Holmium Laser Enucleation of the Prostate: Initial Report of the First 230 Egyptian Cases Performed in a Single Center

doi:10.1016/j.urology.2009.12.035

Urology

Volume 76, Issue 2, August 2010, Pages 448-452

https://doi.org/10.1016/j.urology.2009.12.035 Get rights and content

Objectives

To report our experience with the first 230 cases of holmium laser enucleation of the prostate (HoLEP) performed in a single center.

Methods

A total of 230 cases of HoLEP were performed between June 2007 and June 2008. Mean age of patients was 69.8 ± 10.3 years, and 21.3% of patients were either on anticoagulant or antiplatelet treatment. There was no limit for prostate size, with a mean prostate size of 86.5 ± 65.4 g (range: 20-350 g). Follow-up was performed regularly at 1, 3, 6, and 12 months, assessing the Q_max, PVR, and International Prostate Symptom Score.

Results

Weight of prostate chips retrieved after morcellation was 78.6 ± 61.3 g (range: 10-350), with enucleation time 102.2 ± 55.4 minutes and morcellation time 19.3 ± 10.1 minutes, leading an estimated efficiency rate of 0.64 g/min. The rate of decrease in prostate volume and prostate-specific antigen was 90.8% and 82.5%, respectively. At 1 month, mean Q_max increased from 7.7 ± 2.3 to 25.8 ± 10.1 mL/s (P ≤.001), mean PVR decreased from 171.3 ± 126.3 to 41.6 ± 45.7 mL (P ≤.001), and mean international prostate symptom score improved from 17.3 ± 6.7 to 6.6 ± 3.4 (P ≤.001). These improvements were sustained throughout a 12-month follow-up period. Temporary irritative symptoms were evident in 34.6% and stress urinary incontinence in 9%, both of which were self-limited on medical treatment and Kegel exercises, respectively. Only 1 patient with pancytopenia required blood transfusion and there was no case for transurethral resection syndrome.

Conclusions

HoLEP is a safe and an effective modern modality for the treatment of symptomatic BPH regardless of the gland size, with satisfactory clinical outcome.

Section snippets

Patients

Between June 2007 and June 2008, a series of 230 consecutive patients underwent HoLEP and tissue morcellation in our institution. Indication for prostatectomy and demographic characteristics of the study group with their preoperative data are illustrated in Table 1. The protocol for this study was approved by the hospital review board, and the patients consented to participate in this study. There was no limit for prostate size (range: 20-350 g). Among our study group, 129 patients were

Results

HoLEP was successfully performed as described with the 3-lobe technique in 146 patients and the 2-lobe technique in 81 patients. In another 3 patients, laser malfunctions were encountered. In 2 patients, HoLEP was rescheduled on the next day after fixing the machine and in the third patient; the machine broke while doing the initial 5 o'clock incision, the procedure was converted to transurethral resection of the prostate (TURP). Disintegration of bladder stones was performed in the same

Comment

Until the advent of TURP in the 1930s, open prostatectomy was the only known surgery for BPH.² TURP being less invasive has replaced open prostatectomy to become the benchmark treatment for men with lower urinary tract symptoms secondary to BPH.³ Nevertheless, TURP has its own morbidity. In a study involving 3861 consecutive patients with BPH who underwent TURP between 1971 and 1996, the reported TURP mortality was 0.1% (5 patients), with an overall operative morbidity and blood transfusion

Conclusions

HoLEP appears to be a good alternative to the gold standard treatment for BPH in terms of safety and efficiency. Together with tissue morcellator, HoLEP can be a safe and an effective modality to treat symptomatic BPH irrespective of the adenoma size. In our hands the technique is reproducible and can be mastered.

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Cited by (18)

Complications of laser enucleation of the prostate: Results at two institutions
2017, Urological Science
Citation Excerpt :
No patients had ureteral orifice injury. The incidence of bladder or ureteral orifice injury in our study was less than other studies.5,7,20 One possible reason was that we cautiously prevented these two complications by holding a clear surgical view and avoiding morcellation while severe hematuria existed.
Benign prostate hyperplasia (BPH) is a common disease with bothersome symptoms. Conventional transurethral resection of prostate is the gold standard surgical treatment. Recently, various laser enucleation techniques of the prostate for BPH have been adopted worldwide. We report perioperative and postoperative complications with the modified Clavien classification system at two institutions.
We performed a retrospective analysis through chart review among patients who had undergone laser enucleation of the prostate for BPH in two tertiary referral centers between January, 2009 and December, 2012. The primary outcome was peri- and postoperative complications, whereas secondary outcome was duration of hospital stay and catheterization. The mean age of 271 patients was 72.1 years (range, 51–93 years). Their mean prostate volume was 62.8 mL (range, 22–270 mL). Fifty-seven (21%) patients had prostate volume > 80 mL. There were 101 patients and 169 patients in the diode and thulium groups, respectively.
No patients had Grade 5 complications. There were Grade 4a complications in three (1.1%) patients, Grade 3a in 22 (8.1%) patients, Grade 2 in nine (3.3%) patients, and Grade 1 in 62 (22.9%) patients. The prostate volume > 80 mL was not significantly related to higher complication rate (p = 0.456). The average duration of hospital stay and catheterization were 3.05 ± 0.75 days and 2.25 ± 1.29 days. Four patients (1.5%) needed secondary resection for residual prostate tissue. The complication rate of acute urine retention (AUR; p = 0.285), urethral stricture (p = 0.996), minor (p = 0.430), major (p = 0.371), or all complications (p = 0.105) was not statistically different between diode and thulium groups.
Laser enucleation of the prostate was a safe treatment with low significant complication rate, even for large-volume prostates. The complication rates between diode and thulium lasers were not significantly different. The reoperation rate of laser enucleation was very low but patients with extremely large prostate volume may have higher risk.
Outcomes of Holmium Laser Enucleation of the Prostate in the Re-Treatment Setting
2017, Journal of Urology
Citation Excerpt :
While the shorter operative time clearly demonstrates that rHoLEP is technically feasible, the faster time may also reflect more attending participation at these teaching institutions due to the possibility that HoLEP in a reoperative field would be more challenging for a trainee secondary to the altered prostate morphology and anatomy. Men in the current series who underwent rHoLEP had excellent functional outcomes, similar to those in the pHoLEP arm and in other large series.13–15 In terms of voiding parameters PVR improved in both groups by at least 150 ml and Qmax improved by more than 14 ml per second.
Holmium laser enucleation of the prostate can also be applied in the re-treatment setting when other benign prostatic hyperplasia therapies fail. We compared outcomes in men who underwent holmium laser enucleation of the prostate in the primary vs the re-treatment setting.
We retrospectively reviewed the records of 2,242 patients who underwent holmium laser enucleation of the prostate at a total of 4 academic hospitals between 2003 and 2015. Patient demographics, and operative and perioperative outcomes were compared between re-treatment and primary holmium laser enucleation of the prostate.
Of the 360 of 2,242 men (16%) who underwent re-treatment holmium laser enucleation of the prostate the procedure was done for residual urinary symptoms in 71%. The most common primary procedure was transurethral resection of the prostate in 42% of cases. Mean time between prior benign prostatic hyperplasia surgery and re-treatment was 68 months (range 1 to 444). There were no significant differences in age, prostate size, AUA (American Urological Association) symptom score or average flow rate between the cohorts. Perioperatively, re-treatment holmium laser enucleation of the prostate was associated with significantly shorter operative time, reduced blood loss, lower specimen weight and shorter length of stay. The AUA symptom score improved in both groups, although it remained higher in men who underwent re-treatment (6.5 vs 5.0, p <0.001). The likelihood of clot retention (4.7% vs 1.8%, p = 0.01) and urethral stricture (3.3% vs 1.5%, p = 0.043) was slightly higher in the re-treatment group.
Immediate perioperative outcomes of holmium laser enucleation of the prostate performed in the re-treatment setting were no different from those in the primary setting. While re-treatment was associated with an increased likelihood of clot retention, urethral stricture and higher AUA symptom score, these minimal differences must be considered against the overall favorable symptom improvement across both cohorts.
Prostate tissue retrieval after holmium laser enucletion of the prostate; Assessment of non-morcellation approaches
2016, Arab Journal of Urology
Citation Excerpt :
With the evolution of bipolar technology resection of the partially detached adenoma can be achieved without the need to change the irrigant and maintaining safety using an isotonic irrigant. Table 3 [7,12,14–24] reviews the role of non-morcellation tissue retrieval approaches used in contemporary series of transurethral enucleation procedures. In the present study, we exclusively report on these approaches in our growing HoLEP series.
To review non-morcellation approaches for tissue retrieval after holmium laser enucleation of the prostate (HoLEP) and whether these approaches demolish the advantages of the HoLEP procedure.
We reviewed our prospectively maintained laser prostate database for HoLEP procedures where non-morcellation approaches were used for retrieval of the enucleated adenoma. Non-morcellation approaches were adopted in cases of morcellator malfunction or whenever concomitant pathology indicated laparotomy. Patients were stratified into the laparotomy group (Group I) or the transurethral resection (TUR) group (Group II). Safety and efficacy of each approach were assessed and compared.
Between August 2012 and July 2015, of 392 HoLEP procedures non-morcellation approaches were used for tissue retrieval in 37 (9.4%). In 19 procedures a laparotomy approach was adopted (17 mini-laparotomies and two conventional laparotomies for concomitant diverticulectomy). TUR of the enucleated adenoma was adopted in 18 patients. Baseline demographic data and indications for surgery were comparable between the groups. However, significantly larger prostates were treated in Group I. There were no significant differences between the groups for tissue retrieval time, histopathological findings of retrieved tissue, and peri-procedure biochemical changes. However, significantly more tissue was retrieved (median tissue weight 115 vs 38 g) and at a faster rate (4.6 vs 1.09 g/min) in Group I. The median hospital stay was similar in both groups, but the median time to catheter removal was longer in Group I (5 vs 2 days). Minimal and similar peri-procedure complications were reported in both groups and in both groups there was a significant and comparable improvement in all urinary outcome measures.
In the absence or malfunction of a tissue morcellator, or whenever concomitant pathology indicates laparotomy, non-morcellation tissue retrieval approaches are feasible options for endourologists practicing transurethral enucleation of prostate adenoma. These approaches are valid alternatives retaining most of the advantages of the transurethral prostate enucleation procedure.
'Minimum-incision' endoscopically assisted transvesical prostatectomy: Surgical technique and early outcomes
2014, Arab Journal of Urology
Citation Excerpt :
The results of the present trial show a pronounced improvement in patients’ symptoms and voiding function immediately after catheter removal, followed by a significant improvement during the subsequent follow-up period. These results are consistent with those previously reported for HoLEP, laparoscopic and open enucleation of the prostate [4,7,12,16]. The postoperative hospital stay reported in the studies of surgical treatments for BPO is influenced by perioperative complications, catheterisation time and discharge policies.
To describe the surgical technique and report the early outcomes of a ‘minimum-incision’ endoscopically assisted transvesical prostatectomy (MEATP) for managing benign prostatic obstruction secondary to a large (>80 g) prostate.
In a prospective feasibility trial, 60 men with large benign prostates underwent MEATP. The baseline and postoperative evaluation included the International Prostate Symptom Score (IPSS), a measurement of maximum urinary flow rate (Q_max), and the postvoid residual (PVR) urine volume. The adenoma was enucleated digitally through a 3-cm suprapubic skin incision, and haemostasis was completed with endoscopic coagulation of the prostatic fossa. Perioperative complications were recorded and stratified according to the modified Clavien–Dindo score.
The mean (SD, range) prostate weight estimated by ultrasonography was 102.9 (15.4, 80–160) g, the operative duration was 52 (8, 40–65) min, the haemoglobin loss was 2.1 (1, 0.4–5) g/dL, the catheterisation time was 5.2 (1.3, 4–9) days, and the hospital stay was 6.2 (1.4, 5–10) days. There were 21 complications recorded in 16 (27%) patients, and most (86%) were of grades 1 and 2. The most frequent complications were bleeding requiring a blood transfusion (8%), and prolonged drainage (5%). There was a significant improvement at 3 months after surgery in the IPSS (8.6 vs. 21.6, P < 0.001), Q_max (19.5 vs. 7.7, P < 0.001), and PVR (15.8 vs. 83.9 mL, P < 0.001).
MEATP is feasible, safe and effective. Comparative studies and long-term data are required to determine its role in the surgical treatment of large-volume BPH.
A prospective, randomized clinical trial comparing plasmakinetic resection of the prostate with holmium laser enucleation of the prostate based on a 2-year followup
2013, Journal of Urology
We compared plasmakinetic resection with holmium laser enucleation of the prostate for the treatment of benign prostatic hyperplasia by analyzing 2-year followup data from a prospective randomized clinical trial.
A total of 280 patients were randomly treated with plasmakinetic resection or holmium laser enucleation of the prostate. Perioperative and postoperative outcome data were obtained during a 2-year followup.
No significant differences between the 2 surgical groups were observed in the preoperative data. Both groups displayed significant improvements after surgery. However, we identified no significant differences between the 2 groups in the 2-year followup data for I-PSS (International Prostate Symptom Score), quality of life scores or maximum flow rate values. Patients in the holmium laser enucleation group displayed a lower risk of hemorrhage, shorter bladder irrigation and catheter times, and shorter hospital stays. A larger amount of prostate tissue was retrieved in the holmium laser enucleation group, but the operation time was longer for this group than for the plasmakinetic resection group.
Plasmakinetic resection and holmium laser enucleation of the prostate are effective and safe treatments for benign prostatic hyperplasia. Holmium laser enucleation of the prostate can be applied to prostates of all sizes, and involves less risk of hemorrhage, decreased bladder irrigation and catheter times, as well as reduced hospital stay. Thus, we believe holmium laser enucleation of the prostate should be proposed as a potential new gold standard surgical therapy instead of transurethral resection of the prostate for patients with benign prostatic hyperplasia.
Holmium laser enucleation of the prostate: A modified enucleation technique and initial results
2012, Journal of Urology
Citation Excerpt :
To assess the efficiency of our technique for HoLEP the operative parameters were evaluated. For the 189 patients who underwent our new HoLEP, mean operative time and enucleating time was 54 and 36 minutes, respectively, both significantly shorter than those previously published.1,5,16–19 We believe these technical modifications in our approach facilitate enucleation and decrease operative time.
Although holmium laser enucleation of the prostate has been proven to be an excellent technique for the treatment of benign prostatic hyperplasia, it has not been widely applied due to technical difficulties and longer operative time. We modified the current technique of enucleation and present our initial experience.
A total of 189 patients with benign prostatic hyperplasia underwent prostatectomy with our modified technique for holmium laser enucleation of the prostate. Intraoperative and postoperative data were prospectively collected. For followup International Prostate Symptom Score, quality of life, maximal flow rate and post-void residual urine were recorded.
Mean ± SD preoperative prostate volume was 78.1 ± 24.3 cc and 60.9 ± 39.2 gm tissue were enucleated. Mean operative and enucleation times were 54.7 ± 21.1 and 36.5 ± 16.3 minutes, respectively. Mean serum hemoglobin decrease was 0.98 ± 0.72 gm/dl. Mean catheter time was 1.2 ± 0.5 days and mean postoperative hospital stay was 4.9 ± 3.4 days. Serious complications were not observed. Three patients complained of transient stress incontinence which resolved within 3 months. Significant improvement occurred in International Prostate Symptom Score, quality of life, maximal flow rate and post-void residual urine volume at 3 and 6-month followup compared with the preoperative baseline.
The modified holmium laser enucleation of the prostate technique is effective and safe when treating benign prostatic hyperplasia.

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Prostatic Diseases and Male Voiding DysfunctionHolmium Laser Enucleation of the Prostate: Initial Report of the First 230 Egyptian Cases Performed in a Single Center

Objectives

Methods

Results

Conclusions

Section snippets

Patients

Results

Comment

Conclusions

Urology

Urology

Urology

Urology

Urology

J Urol

J Urol

J Urol

J Urol

Urology

J Urol

Urology

Guidelines on benign prostatic hyperplasia

Prevalence

Combination holmium and Nd:YAG laser ablation of the prostate: initial clinical experience

J Endourol

Prostatic Diseases and Male Voiding Dysfunction
Holmium Laser Enucleation of the Prostate: Initial Report of the First 230 Egyptian Cases Performed in a Single Center