Tips and Tricks of Endoscopic Anatomical Enucleation of the Prostate
Pierluigi Bove, MD, explores surgical technique, device selection, and procedural optimization of endoscopic enucleation of the prostate.
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HoLEP
The King of Enucleations: HoLEP
Mitchell R. Humphreys, MD, MPH, delves into benign prostatic hyperplasia management and holmium laser enucleation (HoLEP).
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Morcellation and Potential HoLEP Complications
Amy E. Krambeck, MD, discusses HoLEP morcellation and its associated complications, emphasizing procedural refinements and patient safety.
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Holmium Laser Enucleation of the Prostate (HoLEP): Current Era Techniques and Outcomes
Amy E. Krambeck, MD, discusses holmium laser enucleation of the prostate, emphasizing its advantages, indications, and technical refinements.
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Morcellation and Potential HoLEP Complications
Amy E. Krambeck, MD, presents a detailed overview of morcellation and its potential complications, particularly in Holmium Laser Enucleation of the Prostate (HoLEP). In this 14-minute presentation, she explains the technical requirements for performing morcellation.
Dr. Krambeck narrates a video of the procedure’s steps. She highlights how challenging nodules can sometimes require additional laser grooves to enable effective morcellation.
Complications during morcellation are also reviewed. Intraoperative issues include capsular perforations and bladder injuries. Injury to the ureteral orifices, while rare, can occur during morcellation. Dr. Krambeck also discusses postoperative complications and their management, including bleeding, clot retention, and infections such as UTIs or epididymitis. Incontinence, mainly urge incontinence, is another common postoperative issue. However, with proper technique, HoLEP and morcellation present low complication rates and excellent patient outcomes.
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Practical Considerations of Laser Enucleation Programs
Ilya Sobol, MD, provides an in-depth analysis of the practical considerations involved in implementing and managing laser enucleation programs for benign prostatic hyperplasia (BPH). His discussion focuses on the technical aspects, patient selection, and logistical requirements essential for the successful execution of these programs.
Dr. Sobol outlines the advantages of laser enucleation techniques, such as holmium laser enucleation of the prostate (HoLEP). Dr. Sobol also discusses the technical expertise required for performing laser enucleation. He highlights the necessity for specialized training and experience to master the technique. Logistical considerations are also addressed, including the need for appropriate facilities and equipment.
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Overview of Current Surgical BPH
Amy Krambeck, MD, provides a comprehensive overview of current surgical options for treating benign prostatic hyperplasia (BPH), focusing on their efficacy, safety, and practical application. Her analysis emphasizes the evolution of surgical techniques and the criteria for selecting the most appropriate intervention for each patient.
Dr. Krambeck begins by discussing transurethral resection of the prostate (TURP), noting its potential complications, such as bleeding, infection, and the risk of TUR syndrome, which necessitates careful patient selection and postoperative monitoring. She then explores newer surgical techniques as alternatives to TURP, among these, laser therapies such as holmium laser enucleation of the prostate (HoLEP) and photoselective vaporization of the prostate (PVP). Dr. Krambeck also addresses minimally invasive surgical options like prostatic urethral lift (PUL) and water vapor thermal therapy.
The discussion includes a review of the practical considerations for each surgical option, including patient factors such as prostate size, comorbidities, and symptom severity. Complications and postoperative care are also discussed.
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Overview of Current MIST: Practical Considerations
Kevin C. Zorn, MD, FRCSC, FACS, provides an authoritative overview of current minimally invasive surgical techniques (MIST) for the treatment of benign prostatic hyperplasia (BPH). His analysis emphasizes the advancements in MIST and their role in providing effective and patient-friendly alternatives to traditional surgical approaches.
Dr. Zorn highlights the primary MIST options currently available, including transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), holmium laser enucleation of the prostate (HoLEP), and newer techniques such as water vapor thermal therapy and prostatic urethral lift (PUL). The procedural nuances of each MIST option are discussed in detail.
Dr. Zorn examines the outcomes and benefits of MIST as well as the challenges and limitations of the procedures. Future directions in MIST are considered, with Dr. Zorn highlighting ongoing research and innovation to further refine these techniques and expand their applicability. The integration of advanced imaging technologies and the development of novel therapeutic devices hold promise for enhancing the precision and effectiveness of MIST.
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Learning HoLEP Once Already in Practice: Value, Learning Curve, and Tips/Tricks
Rebecca C. Gerber, MD, presents practical guidance on the use of Holmium Laser Enucleation of the Prostate (HoLEP) in clinical practice. Dr. Gerber begins by enumerating the benefits of HoLEP as a treatment, and pre-operative requirements for patients.
Dr. Gerber then provides an overview of perioperative considerations and the steps for the procedure. She presents a video demonstration of the procedure in practice, providing her clinical perspective for each step.
Dr. Gerber concludes by presenting examples of past HoLEP procedures, and providing her perspectives on which cases are better for practitioners with less HoLEP experience. She highlights the benefits of using HoLEP to treat catheter-dependent patients.
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Point-Counterpoint: HoLEP vs. GreenLightTM PVP – HoLEP
Karen L. Stern, MD, discusses holmium laser enucleation of the prostate’s (HoLEP’s) greater efficiency, safety, and durability compared to GreenLightTM photosensitive vaporization of the prostate (PVP). Dr. Stern references a 2020 study that found improved outcomes with HOLEP over PVP regarding operative time, tissue removal, International Prostate Symptom Score (IPSS) at one year, Qmax, post-void residual volume (PVR), and post-operative prostate-specific antigen (PSA). Dr. Stern then discusses small-volume prostates, emphasizing HoLEP’s effectiveness.
However, she acknowledges that PVP and transurethral resection of the prostate (TURP) are acceptable modalities in treating small-volume prostates, contrary to the treatment of large-volume prostates. Dr. Stern then reviews American Urological Association (AUA) guidelines. These note that HoLEP may serve to treat BPH and lower urinary tract symptoms (LUTS) regardless of prostate size. The AUA further notes that PVP may be less effective for large-volume prostates.
In a review of other factors, the AUA cites a 2020 study showing that PVP had a bladder outlet obstruction retreatment rate of about 27% compared to HoLEP at 5%. Dr. Stern also explains that the majority of HoLEP patients experience same-day catheter removal and discharge from hospital stays. She then evaluates the safety profile of HoLEP and PVP, finding a low rate of perioperative complications with HoLEP and high rates of urgency with PVP. Dr. Stern highlights the increased quality of life produced by HoLEP and its increased durability, boasting a reoperative rate of less than 1% per lifetime. Dr. Stern completes her discussion by reiterating HoLEP’s status as the gold standard in the surgical treatment of BPH.
This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: HoLEP vs. GreenLightTM PVP– GreenLightTM PVP.”
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When All Else Fails: Holmium Laser Enucleation of the Prostate as Retreatment for BPH
Nicole L. Miller, MD, FACS, Associate Professor of Urology at Vanderbilt University Medical Center, discusses Holmium laser enucleation of the prostate (HoLEP), particularly focusing on the retreatment setting. AUA guidelines have recently been updated and now mirror EAU guidelines which suggest sizing a prostate before determining treatment options. Dr. Miller examines case studies that underscore the effectiveness of HoLEP in removing large prostates after the patients had previously undergone unsuccessful treatments, including transurethral resection of the prostate (TURP) and prostatic urethral lift. She then analyzes outcomes of a study that compared primary HoLEP (pHoLEP) to retreatment (rHoLEP) observing that the retreatment setting patients experienced shorter operative times, shorter length of stay, had less tissue resected, and had a higher rate of urethral stricture and clot retention. In spite of its utility, HoLEP has not been widely adopted and represents 4% of procedures, which Dr. Miller attributes to the steep learning curve associated with HoLEP. Lastly, she enumerates the barriers within the US medical system to physicians undertaking the HoLEP learning process and concludes that while Europe has numerous options for physicians to learn the technique, the American focus on robotic surgery means that fewer students learn open orifices surgical procedures.
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