|Year : 2006 | Volume
| Issue : 1 | Page : 49-52
Holmium laser assisted 'anatomical' enucleation of adenoma of benign hyperplasia of prostate
Shivadeo S Bapat, Ketan V Pai, Satyajeet S Purnapatre, Pushkaraj B Yadav, Abhijit S Padhye
Department of Urology, Maharashtra Medical Foundation's Ratna Memorial Hospital, 986, Senapati Bapat Road, Pune - 411053, India
Shivadeo S Bapat
Janhavi, 797/4 Bhandarkar Inst. Road, Pune - 411004
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: To present our technique of Holmium Laser assisted "ANATOMICAL" enucleation of the benign prostatic adenoma (HoLEP) in 219 patients. Procedure is based on the principle of digital enucleation of the adenoma from its surgical capsule, but performed entirely by perurethral endoscopic technique assisted by Holmium Laser. Materials and Methods: From March 2001 to November 2004, 219 patients under went HoLEP. After the initial cuts from bladder neck to verumontanum at 5 and 7 o'clock position, capsule is identified. The beak of the resectoscope sheath was inserted in the plane between the capsule and the adenoma and the adenoma was physically pushed away towards the urethra from the capsule. Laser was used to coagulate the bleeders, to cut the mucosal attachments and tough stromal tissue. Procedure was repeated for median and two lateral lobes. There was minimal bleeding and fluid absorption. Complications were few. Results: In 206 cases successful enucleation of the adenoma was carried out. First 13 cases formed part of the learning curve and were completed by standard transurethral resection of prostate (TURP). IPSS score dropped from average of 23 to 8 and peak flow improved from<11 to >20. No patient had postoperative urinary incontinence or stricture. Conclusions: HoLEP is an effective alternative to TURP. Ultimate end results replicate the end results of open enucleation of BPH without its morbidity and have all the advantages of endoscopic surgery. It offers distinct advantages over standard TURP as the incidence of blood transfusion and fluid absorption are greatly minimized.
Keywords: Benign prostatic adenoma, holmium laser enucleation
|How to cite this article:|
Bapat SS, Pai KV, Purnapatre SS, Yadav PB, Padhye AS. Holmium laser assisted 'anatomical' enucleation of adenoma of benign hyperplasia of prostate. Indian J Urol 2006;22:49-52
|How to cite this URL:|
Bapat SS, Pai KV, Purnapatre SS, Yadav PB, Padhye AS. Holmium laser assisted 'anatomical' enucleation of adenoma of benign hyperplasia of prostate. Indian J Urol [serial online] 2006 [cited 2020 Jan 18];22:49-52. Available from: http://www.indianjurol.com/text.asp?2006/22/1/49/24655
| Introduction|| |
Benign hyperplasia of prostate gland (BPH) is one of the commonest conditions afflicting the ageing male population. Incidence increases with age. Those who are symptomatic need treatment. In yester years open enucleation of the benign adenoma within its "ANATOMICAL" or surgical capsule was the mainstay of the treatment. This was achieved either through transvesical, retropubic or perineal approaches. Apart from morbidity of the operative procedure, the long term results of the successful open operations were excellent. Transurethral resection of prostate (TURP) is an exacting procedure requiring long learning curve and is not without its share of complications. This prompted the urologist all over to try less exacting and minimally invasive procedures. All the newer modalities of surgical procedures are being compared with TURP which is considered as the 'gold standard'. Lasers are the latest entrants in the modalities of surgical management of BPH. Author wishes to present results of 219 endoscopic enucleation of prostatic adenoma within its "ANATOMICAL" or surgical capsule with the help of holmium laser (HoLEP). Ultimate end results replicate the end results of open enucleation of BPH without its morbidity and have all the advantages of endoscopic surgery.
| Materials and Methods|| |
From March 2001 to November 2004, 219 patients with BPH underwent Holmium laser enucleation with Sphinx Lisa Laser (80-Watts and 550 m end firing laser fibre, Lisa Laser Products OHG - Katlenburg, Germany). Enucleation was carried out with continuous irrigation resectoscope (26 Fr.) with 30° telescope. The laser fibre was passed through 'Kuntz' working element (Karl Storz - Tuttlingen, Germany). Sterile water was used for irrigation in all the cases that was kept 60 centimetres above the level of the symphysis pubis. Age of the patients ranged from 51 to 93 years. All patients were investigated as per the institutional protocol and significant number of patients had associated co-morbid conditions like Diabetes Mellitus 65 (29%), Ischemic heart disease 24 (11%), Myocardial infarction 12 (5.4%), Permanent pacemaker 4 (1.8%), Cerebro vascular accident 5 (2.2%), Chronic obstructive pulmonary disease 18 (8.2%), Chronic renal failure 8 (3.6%), Parkinson's disease 3 (1.3%) and Hypothyroidism 2 (0.2%). Many patients had two or more co-morbid conditions. All patients were operated by the same urologist under epidural or spinal anaesthesia except 3 cases, which were operated under local anaesthesia + sedation. Urethra was dilated to 30 Fr. Otis urethrotomy cut was taken only if the urethra was tight or the estimated size of the gland was more than 30 grams. Principle of endoscopic enucleation of BPH adenoma is like that of digital enucleation [Figure - 1]a, b. In HOLEP, first two incisions are taken by laser from bladder neck, one each from 5 and 7 o'clock position to the level of verumontanum. After completing the two incisions, they are joined in front of the verumontanum (veru) [Figure - 2]a,b. This transverse incision in front of veru is deepened till the smooth surface of the surgical capsule is visualised. Quite often presence of tiny dark prostatic calculi confirms that the surgical capsule has been reached. Carefully the beak of the resectoscope sheath is dipped down under the just freed edge of the adenoma in front of the veru and gently the beak is elevated [Figure - 3]a,b. The adenoma will easily peel off the surgical capsule which is seen as a smooth shining surface. Beak is advanced further under the separated adenoma and the adenoma is still pushed anteriorly. It is very important to realize that the capsule gently curves upwards. Gradually the median lobe will be seen only attached to the bladder mucosa between 5 and 7 o'clock position, which is incised by laser and the lobe pushed in to the bladder. Bladder neck is next incised at 6 o'clock position, deep enough to open the neck. Perforation should be avoided. Haemostasis in the resected area is achieved by de-focussed laser fire. Next step is to take a semicircular incision on the apical part of the prostatic lobe at the level of the veru and ending at 12 o'clock. Incision is deepened till the whitish adenoma is clearly exposed. Another incision is taken in the midline at 12 o'clock position from the bladder neck to the veru level to meet the earlier circular incision. For enucleating the patient's left lobe, resectoscope sheath is rotated so that the telescope faces 11 o'clock position. This will bring the beak of the resectoscope sheath at 5 o'clock position. With the 30° telescope, the apical adenoma at 5 o'clock position and the mucosal incision will be clearly seen. The beak is gently pressed on the adenoma just inside the incision and the adenoma is pushed towards the urethra. Adenoma will start peeling off its surgical capsule. Once the plane is identified, the beak is used to push the adenoma off the capsule in all its remaining attachments. Laser will be needed to incise tough attachments and to coagulate the bleeders. It is very important to remember that the surgical capsule of the prostate gently curves towards midline. Attachments at 12 o'clock position are then incised. Ultimately the enucleated lobe is pushed into the bladder cavity by incising the mucosal attachments in the 1 to 5 o'clock sector. Similar procedure is carried out for enucleating the remaining lobe. If the size of the lateral lobes is big, after initial mobilization of the adenoma at the veru level from the capsule, the lobe is divided into two by a longitudinal incision from bladder neck to the mobilised part of the adenoma. If there is no prominent median lobe, initial incision is taken at the bladder neck at 6 o'clock position till the capsule is visualised. Similar procedure is followed for enucleation of the two lateral lobes. Final inspection of the enucleated fossa is carried out to visualise if there are any left over adenomas and they are resected by holmium laser. Haemostasis is assured. Enucleated adenomas are then removed. We use two techniques. Tissue punch (Karl Storz - Tuttlingen, Germany) is passed through the resectoscope sheath and the enucleated adenomas are cut into small pieces and then evacuated like TUR chips. This is a slow process and for large adenomas it takes considerable time. But since we have acquired the Lumenis VersaCut morcellator (Lumenis Ltd. - Yokneam, Israel), the evacuation time is drastically reduced, thus greatly cutting down the operating time. For using the morcellator, the resectoscope sheath is removed and a rigid Nephroscope with offset telescope (26 Fr.) is inserted. Finally a 22 Fr. three way Foley catheter is passed. Irrigation is maintained till the next morning (16 to 20 hours). Catheter is removed 24 to 36 hours after the surgery and the patient is discharged the same evening or the next day. Weight of the enucleated gland varied from 7 to 50 grams.
| Results|| |
In 206 cases successful enucleation of the adenoma with the help of Holmium laser was carried out. First 13 cases formed part of the learning curve and were completed by standard TURP. International Prostate Symptom Score decreased from 23 to 8 and peak urinary flow rate improved from <11 to >19.4 ml/sec. 6 patients (2.7 %) developed secondary bladder neck obstruction that needed bladder neck incision. Permanent incontinence and stricture urethra was not observed in any patient. Follow up ranged from 1 to 36 months. In two patients adenocarcinoma prostate (CAP) was detected on histological examination, although there was no evidence of CAP preoperatively. Complications were few: conversion to TURP-13 (learning curve), subtrigonal perforation-4, capsular perforation-2, reactionary bleeding-1, blood transfuson-1, secondary bladder neck contracture-6.
| Discussion|| |
TURP is considered as a gold standard. However various published reports do mention the complication rates up to 18 %. Many alternative modalities of minimally invasive endoscopic management of BPH have been introduced. There is a common disadvantage in all these modalities, that they become increasingly ineffective as the size of the BPH increases. Holmium laser is the latest entrant in the management of BPH.
Holmium laser has certain unique properties, that makes it eminently suitable in the management of BPH. Its wave length is 2140 nm and it is strongly absorbed by water and is in the near infra red range of the electromagnetic spectrum. It is a pulsed laser and has penetration of only 0.5 mm. Holmium laser energy can be transmitted through a glass fibre. With the burst of energy in kilowatt range, precise tissue vaporisation at the tip of the laser fibre can be achieved. Another advantage of holmium laser is the fact that at the time of energy release it not only vaporizes the tissue but also seals the blood vessels (both arteries and veins). This is the single most important fact that minimizes the blood loss and fluid absorption during enucleation of BPH. If a bleeder is encountered, by defocusing the laser beam excellent coagulation of the bleeding point can be achieved. Apart from these properties it is an excellent energy for crushing stones of any hardness.
A prospective controlled trial was conducted in our institution where 50 patients were operated (26 - TURP and 24 - HoLEP). They were matched for age and size of BPH. All underwent intraoperative ethanol monitoring and serum sodium estimation pre and postoperatively. Results conclusively proved that the fluid absorption was nil to minimal in HoLEP and more in TURP. It was more with larger glands.
With the increase in the size of BPH, resection time also increases and for large adenomas a staged procedure may be required. Mebust et al reviewed 3885 TURP procedures and has reported increased incidence of intraoperative bleeding and TUR syndrome when the resection time was greater than 90 minutes. During HoLEP the visual field is clear all the time and chances of bleeding and fluid absorption are minimal. Ramsay et al, Moody and Lingman and Kuntz & Lehrich  reported the outcome of their experience of HoLEP for large adenomas and compared their results with open prostatectomy. They observed significant decrease in the blood loss and hospital stay. Incidence of post operative stricture and secondary bladder neck contracture was not seen after enucleation of large adenomas.
After enucleation of the median lobe, incision of the bladder neck helps in pushing the lateral lobes in to the bladder. However if the lateral lobe was very large, it was divided into two or three parts and then pushed to the bladder cavity one by one.
In four patients who were on long term treatment with Finasteride, enucleation was technically more difficult as the plane of separation was difficult to develop. In two of these patients capsular perforation occurred. Histopathologically there was preponderance of stromal tissue.
As the bulk of the adenoma is enucleated by mechanical pushing of the adenoma off its surgical capsule, total usage of holmium laser energy was quite low. Thus the effect of heat & necrosis on the enucleated fossa was less.
Patients on anticoagulants, implanted pace makers and compromised cardiac reserve can be operated by Holmium laser safely. Author has operated such three cases under local anesthesia and sedation.
Blood loss was minimal, hence no blood transfusion was needed. In the present series only one patient needed blood transfusion and was one out of the first 13 patients, that formed the learning curve.
Catheter was removed either on the first or the second post operative day and the patient was discharged soon after satisfactory urination is established.
No patient developed stricture urethra. Six patients developed secondary bladder neck obstruction that needed bladder neck incision about 3 to 6 months after HoLEP.
One important aspect of HoLEP surgery was the time taken for the entire procedure. HoLEP takes longer than the standard TURP. Further more removal of enucleated adenoma from the bladder cavity adds to the time. Tissue punch is a very simple and safe instrument. It can be passed through the existing resectoscope sheath and same 30° telescope fits the punch. It is a slow process and adds extra time for the entire procedure. Since we have acquired the Lumenis VersaCut morcellator, removal of the enucleated adenoma has shortened the evacuation time to just a few minutes. However for the introduction of the morcellator, resectoscope assembly has to be removed and a 26 Fr. rigid Nephroscope with offset telescope has to be introduced in to the urethra. Morcellator has to be handled very carefully. Injury to the bladder mucosa is a potential complication.
Cost of Holmium laser and the morcellator together is quite high. But Fraundorfer & Gilling  have shown that if a minimum of 93 patients are treated by HoLEP every year, it will become cost effective. However these economic calculations may not be applicable to a developing country like India. If the Institutions subsidize the cost of the laser charged per patient, it will be cost effective. As such the maintenance cost of the laser is very low indeed and a single fibre can be easily used for over 60 HoLEP operations.
HoLEP is a technically demanding endoscopic procedure. However author is of the opinion that those who are well trained in the art of TURP can easily master HoLEP. It is important to understand the three dimensional structure of the prostate and the adenoma within. In TURP, the operator is within the urethra and gradually works himself centrifugally to the capsule. Whereas, in HoLEP the operator first identifies the surgical capsule and pushes the adenoma away from it centripetally. It is advisable to start learning on smaller prostatic adenomas and as the experience builds up larger glands can be enucleated.
| Conclusion|| |
HoLEP is an effective alternative for TURP. It can be used even for large adenomas. Complications are minimal. Ultimate end results replicate the end results of open enucleation of BPH without its morbidity and have all the advantages of endoscopic surgery. It offers distinct advantages over standard TURP as the incidence of blood transfusion and fluid absorption are greatly minimized with short hospital stay.
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[Figure - 1], [Figure - 2], [Figure - 3]