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  • Holimum Laser Enucleation of the Prostate (HoLEP)

    About the Author:

    Dr. Jessica Mandeville MD

    Dr Jessica Mandeville MD

    Jessica Mandeville, MD is a urologist practicing at the Lahey Clinic, Burlington, MA.   She completed a prestigious 2 year fellowship in management of complex urinary stones and the laser treatment of benign enlargement of the prostate with Dr. James E. Lingeman at Indiana University. She is one of few urologist in New England, with extensive experience in Holmium Laser Enucleation of Prostate (HoLEP).

    Surgical Steps of HoLEP broken down into 9 steps.

    Step 1:-Evaluation of prostate and cutting initial incision (6 o’clock)

    The procedure is begun by insertion of the 28 French, continuous flow resectoscope with 550 micron, end-firing Holmium laser fiber.   Normal saline is used for irrigation.  In this patient, endoscopic evaluation of the prostatic urethra reveals significant bilobar hypertrophy without a substantial median lobe component.  The patient’s pre-operative transrectal ultrasound (TRUS) volume was 160cc.

    The laser power settings are initially set to 2 Joules and 40 Hertz. The initial incision is made at the 6 o’clock position, which corresponds to the natural groove between the large lateral lobes.    The 6 o’clock position is chosen in this patient, as he does not have a significant median lobe component.  In the case of a patient with a large median lobe, the initial incision is made at either the 5 o’clock or 7 o’clock position in a groove between the median and lateral lobe.  In such a situation, the median lobe is resected in conjunction with either the right or left lateral lobe.

    At the level of the bladder neck, the incision should be deepened until the point where the groove becomes nearly flush with the trigone.  The incision should be carried distally to a point just proximal to the verumontanum.  As seen in the video, bleeding vessels should be coagulated with the fiber while the groove is being cut in order to avoid obscuring the capsule with blood or clots.

    In patients with very large glands, a large amount of tissue can be encountered while cutting the initial groove.  The surgeon must be diligent to ensure that the initial groove is dissected all the way down to the capsule and not simply down to an underlying nodule.  This often requires multiple passes of the laser fiber through the initial groove.

    While cutting the initial groove, the resectoscope is rotated side to side and the beak of the scope is used to widen the groove and to begin to gently move the medial aspects of the lateral lobes over the surface of the capsule.  The incision is completed when the surgical capsule is identified along the full length of the groove.  The capsule possesses a glistening surface with fine vessels coursing over it.  The adenomatous tissue easily slides back and forth over the surface of the capsule.

    Step 2: -Initial Apical Dissection (Left Side)


    The apical dissection of the left lateral lobe is begun by incising the overlying urethral mucosa just lateral to the verumontanum.  For this portion of the procedure, the laser power settings are dropped down to 2 Joules and 20 Hertz, given the close proximity to the external sphincter.   Once the overlying mucosa has been incised, the beak of the resectoscope is used to gently lift the distal aspect of the apex of the left lateral lobe off of the capsule.

    The laser is used to continue this cut and ensure it meets up with the initial 6 o’clock groove.  Then, using a combination of cutting with the laser and blunt dissection with the beak of the resectoscope the surgeon continues to roll the apex of the left lateral lobe off of the underlying capsule.

    Step 3:-Apical and Lateral Dissection (Left Side)


    Enucleation of the left lateral lobe is continued in a circumferential fashion from the 5 o’clock position to the 1 o’clock position. A combination of blunt dissection with the beak of the resectoscope and cutting with the laser fiber is employed. Care is taken to stay in only one plane of dissection – the plane between the adenomatous tissue and the surgical capsule.
    The surgeon must frequently pause to maneuver the scope distally and anteriorly to be sure that no portion of the lateral lobe is being left behind as he or she approaches the 12 o’clock position. This helps ensure that the distal aspect of the lateral lobe is dissected in its entirety. The surgeon must always take extreme caution to avoid injury to the external sphincter when maneuvering the resectoscope and laser fiber distally. When the proper plane between adenoma and capsule is identified, it leads the surgeon in the appropriate direction of dissection while avoiding injury to the sphincter. As mentioned previously, all bleeding vessels should be coagulated with the laser fiber as they are encountered so as to prevent obscuring the plane between adenoma and capsule with blood or clots.

    Step 4: -Anterior Dissection


    At this point in the enucleation, the laser power settings can be increased back to 2 Joules and 40 Hertz, as the dissection is being carried out at a safe distance from the external sphincter.  The dissection is now carried up and over the top of the left lateral lobe and beyond the 12 o’clock position.  This maneuver requires steep upward angulation of the surgeon’s hands in order push down on the lobe while dissecting it off of the capsule anteriorly.  Again, a combination of blunt dissection and cutting with the laser fiber is employed.  When working on very large prostates, it can be challenging to stay in the proper plane of dissection during this portion of the procedure due to the steep angle and bulky tissue.  It is important to make cuts with the laser directly on top of the capsule in order to prevent the development of multiple planes.

    Step 5: -Completion of Anterior Dissection and Entry into Bladder Neck


    The enucleation of the anterior portion of the left lateral lobe is continued with a combination of blunt dissection with the beak of the resectoscope and cutting with the laser fiber.  The lateral lobe is rolled down off of the capsule and ultimately the anterior bladder neck fibers are encountered.  The bladder neck fibers and bladder neck mucosa are cut with the laser and the bladder is entered.  The anterior bladder neck attachments to the left lateral lobe are further dissected until the left lateral lobe is freed in its entirety anteriorly.

    Step 6: -Division of the Anterior Commissure


    The resectoscope is rotated such that the laser fiber is exiting at the 12 o’clock position and it is drawn back down the prostatic urethra over the top of the left lateral lobe.  This confirms that the anterior dissection of the left lateral lobe has been completed in its entirety.  Once the surgeon has confirmed that the anterior dissection is complete, the anterior commissure can be divided.  The resectoscope is re-advanced back into the bladder keeping the laser fiber at the 12 o’clock position.  The resectoscope is angled steeply upward and an anterior incision is made from the bladder neck to the level of the verumontanum.  The surgeon must brace his or her hands against the perineum so as to prevent inadvertent slipping of the fiber into the external sphincter as the incision is carried distally.  The incision at the anterior commissure is carried down to the capsule and is joined to the previous resection plane at the 1 o’clock position.  At this point, all that remains to be divided anteriorly is a thin mucosal strip, which is in close proximity to the sphincter (see next chapter).

     Step 7: -Encircling of Lateral Lobe (Left) & Division of Mucosal strip


    In order to bring the mucosal strip into a position a safe distance from the sphincter for division, the lobe is encircled to “catch” the strip and bring it into the prostatic fossa.  Starting at the 12 o’clock, the resectoscope is pushed against the capsule and rotated around and then underneath the lobe.  The resectoscope is then slowly drawn distally until the mucosal strip comes into view projecting into the midline of the prostatic fossa.

    The laser fiber settings are dropped down to 2 Joules and 20 Hertz and division of the mucosal strip commences.  The strip of tissue is pushed into the fossa and away from the sphincter during division.  If the mucosal strip cannot be divided in its entirety on the first pass, the resectoscope is used to re-encircle the distal aspect of the lobe and bring the strip back into view in the midline.  The remaining mucosal strip attachments can then be easily identified and divided without causing injury to the sphincter (not shown).

     Step 8: -Completion of Dissection of the Fossa (Left)


    To complete the dissection of the left lateral lobe, the adenoma must be detached from the lateral wall and the floor of the fossa.  The lateral wall attachments are addressed first.  From the bladder neck to the apex, the adenoma is dissected free from the underlying capsule.   The beak of the resectoscope is used to put the lobe on the appropriate amount of tension such that the plane between adenoma and capsule can be readily identified.  The resectoscope is continuously rotated such that the laser fiber exits perpendicular to the attachments that are being divided.  A combination of cutting with the laser fiber and blunt dissection with the beak of the resectoscope is employed to complete this portion of the dissection.

    Once the surgeon is satisfied with the dissection of the lateral attachments to the adenoma, the attachments to the floor of the fossa are addressed.  The resectoscope is drawn distally until the end of the lobe is encountered.  Again, the beak of the resectoscope is used to generate the appropriate amount of tension such that the plane between adenoma and capsule can be identified.  The laser fiber is swept back and forth at the 6 o’clock position while using the beak of the resectoscope to push the adenoma off of the capsule.

    The surgeon then continues to push the adenoma off of the capsule of the floor of the fossa with the goal of pushing the lobe through the bladder neck and into the bladder, thus leaving only the bladder neck attachments to divide.  This maneuver can largely be completed with blunt dissection.  Once the lobe has been pushed into the bladder, all that remains is a stalk of tissue at the bladder neck.  This remaining stalk of tissue is tensioned by the adenoma, which is now floating within the bladder.  The laser fiber is swept across this band of tissue to divide it and free the left lateral lobe in its entirety.  The right lobe is then enucleated in the exact same manner.

    Step 9: -Morcellation


    Once both lobes have been completely enucleated and pushed into the bladder, morcellation of the tissue can commence.   The fossa should be inspected for any significant bleeding.  Any oozing vessels should be coagulated so as to allow for better visualization during morcellation.   Clear visualization of the adenomatous tissue is essential in preventing inadvertent injury to the bladder.

    When adequate hemostasis has been achieved with the laser, the surgeon must switch from the continuous flow resectoscope to a long rigid nephroscope.  It is imperative that dual inflow through the nephroscope is employed in order to maintain adequate distention of the bladder.  If dual inflow is not used, the suction of the morcellator (which serves as outflow) is strong enough to aspirate the wall of the bladder and cause significant injury.  Additionally, it is important that the operating room staff members continuously monitor the irrigation bags to be sure that irrigation fluid never runs dry during morcellation.

    The morcellator blades are inserted through the working channel of the rigid nephroscope, positioned underneath the adenoma, and light suction is employed to engage the tissue between the blades.  Once the tissue has been engaged, full suction and cutting can then be used to morcellate the tissue.  Morcellation is continued until all tissue has been removed.

    The fossa and bladder are then inspected to be sure that no tissue remains and that no inadvertent injuries have been made to the bladder.  The surgeon can then switch back to the continuous flow resectoscope to coagulate any remaining oozing vessels and be sure that hemostasis is excellent prior to removing the resectoscope and inserting the 3-way catheter (not shown).

    A 22 French 3-way catheter is inserted and 50cc of sterile water are instilled into the balloon.  CBI is initiated and continued overnight.  The 3-way catheter is removed early on the morning of post-operative day number one and the patient is discharged to home after voiding.

    Introduction

          Transurethral resection of the prostate (TURP) has long been regarded as the standard treatment of bladder outlet obstruction (BOO) related to benign prostatic hyperplasia (BPH) in small to moderate-sized prostate glands.  For larger prostate glands, open simple prostatectomy (OP) has been the standard surgery performed for removal of large, obstructing adenomas.  Both TURP and OP have demonstrated long-term, durable and reproducible results in the treatment of BPH.   However, these procedures are not without complications which include, but are not limited to, bleeding and blood transfusion requirements, fluid absorption and TUR syndrome (monopolar resection with hypotonic irrigation), prolonged catheterization and/or hospital stay, bladder neck contracture (BNC), and urethral stricture.  While the advent of bipolar electrocautery resection using normal saline irrigation has certainly reduced the incidence of TUR syndrome, the previously mentioned complications are concerning to all practicing urologists and their patients.1,2

    Over the past two decades, numerous new techniques for the treatment of BPH have emerged, and laser therapy in particular has gained widespread use among urologists. Since the time it was first introduced in 1996, Holmium Laser Enucleation of the Prostate (HoLEP) has been the most rigorously studied, minimally invasive technique used in the treatment of prostatic obstruction.2,3  A variety of randomized control trials (RCT) exist which have compared the efficacy and safety of HoLEP to TURP and OP, and the results of medium and long-term follow-up series have demonstrated excellent durability of HoLEP.4,5,6

    Evidence supporting the viability of HoLEP in the treatment of BPH

    In 2007, Ahyai and colleagues reported  3-year results of an RCT study which compared HoLEP and TURP for the treatment of glands under 100 grams (mean 51.7g).  In this study, they demonstrated that both procedures resulted in comparable statistically significant improvements in American Urological Association Symptom Score (AUASS), maximum flow rate (Qmax), and post void residual urine volume (PVR).  In this study, perioperative results were more favorable in the HoLEP patient cohort, as patients in this group had significantly less blood loss and no transfusion requirements.  Furthermore, patients in the HoLEP cohort had shorter median length of catheterization (LOC) as compared to patients in the TURP cohort (1 day vs 2 days), as well as shorter length of hospitalization (2 days vs 3 days).  Finally, rates of reoperation, BNC, and urethral stricture were the same among both groups.5  In 2008, the same group reported 5-year follow up results of an RCT comparing HoLEP to OP for the treatment of glands over 100 grams. In both groups, there was no statistically significant difference between post-operative AUASS, Qmax, and PVR at 5 years (or at any point of earlier follow-up).  Again, the perioperative outcomes heavily favored the HoLEP group, as evidenced by a significantly lower blood transfusion rate (0% vs 13.3%), shorter LOC (30 hours vs 194 hours), and shorter length of hospitalization (70 hours vs 250 hours).  Operative time was significantly shorter for the OP group (91 minutes vs 136 min), however this was attributed to an initial lack of a morcellating device, as they reported a significant decrease in operative time when morcellation was employed (data not published).  Again, in both groups, the rates of urethral stricture or BNC requiring intervention were similar (5% HoLEP, 6.7% OP).  No patient from either cohort required re-operation for BPH regrowth.6

    More recently, Krambeck and associates reported on their experience with over 1,000 HoLEP procedures and included results at short-term (0-6 months), intermediate-term(6-12 months), long-term(13 months to 5 years), and greater than 5-year follow-up.  In this extremely large series of patients, they reported a mean pre-operative prostate volume of 99.3cc (9 – 391cc), mean AUASS of 20.3, mean Qmax of 8.4 ml/sec, and mean preoperative prostate specific antigen (PSA) of 7.2mg/dL.  The mean post-operative AUASS at 1 month was 8.7 and this further declined to 5.9, 5.3, and 5.1 at 6 months, > 12 months, and >5 years.  At one month post-operatively Qmax improved to 17.9 ml/sec and improved slightly further at 6 months (19.6 ml/sec) and 12 months (22.7 ml/sec).  Flow rate was not routinely measured after 1 year of follow-up.  The rates of urethral stricture (those that required office dilation) at short-term, intermediate-term, long-term and greater than 5-year follow up were 0.9%, 1.3%, 1.3% and 0%.  The incidence of BNC at the same points of follow-up were 0%, 0.8%, 1.3%, and 6% respectively.  This group additionally reported results on post-operative incontinence at the previously mentioned points of follow-up.  Stress incontinence was noted in 12.5%, 3.4%, 1.8% and 4.8% respectively, while urge incontinence was present in 11.5%, 3.1%, 1.5%, and 2.2% respectively.  The high early incontinence rates were felt to be attributable to the radical tissue debulking achieved with the HoLEP procedure and the authors noted that by 1 year post-operatively, the incidence of incontinence was dramatically reduced to levels seen with other transurethral surgeries.  In this series, 1 patient (0.1%) required re-intervention (HoLEP) for prostatic regrowth.  A total of 3 patients (0.3%) were unable to void spontaneously over the course of follow-up, and all 3 of these patients had documented evidence of neurogenic bladder.  Finally, the mean PSA in patients with greater than 5 years of follow-up was 0.95mg/dL, a further testament (in addition to the low rate of re-operation for regrowth) to the long-term durability of HoLEP for the treatment of BPH.3

    HoLEP and post-operative PSA reduction and stability

                When complete enucleations are performed, HoLEP can produce PSA reductions of over 80%.  The significant reduction in PSA is related to the radical debulking capability of HoLEP and is similar to the PSA reductions seen with OP.  After a patient undergoes a HoLEP procedure, a new “reset” PSA level should be obtained and sustained, as the transition zone of the prostate produces the great majority of PSA.

    Elmansy and colleagues have evaluated PSA velocity (PSAV) as a means to assess for treatment durability after HoLEP and to assess for the development of a malignancy after HoLEP.  This group followed a cohort of 335 patients who underwent HoLEP procedures.  A total of 9 patients developed prostatic adenocarcinoma during the course of the study.  They noted no differences with regards to preoperative prostate volume (75.33g and 73.95g) or resected tissue weight (51.4g and 44.46g) in patients with and without progression to adenocarcinoma of the prostate.  They did, however, note a significant difference in preoperative PSA (5.44 benign group, 9.46 malignant group), postoperative PSA nadir (0.91 benign group, 5.83 malignant group), and percent PSA reduction (75.39% benign group, 47.49% malignant group).  The mean PSAV values for the benign group at 1 and 3 years were 0.13 and 0.09 ng/ml/year, respectively.  For the malignant group, the PSAV values at the same time points were 1.28 and 2.4 ng/ml/year.  In this large cohort of patients undergoing HoLEP in whom malignancy was not present, the extremely low PSAV values confirm the durability of the HoELP procedure with regards to permanent tissue removal.7  It should be noted that in patients who do not demonstrate significant reductions in PSA after HoLEP or in those with elevated PSAV after HoLEP, a diagnosis of adenocarcinoma should be considered, and appropriate actions for diagnosis and or treatment, when indicated, should be pursued.

    Additional benefits of HoLEP – Treating anticoagulated patients.

    While it is preferential to cease anticoagulants prior to performing HoLEP procedures, there are instances in which anticoagulation cannot be safely discontinued and HoLEP must be performed while a patient is actively anticoagulated.  Circumstances which may preclude safe interruption of anticoagulation include patients with mechanical heart valve replacements, patients with significant coronary artery disease and/or those with drug-eluting coronary artery stents, patients with carotid stenosis and/or history of TIA or stroke, patients with cardiac arrhythmias such as atriral fibrillation and patients with a history of thromboembolic disease.   In 2006, Elzayat and associates published results on 48 patients who underwent HoLEP while anticoagulated.  Fourteen patients had therapeutic international normalized ratio values (INR; mean 2.0) and 34 patients had been transitioned to therapeutic low molecular weight heparin (LMWH).  They reported a 14.2% transfusion rate in the patients with therapeutic INR values and a 14.7% transfusion rate in patients receiving LMWH.  Both of these transfusion rates are lower than reported rates of transfusion in patients undergoing TURP while anticoagulated.  In 2009, Tyson and Lerner published the results of a series in which they performed HoLEP on 13 patients on warfarin (mean INR 1.5) and in 25 patients on aspirin.  Two patients (8%) in the aspirin group and 5 patients (14%) in a control, non-anticoagulated group required termination of the procedure secondary to hematuria-induced poor visibility.  No blood transfusions were required in any patients, regardless of anticoagulation status.9  While interruption of anticoagulation should always be considered in patients undergoing transurethral prostate surgery, in those patients in whom cessation of anticoagulants is deemed unsafe, HoLEP can still be performed, albeit with higher rates of transfusion than those seen in non-anticoagulated patients undergoing the same procedure.

    Conclusion

    HoLEP is a safe and effective, minimally invasive means of treating BOO related to BPH.  It can be performed for glands of all sizes, and in experienced hands, it is equivalent, and in many aspects, superior to TURP and OP in terms of safety, efficacy and long-term durability.  HoLEP truly has the potential to become the new gold standard for treating BPH in men with glands of all sizes.   Unfortunately, a somewhat steep learning curve associated with mastering the HoLEP procedure has lead to slow acceptance and uptake of the procedure among urologists in the United States.  The development of training simulators and surgeon mentoring programs will be required to help urologists overcome this learning curve and begin offering the procedure to their patients.

     References

    1. Burke N, Whalen JP, Goeree L, et al.: Systematic review and meta-analysis of transurethral resection of the prostate versus minimally invasive procedures for the treatment of benign prostatic obstruction.  Urology 2010, 75:1015-1022.

     

    2.  Mandeville J, Gnessin E, and Lingeman J:  New advances in Benign Prostatic Hyperplasia: Laser Therapy.  Curr Urol Rep 2011, 12:56-61.

     

    3.  Krambeck AE, Handa SE, and Lingeman JE: Experience with more than 1000 holmium laser prostate enucleations for benign prostatic hyperplasia.  J Urol 2010, 183:1105-1109.

     

    4.  Gilling PJ, Aho TF, Frampton CM, et al.: Homium laser enucleation of the prostate: results at 6 years.  Eur Urol 2008, 53:744-749.

     

    5.  Ahyai SA, Lehrich K, and Kuntz RM: Holmium laser enucleation of the prostate versus transurethral resection of the prostate: 3-year follow-up of a randomized clinical trial.  Eur Urol 2007, 52:1456-1464.

     

    6.  Kuntz RM, Lehrich K, Ahyai SA: Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams:  5-year follow-up results of a randomized clinical trial.  Eur Urol 2008, 53:160-168.

     

    7.  Elmansy HM, Elzayat EA, and Sampalis JS et. al.: Prostate specific antigen velocity after holmium laser enucleation of the prostate: possible predictor of for the assessment of treatment effect durability for benign prostatic hyperplasia and detection of

    malignancy.  Urol 2009, 74:1105-1110.

     

    8.  Elzayat EA, Habib E and Elhilali M:  Holmium laser enucleation of the prostate on anticoagulation therapy or with bleeding disorder.  J Urol 2006, 175:1428-1432.

     

    9.  Tyson MD and Lerner LB:  Safety of holmium laser enucleation of the prostate in anticoagulated patients.  J Endourol 2009, 23:1343-1346.

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