Early-Stage Clinical Experiences of Holmium Laser Enucleation of the Prostate (HoLEP)

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1 JRural Med 2007 ; 2 : Original article Early-Stage Clinical Experiences of Holmium Laser Enucleation of the Prostate (HoLEP) Shuzo Hamamoto 1,TakehikoOkamura 1,HideyukiKamisawa 1,KentaroMizuno 1, Makoto Katou 1 and Kenjiro Kohri 2 1 Department of Urology, Anjo Kosei Hospital, Aichi, Japan 2 Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan Abstract Objective : Recently, holmium laser enucleation of the prostate (HoLEP) has been established as one method of endoscopic surgery for the treatment of benign prostate hyperplasia (BPH). The purpose of our study was to assess initial clinical experiences with HoLEP at our hospital. Patients and Methods : Aretrospective analysis was conducted of 28 patients with obstructive symptoms due to BPH who underwent HoLEP during the 13 months between February 2004 and March Results : The mean age of the patients was 67.4 years (range 59 to 78 years). The mean enucleation tissue weight was 24.3 g (range 2 to 95 g), and the average operation time was 94.1 minutes (range 40 to 268 minutes). The mean duration of postoperative catheterization was 3.4 days (range 1to6days).Themeanurine flow rate improved, and each patient s satisfaction for voiding, measured on a 5-point scale, was good. There were no major complications during the operations except one case, which was completed with TUR-P because of uncontrollable bleeding. Correspondence to : Shuzo Hamamoto Department of Nephro-urology, Nagoya City University, Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, , Japan hamamo10@soleil.ocn.ne.jp No patients required transfusions. Long-term complications included five cases of stress incontinence (19%), four of urethral stricture (14%), and three temporary retention, two of which required re-catheterization (10%). Conclusion : HoLEP can be performed without major intraoperative complications. It is an effective treatment for obstructive symptoms due to BPH. However, there are many postoperative problems that must be resolved, including stress incontinence and urethral stricture because of our lack of experience, with HoLEP. Key words : holmium laser enucleation of the prostate (HoLEP), benign prostate hyperplasia (BPH) Introduction HoLEP is one of the transurethral prostate treatments for obstructive symptom due to benign prostate hyperplasia ( BPH ). Conventional treatment is the transurethral resection of prostate (TUR-P), which has been regarded as the gold standard, and this is the method with which most urologists are familiar. However, many urologists feel uneasy about TUR-P because of the potential need for a blood transfusion in cases with either significant bleeding or transurethral resection syndrome ( TUR syndrome ). Furthermore, open simple prostatectomy is 2007 The Japanese Association of Rural Medicine 93

2 required in cases of significantly enlarged prostates, exceeding 100 g 1). The depth of tissue penetration of the Holmium laser is superficial, and it is effective in coagulating small blood vessels. The HoLEP procedure is performed using normal saline as irrigation. Therefore, there is a low possibility of significant bleeding or transurethral resection syndrome during the operation. Several studies have concluded that it is a safe and effective treatment that is equally comparable with TUR-P or open simple prostatectomy 2-5). At the time of this study, there had been 28 cases that were treated with HoLEP in our hospital. We retrospectively evaluated these cases, including perioperative complications and patients quality of life after HoLEP. Patients and methods We retrospectively analyzed the data from 28 patients who underwent HoLEP in our department (J. A. Aichi Anjo Kosei Hospital) during the 13 months between February 2004 and March All of the patients received transabdominal ultrasonography and physical examinations, including digital rectal examinations (DRE). Serum prostate specific antigen (PSA) levels were also evaluated in all cases. Patients with increased PSA or suspicious DRE underwent prostate needle biopsy, and were excluded if diagnosed with prostate cancer. During the 13- month period, all of the operations were performed by one surgeon who followed previously described techniques 6).A550-nm endfiring holmium laser fiber using a 26 Fr continuous-flow resectosocpe was used. Normal saline was used as irrigation in all cases. The enucleated prostate tissue was evacuated from the bladder with a Versa Cut morcellator. After the operation, a 24 Fr three-way catheter was indwelled with a 50 ml balloon cuff, and if necessary, continuous bladder irrigation was performed through the catheter. There was a follow-up period of more than six months for all patients. Eight categories were examined for this study ; patient background, operation time (enucleation time including morcellation), enucleated tissue weight, duration of postoperative catheterization, preoperative and postoperative urine flow rates, International Prostate Symptom Score (IPSS), intraoperative or long-term complications, and patient satisfaction ratings of postoperative voiding. Long-term complications, IPSS, and patient satisfaction ratings were determined by sending a letter to each patient more than six months after his operation. Patient satisfaction ratings were obtained using an original questionnaire (Table 1). Results Table 1 Patient satisfaction rating Q1. How do you feel about your voiding since your operation? a) very satisfied b) almost satisfied c) neither d) slightly dissatisfied e) very dissatisfied Q2. If another person required this operation, would you recommend it? a) yes b) no The mean age of the patients was 67.4 years (range 59 to 78 years). The mean enucleation tissue weight was 24.3 g (range 2 to 95 g). Four patients (14%) were diagnosed with prostate cancer after the operation. The sequential data of operation time, enucleation weight, and duration of postoperative catheterization are shown in Figures 1 and 2. The average operation time including morcellation was 94.1 minutes (range 40 to 268 minutes). The operation time per enucleation weight became increasingly shorter as the surgeon gained experience in performing HoLEP. The mean duration of postoperative catheterization was 3.4 days (range 1 to 6 days). The perioperative complications are summarized in Table 2. In one case, the surgery was completed with TUR-P because of uncontrollable bleeding while using HoLEP. However, no patients 94

3 Table 3 Pre and postoperative data of UFM and IPSS Mean UFM (ml/s) IPSS Preoperative 10.9 ( ) (±7.3) Postoperative 17.3 ( ) 6.08 (±5.7 ) (p < 0.05) Figure 1 Sequential data of operation time and enuclation weight Figure 2 Duration of postoperative catheterization Table 2 Perioperative complications Intraoperative Blood transfusion 0 (0%) Bladder injury 0 (0%) Switch to TUR-P 1 (3%) Postoperative Stress incontinence 5 (19%) Urethral stricture 3 (10%) Bladder neck contracture 1 (3%) Recatheterization 2 (7%) Remorcellation for residual adenoma 1 (3%) Total 13 (46.4%) Figure 3 Patient satisfaction rating (1) required blood transfusion, and there were no bladder injuries or cases of TUR syndrome. Five patients complained of stress urinary incontinence that required the use of absorbent pads after more than six months. Three patients complained of weak voiding which was caused by post-operative distal urethral strictures. These strictures occurred between three and six months after the operations. Two of the three patients were treated with urethral dilation, and the other required a urethral incision. These cases were predominantly in the period soon after the introduction of the HoLEP procedure. Figure 4 Patient satisfaction rating (2) Three patients developed temporary urinary retention; two of them required re-catheterization. The other patient required re-morcellation because of residual prostate tissue in the bladder. Pre and postoperative mean urine flow rates and IPSS are shown in Table 3. Both of these 95

4 measures improved significantly after the operation. The results of the questionnaire addressing patient satisfaction (Table 1) are shown in Figures 3and4. More than 80% of the patients responded favorably to question 1. More than 75% of the patients answered yes to question 2. There were 4 patients who answered no ; three of them complained of stress incontinence, and one patient suffered from weak voiding. Discussion As the population ages,thenumberofpatients with dysuria caused by enlarged BPH is increasing 7,8).There are many kinds of treatments for BPH, including conservative medical treatments, warm temperature therapy, and endoscopical or open surgical management. The current therapy of choice is some type of medical treatment, such as alpha-1 adrenergic blockers. However, there are many patients who do not respond to such treatment or who have unsatisfactory results, and occasionally, they may experience urinary retention and repeated urinary tract infections. TUR-P is generally thought to be safe and effective so it has been the gold standard procedure to use in endoscopic surgery for lower urinary tract symptoms caused by BPH. However, there is the possibility of bleeding that will require a blood transfusion or cause TUR syndrome, depending on the case and differences in the ability of the surgeon 9). HoLEP is an endoscopic treatment that was first reported by Gilling in ). We introduced HoLEP for the first time in Two features of the Holmium laser are that the depth of tissue penetration is superficial (0.4 nm) and it can be used for incision, ablation, and coagulation. Because of this, it can be used in a manner similar to that of using an index finger during open prostatectomy. However, compared to TUR-P it is difficult to master HoLEP because of retrograde resection, the necessity of adequate devices, and the longer time requirements. In our experience, it has taken about one year for urologists to be able to perform efficient operations with few complications. In 2002, El-Hakim et al. reported that it takes, on average, 20 cases for a surgeon to become adept with the HoLEP technique 11). In most cases, a spinal anesthesia was used, but for a few patients, general anesthesia was necessary. Operation time was not related to enucleation weight, and the HoLEP technique was more easily performed after about one year of experience. No patients required blood transfusions, and no patients experienced bladder injuries or TUR syndrome. In one case, the procedure was finished using TUR-P. TUR-P is the most popular endoscopic surgery for BPH. In a review of 3,885 TUR-P patients 1), Mebust et al. found that the most common shortterm complications were intraoperative bleeding requiring transfusion (2.5%), TUR syndrome (2%), and postoperative blood transfusion (3.9%), but there were few intraoperative complications in the cases we reviewed, even though HoLEP had been newly adopted. It is obvious from the data of El- Hakim et al. 11) that HoLEP is a minimally invasive operation. In our cases, the duration of postoperative catheterization became increasingly shorter as we became more experienced with the technique, and therefore, we expect to continue to improve in the future. In the near future, we are going to begin performing HoLEP as an outpatient surgery for BPH. Eleven patients (32%) suffered from some postoperative urinary symptoms including stress incontinence (19%) and urethral stricture (10%). Elzayat et al. reported that 4.2% of patients had stress urinary incontinence, which resolved within one to six months with anticholinergic medical therapy, and 10% had urethral stricture 12). This stress incontinence rate is much higher than reported elsewhere for TUR-P. The initial lack of endoscope operation techniques, in particular the excessive attraction of the sphincter muscle to the endoscope, was thought to be the major reason because these complications were primarily observed soon after the HoLEP procedure was 96

5 introducted. Postoperative voiding data (UFM and IPSS) improved passably, and therefore, our results confirm previous reports that it is an equally effective procedure for urinary obstructive symptom. Patient satisfaction ratings of voiding symptoms were satisfactory in spite of postoperative complaints. To decrease long-term complications such as urinary incontinence and urethral stricture, we would still like to improve this operation technique and consider other devices. Conclusion HoLEP is a minimally invasive operation for BPH and has few intraoperative complications. Reduced blood loss, evasion of TUR syndrome, and shorter catheterization make this procedure a feasible and effective alternative to TUR-P or open prostatectomy. We believe that HoLEP will become one of the major options for outpatient surgery for BPH. Reference 1. Mebust WK, Holtgrewe HL, Cockett AT, et al. Transurethral prostatectomy : immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 1989 ; 141 : Narmada Gupta, Sivaramakrishna, Rajeev Kumar, et al. Comparison of standard transuretheral resection, transurethral vapour resection and holmium laser enucleation of the prostate for managing benign prostatic hyperplasia of >40g. BJU Int 2006 ; 97 : Aho TF, Gilling PJ, Kennett KM, et al. Holmium laser bladder neck insicion versus holmium enucleation of the prostate as outpatient procedures for prostates less than 40 grams : a randomizes trial. J Urol 2005 ; 174 : Kuo RL, Paterson RF, Siqueria TM, et al. Holmium laser enuculeation of the prostate: morbidity in a series of 206 patients, Urology 2003 ; 62 : Matthew D, Peterson, Brain R, et al. Holmium laser enuculeation of the prostate for men with urinary retention, J Urol 2005 ; 174 : Kuo RL., Paterson RF, Kim SC, et al. Holmium Laser Enuculation of the Prostate (HoLEP) : a technical update. World J Aurg Oncol 2003 ; 1:6. 7. Kirby RS. The natural history of benign prostatic hyperplasia : what have we learned in the last decade? Urology 2000 ; 56 : Berry SJ, Coffey DS, Walsh PC, et al. The development of human benign prostatic hyperplasia with age. J Urol 1984 ; 132 : Borboroglu PG, Kane CJ, Ward JF, et al. Immediate and postoperative complications of transurethral prostatectomy in the 1990 s. J Urol 1999 ; 162 : Gilling PJ, Cass CB, Cresswell MD, et al. Holmium laser resection of the prostate; preliminary results of a new method for the treatment of benign prostatic hyperplasia, Urology 1996 ; 47 : El-Hakim A, Elhilali MM, et al. Holmiumlaser enucleation of the prostate can be taught: the first learning experience. BJU Int 2002 ; 90 : Elzayat EA, Habib EI, Elihilali MM, et al. Holmium laser enucleation of the prostate : a size-independent new Gold standard, Urology 2005 ; 66 :