Holmium laser enucleation of the prostate with tissue morcellation: initial United States experience.

BENIGN PROSTATIC HYPERPLASIA (BPH) affects 70% of men over age 70 and is a significant cause of morbid. ity in this population.1 Endoscopic surgery for BPH has evolved over the past decade with technological advances that offer significant advantages in perioperative and postoperative morbidity and hospital stay. One of the technological advances has been the holmium laser, a multifunction tool in urology that can be used for intracorporeallithotripsy, stricture and ureteropelvic junction incision, excision and ablation of urothelial tumors or condylomata, and resection/vaporization of prostatic adenomataus tissue. We report the initial use in the United States of the holmium laser with transurethral tissue morcellation for the endoscopic treatment of BPH. The surgical technique for the use of the holmium laser in the treatment of BPH has evolved over the past 5 years, due in large part to the work of Gilling and associates.25 Initially, the holmium laser energy was used in concert with Nd:YAG energy to vaporize and coagulate tissue, and the procedure was termed "combination endoscopic laser ablation of the prostate" or CELAP. Unfortunately, many of the irritative voiding symptoms experienced by patients undergoing visual laser ablation of the prostate (VLAP) with the Nd: Y AG laser were also seen using the dual-laser technique. Vaporization alone was next used with holmium energy (holmium laser ablation of the prostate, or HoLAP) with excellent voiding results and low rates of transfusions, but the time required to vaporize significant volumes of adenoma was excessive. Using the holmium laser to resect the prostate into its anatomic lobes (HoLRP) was the next step in the development of the technique. This method also provided excellent results, but the issue of how to remove the large adenomas from the bladder after resection was unresolved. Development of a transurethral tissue morcellator now allows efficient removal of adenomatous tissue of any size. The technique has progressed to a true anatomic enucleation, similar to an endoscopic open ·prostatectomy, abbreviated HoLEP (holmium laser enucleation of prostate), which is the procedure on which this work is based. The surgical advantages of HoLEP compared with standard transurethral electroresection (TURP) are in the areas of blood loss and electrolytic effects of irrigant. The laser technique is hemostatic, allowing operation in a virtually bloodless field, and decreases or eliminates the need for postoperative bladder irrigation. Consequently, catheters may be removed earlier, length of stay is decreased, and return to normal activity is hastened. The reported blood transfusion rate is 1 per 1000 procedures.6 Additionally, patients with altered coagulation profiles from therapeutic or pathologic etiologies may undergo HoLEP without increased bleeding complications. Because thermal energy is the mechanism through which the holmium laser works, physiologic irrigants, such as normal saline, may be used for HoLEP. The use of normal saline eliminates the risk of dilutional hyponatremia and potential TUR syndrome. The combination of the hemostatic capabilities of the holmium laser and transurethral tissue morcellation allow enucleated adenoma of very large size to be removed effectively from the bladder, offering a possible alternative to open prostatectomy. In this work, we review the first 61 HoLEPs with tissue morcellation performed at our institution.