V1564: Some techniques to achieve high enucleation efficiency when performing holmium laser enucleation of the prostate
VideoIntroduction and Objectives
Holmium laser enucleation of the prostate (HoLEP) has become an increasingly popular treatment for symptomatic benign prostatic hyperplasia (BPH). HoLEP allows complete removal of the tissue in the transition zone regardless of the prostate size. Despite the advantages of HoLEP, considerable training and a long learning curve is required to master this surgical technique for safe operation. This video introduces our en bloc enucleation technique with lateral median approach to median lobe, which enables a surgeon to perform safer and quicker operation.
Nearly 200 patients underwent HoLEP in our institution since the introduction of this surgical method. The first ten patients were operated with an ordinary technique introduced by Gilling, et al in 1996, which enucleate the lobes separately starting with the median lobe. We had difficulty in enucleating the median lobe and often caused the prostate capsule perforation into retrovesical space near the bladder neck, since the surgical capsule was anatomically very thin and the exfoliation angle was very sharp at that lesion. So we came up with the en bloc enucleation technique with lateral median approach to the median lobe. The procedure consists of following maneuvers: 1) Early encircling mucosal incision at apical adenoma, 2) Lateral approach to bladder neck at upper portion, 3) Lateral to median exfoliation of median lobe at bladder neck, 4) Retrograde exfoliation of hang down adenoma at 12 o’clock position, 5) En bloc downward morcellation of the enucleated adenoma.
Introduction of the technique gave a surgeon clear information on the relation between bladder neck and adenoma to be enucleated. The technique enabled us en bloc enucleation of the prostate adenoma, which helped us to shorten the learning curve when mastering the HoLEP procedure. The daramatic improvement in the efficiency of HoLEP was observed with enucleation efficiency (enucleated gram weight/operation time in minutes) achieving nearly 1.0 gram/minute (figure).
We feel that HoLEP represents a safe and effective treatment for patients with symptomatic BPH and we hope that the presentation of this technique will improve operative times and shorten the learning curve for urologists mastering the HoLEP procedure.