Holmium:YAG Laser Enucleation of the Prostate: Technical Details

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HolmiumYAG Laser Enucleation of the Prostate
Technical Details

• Brian C. Fong
• Mostafa M. Elhilali
• McGill University
• Montreal, Quebec, Canada

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Introduction

• HolmiumYAG laser enucleation of the prostate
  (HoLEP) was originally described by Gilling et
  al.
• Advantages
• Hemostatic may be used on anticoagulated
  patients
• Normal saline as irrigating fluid
• No prostatic size limit
• Decreased catheter time, blood loss, hospital
  stay
• Comparative results with standard TURP

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Introduction

• Disadvantages
• Increased time for resection
• Initial cost
• Some tissue lost as thermal artifact
• Steep learning curve
• Objective of this video article
• To present the two and three lobe technique for
  HoLEP with emphasis on some technical details

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Learning Curve

• Most urologist trying this technique for the
  first time get lost during the dissection and
  therefore are discouraged
• Our institutional experience notes that residents
  can adopt this technique after an average of 20
  procedures (publication submitted)

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Learning Curve

• Resident vs. Staff HoLEP Experience

TRUS Transrectal Ultrasound IPSS
International Prostate Symptom Score Qmax
Maximum Urine Flowmetry Rate
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Technique

• Size and anatomy dictates the type of procedure
  most appropriate for the patient
• Two techniques
• Two lobe technique
• small or non-existent median lobe
• Three lobe technique
• large median lobe

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Equipment

• 80-100 Watt laser source
• Ideal setting 2 Joules at 40-50 Hz
• 26 French continuous flow resectoscope with
  modified sheath for laser tip
• 500 ?m end firing quartz laser fiber
• end stripped before each use
• 20-30 procedures possible per fiber
• 7 French stabilizing laser catheter
• Normal saline irrigation solution
• Video monitoring system
• Tissue morcellator

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Step 1

• 5 OClock Incision and
• Decision on Median Lobe Enucleation
• Two-Lobe Technique
• 5 oclock incision from bladder neck to
  verumontanum
• Prepare for enucleation of left lateral lobe
• Three-Lobe Technique
• 5 oclock incision from bladder neck to
  verumontanum
• Similar incision at 7 oclock
• Prepare for enucleation of middle lobe

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Step 2

• Incision Near Verumontanum
• Made to define the depth where a plane of
  enucleation can be identified between adenoma of
  lateral lobe and surgical capsule

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Step 3

• Blunt Enucleation
• This mobilizes the lobe off the surgical capsule
  and away from the sphincter

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Step 4

• Dissection To Bladder Neck
• Extension of dissection forward allows separation
  of the lateral lobe from the bladder neck

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Step 5

• 12 Oclock Incision
• This allows for dissection of both lobes from 12
  o clock - 3 o clock between the left lobe and
  the surgical capsule or 12 oclock - 9 oclock
  between the right lobe and the surgical capsule

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Step 6

• Release of Mucosa From Sphincter
• Identify the band of mucosa holding the lobe
  inside the sphincter at 1-2 oclock or 10-11
  oclock.
• Retract the fiber into sheath with energy reduced
  to 80 Watts from 100 Watts
• Short cuts made to release this band

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Step 7

• Joining Planes From Above and Below
• This will enucleate the lateral lobe into the
  bladder

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Step 8

• Completion of Two-Lobe Technique
• Start dissecting the remaining lobe by incision
  in front of the verumontanum and identifying the
  plane
• Blunt dissection similar to the other side but
  including the median lobe up to the bladder neck
• Repeat the incision of the band at 10-11 oclock
  to enucleate the lobe to the bladder

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Step 9

• Hemostasis
• Use setting of 1.5 J and 30 Hz (45 Watts) to
  reduce heat trauma, particularly at the sphincter

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Step 10

• Morcellation
• Resectoscope removed and 27 French standard
  nephroscope sheath and indirect lens used so the
  morcellator can be inserted
• Employment time consistently varies
• Morcellation up to 7 grams per minute
• Avoid bladder injury
• Ensure bladder is full at all times
• Use suction to bring tissue closer to prostatic
  fossa
• At the end of procedure, inspect bladder and
  fossa to ensure hemostasis

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Immediate Post-operative Care

• 22 French Two-Way catheter inserted
• Intermittent bladder irrigation can be set up
  with Y-connector if required
• Lasix 20 mg iv usually given to eliminate saline
  absorbed during procedure
• Usually no post-op bloodwork required
• Catheter can be removed the next morning and
  patient discharged within 24 hours

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Conclusion

• HoLEP offer clear advantages to TURP such as
  reduced catheter times, hospitalization, blood
  loss along with the ability to operate on
  anticoagulated patients and large prostates
• Our video has illustrated the importance of blunt
  dissection to remain in the anatomic plane
• We hope a clear understanding of the steps of the
  two lobe and three lobe technique will help
  reduce the frustrations encountered during early
  adoption of this technique

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References

• Gilling PJ, Cass CB, Cresswell MD, et al The use
  of the holmium laser in the treatment of benign
  prostatic hyperplasia. J Endourol 1996 10
  459-461.
• El-Hakim A, Elhilali MM Holmium Laser
  Enucleation of Prostate initial teaching
  experience and technical advances. BJU Intl 2002
  (Submitted).
• Gilling PJ, Kennett KM, et al Holmium laser
  enucleation of the prostate (HoLEP) combined with
  transurethral tissue morcellation an update on
  the early clinical experience. J Endourol 1998
  12 457-9.
• Gilling PJ, Kennett KM, et al Holmium laser
  enucleation of the prostate for glands larger
  than 100g an endourologic alternative to open
  prostatectomy. J Endourol 2000 14 529-31.

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Authors

• Brian C. Fong, M.D.
• Urology Resident, McGill University
• Mostafa M. Elhilali, M.D.
• Professor, Division of Urology, McGill University
• Address for Correspondence
• Mostafa M. Elhilali, M.D.
• Royal Victoria Hospital
• 687 Pine Avenue West, S6.95
• Montreal, Quebec, Canada, H3A 1A1
• E-mail mostafa.elhilali_at_muhc.mcgill.ca