Holmium Laser Enucleation of the Prostate (HoLEP) for Benign Prostatic Hyperplasia (BPH)
Use the link below to share a full-text version of this article with your friends and colleagues. Learn more. To evaluate, in a prospective study, the complications in patients undergoing holmium laser enucleation of the prostate HoLEP at our institution, and to review previous reports to determine the overall incidence and types of various complications, and analyse their causes and means of prevention.
HoLEP was completed successfully in patients The morcellation device and laser malfunctioned in two patients each. A blood transfusion was required during HoLEP in one patient; other complications included capsular perforation 9.
A blood transfusion was needed after HoLEP in 1. Transient urinary incontinence was the commonest complication after HoLEP, in There was a low incidence of complications with HoLEP; most were minor and easily managed. Our results are comparable with those published previously, and establish HoLEP as safe and reproducible procedure.
It is a safe and effective procedure for treating symptomatic BPH, independent of prostate size, and with low morbidity and a short hospital stay. Nevertheless, a limitation of this technique is the experience and training required, and the relatively few experts in the field [ 1 ]. This significant learning curve is the most daunting impediment to adopting this attractive technique, particularly for surgeons who are not in a situation where they can be closely mentored.
The concern is that a patient will have Transurethrale Holmiumlaser Enukleation der Prostata adverse outcome because of the inexperience of the surgeon. To address this issue, we prospectively reviewed the complications occurring in the first patients operated by one surgeon at our institution. We also assessed the previous reports of HoLEP, to determine the overall incidence and types of various complications, and to analyse their causes and means of prevention.
Abdominal ultrasonography was used to measure prostate volume and the postvoid residual urine volume PVRand uroflowmetry was used in all patients except those in urinary retention. All HoLEP procedures were performed as described previously [ 2 - 4 ]. Spinal or epidural anaesthesia was usually preferred, except in patients with coagulopathy and failed regional anaesthesia, in whom general anaesthesia was used.
Normal saline was used for irrigation. After enucleation, haemostasis was achieved by defocusing the laser over targeted areas at settings of 2. Enucleated tissues were morcellated using a Versa Cut morcellator Lumenis introduced through an offset rigid nephroscope.
Resected prostatic tissue was assessed histopathologically in all patients. All the complications during and after HoLEP were analysed, and previous publications reviewed to document the incidence and type of various complications reported. The procedure was completed successfully in patients From the initial series of 25 consecutive patients, eight required conversion to TURP, due to failure to progress during enucleation of the lateral lobes.
Five patients had round adenomas with a smooth surface that did not engage in the morcellation blades. These adenoma tissues were cut into small pieces in the bladder, with a serrated loop, and then removed mechanically with a nephroscopic alligator forceps. Capsular perforation was the commonest complication during HoLEP, in 9.
One patient with anaemia before HoLEP haemoglobin 8. No patient had any evidence of TUR syndrome. A blood transfusion was required in four patients after HoLEP. There was minimal oozing from the prostatic fossa, which was fulgurated with electrocautery. One patient with a haemoglobin level of 8. Two patients were taught clean intermittent catheterization due to failure of a second trial without catheter; their cystoscopy revealed a wide open prostatic fossa.
Stress urinary incontinence after HoLEP improved in all except two patients, at a mean range duration of However, he failed Transurethrale Holmiumlaser Enukleation der Prostata respond to this and is currently using a penile clamp. Of these, five patients were from the first 50 cases. We attribute the progressive decrease Transurethrale Holmiumlaser Enukleation der Prostata the incidence of stenotic complications to modifications in our technique.
The need Transurethrale Holmiumlaser Enukleation der Prostata TURP in eight patients might also explain the higher incidence of stenotic complications in the initial 50 patients. There are no standard criteria for reporting complications, thus comparison with reported data is difficult.
The complications Transurethrale Holmiumlaser Enukleation der Prostata surgery were defined as those related to technical difficulties of the procedure. Larger blood vessels can be coagulated by defocusing the laser fibre, i. Also in HoLEP, blood vessels are transected once during the enucleation procedure off the capsule; during TURP the vessels are repeatedly cut until the prostatic capsule is reached [ 10 ].
Hence, the overall incidence of blood transfusion is low during HoLEP, even for large prostates [ 11 ]. The holmium laser is an endoscopic haemostatic scalpel that cuts and coagulates the vessels simultaneously, Transurethrale Holmiumlaser Enukleation der Prostata decreasing the absorption of irrigation fluid. The coagulative properties of the holmium laser adequately seal venous channels and prevent the absorption of irrigation fluid [ 33 ].
Additionally, the use of normal saline obviates the risk of dilutional hyponatraemia. We found that The preoperative prostate weight, duration of irrigation, total amount of irrigation fluid used and weight of resected prostatic tissue all directly influence the amount of fluid absorption [ 34 ]. The plane of enucleation is characterized by flimsy transverse or diagonal fibres with Transurethrale Holmiumlaser Enukleation der Prostata running from capsule to adenoma.
During enucleation, the surgical capsule appears very thin or even perforated, which is not the case most of the time [ 12 ]. Little or no periprostatic fat is visible at the margins; iv subtrigonal perforation bladder neck false passage ; likely to occur in large prostates, especially with large median lobes, during initial insertion of the resectoscope [ 14 Transurethrale Holmiumlaser Enukleation der Prostata. The acute angle at the junction of the prostatic capsule and bladder makes it more prone to free perforation.
Proper use of the resectoscope beak Transurethrale Holmiumlaser Enukleation der Prostata repeated orientation during enucleation can help to decrease the risk of this injury. Capsular perforations are more common while learning HoLEP and in smaller prostates [ 10 ].
In smaller fibrotic prostates the surgical capsule is often less distinct and the plane of dissection more difficult than in larger glands, in which the greater degree of peripheral compression tends to create a more easily identifiable plane [ 15 ].
Threatened and covered perforation does not change the postoperative course of the patient; only free or subtrigonal perforation need attention, as they can lead to significant extravasation of irrigation fluid in the extraperitoneal space. Most of these patients can be managed by urethral catheter drainage. If there is extensive extravasation and concern about infecting perivesical tissue, suprapubic drainage should be instituted [ 16 ]. Bladder injury is a potential hazard of morcellation, and can be averted by thorough haemostasis and bladder distension before Transurethrale Holmiumlaser Enukleation der Prostata morcellation [ 17 ].
The operator must be careful not to engage the bladder mucosa. If this happens, the foot should be taken off the pedal, and the pump suction released by opening the hinged gate on the roller pump. The injury to the bladder mucosa is generally minor and uneventful. Such patients may need open surgery to close the perforation [ 19 ].
To limit the incidence of Transurethrale Holmiumlaser Enukleation der Prostata injury some authors advocated morcellation in the prostatic fossa [ 12 ].
Small round prostate adenomas are sometimes difficult to morcellate because they dislodge from the morcellator blades. These could be irrigated out or removed with the serrated loop.
When they persist, incising the surface with the laser fibre renders them irregular enough for morcellation [ 12 ]. For patients in whom the vision is unclear or the prostatic tissue tough, morcellation can be postponed to another session [ 2021 ]. Injuries to the ureteric orifice occur most often while resecting large and endovesically developed median lobes.
Careful identification of the ureteric orifice before starting enucleation and relocating it repeatedly thereafter can avoid this injury. When the orifice is very close to the median lobe, Transurethrale Holmiumlaser Enukleation der Prostata bladder should be filled to move the orifice away from the median lobe and make it visible [ 9 Transurethrale Holmiumlaser Enukleation der Prostata. Care must be taken to avoid Transurethrale Holmiumlaser Enukleation der Prostata the trigone.
For better orientation, the surgeon should work back and forth from one lateral incision to the other, keeping the same depth of dissection [ 12 Transurethrale Holmiumlaser Enukleation der Prostata. The possible additional procedures that might be needed include: i perineal urethrotomy; if the length of the resectoscope is insufficient to perform the enucleation [ 1121 ]; ii cystostomy might be needed for associated large or multiple bladder stones, or to remove Transurethrale Holmiumlaser Enukleation der Prostata morcellated large adenoma.
In such situations, the enucleated prostate volume might occupy most of the bladder volume, leaving inadequate space for safe morcellation [ 21 ]; iii TURP might be needed during the learning phase or to complete the procedure in case of machine malfunction Transurethrale Holmiumlaser Enukleation der Prostata 35 ]. The overall decrease in haemoglobin is 1. The incidence of blood transfusion is low except in patients with coagulopathy, in whom the requirement increases dramatically to 8.
Blood loss is only marginally higher Transurethrale Holmiumlaser Enukleation der Prostata patients with a larger prostate, with no clinical implication [ 9 ]. Other factors that increase the need for blood transfusion include preoperative anaemia and retained prostate tissue due to malfunction of morcellation.
Capsular sinuses are unlikely to coapt in presence of retained tissue, resulting in bleeding [ 14 ]. Recurrent failure of a trial to void is mainly attributed to primary detrusor failure rather than to incomplete resection. It is also unclear if the Transurethrale Holmiumlaser Enukleation der Prostata UTI was clinical or subclinical. Some patients might develop fever unrelated to the UTI [ 1224 ]. The incidence of epididymitis or sepsis is rare, with only one case reported [ 1123 ].
It is probably caused by the high laser energy applied to the capsule [ 8 ]. Increasing experience and technical refinement of the enucleation time can decrease the incidence of irritative voiding symptoms [ 17 ]. This inflammatory effect is probably related to tissue regeneration on the surface of the surgical cavity. They found that discomfort in Transurethrale Holmiumlaser Enukleation der Prostata patients was mild and no patients had a severe grade of dysuria.
The higher incidence of transient incontinence is probably due to more complete removal of the adenoma and weakening or stretching of the external sphincter from lack of use [ 36 ].
The severity of incontinence was not graded in any series. These dimensions might seem greater to a novice surgeon and one incision will usually suffice [ 12 ]. Withdrawing the resectoscope inside the sphincter allows a better view of the remaining attachments.
Short bursts of the laser are used to cut the mucosa only [ 3 ]. The lack of leakage of monopolar current is a possible explanation for the lower incidence of Transurethrale Holmiumlaser Enukleation der Prostata urethral stricture in HoLEP.
Most strictures are at the external meatus, probably secondary to the use of a larger nephroscope for morcellation [ 19 ]. The use of a smaller Transurethrale Holmiumlaser Enukleation der Prostata resectoscope and reduction of movements of the resectoscope within the urethra by using an inner rotating sheath might contribute to the lower incidence of stricture formation [ 610 ]. The incidence of bladder neck contracture in HoLEP is 0—3.