AUA2023 BEST VIDEOS Veil-sparing Holmium Laser Enucleation of the Prostate: Technical Modification for Optimized Postoperative Urine Control

By: Ahmed M. Elshal, MD, Urology & Nephrology Center, Mansoura University, Egypt | Posted on: 30 Aug 2023

Holmium laser enucleation of the prostate (HoLEP) was described more than 25 years ago.1 Over the years growing evidence supporting its safety, efficacy, and durability for treating BPH was established.2

Many techniques have been described for doing HoLEP; they entail retrograde transurethral enucleation of the prostate adenoma. In most of these techniques, the tricky apical separation is done at the end of the procedure by urethral mucosal ventral incision.3-5

Over years, many technical modifications have been described for doing HoLEP, most of them aimed at reducing early postoperative urine incontinence (UI) and to abridge learning difficulties.6

Transient UI after HoLEP was variably reported from 8.5% to 42.7%.7 Fortunately enough, it is time related and most of them recover, yet it is a frustrating event both for the surgeon and patient. Understanding anatomical facts behind this transient leak may help in adopting better strategies to reduce it.

The mechanism of post-HoLEP transient UI was thought to be secondary to excessive stretch of the sphincter following a prolonged procedure with late separation of the prostatic apex.8 Furthermore, alterations in urethral mucosal or submucosal tissue at the prostatic apex may contribute to post-HoLEP transient UI, bearing in mind that the mucosal lining extends from the bladder neck to the bulbar urethra with longitudinal arrangement through the prostatic urethra covering the sphincter.9 Using HoLEP principles of laser assisted retrograde, blunt enucleation without early mucosal incisions at the apex ends up tearing the urethral mucosa longitudinally and strips the sphincter from its mucosal covering.

Veil-sparing HoLEP, a uniform technique for laser assisted enucleation of the prostate, aims at optimization of post-HoLEP urine control and abridging learning difficulties by using standardized consecutive steps throughout the whole procedure. The technique entails lobe by lobe enucleation with early complete separation of the prostate apex. The prostatic apex is released once the apical plane is bluntly developed using more proximal periapical mucosal incision (see Figure).

Figure. The blue dotted line refers to the plane of the axial section diagram. HoLEP indicates holmium laser enucleation of the prostate.

To enhance reproducibility of the technique, the steps were abbreviated as “IT PAS ABCD.”10

Between April 2016 and December 2020, a clinical trial was conducted. Patients with symptomatic BPH were randomly allocated to standard HoLEP vs veil-sparing HoLEP. The primary endpoint of this trial was post-HoLEP UI both subjectively and objectively using 1-hour pad test. All perioperative parameters, urinary outcome measures, and complications were assessed and compared.

Median preoperative prostate size was 138 (range 50-282) and 128 (range 50-228) ml in standard HoLEP and veil-sparing HoLEP groups respectively. The number of patients subjectively reporting UI, the number of patients with positive 1-hour pad test, as well as the grade of UI reported throughout the first 4 months after surgery were significantly favoring veil-sparing HoLEP.

Post-HoLEP urine transient incontinence following veil-sparing HoLEP was significantly reduced. The degree, as well as the duration of transient post-HoLEP urine leak, was minimized by optimization of surgical technique. Furthermore, this technique offers structured approach for HoLEP learning.

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