The HoLEP
Chapter 14

Detailed Surgical Techniques for Benign Prostatic Hyperplasia

This chapter provides a detailed, step-by-step guide to the surgical techniques for the most common procedures used in the management of benign prostatic hyperplasia. A thorough understanding of these techniques is essential for any urologist performing BPH surgery.

Holmium Laser Enucleation of the Prostate (HoLEP): A Step-by-Step Guide

Patient Positioning and Setup:

  1. The patient is placed in the dorsal lithotomy position.
  2. A 26-Fr continuous flow resectoscope with a laser bridge is used.
  3. The holmium laser is set to a power of 80-100 W (2 J, 40-50 Hz).

Surgical Technique (Three-Lobe Approach):

  1. Initial Incisions: The procedure begins with incisions at the 5 and 7 o’clock positions at the level of the bladder neck, extending down to the verumontanum. These incisions are deepened until the circular fibers of the surgical capsule are identified.
  2. Median Lobe Enucleation: The median lobe is then dissected from the underlying capsule in a retrograde fashion, from the verumontanum towards the bladder neck. The laser is used to coagulate any bleeding vessels as the dissection proceeds. Once freed, the median lobe is pushed into the bladder.
  3. Lateral Lobe Incision: An incision is made at the 12 o’clock position, from the bladder neck to the verumontanum, again down to the surgical capsule.
  4. Lateral Lobe Enucleation: The lateral lobes are then enucleated sequentially. The dissection is carried out in the plane between the adenoma and the surgical capsule. The laser fiber is used to peel the adenoma away from the capsule. The dissection proceeds circumferentially, connecting the initial incisions.
  5. Apical Dissection: The final step is the apical dissection, where the remaining attachments of the adenoma at the apex of the prostate are divided. Care must be taken to preserve the external urethral sphincter.
  6. Morcellation: Once the adenoma has been completely enucleated and pushed into the bladder, a nephroscope with a mechanical morcellator is introduced. The enucleated tissue is then morcellated and aspirated from the bladder.

Bipolar Enucleation of the Prostate (TUEB): A Step-by-Step Guide

Patient Positioning and Setup:

  1. The patient is positioned in the dorsal lithotomy position.
  2. A standard 26-Fr bipolar resectoscope is used with a specialized enucleation electrode (e.g., a “button” or “loop” electrode).
  3. The bipolar generator is set to a blended cutting and coagulation mode.

Surgical Technique:

  1. Initial Incisions: Similar to HoLEP, the procedure begins with incisions at the 5 and 7 o’clock positions to delineate the median lobe.
  2. Median Lobe Enucleation: The median lobe is dissected from the surgical capsule using the bipolar electrode. The electrode is used to mechanically push and peel the adenoma while the bipolar energy provides hemostasis.
  3. Lateral Lobe Enucleation: The lateral lobes are then enucleated in a similar fashion, starting with an incision at the 12 o’clock position.
  4. En Bloc Technique: Alternatively, an en bloc technique can be used, where the entire adenoma is enucleated as a single piece. This often involves creating a “horseshoe” shaped incision around the verumontanum and dissecting the adenoma from the apex towards the bladder neck.
  5. Morcellation: The enucleated tissue is morcellated and removed from the bladder as in the HoLEP procedure.

GreenLight Laser Photoselective Vaporization (PVP): A Step-by-Step Guide

Patient Positioning and Setup:

  1. The patient is in the dorsal lithotomy position.
  2. A 22-Fr continuous flow cystoscope with a laser channel is used.
  3. The 180W XPS GreenLight laser system is used.

Surgical Technique:

  1. Vaporization of the Median Lobe: The procedure typically begins with the vaporization of the median lobe, if present. The laser fiber is held a few millimeters from the tissue surface, and the laser energy is applied to vaporize the tissue.
  2. Creation of a Prostatic Fossa: The surgeon then proceeds to vaporize the lateral lobes, creating a wide and open prostatic fossa. The vaporization is carried out systematically, from the bladder neck to the verumontanum.
  3. Hemostasis: The GreenLight laser has excellent hemostatic properties. Any bleeding points can be addressed by defocusing the laser beam and “painting” the bleeding area.
  4. Endpoint: The procedure is complete when a wide, patent channel has been created and the surgical capsule is visible.

Robot-Assisted Simple Prostatectomy (RASP): A Step-by-Step Guide

Patient Positioning and Setup:

  1. The patient is placed in a steep Trendelenburg position.
  2. The da Vinci Surgical System is used with a standard five-port configuration.

Surgical Technique:

  1. Bladder Drop: The procedure begins with the mobilization of the bladder from the anterior abdominal wall.
  2. Prostatic Capsule Incision: A transverse incision is made in the anterior prostatic capsule, approximately 1-2 cm distal to the bladder neck.
  3. Adenoma Enucleation: The plane between the adenoma and the surgical capsule is identified, and the adenoma is enucleated using the robotic instruments. The dissection is carried out circumferentially, freeing the adenoma from the capsule.
  4. Bladder Neck Transection: The adenoma is then transected at the level of the bladder neck.
  5. Urethral Transection: The urethra is divided at the apex of the prostate, taking care to preserve the external sphincter.
  6. Adenoma Removal: The enucleated adenoma is placed in a specimen retrieval bag and removed through one of the port sites.
  7. Reconstruction: The bladder neck is then reconstructed and anastomosed to the urethral stump using a running suture.