‘En Bloc’ HoLEP with early apical release in men with benign prostatic hyperplasia

Abstract

Purpose

HoLEP represents an excellent treatment option for benign prostatic hyperplasia. Recently, ‘en bloc’ techniques resulting in improved visualization, shorter surgical times, and easier recognition of the dissection plane have been described. In this paper we describe the ‘En bloc’ HoLEP technique with early apical release.

Materials and methods

Between January 2015 and March 2017, 137 consecutive patients were subjected to this technique by a single surgeon. The following parameters were measured pre- and post-procedure: International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), post-void residual urine (PVR) and PSA. Complications were recorded.

Results

Mean (SD; range) age was 66 years (8.0; 51–84), mean PSA was 4.8 ng/ml (7.0; 0.3–70), mean prostate volume was 75.63 ml (42.1; 37–253), mean volume of prostatic tissue removed was 65.9 ml (35.8; 30–217). Mean surgical duration was 47.58 min (21.3; 15–120 min): enucleation 31.5 min (14.9; 5–80 min), morcellating 6.9 min (6.6; 1–60 min). Mean hospitalization duration was 1.2 days (range 1–3), mean catheterization time was 1.2 days (range 1–5). The rate of stress urinary incontinence (SUI) was 5.8, 1.5 and 0.7% at 1, 3, and 6 months post-operation, respectively. Compared to pre-operative values, IPSS, Qmax, and PVR showed significant improvements at 1, 3, 6, and 12 months following the operation (p < 0.05).

Conclusions

‘En Bloc’ HoLEP with early apical release is a safe technique that allows for easier recognition of the surgical plane and preserves the external sphincter’s mucosa to provide low rates of post-operative stress incontinence and significant functional results.

This is a preview of subscription content, log in to check access.

Fig. 1
Graph 1

Abbreviations

5-ARI:

5-Alpha reductase inhibitors

ASAP:

Atypical small acinar proliferation

BPH:

Benign prostatic hyperplasia

BPO:

Benign prostatic obstruction

GreenLEP:

Green light enucleation of prostate

HoLEP:

Holmium laser enucleation of prostate

IPSS:

International Prostate Symptom Score

LUTS:

Lower urinary tract symptoms

PSA:

Prostate-specific antigen

PVR:

Post-void residual urine

Q max :

Maximum peak flow

QoL:

Quality of life

SD:

Standard deviation

SUI:

Stress urinary incontinence

ThuLEP:

Thulium laser enucleation of prostate

TURP:

Transurethral resection of prostate

TWOC:

Trial without catheter

References

  1. 1.

    Calogero AE, Burgio G, Condorelli RA, Cannarella R, La Vignera S (2018) Epidemiology and risk factors of lower urinary tract symptoms/benign prostatic hyperplasia and erectile dysfunction. J Aging Male 2:1–8

    Google Scholar 

  2. 2.

    Montorsi F, Saitta G, Suardi N (2018) Surgical treatment for LUTS/BPH: laser devices—chapter 13. In: Morgia G, Russo GI (eds) Lower urinary tract symptoms and benign prostatic hyperplasia, 1st edn. Academic Press, Cambridge. eBook ISBN: 9780128113981. Paperback ISBN: 9780128113974

  3. 3.

    Gravas S, Bachmann A, Reich O, Roehrborn CG, Gilling PJ, De La Rosette J (2011) Critical review of lasers in benign prostatic hyperplasia (BPH). BJU Int 107(7):1030–1043

    PubMed  Article  Google Scholar 

  4. 4.

    Gilling PJ, Fraundorfer MR (1998) Holmium laser prostatectomy: a technique in evolution. Curr Opin Urol 8(1):11–15

    CAS  PubMed  Article  Google Scholar 

  5. 5.

    Yin L, Teng J, Huang CJ, Zhang X, Xu D (2013) Holmium laser enucleation of the prostate versus transurethral resection of the prostate: a systematic review and meta-analysis of randomized controlled trials. J Endourol 27(5):604–611

    PubMed  Article  Google Scholar 

  6. 6.

    Gilling PJ, Wilson LC, King CJ, Westenberg AM, Frampton CM, Fraundorfer MR (2012) Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. BJU Int 109(3):408–411

    PubMed  Article  Google Scholar 

  7. 7.

    Moody JA, Lingeman JE (2001) Holmium laser enucleation for prostate adenoma greater than 100 gm.: comparison to open prostatectomy. J Urol 165(2):459–462

    CAS  PubMed  Article  Google Scholar 

  8. 8.

    Montorsi F, Naspro R, Salonia A, Suardi N, Briganti A, Zanoni M, Valenti S, Vavassori I, Rigatti P (2004) Holmium laser enucleation versus transurethral resection of the prostate: results from a 2-center, prospective, randomized trial in patients with obstructive benign prostatic hyperplasia. J Urol 172(5 Pt 1):1926–1929

    PubMed  Article  Google Scholar 

  9. 9.

    Glybochko PV, Rapoport LM, Enikeev ME, Enikeev DV (2017) Holmium laser enucleation of the prostate (HoLEP) for small, large and giant prostatic hyperplasia: tips and tricks. Urologia 84(3):169–173. https://doi.org/10.5301/uj.5000232 (Epub 2017 May 10)

    PubMed  Article  Google Scholar 

  10. 10.

    Hurle R, Vavassori I, Piccinelli A, Manzetti A, Valenti S, Vismara A (2002) Holmium laser enucleation of the prostate combined with mechanical morcellation in 155 patients with benign prostatic hyperplasia. Urology 60(3):449–453

    PubMed  Article  Google Scholar 

  11. 11.

    Gilling PJ, Cass CB, Malcolm AR, Fraundorfer MR (1995) Combination holmium and Nd:YAG laser ablation of the prostate: initial clinical experience. J Endourol 9(2):151–153

    CAS  PubMed  Article  Google Scholar 

  12. 12.

    Kelly DC, Das A (2012) Holmium laser enucleation of the prostate technique for benign prostatic hyperplasia. Can J Urol. 19(1):6131–6134

    PubMed  Google Scholar 

  13. 13.

    Krambeck AE, Handa SE, Lingeman JE (2010) Experience with more than 1,000 holmium laser prostate enucleations for benign prostatic hyperplasia. J Urol 183(3):1105–1109

    PubMed  Article  Google Scholar 

  14. 14.

    Baazeem AS, Elmansy HM, Elhilali MM (2010) Holmium laser enucleation of the prostate: modified technical aspects. BJU Int. 105(5):584–585

    PubMed  Article  Google Scholar 

  15. 15.

    Scoffone CM, Cracco CM (2016) The en-bloc no-touch holmium laser enucleation of the prostate (HoLEP) technique. World J Urol 34(8):1175–1181

    PubMed  Article  Google Scholar 

  16. 16.

    Minagawa S, Okada S, Morikawa H (2017) Safety and effectiveness of holmium laser enucleation of the prostate using a low-power laser. Urology. 110:51–55. https://doi.org/10.1016/j.urology.2017.08.034 (Epub 2017 Sep 4)

    PubMed  Article  Google Scholar 

  17. 17.

    Hiraoka Y, Shimizu Y, Iwamoto K, Takahashi H, Abe H (2007) Trial of complete detachment of the whole prostate lobes in benign prostate hyperplasia by transurethral enucleation of the prostate. Urol Int 79(1):50–54

    PubMed  Article  Google Scholar 

  18. 18.

    Hiraoka Y (1983) A new method of prostatectomy, transurethral detachment and resection of benign prostatic hyperplasia. J Nippon Med Sch 50:896–898

    CAS  Article  Google Scholar 

  19. 19.

    Hiraoka Y, Akimoto M (1989) Transurethral enucleation of benign prostatic hyperplasia. J Urol 142:1247–1250

    CAS  PubMed  Article  Google Scholar 

  20. 20.

    Shimizu Y, Hiraoka Y, Iwamoto K, Takahashi H, Abe H (2005) Measurement of residual adenoma after transurethral resection of the prostate by transurethral enucleation technique. Urol Int 74:102–107

    PubMed  Article  Google Scholar 

  21. 21.

    Kim YJ, Lee YH, Kwon JB, Cho SR, Kim JS (2015) A novel one lobe technique of thulium laser enucleation of the prostate: ‘all-in-one’ technique. Korean J Urol 56(11):769–774

    PubMed  PubMed Central  Article  Google Scholar 

  22. 22.

    Gomez Sancha F, Cuadros Rivera V, Georgiev G, Bocevski A, Kotsev J, Herrmann T (2015) Common trend: move to enucleation—is there a case for GreenLight enucleation? Development and description of the technique. World J Urol 33(4):539–547

    PubMed  Article  Google Scholar 

  23. 23.

    Gong YG, He DL, Wang MZ, Li XD, Zhu GD, Zheng ZH, Du YF, Chang LS, Nan XY (2012) Holmium laser enucleation of the prostate: a modified enucleation technique and initial results. J Urol 187(4):1336–1340

    PubMed  Article  Google Scholar 

  24. 24.

    Kuo RL, Paterson RF, Kim SC, Siqueira TM Jr, Elhilali MM, Lingeman JE (2003) Holmium laser enucleation of the prostate (HoLEP): a technical update. World J Surg Oncol 1(1):6

    PubMed  PubMed Central  Article  Google Scholar 

  25. 25.

    Minagawa S, Okada S, Sakamoto H, Toyofuku K, Morikawa H (2015) En-Bloc technique with anteroposterior dissection holmium laser enucleation of the prostate allows a short operative time and acceptable outcomes. Urology 86(3):628–633

    PubMed  Article  Google Scholar 

  26. 26.

    Miernik A, Schoeb DS (2018) “Three horse shoe-like incision” holmium laser enucleation of the prostate: first experience with a novel en bloc technique for anatomic transurethral prostatectomy. World J Urol. https://doi.org/10.1007/s00345-018-2418-0

    PubMed  PubMed Central  Article  Google Scholar 

  27. 27.

    Rapoport LM, Sorokin NI, Sukhanov RB, Dymov AM, Enikeev DV, Davydov DS, Danilov SP (2018) En bloc holmium laser enucleation of the prostate (HOLEP EN BLOC): our experience. Urologiia 3:83–87

    Article  Google Scholar 

  28. 28.

    Wilson LC, Gilling PJ, Williams A, Kennett KM, Frampton CM, Westenberg AM, Fraundorfer MR (2006) A randomised trial comparing holmium laser enucleation versus transurethral resection in the treatment of prostates larger than 40 grams: results at 2 years. Eur Urol 50(3):569–573

    PubMed  Article  Google Scholar 

  29. 29.

    Naspro R, Suardi N, Salonia A, Scattoni V, Guazzoni G, Colombo R, Cestari A, Briganti A, Mazzoccoli B, Rigatti P, Montorsi F (2006) Holmium laser enucleation of the prostate versus open prostatectomy for prostates > 70 g: 24-month follow-up. Eur Urol 50(3):563–568

    PubMed  Article  Google Scholar 

  30. 30.

    Gupta N, Sivaramakrishna, Kumar R, Dogra PN, Seth A (2006) Comparison of standard transurethral resection, transurethral vapour resection and holmium laser enucleation of the prostate for managing benign prostatic hyperplasia of > 40 g. BJU Int 97(1):85–89

    PubMed  Article  Google Scholar 

  31. 31.

    Fayad AS, Sheikh MG, Zakaria T, Elfottoh HA, Alsergany R (2011) Holmium laser enucleation versus bipolar resection of the prostate: a prospective randomized study. Which to choose? J Endourol 25(8):1347–1352

    PubMed  Article  Google Scholar 

Download references

Acknowledgements

Cristina Sala Ripoll - Creative Commons License (CC BY-NC-ND).

Author information

Affiliations

Authors

Contributions

SG: protocol/project development, data collection or management, data analysis, manuscript writing/editing. JEAB: protocol/project development, manuscript writing/editing. JFA: protocol/project development. LLG: protocol/project development. JRE: protocol/project development. NS: data collection or management, data analysis, manuscript writing/editing. FG-S: protocol/project development, data collection or management, manuscript writing/editing

Corresponding author

Correspondence to Fernando Gómez-Sancha.

Ethics declarations

Conflict of interest

Gómez-Sancha F: Boston Scientific® (proctor, lecturer, advisory board); Lumenis® (lecturer).

Informed consent

All 137 patients signed an informed consent declaring to have understood the purposes, benefits, and risks of the proposed treatment.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Saitta, G., Becerra, J.E.A., del Álamo, J.F. et al. ‘En Bloc’ HoLEP with early apical release in men with benign prostatic hyperplasia. World J Urol 37, 2451–2458 (2019). https://doi.org/10.1007/s00345-019-02671-4

Download citation

Keywords

  • Benign prostatic hyperplasia
  • Prostate-specific antigen
  • IPSS
  • En bloc enucleation
  • Holmium laser