A healthy 67-year-old man with no prior surgical history presents to the clinic with bothersome lower urinary tract symptoms refractory to medical therapy.
Physical Exam and Diagnosis:
Digital rectal examination reveals an enlarged prostate without focal nodularity. Examination of the abdomen and genitalia is otherwise unremarkable. His prostate size is 73 g on computed tomography. His prostate-specific antigen (PSA) is 3.25, and urinalysis is bland.
Intervention:
The patient was consented for thulium fiber laser enucleation of the prostate (ThuLEP) for his right lateral lobe and holmium laser enucleation of the prostate (HoLEP) for his left lateral lobe. With a 26 French continuous flow rigid cystoscope, a 550-µm holmium laser fiber (Lumenis™ Pulse 120H with MOSES™ Technology, Boston Scientific) at 2.0 J and 50 Hz treated the left lateral lobe, whereas a 550-µm thulium fiber laser (SOLTIVE™ Super Pulsed Laser System, Olympus) at 4.0 J and 14 Hz treated the right lateral lobe. Both prostatic lobes underwent an initial anterior release of the adenoma followed by a posterior release in a “Top-Down” fashion. Hemostasis was maintained on each side with the respective laser used for enucleation.
Outcomes:
The total enucleation and coagulation times were 34 minutes for HoLEP and 38 minutes for ThuLEP. HoLEP demonstrated a more efficient enucleation rate per cut, which may reflect the surgeon’s extensive experience with this technique. Furthermore, the surgeon reported better identification of the prostatic capsule with HoLEP, whereas ThuLEP provided superior spot coagulation. HoLEP resulted in less charring than ThuLEP in both cutting and coagulation of prostatic tissue. The sequencing of enucleation is a potential source of bias, as the second lobe had improved irrigant flow and working space.
Follow-up:
Postoperative follow-up showed an excellent urinary stream without complications and a PSA of 0.04. Histopathology confirmed 40 g of benign prostate tissue removed.
- Seyedamirvala Saadat, Department of Urology, University of California, Irvine, California, USA.
- Bruce M. Gao, Department of Urology, University of California, Irvine, California, USA.
- Brandon Camp, Department of Urology, University of California, Irvine, California, USA.
- Jaime Altamirano-Villarroel, Department of Urology, University of California, Irvine, California, USA.
- Seyed Amiryaghoub M. Lavasani, Department of Urology, University of California, Irvine, California, USA.
- Mark Sarwat Hana, Department of Urology, University of California, Irvine, California, USA.
- Andrei D. Cumpanas, Department of Urology, University of California, Irvine, California, USA.
- Jacob C. Tsai, Department of Urology, University of California, Irvine, California, USA.
- Zachary E. Tano, Department of Urology, University of California, Irvine, California, USA.
- Akhil Das, Department of Urology, University of California, Irvine, California, USA.