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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Topic: BPH
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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MIST Procedures and Sexual Dysfunction
Faysal A. Yafi, MD, FRCSC, discusses minimally invasive surgical procedures and their impact on sexual dysfunction.
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Surgical BPH: 2024 Updates and Where Are We Going
Nicole L. Miller, MD, FACS, delivers an incisive update on the surgical management of benign prostatic hyperplasia (BPH). In this 11-minute presentation, Dr. Miller outlines the current AUA guidelines, highlighting a broad spectrum of treatments tailored to prostate size. Trends in national data reveal that transurethral resection of the prostate (TURP) remains the dominant procedure, while minimally invasive options like UroLift have gained substantial traction.
Dr. Miller discusses emerging technologies, including the OptilumeⓇ BPH System. She also reviews promising data on MRI-guided transurethral ultrasound ablation (TULSA). Advanced laser techniques, particularly holmium pulse modulation, and thulium fiber laser, are explored for their efficacy in enucleation procedures, showing advantages in operative time, hemostasis, and same-day discharge rates. Miller highlights evolving techniques like en bloc enucleation with early apical release. A brief discussion on robotic-assisted simple prostatectomy includes recent shifts toward single-port approaches.
Dr. Miller stresses the importance of aligning treatment with patient preferences and quality-of-life goals, emphasizing shared decision-making as central to optimizing outcomes in this rapidly advancing field.
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Optilume for BPH
Sunchin Kim, MD, offers an in-depth exploration of OptilumeⓇ, a novel therapy for benign prostatic hyperplasia (BPH).
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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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Posterior Stenosis – Post-Radiation or Anti-BPH Procedures
Dmitriy Nikolavsky, MD, discusses urethral stricture and stenosis management following radiation and anti-BPH procedures, highlighting surgical challenges, outcomes, and the evolution of treatment strategies.
In this 11-minute presentation, Nikolavsky explores the differences in stricture occurrence across treatment types. Surgical approaches are tailored based on oncologic status, patient preference, and local tissue health. Buccal mucosal grafts for dorsal urethroplasty are highlighted as a promising technique. Notably, dorsal-only urethroplasty has demonstrated comparable success to EPA with a lower incidence of postoperative incontinence.
Dr. Nikolavsky emphasizes the difficulties of traditional excision procedures in radiated fields, proposing dorsal-only urethroplasty as a better alternative due to its minimal disruption of adjacent structures. He shares evidence from multi-institutional studies that support its efficacy.
With a call to challenge established dogmas, Nikolavsky underscores the need to refine guidelines and expand the use of innovative approaches like dorsal urethroplasty to improve patient outcomes.
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TURP in 2024
Granville L. Lloyd, MD, provides a comprehensive overview of therapies for benign prostatic hyperplasia (BPH), focusing on the evolution from medical to procedural interventions. In this 9-minute presentation, he highlights the ongoing development and competition among various technologies, emphasizing procedural therapy over medical management in terms of sexual outcomes. Dr. Lloyd’s presentation describes the wide array of procedural options, including TURP, Rezūm, UroLift, and newer approaches like Optilume.
The economic and clinical burden of BPH is underscored. Dr. Lloyd advocates for a personalized approach to selecting the appropriate therapy, utilizing the best tool available for each patient while acknowledging the evolving role of newer technologies.
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HoLEP
Lori B. Lerner, MD, delves into the complexities of enucleation techniques for treating benign prostatic hyperplasia (BPH), emphasizing the importance of understanding prostate anatomy. In this 11-minute presentation, she highlights how individual anatomical variations influence surgical decisions and outcomes, particularly in laser enucleation.
Dr. Lerner outlines different approaches to enucleation, involving strategic incisions to address each patient’s specific anatomy. She discusses complex cases, such as patients with a significant portion of their prostate extending into the bladder, nodular prostates, or elevated bladder necks, which necessitate tailored approaches.
Dr. Lerner’s presentation underscores the necessity of careful preoperative imaging, using tools like MRI or CAT scans, to map the prostate’s structure and guide the surgical approach. She advocates against routine excessive testing, emphasizing responsible and targeted use of diagnostic tools to inform clinical decisions without unnecessary expenditure. Lerner also addresses potential complications such as postoperative stress urinary incontinence.
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Optilume
Garrett D. Pohlman, MD, discusses the Optilume BPH procedure, a novel treatment for benign prostatic hyperplasia (BPH). In this 11-minute talk, Pullman gives step-by-step instructions for the Optilume placement procedure, emphasizing how the treatment can be tailored to individual patients based on prostate size, anatomy, and personal preferences.
Pullman discusses the safety and efficacy of Optilume, as well as data from studies like Pinnacle and Everest. He also shares that the placement procedure can be performed in various settings, including outpatient surgery centers and offices. He asserts that Optilume BPH is a promising, durable, and patient-friendly option for treating BPH.
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Should MIST be First Line Treatment for BPH?
Seth K. Bechis, MD, explores the question of whether or not minimally invasive surgical therapies (MIST) should be first line treatment for BPH. He begins by highlighting the prevalence of BPH in men over 60. He acknowledges that combination therapy is extremely effective in combating BPH in the short-term, but it has several long-term risks which impact patient QoL.
Dr. Bechis highlights the negative side-effects of 5-ARIs, alpha blockers, and surgery post-medication-failure. Side-effects included increased risk of cardiac failure, dementia, depression, and sexual dysfunction.
Dr. Bechis then examines current MIST procedures for BPH treatment, including prostatic urethral lifts, water vapor thermal therapy, temporarily implanted nitinol devices, and balloons. He examines the durability, effectiveness, and side-effects for each procedure, and compares them to patients on medication
Dr. Bechis concludes by comparing the cost effectiveness of MIST procedures to the cost of medication, taking into account IPSS improvement and Quality-Adjusted Life Years over time. Overall, he suggests that MIST procedures should be explored as a first line treatment for BPH.
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The Prostatic Urethral Lift (Urolift): Back to Basics
Matthew C. Ercolani, MD, FACS, provides an overview of UroLift, a minimally invasive procedure for benign prostatic hyperplasia (BPH). In this 11-minute presentation, Ercolani explains his reasoning for performing the UroLift procedure and its benefits compared to other options.
Dr. Ercolani reviews the optimal patient profile, best placement locations, and areas to avoid when performing the implant procedure. He then shares a video of implantation, illustrating how to customize Urolift placement and providing a “before and after” comparison.
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