patients undergoing treatment of BPH, this side effect may have a negative impact on quality of life and can adversely affect sexual function. 29 In an effort to maintain antegrade ejaculation after surgery, bladder neck preservation techniques have been described. 30 The bladder neck can be preserved in all HoLEP techniques, by sparing the bladder neck when incising the 5 and 7 o’clock 13 HoLEP techniques – lessons learned