Holmium:YAG Laser Enucleation of the Prostate: Technical Details

1. Holmium:YAG Laser Enucleation of the Prostate: Technical Details Brian C. Fong Mostafa M. Elhilali McGill University Montreal, Quebec, Canada

2. Introduction • Holmium:YAG laser enucleation of the prostate (HoLEP) was originally described by Gilling et al. • Advantages • Hemostatic; may be used on anticoagulated patients • Normal saline as irrigating fluid • No prostatic size limit • Decreased catheter time, blood loss, hospital stay • Comparative results with standard TURP

3. Introduction • Disadvantages • Increased time for resection • Initial cost • Some tissue lost as thermal artifact • Steep learning curve • Objective of this video article • To present the two and three lobe technique for HoLEP with emphasis on some technical details

4. Learning Curve • Most urologist trying this technique for the first time get lost during the dissection and therefore are discouraged • Our institutional experience notes that residents can adopt this technique after an average of 20 procedures (publication submitted)

5. Learning Curve Resident vs. Staff HoLEP Experience TRUS = Transrectal Ultrasound; IPSS = International Prostate Symptom Score; Qmax = Maximum Urine Flowmetry Rate

6. Technique • Size and anatomy dictates the type of procedure most appropriate for the patient • Two techniques • Two lobe technique • small or non-existent median lobe • Three lobe technique • large median lobe

7. Equipment • 80-100 Watt laser source • Ideal setting: 2 Joules at 40-50 Hz • 26 French continuous flow resectoscope with modified sheath for laser tip • 500 m end firing quartz laser fiber • end stripped before each use • 20-30 procedures possible per fiber • 7 French stabilizing laser catheter • Normal saline irrigation solution • Video monitoring system • Tissue morcellator

8. Step 1 5 O’Clock Incision and Decision on Median Lobe Enucleation • Two-Lobe Technique • 5 o’clock incision from bladder neck to verumontanum • Prepare for enucleation of left lateral lobe • Three-Lobe Technique • 5 o’clock incision from bladder neck to verumontanum • Similar incision at 7 o’clock • Prepare for enucleation of middle lobe

11. Step 2 Incision Near Verumontanum • Made to define the depth where a plane of enucleation can be identified between adenoma of lateral lobe and surgical capsule

13. Step 3 Blunt Enucleation • This mobilizes the lobe off the surgical capsule and away from the sphincter

15. Step 4 Dissection To Bladder Neck • Extension of dissection forward allows separation of the lateral lobe from the bladder neck

17. Step 5 12 O’clock Incision • This allows for dissection of both lobes from 12 o’ clock - 3 o’ clock between the left lobe and the surgical capsule or 12 o’clock - 9 o’clock between the right lobe and the surgical capsule

19. Step 6 Release of Mucosa From Sphincter • Identify the band of mucosa holding the lobe inside the sphincter at 1-2 o’clock or 10-11 o’clock. • Retract the fiber into sheath with energy reduced to 80 Watts from 100 Watts • Short cuts made to release this band

21. Step 7 Joining Planes From Above and Below • This will enucleate the lateral lobe into the bladder

23. Step 8 Completion of Two-Lobe Technique • Start dissecting the remaining lobe by incision in front of the verumontanum and identifying the plane • Blunt dissection similar to the other side but including the median lobe up to the bladder neck • Repeat the incision of the band at 10-11 o’clock to enucleate the lobe to the bladder

26. Step 9 Hemostasis • Use setting of 1.5 J and 30 Hz (45 Watts) to reduce heat trauma, particularly at the sphincter

28. Step 10 Morcellation • Resectoscope removed and 27 French standard nephroscope sheath and indirect lens used so the morcellator can be inserted • Employment time consistently varies • Morcellation up to 7 grams per minute • Avoid bladder injury • Ensure bladder is full at all times • Use suction to bring tissue closer to prostatic fossa • At the end of procedure, inspect bladder and fossa to ensure hemostasis

30. Immediate Post-operative Care • 22 French Two-Way catheter inserted • Intermittent bladder irrigation can be set up with Y-connector if required • Lasix 20 mg iv usually given to eliminate saline absorbed during procedure • Usually no post-op bloodwork required • Catheter can be removed the next morning and patient discharged within 24 hours

31. Conclusion • HoLEP offer clear advantages to TURP such as reduced catheter times, hospitalization, blood loss along with the ability to operate on anticoagulated patients and large prostates • Our video has illustrated the importance of blunt dissection to remain in the anatomic plane • We hope a clear understanding of the steps of the two lobe and three lobe technique will help reduce the frustrations encountered during early adoption of this technique

32. References • Gilling PJ, Cass CB, Cresswell MD, et al: The use of the holmium laser in the treatment of benign prostatic hyperplasia. J Endourol 1996; 10: 459-461. • El-Hakim A, Elhilali MM: Holmium Laser Enucleation of Prostate: initial teaching experience and technical advances. BJU Intl 2002 (Submitted). • Gilling PJ, Kennett KM, et al: Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience. J Endourol 1998; 12: 457-9. • Gilling PJ, Kennett KM, et al: Holmium laser enucleation of the prostate for glands larger than 100g: an endourologic alternative to open prostatectomy. J Endourol 2000; 14: 529-31.

33. Authors Brian C. Fong, M.D. Urology Resident, McGill University Mostafa M. Elhilali, M.D. Professor, Division of Urology, McGill University Address for Correspondence: Mostafa M. Elhilali, M.D. Royal Victoria Hospital 687 Pine Avenue West, S6.95 Montreal, Quebec, Canada, H3A 1A1 E-mail: mostafa.elhilali@muhc.mcgill.ca