Th evidence shows that right after HoLEP about 17-22% of patients suffer incontinence and after 3 months, 80% of those are recovered. Since incontinene includes stress incontinence, it means that those patients actually have healed because stress and urge incontinene could be separated as the former is due to stress while the latter is due to urge.
This shows that stress incontinene could be recovered or else only those patients who have urge incontinene would recover. Looking at the scientific evidence that is what the evidence is telling us. Make sense?
New advance in HoLEP: the en bloc no touch enucleation (ver I-100W laser, ver II is low power of 50W)
The good news: it is real and a very clever and impressive technique, which definitely will benefit patients. This technique produces almost no incontinence.
The bad news: there is little chance one could persuade his urologist to use it. My limited experience of dealing with several urologists let me form the opinion that urologists are somewhat conservative, not too easily excited about new techniques and not too eagle to adopt new techniques.
To understand this new technique. We must first understand the conventional 3 lobes technique. Because HoLEP requires morcellation thus the operation time is longer than TURP. Long operation time causes more complications. To overcome this problem, Some urologists t simplify the 3 lobes to 2 lobes then to the ultimate 1 lobe techniques. They are described below
A) The conventional 3 lobes enucleation techniques
Enucleation means cut out the entire piece of organ like an eye. For BPH. To understand more, watch videos:
youtu.be/9SuRWtIC2HQ
youtu.be/1EFeJ83QifU
(Paste link on YouTube search bar.)
HoLEP was invented in 1998 by Peter Gilling and a colleague. The 3 lobes technique has been in use since and is still in use today.
Ext sphincter
|
| _______________________wall
| bladder neck
|
| _____________________7 o'clock
|
----------------------
VM | _____________________ 12 o'colock
----------------------
| _____________________5 o'clock
|
|
|
| ______________________ bladder neck
| wall
|
Ext sphincter
Figure 1: 3 lobes technique: the initial three cuts at 5,7 and 12 o'clock
In the 3 lobes technique, 3 cuts are made, at 5, 7 and 12 o'clock. See figures 1. These cuts are deep and are down to the surgical capsule. They are difficult to make and have to be done slowly and carefully, else the capsule would be perforated. From the verumontanum to the bladder neck, it looks like a trough. The bottom edges are the 5 and 7 o'clock lines. Enclosed within these two lines is the middle lobe. The 12 o'clock cut is at the top and is the most difficult cut to make because it is harder to see the roof.
In front of the veru, another transverse cut is made to joining the 5 and 7 o'clock cuts together.
The transverse cut is thenslightly lifted and that strip of tissue which include the middle lobe is slowly enucleated towards the bladder neck.
The 12 o'clock cut now separates the left and right lateral lobes. They are then next enucleated from the veru towards the bladder neck.
Now all three lobes of adenoma are hanging by thin piece of tissue on the bladder neck. This tissue is then cut loose and the 3 lobes of tissues are then pushed into the bladder and be morcellated by the morcellator.
B) The 2 lobes technique
It was recognized that the 3 lobes enucleation took a longer time than TURP. The longer the operating time, the more complications. Thus, other techniques were invented to shorten the operating time. They are the 2 lobes and 1 lobe (en bloc) techniques.
In the 2 lobes technique, the cut at 7 o'clock is omitted..
This video shows the 2 lobes HoLEP technique:
youtu.be/LgP8yknqS4o
C) 1 lobe technique
There are many ways to do the 1 lobe technique. Below is an example. First a cage is cut to surround the front and part of the sides of the veru. The cage ends at the left and right lateral lobes. Then one of these end points goes up vertically along the lobe and joints the other end point like an arc. This cage and arc form a defensive perimeter to protect the veru and the external sphincter.
Enucleation starts from this initial cuts of the defensive perimeter towards the bladder in one piece.
This is a video showing the operation :
youtu.be/ShJ6GLAR2MY
Ext sphincter
|
| _______________________Rt. lateral lobe
| |
| |
| |___________
| | VM-sphincter cage
---------------------- |
VM | I -- bladder neck
---------------------- |
| ________x___|
| |
| |
| |
| ___|____________________.......
| Lt. lateral lobe
|
Ext sphincter
Figure 2: an example of a 2 lobes technique. A cage is formed to protect the veru and external sphincter.
D) the en bloc (in one piece) no touch technique
[ a Note: "There were neither long-term nor transient stress urinary incontinences (only urgent micturitions during the first 10-15 days after catheter removal. Less post operation hemostasis and no incontinence are the benefits of this reduced heat damaged technique, in addition to the reduced operation time.]
This technique is very different then the above techniques. Imagine u have a piece of label glued to a piece of wood by a rubbery glue. U try to remove the label by first lifting up one of the corners by ur fingers . This rubbery glue has the property that it won't break easily so between the lifted off corner label and the glass, the glue is stretched and becomes many of thin rubber fibers holding the label to the wood. Ur fingers are not allowed to use too much force else the label will be torn apart. For a given force, further lifting of the label is no longer possible. U are then given a micro propane torch to cut the fibers. The best way is to aim ur touch towards the middle of a fiber because then u won't burn the wood or the label.
In the above, the wood is the capsule and the label is the adenoma. In HoLEP, the mechanical force comes from the metal sheath holding the fibre. U don't want to apply too much mechanical force because it will cause more complications by putting more stress on the tissues. But with too little force, the angle between the label and the wood will be too small and the flame will be too close to the wood and the heat will damage the wood. So it is an optimization issue. U want to apply the smallest force to lift the adenoma and yet won't burn the capsule. It was found when the frame is about 3-4 mm away from the fiber to be cut and that the force is such that the angle is large enough so that the capsule is not heated up too much.
Normally, the laser is used to cut tissues. "No touch" means, the laser is at a distance of 3-4mm from a fiber and is not used to cut tissues.
Another feature of this technique is that the cut enters the adenoma only at one single point. That point is located between the front of the veru and the left lateral lobe and is marked x in figure 2. "x" is on the 5 o'clock line This point is the easiest to find the surgical capsule and is a kind of cleavage plane. From this point on, the enucleation will always be on the surgical plane by using the optimum mechanical force and optimum flame distance discuss above. This eliminate the problems having to make 3 lines to the surgical plane, all are difficult and could be dangerous. Also, the enucleation and hemostasis are always carried out on the surgical plane.
It is well known that the higher the temperature, the more post operation complications. Thus, the next optimizing is the power of the holium laser and the inventor of the en bloc no touch
techinque found that he could reduce the power from 100 to 50 watts and the technique still works. Obviously, less power is better for complications.
The helium laser wavelength of 2140nm is absorbed by water. "The plasma( ionized particles) bubble that forms at the tip of the fiber connected to the holmium:yttrium-aluminum-garnet laser makes it possible to work on stones and soft tissues. The coagulation of the prostatic tissue is caused by the hot water-vapor bubble that forms on the edge of the plasma bubble. During lithotripsy, guidewires and baskets within the expansion area of the plasma bubble risk damage." The bubbles creates "laser-induced pressure waves that can ablate tissues".
To understand more, the advantages of the technique is given in this abstract
www.semanticscholar.org/paper/High-power-HoLEP%3A-no-thanks!-Scoffone-Cracco/a95a6e182576fbccdd934cc730395d730c96bd37
"High-power HoLEP: no thanks!"
Cesare Marco Scoffone, Cecilia Maria CraccoWorld Journal of Urology2018
Abstract
"We read with much interest the editorial on transurethral Endoscopic Enucleation of the Prostate (EEP) [1]. This novel acronym has the irrefutable merit to accommodate all laserand non-laser-based transurethral techniques able to radically enucleate the obstructing prostatic adenoma, matching the durable functional results of open prostatectomy. However, it is worthwhile to underline the heterogeneity of such EEP techniques, depending on the complementary energy source (monopolar, bipolar, plasmakinetic or laser) employed to incise, coagulate and/or vaporize the prostatic tissue, in support of the blunt mechanical detachment of the adenoma from the surgical capsule obtained using the beak of the endoscope. Nowadays, urologists have to be familiar with the physical properties of the energies daily used in the operating room, to correctly employ them, take advantage of their features and prevent damages due to their inappropriate application. Consequently, the choice of the energy source for EEP is not secondary at all. In our opinion, HoLEP (Holmium:YAG laser enucleation of the prostate) stands out among all EEP approaches thanks to the precious and unique features of the holmium:YAG (Ho:YAG) laser. In our experience [2], HoLEP takes only a limited advantage of both mechanical detachment of the adenoma (avoiding energy delivery to the capsule but forcing the anatomical planes, possibly causing harmful traction of the sphincter, capsular perforations or adenoma ruptures) and incisional ability of the Ho:YAG laser (further improved by the increased power of the latest devices up to 120/140 W, delivering a relevant amount of energy to the capsule in a contact mode and once again cutting tissues regardless of the anatomical planes). Rather, the major part of the enucleation phase is carried out using the singular ability of the Ho:YAG laser to generate the so-called plasma bubble at the tip of the end-firing fiber, maintained at a short distance from the tissue. The plasma bubble transfers its energy to the surrounding water, first generating a rapidly expanding hot water vapor bubble with coagulating effects, then rapidly collapsing and producing pressure waves able to ablate tissues [3–5]. The search for the right distance between laser fiber tip and tissue is crucial: if too far laser energy is dispersed within the irrigating medium, if in direct contact, cuts sharply. A distance of about 3–4 mm allows the plasma bubble to dissolve the connecting shoots between the adenoma and capsular plane, gently put in tension by lifting the adenoma from the capsular plane with the tip of the resectoscope, and to produce an effective hemostasis, evident thanks to the “whitening effect” on the tissue. This is what we called the “no-touch” approach [2, 6]. The “no-touch” approach seems to deliver less laser energy directly to the capsule, one of the mechanisms possibly triggering postoperative storage symptoms, occurring from 1 to 68% of cases [7–10]. Although usually improving within a relatively short time, such symptoms have a major impact on the patient’s quality of life, causing restricted activities, social withdrawal, depression, and additional economic costs. In our series of “en bloc no-touch” HoLEPs, the incidence of postoperative storage symptoms is about 10%, with the additional advantage of a reduced traction of the sphincteric mucosa, progressively and/or early released when enucleating the adenoma in a single horseshoe-like piece with a single 5 o’clock incision, or in a single piece with no urethral incisions (“totally en bloc” approach) [6]. Since the introduction of HoLEP in 1998, urologists mainly performed it using the 100 W Ho:YAG laser device (power 80–100 W, energy 2 J, frequency 40–50 Hz) [11, 12], sometimes empirically decreasing laser energy for apical incisions [13]. Two years ago, after more than 250 “en bloc no-touch” HoLEPs performed with the traditional On behalf of UROICE–International Collaboration in Endourology."
The details are given in
"HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HoLEP): OUR EXPERIENCE WITH THE LEARNING CURVE AND THE DEVELOPMENT OF THE ‘EN-BLOC NO-TOUCH’ TECHNIQUE"
*Cesare Marco Scoffone, Cecilia Maria Cracco"
emj.europeanmedical-group.com/wp-content/uploads/sites/2/2018/02/Holmium-Laser-Enucleation-of-the-Prostate-HoLEP-Our-Experience-with-the-Learning-Curve-and-the-Development-of-the-‘En-Bloc-No-Touch’-Technique.pdf
Also watch video:
youtu.be/CH-tOgKVAvk
(scroll further down the list of videos and u will see Scoffone)
Difficulty encountered during conventional HoLEP
"During this first part of the learning curve we thoroughly analysed the steps that we considered critical and difficult to perform:
1) Finding the correct plane between prostatic capsule and adenoma three times during the procedure, at 5, 7, and 12 o’clock, with the risk of enucleating in an incorrect plane within the adenoma, to perforate the capsule and/or to undermine the bladder neck at the beginning of the procedure.
2) Performing an adequate 12 o’clock incision, avoiding significant bleeding if too deep or a too-distal descent towards the sphincter.
3) A ording the rotation of the lateral lobes around the axis of their residual attachment to the bladder neck, while progressing with their enucleation, without losing the correct orientation.
4) Obtaining a clear vision of the mucosal strip from 10 to 2 o’clock, for its safe incision maximally preserving the external sphincter."
Why ‘En-Bloc’
Adenoma enucleation begins at the apex lateral to the verumontanum, usually on the left side. The cleavage plane between adenoma and capsule is prominent at this site and particularly easy to identify. This incision between left and median lobe can be retrogradely deepened and widened towards the bladder neck, but this step is optional (partially ‘en-bloc’ approach, most frequently applied, obtaining a nal horseshoe-like adenoma). Otherwise, the dissection is carried out without separating the median and the lateral lobes, with an intact prostatic urethra (complete ‘en-bloc’ approach). In both cases the correct plane has to be identified only once instead of three times, reducing the risk of error.
The left lobe is then isolated from the apex towards the bladder neck in a side-to-side manner, ascending cranially from 5 to 3 o’clock (Figure 1). Its detachment is completed from 3 to 12 o’clock and goes on towards the right side from 12 to 9 o’clock. Going back to the initial left apical incision - when performed - the mucosa is horizontally incised above the verumontanum, reaching the apex of the right lobe; the median lobe is then isolated, reaching the bladder neck, and remains attached to the right lobe. Enucleation of the right lobe goes on as described for the left lobe, from 7 to 9 o’clock, circumferentially joining its already detached superior part from 9 to 12 o’clock. The enucleated ‘en-bloc’ adenoma is now xed from 10 to 2 o’clock only by a residual urothelial strip (while behind it the adenoma is almost completely detached) (Figure 2), which has to be incised before pushing the adenoma within the bladder under direct vision, limiting the risk of potential sphincteric damage. This progressive ‘en-bloc’ enucleation of the adenoma kept in place until the very last steps of enucleation by the anterior mucosa avoids its bothersome mobility. Two oblique incisions are nally made on the residual mucosa of the lateral lobes, and a nal horizontal incision is performed on the residual mucosal strip at 12 o’clock, as proximal as possible to the bladder neck. Now the completely enucleated adenoma can be pushed inside the bladder lumen for morcellation.
Why ‘No-Touch’
The mucosa at the apex lateral to the verumontanum is initially incised, but afterwards the capsular plane is mainly developed using blunt dissection. The adenoma is detached lifting it with the beak of the endoscope, serving as the surgeon’s nger during open simple prostatectomy, and progressively uncovering the correct capsular plane under vision (Figure 1). The laser energy is mainly employed to release the connective shoots put in tension by pushing the adenoma away from the capsule. Vision is optimal, blood vessels can be easily identi ed in advance (Figure 3) and can undergo targeted haemostasis, defocusing the laser to 2-3 mm. The laser bre is activated at a short distance from the tissue, most commonly dissolving rather than incising it. This e ect is particularly evident using the 120W device, reducing laser frequency and employing the medium-long pulse length. In this way, small adenomas and areas of strongly adhering capsule may be a orded without capsular perforation. Both the use of mechanical detachment and the ‘no-touch’ approach allow less energy supply to the capsular plane, implying fewer postoperative voiding symptoms.
Plse go to the original paper to see tables 3 and 4.
Clinical Outcomes
From 2012 HoLEP was always performed according to the described ‘en-bloc no-touch’ technique, standardised step by step. The hospital stay ranged from 2 to 3.5 days for all patients, the rst day being the day of surgery, the second postoperative day being the day of irrigation removal as well as catheter removal when possible a couple of hours afterwards, and the third postoperative day being the alternative day of catheter removal early in the morning. Since our hospital does not have an emergency department the current policy is to monitor spontaneous voiding for 24 hours after catheter removal, before sending the patient home.
As shown in Table 3 and Table 4, HoLEP effciency was globally increased, performing the procedure more frequently in 2013 and 2014 than in 2011 and 2012 (from 1-3 to 7 times a month). Year after year prostatic adenomas of increasing volumes were removed with shorter total operating times, employing less time for the enucleation and less energy as well. The small increase in the morcellation time (which is more device- dependent than surgeon-dependent) is related to the corresponding increase in adenoma weight removed.
In 2012 there were three patients (8.8%) requiring postoperative endoscopic haemostasis, in 2013 two (2.5%), and in 2014 one (1.7%). There were neither long-term nor transient stress urinary incontinences (only urgent micturitions during the first 10-15 days after catheter removal). Overall, seven patients (4%) required recatherisation, followed by successful catheter removal.
[Note: in 2014, "There were neither long-term nor transient stress urinary incontinences (only urgent micturitions during the first 10-15 days after catheter removal. Less post operation hemostasis and no incontinence are the benefit of this reduced heat damaged technique.]
In HoLEP, (1) if the initial cut at 5 or 7 o'clock extends to the grooves next to the verumontanum, it will produce retrograde ejacualtion, and (2) If any cut occurs in the areas on the left and right lateral lobes next to the verumontanum and within the same height of the verumontanum, it will also produce retrograde ejaculation.
To my knowledge, in HoLEP, the tissues removal does enter into the above mentioned 2 zones. And this is why the percentage of retrograde ejacualtion is so high, 70-80%, but would be patients are told to expect 100% .
So any ejacualtion preservation techniques will have to avoid these areas plus some margin.
I first read about it in a paper given at the 32nd Annual EAU Congress, 24-28 March 2017, London, United Kingdom. This was just a few months before my surgery. The technique was developed by a Dr. in Turin Italy.
The paper, Holmium laser enucleation of the prostate by an en-bloc and bladder neck preserved technique
Eur Urol Suppl 2017; 16(3);e2135, was presented by a Dr. Meng X of The First Affiliated Hospital of Nanjing Medical University, Dept. of Urology, Nanjing, China
The conclusion of the paper is...
CONCLUSIONS: HoLEP by a en-bloc and bladder neck preserved technique has the potential to obtain good functional outcome with small injury and high efficiency, especially for patients who need to preserve normal sexual function and anterograde ejaculation.
In another part of the paper the presenter says....
Before operation, 152 patients had sexual activity and anterograde ejaculation, therein normal anterograde ejaculation presented in 128 patients postoperation, while 24 patients (15.8%) felt no semen ejaculation.
Other research reports emphasize that the technique is much easier to learn than the Gilling technique thus it could be taught more quickly. The downside is that it is not available in the US. So one would have to travel to Italy or China.
Since doctors can learn this technique more quickly let’s hope it will spread quickly in the US.
PAE is/was undergoing clinical trials at Tampa general in Tampa FL Another option is FLA-BPH, it is available in a limited number of clinics. Both are preformed by interventional radiologists NOT urologists. Since they are new it is unlikely that they are covered by insurance.
I just ran a search on prostate artery embolization (PAE) doctors and found that Mount Sinai hospital is performing the procedure. PAE was developed in Spain and it appears to be catching on here in the US. I don’t know much about it other than it is FDA approved according to the Mount Sinai page.
In the past I spent tons of time reading posts on patients.info on Urolift because I was scheduled to go for Urolift but My insurance rejected my preauthorization. My impression of those posts is that people discuss how to deal with complications, what to expect during the procedure, etc. But very few strong recommendation posts, like Urolift worked out so good for me, it must work for u as well, go for it!
On the contrary, in this thread I saw posts strongly recommending HoLEP, like sure I got RE, sure I got continence, but I pee like a horse , I am so happy now, go for it!
Is my impression correct, or just me feeling that way???