Enucleation of the Prostate for the Treatment of Benign Prostatic Hyperplasia Using a 980 nm Diode Laser

Summary

Here, we present a protocol for modified 980 nm diode laser enucleation to treat large volume benign prostatic hyperplasia.

Abstract

In the aging male population, the occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem. Here, we introduce a new technique called 980 nm diode laser enucleation (DiLEP) to treat BPH¹. Diode lasers can absorb both water and hemoglobin at the same time, so they are good for cutting and hemostasis². The diode laser was approved by the FDA in 2007, and has been used in the treatment of BPH because of its effective cutting and hemostasis effect³. DiLEP presents several advantages over other techniques, such as TURP, HoLEP, and PVP. During the procedure, we define the boundary of a high-volume prostate and separate it into three lobes with a diode laser by burning two rings and one groove (like a Cupid's arrow). Compared to other procedures, mDiLEP has fewer intraoperative complications, a shorter learning curve, and achieves more tissue resection.

Introduction

Compared with traditional transurethral resection of the prostate (TURP), laser surgeries have gradually become more popular due to their better patient tolerance, lower amounts of intraoperative blood loss, efficacy, and shorter postoperative recovery^4,5.

In recent years, the fastest growing techniques have involved the use of lasers of various wavelengths. At present, many types of lasers with different characteristics can be used to complete prostate enucleation. Since the diode laser was approved by the US FDA for prostatic hyperplasia in 2007, its use has gradually increased in the treatment of BPH because of its outstanding cutting ability and hemostasis effect⁶. The laser wavelength determines the degree of absorption by water and hemoglobin. A diode laser with a wavelength of 980 nm provides the highest combined absorption rate of water and hemoglobin. The tissue penetration ability is 0.5 mm, and it can produce coagulation effects in deeper tissue, which makes it have a very good tissue ablation and hemostasis ability^7,8.

Many research centers have begun to use DiLEP for the treatment of benign prostatic hyperplasia. In practice, traditional DiLEP has a longer learning curve and presents no obvious advantages related to urinary sphincter protection⁹. Based on the above reasons, traditional DiLEP was modified in our center to improve the value of diode laser treatment in patients with BPH.

Protocol

All methods described here have been approved by ethics committee of Beijing Hospital. Indications for surgery are according to the European Association of Urology guidelines for nonneurogenic male LUTS. Contraindications include suspected prostate cancer or detrusor dysfunction.

1. Instruments for operation

1. Ensure the availability of diode laser (980 nm) equipment with a power including continuous mode (80-100 W).
2. Employ a laser fiber and 0.9% saline solution for intraoperative bladder irrigation.
3. Use a 26 F laser resectoscope to acquire good visualization and enhance efficiency.

2. Preparation for operation

1. Perform skin preparation on the day of the operation.
2. Provide an intravenous antibiotic preoperatively to all patients¹⁰.
   NOTE: Cefuroxime sodium (1.5 g in 100 mL of 0.9% sodium chloride) is provided 30 min before the operation.
3. Before anesthesia, make the patient lay down on the operating table.
   NOTE: General anesthesia is effective and appropriate for this operation. The anesthetists should determine the mode of anesthesia depending on the patient's general condition.
4. Drape the patient in a sterile fashion in the dorsal lithotomy position.

3. Procedure steps

1. Observation
   1. Directly observe the urethra, verumontanum, bladder neck, ureteral orifices, bladder mucosa, and trabecular hyperplasia by resectoscope (15-30°).
2. Design the range of enucleation (Cupid's arrow).
   1. Circularly incise (depth to gland, width about 3-4 mm) the bladder neck mucosa with a laser (Figure 1).
   2. Circularly incise (depth to gland, width about 3-4 mm) the prostatic urethra mucosa at the proximal end of the verumontanum with a laser (Figure 2).
      NOTE: Confirm anatomical mark before incision in order to avoid injury of the bladder neck mucosa and sphincter urethrae. Use a laser power of 80-100 W during the operation except for hemostasis.
   3. Connect the concentric circles of the bladder neck and the apex of the prostate in the posterior urethra at a 12 o'clock position.
   4. Incise the left lobe and right lobe with the laser (Figure 3).
      NOTE: Once the 12 o'clock position of the posterior urethra is pre-incised, retain the distal mucosa. The concentric circles formed at the neck of the bladder and the apex of the prostate are called Cupid's arrows.
3. Making a channel
   1. Find the surgical capsule at the 5 and 7 o'clock positions of the apex of the prostate.
   2. Find the surgical capsule at the 5 and 7 o'clock surgical capsule positions.
   3. Connect the 5 and 7 o'clock surgical capsule positions with a laser (Figure 4).
   4. At the 6 o'clock position of the apex of the prostate, separate the median lobe from the surgical capsule from the apex of the prostate to the bladder neck with a laser (Figure 5).
      NOTE: If the volume of the prostate is >80 mL, the median and lateral lobes will be completely separated at the 5 and 7 o'clock positions of the apex of the prostate.
4. Enucleation of the left and right lobes
   1. In a counterclockwise direction, enucleate the right lobe at 6 and 12 o'clock from the apex of the prostate to the bladder neck with a resectoscope (Figure 6).
   2. In a clockwise direction, enucleate the left lobe at 6 and 12 o'clock from the apex of the prostate to the bladder neck (Figure 7).
   3. Push all the glands into the bladder after enucleation.
      NOTE: If the volume of the prostate is >80 mL, enucleate the median and lateral lobes in the proper sequence; then, push into the bladder.
5. Hemostasis
   1. Use a lower laser power (50 W) to stop bleeding around the surgical site. Maintain an appropriate distance (i.e., 1-3 mm).
6. Morcellate the prostate tissue.
   1. Morcellate the enucleated prostatic tissue into small pieces (as small as possible) with a morcellator and then remove the tissue from the bladder (Figure 8).
7. Catheterization
   1. Remove the morcellator from the urethra.
   2. Gently place a 22 F Foley catheter through the urethral orifice into the bladder cavity with 30 mL of water in the balloon after sufficiently lubricating the urethra with lidocaine gel.
8. Postoperative care¹⁰
   1. Let the patient lay down on the bed for approximately 3 h postoperatively in the care unit until they completely wake up from anesthesia. Make sure that patient monitors and medical oxygen are available during this time.
   2. Once the patient has completely woken up, return the patient to the ward. Let the patient begin to drink some water and eat some food. Record any urine output and pay attention to the color of the urine.

Results

A total of 40 patients with BPH who underwent DiLEP were included in one of our studies. An independent sample t-test was used as the statistical method. All patients successfully completed the operation. Almost all of the patients had the catheter removed within 5 days postoperative (Table 1). All patients returned to the hospital for follow-up examinations in the 1^st, 3^rd, and 12^th months postoperatively. The International Prostate Sympt...

Discussion

At present, the 980-mm diode laser is beginning to be used for the treatment of BPH⁵. Few reports have described related clinical studies. Compared to the effect of TURP in the treatment of BPH, many studies have shown that DiLEP causes less blood loss, achieves better urination function, and has shorter catheter retention times^9,13,14,15.

Her...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
HU Diode Laser	Beijing L.H.H.Medical Science Development Co., Ltd	HU-150	Wavelength: 980nm Maximum Power: 150W Operation Mode: Continuous and pulsed
Optical Fiber	Beijing L.H.H.Medical Science Development Co., Ltd	YYGX600	Fiber core diameter: 600 μm Fiber length: 2m
Morcellator System	Beijing L.H.H.Medical Science Development Co., Ltd	PXQ-01	Rotate Speed: 100-3000rpm MAX. Vacuum Pressure: -80KPa Rated Output Torque: 12mNm Blade Size: Φ5.0*390mm; Φ3.5*390mm Blade Work Mode: Corotation alternates reversal