Introduction

Preoperative Preparation and Planning

Before a patient undergoes laser treatment of BPH, it is imperative to determine that the patient is an appropriate candidate, with evidence of lower urinary tract symptoms (LUTS) secondary to bladder outlet obstruction from BPH. In 2010, the American Urological Association (AUA) provided specific guidelines for the management of men with BPH. If initial evaluation includes findings of an abnormal digital rectal examination (DRE) concerning for prostate cancer, hematuria, abnormal prostate-specific antigen (PSA) levels, predominantly irritative LUTS or primarily bothered by nocturia, recurrent infections, palpable bladder, history or risk for urethral stricture, or neurologic issues, the patient should undergo additional testing as indicated before treating BPH. Additional testing, including a voiding diary, serum creatinine to assess renal function, urine culture, urine cytology, cystoscopy, and imaging studies to assess prostate size, as well as other pathology such as bladder stones and hydronephrosis, uroflowmetry, postvoid residual, or urodynamic testing should be performed as clinically indicated.

Management options for men with LUTS secondary to BPH include watchful waiting, medical therapy, indwelling Foley catheter, suprapubic tube, or clean intermittent catheterization for those with urinary retention and surgery. The AUA symptom index (AUASI) has seven symptom questions and one quality of life question. The AUASI is used to categorize men with BPH into groups based on severity of symptoms. Watchful waiting is preferred for the management of patients with mild symptoms (AUASI score <8) and patients with moderate or severe symptoms (AUASI score ≥8) who are not bothered by their LUTS and have not developed complications of BPH such as renal insufficiency, urinary retention, recurrent urinary tract infections (UTIs), or bladder stones.

Interventional therapy should be discussed for men with moderate (AUASI 8–19) or severe symptoms (AUASI >19) or significant bother with sufficient evidence of prostatic obstruction. Additional testing with uroflowmetry, postvoid residual, cystoscopy, urodynamics, or imaging of the bladder and kidneys can be performed as indicated to confirm prostatic obstruction. Options for interventional therapy include medical management; minimally invasive therapies such as transurethral needle ablation and transurethral microwave therapy; and surgical options, including transurethral modalities such as incision of the prostate, resection, coagulation, vaporization, and enucleation of the prostate, as well as more invasive options such as laparoscopic or robotic or open simple prostatectomy. Newer surgical interventions for BPH including prostatic urethral lift and prostatic artery embolization are also available but are lacking long-term data. Although many men may pursue surgical intervention only after medical therapy has failed, this is not a requirement because some men may wish to pursue definitive treatment if they are significantly bothered by their symptoms. AUA guidelines recommend surgery over medical therapy for patients with complications of BPH, including bladder stones, renal insufficiency, urinary retention, recurrent infections, or gross hematuria secondary to BPH.

If surgical intervention is elected, the choice of approach should be based on the patient’s presentation, anatomy, surgeon experience and comfort level with each technique, and a discussion of the risks and benefits of each. Although TUIP should only be offered to men with small (≤30 mL) prostates and simple prostatectomy should only be considered for men with large (≥80 mL) prostates, laser enucleation of the prostate can treat both large and small prostates. Laser vaporization of the prostate has also been used to treat prostates of all sizes, though a staged approach may be required for very large prostates. Imaging to assess the size of the prostate is helpful in determining the optimal treatment approach and estimating the duration of the procedure.

Risks of outlet procedures performed using laser technology should be discussed preoperatively. These include bleeding, need for transfusion, infection, retrograde ejaculation, persistent urinary symptoms, dysuria, urinary incontinence, erectile dysfunction, bladder neck contracture, urethral stricture, injury to the bladder or ureteral orifices, or injuries related to positioning. In the case of laser enucleation in which morcellated prostate tissue is sent for pathological analysis, the patient should also be counseled regarding the risk of finding incidental prostate cancer, which has been reported to be 5.7% to 11.7%. Additional risks of surgery not specific to transurethral prostate surgery include deep vein thrombosis and pulmonary embolism, myocardial infarction, stroke, pneumonia, and even death. Removal of obstructive prostatic tissue with lasers is always performed with normal saline, so men are not at risk for TUR (transurethral resection) syndrome (severe hyponatremia).

After the workup has been performed confirming bladder outlet obstruction secondary to BPH and the patient elects laser treatment, counseling on the postoperative course is necessary so expectations can be managed appropriately. For men electing to undergo greenlight vaporization of the prostate, most will generally go home on the day of surgery and return to the clinic within several days for a voiding trial if a catheter is placed at the end of the procedure. Many will experience irritative LUTS that should gradually improve.

Men undergoing HoLEP stay in the hospital overnight. A voiding trial may be performed on the first postoperative day based on clinical judgment. Some patients may experience mild stress incontinence in the early postoperative period and should be taught how to perform Kegel exercises. Men with very large prostates may require cystotomy or perineal urethrostomy to facilitate HoLEP, which should be discussed preoperatively, as well as the need for an indwelling catheter for 1 to 2 weeks if cystotomy or urethrostomy is performed.

Before surgery, a urine culture should be sent and the patient treated with culture specific antibiotics as indicated. The AUA Best Practice Policy Statement on Urologic Surgery Antimicrobial Prophylaxis (2008) recommends less than 24-hour antibiotic prophylaxis for patients undergoing transurethral surgery on the prostate. Antibiotic prophylaxis should be extended beyond 24 hours if a catheter was present before the procedure, placed at the time of the procedure or for bacteriuria. Recommended antibiotic regimens by the AUA include but are not limited to fluoroquinolones, trimethoprim–sulfamethoxazole, gentamicin and ampicillin, first- or second-generation cephalosporins, or amoxicillin–clavulanate.

A basic metabolic panel, complete blood count to assess preoperative hematocrit and platelet count, an international normalized ratio and partial thromboplastin time to assess for coagulopathy, and type and screen should be sent before the procedure. If the patient is taking antithrombotic therapy, the timing and risks of stopping these medications in the perioperative period should be discussed with the patient and his medical provider. Although studies have shown that laser ablation and enucleation of the prostate can be performed safely while taking these medications, it is still preferable to stop antithrombotic therapy if it is medically safe.

Patient Positioning

For transurethral surgery of the prostate, patients are placed in the dorsal lithotomy position. After anesthesia is administered, the patient is positioned on the operative table so that his buttocks are at the edge of the lower table break. Adequate padding should be placed under the sacrum because pressure to this area increases when the legs are placed in stirrups. The arms are generally secured on padded arm boards at an angle of less than 90 degrees. Tucking the arms at the patient’s side can put the fingers and hands at risk for injury from raising or lowering the lower portion of the bed or from the stirrups. The legs are elevated simultaneously when placing them in stirrups to avoid dislocation of the hips and rotational stress of the lumbar spine. The hips are flexed 80 to 100 degrees and abducted 30 to 45 degrees from the midline. A more exaggerated lithotomy position (flexion >90 degrees) is sometimes necessary to allow manipulation of the scope during the procedure. The weight of the leg should be placed on the foot or heel and not on the calf muscles. Prolonged pressure on the calf muscles can result in compartment syndrome of the lower leg. Additionally, pressure over the lateral portion of the knee should be avoided because compression of the common peroneal nerve, which runs over the fibula in this location, can result in a nerve palsy and foot drop.