V02-01: Ultrasound-guided morcellation during difficult Holmium Laser Enucleation of the Prostate (HoLEP)
Holmium Laser Enucleation of the Prostate (HoLEP) has emerged as a standard of care in the treatment of benign prostatic hyperplasia (BPH). This operation entails two distinct parts - laser enucleation of the adenoma from the surrounding prostatic capsule followed by morcellation of this enucleated prostate from within the distended bladder. HoLEP is associated with a steep learning curve and multiple studies have reported bladder injury sustained during the morcellation portion of the operation as a potential catastrophic complication, occurring in up to 6% of cases. The risk of this complication increases when there is poor intravesical visualization due to either a bloody field or poor optics. The aim of this study is to report the novel use of bladder ultrasound during morcellation to assist with safe completion of HoLEP.
Enucleation is performed using a 26-French continuous flow scope, off-set laser bridge with a laser stabilization catheter, and a 550μm holmium laser fiber. Once the median, left, and right lateral lobes have been enucleated, the outer sheath is removed and the nephroscope is inserted to facilitate morcellation. Under dual inflow irrigation, the Piranha morcellator (Richard Wolf, Knittlingen, Germany) is then introduced and set to the manufacturer’s recommended settings of 1,500 rpm. A 3.5-MHz convex abdominal ultrasound transducer (Hitachi Prosound Alpha 7; Hitachi Aloka Medical America, Wallingford, CT) under B-mode is used to visualize the bladder, predominantly in the sagittal orientation. Morcellation proceeds under simultaneous ultrasound and direct cystoscopic guidance.
The distended bladder is visualized concurrently with the ultrasound console and via the nephroscope as the Piranha engages the adenoma and begins morcellation. Once the adenoma is engaged, the operator then drops their hands to place the morcellator in the center of the bladder. Ultrasound provides real-time confirmatory feedback and serves as an additional guide as to the location of the morcellator in relation to the adenoma and bladder.
Here we demonstrate the use of intraoperative bladder ultrasound as a visual aid to assist during the morcellation portion of HoLEP. This proof of concept demonstrates that ultrasound can be an additional tool to utilize during difficult cases when cystoscopic visualization during morcellation is relatively limited. This can be important for urologists early in their learning curve, as this secondary verification facilitates safer morcellation in completing this challenging operation.