The prostate adenoma also called benign prostatic hyperplasia should be treated when it causes a significant impact on the urinary tract and exposed to the occurrence of complications. Among the various possible methods of treatment, enucleation of the prostate adenoma holmium laser (HOLEP®) described herein has a number of advantages.
The benign prostatic hyperplasia (benign prostatic hyperplasia)
This is a significant increase in prostate volume (the usual normal prostate volume is of the order of 15 to 20 grams) which occurs depends on the periurethral glands of the prostate, i.e in the central portion of the gland, the contact of the urethra through which urine flows.
Therefore it induces an obstruction at the prostatic portion of the urethra at the neck of the bladder, causing a disorder of the flow of urine.
This benign prostatic hyperplasia affects men, especially after age 50, with 2 million French relevant and 80,000 annual operations.
It should be suspected in case of symptoms and discomfort during urination.
You have to treat this prostate adenoma:
- When the patient’s comfort is altered;
- When adenoma causes such an impact on the urinary tract that could damage irreparably: alterations of the bladder wall (thickening, diverticula), incomplete bladder emptying resulted in the presence of significant residual urine after urination, incomplete or chronic urinary retention or inability to urinate, stone formation in the bladder, repercussion on the upper urinary tract with dilated renal cavities and development of obstructive renal failure.
Various treatments are possible.
They are most often medicated with the use of molecules (plants, alpha blockers, hormones) which can reduce the size of the prostate or to relax the muscles to promote an expansion of the urethra and a better flow of urine.
Conventional surgical treatments indicated for failure of medical treatment, are to remove the prostate adenoma, which is placed as an egg in an eggcup. The goal is to remove the egg leaving in place the egg cup. This intervention does not therefore removes the entire prostate but leaves in place its hull.
The two most conventional methods to surgically remove the prostate adenoma are:
– Surgery by opening the abdomen: it is the bladder adenomectomy trans (operation HRYNTCHAK or FREYER) or retro pubic prostatectomy (MILLIN operation);
– Endoscopic surgery, which is still currently considered the “gold standard” to which other comparable techniques. This is the trans urethral resection of the prostate (TURP: trans urethral resection of the prostate), which with the current section and coagulation electrocautery cutting the chips in adenoma while respecting the terms of the prostatic capsule .
This is the volume of the adenoma which determines the choice between open surgery and trans urethral resection of the prostate.
Innovative surgical techniques being developed include:
- The use of surgical lasers. Three types of lasers are suitable for endoscopic surgery of benign prostatic hyperplasia:
1. Lasers using a KTP crystal Nd as laser GREENLIGHT: he made a vaporization of the prostate adenoma;
2. Lasers using a crystal Thulium-YAG laser as RevoLix: it is suitable for the vapo-resection and enucleation of the Spray-benign prostatic hyperplasia;
3. Lasers using a Holmium: YAG crystal as the laser LUMENIS: it is suitable for enucleation of the prostate adenoma.
- Endoscopic tissue destruction of prostate adenoma by bipolar vaporization with use of an electric current of high-energy (180 to 300 W).
- local elevation of intra-prostatic temperature (or thermotherapy) transurethral microwave to expand the prostatic portion of the urethra;
- embolization injection into the arteries vascularizing the prostate particles of sand size to the occlude to result in the collapse of the adenoma. It is still experimental method and less valued than before.
The holmium laser enucleation of the prostate adenoma:
HOLEP® (Holmium Laser Enucleation of the Prostate)
The fiber laser used emits radiation which separates the central adenoma of the peripheral portion of the prostate by releasing the block gradually released lobes inside the bladder. These will then fragmented using a “morcellator” to be discharged through the urethra and be analyzed, in particular to confirm the Benin character of the adenomatous tumor.
Enucleation with LUMENIS laser uses a Holmium laser fiber of high power (100 watts) manipulated by the surgeon using an endoscope introduced into the urethra.
The surgeon has a magnification of the surgical field during this video-surgery, by using a high definition camera, connected to the optics of the endoscope, which restores him the image of the operative field on the big screen of a monitor.
The wavelength of the radiation generated by the Holmium laser is 2140 nm, and its absorption depth is only 0.5 mm, thereby precisely cut the target area, while the wavelengths used by the other laser techniques penetrate well beyond what is seen in area. The section obtained with the holmium laser is WYSIWYG (What You See Is What You Get).
The procedure is performed under permanent irriguation saline which favors limiting local temperatures, lack of diffusion of the laser radiation to structures other than those covered by the cutting and good endoscopic vision.
Holmium HOLEP® method employed by the laser penetrates the tissue precisely in order to vaporize quickly limiting complications, reoperations rates, thermal effects, necrosis or collateral damage. The risk of bleeding (hemostasis) associated with its use are lower than those associated with conventional transurethral resection.
The advantages of the technique are:
- A limitation of the duration of urinary catheterization in postoperative remains, therefore reducing the risk of infection;
- The possibility of treating all prostate adenomas no size limitation;
- A large amount of prostate tissue is subjected to pathological examination;
- Shortening the length of hospitalization, surgery may be in well-selected cases, performed as an outpatient hospitalization;
- Earlier resumption of personal and professional activities;
- The absence of risk of severe metabolic DISORDERS ionic type-TURP syndrome can complicate conventional trans urethral resection and related reabsorption current irrigation by glycine used for this intervention while HoLEP is performed under irrigation physiological serum ;
- The procedure is particularly suitable for patients with cardiovascular disease and treated with anticoagulants and / or Antiplatelet, due to the limitation of bleeding risk.
The HoLEP almost never leads to impotence, with resumption of sexual activity after only a few weeks. Retrograde ejaculation is against a constant consequence of this intervention should not be offered if the patient has with his girlfriend a design project.
To prevent potential risks associated with this procedure, the urologist recommends using:
– To antibiotics preoperatively flash according to the recommendations of learned societies, to prevent the risk of infection
– Anticoagulant for patients at risk of phlebitis or embolism
– The postoperative rehabilitation of the sphincter in cases of urinary incontinence events.
During the month after surgery, the patient should drink a lot, limit its efforts, avoid alcohol and spices. Regular monitoring at his urologist will allow it to monitor the effects of the intervention – that is acquired after a recovery period of three months following the completion of the intervention – and monitor the possible occurrence of a cancer on the remaining shell of his prostate.
The HoLEP is gaining ground as the new “gold standard” surgical treatment of benign prostatic hyperplasia and US and European Associations of Urology (AUA & EAU) advocate its use in first-line in this indication.
Dr. DAVODY speaks in his own name and receives no sponsorship from the company LUMENIS.
Laser technique HoLEP:
(French) Laser technique HoLEP seen by the French Association of Urology (AFU)
(French) Laser HOLEP Technic Video of 7 minutes :
Method HOLEP – LUMENIS :