The patient is placed under general anesthesia and in the dorsal lithotomy position. GreenLEP is conducted using a Wolf™ double-flow endoscope 24.5- Fr, with continuous saline irrigation of the bladder. The Wolf endoscope specializes in blunt dissection. The tip of the scope is 5mm back from the tip of the external sheath, allowing for clear vision during the mechanical dissection. An HPS 2090 fiber is connected to the Greenlight XPS 532-nm laser generator. The procedure is based on the combination of both laser and mechanical energies. The adenoma is enucleated “en-bloc” according to surgical steps previously described by Fernando Gomez Sancha. An oscillating morcellator with a single-use blade (Wolf-Piranha) is used by the end of the surgery.
Procedure Steps:
- 1. Correctly identify the striated sphincter, the verumontanum, prostatic lobes and ureteral orifices through regular urethrocystoscopy.
- 2. Then, primarily using coagulation (40 Watts), a horizontal mark is created at the anterior part, clearly above the urinary sphincter. This mark must be considered as a security line that should never be crossed during the procedure.
- 3. To perform 'en-bloc' enucleation of the prostate, the capsular plane is found posteriorly, laterally to the verumontanum, through coagulation of the mucosa and then vaporization (80 Watts) of the tissue.
- 4. After the first contact with the prostatic capsule on the right side with the tip of the scope, the dissection is carried out laterally and anteriorly to the apex.
- 5. We proceed to carry out the same dissection on the opposite side to perform an early apical release. The release will protect the integrity of the external sphincter during mechanical maneuvers.
- 6. The enucleation is carried out from the apex and then laterally and anteriorly mainly using mechanical energy by pushing the lobe towards the bladder. Occasionally, hemostasis is performed during this step using coagulation.
- 7. Once the enucleation is completed laterally and anteriorly, the procedure is repeated on the left side.
- 8. The final step of the procedure consists of enucleating the posterior part of the median lobe to detach the adenoma in one piece and to push it into the bladder.
- 9. Hemostasis is performed with extreme care before conventional morcellation, as previously described, at the end of a HoLEP procedure.
Learning Points:
Green laser enucleation of the prostate is an anatomical en-bloc endoscopic enucleation using a side firing fiber that requires several key points:
- Using the proper instruments
- Finding your landmarks
- Early apical release first
- Favoring mechanical dissection to visualize the correct plane (prostatic capsule)
- Carrying out the hemostasis throughout the procedure: clear vision
- Favoring the dissection of the upper part of the prostate at the very beginning of the procedure, otherwise the adenoma will lift up
- Even after a good enucleation, do not forget that complications occur during morcellation
- Following the safety rules for morcellation: vision-bladder fully distended-nephroscope in the middle-adenoma cover the bladder - train the OR team!
