Technical aspects of holmium laser enucleation of the prostate for benign prostatic hyperplasia

Clinical outcomes of holmium laser enucleation of the prostate: A large prospective registry-based patient cohort study under regular follow-up protocol

PURPOSE

To evaluate the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) in a large prospective cohort of patients with benign prostatic hyperplasia (BPH) through systematic follow-up at a single institution.

MATERIALS AND METHODS

Clinical outcomes were analyzed between August 2008 and June 2022. Patients were followed-up at 2 weeks, 3 months and 6 months postoperatively.

RESULTS

A total of 3,000 patients (mean age, 69.6±7.7 years) underwent HoLEP. Baseline total International Prostate Symptom Score (IPSS) was 19.3±7.7 and maximum flow rate (Qmax) was 9.4±4.8 mL/s. Mean total prostate volume was 67.7±3.4 mL. Total operation time was 60.7±31.5 minutes, and catheterization time was 1.0 days (range, 1.0-1.0 days). At 6 months postoperatively, the total IPSS decreased to 6.6±5.8 and Qmax increased to 22.2±11.3 mL/s. Complications at 6 months postoperatively included stress urinary incontinence (SUI) in 36 patients (1.9%), urgency urinary incontinence (UUI) in 25 (1.3%), bladder neck contracture (BNC) requiring transurethral incision (TUI) in 16 (0.5%), and urethral stricture in 29 (1.0%). Eleven patients (0.4%) with prostatic fossa stones required stone removal. Sixty-one patients (2.0%) required secondary surgery (transurethral coagulation, 16 [0.5%]; TUI for BNC, 16 [0.5%]; stone removal for prostatic fossa stones, 11 [0.4%]; and endoscopic internal urethrotomy for urethral stricture, 18 [0.6%]).

CONCLUSIONS

Mid-term follow-up results after HoLEP in BPH patients showed excellent efficacy and low complication rates. Unlike previous reports, the incidence of SUI and UUI after HoLEP was low, but the occurrence of de novo stone formation in prostatic fossa was notable.

Effect of detrusor underactivity on surgical outcomes of holmium laser enucleation of the prostate

OBJECTIVE

To evaluate the effect of detrusor underactivity (DUA) on the postoperative outcomes of holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Patients with BPH who underwent HoLEP between January 2018 and December 2022 were enrolled in this prospective database study. Patients were divided into DUA (bladder contractility index [BCI] <100) and non-DUA (BCI ≥100) groups. Objective (maximum urinary flow rate [Qmax], post-void residual urine volume [PVR]) and subjective outcomes (International Prostate Symptom Score [IPSS], Overactive Bladder Symptom Score [OABSS], satisfaction with treatment question [STQ], overall response assessment [ORA], and willingness to undergo surgery question [WUSQ]) were compared between the two groups before surgery, and at 3 and 6 months after HoLEP.

RESULTS

A total of 689 patients, with a mean (standard deviation [SD]) age of 69.8 (7.1) years, were enrolled. The mean (SD) BCI in the non-DUA (325 [47.2%]) and DUA (364 [52.8%]) groups was 123.4 (21.4) and 78.6 (14.2), respectively. Both objective (Qmax and PVR) and subjective (IPSS, IPSS-quality of life, and OABSS) outcomes after surgery significantly improved in both groups. The Qmax was lower in the DUA than in the non-DUA group postoperatively. At 6 months postoperatively, the total IPSS was higher in the DUA than in the non-DUA group. There were no significant differences in surgical complications between the two groups. Responses to the STQ, ORA, and WUSQ at 6 months postoperatively demonstrated that the patients were satisfied with the surgery (90.5% in the DUA group; 95.2% in the non-DUA group), their symptoms improved with surgery (95.9% in the DUA group; 100.0% in the non-DUA group), and they were willing to undergo surgery again (95.9% in the DUA group; 97.9% in the non-DUA group). There were no significant differences in the responses to the STQ and WUSQ between the two groups.

CONCLUSION

Our midterm results demonstrated that patients with BPH and DUA showed minimal differences in clinical outcomes after HoLEP compared to those without DUA. The overall satisfaction was high in the DUA group.

Effect of Self-Training Using Virtual Reality Head-Mounted Display Simulator on the Acquisition of Holmium Laser Enucleation of the Prostate Surgical Skills

PURPOSE

We aimed to evaluate the effect of self-training using a virtual reality head-mounted display simulator on the acquisition of surgical skills for holmium laser enucleation surgery.

METHODS

Thirteen medical students without surgical skills for holmium laser enucleation of the prostate were trained using multimedia to learn the technique via simulator manipulation. Thereafter, participants performed the technique on a virtual benign prostatic hyperplasia model A (test A). After a 1-week wash-out period, they underwent self-training using a simulator and performed the technique on model B (test B). Subsequently, participants were asked to respond to Training Satisfaction Questions. Video footage of hand movements and endoscope view were recorded during tests A and B for later review by 2 expert surgeons. A 20-step Assessment Checklist, 6-domain Global Rating Scale, and a Pass Rating were used to compare performance on tests A and B.

RESULTS

Thirteen participants completed both tests A and B. The 20-step Assessment Checklist and 6-domain Global Rating Scale evaluation results showed significantly improved scores in test B than in test A (P<0.05). No evaluator rated participants as passed after test A, but 11 participants (84.6%) passed after test B. Ten participants (76.9%) indicated that the simulator was helpful in acquiring surgical skills for holmium laser enucleation of the prostate.

CONCLUSION

The virtual reality head-mounted display holmium laser enucleation of the prostate simulator was effective for surgical skill training. This simulator may help to shorten the learning curve of this technique in real clinical practice in the future.

Efficacy and safety of low power holmium laser enucleation of the prostate: A prospective short- and medium-term single-blind randomized trial

PURPOSE

We evaluated the efficacy and safety of mid-term follow-up in low-power (LP) Holmium laser enucleation of the prostate (HoLEP) compared with high-power (HP) surgery for benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

This prospective, single-blind, randomized controlled study was conducted between September 2020 and April 2021. Ninety male patients >50 years who underwent HoLEP for BPH were randomly assigned to HP (80 W/2 J/40 Hz) and LP (24 W/2 J/12 Hz) groups. The primary endpoint was the total International Prostate Symptom Score (IPSS) six months after surgery. The secondary endpoints were perioperative results and postoperative outcomes at two weeks, three and six months after the surgery, including Clavien-Dindo complication classification.

RESULTS

At six months after HoLEP, 41 and 42 patients were followed up in the HP and LP groups, respectively. There was no difference in the preoperative characteristics between the two groups. The prostate volumes were 67.1±23.7 mL for the HP group and 64.3±25.7 mL for the LP group (p=0.592), respectively. Although the total operative time was significantly longer by 13.1 minutes in the LP group (47.8±20.3 min vs. 60.9±23.3 min, p=0.006), the total delivered energy was significantly lower, which was only about 68% of the HP group (58.2±23.9 kJ vs. 39.9±13.2 kJ, p<0.001). Surgical outcomes significantly improved postoperatively in both groups compared to baseline, except for storage symptoms. Improvement in IPSS storage subscore was observed from the immediate postoperative 2 weeks in the LP group (8.1±3.1 to 6.9±3.8, p<0.001), whereas there was no significant recovery in the HP group (8.0±3.2 to 7.7±3.4, p=0.842). In the 6-month follow, there was no significant difference between the two groups in the IPSS total score (5.9±5.6 vs. 7.3±5.3, p=0.260) as well as IPSS storage subscore. In addition, there was no significant difference in postoperative complications, including bleeding or urinary incontinence, between the two groups.

CONCLUSIONS

The HoLEP procedure performed using an LP laser device resulted in lower total delivered energy, faster recovery, and significantly improved surgical outcomes up to mid-term follow-up. There was no difference in efficiency or safety between the HP device system.

Risk Factors of Salvage Procedure for Refractory Morcellation During Holmium Laser Enucleation of the Prostate

PURPOSE

We aimed to identify the risk factors for salvage procedure (SP) required for refractory adenomatous tissue resistant to morcellation during holmium laser enucleation of the prostate (HoLEP).

METHODS

Patients who underwent HoLEP between January 2010 and April 2020 at Seoul National University Hospital were analyzed. SPs were defined as cases of conversion to resection of the prostatic tissue using an electrosurgical loop after morcellation or secondary morcellation a few days after surgery or conversion to open cystotomy.

RESULTS

Among a total of 2,427 patients, 260 were identified as having SP (SP group) (transurethral resection-nodule [n = 250, 96.1%], secondary morcellation a few days after surgery [n = 9, 3.5%], and conversion to open cystotomy [n = 1, 0.4%]). Patients in the SP group were older and had higher 5-α reductase inhibitors use, higher prostate-specific antigen, larger total prostate volume, and larger transition zone volume (TZV) than those in the non-SP group. In the multivariable logistic regression analysis, only age and TZV were associated with SP. Compared to 40s and 50s, the odds ratios (ORs) were 3.84 in 60s (95% confidence interval [CI] 1.37-10.78, P = 0.011), 4.53 in 70s (95% CI, 1.62-12.62, P = 0.004), and 6.59 in 80s or older (95% CI, 2.23-19.46, P = 0.001). The ORs of the SP were analyzed per TZV quartile. Compared to TZV ≤ 20.3 mL, the OR was 3.75 in 32.0 mL < TZV ≤ 50.4 mL (95% CI, 2.00-7.04, P < 0.001) and 8.25 in 50.4 mL < TZV (95% CI, 4.06-16.77, P < 0.001).

CONCLUSION

The risk of refractory morcellation increased in patients aged > 60 years or those with TZV > 32 mL. In order to more efficiently remove these resistant adenomas, it is necessary to develop more efficient morcellators in the future.

Comparison of Emergency Room Visits and Rehospitalization for Bleeding Complications following Transurethral Procedures for the Treatment of Benign Prostatic Hyperplasia: A Population-Based Retrospective Cohort Study

Background: The postoperative bleeding complications associated with laser surgery of the prostate and transurethral resection of the prostate (TURP) were compared. Methods: We used the Taiwan National Health Insurance Research Database to conduct an observational population-based cohort study. All eligible patients who received transurethral procedures between January 2015 and September 2018 were enrolled. Patients who received laser surgery or TURP were matched at a ratio of 1:1 by using propensity score matching, and the association of these procedures with bleeding events was evaluated. Results: A total of 3302 patients who underwent elective transurethral procedures were included. The multivariable Cox regression analysis revealed that diode laser enucleation of the prostate (DiLEP) resulted in significantly higher emergency room risks within 90 days after surgery due to clot retention than the Monopolar transurethral resection of the prostate (M-TURP) (Hazard Ratio: 1.52; 95% Confidence Interval [CI], 1.06–2.16, p = 0.022). Moreover, GreenLight photovaporization of the prostate (PVP) (0.61; 95% CI, 0.38–1.00 p = 0.050) and thulium laser vaporesection of the prostate (ThuVARP) (0.67; 95% CI, 0.47–0.95, p = 0.024) resulted in significantly fewer rehospitalization due to clot retention than did M-TURP. No significant increase in blood clots were observed in patients using comedications and those with different demographic characteristics and comorbidities. Conclusions: Among the investigated six transurethral procedures for Benign prostatic hyperplasia, PVP and ThuVARP were safer than M-TURP because bleeding events and clot retention were less likely to occur, even in patients receiving anticoagulant or antiplatelet therapy. However, DiLEP and holmium laser enucleation of the prostate (HoLEP) did not result in fewer bleeding events than M-TURP.

Bipolar Transurethral Enucleation of the Prostate: Is it a size-independent endoscopic treatment option for symptomatic benign prostatic hyperplasia?

Background

Bipolar Transurethral Enucleation of the Prostate (B-TUEP) is recommended as a first-choice treatment for benign prostatic obstruction in prostates >80 ml. Differently, B-TUEP is only considered as an alternative option after TURP for smaller prostates (30–80 ml). The aim of our study is to assess the relation between prostate size and surgical outcomes after B-TUEP.

Methods

We performed a retrospective analysis of data collected from 172 patients submitted to B-TUEP. Patients were segregated according to tertiles of prostate volume (PV) (≤60 ml, 61–110 ml, >110 ml). For each group we evaluated enucleation efficacy (enucleated weight/enucleation time), complication rates, urinary and sexual function parameters. Functional and sexual parameters were compared between groups at baseline, 1 and 3 months follow up. Descriptive statistics and linear and logistic regression models tested the association between PV and postoperative complications/outcomes.

Results

Operative time and weight of enucleated adenomas increased along with prostate volumes (all p≤0.01). Enucleation efficacy was higher in men with PV >110 ml compared to other groups (p≤0.001). Length of hospital stay, catheterization time and rates of postoperative complications, such as transfusion and clot evacuation rates and bladder neck/urethral strictures, were comparable between groups. Urinary symptoms improved at 1-and 3-months in each group as compared to baseline evaluation (all p<0.01) but they did not differ according to PV. In each group maximum urinary flow and post-void residual volume significantly improved at 3 months compared to baseline (all p≤0.01), without differences according to PV. Sexual symptoms were similar between groups at each follow up assessment. At multivariable linear and logistic regression analysis, prostate volume was not associated with postoperative functional outcomes and complications. Conversely, patient’s comorbid status and antiplatelet/anticoagulation use were independently associated with postoperative complications.

Conclusion

According to our findings, B-TUEP should be considered a “size independent procedure” as it can provide symptom relief in men with prostates of all sizes with the same efficacy and safety profile.

Is 'Omega Sign' anatomical endoscopic enucleation of the prostate technique reproducible?

We aimed to evaluate the learning curve of the surgically standardised 'Omega Sign' anatomical endoscopic enucleation (AEEP) of the prostate surgery technique for junior surgeons. This study is a retrospective comparison of cases that underwent AEEP by a mentor surgeon and three junior surgeons who have completed their learning curve. A video-based laser enucleation of the prostate assessment tool (LEAT) composed of 8 steps of the technique was used to assess a senior surgeon and junior surgeons' surgical compatibility and consistency. The surgeon who defined Omega Sign technique was determined as group 1, and cases by three junior surgeons were identified as group 2. The end points were to assess the reproducibility and repeatability and operative post-operative outcomes of the technique. 55 patients' videos were rated by five experienced endourologists. There was no significant difference in LEAT scores between the groups among all steps. The most symmetry was found in the 1st and 3rd steps. Inter-rater consistency was also high for each step, with no statistically significant difference between the evaluators. The standardised anatomical 'Omega Sign' technique is reproducible for the junior surgeons. The operative steps can be performed with high consistency, and the functional and perioperative outcomes are comparable with the senior surgeon.

Two-year follow-up after holmium laser enucleation of the prostate and bipolar transurethral resection of the prostate: a prospective randomized study

Background

Different treatment options are available for the management of BPH. Our study aimed to compare the surgical outcomes of a holmium laser enucleation of the prostate (HoLEP) and a bipolar transurethral resection of the prostate (Bipolar-TURP) after 2 years.

Methods

Our prospective randomized study included 114 patients: 55 patients underwent HoLEP procedure and 59 patients underwent bipolar TURP procedure. All patients underwent a complete preoperative assessment and a physical examination. The postoperative follow-up data included Q max and IPSS recordings at 1, 3, 6, 12, and 24 months and PVR urinary volume recordings at 6 and 12 months. Any postoperative complications were also recorded.

Results

There were no statistically significant differences between both groups regarding IPSS and Q max scores at one and 24 months postoperative. Also, there were no statistically significant differences between both groups regarding postoperative PVR at 6 and 12 months. One patient in the HoLEP group developed total incontinence after surgery.

Conclusion

Our study did not show a significant difference between HoLEP and bipolar TURP regarding postoperative Q max and IPSS scores at 24 months of follow-up.

Evaluation of Holmium Laser Enucleation of the Prostate Learning Curves with and without a Structured Training Programme

Background/Aims

To evaluate perioperative parameters, early functional outcomes, and the safety profile of holmium laser enucleation of the prostate learning curves with and without mentoring.

Methods

The learning curves of 2 surgeons of their first 100 consecutive patients treated with holmium laser enucleation of the prostate were retrospectively analyzed. We analyzed demographic parameters, clinical outcomes, adverse events, and the progress during each learning experience.

Results

The only statistically significant differences between the two learning curves were found for operation time (138.2 ± 60.7 vs. 98.2 ± 37.7 min; p < 0.001) in favor of the supervised approach, the total weight of resected prostatic tissue (81.5 ± 50.5 vs. 65.0 ± 6.7 g; p < 0.001) with more tissue removal by the surgeon without guidance, and the perioperative hemoglobin drop (1.9 ± 1.4 vs. 1.1 ± 1.0 g/dl; p < 0.001) in favor of the learning curve with a training programme. In multivariate logistic regression, the time factor was independently associated with a higher drop in hemoglobin levels (OR 1.015; 95% CI 1.000-1.023; p = 0.001). The improvements of clinical outcomes as determined by International Prostate Symptom Score, quality of life, peak urinary flow rate and postvoid residual volume were comparable. After the first 50 procedures the mean operation time significantly improved from 147 to 107.5 minutes for the learning curve without supervision (p < 0.001), whereas the surgical time was consistent throughout the 100 cases with a mentoring programme. The overall incidence of treatment-related adverse events was significantly higher without the training programme (16 vs. 5%; p = 0.008).

Conclusions

Our study clearly showed the benefits of a structured training programme to overcome the steep learning curve.

The "Omega Sign": a novel HoLEP technique that improves continence outcomes after enucleation

PURPOSE

Holmium-laser enucleation of the prostate (HoLEP) has been a promising prostate surgery since its first introduction. Although there are 10 different HoLEP techniques in the literature, stress urinary incontinence (SUI) is common, because surgery is not performed based on the topographic anatomy of the external sphincter. We have developed a new HoLEP method named as the ''Omega Sign technique", which is based on the topographic anatomy of the external sphincter and could provide better continence outcomes by decreasing SUI rates.

MATERIALS AND METHODS

The data of 400 patients who underwent HoLEP by a single surgeon between May 2016 and February 2019 were retrospectively reviewed. The patients were divided into two groups, the first underwent the Gilling's technique (Group 1) and the second the novel ''Omega Sign'' technique (Group 2). Continence status and post-micturition symptoms (PMS) were evaluated according to the standards recommended by the international continence status.

RESULTS

The data of 400 HoLEP procedures between May 2016 and February 2019 were analyzed, comparing Group 1 (n = 200) and Group 2(n = 200). SUI rate was significantly lower in Group 2 at the day of catheter removal and first month (p < 0.005). In addition, urge urinary incontinence (UUI) rate and PMS were significantly lower in Group 2.

CONCLUSIONS

We could demonstrate improved continence results, comparable functional outcomes and equally minimal complications with the standard HoLEP technique. We believe that, the novel 'Omega sign' technique decreases SUI rates and will become standardised and easy to understand, thereby bringing and creating a shorter learning curve.

The Learning Curves for Laser Application in Urology Procedures: Review of the Literature

Introduction: Currently, a laser is a popular technology in urological surgeries. The important laserrelated issue is the time when a surgeon reaches an acceptable level of safety and efficacy using laser technology. Methods: In this review, we aimed to assess the learning curves of three types of surgeries in urology, including photoselective vaporization of the prostate (PVP), holmium laser enucleation of the prostate (HoLEP) and retrograde intra-renal surgeries (RIRSs). Here, we searched Medline, Web of Science, Google Scholar, EMBASE, and Scopus for such keywords as Urology, laser, laser vaporization, prostate, nephrolithiasis, benign prostatic hyperplasia (BPH), and learning curve. Results: We evaluated 14 studies about PVP, 17 about RIRS, and 29 studies about HoLEP. Also, we separately discussed the learning curves of these three kinds of surgeries in detail. Conclusion: All the urologists, even expert surgeons, should attend a formal training course and have a skilled tutor present at their first cases.

Temporal modulation of optical energy for enhanced photothermal hemostasis of intraoperative bleeding during laser treatment

Intraoperative bleeding during laser treatment of benign prostate hyperplasia (BPH) often impedes cystoscopic vision, necessitating the use of conventional hemostatic devices. This study proposes an optical technique to improve the efficacy of photothermal hemostasis of bleeders during laser prostatectomy by temporally modulating a 532 nm laser beam. A perfused porcine kidney model is established to quantitatively investigate various optical pulse patterns and irradiation modes. Thermal simulations demonstrate a high success rate of complete hemostasis achieved by the modulated 532 nm pulse pattern. In comparison to the irradiation modes typically employed for hemostasis, the modulated 532 nm mode exhibits a short coagulation time and minimal thermal injury. ex vivo and in vivo cystoscopic observations validate the clinical feasibility of the proposed optical energy modulation method to regulate intraoperative bleeding.

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.

[Low power seven-step two-lobe holmium laser enucleation of the prostate technique for surgical treatment of benign prostatic hyperplasia]

OBJECTIVE

To evaluate the safety and efficacy of the seven-step two-lobe holmium laser enucleation of the prostate (HoLEP) technique with low power laser device, and to introduce the detailed operating procedures, key points, short-term outcomes of this modified HoLEP technique.

METHODS

From March 2016 to November 2017, 90 patients underwent HoLEP in Peking University Third Hospital. The patients were divided into two groups: high-power group (32 patients) were performed with traditional Gilling's three-lobe enucleation using high power (90 W) laser; Low-power group (58 patients) were performed with seven-step two-lobe enucleation using low power (40 W) laser. The main steps of the low power seven-step two-lobe HoLEP phase included: (1) The identification of the correct plane between adenoma and capsule at 5 and 7 o'clock laterally to the veru montanum; (2) The connection of the bilateral plane by making a adenoma incision at the proximal point of veru montanum; (3) The extension of the dorsal plane under the whole three lobes between adenoma and capsule towards the bladder neck; (4) The separation of the middle lobe from two lateral lobes by making two retrograde incisions separately from apex 5 and 7 o'clock towards the bladder neck; (5) The enucleation of the middle lobe adenoma by extending the dorsal plane through into the bladder; (6) The prevention of the apex mucosa by making a circle incision at the apex of the prostate; (7) The en-bloc enucleation of the two lateral lobe adenomas by extending the lateral and ventral plane between adenoma and capsule from 5 and 7 o'clock to 12 o'clock conjunction and through into the bladder.

RESULTS

The mean patient age was (66.25±5.37) years vs. (68.00±5.18) years; The mean body mass indexes were (24.13±4.06) kg/m² vs. (24.57±3.50) kg/m²; The mean prostate specific antigen values were (3.23±2.47) μg/L vs. (6.00±6.09) μg/L; The average prostatic volumes evaluated by ultrasound was (49.03±20.63) mL vs. (67.55±36.97) mL. There was no significant difference between the two groups. Furthermore, there were no significant differences in terms of perioperative and follow up data, including operative time; enucleation efficiencies; hemoglobin decrease; blood sodium and potassiumthe change postoperatively; catheterization duration and hospital stay; the international prostate symptom scores and quality of life scores pre- and post-operatively. There was 1 transurethral resection of the prostate (TURP) conversion in high-power group and 1 transfusion in low-power group during the operations. The follow-up one month after operation showed no severe stress incontinence in both the groups, whereas 3 cases ejaculatory dysfunctions in high-power group versus 1 case in low-power group were observed; Other surgeryrelated complications included: 2 cases postoperative hemorrhage (Clavien II and Clavien IIIb) in high-power group, 2 cases postoperative temperature more than 38 °C (Clavien I) and 1 case dysuria following catheter removal (Clavien I) in low-power group.

CONCLUSION

Low power laser device can be applied safe and effectively for HoLEP procedure using the seven-step two-lobe HoLEP technique. The outcomes comparable with high power laser HoLEP can be achieved.

Current surgical techniques of enucleation in holmium laser enucleation of the prostate

Holmium laser enucleation of the prostate (HoLEP) has been accepted as the most efficient method of transurethral surgery for benign prostatic hyperplasia. The originally developed three-lobe technique has popularized this surgery; this method is based on three longitudinal incisions, by which the median lobe is removed, and subsequently, both lateral lobes are enucleated. To maintain a consistent surgical plane and to minimize sphincteric damage, the traditional three-lobe technique is continuously being refined and evolving. A few modifications of the original technique have been developed, and several en bloc enucleation methods have been introduced. However, more clinical evidence is required to show the superiority of newer techniques over the original three-lobe technique in terms of efficacy and long-term side effects. To date, none of the newer techniques have been accepted as a standard technique for HoLEP.

Two-year Follow-up in Bipolar Transurethral Enucleation and Resection of the Prostate in Comparison with Bipolar Transurethral Resection of the Prostate in Treatment of Large Prostates. Randomized Controlled Trial

OBJECTIVE

To assess the safety and long-term efficacy of bipolar transurethral enucleation and resection of the prostate (B-TUERP) in the treatment of enlarged prostate in comparison with bipolar transurethral resection of the prostate (B-TURP).

MATERIALS AND METHODS

From June 2015 to March 2019, a total of 240 patients with enlarged prostates of more than 80 gm were randomized into 2 groups, each containing 120 patients. Patients in group A were subjected to B-TUERP while those in group B underwent B-TURP. The perioperative data and postoperative outcomes followed at 1, 6, and 24 months after surgery at which points they were analyzed, and a comparison made between the 2 groups.

RESULTS

There were no significant differences in the preoperative parameters of the 2 groups. Comparing with B-TURP, B-TUERP had longer operative time (105.09 ± 31.08 vs 61.09 ± 29.28 min), more resected prostatic tissue (50.41 ± 13.07 vs41.12 ± 8.91 g) and had less hemoglobin drop (1.5 vs 2g/dL). In addition, indwelling catheter time, postoperative bladder irrigation duration, and hospital stay were significantly shorter in the B-TUERP group than in the B-TURP group. At 24 month after the procedure, patients with B-TUERP achieved better results of International Prostate Symptom Score (6 vs 7 P = .008), quality of life (1 vs 2, P = .243), maximal flow rate (24.9 ± 5.74 vs 20.09 ± 3.27mL/sec, P = .034), post-voiding residual urine volume (18.64 ± 3.28 vs 24.74 ± 4.02 mL, P = .001), and residual prostate volume (18.64 ± 3.28 vs 20.74 ± 4.02 mL, P < .001). On the other hand, there were no significant differences in postoperative complications between both groups.

CONCLUSION

B-TUERP is a more effective modality in the treatment of enlarged prostate compared to B-TURP with almost no variation in safety.

Quality of life after photo-selective vaporization and holmium-laser enucleation of the prostate: 5-year outcomes

This study was aimed to compare serial long-term postoperative changes in quality-of-life (QoL) between photoselective-vaporization (PVP) using 120W-High-Performance-System and holmium-laser-enucleation (HoLEP) in benign-prostatic-hyperplasia (BPH) patients and to identify factors influencing the QoL improvement at the short-term, mid-term and long-term follow-up visits after surgery. We analyzed 1,193 patients with a baseline QoL-index ≥2 who underwent PVP (n = 439) or HoLEP (n = 754). Surgical outcomes were serially compared between the two groups at up to 60-months using the International-Prostatic-Symptom-Score (I-PSS), uroflowmetry, and serum PSA. We used logistic regression analysis to identify predictors of QoL improvement (a reduction in the QoL-index ≥50% compared with baseline) at the short-term (12-months), mid-term (36-months), and long term (60-months) follow-up after surgery. In both groups, the QoL-index was decreased throughout the entire follow-up period compared with that at baseline. There were no significant differences in postoperative changes from the baseline QoL-index between the two groups during the 48-month follow-up, except at 60-months. The degree of improvement in QoL at 60-months after HoLEP was greater than that after PVP. A lower baseline storage-symptom-subscore and a higher bladder-outlet-obstruction-index (BOOI) were independent factors influencing QoL improvement at the short-term. No independent factor influences QoL improvement at the mid- or long-term.

A Novel Technique of Morcellation Using a Pneumovesicum After Holmium Laser Enucleation of the Prostate in Complicated Situations: Our Initial Experience and Tips

Purpose

To describe our initial experience with a novel method of adenoma retrieval using a pneumovesicum (PNV) after Holmium laser enucleation of the prostate (HoLEP).

Methods

From January 2016 to April 2018, a total of 93 consecutive patients treated with HoLEP were enrolled in this study. For tissue morcellation, we used the PNV morcellation technique for an initial series of 21 patients and the conventional technique (Lumenis VersaCut) for a consecutive series of 72 patients. We compared efficiency and safety between the novel technique and the traditional technique. Subgroup analysis was performed to assess the effectiveness of the current technique in the large prostate (>70 mL).

Results

There were significant differences in mean age and prostate volume between the 2 groups. However, there were no significant differences in the baseline characteristics and preoperative parameters in the subgroup analysis of large prostates (>70 mL). The mean morcellation efficiency was higher (8.50±1.94 minutes vs. 1.76±0.45 minutes, P<0.05) and the time of morcellation (7.81±1.25 minutes vs. 34.04±11.14 minutes, P<0.05) was shorter in the PNV group. Moreover, there were no significant differences between groups in hospitalization period (2.62±1.10 days vs. 2.90±1.26 days, P=0.852) and any other postoperative events, including recatheterization, reoperation, clot retention, and urethral stricture (P-value range, 0.194–0.447). In the PNV group, there were some cases of procedure-related complications, including postoperative extravesical leakage (5th case), clot retention (8th case), and recatheterization (9th case).

Conclusions

This method has a higher tissue retrieval efficacy, with the advantage of excellent visibility compared to conventional morcellation. The current method can be applied when a transurethral morcellator is out of order or cannot be used.

Pathological analysis on transurethral enucleation resection of the prostate-related prostate surgical capsule

Introduction

Transurethral enucleation resection of the prostate (TUERP) is one of the most important minimally invasive methods for the treatment of benign prostatic hyperplasia (BPH). There have been many reports on the therapeutic effects of TUERP. However, reports on prostate surgical capsule recognition and pathological analysis are rare.

Aim

To compare the pathological features of the prostate surgical capsule between TUERP and suprapubic open prostatectomy (SOP).

Material and methods

Eighty samples were collected; samples 1–3 were prostate gland tissue, tissue adjacent to the prostate surgical capsule, and prostate surgical capsule tissue, respectively. HE staining was used to analyze the pathological components; the enucleation rate was compared between both groups.

Results

The pathological features of the prostate surgical capsule for both groups were roughly the same: sample 1 was mostly gland, with lesser amounts of smooth muscle and fibrous tissue components; sample 2 was mostly fibrous tissue and a smooth muscle component and a small amount of glandular components, and, closer to the surgical capsule, more fibrous tissue, less glandular component; sample 3 was mainly fibrous tissue, and almost no glandular component; there were the same differences among samples 1–3 in both groups (p < 0.05). The enucleation rate for TUERP and SOP was roughly the same, about 58.2%, and there was no significant difference (p > 0.05).

Conclusions

The prostate surgical capsule in TUERP was similar to SOP, which consisted mainly of smooth muscle and fibrous tissue. Moreover, SOP combined with transurethral resection of the prostate (TURP) can treat BPH for a large volume of prostate (> 100 ml), but its effectiveness and safety need further large-scale clinical trials for confirmation.

Comparison of the efficiency and complications of Lumenis and Wolf morcellators after holmium laser enucleation of the prostate

Introduction:

Holmium laser enucleation of the prostate (HoLEP) is a recognized option for the surgical management of benign prostatic hyperplasia. While the laser parameters and enucleation techniques have been widely studied, the morcellation techniques still remain under-evaluated. The current study evaluates the two commonly used morcellation devices for their in vivo efficiency and patient safety.

Materials and Methods:

A total of 222 patients who underwent HoLEP at two medical centres between January 2011 to December 2013 by a single surgeon were included. Of these 222 patients, the Richard Wolf Piranha Morcellation System, Germany (WM), was used on 140 patients, while on the remaining 82, the Lumenis^® VersaCut™ Morcellator, Yokneam, Israel (LM), was used. These devices were compared for safety parameters such as the incidence of bladder mucosal injury, deep muscle injury, bladder perforation, and bleeding requiring electrocoagulation. The morcellation efficiency (ME) defined as the ratio of the weight of morcellated tissue in grams to the time required for morcellation in minutes was also compared.

Results:

The incidence of bladder mucosal injury, deep muscle injury, and bleeding requiring electrocoagulation was statistically significantly lower for the WM than the LM. None of the patients had a full-thickness bladder perforation with either of the morcellators. The ME was higher for the LM. In eight patients, hard, smooth rounded adenomatous nodules could not be morcellated by the WM and had to be crushed by a stone grasping forceps before morcellation.

Conclusions:

While the LM is a faster morcellator, WM has a better safety profile.

One-year Surgical Outcomes of Complete or Incomplete Enucleation of Prostate by Monopolar Electrocoagulation, Photoselective Vapoenucleation of 120-W GreenLight Laser, and Holmium Laser

OBJECTIVE

To evaluate surgical outcomes of patients who underwent complete or incomplete enucleation technique during a short-term postoperative period.

MATERIALS AND METHODS

Patients having intractable lower urinary tract symptoms/benign prostatic hyperplasia and prostates >30 g with obstructed pattern in the urodynamic examinations were included. They underwent transurethral resection of prostate (TUR-P), 120 W GreenLight laser high power system-photoselective vapoenucleation of prostate (HPS-PVEP), or holmium laser enucleation of prostate (HoLEP). Patients with the size of remnant prostates minus surgical defects <25 g were grouped into the completely enucleated group (group C), and others were grouped into the partially enucleated group (group P).

RESULTS

Mean prostate-specific antigen value was 3.5 ± 4.5 ng/mL, and mean prostate volume was 58.4 ± 31.0 mL. Complete enucleation rates in TUR-P, HPS-PVEP, and HoLEP groups were 39% (37 out of 95), 54.6% (83 out of 152), and 54.4% (31 out of 57), respectively. Complete enucleation rate of the TUR-P was significantly lower than those of the other 2 groups. Compared with group C, group P had lower maximal flow rate, higher bladder outlet obstruction index, and higher overactive bladder symptom scores. Multivariate logistic regression analyses showed that smaller prostate, presence of intravesical prostatic protrusion, HoLEP operation, and surgeons' experience were significant predictors for achieving complete enucleation of prostate. Voiding subscores of group C were significantly higher than those of group P at postoperative 12 months.

CONCLUSION

The performance of HoLEP was superior to other surgical techniques. However, HPS-PVEP with vapoenucleation showed the comparable enucleation rate with that of HoLEP. Complete enucleation was effective in maintaining outcomes of prostate resection, especially voiding subscores.

Laparoscopic Repair of a Vesicosigmoid Fistula Secondary to Holmium Laser Enucleation of the Prostate (HoLEP)

Holmium Laser Enucleation of the Prostate (HoLEP) is a safe and effective treatment option for benign prostatic hyperplasia. However, in some cases, it can lead to life-threatening complications. In particular, morcellation of the resected adenoma may be a very dangerous procedure when performed without clear visualization. We describe the first reported case of a vesicosigmoid fistula secondary to a morcellation injury during HoLEP.

Outcomes of transurethral resection and holmium laser enucleation in more than 60 g of prostate: A prospective randomized study

AIM

Transurethral resection of prostate (TURP) is considered a gold standard surgical procedure. The management of benign prostatic hyperplasia (BPH) has undergone tremendous change in recent years and shifted from open to minimal invasive procedure. With the advancement in technology and skills of surgeons, lasers have been used more liberally, particularly holmium laser. Holmium laser enucleation of prostate (HoLEP) is seen as close rival of TURP. The objective if this study is to observe long- and short-term outcomes of transurethral resection and holmium laser enucleation in the prostate of more than 60 g.

MATERIALS AND METHODS

This prospective randomized study includes 164 patients. Inclusion criteria were age <75 years after failed or poor response to medical therapy, prostatic size >60 g, gross hematuria secondary to BPH, recurrent urinary tract infection, acute urinary retention, postvoid residual >150 ml, and Schafer Grade II or more. BPH associated with neurogenic bladder, stricture urethra, and carcinoma prostate were excluded from the study. Group 1 comprises patients who underwent TURP and Group 2 comprises who underwent HoLEP. Follow-up was done at 1, 3, 6, 12, and 24 months after the surgery.

RESULTS

Data of 144 patients were analyzed. The mean age of patients in TURP and HoLEP group was 66.78 ± 7.81 and 67.70 ± 7.44 years, respectively (P = 0.47), mean prostatic volume was 74.5 ± 12.56 and 75.6 ± 12.84 g, respectively (P = 0.60), operative time was 73.10 ± 10.49 and 89.56 ± 13.81 min, respectively (P = 0.0001). Mean resected tissue was 44.80 ± 9.87 and 48.49 ± 10.87, respectively (P = 0.03). The sexual function did not changed significantly in postoperative follow-up.

CONCLUSION

HoLEP is associated with less blood loss, lower transfusion rates, and a shorter hospital stay. The disadvantage of HoLEP is longer operative time and postoperative dysuria.

Toward Improving Transurethral Prostate Surgery: Development and Initial Experiments with a Prototype Concentric Tube Robotic Platform

INTRODUCTION

Despite the potential clinical advantages of holmium laser enucleation of the prostate (HoLEP), there has been reluctance of the urologic community to adopt the procedure, as a result of a perceived steep learning curve. Thus, we sought to design and develop a transurethral endoscopic robotic platform for HoLEP.

MATERIALS AND METHODS

We developed a novel transurethral, concentric tube robotic platform for HoLEP. We conducted magnetic tracking experiments to compare movements of the end effectors of the robot with those of a rigid endoscope. Additionally, we tested the robot on an HoLEP simulator and with a human cadaveric prostate to assess its ability to maneuver within a small working space.

RESULTS

In the prostate scanning experiment, the area reached by the robot represents a 65% improvement vs the area accessible by a rigid endoscope without tissue deformation. Additionally, the robot performed well within the confines of the prostatic urethra and was able to successfully complete prostate lobe enucleation, on both the HoLEP simulator and with a human cadaveric prostate.

CONCLUSIONS

We have developed a concentric tube robotic platform that is passed through a standard endoscope that is capable of producing complex movements of the end effectors. We have shown that these movements of the concentric tube manipulators are capable of performing tasks that may eventually translate into improved ease of performing HoLEP.

Comparison of Predictive Factors for Postoperative Incontinence of Holmium Laser Enucleation of the Prostate by the Surgeons' Experience During Learning Curve

Purpose:

To detect predictive factors for postoperative incontinence following holmium laser enucleation of the prostate (HoLEP) according to surgeon experience (beginner or experienced) and preoperative clinical data.

Methods:

Of 224 patients, a total of 203 with available data on incontinence were investigated. The potential predictive factors for post-HoLEP incontinence included clinical factors, such as patient age, and preoperative urodynamic study results, including detrusor overactivity (DO). We also classified the surgeons performing the procedure according to their HoLEP experience: beginner (<21 cases) and experienced (≥21 cases).

Results:

Our statistical data showed DO was a significant predictive factor at the super-short period (the next day of catheter removal: odds ratio [OR], 3.375; P=0.000). Additionally, patient age, surgeon mentorship (inverse correlation), and prostate volume were significant predictive factors at the 1-month interval after HoLEP (OR, 1.072; P=0.004; OR, 0.251; P=0.002; and OR, 1.008; P=0.049, respectively). With regards to surgeon experience, DO and preoperative International Prostate Symptom Score (inverse) at the super-short period, and patient age and mentorship (inverse correlation) at the 1-month interval after HoLEP (OR, 3.952; P=0.002; OR, 1.084; P=0.015; and OR,1.084; P=0.015; OR, 0.358; P=0.003, respectively) were significant predictive factors for beginners, and first desire to void (FDV) at 1 month after HoLEP (OR, 1.009; P=0.012) was a significant predictive factor for experienced surgeons in multivariate analysis.

Conclusions:

Preoperative DO, IPSS, patient age, and surgeon mentorship were significant predictive factors of postoperative patient incontinence for beginner surgeons, while FDV was a significant predictive factors for experienced surgeons. These findings should be taken into account by surgeons performing HoLEP to maximize the patient’s quality of life with regards to urinary continence.

Direct Comparison of GreenLight Laser XPS Photoselective Prostate Vaporization and GreenLight Laser En Bloc Enucleation of the Prostate in Enlarged Glands Greater than 80 ml: a Study of 120 Patients

PURPOSE

We compare patient outcomes after 180 W XPS™ GreenLight™ photoselective vaporization of the prostate and GreenLight laser enucleation of the prostate used to surgically manage benign prostatic obstruction.

MATERIALS AND METHODS

Two groups of 60 consecutive patients with enlarged glands (greater than 80 ml) underwent GreenLight laser prostate enucleation or photoselective prostate vaporization (performed by the same surgeon and including the learning curve) and were retrospectively evaluated. Perioperative data from both groups were compared.

RESULTS

The operative time was significantly shorter in the GreenLight laser prostate enucleation group (60 vs 82 minutes, p <0.0001). Complication rates were comparable between the groups. At 2 months the rate of urinary incontinence was significantly higher in the GreenLight laser prostate enucleation group (25% vs 3.4%, p <0.0001) but incontinence rates were similar at 6 months (3.4% vs 0%, p=0.50). At 6 months International Prostate Symptom Score quality of life and post-void residual urine volume had similarly decreased in the 2 groups after the procedure (compared to baseline), whereas the maximum urinary flow rate had greatly improved, significantly favoring the GreenLight laser prostate enucleation group (+78% vs +64%, p <0.0001). Prostate size and prostate specific antigen reductions were significantly higher in the GreenLight laser prostate enucleation group (74% vs 57%, p <0.0001 and 67% vs 40%, respectively, p=0.007). The unplanned hospital readmission rates were similar in both groups (16.7% vs 6.7%, p=0.16).

CONCLUSIONS

Photoselective vaporization of the prostate and GreenLight laser enucleation of the prostate are safe and provide satisfactory short-term functional outcomes in patients with a prostate volume greater than 80 ml. However, the surgical time was longer in the photoselective prostate vaporization group, which also had a higher rate of unplanned hospital readmission, and lower decreases in prostate specific antigen and prostate size.

Multicentre prospective evaluation of the learning curve of holmium laser enucleation of the prostate (HoLEP)

OBJECTIVES

To describe the step-by-step learning curve of the holmium laser enucleation of the prostate (HoLEP) surgical technique.

SUBJECTS/PATIENTS AND METHODS

A prospective, multicentre observational study was conducted, involving surgeons experienced in transurethral resection of the prostate and open prostatectomy but never having performed HoLEP. The main judgment criterion was the ability of the surgeon to perform four consecutive successful procedures, defined by the following: complete enucleation and morcellation within <90 min, without any conversion to standard transurethral resection of the prostate (TURP), with acceptable stress, and with acceptable difficulty (evaluated by Likert scales). Each surgeon included 20 consecutive cases.

RESULTS

Of nine centres, three abandoned HoLEP before the end of the study due to complications, and one was excluded for treating patients off protocol. Only one centre achieved the main judgment criterion of four consecutive successful HoLEP procedures. Overall, the procedures were successfully performed in 43.6% of cases. Reasons for unsuccessful procedures were mainly operative time >90 min (n = 51), followed by conversion to TURP (n = 14), incomplete morcellation (n = 8), significant stress (n = 9), or difficulty (n = 14) during HoLEP. Ignoring operating time, 64% of procedures were successful and four out of five centres did four consecutive successful cases. Of the five centres that completed the study, four chose to continue HoLEP.

CONCLUSION

Even in a prospective training structure, HoLEP has a steep learning curve exceeding 20 cases, with almost half of our centres choosing to abandon or not to continue with the technique. Operating time and difficulty of the enucleation seem the most important problems for a beginner. A more intensely mentored and structured mentorship programme might allow safer adoption of the procedure.

Clinical and Pathological Characteristics of Hard Nodules Resistant to Morcellation During Holmium Laser Enucleation of the Prostate

Purpose:

To identify the clinical and pathological characteristics of hard nodules resistant to morcellation (HNRM) during holmium laser enucleation of the prostate (HoLEP) for benign prostatic hyperplasia (BPH).

Methods:

Between July 2008 and October 2011, 246 patients underwent HoLEP for symptomatic BPH. The first 30 patients were excluded from the analysis due to the learning curve of the procedure. The remaining patients were divided into HNRM (n=29) and non-HNRM groups (n=187), and comparative analysis of the clinical parameters of the two groups was performed. International prostate symptom score analysis and urodynamic studies were performed preoperatively. Histological analysis was performed after hematoxylin and eosin staining and Masson trichrome staining of the HNRM specimens.

Results:

Twenty-nine patients (13.4%) had HNRM. The patients in the HNRM group had significantly higher proportions of advanced age (≥65 years, P=0.029), total prostate volume ≥65 mL (P<0.001), transition zone volume ≥35 mL (P<0.001), serum prostate-specific antigen levels ≥10 ng/mL (P=0.007), and functional urethral length ≥70 mm (P=0.009); larger enucleation weight (P<0.001); longer operation (P=0.001), enucleation (P=0.042), and morcellation times (P<0.001); and higher enucleation ratio (P=0.028) and enucleation efficacy (P=0.001). After adjusting for confounding factors, multivariate logistic regression analysis revealed that age ≥65 years and total prostate volume ≥65 mL were independent risk factors for HNRM. Pathological examination did not reveal any malignant cells, with mainly dense fibrous tissue found in the HNRM.

Conclusions:

HNRM can make morcellation cumbersome and time-consuming, and older patients with larger prostates have a higher incidence of HNRM. However, the histopathology of HNRM revealed mainly fibrotic tissue.

Efficacy and safety of holmium laser enucleation of the prostate for extremely large prostatic adenoma in patients with benign prostatic hyperplasia

Purpose

To evaluate the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) for extremely large prostates.

Materials and Methods

Patients undergoing HoLEP between July 2008 and December 2013 from the Seoul National University Hospital Benign Prostatic Hyperplasia Database Registry were retrospectively analyzed. The patients were divided into three groups according to their total prostate volume (TPV): group A (TPV<100 mL), group B (100 mL≤TPV<200 mL), and group C (TPV≥200 mL); the clinical data of the three groups were compared. All patients were followed up 2 weeks, 3 months, and 6 months after surgery.

Results

A total of 502 patients (group A, 426; group B, 70; group C, 6) with a mean age of 69.0 (standard deviation, ±7.3) years were included in our analysis. The mean prostate volume and prostate-specific antigen level were 68.7±36.9 mL and 4.15±4.24 ng/mL, respectively. The enucleation and morcellation times were longer in group C (p<0.001), and the enucleation efficacy was higher in this group (p<0.001, R²=0.399). Moreover, the mean postoperative catheterization and hospitalization periods were significantly longer in group C (p=0.004 and p=0.011, respectively). However, there were no significant differences between the groups in any other postoperative events, including recatheterization, reoperation, urinary tract infection, clot retention, and bladder neck contracture (p range, 0.516-0.913). One patient in group C experienced recurrence of the urethral stricture.

Conclusions

HoLEP in patients with an extremely large prostate can be performed efficiently and safely.

Transurethral surgical anatomy of the arterial bleeder in the enucleated capsular plane of enlarged prostates during holmium laser enucleation of the prostate

Purpose

To identify the endoscopic vascular anatomy of the prostate during Holmium laser enucleation of the prostate (HoLEP), and analyze the clinical risk factors associated with significant arterial bleeding.

Methods

We identified 107 consecutive patients with benign prostatic hyperplasia who underwent HoLEP between September 2009 and August 2010, performed by a single surgeon (S.J.O.). Two independent reviewers reviewed the surgery video database and completed a prespecified form. The location of bleeding arteries was marked at the level of the bladder neck, proximal prostate, distal prostate, and verumontanum. Arterial bleeding was classified into one of three grades according to bleeding severity (grades 2 and 3 indicate significant bleeding).

Results

The mean prostate volume was 65.1±31.5 mL, and the mean prostate-specific antigen (PSA) level was 3.69±3.58 ng/mL. During the HoLEP procedure, the most common locations of significant bleeders were the 2-5 and 7-10 o'clock positions in the proximal prostate. The average number of bleeding arteries was 12.1±7.9 per procedure, and 1.93±1.20 per 10 mL of prostate volume. Multivariate analysis revealed that prostate volume and serum PSA were significant parameters for estimating the number of bleeding vessels.

Conclusions

During the HoLEP procedure, the most common locations of significant bleeders were the 2-5 and 7-10 o'clock positions in the proximal prostate. Prostate volume was associated with the number of bleeders. A careful approach to the capsular plane of the proximal prostate facilitates early hemostasis during the HoLEP procedure, especially with larger adenomas.

Factors affecting de novo urinary retention after Holmium laser enucleation of the prostate

Objective

Patients can experience urinary retention (UR) after Holmium laser enucleation of the prostate (HoLEP) that requires bladder distension during the procedure. The aim of this retrospective study is to identify factors affecting the UR after HoLEP.

Materials and Methods

336 patients, which underwent HoLEP for a symptomatic benign prostatic hyperplasia between July 2008 and March 2012, were included in this study. Urethral catheters were routinely removed one or two days after surgery. UR was defined as the need for an indwelling catheter placement following a failure to void after catheter removal. Demographic and clinical parameters were compared between the UR (n = 37) and the non-urinary retention (non-UR; n = 299) groups.

Results

The mean age of patients was 68.3 (±6.5) years and the mean operative time was 75.3 (±37.4) min. Thirty seven patients (11.0%) experienced a postoperative UR. UR patients voided catheter free an average of 1.9 (±1.7) days after UR. With regard to the causes of UR, 24 (7.1%) and 13 (3.9%) patients experienced a blood clot-related UR and a non-clot related UR respectively. Using multivariate analysis (p<0.05), we found significant differences between the UR and the non-UR groups with regard to a morcellation efficiency (OR 0.701, 95% CI 0.498–0.988) and a bleeding-related complication, such as, a reoperation for bleeding (OR 0.039, 95% CI 0.004–0.383) or a transfusion (OR 0.144, 95% CI 0.027–0.877). Age, history of diabetes, prostate volume, pre-operative post-void residual, bladder contractility index, learning curve, and operative time were not significantly associated with the UR (p>0.05).

Conclusions

De novo UR after HoLEP was found to be self-limited and it was not related to learning curve, patient age, diabetes, or operative time. Efficient morcellation and careful control of bleeding, which reduces clot formation, decrease the risk of UR after HoLEP.