Anatomical Enucleation of the Prostate with Thulium:YAG Support: Redefinition of the Surgical Approach in Two-Lobe Technique

Lasers in Transurethral Enucleation of the Prostate-Do We Really Need Them

The acronym EEP, coding for transurethral Endoscopic Enucleation of the Prostate, was introduced in 2016 by the European Association of Urology (EAU) guidelines panel on management of non-neurogenic male lower urinary tract symptoms (LUTS) and benign prostatic obstruction (BPO). Since then, a laser-based treatment, Holmium Laser Enucleation of the Prostate (HoLEP), and the current-based treatment of bipolar enucleation of the prostate (BipoLEP) are equally appreciated as valuable options for the management of benign prostatic obstruction (BPO). This was mainly inspired by the results of two meta-analyses on randomized controlled trials, comparing open prostatectomy with either Holmium Laser Enucleation of the Prostate (HoLEP) or bipolar enucleation of the prostate (BipoLEP). Prior to that, HoLEP was embraced as the only valid option for transurethral enucleation, although evidence for equivalence existed as early as 2006, but was not recognized due to a plethora of acronyms for bipolar energy-based treatments and practiced HoLEP-centrism. On the other hand, the academic discourse focused on different (other) laser approaches that came up, led by Thulium:Yttrium-Aluminum-Garnet (Tm:YAG) Vapoenucleation (ThuVEP) in 2009 and, finally, transurethral anatomical enucleation with Tm:YAG support (thulium laser enucleation of the prostate, ThuLEP) in 2010. Initially, the discourse on lasers focused on the different properties of lasers rather than technique or surgical anatomy, respectively. In and after 2016, the discussion ultimately moved towards surgical technique and accepting anatomical preparation as the common of all EEP techniques (AEEP). Since then, the unspoken question has been raised, whether lasers are still necessary to perform EEP in light of existing evidence, given the total cost of ownership (TCO) for these generators. This article weighs the current evidence and comes to the conclusion that no evidence of superiority of one modality over another exists with regard to any endpoint. Therefore, in the sense of critical importance, AEEP can be safely and effectively performed without laser technologies and without compromise.

Transurethral anatomical enucleation of the prostate with Tm:YAG support (ThuLEP): Evolution and variations of the technique. The inventors' perspective

After its introduction, transurethral anatomical enucleation of the prostate with Tm:YAG support (ThuLEP) has evolved as one of the standard techniques of transurethral anatomical endoscopic enucleations of the prostate. Growing evidence has proven ThuLEP as an alternative for the treatment of bladder outlet obstruction caused by benign prostatic enlargement and has been acknowledged by the EAU Guidelines on Management of Non-Neurogenic Male Lower Urinary Tract Symptoms, incl. Benign Prostatic Obstruction. The uniqueness of ThuLEP as a concept made it a blueprint for other laser and nonlaser enucleating techniques based on the emphasis on two principles: widely blunt anatomical dissection and demystification of energy sources as being secondary for transurethral enucleation. The original technique has been technically refined by the inventor and other working groups in the field. The evolutionary modifications followed the academic discourse on anatomical enucleation for measures to prevent early postoperative stress urinary incontinence and preservation of antegrade ejaculation. Variations of the original three-lobe dissection technique were introduced with two-lobe approach or en bloc dissection. The manuscript is accompanied by an instructional video and surgical atlas on the currently most commonly applied two-lobe technique.

[Endoscopic enucleation of the prostate]

The spectrum of surgical procedures for the minimally invasive treatment of benign prostatic hyperplasia (BPH) has significantly increased over the last two decades. The simple suprapubic prostatectomy (subtotal prostatectomy, SP) has largely lost relevance in current practice. On the other hand, transurethral resection of the prostate (TURP) has been further standardized and potentially made safer by the introduction of the bipolar technique and low-pressure systems.Transurethral (endoscopic) enucleation techniques (endoscopic enucleation of the prostate, EEP) are increasingly competing with the current gold standard TURP and are replacing SP for treatment of larger adenomas. This approach is especially related to the rapid development of laser technology, which has sustainably changed the face of modern BPH treatment in a similar way to stone therapy. This has been incorporated in the clinical patient management, clinical studies and standardization of numerous surgical techniques that are systematically described in this article. Additionally, efforts have also been made to use other energy sources, such as bipolar current in EEP. With respect to scientific objectivity, high-quality clinical trials are regularly published which further strengthen the position of EEP.

Anatomical Control of Adenoma Technique: An Accurate Surgical Approach to Thulium Laser Enucleation of the Prostate

OBJECTIVE

To present our 2-lobe technique of thulium laser transurethral enucleation of the prostate. Transurethral resection of prostate and open prostatectomy have been traditionally considered as the gold standard for benign prostatic enlargement surgical treatment. Laser has been recently made available for benign prostatic enlargement surgery to minimize morbidity of traditional surgery.¹ In 2009, Bach et al introduced the use of thulium laser,² describing the 3-lobe technique, which overlaps open prostatectomy but with a greater control of hemostasis.³ Two techniques have been recently published that differ from the original one.^4,5 Kim et al described the "All-in-One" technique,⁴ whereas Wolters et al described a 2-lobe enucleation (left lobe first, then combined enucleation of the right and median lobe).⁵ We developed a different en block enucleation technique.

METHODS

In our 2-lobe enucleation technique, the median lobe is enucleated first, whereas the lateral lobes are dissected and enucleated en bloc. Once the medial lobe is moved into the bladder lumen, the dissection is carried out at 4-o'clock position toward the bladder neck, enucleating the left lobe in an anticlockwise direction. At 12-o'clock position, dissection keeps going beneath the right lobe toward the 9-o'clock position. At this point, an incision is made at 8-o'clock position and enucleation is completed in a clockwise direction toward the 9-o'clock position. The 2 enucleated tissues are finally morcellated.

RESULTS

Preoperative prostate volume was 55 cc. Operative time was 36 minutes. The decrease in hemoglobin was 1.1 g/dL 24 hours after surgery. Catheter was removed in first postoperative day and the patient was discharged home. Removed tissue weighed 45 g and showed <5% Gleason score 3 + 3 adenocarcinoma.

CONCLUSION

Our enucleation technique may offer perioperative outcomes comparable with other approaches in medium-sized prostates (up to 100 mL), and we believe that is helpful in following correctly the surgical capsule plane. This technique speeds up the procedure and helps to leave no tissue behind.