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HoLEP: Holmium Laser Enucleation of the Prostate

Endoscopic enucleation of the prostate is a minimally invasive therapeutic procedure for the treatment of benign prostate hyperplasia. The first surgical step consists of the endoscopic enucleation and relocation of the prostate adenoma into the bladder. The adenoma is divided and removed in the second step using a special instrument (morcellation).

Indications for HoLEP Prostate Surgery

The indications for endoscopic enucleation of the prostate (EEP) do not differ in principle from TURP. Surgical treatment of benign prostatic hyperplasia is necessary in cases of recurrent urinary retention, recurrent urinary tract infections, recurrent hematuria, bladder stones, postrenal acute kidney injury, and large bladder diverticula. The most common indication is moderate to severe symptoms of BPH, which are inadequately relieved with medication and limit the patient's quality of life.

Endoscopic enucleation of the prostate (EEP) is an alternative to TURP and open simple prostatectomy (Kim et al., 2013). With good technical expertise, any prostate volume can be treated effectively. Various energy techniques are used for tissue dissection:

• HoLEP: Holmium laser enucleation of the prostate
• ThuLEP: Thulium laser enucleation of the prostate
• GreenLEP: Greenlight laser enucleation of the prostate
• BipolEP: Bipolar enucleation of the prostate

Contraindications for Endoscopic Enucleation of the Prostate

Large bladder diverticula requiring surgery, huge urinary bladder stones, contraindications to lithotomy position, short life expectancy, and untreated urinary tract infections.

Surgical Technique of (Laser) Enucleation of the Prostate

Patient preparation:

Preoperative patient preparation is comparable to TURP.

Apical paracollicular incision:

The early circular apical incision protects the sphincter from tensile stress or termal damage during the subsequent enucleation [fig. apical incision]. In the ventral area (between 10 and 2 o'clock), incise with a significantly greater distance to the sphincter.

Enucleation of the adenoma:

Dissect the tissue following the pseudocapsule of the adenoma. The correct enucleation layer is most easily found paracollicularly (between 4 and 6 o'clock) and is recognizable by the circular fibers [fig. enucleation of the adenoma]. Follow the correct layer on both sides to the ventral until the adenoma can be dissected circularly into the urinary bladder (en bloc technique). Alternatively, perform incisions for each lobe of the prostate and dissect the lobes seperately into the bladder (three-lobe technique).

Intravesical morcellation:

The intravesical prostate adenoma is removed using a morcellator. During morcellation, fill the bladder adequately and keep the morcellator at a sufficient distance from the bladder wall. Insert an 18 CH irrigation catheter after enucleation and morcellation. Send the fragments for pathological examination. 

Postoperative Management after HoLEP

Remove the irrigation catheter after 1–2 days, depending on the postoperative hematuria. Control sufficient bladder emptying with ultrasound imaging.

Complications of Endoscopic Enucleation of the Prostate

Bleeding

The intraoperative risk of bleeding is significantly reduced compared to TURP. However, postoperative bleeding requiring intervention is possible.

Infections

The cause for postoperative urinary tract infections is an ascending catheter infection and the (already existing) bacterial colonization of the prostate (risk factor urinary retention with bladder catheter). Perioperative antibiotic prophylaxis reduces the likelihood of infectious complications. An epididymitis occurs in 2%.

Other complications:

Bladder injury during morcellation, retrograde ejaculation, urethral stricture, bladder neck stricture, and sphincter injury with urinary incontinence.

References

Kim M, Lee HE, Oh SJ. Technical aspects of holmium laser enucleation of the prostate for benign prostatic hyperplasia. Korean J Urol. 2013 Sep;54(9):570-9. doi: 10.4111/kju.2013.54.9.570.

R. M. Kuntz, K. Lehrich, and S. A. Ahyai, “Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial.,” Eur Urol, vol. 53, no. 1, pp. 160–166, 2008.

  Deutsche Version: HoLEP: Technik und Komplikationen der Laser-Enukleation der Prostata