Transurethral Surgical Anatomy of the Arterial Bleeder in the Enucleated Capsular Plane of Enlarged Prostates During Holmium Laser Enucleation of the Prostate

Abstract

PurposeTo identify the endoscopic vascular anatomy of the prostate during Holmium laser enucleation of the prostate (HoLEP), and analyze the clinical risk factors associated with significant arterial bleeding.MethodsWe identified 107 consecutive patients with benign prostatic hyperplasia who underwent HoLEP between September 2009 and August 2010, performed by a single surgeon (S.J.O.). Two independent reviewers reviewed the surgery video database and completed a prespecified form. The location of bleeding arteries was marked at the level of the bladder neck, proximal prostate, distal prostate, and verumontanum. Arterial bleeding was classified into one of three grades according to bleeding severity (grades 2 and 3 indicate significant bleeding).ResultsThe mean prostate volume was 65.1±31.5 mL, and the mean prostate-specific antigen (PSA) level was 3.69±3.58 ng/mL. During the HoLEP procedure, the most common locations of significant bleeders were the 2-5 and 7-10 o'clock positions in the proximal prostate. The average number of bleeding arteries was 12.1±7.9 per procedure, and 1.93±1.20 per 10 mL of prostate volume. Multivariate analysis revealed that prostate volume and serum PSA were significant parameters for estimating the number of bleeding vessels.ConclusionsDuring the HoLEP procedure, the most common locations of significant bleeders were the 2-5 and 7-10 o'clock positions in the proximal prostate. Prostate volume was associated with the number of bleeders. A careful approach to the capsular plane of the proximal prostate facilitates early hemostasis during the HoLEP procedure, especially with larger adenomas.

A Focused Review on the Effects of Preoperative 5α-Reductase Inhibitors Treatment in Patients Undergoing Holmium Laser Enucleation of the Prostate: What Do We Know So Far?

“…The mentioned literature review yielded only seven studies (including two congress abstracts) related to the impact of 5-ARIs on HoLEP. 2,[4][5][6][7][8][9] In all studies, the data were collected retrospectively. Two used retrospective video recording for evaluation of the surgical technique characteristics, one of them for bleeding severity and the other for enucleation difficulty.…”

“…Multivariate analysis, however, found prostate volume to be the only significant parameter. 4 Another retrospective study by Kikuchi and coworkers evaluating postoperative infectious complications enrolled 190 patients undergoing HoLEP. Thirty-seven of those, almost 20%, were on dutasteride treatment.…”

Holmium laser enucleation of the prostate: Problem‐based evolution of the technique

“…During HoLEP, most bleeding problems emerge when you dissect out of this anatomical plane and penetrates the adenoma or the peripheral zone. This is particularly important at the lateral aspect of the proximal prostate and bladder neck level where the urethral branches of the prostatic artery penetrate the adenoma (Choo, Lee, Bae, Cho, & Oh, 2014).…”

Transurethral Enucleation and Resection of the Prostate: Contemporary Role in the Surgical Treatment of Benign Prostatic Hyperplasia

“…Moreover, blood loss is another frequent complication that has been shown by several studies to be less frequent with TUERP than with TURP or open prostatectomy [28,29,34]. This can be explained by the early control of bleeders as they exit the surgical capsule towards the adenoma [18,19].…”

“…The main concept of this modification is to help define the capsular plane early during the procedure particularly at 2-5 and 7-10 o'clock positions of the bladder neck where most bleeders are located [18]. This would allow an under-vision onestep control of those bleeders that will help achieve a bloodless resection of the enucleated adenoma in a timely manner thereby reducing resection time and preventing complications particularly bleeding [18,19]. This is difficult to do during the standard TURP where vessels are repeatedly cut before reaching the capsule [20,21].…”