4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 incisions and enucleating in the distal-to-proximal approach without performing any incisions in the bladder neck. This requires identification of the fibers of the bladder neck when enucleating the adenoma before going into the bladder at the final stage of enucleation. In a retrospective report, among 213 patients who underwent en-bloc bladder neck sparing HoLEP, 88.3%had antegrade ejaculation after surgery. 30 There are no reports of the results of these techniques with long term followup, and rates of re-treatment and bladder neck contractures are not known. Surgical equipment Most commonly, a26Frenchcontinuousflowendoscope with a 30° lens used with a laser bridge. A550-micron end-fire laser fiber is inserted through a 7 French laser catheter that has a locking adapter that stabilizes the fiber. The irrigation fluid used is normal saline. We currently use a high-power 120W laser generator with a dual-foot pedal. The laser settings are usually 2J and 50Hz in wide-pulse for enucleation and 2J and 30Hz, wide-pulse mode for hemostasis and apical dissection. The dual-pedals allow easy switching between these two laser settings as needed. Morcellation is done with a 26.5 French offset nephroscope and a 5Fr oscillating soft-tissuemorcellator unit with a single-use blade. The nephroscope fits inside the outer sheath of the 26 French continuous flow endoscope with an adapter. The adapter allows us to omit the need for re- introduction of the nephroscope through the urethra. In addition, to maximize visibility and prevent injury to the bladder mucosa by the endoscopic soft- tissue morcellator, both ports of the continuous flow endoscope are used for inflow. The blades of the morcellator have a reciprocating hollow blade with suction and are positioned under the adenoma inside the bladder. The initial morcellator setting is 450 rotations-per-minute (RPM) and is changed if needed. Energy HoLEP employs a 2140nm wavelength Ho:YAG laser that is absorbed by water and water-containing soft tissue and has a soft tissue penetration depth of only 0.4 mm, and an incision depth of 2 mm. 31 At a distance of less than 3 mm from the tissue, the laser will achieve hemostasis, and in direct contact with the tissue, it will achieve cutting and/or vaporization of the prostatic tissue. The minimal depth of absorption of holmium laser energy in tissue and the absorption of energy in normal saline allows the surgeon to be more precise in cutting the tissue. The ultimate outcome of the holmium laser on tissue is the “what you see is what you get” effect. 32,33 Pulse width does not affect energy output but delivers the same energy for a longer time. The newer 120 Watt laser has the option for using a wider pulse (longer pulse) which has been shown to lessen fiber degradation during lithotripsy, 34 and have a better coagulation effect, but does not affect the soft- tissue incision depth. 31,35 Recently, a modulated pulsed holmium laser energy used initially at lower settings technology for lithotripsy has been optimized for HoLEP at higher energy settings. This newer andmore powerful laser has been shown to reduce enucleation and hemostasis times. 36,37 Morcellation The purpose of morcellation is to remove of the enucleated prostatic tissue safely out of the bladder. Electromechanical morcellation of enucleated prostatic tissue was first described in 1998. 38 Newer generations of these devices have made much progress in an effort to enhance efficiency (measured in grams removed per minute) and safety. During morcellation, especially for small-volume bladders, or when bleeding hampers visualization – there is a risk of damaging the bladder wall, mostly the posterior wall or the dome of the bladder. 39 The morcellator is introduced through an offset nephroscope. Once enucleation is completed, just prior to endoscopic soft-tissue removal, it is important to not let the bladder drain completely. The rapid decompression of the bladder may cause bleeding from the bladder lining or prostate capsule which affects visualization. The commonly available morcellators differ in theway their cutting blademoves - the Pirhana (Richard Wolf, Knuittlingen, Germany) has a toothed oscillating blade, DrillCut (Karl Storz, Tuttlingen, Germany) has a toothed rotating blade, and the VersaCut (Lumenis, Santa Clara, CA, USA) has a non- toothed guillotine blade. The morcellator devices have one or two pedals and enable the surgeon to perform suction-only or suction-and-morcellation (either by a different pedal or by pushing the single pedal lightly for suction and forcefully for suction andmorcellation). Head-to-head studies have failed to find a significant difference in the efficiency and rate of complications of the different devices. 40,41 A recent review of 26 studies and 5,652 patients assessed the efficiency and safety of the three availablemorcellators: efficiencywas 5.3, 5.29, and 3.95 g/min for the DrillCut, Pirhana, and VersaCut devices respectively. Bladder wall injury was more commonwith the VersaCut device (5.23%) compared to the Pirhana (1.24%) and DrillCut (1.98%), but VersaCut had the lowest malfunction rates (0.74%) compared to Pirhana (2.07%) and DrillCut (7.86%). 39 14 Shvero ET AL.