Holmium laser enucleation of the prostate: patient selection and perspectives

Abstract

BackgroundMultiple endoscopic surgical options exist to treat benign prostatic hyperplasia (BPH), including holmium laser enucleation of the prostate (HoLEP). HoLEP alleviates obstructive prostatic tissue via enucleation, both bluntly with a resectoscope and by cutting tissue with the holmium laser, and removal of adenoma via morcellation. This article reviews patient selection for HoLEP in order to optimize outcomes, costs, and patient satisfaction.MethodsA literature review of all studies on HoLEP was conducted. Studies that focused on outcomes in regard to patient and procedural factors were closely reviewed and discussed.ResultsVarious studies found that men with large or small prostates, on antithrombotic therapy, in urinary retention, with bladder hypocontractility, with prostate cancer, undergoing retreatment for BPH, or in need of concomitant surgery for bladder stones and other pathologies do well with HoLEP, as demonstrated by excellent functional and symptomatic outcomes as well as low complication rates. There is a 74–78% rate of retrograde ejaculation following HoLEP. Techniques to preserve ejaculatory function following enucleative techniques have not been able to demonstrate a significant improvement.ConclusionPatient selection for HoLEP can include most men with bothersome BPH who have evidence of bladder outlet obstruction and are healthy enough to undergo surgery. The ability to safely perform concomitant surgery with HoLEP benefits the patient by sparing them an additional anesthetic and also decreases costs. Patients should be made aware of the risk of retrograde ejaculation following HoLEP and counseled on treatment alternatives if maintaining ejaculatory function is desired.

A Feasibility Study Utilizing the Thulium and Holmium Laser in Patients for the Treatment of Recurrent Benign Prostatic Hyperplasia after Previous Prostatic Surgery

“…During tissue resection in the apex area, some surgeons prefer not to resect near the seminal crest in order to avoid sphincter damage, especially in large volume prostates > 80 mL. As already stated, HoLEP has been proven to be a size-independent procedure with excellent long-term results [7,17,18]. There is no doubt that enucleation of the prostate with either holmium or thulium laser leads to the same efficacy after previous prostate surgery.…”

Current status of holmium laser enucleation of the prostate

“…Once all prostate tissue is extracted and hemostasis is fully achieved, a three‐way Foley catheter is generally placed and bladder irrigation is initiated continuously if required …”

“…In open prostatectomy for BPH or prostate adenoma, surgeons often encounter large amounts of bleeding. Several therapeutic modalities have emerged to address these side‐effects, such as plasmakinetic resection of the prostate, plasmakinetic enucleation of the prostate, HoLEP, holmium laser resection of the prostate and PVP …”

“…Several therapeutic modalities have emerged to address these side-effects, such as plasmakinetic resection of the prostate, plasmakinetic enucleation of the prostate, HoLEP, holmium laser resection of the prostate and PVP. 1 The definitive feature of these surgical procedures is the removal of adenoma causing obstruction of urine flow, but the methods vary between resection, vaporization, ablation and enucleation. Enucleation by HoLEP also requires morcellation to remove the enucleated prostate tissue.…”

“…Once all prostate tissue is extracted and hemostasis is fully achieved, a three-way Foley catheter is generally placed and bladder irrigation is initiated continuously if required. 1,5 Surgeons carry out these techniques with their mentors for the first 20 HoLEP cases as the training period. 6…”