Holmium laser enucleation of the prostate (HoLEP) is recognized by the AUA guidelines as a size-independent surgical treatment for benign prostatic hyperplasia.¹ The procedure is minimally invasive and durable, and has a low risk of complications and a short recovery time. This semi-live surgery is intended to demonstrate evolution in the surgical technique of endoscopic enucleation paired with state-of-the-art laser technology to improve patient outcomes following HoLEP.

Case Presentation: A 58-year-old male with bothersome lower urinary tract symptoms (LUTS), hesitancy, weak stream, and nocturia, despite tamsulosin 0.4 mg and finasteride 5 mg orally daily

• AUA Symptom Index: 20
• Quality of Life: 4
• Uroflow: prolonged plateau flow, maximum flow rate 7.1 mL/s
• Post-void residual: 45 mL
• Office cystoscopy: trilobar hyperplasia with intravesical median lobe
• Multiparametric MRI prostate: 100 cc, no high-risk lesion (Figure 1)
• Past medical history: stage 3 chronic kidney disease, elevated PSA (13.7 ng/mL) status post 4 negative prostate biopsies

Figure 1. Coronal image of multiparametric prostate MRI.

Steps of the operation:

1. Identify important structures and landmarks: ureteral orifices, verumontanum, external genitourinary sphincter (EGUS)
2. Early apical release: inverted V incision to release the posterior apex of the prostate, circumferential incision in prostatic urethral mucosa to release the anterior apex of the prostate (Figures 2 and 3)
3. Lateral enucleation plane development
4. Identification and incision of anterior and lateral bladder neck fibers
5. Division of lateral and median lobe attachments
6. Transitional zone adenoma pushed en bloc into the bladder
7. Division of bladder neck attachments
8. Hemostasis
9. Morcellation

Figure 2. Early apical release en-bloc holmium laser enucleation of the prostate: inverted V incision to release the posterior apex of the prostate.

Figure 3. Early apical release en-bloc holmium laser enucleation of the prostate: circumferential incision in prostatic urethral mucosa to release the anterior apex of the prostate.

While there are different surgical techniques for endoscopic enucleation of the prostate, the en-bloc technique is increasingly being performed. En-bloc enucleation of the prostate involves removal of the entire transitional zone of the prostate as a single tissue block. Potential advantages of the en-bloc technique include shorter operative time, decreased bleeding, reduced risk of transient stress urinary incontinence, and improved histopathological examination.^2,3 It has also been suggested that utilization of the en-bloc technique during the initial learning curve allows for a faster, more efficient operation without any difference in functional outcomes or major complications.⁴ One reason for this may be that the en-bloc technique offers better visualization due to continuous laminal irrigation flow in the narrow working space and faster identification of the surgical dissection plane.

Early apical release of the prostate is often combined with en-bloc endoscopic enucleation of the prostate. The technique of early apical release is intended to reduce the risk of unintentional injury to the urethra and EGUS by decreasing traction on the prostatic apex and preserving the urethral mucosa overlying the EGUS. A study by Saitta et al found that early apical release was associated with a lower risk of urinary incontinence after HoLEP.⁵ However, a subsequent study found no significant difference in the rate of urinary incontinence in patients with and without early apical release. Therefore, the benefit of early apical release to reduce the risk of transient urinary incontinence remains uncertain and is an area for future research.

This semi-live surgery also highlights the benefit of using Moses pulse modulation for HoLEP. The holmium laser pulse is modulated such that the first part of the laser pulse, referred to as the initiation sequence, is emitted creating a small vapor cavity, through which the second part of the pulse is delivered. The end result is optimized energy delivery. The clinical benefit of Moses technology for HoLEP was evaluated in a randomized controlled trial from our center comparing HoLEP with and without Moses pulse modulation. Our study found HoLEP with Moses pulse modulation to result in shorter operative time and hemostasis time, and reduced blood loss.⁶ Similar findings were reported in a systematic review and meta-analysis of 7 comparative studies (814 patients) of HoLEP with and without Moses pulse modulation.⁷ Patients treated with Moses technology had shorter enucleation and operative times, as well as better hemostasis. When considering the utilization of en-bloc technique, early apical release, and Moses technology collectively for endoscopic enucleation of the prostate, as was highlighted in this semi-live surgery, there is evidence for improved outcomes. Socarrás and colleagues conducted a single-arm prospective study comparing en-bloc Moses laser enucleation of the prostate with early apical release to non-Moses en-bloc HoLEP.⁸ En-bloc Moses laser enucleation of the prostate with early apical release was significantly better than en-bloc HoLEP in terms of surgical time, enucleation time, ablation rate, and hemostasis time. Moses pulse modulation has also been shown to result in a reduced risk of fiber tip degradation during HoLEP which may allow for more effective tissue cutting.⁹ Perhaps the most notable benefit of Moses technology is the ability to safely treat and send many patients home with same-day discharge.¹⁰ Previously, all HoLEP patients required an overnight hospital stay, but the clinical paradigm surrounding HoLEP has vastly improved with the introduction of this laser technology.