Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate (HoLEP).

The overall goal of this surgical intervention is to treat hyperplastic prostate and to relieve urethral obstruction caused by benign prostatic hyperplasia or BPH. This method helps us to answer the key questions about how to enucleate the prostate and how to do the surgical treatment for BPH. The main advantages on this method are that it is minimally invasive and it allows quick recovery after the surgery.

Holmium Laser Enucleation of the prostate should be proposed as a new gold standard instead of the old one, transurethal resection of the prostate, because it is a low application load and quick recovery. We treated more than 2000 patients in the past 10 years and got very good results. Before beginning the procedure assess the BP of each patient in accordance with the European Association of Urology guidelines.

After administering the appropriate anesthesia, place the patient in the lithotomy position and gently insert a continuous plastiscope into the patients urethral tract without damaging the mucosal tissue. Carefully observe the prostate, urethra, and bladder. Using a visual obturator, locate the uretal orifices including the medium lobe volume and the amount of intra-vesicle tissue.

After locating the verumontanum, insert hand pieces equipped with a laser fiber connected to a laser instrument and set the laser power to 80 to 100 watts, at 1.6 to two joules per second, and 40 to 50 hertz. Tunnel the incision around the six o'clock position of the prostate and use a 100 watt versiapulsium laser to make a short horizontal incision around the six o'clock position in front of the verumontanum to locate the surgical capsule of the prostate. Finding the surgical capsule is critical to the success of this procedure as this is the plane in which we will do the whole aplasia.

Expose the prostate surgical capsule from the verumontanum to the bladder neck. Then, create a tunnel from the apex toward the back of the bladder neck, taking care that the mucosa and the muscle are protected to facilitate efficient urinary control. To remove the lateral lobe, use a scope sheath combined with laser cutting and blur separation to enucleate the left lateral lobe from the six o'clock to the 12 o'clock position at the level of the surgical capsule.

Then, enucleate the right lateral lobe as just demonstrated. Hang the enlarged prostate in the 12 o'clock position of the bladder neck without cutting down. Remove the enlarged prostate tissue from the bladder neck and push the excised tissue into the bladder.

Recheck the prostate capsule to ensure no active bleeding occurs. Then, remove all of the enlarged glands and stop any severe bleeding points. After making holes in the surface of the prostate gland, equip the morcellator and the match tube according to the manufacturers instructions and insert the morcellator and a 26-french nephroscope into the patients urethral tract.

Carefully and efficiently invert the morcellator so that the opening faces downward in the bladder to remove large and firm tissues, as well as fibrotic spherical glands with smooth surfaces and firm tissues. Keep the bladder sufficiently engorged with saline to avoid bladder injury throughout the procedure, taking care not to injure the bladder wall during the morcellation process. When all of the tissue has been removed, observe the general condition of the bladder.

If no reserved tissue is left, insert a new catheter and irrigate normal saline into the bladder until the solution is clear or only slightly reddish. Remove the catheter when the urine becomes clear without gross hematuria. After hospital discharge, examine the follow up data of the patient for one, six, and 12 months, including the International Prostate Symptom Score, Overactive Bladder Scoring System, and quality of life and QMAC scores.

Prostatic tissue removed by morcellation can be analyzed pathologically, post-surgery, as appropriate. In this representative study, pre and postoperative outcomes were assessed for 100 patients treated for benign prostatic hyperplasia, as just demonstrated. In 47 patients, the International Prostate Symptom Score was significantly decreased between four to 24 weeks after the prostate enucleation and morcellation procedures.

Once mastered, this technique can be finished in only one hour and depending on the size of the prostate, if it is properly performed. While attempting the procedure, it is very important to finish the preoperative exam before beginning the surgery. After watching this video, you should have a very good understanding of how to perform HoLEP, the laser enucleation of the prostate which causes the bi-BPH.