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      The en-bloc no-touch holmium laser enucleation of the prostate (HoLEP) technique

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      World Journal of Urology

      Springer Science and Business Media LLC

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          A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams).

          Holmium laser enucleation of the prostate (HoLEP) is a surgical treatment for bladder outlet obstruction secondary to benign prostatic hyperplasia. HoLEP is a transurethral procedure that uses the holmium laser fiber (wavelength 2,140 nm) to dissect whole prostatic lobes off of the surgical capsule in retrograde fashion, while maintaining excellent hemostasis. The lobes are removed from the bladder by a purpose built transurethral morcellator, which means that large volume prostates can be enucleated endoscopically. We compared this procedure with transurethral prostate resection (TURP) in a randomized trial by evaluating outcomes in patients with a prostate volume of 40 to 200 ml on transrectal ultrasound. A total of 61 patients with urodynamically proved bladder outlet obstruction secondary to benign prostatic hyperplasia were randomized to TURP or HoLEP. Perioperative parameters recorded included resectoscope, laser, electrocautery, morcellation and catheter time, hospital stay, bladder irrigation, volume blood transfusion the rate and resected tissue weight. Patients were followed 1, 3, 6 and 12 months postoperatively with peak urinary flow rate measurement and quality of life and American Urological Association symptom scores. Patients also underwent urodynamic assessment at 6 months with measurement of peak detrusor pressure at maximal flow, post-void residual volume and prostate volume by transrectal ultrasound. Continence, potency and all adverse events were recorded at each visit. HoLEP was superior to TURP in terms of mean catheter time (17.7 +/- 0.7 vs 44.9 +/- 10 hours) and hospital stay (27.6 +/- 2.7 vs 49.9 +/- 5.6 hours) but it required more time to perform (62.1 +/- 5.9 vs 33.1 +/- 3.7 minutes). More prostate tissue was removed in the HoLEP group (40.4 +/- 5.7 vs 24.7 +/- 3.4 gm). HoLEP was also superior to TURP in terms of relieving urodynamic obstruction at 6 months of followup (postoperative detrusor pressure at maximum flow 20.8 +/- 2.8 vs 40.7 +/- 2.7 cm H2O). HoLEP and TURP led to significant improvements in peak flow rates, symptom scores and quality of life scores compared with baseline and there was no significant difference between the 2 procedures with respect to these parameters at 12 months. Fewer adverse events were recorded in the HoLEP group. HoLEP is superior to TURP for relieving bladder outlet obstruction in men with benign prostatic hyperplasia. It allows more rapid catheter removal and hospital discharge. It requires more time to perform than TURP but more prostate tissue is removed, resulting in similar efficiency in tissue retrieval. HoLEP is equivalent to TURP in relieving men of lower urinary tract symptoms and in improving peak urinary flow rates at 12 months of followup.
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            Prospective evaluation of the learning curve for holmium laser enucleation of the prostate.

            In a prospective manner we evaluated the learning experience of an endourologist inexperienced with holmium laser prostate enucleation and its impact on surgical outcome. We also reviewed the literature to document technical features of holmium laser prostate enucleation at different institutions. Patient demographic, perioperative and followup data were analyzed. To assess the impact of the learning curve on postoperative outcome patients were divided into group 1--patients 1 to 50, group 2--51 to 100 and group 3--101 to 162. The effect of the learning curve and weight of resected tissue on enucleation and morcellation efficiency was studied. Holmium laser prostate enucleation was successfully completed in 93.82% of patients. Eight patients required conversion to transurethral prostate resection. Enucleation and morcellation efficiency was 0.49 and 2.75 gm per minute, respectively. Enucleation efficiency attained a plateau after 50 cases. Postoperative outcome was compared in the 3 patient groups. There was a higher incidence of capsular perforation and stenotic urethral complications in group 1. In the literature a mean of 57.09% of tissue (range -9.6 to 81.9%) was retrieved after holmium laser prostate enucleation and mean efficiency was 0.52 gm per minute (range -0.11 to 1.09). Efficiency increased proportionally with resected prostate weight. An endourologist inexperienced with holmium laser prostate enucleation can perform the procedure with reasonable efficiency after about 50 cases with an outcome comparable to that of experts, as described in the literature. During the learning curve conversion to transurethral prostate resection can be done without any harm to the patient.
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              Holmium laser enucleation of the prostate: results at 6 years.

              The issue of durability is an important concern when evaluating new surgical modalities. To date, only 24-mo data have been published on holmium enucleation of the prostate (HoLEP) despite its widespread use worldwide although 4-yr data exist for the earlier technique of holmium resection. This study addresses the issue of durability of HoLEP. All patients who had undergone HoLEP and been evaluated in three prospective trials conducted at this institution between 1997 and 2002 were evaluated. Patients available at follow-up had data assessed on the International Prostate Symptom Score (IPSS), maximal flow rate (Qmax), quality of life (QOL), International Continence Society Male Short Form (ICS-SF), International Index of Erectile Function (IIEF), Benign Prostatic Hyperplasia Impact Index (BPHII), and continence questionnaire. The mean follow-up was 6.1 yr (range: 4.1-8.1 yr). The mean age of the patients at follow-up was 75.7 yr (range: 58-88 yr). Of 71 HoLEP patients originally studied on the protocol, 38 (54%) were available for analysis, 14 were deceased, and 19 were lost to follow-up. The mean IPSS for this group was 8.5 (range: 0-24) and Q(max) 19 ml/s (range: 6-28 ml/s). The QOL score was 1.8 (range: 0-5) and the BPHII 2.0 (range: 0-11). One patient (1.4%) had undergone reoperation, an additional HoLEP. Overall, 92% were either satisfied or extremely satisfied with their outcome. HoLEP is durable and most patients remain satisfied or extremely satisfied with the long-term outcome.
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                Author and article information

                Journal
                World Journal of Urology
                World J Urol
                Springer Science and Business Media LLC
                0724-4983
                1433-8726
                August 2016
                December 11 2015
                August 2016
                : 34
                : 8
                : 1175-1181
                Article
                10.1007/s00345-015-1741-y
                © 2016

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