Name: Enucleation of the Prostate for the Treatment of Benign Prostatic Hyperplasia Using a 980 nm Diode Laser (Video) | JoVE Journal
Uploaded: 2020-05-05T13:00:00.000+00:00
Duration: 5 min 28 s
Description: Learn diode laser enucleation for treating benign prostatic hyperplasia using a 980 nm wavelength system. This technique reduces intra-operative complications and offers a shorter learning curve for urologists.

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5 minutes

The authors would like to acknowledge the support of the National Key Research and Development Program of China (Grant 2017YFC840102).

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
<ol>
	<li>Ensure the availability of diode laser (980 nm) equipment with a power including continuous mode (80-100 W).</li>
	<li>Employ a laser fiber and 0.9% saline solution for intraoperative bladder irrigation.</li>
	<li>Use a 26 F laser resectoscope to acquire good visualization and enhance efficiency.</li>
</ol>
2. Preparation for operation
<ol>
	<li>Perform skin preparation on the day of the operation.</li>
	<li>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.</li>
	<li>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&#39;s general condition.</li>
	<li>Drape the patient in a sterile fashion in the dorsal lithotomy position.</li>
</ol>
3. Procedure steps
<ol>
	<li>Observation
	<ol>
		<li>Directly observe the urethra, verumontanum, bladder neck, ureteral orifices, bladder mucosa, and trabecular hyperplasia by resectoscope (15-30&#176;).</li>
	</ol>
	</li>
	<li>Design the range of enucleation (Cupid&#39;s arrow).
	<ol>
		<li>Circularly incise (depth to gland, width about 3-4 mm) the bladder neck mucosa with a laser (Figure 1).</li>
		<li>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.</li>
		<li>Connect the concentric circles of the bladder neck and the apex of the prostate in the posterior urethra at a 12 o&#39;clock position.</li>
		<li>Incise the left lobe and right lobe with the laser (Figure 3). 
		NOTE: Once the 12 o&#39;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&#39;s arrows.</li>
	</ol>
	</li>
	<li>Making a channel
	<ol>
		<li>Find the surgical capsule at the 5 and 7 o&#39;clock positions of the apex of the prostate.</li>
		<li>Find the surgical capsule at the 5 and 7 o&#39;clock surgical capsule positions.</li>
		<li>Connect the 5 and 7 o&#39;clock surgical capsule positions with a laser (Figure 4).</li>
		<li>At the 6 o&#39;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 &#62;80 mL, the median and lateral lobes will be completely separated at the 5 and 7 o&#39;clock positions of the apex of the prostate.</li>
	</ol>
	</li>
	<li>Enucleation of the left and right lobes
	<ol>
		<li>In a counterclockwise direction, enucleate the right lobe at 6 and 12 o&#39;clock from the apex of the prostate to the bladder neck with a resectoscope (Figure 6).</li>
		<li>In a clockwise direction, enucleate the left lobe at 6 and 12 o&#39;clock from the apex of the prostate to the bladder neck (Figure 7).</li>
		<li>Push all the glands into the bladder after enucleation. 
		NOTE: If the volume of the prostate is &#62;80 mL, enucleate the median and lateral lobes in the proper sequence; then, push into the bladder.</li>
	</ol>
	</li>
	<li>Hemostasis
	<ol>
		<li>Use a lower laser power (50 W) to stop bleeding around the surgical site. Maintain an appropriate distance (i.e., 1-3 mm).</li>
	</ol>
	</li>
	<li>Morcellate the prostate tissue.
	<ol>
		<li>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).</li>
	</ol>
	</li>
	<li>Catheterization
	<ol>
		<li>Remove the morcellator from the urethra.</li>
		<li>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.</li>
	</ol>
	</li>
	<li>Postoperative care10
	<ol>
		<li>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.</li>
		<li>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.</li>
	</ol>
	</li>
</ol>

<ol><li>Maliszewski, T. M., Sikorski, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((574+Diode+laser+980+nm+for+the+treatment+of+BPH%3A+Long-term+comparison+of+the+enucleation+vs.+vaporization%5BTitle%5D)+AND+%22European+Eurology%22%5BJournal%5D)">574 Diode laser 980 nm for the treatment of BPH: Long-term comparison of the enucleation vs. vaporization.</a> European Eurology. 14 (2), 137-151 (2015).</li>
<li>Lerner, L. B., Rajender, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laser+prostate+enucleation+techniques%5BTitle%5D)+AND+%22Canadian+Journal+of+Urology%22%5BJournal%5D)">Laser prostate enucleation techniques.</a> Canadian Journal of Urology. 22 (Suppl 1), 53-59 (2015).</li>
<li>Das, A. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+retrospective+comparison+of+diode+to+holmium+for+laser+enucleation+of+the+prostate%5BTitle%5D)+AND+%22Canadian+Journal+of+Urology%22%5BJournal%5D)">A retrospective comparison of diode to holmium for laser enucleation of the prostate.</a> Canadian Journal of Urology. 26 (4), 9836-9842 (2019).</li>
<li>Hruby, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Eraser+Laser+Enucleation+of+the+Prostate%3A+Technique+and+Results%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">Eraser Laser Enucleation of the Prostate: Technique and Results.</a> European Urology. 63 (2), 341-346 (2013).</li>
<li>Lerner, L. B., Archana, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laser+prostate+enucleation+techniques%5BTitle%5D)+AND+%22Canadian+Journal+of+Urology%22%5BJournal%5D)">Laser prostate enucleation techniques.</a> Canadian Journal of Urology. 22 (5 Suppl 1), 53(2015).</li>
<li>Leonardi, R., Caltabiano, R., Lanzafame, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Histological+evaluation+of+prostatic+tissue+following+transurethral+laser+resection+%28TULaR%29+using+the+980+nm+diode+laser%5BTitle%5D)+AND+%22Archivio+Italiano+di+Urologia+e+Andrologia%22%5BJournal%5D)">Histological evaluation of prostatic tissue following transurethral laser resection (TULaR) using the 980 nm diode laser.</a> Archivio Italiano di Urologia e Andrologia. 82 (82), 1-4 (2010).</li>
<li>Kahokehr, A., Gilling, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Enucleation+techniques+for+benign+prostate+obstruction%3A+Which+one+and+why%3F%5BTitle%5D)+AND+%22Current+Opinion+in+Urology%22%5BJournal%5D)">Enucleation techniques for benign prostate obstruction: Which one and why?</a> Current Opinion in Urology. 24 (1), 49-55 (2013).</li>
<li>Chung, D. E., Te, A. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((New+techniques+for+laser+prostatectomy%3A+an+update%5BTitle%5D)+AND+%22Therapeutic+Advances+in+Urology%22%5BJournal%5D)">New techniques for laser prostatectomy: an update.</a> Therapeutic Advances in Urology. 1 (2), 85-97 (2014).</li>
<li>Wu, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+comparative+study+of+diode+laser+and+plasmakinetic+in+transurethral+enucleation+of+the+prostate+for+treating+large+volume+benign+prostatic+hyperplasia%3A+a+randomized+clinical+trial+with+12-month+follow-up%5BTitle%5D)+AND+%22Lasers+in+Medical+Science%22%5BJournal%5D)">A comparative study of diode laser and plasmakinetic in transurethral enucleation of the prostate for treating large volume benign prostatic hyperplasia: a randomized clinical trial with 12-month follow-up.</a> Lasers in Medical Science. 31 (4), 599-604 (2016).</li>
<li>Wang, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Photoselective+Vaporesection+of+the+Prostate+via+an+End-firing+Lithium+Triborate+Crystal+Laser%5BTitle%5D)+AND+%22Journal+of+Visualized+Experiments%22%5BJournal%5D)">Photoselective Vaporesection of the Prostate via an End-firing Lithium Triborate Crystal Laser.</a> Journal of Visualized Experiments. (135), e57336(2018).</li>
<li>Shigemura, K., Tanaka, K., Yamamichi, F., Chiba, K., Fujisawa, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+Predictive+Factors+for+Postoperative+Incontinence+of+Holmium+Laser+Enucleation+of+the+Prostate+by+the+Surgeons%27+Experience+During+Learning+Curve%5BTitle%5D)+AND+%22International+Neurourology+Journal%22%5BJournal%5D)">Comparison of Predictive Factors for Postoperative Incontinence of Holmium Laser Enucleation of the Prostate by the Surgeons' Experience During Learning Curve.</a> International Neurourology Journal. 20 (1), 59-68 (2016).</li>
<li>Stroman, L., Ellis, D., Toomey, R., Mazaris, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((An+18-month+Audit+of+TURP+Complications+using+the+Clavien-Dindo+Classification+System%5BTitle%5D)+AND+%22Journal+of+Urology%22%5BJournal%5D)">An 18-month Audit of TURP Complications using the Clavien-Dindo Classification System.</a> Journal of Urology. 1 (3), 3(2013).</li>
<li>Li, B., Xu, A., Zou, Y., Liu, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+Randomized+Trial+Comparing+Diode+Laser+Enucleation+of+the+Prostate+with+Plasmakinetic+Enucleation+and+Resection+of+the+Prostate+for+the+Treatment+of+Benign+Prostatic+Hyperplasia%5BTitle%5D)+AND+%22Journal+of+Endourology%22%5BJournal%5D)">A Randomized Trial Comparing Diode Laser Enucleation of the Prostate with Plasmakinetic Enucleation and Resection of the Prostate for the Treatment of Benign Prostatic Hyperplasia.</a> Journal of Endourology. 27 (10), 1254-1260 (2013).</li>
<li>Lerner, L. B., Rajender, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laser+prostate+enucleation+techniques%5BTitle%5D)+AND+%22Canadian+Journal+of+Urology%22%5BJournal%5D)">Laser prostate enucleation techniques.</a> Canadian Journal of Urology. 22 (5 Suppl 1), 53(2015).</li>
<li>Wu, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+comparative+study+of+diode+laser+and+plasmakinetic+in+transurethral+enucleation+of+the+prostate+for+treating+large+volume+benign+prostatic+hyperplasia%3A+a+randomized+clinical+trial+with+12-month+follow-up%5BTitle%5D)+AND+%22Lasers+in+Medical+Science%22%5BJournal%5D)">A comparative study of diode laser and plasmakinetic in transurethral enucleation of the prostate for treating large volume benign prostatic hyperplasia: a randomized clinical trial with 12-month follow-up.</a> Lasers in Medical Science. 31 (4), 599-604 (2016).</li>
<li>Xu, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+randomized+trial+comparing+diode+laser+enucleation+of+the+prostate+with+plasmakinetic+enucleation+and+resection+of+the+prostate+for+the+treatment+of+benign+prostatic+hyperplasia%5BTitle%5D)+AND+%22Journal+of+Endourology%22%5BJournal%5D)">A randomized trial comparing diode laser enucleation of the prostate with plasmakinetic enucleation and resection of the prostate for the treatment of benign prostatic hyperplasia.</a> Journal of Endourology. 27 (10), 1254-1260 (2013).</li>
<li>Yang, S. S., Hsieh, C. H., Lee, Y. S., Chang, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Diode+laser+%28980+nm%29+enucleation+of+the+prostate%3A+a+promising+alternative+to+transurethral+resection+of+the+prostate%5BTitle%5D)+AND+%22Lasers+in+Medical+Science%22%5BJournal%5D)">Diode laser (980 nm) enucleation of the prostate: a promising alternative to transurethral resection of the prostate.</a> Lasers in Medical Science. 28 (2), 353-360 (2013).</li>
<li>Liu, L., Cheng, F., Li, H., Yu, W., Rao, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+Clinical+Effect+Between+Transurethral+1+470+nm+Diode+Laser+Enucleation+of+the+Prostate+and+Transurethral+Bipolar+Plasmakinetic+Resection+of+Prostate%5BTitle%5D)+AND+%22Medical+Journal+of+Wuhan+University%22%5BJournal%5D)">Comparison of Clinical Effect Between Transurethral 1 470 nm Diode Laser Enucleation of the Prostate and Transurethral Bipolar Plasmakinetic Resection of Prostate.</a> Medical Journal of Wuhan University. 39 (5), 809-812 (2018).</li>
<li>Nair, S. M., Pimentel, M. A., Gilling, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+Review+of+Laser+Treatment+for+Symptomatic+BPH+%28Benign+Prostatic+Hyperplasia%29%5BTitle%5D)+AND+%22Current+Urology+Reports%22%5BJournal%5D)">A Review of Laser Treatment for Symptomatic BPH (Benign Prostatic Hyperplasia).</a> Current Urology Reports. 17 (6), 1-8 (2016).</li>
<li>Cho, M. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Predictor+of+de+novo+urinary+incontinence+following+holmium+laser+enucleation+of+the+prostate%5BTitle%5D)+AND+%22Neurourology%2C+Urodynamics%22%5BJournal%5D)">Predictor of de novo urinary incontinence following holmium laser enucleation of the prostate.</a> Neurourology, Urodynamics. 30 (7), 1343-1349 (2011).</li>
<li>Herrmann, T. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+outcome+after+endoscopic+enucleation+of+the+prostate%3A+From+monopolar+enucleation+to+HoLEP+and+from+HoLEP+to+EEP%5BTitle%5D)+AND+%22Der+Urologe.+Ausg.+A%22%5BJournal%5D)">Long-term outcome after endoscopic enucleation of the prostate: From monopolar enucleation to HoLEP and from HoLEP to EEP.</a> Der Urologe. Ausg. A. 55 (11), 1446(2016).</li>
</ol>

The authors have nothing to disclose.

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 times9,13,14,15.
Her...

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 recovery4,5.
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 ability7,8.
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.

<table><tbody><tr><td>HU Diode Laser</td><td>Beijing L.H.H.Medical Science Development Co., Ltd</td><td>HU-150</td><td>Wavelength: 980nm&lt;br/&gt; Maximum Power: 150W&lt;br/&gt; Operation Mode: Continuous and pulsed</td></tr><tr><td>Optical Fiber</td><td>Beijing L.H.H.Medical Science Development Co., Ltd</td><td>YYGX600</td><td>Fiber core diameter:&lt;br/&gt; 600 &amp;mu;m&lt;br/&gt; Fiber length: 2m</td></tr><tr><td>Morcellator System</td><td>Beijing L.H.H.Medical Science Development Co., Ltd</td><td>PXQ-01</td><td>Rotate Speed: 100-3000rpm&lt;br/&gt; MAX. Vacuum Pressure: -80KPa&lt;br/&gt; Rated Output Torque: 12mNm&lt;br/&gt; Blade Size: &amp;Phi;5.0*390mm; &amp;Phi;3.5*390mm&lt;br/&gt; Blade Work Mode: Corotation alternates reversal</td></tr></tbody></table>

enucleation of the prostate for the treatment of benign prostatic hyperplasia using a 980 nm diode laser

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

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&#39;s arrow). Compared to other procedures, mDiLEP has fewer intraoperative complications, a shorter learning curve, and achieves more tissue resection.

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 1st, 3rd, and 12th months postoperatively. The International Prostate Sympt...

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

In the aging male population, the occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem. ...

enucleation-prostate-for-treatment-benign-prostatic-hyperplasia-using

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Learn diode laser enucleation for treating benign prostatic hyperplasia using a 980 nm wavelength system. This technique reduces intra-operative complications and offers a shorter learning curve for urologists.

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

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