HoLEP: HOLMIUM laser enucleation of prostate adenoma – The principle of treatment

Enucleation of prostate adenoma with holmium laser (HoLEP), has been practiced for about twenty years. It is now performed according to well-standardized techniques by the various surgeons who adopted it. The enucleation of the adenoma of the prostate with the HOLMIUM laser was developed progressively from the techniques of vaporization and vapo-resection endoscopic which used lasers of high power (more than 60 Watt) to increase the efficiency of These laser surgical procedures.

Theoretical bases

The Holmium laser has a wavelength of 2.1 microns. This laser beam is strongly absorbed by water and penetrates very superficially into the tissues, approximately over a distance of 0.4 mm.

 

Penetration depth Laser

 

Pulsed operation of this laser reduces thermal and combustion effects that are more important with lasers operating in continuous emission mode such as Thullium lasers (NdYAG) or using KTP crystal. The superficial penetration of the Holmium laser beam minimizes the coagulation zone and collateral damage to neighboring tissues. This laser allows a clear and precise cut of the tissues and vaporizes little.

The cut effect is WYSIWYG (What You See Is What You Get). The control of this penetration depth of the laser beam and its absorption by water reduce the energy that can reach the tissues not targeted by the surgeon and thus contribute to the safety of the surgical procedure. Hemostasis is obtained by modifying the laser parameters and defocusing the laser beam.

The development of adenoma in the context of benign prostatic hypertrophy creates a natural cleavage plan between healthy and pathological tissues that can be exploited surgically, whether during the classic open procedure of adenomectomy Trans-vesical or with recent endoscopic techniques such as HoLEP. The increasing practice of this enucleation of prostatic adenoma with holmium laser has confirmed the use of this cleavage plan, which is developed retrograde by the surgeon, from the veru montanum to the bladder neck.

 

 

Holep laser operation vs traditional transurethral

The technological development of effective moratoriums introduced by the transurethral route made it possible to envisage that the prostatic lobes, or even the entire adenoma of the prostate, are released in a monoblock in the bladder. It is there that they are broken up so as to reduce the large volume of each lobe into fine chips which can be easily extracted by aspiration through the urethral canal. Evidence for the effectiveness of HoLEP is now well documented, particularly from several randomized trials. The HoLEP also compares favorably through these studies, with the transurethral resection of the classical prostate to the electric current, as well as with the open operation of adenomectomy.

Indication and selection of patients:

The ideal patient to be operated according to this HoLEP technique presents a disabling micturition discomfort. The symptoms are related to the obstruction of the urethro-cervico-prostatic pathway due to the development of the prostate adenoma.

All prostate adenomas, whatever their size, are accessible to this holmium laser enucleation. The biggest adenoma that was treated by the promoter of the technique, the New Zealand Peter GILLING, weighed more than 1 kg.

The anatomical aspect of the development of this prostate adenoma also does not interfere with the quality of the outcome of the procedure. Moreover, a voluminous pathological prostatic median lobe is particularly favorable for the realization of this technique. However, laser enucleation of the adenoma of the prostate is a difficult procedure that requires a long learning from the surgeon. The larger the adenoma, the more difficult the procedure is and requires a surgeon particularly trained in this
technical.

Aspirin, anticoagulants or platelet anti-aggregants are usually interrupted or relayed a few days before surgery, but it is possible to carry out this surgical intervention on these fragile patients even if the interruption of these treatments is not Not possible.

The surgical indications of HoLEP are the same as those of conventional transurethral resection to electrical current: recurrent prostatitis, bleeding (haematuria) of prostatic origin, complication of severe prostatic obstruction (formation of bladder stones or The high urinary tract with distension of the renal cavities).

This intervention is carried out under a continuous liquid irrigation flow. There is, therefore, an important fluid resorption, but since this irrigation liquid is isotonic saline, there is no risk of hyponatremia or TURP syndrome with this technique. This factor, combined with the quality of haemostasis obtained by the use of the laser, makes it possible virtually to propose this intervention to any patient whose condition makes it possible to envisage anesthesia.

Reference:

Holmium Laser Enucleation of the Prostate (HoLEP) – P Gilling. BJU Int 101 (1), 131-142. 1. 2008