V8-11: HOLMIUM LASER ENUCLEATION OF THE PROSTATE FOR GLANDS GREATER THAN 200 GRAMS
VideoIntroductions and Objectives
Holmium laser enucleation of the prostate (HoLEP) is a well established technique for surgical management of benign prostatic hyperplasia (BPH). However, enucleation of extremely large prostates requires special considerations and has a separate learning curve. Our objective is to illustrate techniques that can improve the efficiency of the procedure for large glands.
A 69 year old male with BPH presented with urinary retention of 3 months duration despite maximal medical therapy. History is significant for prostate specific antigen (PSA) elevation of 24 ng/mL and multiple prostate biopsies which were negative for malignancy. Transrectal ultrasound volume was estimated to be over 200 grams (g). The patient subsequently underwent HoLEP.
Modifications to the standard HoLEP technique have been developed for management of very large glands. Blunt dissection with the beak of the scope is emphasized. Manipulating the scope over the top of the lobe can be physically challenging. In most cases, the median lobe is incorporated into one of the lateral lobe dissections. This saves time because an additional posterior incision is not required. Only in rare cases where a massive median lobe is present is the median lobe resected separately. Disorientation is a common pitfall encountered when resecting large adenomas and maintaining proper orientation during the dissection is critical. Occasionally, a very large lobe cannot be advanced into the bladder. When this occurs, it is left in place and enucleation of the second lobe is begun. If pushing the second lobe into the bladder is also unsuccessful, morcellation in the prostatic fossa is necessary. After removing a significant volume of tissue, the lobes can be advanced into the bladder where morcellation is completed. Meticulous hemostasis is essential prior to morcellation. In this case, a total of 259 g of benign tissue was enucleated. Enucleation and morcellation times were 100 and 80 minutes, respectively. The Foley catheter was removed the following morning and the patient was discharged.
Our previously reported data show that, while technically challenging, HoLEP can be effectively performed in patients with glands greater than 200 g. In experienced hands, HoLEP is an attractive alternative to open or laparoscopic-based surgical techniques for management of very large adenomas.