HoLEP vs ThuLEP: Comparing Laser Enucleation Techniques in Prostate Surgery "Presentation" - Bruce Gao

August 17, 2024

At the World Congress of Endourology and Uro-Technology, Bruce Gao presents a case study comparing holmium laser enucleation of the prostate (HoLEP) and thulium fiber laser enucleation of the prostate (ThuLEP) performed on the same patient with symmetrical lateral lobes. Dr. Gao describes the surgical technique, highlighting differences between the two laser types. The left lobe undergoes HoLEP, while the right lobe receives ThuLEP. The study notes that HoLEP provides superior identification of the prostatic capsule, while ThuLEP offers better on-spot coagulation.

Biographies:

Bruce Gao, MD, Urologist, Department of Urology, University of California, Irvine, CA


Read the Full Video Transcript

Bruce Gao: Laser energy effects on prostate enucleation within the same patient with symmetrical lateral lobes. A healthy 67-year-old male with bothersome lower urinary tract symptoms was evaluated in the urology clinic. Digital rectal exam demonstrated an enlarged prostate with no focal nodularity.

On CT scan, his prostate volume was 73 cc, and his PSA was 3.25. The patient was consented for endoscopic prostate enucleation. Enucleation was performed with a 26 French continuous flow rigid cystoscope with a laser bridge. The left lateral lobe underwent holmium laser enucleation of the prostate, and the right lateral lobe underwent thulium fiber laser enucleation of the prostate. Both prostatic lobes underwent an initial anterior release of the adenoma followed by a posterior release. Hemostasis was maintained on each side with the respective laser used for enucleation. Cystourethroscopy demonstrated a high bladder neck with bilateral lateral lobe hypertrophy. The operation started at the distal prostatic urethra, whereby the thulium fiber laser at four joules and 14 hertz created a seven o'clock incision, and the holmium fiber at two joules and 50 hertz created a five o'clock incision.

Each incision was carried down to the interface between the prostatic adenoma and the prostatic capsule. Following this, longitudinal 12 o'clock incisions were created. The thulium incision on the left was already made, given that the ThuLEP was performed after the HoLEP. We then began to perform lateral lobe enucleation. This is the posterior plane of the dissection.

Here you can see that there is an excellent plane between the prostatic adenoma and the capsule. Top-down lateral lobe enucleation was then performed. This was conducted with a combination of laser energy and blunt dissection. This plane was created with the intention of connecting to the posterior plane. The thulium fiber laser exhibits increased tissue char in comparison to the holmium laser. Finally, five and seven o'clock bladder neck incisions were created to connect with the initial five and seven o'clock incisions at the prostatic apex.

Here, additional anterior plane dissection is performed. The contour of the prostatic adenoma is followed with the laser and the beak of the cystoscope in a circumferential manner until the entire prostate is enucleated. Again, a combination of laser energy and blunt dissection was used to separate the prostatic adenoma from the prostatic capsule.

Finally, the remaining attachments to the adenoma were freed at the bladder neck, and both lateral lobes were finally released into the bladder. At the conclusion of the case, hemostasis was achieved with each laser modality. Small bleeders were spot-welded by defocusing the laser on the prostatic tissue until bleeding was controlled. The enucleation and coagulation times for the left lobe holmium laser and right lobe thulium fiber laser were 34 and 38 minutes, respectively. Superior identification of the prostatic capsule was observed with HoLEP. On-spot coagulation was superior with ThuLEP. The sequencing of enucleation is a potential source of bias as the second lobe had improved irrigant flow and working space.

Postoperative pathology reported 40 grams of benign prostatic tissue excised. Postoperatively, the patient endorsed an excellent urinary stream, and his follow-up PSA was 0.4.