Holmium-Laser

HoLEP: The realization of HOLMIUM laser enucleation of prostate adenoma

HOLMIUM (HOLEP) prostate adenoma enucleation requires a surgeon trained in this technique and having the specific equipment necessary for its realization.

 

Preoperative preparation

All patients have prior cytobacteriological analysis of urine, a PSA assay, and often a flow meter.

The voiding discomfort was assessed by the symptomatic IPSS score and the prostate volume was determined by suprapubic and / or endorectal ultrasound before the surgery was performed.

Urodynamic tests are not routinely used in this indication and are performed only if there is uncertainty regarding the diagnosis of obstruction of the lower urinary tract.

Preliminary endoscopy using a flexible fibroscope is only performed if there is suspicion of a narrowing of the urethra or as part of a hematuria test.

In the case of complete bladder retention, the ultrasound should include an ultrasound that determines the volume of the prostate gland, the state of the upper urinary tract and, in particular, the existence of a dilatation of the renal cavities, as well as the condition of the bladder with d Possible signs of struggle.

The procedure can be performed under general or loco-regional (epidural) anesthesia.

In the usual cases, in the absence of urinary infection, antibiotic prophylaxis is administered at the time of anesthetic induction.

Wearing compression stockings is recommended to limit the risk of thromboembolic complication.

The patient is operated in the waist position, close to the gynecological position, with the hips flexed at 90 °, as this position allows the free rotation of the endoscopic resector which is necessary to follow the different planes of the enucleation.

The urethra is lubricated with a gel prior to the introduction of the 26-gauge dual current rescuer.

Equipment:

The surgeon must have a powerful Holmium laser, at least 60 watt.

We use the Lumenis laser 100 watt.

Laser Lumenis

 

The laser fiber has a caliber of 550 μ.

 

Fibre laser lumenis

 

We use a dual-current laser resonator 26 of the brand Storz or Wolf equipped with a 30 ° optics. The procedure is performed in video surgery using a high definition endoscopic camera attached to the optics.

The second stage of the procedure is performed by means of a morcellator comprising a handpiece, circularly rotating blades 5 mm in diameter, a double pedal and a vacuum pump so as to ply the enucleated adenomatous lobe Against the morcellator.

We use a lateral slot Wolf morcellator for safety. This morcellator is passed in a nephroscope of right angle of mark Wolf comprising a wide channel operator.

 

Morcellateur Wolf

Single flow current irrigation is used to keep the bladder distended during this morcellation. The walls of the bladder are thus separated from the blades of the morcellator so as to avoid a bladder wound.

The procedure

The usual and most classic technique is the technique of the three lobes of GILLING.

Each of the three prostatic lobes (two lateral physiological lobes and a possible pathological medial lobe) are enucleated retrograde.

This enucleation leads to a large prostatic chamber comparable to that obtained by open-celled adenomectomy.

After revision of haemostasis, the transurethral morcellator is used to extract enucleated adenomatous tissues.

 

Post-operative care

After a short visit to a post-surgery unit, the surgeon is returned to his room.

A bladder catheter with a continuous irrigation flow of physiological saline drains and washes the bladder.

This probe is withdrawn at 6 o’clock the next day or the day following the operation according to the volume of the enucleated adenoma.

The patient is discharged during the same morning after the patient has urinated by natural routes twice.

There is no systematic prescription for antibiotic treatment.

As in the case of traditional transurethral resection to the electric current, the need to replace a new indwelling probe only occurs in 5 to 10% of cases. This probe is usually removed successfully the next day.

There is no restriction to the resumption of the usual activities of the surgery as soon as the urine is no longer tainted with blood.

Doctor DAVODY speaks for himself and does not receive any sponsorship from the companies LUMENIS, WOLF and STORZ.