Name: surgical treatment for benign prostatic hyperplasia: holmium laser enucleation of the prostate (holep).
Uploaded: 2018-03-06T12:30:00
Description: Watch this Scientific Journal Video about Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate HoLEP. at JoVE.com

The authors have nothing to disclose.

Ethical approval was obtained from the Ethics Committee of Shanghai Ninth People&#39;s Hospital and the written informed consent of each patient were obtained in our study.
1. Patients and Surgical Materials
Notes: Patients diagnosed with BPH and need surgical treatment in accordance with the European Association of Urology (EAU) guidelines can be included10. This surgical procedure requires experience and a long learning curve...

<ol>
	<li>Bushman, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Etiology,+epidemiology,+and+natural+history+of+benign+prostatic+hyperplasia.">Etiology, epidemiology, and natural history of benign prostatic hyperplasia.</a> Urol Clin North Am. 36 (4), 403-415 (2009).</li><li>Millin, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Retropubic+prostatectomy;+a+new+extravesical+technique;+report+of+20+cases.">Retropubic prostatectomy; a new extravesical technique; report of 20 cases.</a> Lancet. 2 (6380), 693-696 (1945).</li><li>Kahokehr, A. A., Gilling, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Which+laser+works+best+for+benign+prostatic+hyperplasia?.">Which laser works best for benign prostatic hyperplasia?.</a> Curr Urol Rep. 14 (6), 614-619 (2013).</li><li>Gilling, P. J., Cass, C. B., Malcolm, A. R., Fraundorfer, M. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Combination+holmium+and+Nd:YAG+laser+ablation+of+the+prostate:+initial+clinical+experience.">Combination holmium and Nd:YAG laser ablation of the prostate: initial clinical experience.</a> J Endourol. 9 (2), 151-153 (1995).</li><li>Fraundorfer, M. R., Gilling, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Holmium:YAG+laser+enucleation+of+the+prostate+combined+with+mechanical+morcellation:+preliminary+results.">Holmium:YAG laser enucleation of the prostate combined with mechanical morcellation: preliminary results.</a> Eur Urol. 33 (1), 69-72 (1998).</li><li>Chen, Y. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospective,+randomized+clinical+trial+comparing+plasmakinetic+resection+of+the+prostate+with+holmium+laser+enucleation+of+the+prostate+based+on+a+2-year+followup.">A prospective, randomized clinical trial comparing plasmakinetic resection of the prostate with holmium laser enucleation of the prostate based on a 2-year followup.</a> J Urol. 189 (1), 217-222 (2013).</li><li>Kahokehr, A., Gilling, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Enucleation+techniques+for+benign+prostate+obstruction:+which+one+and+why?.">Enucleation techniques for benign prostate obstruction: which one and why?.</a> Curr Opin Urol. 24 (1), 49-55 (2014).</li><li>Kuntz, R. M., Lehrich, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transurethral+holmium+laser+enucleation+versus+transvesical+open+enucleation+for+prostate+adenoma+greater+than+100+gm.::+a+randomized+prospective+trial+of+120+patients.">Transurethral holmium laser enucleation versus transvesical open enucleation for prostate adenoma greater than 100 gm.:: a randomized prospective trial of 120 patients.</a> J Urol. 168 (4 Pt 1), 1465-1469 (2002).</li><li>Elzayat, E., Habib, E., Elhilali, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Holmium+laser+enucleation+of+the+prostate+in+patients+on+anticoagulant+therapy+or+with+bleeding+disorders.">Holmium laser enucleation of the prostate in patients on anticoagulant therapy or with bleeding disorders.</a> J Urol. 175 (4), 1428-1432 (2006).</li><li>Oelke, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EAU+guidelines+on+the+treatment+and+follow-up+of+non-neurogenic+male+lower+urinary+tract+symptoms+including+benign+prostatic+obstruction.">EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction.</a> Eur Urol. 64 (1), 118-140 (2013).</li><li>Xu, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+and+safety+of+an+improved+technique+of+holmium+laser+enucleation+of+the+prostate+versus+open+prostatectomy+in+treating+enlarged+prostates+combined+with+multiple+bladder+stones:+one-year+of+followup.">Efficacy and safety of an improved technique of holmium laser enucleation of the prostate versus open prostatectomy in treating enlarged prostates combined with multiple bladder stones: one-year of followup.</a> Int J Clin Exp Med. 9 (12), 23612-23617 (2016).</li><li>Chen, Q., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+improved+morcellation+procedure+for+holmium+laser+enucleation+of+the+prostate.">An improved morcellation procedure for holmium laser enucleation of the prostate.</a> J Endourol. 26 (12), 1625-1628 (2012).</li><li>El Tayeb, M. M., Borofsky, M. S., Paonessa, J. E., Lingeman, J. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Wolf+Piranha+Versus+Lumenis+Versacut+Prostate+Morcellation+Devices:+A+Prospective+Randomized+Trial.">Wolf Piranha Versus Lumenis Versacut Prostate Morcellation Devices: A Prospective Randomized Trial.</a> J Urol. , (2015).</li><li>Gilling, P. J., Aho, T. F., Frampton, C. M., King, C. J., Fraundorfer, M. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Holmium+laser+enucleation+of+the+prostate:+results+at+6+years.">Holmium laser enucleation of the prostate: results at 6 years.</a> Eur Urol. 53 (4), 744-749 (2008).</li><li>Shah, H. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+evaluation+of+the+learning+curve+for+holmium+laser+enucleation+of+the+prostate.">Prospective evaluation of the learning curve for holmium laser enucleation of the prostate.</a> J Urol. 177 (4), 1468-1474 (2007).</li><li>Gratzke, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EAU+Guidelines+on+the+Assessment+of+Non-neurogenic+Male+Lower+Urinary+Tract+Symptoms+including+Benign+Prostatic+Obstruction.">EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction.</a> Eur Urol. 67 (6), 1099-1109 (2015).</li><li>Vincent, M. W., Gilling, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=HoLEP+has+come+of+age.">HoLEP has come of age.</a> World J Urol. 33 (4), 487-493 (2015).</li><li>Qian, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+outcomes+and+complications+following+B-TURP+versus+HoLEP+for+the+treatment+of+benign+prostatic+hyperplasia:+a+review+of+the+literature+and+Meta-analysis.">Functional outcomes and complications following B-TURP versus HoLEP for the treatment of benign prostatic hyperplasia: a review of the literature and Meta-analysis.</a> Aging Male. 20 (3), 184-191 (2017).</li><li>Xu, H., Chen, Y. B., Gu, M., Chen, Q., Wang, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+noise+hazard+during+the+holmium+laser+enucleation+of+prostate.">Evaluation of noise hazard during the holmium laser enucleation of prostate.</a> BMC Urol. 17 (1), 71 (2017).</li><li>Gilling, P. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+results+of+a+randomized+trial+comparing+holmium+laser+enucleation+of+the+prostate+and+transurethral+resection+of+the+prostate:+results+at+7+years.">Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years.</a> BJU Int. 109 (3), 408-411 (2012).</li></ol>

In this protocol, we introduce a procedure for the surgical treatment of BPH. HoLEP can be employed in daily clinical practice. As mentioned, the development of BPH surgery includes three landmarks. The first is the open surgery. Retropubic prostatectomy and suprapubic open prostatectomy have extensively been employed in the clinical setting for a long time. Despite this, the technique involves severe adverse side effects, which are often observed during the perioperative period. These side effects include hemorrhage, la...

Benign prostatic hyperplasia (BPH), which is hyperplasia of the prostate gland, occurs in elderly males. This condition starts at approximately 40 y old, and morbidity can reach 50%-60% for men in their 60s and 80%-90% for men in their 70s and 80s1. BPH causes progressive obstruction, lower urinary tract symptoms, retention and its complications, and even renal failure, all of which lower the quality of life of the elderly male. After medical therapy, surgical treatment is often used as the most efficient treatment for symptomatic BPH.
Various types of surgery have been developed to treat the symptoms of BPH, including the first open prostatectomy introduced in 18942 and transurethral endoscopic surgery (TURP) a century later. Since its development, TURP has been regarded as the gold standard to surgically alleviate prostate enlargement.
The holmium laser operates at a wavelength of 2120 nm, which is similar to that of the tissue water3, which induces vaporization of water. Tissue penetration reaches 0.4 mm, and coagulation can also be operated with it. The process was first introduced for BPH in 19944. In 1998, Peter Gilling used the device to perform enucleation application5. As proposed by Peter Gilling et al. in the 1990s4, holmium laser enucleation of the prostate (HoLEP) is used to treat BPH by combining the two earlier types of surgery, including the open enucleation and the TURP4. With the development of the hyperplasia process, the prostatic peripheral zone is compassed by the transitional zone (TZ) to form a so-called surgical capsule. HoLEP allows the removal of the hyperplasic part of the prostate, the TZ, which separates the prostate capsule. Thus, HoLEP, as the anatomical surgery, can enucleate the enlarged prostate zone from the formed separation between TZ and capsule. Compared with the traditional surgical method, HoLEP may be safer, more efficient, and thorough with durable outcomes. Compared with TURP, holmium reduced the duration, irrigation time, and catheter time of the procedure and shortened hospital stay.6,7,8 The technique can also be performed safely on patients who are on anticoagulant therapy or with bleeding disorders9. Though there are different kinds of procedures for HoLEP, the main procedure is the same as mentioned in the following. We also introduce our own experiences and the innovation for this method in order to make it easier to accept and shorten the learning curve. The procedure is particularly suitable for large prostates and those combined with bladder stones, given that the holmium laser can also be used for lithotripsy8. This article introduces this technique and the detailed procedure.

<table border="0" cellpadding="0" cellspacing="0" width="1069">
	<tbody>
		<tr height="40">
			<td height="40" style="height:40px;width:260px;">holmium laser</td>
			<td style="width:205px;">Lumenis, USA</td>
			<td style="width:344px;"></td>
			<td style="width:260px;">PowerSuite 100W</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">mechanical morcellator</td>
			<td>Lumenis, USA</td>
			<td></td>
			<td>VersaCut</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">27Fr continuous flow resectoscope</td>
			<td>Storz, Tuttlingen, Germany</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

surgical treatment for benign prostatic hyperplasia: holmium laser enucleation of the prostate (holep).

Benign prostatic hyperplasia (BPH) commonly occurs among elderly males. The condition causes symptoms in the lower urinary tract, thereby reducing the quality of life. BPH includes 2 major treatments: medication and surgery. Surgical treatment is often the most effective and final intervention. Holmium laser enucleation of the prostate (HoLEP), one of the most efficient surgical procedures for BPH, is conducted transurethrally. During surgery, the most important and most difficult part is to locate the surgical capsule of the prostate, which is consistent to the idea of anatomic surgery. Different skills may be needed in treating different parts of the prostate. HoLEP tends to be efficient and safe with good hemostatic properties, and able to treat bladder calculus, which may be the complications of BPH. The technique is particularly suitable for prostate of varying volumes and sizes. Indeed, HoLEP also presents certain disadvantages, such as a long learning curve and costly equipment. Regardless, this method may be the "new standard" and the excellent method for the surgical treatment of BPH.

Retrospective data, collected from 2015 to 2016, were obtained from the clinical database of our department. A total of 100 patients treated for BPH were enrolled in the study. Perioperative outcomes were included: operation time (OT), hemoglobin decrease after surgery, Na+ variation, hospital stay duration, bladder irrigation duration and following-up data. Basic patient characteristics were also collected during our study. In addition, the catheterization time and hospitaliza...

Watch this Scientific Journal Video about Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate HoLEP. at JoVE.com

Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate HoLEP.

Here we present a safe and efficient protocol, holmium laser enucleation of the prostate, to treat benign prostatic hyperplasia.

Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate (HoLEP).

Benign prostatic hyperplasia (BPH) commonly occurs among elderly males. The condition causes symptoms in the lower urinary tract, thereby reducing the ...

The overall goal of this surgical intervention is to treat hyperplastic prostate and to relieve urethral obstruction caused by benign prostatic hyperplasia or BPH. This method helps us to answer the key questions about how to enucleate the prostate and how to do the surgical treatment for BPH. The main advantages on this method are that it is minimally invasive and it allows quick recovery after the surgery.Holmium Laser Enucleation of the prostate should be proposed as a new gold standard instead of the old one, transurethal resection of the prostate, because it is a low application load and quick recovery. We treated more than 2000 patients in the past 10 years and got very good results. Before beginning the procedure assess the BP of each patient in accordance with the European Association of Urology guidelines.After administering the appropriate anesthesia, place the patient in the lithotomy position and gently insert a continuous plastiscope into the patients urethral tract without damaging the mucosal tissue. Carefully observe the prostate, urethra, and bladder. Using a visual obturator, locate the uretal orifices including the medium lobe volume and the amount of intra-vesicle tissue.After locating the verumontanum, insert hand pieces equipped with a laser fiber connected to a laser instrument and set the laser power to 80 to 100 watts, at 1.6 to two joules per second, and 40 to 50 hertz. Tunnel the incision around the six o'clock position of the prostate and use a 100 watt versiapulsium laser to make a short horizontal incision around the six o'clock position in front of the verumontanum to locate the surgical capsule of the prostate. Finding the surgical capsule is critical to the success of this procedure as this is the plane in which we will do the whole aplasia.Expose the prostate surgical capsule from the verumontanum to the bladder neck. Then, create a tunnel from the apex toward the back of the bladder neck, taking care that the mucosa and the muscle are protected to facilitate efficient urinary control. To remove the lateral lobe, use a scope sheath combined with laser cutting and blur separation to enucleate the left lateral lobe from the six o'clock to the 12 o'clock position at the level of the surgical capsule.Then, enucleate the right lateral lobe as just demonstrated. Hang the enlarged prostate in the 12 o'clock position of the bladder neck without cutting down. Remove the enlarged prostate tissue from the bladder neck and push the excised tissue into the bladder.Recheck the prostate capsule to ensure no active bleeding occurs. Then, remove all of the enlarged glands and stop any severe bleeding points. After making holes in the surface of the prostate gland, equip the morcellator and the match tube according to the manufacturers instructions and insert the morcellator and a 26-french nephroscope into the patients urethral tract.Carefully and efficiently invert the morcellator so that the opening faces downward in the bladder to remove large and firm tissues, as well as fibrotic spherical glands with smooth surfaces and firm tissues. Keep the bladder sufficiently engorged with saline to avoid bladder injury throughout the procedure, taking care not to injure the bladder wall during the morcellation process. When all of the tissue has been removed, observe the general condition of the bladder.If no reserved tissue is left, insert a new catheter and irrigate normal saline into the bladder until the solution is clear or only slightly reddish. Remove the catheter when the urine becomes clear without gross hematuria. After hospital discharge, examine the follow up data of the patient for one, six, and 12 months, including the International Prostate Symptom Score, Overactive Bladder Scoring System, and quality of life and QMAC scores.Prostatic tissue removed by morcellation can be analyzed pathologically, post-surgery, as appropriate. In this representative study, pre and postoperative outcomes were assessed for 100 patients treated for benign prostatic hyperplasia, as just demonstrated. In 47 patients, the International Prostate Symptom Score was significantly decreased between four to 24 weeks after the prostate enucleation and morcellation procedures.Once mastered, this technique can be finished in only one hour and depending on the size of the prostate, if it is properly performed. While attempting the procedure, it is very important to finish the preoperative exam before beginning the surgery. After watching this video, you should have a very good understanding of how to perform HoLEP, the laser enucleation of the prostate which causes the bi-BPH.

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