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The “Omega Sign”: a novel HoLEP technique that improves continence outcomes after enucleation

A Letter to the Editor to this article was published on 20 March 2021

Abstract

Purpose

Holmium-laser enucleation of the prostate (HoLEP) has been a promising prostate surgery since its first introduction. Although there are 10 different HoLEP techniques in the literature, stress urinary incontinence (SUI) is common, because surgery is not performed based on the topographic anatomy of the external sphincter. We have developed a new HoLEP method named as the ‘’Omega Sign technique”, which is based on the topographic anatomy of the external sphincter and could provide better continence outcomes by decreasing SUI rates.

Materials and methods

The data of 400 patients who underwent HoLEP by a single surgeon between May 2016 and February 2019 were retrospectively reviewed. The patients were divided into two groups, the first underwent the Gilling’s technique (Group 1) and the second the novel ‘’Omega Sign’’ technique (Group 2). Continence status and post-micturition symptoms (PMS) were evaluated according to the standards recommended by the international continence status.

Results

The data of 400 HoLEP procedures between May 2016 and February 2019 were analyzed, comparing Group 1 (n = 200) and Group 2(n = 200). SUI rate was significantly lower in Group 2 at the day of catheter removal and first month (p < 0.005). In addition, urge urinary incontinence (UUI) rate and PMS were significantly lower in Group 2.

Conclusions

We could demonstrate improved continence results, comparable functional outcomes and equally minimal complications with the standard HoLEP technique. We believe that, the novel ‘Omega sign’ technique decreases SUI rates and will become standardised and easy to understand, thereby bringing and creating a shorter learning curve.

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Abbreviations

HoLEP:

Holmium laser enucleation of the prostate

TUR-P:

Transurethral prostate resection of the prostate

OP:

Open prostatectomy

BPH:

Benign prostate hyperplasia

SUI:

Stress urinary incontinence

ES:

External sphincter

BMI:

Body mass index

PSA:

Prostate specific antigen

IPSS-T:

Total international prostate symptom scores

IPSS-S:

Storage international prostate symptom scores

IPSS-V:

Voiding international prostate symptom scores

QoL:

Quality of life

Qmax:

Mean maximal urinary flow rate

PVR:

Postvoid residual urine volume

OT:

Operation time

EE:

Enucleation efficiency

HT:

Hospitalization time

CRT:

Catheterization removal time

PMS:

Post-micturition symptoms

ICS:

International continence status

LUTS:

Low urinary tract symptoms

UUI:

Urge urinary incontinence

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Funding

This study was not funded.

Author information

Affiliations

Authors

Contributions

LT: project development, data analysis, manuscript writing, and management. SY: data collection and manuscript writing. EK: data analysis and manuscript writing. EG: project development and manuscript writing. SY: data collection. HCA: data analysis. MY: data collection. TT: manuscript writing and editing.

Corresponding author

Correspondence to Engin Kaya.

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The authors declare that they have no conflict of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the Helsinki Declaration and its later amendments or comparable ethical standards.

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345_2020_3152_MOESM1_ESM.tiff

Supplementary file1 Supplementary file1 Figure 1 (SM 1): The external urethral sphincter (EUS) and internal urethral sphincter (IUS) in a male foetus (12 weeks of gestation). Three-dimensional reconstruction in (A) anterior view, (B) posterior view, (C) right-lateral view, (D) superior view, and (E) inferior view. The EUS is shown in blue, and the IUS is shown in pink. The urethra and prostate are shown in light grey. Anterior and posterior directions are represented by the letters ‘‘a’’ and ‘‘p.’’ Immunohistochemically stained sections: Sections from inferior (F) to superior (H) stained immunohistochemically for striated muscle, showing the EUS (black arrowheads). Panels (I) through (K) are from same level as sections (F) through (H), stained immunohistochemically for smooth muscle, showing the IUS (red arrowheads). Note the smooth muscle tissue at the dorsal side of the urethra, where the striated muscle of the external sphincter is lacking; see red arrow in (J). Red lines in (C) illustrate the level of the sections as seen in (F) through (H). L = levator ani muscle; PB = pubic bone; R = rectum; U = urethra; bar = 0.5 mm. *This figure was used with special permission of Christian Wallner (Departments of Anatomy and Embryology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands) (TIFF 587 kb)

345_2020_3152_MOESM2_ESM.tiff

Supplementary file2 Supplementary file2 Figure 2 (SM2): A1/A2: Bladder neck incisions. B1/B2: Apical incisions. C1/C2: Joining of the bladder neck with the apical incisions bilaterally. D1/D2: Distal end of the anterior incision. E1/E2: Extension of the anterior incision to the bladder neck. F1/F2: Lateral lobe incisions. G1/G2: Final incisions performed just proximally to the verumontanum. H1/H2: Blunt dissection of the median lobe. I1/I2: Complete enucleation of the median lobe adenoma. J1/J2: Pre-prepared initial enucleation of lateral lobes is extended retrogradely to the bladder neck and 2 to 10 o’clock position anteriorly. K1/K2: The lateral lobes are pushed down and separated from the mucosa at 2 o’clock and 10 o’clock positions. Figure 3 (SM-2): Observation of the Omega Sign formed by the preserved mucosa. 3a: retrograde view of the surgical loge from urethra. 3b: Antegrade view of surgical loge from the bladder (TIFF 1884 kb)

Supplementary file3 (DOCX 14 kb)

Supplementary file4 (DOCX 46 kb)

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Tunc, L., Yalcin, S., Kaya, E. et al. The “Omega Sign”: a novel HoLEP technique that improves continence outcomes after enucleation. World J Urol 39, 135–141 (2021). https://doi.org/10.1007/s00345-020-03152-9

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Keywords

  • Holmium laser
  • HoLEP
  • Omega Sign
  • Laser enucleation