Current surgical techniques of enucleation in holmium laser enucleation of the prostate

Abstract

Holmium laser enucleation of the prostate (HoLEP) has been accepted as the most efficient method of transurethral surgery for benign prostatic hyperplasia. The originally developed three-lobe technique has popularized this surgery; this method is based on three longitudinal incisions, by which the median lobe is removed, and subsequently, both lateral lobes are enucleated. To maintain a consistent surgical plane and to minimize sphincteric damage, the traditional three-lobe technique is continuously being refined and evolving. A few modifications of the original technique have been developed, and several en bloc enucleation methods have been introduced. However, more clinical evidence is required to show the superiority of newer techniques over the original three-lobe technique in terms of efficacy and long-term side effects. To date, none of the newer techniques have been accepted as a standard technique for HoLEP.

A global knowledge, attitudes and practices survey on anatomical endoscopic enucleation of prostate for benign prostatic hyperplasia among urologists

“…Learning curve is another important aspect in achieving good outcomes. The most common modality employed to perform AEEP was noted as HoLEP (54.1%) (Gilling, Cass, Cresswell, & Fraundorfer, 1996), with the three‐lobe enucleation technique as the most common technique employed (40.3%) (Oh, 2019). Importantly, 50.3% graded their skill in performing AEEP as above average.…”

Enucleation of the prostate: An anatomical perspective

“…The 3‐lobe technique typically involves three longitudinal incisions on the prostate that are made to enucleate the median lobe and both lateral lobes from the level of the bladder neck to the striated sphincter. Subsequently, modified surgical techniques have been developed by many surgeons (Endo et al., 2010; Gong et al., 2012; Kim et al., 2013; Oh, 2019), and the surgical technique has evolved significantly. Since about 2010, several en bloc enucleation methods have emerged worldwide (Miernik & Schoeb, 2019; Minagawa, Okada, Sakamoto, Toyofuku, & Morikawa, 2015; Saitta et al., 2019; Scoffone & Cracco, 2016).…”

“…The capsule is found by starting an incision along the border between the left lateral lobe and the urethra from the left side of the verumontanum. Oh (2019), and Kim et al. (2013) made initial small longitudinal incisions on both sides of the verumontanum to identify the prostatic capsule and later connected the two incision lines with new longitudinal incisions starting at the 5 and 7 o'clock positions of the bladder neck.…”

“…Therefore, very careful preservation of the mucosal tissues around the urethra may be required to prevent urinary incontinence. The surgical technique involving an early inverted V‐shape mucosal incision (Oh, 2019) is based on this possibility. It was previously shown that a mucosal incision should be directed towards the prostatic adenoma without directly contacting the sphincter (Kim et al., 2013).…”

“…It was previously shown that a mucosal incision should be directed towards the prostatic adenoma without directly contacting the sphincter (Kim et al., 2013). A more recent revised technique involves making the incision at a more medial position (Oh, 2019). This is because the presence of the urethral mucosal layer on the surface of the sphincter might be advantageous to prevent temporary incontinence immediately after surgery (Figure 1).…”