Laser Enucleation of the Prostate (HoLEP)

Fig. 15.1

The 100-W Versapulse holmium laser and Lumenis 120H used to perform HoLEP

The holmium laser energy can be transmitted along flexible quartz fibers of varying diameters, ranging from 100 to 1000 μm. The ability to use multiple-sized fibers allows the holmium laser to be used not only with a cystoscope but also with rigid and flexible ureteroscopes. In general, larger laser fibers such as the 550 or 1000 μm SlimLine end firing (Fig. 15.2) and more recently the 550 μm Moses fiber are generally preferred when performing a HoLEP. Several different companies offer both disposable and reusable quartz laser fibers. The ability to sterilize and reuse the holmium laser fibers up to 20–30 reduces equipment costs of HoLEP unlike other laser surgical technologies [25, 31]. When performing HoLEP, the laser fiber is routinely stripped of its protective cladding (5–6 cm) and placed through a 7 Fr stabilizing catheter (Cook, Spencer, IN). The catheter is secured in place with a Luer-Lok injection port (Baxter, Deerfield, IL). When using a 1000 μm fiber, the tip of the stabilizing catheter needs to be cut to allow the passage of the larger diameter fiber (Fig. 15.3).

../images/312378_2_En_15_Chapter/312378_2_En_15_Fig2_HTML.jpg — Fig. 15.2

The 550 μm (a) and 1000 μm (b) quartz laser fiber used to perform HoLEP

../images/312378_2_En_15_Chapter/312378_2_En_15_Fig3_HTML.png — Fig. 15.3

The disassembled laser scope and protective laser catheter. The device shown is the Storz 28 Fr set consisting of a 28 Fr outer sheath, inner sheath with stabilizing ring, and 30-degree telescope lens. The laser catheter fits through the working element of the scope and is held in place by the stabilizing ring

Two different companies manufacture laser scopes that can be used to perform HoLEP. Olympus (Hamburg, Germany) has a 27 Fr, and Storz (Tuttlingen, Germany) produces a 26 and 28 Fr continuous flow resectoscope with a dedicated inner sheath that incorporates a laser channel (Olympus) and a laser ring (Stortz) to stabilize and centralize the laser fiber during enucleation (see Fig. 15.3). Regardless of the laser scope used to perform HoLEP, a 30-degree lens is necessary to adequately visualize the prostate and laser tip. Due to the extreme hand movements necessary to perform HoLEP, an endoscopic camera with a swivel base is recommended. High definition video systems, such as those provided by Stryker (Kalamazoo, MI) and Olympus (Hamburg, Germany), improve visualization of the surgical plane between true prostate and adenoma, facilitating enucleation and improving HoLEP efficiency. Since HoLEP is a laser-based therapy, normal saline irrigation is used in all cases.

Once enucleation of the prostate has been completed, the tissue must be removed using a tissue morcellator . Prior to the introduction of the tissue morcellator , the inner working elements of the laser scope are removed, leaving only the outer sheath traversing the length of the urethra. An offset long 26 Fr nephroscope with an adapter bridge and a 5 mm working channel is then used to visualize the intravesical tissue morcellation (Fig. 15.4a). There are two commercially available morcellators: the Piranha (Richard Wolf, Knittlingen, Germany) and the Versacut (Lumenis). The morcellator consists of a handpiece with reciprocating blades and controller box with suction pump and is operated by a foot pedal (Fig. 15.4b). Continuous flow irrigation is not utilized during morcellation. A third inflow line is attached to the outflow channel due to the intense suction potential of the morcellator. The Piranha system uses two pedals for suction only and suction/morcellation, whereas the Versacut consolidates the two functions into one pedal with partial depression initiating suction and complete depression causing the morcellator blades to cycle along with suction. Comparison of the two morcellators has demonstrated excellent tissue removal; however, in a comparative trial, the Piranha morcellator was more efficient and had fewer complications compared to the Versacut [32]. After all the tissues are removed, a 22 Fr three way urethral catheter is placed with 60 ml in the balloon for an average of 15 h and in the absence of any complication removed the morning after surgery to initiate a void trial.

../images/312378_2_En_15_Chapter/312378_2_En_15_Fig4_HTML.jpg — Fig. 15.4

(a) The long nephroscope shown here has a 5 mm working channel and a length adapter bridge and permits the passage of the morcellator and grasping forceps. The grasping forceps can be used to remove small fragments rather than morcellating. The Wolf Piranha morcellator is seen between the graspers and nephroscope. (b) The morcellator has a pump suction device that allows for a simultaneous removal of the prostate tissue at time of morcellation

HoLEP: Step by Step

Preoperative Evaluation

Prior to undergoing HoLEP, patients should have an appropriate preoperative evaluation. Though workup may be tailored to the individual patient, this should typically include a patient history, AUA symptom score (or appropriate validated metric), and urinary flow with postvoid residual. Laboratory evaluation, including complete blood count (CBC), electrolytes with creatinine, and serum prostate-specific antigen (PSA), should be obtained. Despite the evidence that HoLEP can be offered to patients with LUTS/BPH independent of gland size, it is recommended that a transrectal ultrasound (TRUS) volume study be obtained in patients without any prior imaging (computed tomography or magnetic resonance imaging). Once a surgeon masters HoLEP, he or she can expect operative times to range from 30–60, 90–120, and more than 120 min for prostate glands less than 80 g, 80–150 g, and greater than 150 g, respectively. In general, patients who have had prior transurethral procedures and/or those with a history or risk factors for urethral stricture should undergo a preoperative cystoscopy prior to surgery. Lastly, if patients suffer from severe urgency, frequency, incontinence or have other neurologic comorbidities, a full urodynamic study can be beneficial in differentiating between significant detrusor instability versus bladder outlet obstruction.

As with any surgical procedure, obtaining informed consent is required. HoLEP has been associated with high rates of transient urinary incontinence (1.3–44%) with persistent incontinence beyond 3 months postoperatively occurring in less than 2–5% of patients [33, 34]. Retrograde ejaculation is noted to range from 80% to 100% of patients, but erectile function is preserved after HoLEP [19]. Though the risk of clinically significant bleeding is less than 1% [4], even in the setting of anticoagulation or bleeding diathesis [17], the possibility of transfusion should be discussed. Morcellation injury can have major ramifications; however, a recent study showed zero morcellation injuries with the Piranha system [35], which was similarly reported by Krambeck et al. in over 1000 HoLEPs where only one morcellation injury requiring an open repair occurred [36].

Operative Preparation

Patients are positioned in the dorsal lithotomy position. Spinal or general anesthesia with a laryngeal mask airway (LMA) or endotracheal tube are appropriate for patients undergoing HoLEP. An LMA with a combination of narcotics, benzodiazepines, and poropofol provides adequate anesthesia with expeditious induction and a gentle emersion after surgery. The urethra is dilated to 30–32 Fr in order to accommodate outer sheath of the continuous flow laser resectoscope. After instilling additional lubricant transurethrally with a Toomey syringe, the outer sheath is introduced with the Timberlake obturator. The laser resectoscope with 7 Fr laser stabilizing catheter is placed through, and attached to, the outer sheath. Several laser fibers, including a 550 or 1000 μm single, reusable, or Moses fiber, are available and fit through the 7 Fr laser guide. The cladding on the laser fibers is routinely stripped back 5–6 cm in anticipation of laser break back because of high-energy usage during HoLEP. The preferred irrigant is normal saline, which enters via Y tubing connecting two 3 l saline bags to the inflow port.

Assessment of Anatomy and Creation of Posterior Plane

Once the resectoscope has been attached securely with the external continuous flow sheath, the anatomy of the patient is assessed. Ideally, the surgeon should take note of variations in the structure of the prostate, such as a large median lobe, a high or tight bladder neck, or a defect from prior BPH surgery. In some instances, the patient’s body habitus or prostate is too large to breach the bladder neck with the resectoscope. In this situation, a perineal urethrostomy can safely be performed prior to HoLEP and closed at the conclusion of the case. These patients should maintain a Foley catheter for 1 week.

Visualizing the ureteral orifices (UO) is good practice but should not prolong the case. Oftentimes the UOs are obscured by the intravesical projection of the prostate, particularly with a large median lobe. Evaluating if the patient has bilobar or trilobar hypertrophy will determine if a single 6 o’clock or a two-cut (5 and 7 o’clock) initial groove will be required. In the situation of a two-cut approach, enucleation of the median lobe should follow after the 5 and 7 o’clock grooves are connected. Removing the median lobe will create more space in the prostatic fossa and better demarcate the surgical capsule, which will expedite the subsequent lateral lobe dissections (Fig. 15.5).

../images/312378_2_En_15_Chapter/312378_2_En_15_Fig5_HTML.jpg — Fig. 15.5

View of the initial posterior incision, starting at the 6 or 5 and 7 o’clock positions, depending on the presence of a median lobe

Standard laser settings during the initial part of a HoLEP are 2 joules (J) and 40 hertz (Hz). The initial groove should be deepened until the capsule is reached, which can be identified most readily by horizontal capsular blood vessels or circular fibers near the bladder neck (Figs. 15.6 and 15.7). This depth near the bladder neck should be familiar to surgeons with experience in ablative procedures of the prostate. Gentle movements with the beak of the scope during the initial incision can widen the initial groove to help identify the capsule. Once the 5 and 7 o’clock grooves are transversely connected, undermining the median lobe should proceed proximally using the beak of the scope to lift the adenoma upward while utilizing the thermal laser energy to release attachments between true prostate and prostate adenoma. The proper plane should demonstrate a cobweb appearance with separation of the adenoma from the prostatic capsule (Fig. 15.8). Once the posterior attachments between the median lobe and the surgical capsule have been released, the median lobe is pushed into the bladder lumen and remains tethered by mucosal tissue at the bladder neck. Separating the adenoma from the bladder neck requires precise lasering near the bladder neck to avoid dissecting up the backside of the median lobe. Tension needs to be applied to the median lobe in order to cut the mucosal attachments. Localizing the UOs during this step is critical as the resectoscope can recoil into the UOs, creating the potential for a laser injury to the ureter.

../images/312378_2_En_15_Chapter/312378_2_En_15_Fig6_HTML.jpg — Fig. 15.6

Circular fibers at the bladder neck, identifying the capsule

../images/312378_2_En_15_Chapter/312378_2_En_15_Fig7_HTML.jpg — Fig. 15.7

The cobweb appearance with separation of the adenoma from the prostatic capsule

../images/312378_2_En_15_Chapter/312378_2_En_15_Fig8_HTML.jpg — Fig. 15.8

The anterior plane of dissection carried from the 10 to 2 o’clock position through the bladder mucosa so that the scope enters the lumen of the bladder. Note the laser fiber and capsule superiorly and the adenoma inferiorly

If the median lobe is small or moderately sized, it does not need to be enucleated separately. A single posterior groove can be made, and any posterior tissue can be enucleated with the lateral lobe tissue.

Enucleation of Lateral Lobes

After enucleation of the median lobe or after the single posterior incision has been completed, attention is then turned to the lateral lobe tissue. The lateral lobes are enucleated individually, beginning at the initial groove just proximal and lateral to the verumontanum. A superficial incision of the mucosa is created by making a short horizontal cut, just enough to allow the entrance of the beak of the scope. The laser energy should then be decreased to 2 J and 20 Hz to minimize potential damage to the external sphincter complex from direct iatrogenic laser injury or thermal injury from heat dispersion. The scope is gently rotated around the apex of the adenoma using a combination of blunt dissection and lasering until the scope is placed in the 2 o’clock position, with capsule residing above the scope and adenoma below. It is important to extend the anterior plane of dissection beyond the midline to facilitate enucleation of the second lobe. Once the anterior plane has been developed away from the sphincter complex, the laser energy is increased to the back to 2 J and 40 Hz. The anterior plane of dissection is then carried toward the bladder neck using the scope to apply downward pressure on the adenoma and the laser to separate any capsule attachments and cauterize any perforating vessels. It is important to maintain a broad plane of dissection from the 10 to 2 o’clock position when advancing the anterior plane toward the bladder neck. Once the vertical bladder neck fibers are incised to reveal the lumen of the bladder, the bladder neck should be formalized before entering back into the true prostatic lumen to incise the anterior commissure (see Fig. 15.8).

The two lobes are divided by repositioning the scope in the prostatic urethra and dividing the anterior commissure at the 12 o’clock position (Fig. 15.9). The incision is carried from the bladder neck to the apex. By incising the anterior commissure, the anterior plane should be visible posteriorly and provide a visual aid to avoid excessive dissection distally that might impact or injure the sphincter complex.