Surgery for Benign Prostatic Obstruction



Surgery for Benign Prostatic Obstruction


MUSAAB YASSIN

SANDIP M. PRASAD

HASHIM HASHIM



Benign prostatic hyperplasia (BPH) is a histologic diagnosis that refers to the proliferation of smooth muscle and epithelial cells within the prostatic transition zone. The precise etiology is unknown (1,2,3). Lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement are thought to result from bladder outlet obstruction (BOO) from the enlarged tissue (static component) and from increased smooth muscle tone and resistance within the enlarged gland (dynamic component). Both of these would results in LUTS secondary to benign prostatic obstruction (BPO). Obstructive voiding symptoms (e.g., hesitancy, slow stream, intermittent stream) have often been attributed to BPO. Overactive bladder symptoms (e.g., frequency, urgency, nocturia) secondary to detrusor overactivity (a urodynamic diagnosis) is thought to be a contributor to the storage symptoms seen in LUTS secondary to BPO (LUTS/BPO) (3).

It has been reported that among 50-year-old men the lifetime incidence of surgical or medical intervention for BPO may be as high as 35% (4). Wasson et al. (5) found that in a 3-year, multicenter, randomized controlled trial (RCT) comparing men with moderate LUTS/BPO treated by either watchful waiting or transurethral resection of the prostate (TURP), 24% of men in the watchful waiting arm eventually underwent surgical intervention.

Although LUTS/BPO is not often a life-threatening condition, its impact on quality of life (QoL) can be significant and should not be underestimated (6). The most important motivations for seeking treatment were the severity and the degree of bother associated with the symptoms. These were also important considerations when assessing BPO and deciding when treatment is indicated (3).

It is necessary as health care professionals to be aware of the complex dynamics and interactions of the bladder, bladder neck, prostate, and urethra and their effect on patients’ symptoms (3). Recently, the treatment was more focused on the alteration of disease progression and prevention of complications that can be associated with LUTS/BPO in addition to the traditional approach of improving bothersome LUTS (7). A variety of conservative and pharmacologic treatments are employed including alpha-adrenergic antagonists (alpha-blockers), 5-alpha-reductase inhibitors (5-ARIs), anticholinergics, and phytotherapeutics (3) before surgical therapy is considered.

Surgical management of BPO has evolved significantly along with changes in medical management. A century ago, open prostatectomy was considered the standard surgical treatment of men with LUTS/BPO requiring removal of the adenoma. Subsequently, TURP was developed and became the first significant “minimally invasive surgical procedure.” More recently, a number of alternative surgical therapies have been introduced to treat men with BPO, most prominently laser-based therapies.




CONSERVATIVE AND MEDICAL THERAPY

Following a thorough history, directed physical examination and assessment, conservative and medical therapy should be the initial treatments of choice. The medical treatment algorithms are described in Figures 30.2 and 30.3 (adopted from the European Association of Urology guidelines) but will not be discussed in this chapter.


INDICATIONS FOR SURGERY

There are certain absolute indications for surgical treatment of LUTS/BPO (Table 30.2). Typically, however, the management of patients depends on the degree of inconvenience they experience from their LUTS. The AUA clinical guidelines on LUTS/BPO recommend that men who experience nonbothersome symptoms of BPO should not be managed surgically. Patients with bothersome symptoms should undergo treatment, and the physician should review the benefits and risks of all approaches and interventions with the patient.


SURGICAL TECHNIQUES

There are several surgical techniques that can be considered for treating voiding LUTS/BPO. They can be divided into the following:



  • Minimally invasive therapy (MIT)


  • Endoscopic transurethral surgical treatments


  • Open surgical procedures


  • Laparoscopic or robot-assisted procedures


  • Investigational procedures


Minimally Invasive Therapy

MIT includes procedures that destroy or denature prostate tissue using a variety of energy sources, injected agents, or physical methods to draw open the prostatic urethra, that is, the procedures that do not lead to the physical removal of prostatic tissue. Laser prostate treatments are not included as they are generally used to remove tissue by ablation, resection, or enucleation (7).

The growing concern over the morbidity associated with treatment for BPO with TURP or open simple prostatectomy was a primary driving force behind the development of MIT approaches. These therapies typically are available for the treatment of patients with bothersome LUTS/BPO. Many of these minimally invasive treatments rely on the administration of high temperatures to produce coagulative necrosis of the prostate tissue. Ultimately, the goal of such hyperthermic treatment is to enlarge the prostatic fossa, similar to a surgical debulking but without the morbidity of surgery. However, these procedures are rarely done even in major North American and European centers.


Transurethral Microwave Thermotherapy

Transurethral microwave thermotherapy (TUMT) heats the prostate using a microwave antennae mounted on a urethral catheter and does not require cystoscopy except for initial measurement of prostatic length. This interventional therapy is effective in partially relieving the symptoms and bother believed secondary to BPO (3). The durability of TUMT treatment appears to have improved with the development of higher energy devices.

Practical Considerations. TUMT is likely more effective than medical therapy in reducing patients’ LUTS, but it is likely less effective than surgical therapy. It is the least operator-dependent of the BPO interventions and predicting responders is difficult and inconsistent (3).

The view that these approaches lack sufficient durability of effect has resulted in a limited role of TUMT in the management of LUTS, despite potential advantages including outpatient capability, lack of sexual side effects, and avoidance of general anesthesia (3).


Transurethral Needle Ablation

Transurethral needle ablation (TUNA) affects prostate tissue by a thermal mechanism, with heat delivered via radiofrequency energy. Radiofrequency ablation (RFA) relies on the effects of passing electric current through tissue. This results in creation of lesions leading to coagulative necrosis. Initially,
RFA was delivered as a monopolar technology in the form of TUNA of the prostate, but bipolar technology was subsequently developed (7).






FIGURE 30.2 Treatment algorithm of male lower urinary tract symptoms (LUTS) using medical and/or conservative treatment options. Treatment decisions depend on results assessed during initial evaluation. Minus (-) indicate the absence and plus (+) the presence of the condition. IPSS, International Prostate Symptom Score; OAB, overactive bladder symptoms. (Reprinted with permission from Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013;64[1]:118-140. Copyright © 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

A TUNA procedure involves cystoscopically placing two needles directly into the prostate by piercing the urethra and then administering radiofrequency energy that heats the prostate tissue to 100°C. As with microwave therapy devices, TUNA induces a coagulative necrosis effect. The efficacy of TUNA is comparable to that of microwave thermotherapy (8).

Practical Considerations. TUNA of the prostate is an appropriate and effective treatment alternative for bothersome moderate or severe LUTS/BPO (3). It is safe with low perioperative complications including bleeding. It has a low to nonexistent rate of sexual dysfunction and is attractive for that alone. Further surgical intervention is more likely to occur with TUNA compared with TURP, although the overall risk for morbidity clearly favors TUNA (3,7,9).


Endoscopic Transurethral Surgical Treatments


Electrosurgery

Transurethral Incision of the Prostate (TUIP) and Monopolar Transurethral Resection of the Prostate (M-TURP). The patient is placed in a dorsal lithotomy position, with the thighs abducted to allow manipulation of the resectoscope. After sterile preparation and draping is completed, the patient’s anterior urethra is calibrated/dilated using Van Buren/Clutton sounds up to 30Fr. It is only necessary to calibrate the anterior urethra; excessive manipulation of the prostatic urethra may result in bleeding, which can make visualization difficult. Proper calibration is essential to reduce the theoretical risk of subsequent fossa navicularis or urethral stricture caused by the resectoscope manipulation, although some data suggest that the use of a urethral catheter postoperatively is the nidus for stricture (10).
A 26Fr or 28Fr resectoscope is then inserted into the urethra. A 3% glycine or sorbitol solution is used for irrigation at gravity pressure. Cutting and coagulation currents should be adjusted to the appropriate levels for the electrical generator used for the case.






FIGURE 30.3 Treatment algorithm of bothersome lower urinary tract symptoms (LUTS) refractory to conservative/medical treatment or in cases of absolute operation indications. Note that this flowchart has been stratified by the patient’s ability to have anesthesia, cardiovascular risk, and prostate size; however, the choice of the surgical techniques also depends on patients’ preferences, willingness to accept surgery-associated side effects, availability of the armamentarium, and surgeon’s experience with the operation technique. HoLEP, holmium laser enucleation of the prostate; HoLRP, holmium laser resection of the prostate; KTP, potassium titanyl phosphate; TUIP, transurethral incision of the prostate; TUMT, transurethral microwave thermotherapy; TUNA, transurethral needle ablation; TURP, transurethral resection of the prostate. (Reprinted with permission from Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013;64[1]:118-140. Copyright © 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

If the prostate volume is small (30 mL or less), the lateral lobes of the prostate are not coapting, there is no median lobe, and there is a high bladder neck, it may be appropriate to proceed with a transurethral incision of the prostate (TUIP), also known as bladder neck incision (BNI), especially in young, sexually active men (7). The bladder should be filled via the continuous-flow resectoscope, and with a TUIP-type electrocautery knife, incisions should be created and deepened until the capsule of the prostate is reached and extended just proximal to the verumontanum. The most popular unilateral incision is located at the 6 o’clock position, although the most commonly performed bilateral incisions are at the 5 and 7 o’clock positions (11).

If the prostate is more than 30 mL, or if there is a median lobe or the lateral lobes are coapting, a TURP is the more appropriate procedure to perform (Table 30.3). Monopolar transurethral resection of the prostate (M-TURP) is performed with an electrocautery loop and glycine or sorbitol irrigation. However, bipolar TURP devices have been developed that permit the resection of prostate tissue in a saline irrigant. If there is a median lobe present, resection should initially begin with this structure to allow the tissue resected later on from the later lobes to flow easily into the bladder. In a stepwise fashion, the median lobe is resected with the electrocautery loop. Resection of the median lobe is complete when bladder neck fibers are visualized. Particularly during the resection of the median lobe, care should be taken to not damage/involve the ureteral orifices in the resection.

Following complete resection of the median lobe of the prostate, attention can be turned to resection of the lateral lobes. There are several methods of doing this, and the surgeon should be comfortable in adapting his or her technique based on the anatomy of the prostate. The authors start resecting the left lobe starting at the 1 o’clock position, creating a trench, and proceeding from the bladder neck to a point just proximal to the verumontanum. This allows the adenoma to fall medially and downward and separates from the capsule. Resection should be carried down to the fibers of the bladder neck and prostatic capsule. The right lobe of the prostate can be resected in a similar
fashion. The surgeon should take care not to resect too deeply and perforate the capsule as well as not to resect beyond (distal to) the verumontanum because that can damage the external urethral sphincter and cause stress urinary incontinence.








TABLE 30.2 INDICATIONS FOR SURGERY









The most frequent indication for surgical management is bothersome voiding LUTS refractory to medical management (12). The following complications of BPO are considered strong indications for surgery:




  • Refractory urinary retention



  • Recurrent urinary infection



  • Recurrent hematuria refractory to medical treatment with 5-alpha reductase inhibitors



  • Renal insufficiency due to BPO



  • Bladder stones


Increased postvoid residual (PVR) volume may also be used as an indication for surgery. However, there is great intraindividual variability and an upper limit requiring intervention has not been defined. Variables most likely to predict the outcome of prostatectomy are severity of LUTS, the degree of bother, and the presence of BPO.


BPO, benign prostatic obstruction; LUTS, lower urinary tract symptom. From Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013;64(1):118-140.


Following complete resection of the lateral lobes, the anterior tissue of the prostate should be inspected. If obstructing tissue is present at this location, it may be resected. The Ellik evacuator can then be used to remove the resected tissue fragments, which should be sent for pathologic analysis. The prostatic fossa should be reinspected because oftentimes open blood vessels are more apparent following Ellik evacuation and additional obstructive adenoma may appear that needs further resecting. Hemostasis should be ensured at the end of the procedure and all prostatic “chips” must be removed from the bladder. If it is difficult to establish hemostasis with the loop electrode, a rolling-ball electrode can be used. A three-way Foley catheter should be placed at the end of the procedure, and the authors use a 22Fr, three-way catheter with a 30-mL balloon. Continuous bladder irrigation with saline is generally necessary overnight; if bleeding persists, the Foley catheter may be placed on gentle and temporary traction.








TABLE 30.3 TRANSURETHRAL INCISION OR RESECTION OF THE PROSTATE







TUIP if:




  • Prostate volume ≤30 mL, high bladder neck, bladder neck stenosis (usually a result of previous TURP), no lateral lobe hypertrophy, no median lobe, usually recommended for young, sexually active men



  • Single incision at 6 o’clock position or bilateral incisions at 5 and 7 o’clock positions from bladder neck to just proximal to verumontanum



  • Deepen to level of prostate capsule


TURP if:




  • Prostate volume >30 mL, coapting lateral lobes, median lobe



  • Resect median lobe, if present, first



  • Resect to bladder neck and capsular fibers



  • Resect lateral lobes in stepwise fashion, from bladder neck to verumontanum



  • Resect anterior tissue if present


Practical considerations. The choice between TURP and TUIP should be primarily based on prostate volume, with prostates 30 mL being mainly considered for TUIP and prostates of 30 to 80 mL for TURP. The advantages of TUIP are reduced bleeding incidents, shorter operation time, avoidance of transurethral resection (TUR) syndrome if using M-TURP, minimal and shorter postoperative bladder irrigation, lower risk of retrograde ejaculation, and shorter times for catheterization and hospitalization. The disadvantages are a higher rate of symptom recurrence and the need for additional surgery (3,11).

Urinary tract infections should be treated prior to TURP or TUIP. Three systematic reviews favored the use of antibiotic prophylaxis which would significantly reduce sepsis and the need for additional antibiotics after TURP. There was also a tendency toward higher efficacy in favor of short antibiotic courses compared to a single dose (11,13,14).

The ideal irrigant fluid for transurethral resection would be minimally conductive to avoid current dissipation from the electrode and to maximize the current at its point of contact with the tissues. Furthermore, the fluid has to be harmless when absorbed in the intravascular space. Such a fluid does not exist.

The types of irrigant fluids commonly used are the following (15):



  • Normal saline (conducts electricity and therefore is not suitable for use with monopolar current): It is the irrigant of choice for diagnostic procedures (including cystoscopy) and for bladder irrigation postoperatively. It is suitable for use with laser resection/vaporization as well as bipolar TURP.


  • Glycine (1.5%) (poor electrical conductor and hence is used for conventional M-TURP electrosurgery): It is relatively hypotonic but not cytolytic and carries a risk of dilutional hyponatremia. Glycine is an amino acid that inhibits neurotransmission in the retina, spinal cord, and midbrain.


  • Water (poor conductor and can be used for M-TURP): It is hypotonic compared with plasma, and there is a risk of dilutional hyponatremia if it is used for prolonged periods of time. In addition, it is cytolytic that has the disadvantage of causing hemolysis if absorbed during TURP.


  • Ethanol monitoring is a fairly new method of assessing fluid absorption during TURP. By using an irrigating fluid containing a trace amount of ethanol, a pocket-sized breathalyzer can measure the patient’s end-expiratory ethanol concentration. Ethanol 1% is the standard strength, although ethanol 2% offers higher sensitivity and is suitable for research purposes (16,17).

Bipolar Transurethral Resection of the Prostate. Bipolar transurethral resection of the prostate (B-TURP) exploits a specialized resectoscope loop that incorporates both the active and return electrodes. This results in a dispersal of the current flow in the body, which theoretically reduces the deleterious effects of any stray current flow. The loop can be used to resect tissue as well as coagulate, vaporize, and transect tissue. Because 0.9% sodium chloride solution is used as an irrigation fluid, the risk of TUR syndrome is virtually eliminated (3).


Both postoperative catheterization and hospitalization times were shorter with B-TURP compared to M-TURP; this was thought to be due to reduced bleeding associated with improved coagulation abilities. Postoperative storage symptoms, particularly dysuria, were less common with B-TURP. However, most of these results were trends favoring B-TURP rather than statistically significant differences (18,19). TUR syndrome has not been reported with B-TURP due to the use of physiologic saline irrigation fluid and reduced fluid absorption during the procedure (11,18,20).

Practical considerations. Although the long-term treatment efficacy of M-TURP is widely accepted, the associated morbidity of M-TURP has led to the development of alternative therapy modalities. The choice of a monopolar or bipolar approach should be based on the patient’s presentation, anatomy, the surgeon’s experience, and discussion of the potential risks and benefits (3,7,11).

To date, five types of bipolar resection devices have been developed, which differ in the way in which bipolar current flow is delivered to achieve the plasmakinetic effect. These include the plasmakinetic system (Gyrus), transurethral resection in saline system (Olympus), Karl Storz, and Wolf. The devices plasmakinetic enucleation of the prostate or the “mushroom” technique has been described with the plasmakinetic bipolar system (Gyrus ACMI, Olympus Corporation, Tokyo, Japan) using 0.9% saline solution as an irrigation fluid. Essentially, mucosa at the apical adenoma is incised close to the verumontanum from the 5 o’clock to the 7 o’clock position. These grooves are deepened to the level of the surgical capsule. The distal middle lobe is dissected from the surgical capsule by the resectoscope sheath tip, and the surgical capsule is identified. Denuded supply vessels and hemorrhage spots on the capsule surface are identified and coagulated using the bipolar plasmakinetic loop to block the blood supply to the lobe. The right and left lobes are enucleated with the loop with arrest of bleeding. Finally, the bladder neck and enucleated lobes hanging at the bladder neck are resected (21,22).


Laser Surgery

An understanding of the wavelength or crystal used to produce laser energy during surgery of the prostate is critical when determining the type of laser vaporization to use. This is because tissue interaction caused by laser energy varies according to the wavelength, applied energy, fiber architecture, and tissue properties. This also means that the clinical results of different wavelengths are not comparable. Non-thermal effects, known as “ablation,” also result in tissue destruction. Functional results will therefore differ in terms of perioperative handling of different laser devices, including learning curve, debulking tissue, durability of results, and type of complications (11).

Several types of new generation lasers for prostate surgery have emerged during the last decade, including the holmium:YAG, potassium titanyl phosphate:yttrium aluminum garnet (KTP:YAG), thulium:yttrium aluminium garnet (thulium:YAG), light blue optics:yttrium aluminium garnet (LBO:YAG), and the diode lasers. Energy can be transmitted through a bare, right-angle or interstitial fiber. Each laser has wavelength-specified energy-tissue interaction. Prostatic tissue destruction results from both thermal and nonthermal effects (11).

Holmium Laser Enucleation of the Prostate and Holmium Laser Resection of the Prostate. Extensive short- and long-term data suggest that holmium laser enucleation of the prostate (HoLEP) remains the modern gold standard alternative to TURP and open prostatectomy. The salutary benefits of the complete removal of the transition zone result in consistent outcomes (7).

As the wavelength of the Ho:YAG laser is strongly absorbed by water, the area of tissue coagulation and the resulting tissue necrosis is limited to 3 to 4 mm beyond contact, which is enough to obtain adequate hemostasis (2). Peak power produces non-thermal, localized tissue destruction, resulting in precise cutting of prostatic tissue (11).

The patient is positioned in dorsal lithotomy as for a TURP. Following dilation of the anterior urethra with sounds, a 26Fr or 28Fr resectoscope is inserted into the urethra. The 550-µm end-fire laser fiber is placed through the laser bridge or laserstabilizing catheter. Normal saline irrigant is used during the procedure, and the resectoscope should be configured to continuous gravity flow.

The technique of HoLEP duplicates the complete adenectomy provided by open or minimally invasive simple prostatectomy. This technique involves identification and dissection in the surgical plane between the adenoma and surgical capsule, and this can be accomplished in a variety of ways. The prostate can be enucleated in a two-lobe or three-lobe technique depending on surgical anatomy and surgeon preference. Once the adenoma has been enucleated, the lobes are displaced into the bladder where a tissue morcellator is then used to retrieve the specimen (7).

If there is a significantly enlarged median lobe, it is often most expeditious to enucleate this structure first, as this maneuver will provide more room to accomplish the lateral lobe dissection (Table 30.4). To enucleate the median lobe, the holmium laser should be set at an energy of 2 J and a frequency of 50 Hz. Two sulci need to be generated at the 5 o’clock position and at the 7 o’clock position (Fig. 30.4). Beginning at the level of the bladder neck in the 5 o’clock position, a groove is cut with the laser along the sulcus from the bladder neck to a point proximal to the verumontanum (Fig. 30.5). This groove is deepened to the level of the surgical capsule. Once accomplished, the process should be repeated at the 7 o’clock position (Fig. 30.6). The final step in the enucleation of the median lobe can then be initiated at a point just proximal to the verumontanum. The laser fiber is moved in a transverse fashion between the apical extent of the 5 and 7 o’clock grooves.
As the distal portion of the median lobe begins to separate away from the capsule, the beak of the resectoscope should be used as a leverage point to assist in lifting the median lobe upward. Once the dissection has reached the level of the bladder neck, the most proximal attachments of the median lobe can be divided and the entire median lobe pushed into the bladder.








TABLE 30.4 HOLMIUM LASER ENUCLEATION OF PROSTATE







  • If median lobe present:




    • Create grooves in 5 and 7 o’clock positions.



    • Carry down to surgical capsule.



    • Join grooves just proximal to verumontanum.



    • Enucleate median lobe in retrograde fashion.



  • Lateral lobe dissection begins just lateral to verumontanum.



  • Develop plane under lateral lobe, on floor of capsule.



  • Dissection moves anteriorly, proceeding from apex to bladder neck.



  • Make incision at 12 o’clock position.



  • Join anterior and lateral dissections.



  • Divide remaining mucosal attachments.



  • Once both lobes are completely enucleated, morcellation can proceed.




    • Take care to always keep morcellator tip in view.







FIGURE 30.4 Cartoon representation of the architecture of the prostate and bladder neck. Dashed lines represent the 5 and 7 o’clock grooves.

If a median lobe was not present, an incision should be created at the 6 o’clock position, and this midline groove should extend from the bladder neck to a point just proximal to the verumontanum (Fig. 30.7).

Dissection of the right lobe is initiated by incising the mucosa lateral to the verumontanum in a transverse fashion, thereby exposing the adenoma near the apex. Once the initial plane is developed under the right lobe, dissection should proceed proximally toward the bladder neck, freeing the lateral lobe from the capsular floor. At some point, it will become apparent that the lateral attachments of the lobe impede dissection. At this point, the surgeon should detach the lateral most aspect of the right lobe, near the apex. During the apical dissection, the laser frequency should be changed to 40 Hz to prevent thermal injury of the urinary sphincter. The dissection should be continued until difficulty is encountered with exposure of the plane proximally. Attention should then be turned to the 12 o’clock region of the prostatic fossa, where the midline groove between the lateral lobes is located. The laser frequency should be readjusted to 50 Hz. Beginning at
the bladder neck and proceeding distally, a groove is cut along this anterior position and should span from the bladder neck to the level of the verumontanum. Once the groove is created, it is again widened and deepened to the level of the surgical capsule along its entire extent. The right lobe should then be enucleated from the anterior aspect of the capsule by angling the tip of the laser fiber between the adenoma and the capsule. Capsular definition is often much easier at the bladder neck, so dissection should begin at that point. It is crucial to identify the extent of the remaining lateral attachments near the apex of the lobe. Once the junction between the planes is defined, usually by a mucosal strip or bridge, it is cut by the laser to join the planes. Laser settings should be adjusted to 2 J and 20 Hz during division of this mucosal strip. At this point, the right lobe will be held only by attachments at the bladder neck level. By following this plane further laterally, any remaining attachments in this area can be freed. Finally, one should proceed under the lobe and finish dividing attachments at the floor of the capsule and the posterior bladder neck. The lobe can then be pushed into the bladder by leveraging upward with the beak of the resectoscope. With complete enucleation of the right lobe, attention should be turned to the left lobe, which is enucleated as previously described for the right lobe. Once all lobes have been dissected free and pushed into the bladder, the capsular surface is then inspected carefully, and any bleeding sites should be addressed by defocusing the laser (positioning the tip of the fiber 2 to 3 mm away from the surface). A dry fossa is essential before beginning morcellation
to optimize visualization and minimize the risk of bladder injury. The final aspect is to remove the enucleated adenoma by morcellation. The inner sheath of the resectoscope, along with the laser fiber and stabilizing catheter, is removed, and the rigid offset nephroscope is then inserted into the outer resectoscope sheath. Under direct visualization, the tip of the morcellator is inserted into the bladder and guided beneath a portion of adenoma. Once a portion of adenoma is engaged by the morcellator, it is important to keep the tip of the morcellator anteriorly within the bladder and within the visual field at all times to avoid bladder injury (23). The bladder should be kept full with continuous irrigating fluid when morcellation is being performed to reduce the risk of the morcellator catching the bladder wall and damaging that.






FIGURE 30.5 The 5 o’clock incision is created with the end-fire holmium laser fiber.

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