Benign enlargement of prostate (BEP), which is. Early Experiences with HoLEP. Original Article ABSTRACT INTRODUCTION. Bhandari BB*

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1 Original Article Early Experiences with HoLEP Bhandari BB* * Consultant Urologist, Shree Birendra Army Hospital, Norvic International Hospital, Alka Hospital ABSTRACT introduction: Holmium Laser Enucleation of Prostate (HoLEP), is emerging as size-independent gold standard for treatment of prostatic adenoma which has been recently introduced in Nepal. The current study was undertaken to assess the early clinical experiences with this relatively newer technology. Methode: A retrospective analytical study of a total of 75 consecutive patients who underwent HoLEP for obstructive symptoms with preoperative diagnosis of Benign Enlargement of Prostate (BEP) were considered for the study. Inpatient and intra-operative data of these patients were analyzed RESULTS: The age of the subjects varied from 55 to 94 years, mean enucleation tissue weight was 40 gms (30 120), mean operating time was 84 mins. Catheterization time ranged from 18 to 72 hours (mean 30 hours), none of the patient required blood transfusion, and mean duration of hospital stay was 1.3 days (1 3). Complication rate was 8 %. International prostate symptom score (IPSS) change was more than 10 in most of the patients in 1 month follow up. Despite all patients screening negative for carcinoma with serum Prostate Specific Antigen (PSA), two patients had histopathological evidence of adenocarcinoma. CONCLUSION: HoLEP is an effective treatment modality for BEP due to its shorter catheter time, shorter hospital stay, minimal risk of blood transfusion, the rare need for perioperative bladder irrigation and quicker return to full activity, but it has a steep learning curve. Keywords: HoLEP, clinical experiences. INTRODUCTION Benign enlargement of prostate (BEP), which is prevalent in up to 43% of men over the age of 60 1, continues to be a leading cause of voiding difficulties. 2 Although symptoms can often be handled adequately with medical therapy, patients who continue to suffer significant voiding problems will eventually require surgical intervention to avoid or treat longterm sequelae such as urinary retention, urinary tract infections, and bladder calculi. 3 Transurethral resection of the prostate (TURP) remains the reference standard for surgical treatment to which all new technologies used are traditionally compared. Correspondence : Lt. Col. Dr. Bharat Bahadur Bhandari Shree Birenndra Army Hospital drbharatbhandari@yahoo.com Nevertheless, TURP has a relatively high complication rate of 15% to 18%, including bleeding requiring blood transfusion (0.4% to 2.5%), transurethral resection (TUR) syndrome (0.8% to 2%), and myocardial arrhythmia (1.1%). 4-6 For this reason, many alternative energy modalities have been developed such as trans urethral microwave thermo therapy, transurethral needle ablation, electrovaporization, interstitial laser coagulation of the prostate, and visual laser ablation of the prostate have been developed. One such technological advance involves the holmium:yag laser. 3,6 Use of the holmium:yag laser in the treatment of BEP has changed significantly over the last decade. The Ho:YAG laser was initially used as a vaporization tool for treating BPH. 7-9 Gilling et al then developed a new concept of resection (holmium laser resection of the prostate) and later a true enucleation of the prostatic Volume 10 Number 2 Jul-Dec

2 adenoma (HoLEP) At the present time, holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation represents the latest refinement of the resection technique. Its wavelength is highly absorbed in a fluid environment, with a depth of tissue penetration of only 0.4mm. It can be used to cut tissue by vaporization and coagulate blood vessels simultaneously at a depth of 1 2mm, generating minimal histological tissue damage. Irritative voiding symptoms do not occur or are minimized. 8,14 By utilizing this procedure, even extremely large glands which previously would have required an open simple prostatectomy can be treated effectively, with decreased bleeding, catheter time and bladder irrigation, no prostate size limitation and no TUR syndrome, with only an overnight hospital stay for the patient Although HoLEP is a promising alternative for the surgical treatment of BPH, the learning curve for the procedure remains a significant obstacle. 3 METHODE Retrospective data of 75 patients who underwent HoLEP in four months period from June to September 2010 were analyzed. All surgeries were performed by the author in different institutions. Pre operative work up consisted of detailed history, including International prostate symptom score (IPSS) and physical examination. Laboratory tests consisted of complete blood count, serum chemistries, serum PSA level and urinanalysis with urine culture. Coagulation profile was done in patients on anticoagulants. Prostatic size estimation was done with digital rectal examination and ultrasound. Post void residual urine volume was estimated ultrasonologically. Flexible cystoscopy was performed in patients where other causes of obstruction such as strictures needed to be excluded. Patients previously diagnosed with prostate cancer or neurogenic bladder were excluded from the study. Patients on anticoagulants were asked to discontinue for 7 days preoperatively and 2 days postoperatively. Enucleation were done, with patients placed in dorsolithotomy position with thigh maximally abducted, with a Fr continuous flow resectoscope and 550 µ laser fiber. Normal saline irrigant was used in all the cases. After enucleation, tissue was retrieved after morcellation with a morcellator in the bladder. All retrieved tissue were subjected to histopathological examination. A 20 Fr 3-way Foley s catheter was placed at the conclusion of the procedure and irrigation was done only if necessary. The operative data consisted of enucleation time, morcellation time, enucleated tissue weight, pathological findings and complications. Patients were kept nil per mouth for 6 hours post operatively and enteral diet was started as soon as he was fully conscious. The catheter was routinely removed the next morning and the patient was discharged from the hospital when he was able to void adequately. All patients were followed up in 5 days, 14 days and 1 month where IPSS score was compared to that before the surgery. Patients who did not present for follow up in 1 month were enquired over the phone. RESULTS The baseline characteristics of the patients are as shown in the Table 1. The age ranged from 55 to 94 years, with mean age of 64 years % of the patients were under medical therapy for obstructive and irritative symptoms due to enlarged prostate, 62.6% presented with retention, 58.7 % had recurrent urinary tract infection and 46.7% had deterioration of renal function. The mean IPSS score was 23 with 3 patients with mild symptoms, 34 with moderate and 38 patients with severe symptoms % of the patients had co-morbidities, out of which 17.3% were on anticoagulants (clopidogrel / aspirin). The operative data are summarized in Table 2. The mean enucleation time ranged from 50 to 160 minutes, with mean time of 84.2 minutes. The steep learning curve, shown in Figure 1 shows significant decrease in the operating time from the first to the last case. The mean morcellating time was 17.3 minutes (10 30 minutes). Enucleated tissue weight was grams (mean 30 grams). 6 patients had intra-operative complications, 2 patients with bladder injury by morcellator and 4 patients had breach in the prostatic capsule. All these patients were managed conservatively, with subsequent good recovery. None of the patients required intra or post operative blood transfusion. The mean hospital stay was 1.3 days (1 3 days). 46 Volume 10 Number 2 Jul-Dec 2010

3 Table 1 : Baseline characteristics of the patients ( n = 75 ) 1. Age group (mean 64) 2. Indication for prostatectomy a. Severe symptoms of prostatism / failed medical therapy b. Chronic retention with renal impairment c. Acute retention d. Deterioration of renal function e. Recurrent urinary tract infection 3. International Prostate Symptom score a. 0 7 b c Co morbidities a. Diabetes Mellitus b. Hypertension c. IHD on anticoagulants d. COPD e. Patient of medication for other conditions 52 (69.3 %) 31 (41.3 %) 16 (21.3 %) 35 (46.7%) 44 (58.7 %) 3 patients 34 patients 38 patients Total : 56 (74.6%) 13 (17.3 %) 27 (36.0 %) 13 (17.3%) 21 (28.0%) 6 (8.0%) Table 2 : Mean operative data Variable Mean (range) 1. Enucleation time (minutes) 84.2 (50 160) 2. Morcellation time (minutes) 17.3 (10 30) 3. Enucleated tissue weight 40 (30 120) (grams) 4. Catheterisation time (hours) 30 (18 72) 5. Hospital stay (days) 1.3 (1-3) 6. Complication rate - Bladder injury - capsular breach 8 % 2 patients 4 patients 7. Intra / Post operative 0 patients (0%) transfusion requirement of Pre and Post operative IPSS scoring is shown in figure 2. Figure 1. Comparison of Pre and Post operative IPSS scores. DISCUSSION Figure 1. Operating time Although all the patients had age adjusted PSA value within reference limits, 2 patients had histological evidence of adenocarcinoma of the prostate. All the patients presented for follow up, where they were assessed by history, clinical examination and necessary laboratory and radiological investigations. Comparison As the population ages, the prevalence of BEP, and its accompanying voiding symptoms, is increasing. 17 The natural history of BEP is often one of progression, with mild symptoms becoming more bothersome over time. Among 50-year-old men, the lifetime incidence of surgical or medical intervention for BEP is estimated to be 35%. 18 Wasson et al found that in a 3-year, multicenter, randomized controlled trial comparing men with moderate symptoms of BPH treated by either watchful waiting or transurethral resection of the prostate (TURP), 24% of men in the watchful waiting arm underwent surgical intervention. 19 In the current study, 69.3 % of the patients had evidence of prostatism or had failed medical therapy. Volume 10 Number 2 Jul-Dec

4 Patients with urinary retention typically require surgical intervention, and this cohort has been previously reported to be at significant risk for adverse perioperative events. 20 Pickard et al performed a prospective study of 3,966 men undergoing prostatectomy, of whom 1,242 presented with urinary retention. The authors found that the urinary retention group had an increased risk of perioperative morbidity, including significantly greater rates of intraoperative complications, most commonly characterized as either uncontrolled bleeding or cardiorespiratory problems, blood transfusion, and unplanned return to the operating room, most commonly for bleeding compared with the group of men not in urinary retention. 21 Similar findings were reported by Doll et al and Thorpe et al. 22,23 In our study, as comparable to similar studies 20, no patient required blood transfusion. The hemostatic action of the laser enables a clear visual field during the enucleation process, and minimizes the risk of significant bleeding necessitating a blood transfusion. 20 HoLEP is an ideal way of treating BEP; the enucleation of the adenoma is an old concept used in open prostatectomy in large glands. HoLEP is suitable for any size of prostate and preserves minimal invasiveness. 7, 24, 25 Until the advent of HoLEP patients with a large prostate were limited to staged TURP or open simple prostatectomy since only these procedures could provide effective removal of large amounts of obstructing adenoma. Unfortunately these 2 options can be associated with significant morbidity, especially bleeding. 26 As with other series, in the current series, prostate of size up to 120 grams were enucleated. Rate of prolonged catheterization following prostatectomy is about 9.2 %, with up to 0.9% requiring permanent catheterization. 20 This is significantly lower with laser enucleation. In the current study, average catheterization time was only 30 hours and all patients were able to void spontaneously following treatment. The intraoperative complications in the current study consisted mainly of minor capsular perforations during enucleation, as well as morcellator-related injuries. These can be attributed to the learning curve as they occurred during the few initial cases. These events resulted in only minor sequelae, as all cases could be managed conservatively with catheter drainage. In HoLEP, tissue is available for histologic analysis. There is minimal burn artefact due to the short absorption length of Holmium and the samples are as good for histologic examination as TURP chips. 11 This resulted in the diagnosis of unsuspected malignancy in 2 patients in this series, each with normal PSA estimations and benign DREs. This represents an important advantage of this technique over the other techniques mentioned in which tissue is not obtained. The mean hospital stay of 1.3 days, with patients discharged without a catheter is also comparable to other published series, most reporting hospital stay ranging from 1 8 days. CONCLUSION TURP greatly supplanted the open simple prostatectomy as the standard treatment for patients with bladder outlet obstruction due to benign enlargement of prostate due to lesser morbidity. HoLEP is emerging as the gold standard for relieving obstructive symptoms in even the largest of prostates as associated complications are minor and the completeness of adenoma removal is unparalleled by any other endoscopic approach. REFERENCES 1. Kirby RS: The natural history of benign prostatic hyperplasia: what have we learned in the last decade? Urology 2000, 56: Jacobsen SJ, Girman CJ, Guess HA, Rhodes T, Oesterling JE and Lieber MM: Natural history of prostatism: longitudinal changes in voiding symptoms in community dwelling men J Urol 1996, 155: Kuo RL, Paterson RF, Kim SC, Siqueira Jr TM, Elhilali MM, Lingeman JE. Holmium laser enucleation of the prostate (HoLEP): a technical update. World J Surg Oncol 2003;1(6): 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: Borboroglu PG, Kane CJ, Ward JF, et al: Immediate and postoperative complications of transurethral prostatectomy in the 1990s. J Urol 1999; 162: Elzayat EA, Habib EI, Elhilali MM. Holmium laser enucleation of the prostate : a size independent new gold standard. Urology 2005; 66 : A. El-Hakim, M.M. Elhilali. Holmium laser enucleation of the prostate can be taught: the first learning experience. BJU Int 2002; 90: Volume 10 Number 2 Jul-Dec 2010

5 8. Kabalin JN. Holmium:YAG laser prostatectomy canine feasibility study. Lasers Surg Med, 1996; 18: Kabalin JN. Holmium:YAG laser prostatectomy: results of U.S. pilot study. J Endourol 1996; 10: Gilling PJ, Cass CB, Malcolm AR, Fraundorfer MR. Combination holmium and Nd:YAG laser ablation of the prostate: initial clinical experience. J Endourol 1995; 9: Gilling PJ, Cass CB, Cresswell MD, Fraundorfer MR. Holmium laser resection of the prostate: preliminary results of a new method for the treatment of benign prostatic hyperplasia. Urology 1996; 47: Fraundorfer MR, Gilling PJ. Holmium:YAG laser enucleation of the prostate combined with mechanical morcellation: preliminary results. Eur Urol 1998; 33: Gilling PJ, Kennett K, Das AK, Thompson D, Fraundorfer MR. Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience. J Endourol 1998; 12: Das A, Kennett KM, Sutton T, Fraundorfer MR, Gilling PJ. Histologic effects of holmium:yag laser resection versus transurethral resection of the prostate. J Endourol 2000; 14: Stephenson AJ, Savard J, Morehouse DD, Taguchi Y, Elhilali MM. Holmium laser enucleation of the prostate with tissue morcellation: a new gold standard for the treatment of benign prostatic hyperplasia?. J Urol 2001; 165 (Suppl.): Gilling PJ, Kennett KM, Fraundorfer MR. Holmium laser enucleation of the prostate for glands larger than 100 g: an endourologic alternative to open prostatectomy. J Endourol 2000; 14: Berry, S. J., Coffey, D. S., Walsh, P. C. and Ewing, L. L.: The development of human benign prostatic hyperplasia with age.j Urol 1984; 132: Oesterling, J. E.: Benign prostatic hyperplasia: a review of its histogenesis and natural history. Prostate Suppl 1996; 6: Wasson, J. H., Reda, D. J., Bruskewitz, R. C., Elinson, J., Keller, A. M. and Henderson, W. G.: A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate.N Engl J Med 1995; 332: Peterson MD, Matlaga BR, Kim SC, Kuo RL, Soergel TM, Watkins SL, and Lingeman JE. Holmium laser enucleation of the prostate for men with urinary retention. J Urol 2005 ;174: Pickard, R., Emberton, M. and Neal, D. E.: The management of men with acute urinary retention. National Prostatectomy Audit Steering Group. Br J Urol 1998; 81: Doll, H. A., Black, N. A., McPherson, K., Williams, G. B. and Smith, J. C.: Differences in outcome of transurethral resection of the prostate for benign prostatic hypertrophy between three diagnostic categories. Br J Urol 1993; 72: Thorpe, A. C., Cleary, R., Coles, J., Vernon, S., Reynolds, J. and Neal, D.E.: Deaths and complications following prostatectomy in 1400 men in the northern region of England. Northern Regional Prostate Audit Group. Br J Urol 1994; 74: Stephenson AJ, Savard J, Morehouse DD, Taguchi Y, Elhilali MM. Holmium laser enucleation of the prostate with tissue morcellation: a new gold standard for the treatment of benign prostatic hyperplasia?. J Urol 2001; 165 (Suppl.): Gilling PJ, Kennett KM, Fraundorfer MR. Holmium laser enucleation of the prostate for glands larger than 100 g: an endourologic alternative to open prostatectomy. J Endourol 2000; 14: Kuo RL, Kim SC, Lingeman JE, Paterson RF, Watkins SL, Simmons GR, and Steele RE. Holmium laser enucleation of the prostate (HoLEP): the Methodist Hospital experience with greater than 75 gram enucleations. J Urol 2003; 170(1): Volume 10 Number 2 Jul-Dec

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