Holmium Laser Enucleation of the Prostate, Tips and Tricks Not Just for Beginners

Abstract

Holmium laser enucleation of the prostate (HoLEP) is an endoscopic procedure that was first introduced in 1998 by Peter Gilling. Numerous studies have since confirmed that the technique is efficacious with durable outcomes, and many investigators now consider HoLEP the new gold standard. The surgeon searches for the capsular plane by making two incisions at the 5- and 7-o'clock positions beginning at the bladder neck and ending at the verumontanum. It is important at this stage to proceed one layer at a time while opening the bladder neck until the circular fibers of the neck are exposed. The surgeon should then proceed from the neck to the verum, deepening and widening the incision by separating the lateral lobe from the median portion. The surgeon should take care at this stage to push laterally with the whole instrument in the apex region detaching the adenoma from the capsule with the laser turned off, thus creating an apical incision along the cleavage plane causing subsequent detachment of the lateral lobe. The transversal incision in front of the verum makes it possible to detect the central cleavage plane at the level of the lateral incisions and to free the median lobe in a retrograde manner. Another indication to bear in mind at this stage of the procedure is lifting and pushing the median lobe distally detaching it along the groove plane until the circular fibers of the neck are visualized. The incision of the anterior commissure should begin at the 12-o'clock position corresponding to the verum at the 6-o'clock position. Proceeding in a retrograde manner, the surgeon should continue opening until the neck is reached. Another useful suggestion concerns the central incision, which, at the level of the neck, must be extended laterally from the 12- to 1-o'clock positions and from the 12- to 11-o'clock positions, separating the lateral lobes and creating a space in which the instrument can be inserted. The lobe should be pushed in a posterior direction to uncover the cleavage plane, which is opened by the laser's pulsating action. At this point, the surgeon proceeds to enucleate the lateral lobe beginning at the cleavage plane at the 6 o'clock position until detachment is attained at the level of the neck. The surgeon should then proceed to carry out apical detachment, which will make it possible to detach the hypertrophic lobe of the capsule leaving only a mucosal bridge. Once detached from the neck, the lobe is pushed toward the bladder placing the apical peduncle in traction at the 12-o'clock position distancing it from the sphincter to safely dissect it close to the adenoma. During the hemostasis, the surgeon uses warm irrigation fluid, inspects for only small arteries, and defocuses the laser to 2–3 mm. Coagulation should be carried out using a high energy for 2–3 seconds. After engaging the piece of the prostate and bringing it to the center of the bladder, morcellation should be carried out using warm irrigation liquid with the distended bladder. The morcellator shaft should be moved in and out of the working channel in small increments, which will favor the engagement of the lobe and efficacious morcellation. Particularly hard fibrous adherences can be removed by slowing the blades' velocity. To conclude, during the learning curve, we suggest that surgeons attempt medium adenomas weighing 30–40 g while they are under strict tutoring; prostate volume is an independent variable for expert surgeons; the time necessary for morcellation does not depend on the surgeon's experience but on the composition of the adenomatous tissue; always search for and detect the cleavage plane and the sphincter; and surgeons need tutoring during the learning curve. No competing financial interests exist. Runtime of video: 5 mins