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Totally-en-bloc no-touch low-power HoLEP
Boston Scientific
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2019
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Description
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Totally-en-bloc = enucleation of the prostatic adenoma in one single piece, with no vertical incisions of the prostatic urethra - No touch = our way of delivering energy during the surgery, not too far (no effect), not in contact (incisional mode), but 2-3 mm far from the tissue, in order to use the plasma/vapor bubble generated at the tip of the laser fiber to dissolve the connecting fibers between the adenoma and the capsular plane - Low-power = over the years we gradually reduced the power of the holmium laser during this procedure, from 100W to less than 40 W, reducing the frequency (18-20 Hz) and setting the energy to 2-2.2 J (long-pulse setting), with better vision and reduced postoperative dysuria - HoLEP = Holmium Laser Enucleation of the Prostate
Clinical Case:
Male patient
65 years old
ASA I
No allergies
Not a smoker
No professional risk factors
BMI 24
BPO causing moderate LUTS
Clinical History:
Worsening LUTS along the years despite alpha-blocker therapy (silodosin 8 mg once daily)
DRE x 2, not suspicious
PSA 2.88 ng/ml
Pathologic uroflowmetry
US = prostate 62 cc, PCR 160 cc, normal kidneys, thickened bladder wall
QoL 4, IPSS score 20
Procedure Steps:
Preliminary endoscopic evaluation of the urethra, of the shape of the adenoma, of the bladder/orifices
Preparation of the right enucleation plane starting from the apex of both lateral lobes
Early circumferential incision of the sphincteric mucosa
Totally-en-bloc enucleation of the prostatic adenoma, toward the bladder neck, without opening it
Final opening of the bladder neck and detachment of the adenoma along It
The adenoma is pushed into the bladder lumen and morcellated
Learning Points:
The preliminary evaluation of volume and shape of the prostate
The initial identification of the right enucleation plane
