Minimally invasive and endoscopic management of benign prostatic

Minimally Invasive and
Endoscopic Management
of Benign Prostatic
Hyperplasia

Overview
 Monopolar and Bipolar Transurethral Resection of the Prostate
 Prostatic Urethral Lift
 Convective Radiofrequency Water Vapor Thermal Therapy
 Transurethral Vaporization of the Prostate
 Transurethral Microwave therapy
 Transurethral Needle Ablation of the Prostate
 Transurethral Incision of the Prostate
 LASER prostate treatments
 Current surgical techniques of enucleation in HoLEP
 Failed,failing and future directions

Indications for Treatment
 Bothersome LUTS which fail to respond to changes in lifestyle or medical
therapy
 Recurrent acute urinary retention
 Renal impairment due to bladder outlet obstruction (so-called high
pressure chronic urinary retention)
 Recurrent haematuria due to benign prostatic enlargement
 Bladder stones due to prostatic obstruction.
 These indications are all relative. Indeed, one can say that there are no
absolute indications for TURP.

Monopolar Transurethral Resection of Prostate
 An endoscopic approach to surgically remove the inner portion of the prostate
that encircles the urethra.
 An electrified wire loop is used to remove the portion of the prostate between
the bladder neck and the verumontanum to a depth of the surgical capsule.
 The current is carried from the cutting loop through the tissue to the return
electrode in the grounding pad.

 Requires a non-ionic irrigant to carry the current through the cutting loop
into the tissue to the grounding pad electrode.
 These non-ionic solutions are hypo-osmolar and can be problematic when
absorbed through open prostate sinuses, leading to acute dilutional
hyponatremia (TUR syndrome).
 The use of iso-osmolar saline in bipolar TURP has reduced the incidence of
TUR syndrome.

Position On The
Table
Dorsal lithotomy position and
appropriate padding
Legs are kept in the correct
position with the thighs making an
angle of no more than 45° with the
plane of the table
Check that the patient is not in
contact with any metal such as the
drip stand or metal on the operating
table

Technique
 General or spinal anesthesia
 Adequate antibiotic coverage
 A quick abdominal examination to provide a baseline for any subsequent
intraoperative examination should a perforation occur
 Shaving of the genitals and perineum is not required, and any variety of
standard skin preparations may be used
 Use of the O’Conor type rectal shield provides ready, sterile access to the
rectum in case the prostate needs to be lifted anteriorly for resection.

 Resectoscope should be assembled to make certain all elements are
appropriately fitted and in working order.
 The use of a video camera mounted to the lens is largely standard
 An instrument that permits a continuous flow of irrigating fluid is preferable
 Irrigating fluid should be maintained at body temperature and placed at the
lowest height relative to the patient to provide adequate visualization.

TURP methods
 Barnes: Start from median lobe,lateral lobes are resected from bottom to top
 Nesbit: Start from 12 O’clock,lateral lobes are resected from top to
bottom,median lobe last to be resected.
 Alcock and flocks: Start from 9 and 3 o’clock,then depends upon the situation
 Mauermayer: Alcock and flocks modification.Start from median lobe,then
resect 9 and 3 O’clock, Recommended for beginners and for large/small
adenoma
 Blandy: Resect middle lobe,control Flock arteries and resect lateral lobes

 The plan for resection can be varied and in general the best approach is
the one best practiced and understood by the urologist
 Before beginning to resect, the bladder should be inspected for any
bladder pathology (e.g., tumor, diverticula )
 The bladder neck, trigone, and position of the ureteral orifices,
verumontanum, and external sphincter should be noted, and their
relationship to the prostatic adenoma confirmed.

 The resection begins with a preliminary CPE, careful lubrication of the
urethra, and an internal urethrotomy if there is the slightest tightness of
the resectoscope sheath
 The presence of a middle lobe should lead the surgeon to start the
resection there.
 Once a median lobe has been removed, the lateral lobes of the prostate
may then be tackled by the resectionist.

THE THREE STAGES OF
TURP
1. Establishing the
landmarks.
2. Removing the main
bulk of tissue.
3. Tidying up.

The three components of
the sphincter mechanism
of the bladder
1.Bladder neck
2.Intramural external
sphincter (just distal to the
Verumontanum)
3. Levator ani.

Make sure that you have
seen the sphincter:
bring the resectoscope out
beyond it, cut off the water
flow and see it contract
like the anus in its
characteristic way

 Having identified the verumontanum and the external sphincter, the next
step is to find the ring of muscle at the bladder neck in the posterior
middle line.
 The purpose of defining this proximal limit is to prevent from
inadvertently encroaching on the trigone and ureteric orifices.

In a patient with a very small middle lobe
the first cut reveals the transverse
smooth muscle fibres of the bladder
neck.
when there is a larger middle lobe
more tissue must be removed
before the bladder neck is exposed.

In the small prostate:
the verumontanum is well
upstream of the sphincter
But in a big bulky prostate:
the lateral lobes bulge
down past the
verumontanum and distort
the sphincter.

All the middle lobe tissue
should be removed from
the bladder neck down to
just upstream of the
verumontanum.

Be caucious about perforation under the
edge of the trigone: Telltale appearance
of a spider’s web, and sometimes a
distinct black hole in the connective tissue
under the neck of the bladder
Once the middle lobe has been neatly
cleaned out, take time to coagulate
Badenoch’s large arteries at 5 and 7
o’clock

Rotate the resectoscope to bring the
anterior commissure into view at 12
o’clock
Take one or two careful chips at 1
o’clock until the bladder neck fibres
and the capsule are disclosed
Remember prostate is very thin
anteriorly

The trench is deepened and the left
lateral lobe falls backwards.
May come across the little arteries
of Flocks at 2 o’clock, which should
be carefully coagulated

 The next step is to remove the lump of lateral lobe which has fallen
inwards and away from the capsule.
 Usually relatively bloodless, because the main arteries have already been
controlled at 2 and 5 o’clock.
 Trim the top of the lateral lobe away in a series of even cuts, keeping the
surface flat .

Do not make the mistake of hollowing out the lateral lobe or you will find that a
thin shell of tissue will flop down and conceal the verumontanum

Leaving only the nubbin
of apical tissue adjacent to
the verumontanum go
over the exposed ‘capsule’
and control the bleeding.

 The prostate chips should be long and “canoe-like” in appearance with a
length equivalent to the extended resection loop.
 One should avoid cutting chips of insufficient length or thickness as this is
inefficient and may lead to an irregular resection bed that hides bleeding
areas.
 In surgeons utilizing the O’Conor shield, digital elevation of the prostate
may aid in resection.

2. Second method
 Many surgeons find it more comfortable to remove the bulk of the lateral
lobes in one circular sequence
 After removing the middle lobe start by taking one lateral lobe from the
bottom upwards, across the commissure between the lateral lobes, and
then down the other lateral lobe to the starting point .

Richard Notley plan of
resection:
After removing the middle
lobe, the operator starts at
7 o’clock and works all
round the clock.

 As resection approaches the anterior commissure a mass of tissue will be
seen hanging down.
 Remember again that the prostate is very thin here: do not hollow it out
but trim it away with the loop pointing laterally rather than upwards.
 Continue the clockwise resection until the rest of the lateral lobe is
removed sparing only the tissue adjacent to the verumontanum.

3. Tidying up
 The apical tissue that has been left behind is removed very carefully.
 The danger here is that the sphincter may be damaged, start this part of
the resection only after the bleeding is completely controlled
 It often helps to insert one finger in the rectum to lift up the
verumontanum and offer the apical tissue to the loop rather than digging
with the loop to scoop it out
 Bleeding is seldom severe in the region and use of the coagulating
current should be minimised

Tidying up
The usual places are just
on either side of the
verumontanum, and up at
2 and 10 o’clock.
These are all carefully
trimmed

Intraoperative and Perioperative Problems
 Hemorrhage (3%)
 Every effort should be made to achieve hemostasis during the
operation to prevent the need for a return to the operating room.
 Perforation (almost always extraperitoneal)
 The prostatovesical junction, prostatic capsule, or the bladder
 The electroresection itself or overdistension of a thinned area of the
prostatic capsule
 The glistening fat of the periprostatic or perivesical spaces is usually
a telltale sign of perforation.
 In unclear cases, cystography may be used to assess the degree of
perforation and the drainage pattern

 TUR syndrome (0.8-2%)
 The scope may need to make multiple trips across the prostatovesical
junction leading to trigone undermining.
 If during initial resection the dorsal aspect of this junction becomes overly
resected, these trips may become more challenging as the scope is forced
to move “uphill” and increase the detachment of the trigone from the
posterior prostate base.

 Persistent penile erection
 May limit the mobility of the resectoscope
 Detumescence may be encouraged with pharmacologic agents such
as phenylephrine
 Considerable attempts should be made with vasoactive substances,
but if these all fail, perineal urethrostomy can be used to gain access
in a dire situation.

Postoperative.
 Bladder neck contracture (2%)
 Urethral stricture (4%)
 Significant hemorrhage in the immediate postoperative period
 Ejaculatory problems (RE -60 to 80%)
 Incontenence (0.6%)
 Post op retention(6-7%)

Postoperative Care.
 The diet can quickly be advanced in the postoperative period.
 In the absence of significant capsular perforation or persistent bleeding,
the catheter can be removed in 24 to 48 hours.
 If minor bleeding persists the patient may be discharged with the catheter
in place with close outpatient follow-up.
 The use of stool softeners in the postoperative period beneficial as
passage of hard, impacted stool may precipitate bleeding.
 Patients should avoid activities that place excessive or uneven pressure on
the perineum (e.g., horse riding) for 4 to 6 weeks

TURP in the Anticoagulated Patient.
 The risk with TURP in the anticoagulated patient is significant
 Withold
NSAIDS for 1 to 3 days Warfarin for 5 days
Clopidogrel for 7 to 10 days Estrogen /temoxifen for 4 weeks
Herbal medicine for 7 days
 LASER options may be preferable in patients who are unable to come off of
anticoagulation for surgery
 Bridging with LMW heparin and early resumption of warfarin after stopping
warfarin 5 days preoperatively.

Bipolar transurethral resection of prostate (B-TURP)
 Specialized resecting loop that incorporates both the active and the
return portions of the circuit on the same electrode.
 The current does not need to run through the patient to a return
electrode, and so is kept at the site of the resection.
 This innovation has also allowed for the resection to take place in ionic
irrigating solution and has eliminated most of the risk for tur-syndrome.

 In dual-loop design, both loops are in close proximity to each other at the
end of the cutting electrode and the electrical energy is able to connect
between the loops and supply the resecting energy there.
 The energy is initially transmitted from the loop into the surrounding
saline (PlasmaKinetic (PK) system ). Once created, the plasma molecules
are able to be excited for use in resection.
 It allows tissue
 Resection at lower temperatures with a lower voltage.
 Simultaneous cutting of tissue with sealing of vessels

 The loop is made of platinum-iridium instead of the standard tungsten
loop. Able to withstand the electrical and thermal stresses that come with
plasma usage
 When using the coagulation setting in this system, Plasma is not created,
and the input energy from the generator is used to increase the tissue
temperature and seals the vessels in the prostate.
 The lower voltage and temperature used in a plasma system minimizes
tissue charring, unnecessary tissue coagulation and a subsequent
decrease in storage symptoms.

Technique of B-TURP
 Almost identical technique to the M-TURP with regard to approach to the
resection.
 However, allows for quicker resections as bleeding vessels are less likely to
be encountered
 Results for the bipolar resection are encouraging, and this technology
will likely replace M-TURP as the gold standard for treatment of BPH in
the coming years

 The overall rate of adverse events is lower with B-TURP (15.5% vs.
28.6%) compared with M-TURP.
 Lower rates of bleeding, transfusion, time with catheter, CBI need,
hyponatremia, and TUR syndrome
 “Cut And Seal” effect on vessels , improved hemostasis and decreased
bleeding complications and transfusion rates [ Issa, 2008].
 Improved visualization ; decrease in capsular perforations and operative
time

 The TURIS systems were originally mistakenly labeled as bipolar systems .
 In reality, the return electrode in these systems was the outer
resectoscope sheath.
 This could potentially predispose the patient’s entire urethra and penis to
the return energy.
 6.3% urethral stricture rate during procedures utilizing the TURis system
reported

 There was no difference between M-TURP and B-TURP for the incidence
of urethral stricture or SUI. [Cornu et al. (2014) ]
 Bladder neck contracture and need for retreatment of BPH do not
appear to be much different from those found with conventional M-
TURP

Prostatic Urethral Lift
 Works by altering prostatic anatomy without ablating tissue.
 Permanent transprostatic implants take the form of sutures
 Delivered by a handheld device through a cystoscope to Mechanically
open the prostatic urethra by compressing the prostate parenchyma

Placement of implants (I) in
the antero-lateral position in
the prostate avoiding the
dorsal veins (DV) and
neurovascular bundles (NV)

Prostatic Urethral
Lift
1.Bladder neck not injured;
Minimum impact on sexual
factors
2.The urethral mucosa stays
intact; minimum dysuria and
other storage symptoms
Contraindicated:
1.Obstructing middle lobe
2. Prostates more than 80 g.

Convective Radiofrequency Water Vapor Thermal
Therapy (Rezum)
 Utilizes convective rather than conductive energy to ablate prostatic
tissue.
 RF power is Utilized to generate thermal energy in the form of water
vapor, which is injected transurethrally into the transition zone of
prostate.
 The water vapor is injected at 103°c for 9 seconds at a pressure slightly
above interstitial pressure, facilitating the dispersion of water vapor
through the cellular interstices via convective energy.

 Upon contact with prostatic tissue, condensation releases 540 calories of
energy per gram onto the exterior cell membrane of the tissue, which
causes cell death and tissue necrosis in a spherical ablative lesion of 1.5 to
2. 0 cm.
 Requires application of lower energy levels for a shorter duration to
induce tissue necrosis .
 Uses 4 kJ per procedure to produce cell necrosis compared with TUNA (20
kJ), TUMT (86 kJ), and other laser ablative technologies (250 kJ).
 Preserves ejaculatory function, unlike TUVP and TURP.

Rezum system
Composed of a generator with a
handheld delivery device that
includes
Transurethral rigid cystoscope
An 18-gauge retractable needle
with 12 vapor-emitting holes
located at the tip of the delivery
device
It utilizes saline irrigation solution
to enhance visualization and cool
the surface of the urethra.

The needle penetrates prostate at
fixed length of 10.25 mm and is
deployed at the 3 and 9 o’clock
positions starting 1 cm distal to the
bladder neck, leaving approximately
1 cm between injection sites to
create contiguous overlapping
thermal lesions distally until the
proximal edge of the verumontanum

 Cautiously used in patients with a gland greater than 80 g and in men who
have urinary retention.
 It can be used in outpatient setting using minimal anesthesia, making it an
attractive option particularly those concerned with preserving sexual
function.

Transurethral Vaporization of the Prostate
 First reported by kaplan and Te in 1995
 Uses the same set of equipment as TURP with the exchange of the
resecting loop for an element with a larger surface area.
 Broader contact area over which the current is delivered to the prostate
tissue and do not involve tissue resection.
 Higher energy used for controlled tissue vaporization with simultaneous
underlying tissue coagulation and improved hemostasis during treatment.

Plasma Button electrode.
 The operative technique and
equipment is similar to a
standard TURP.
 The major difference is the use
of a specially designed electrode
for vaporization and replaces the
standard loop TURP electrode

 Decrease the risk for intraoperative bleeding
 Capsular perforation or conversion to TURP are also rare
 The largest postoperative risk is the need for retreatment for LUTS and risk
for unplanned post-operative recatheterization.
 Slight increase in incontinence compared with TURP
 Increased risk for new ED (12% vs 5%) when compared with TURP

Transurethral Microwave Therapy
 Locally thermoablate prostate while maintaining normal temperatures in the
surrounding nontargeted tissue.
 Uses a specialized urethral catheter with an antenna that generates radially
emitted electromagnetic (EM) waves that produce localized heat
 Prostate parenchyma destruction occurs once a crucial “thermal dose” has
been reached.
 This occurs as part of the multiplicative product of the temperature and
exposure duration.

 The He-TUMT generate intraprostatic temperatures of 45°C to 70°C.
 Reduction in prostate volume is 25%
 Much of the advancement to using higher temperatures was precipitated
by the ability of catheter cooling that would reduce urethral temperatures
during use and reduce intra-procedural patient discomfort.

Mechanism of Action
Nerve Degeneration/Sensory Changes.
The first of these theories appears to rest on the dynamic concept of prostatic
obstruction wherein the tone of the smooth muscle of the prostate causes
obstruction. The thermal damage to the adrenergic fibers essentially induced
a “long-term alfa-blockade, thereby improving LUTS
Morphology Changes.
When heat is applied to a specific portion of the prostate to a sufficient
temperature and duration, an area of necrosis is created. This area of necrosis
eventually contracts to form a scar and reduces overall prostate volume

 Perioperative complications are unlikely, and hospital admission not
required .
 Postoperative catheterization for a period of days is almost certain with
previous generations of TUMT but is becoming less common.
 Transient incontenence (2%)
 Prohibitive need for retreatment

 In-office procedure done under local anaesthesia
 Least operator dependent with an easy learning curve.
 Prostate volumes at the extremes (<25 or >80 g) may impede uniform
heating and lead to suboptimal results.
 In smaller prostates it may lead to unsafe heating of extraprostatic
locations inducing complications such as sphincter injury.
 Patients with pacemakers, defibrillators, and pelvic prosthesis be
excluded for risk of significant electrical or mechanical damage

Transurethral Needle Ablation of the Prostate
 The TUNA system is composed of an RF generator, a disposable urethral
endoscopic catheter that attaches to a reusable catheter handle, and an
optics system.
 The urethra is protected from heat energy by PTFE/nylon sheaths that
extend to cover the proximal portions of the treatment needles
 The urethra is untreated and not denuded, so the patient have minimal
local symptoms
 The protective sheaths also have a thermocouple that monitors the
temperature at the edge of the sheath

Transurethral needle
ablation handpiece
The specialized urethral
endoscopic catheter is
used for this procedure
and is attached to a
reusable control handle.
 This rigid catheter is
placed into the urethra and
advanced into the prostate
under direct vision

Deployed transurethral
needle ablation needles
Once in position,
needles are deployed from
the end of the catheter
into the prostatic
parenchyma.
The needles have a
variable length that can be
adjusted to different
prostate widths and sizes.

 TRUS is performed before procedure to gauge the prostatic size, anatomy, and
prostate width.
 Cystoscopy performed to rule out any bladder pathology and verify the
distance from the bladder neck to the verumontanum.
 The prostate length will determine the number of levels at which needle
deployment will be required.
 Prostates of 3 cm or less are treated at 2 different zone levels.
 A length of 3 to 4 cm will require 3 levels of treatment
 prostates larger than 4 cm requiring 4 zones of treatment.
 The length into the prostate that the needles are deployed is based on the
prostate width.

TECHNIQUE
 The needles are deployed using controls at the catheter handle base using
specialized cystoscope
 The scope often needs to be pressed into the lobe for the needles to “grab”
and keep the catheter from being pushed away from the lobe as the needles
are advanced.
 Needles are deployed directly laterally into the lobes (at 8/10 o’clock position
and 2/4 o’clock position).
 The needles are first deployed in a plane 1 cm below the bladder neck into the
parenchyma, with subsequent placements at 1-cm intervals in the prostate
and the last placement 1 cm proximal to the verumontanum.

 The needle tips are then heated to at least 100°C. It takes only 20 to 30
seconds to reach the treatment temperature, and once it has been
achieved the area is treated for 2 to 3 minutes.
 The needles treat a discrete area around and between the tips creating an
area of coagulative necrosis.

The treated prostate
in transurethral
needle ablation.
The number of zones and
planes required for
treatment is dependent on
prostate size and shape
To treat the entire gland,
multiple planes in each
gland must be treated.

Postoperative care
 A few days of irritative symptoms are normal and likely minimized because
of the minimal effacement of the urethral mucosa.
 If a urinary catheter is placed, it is maintained between 1 and 3 days
 Antibiotics used for up to 2 weeks, and NSAIDs for 10 days.
 The empiric antibiotic treatment is to avoid bacterial proliferation forming
an abscess in the cavitated necrosis of the post-TUNA prostate
 Most patients are able to return to work in 2 to 3 days.

Transurethral Incision of the Prostate
 An operative approach to disrupt the prostatic capsule to alleviate voiding
symptoms.
 Considered in men with small prostate glands (<30 g)
 A unilateral or bilateral incision made through the bladder neck and can
be extended all the way distally to the verumontanum.
 This incision is usually made posterolaterally (in the region of the 5 o’clock
and 7 o’clock positions).

 The ideal patient for this procedure is a young man with a small prostate
who is concerned about either a loss of ejaculation or future fertility.
 This procedure has a lower risk for retrograde ejaculation than other BPH
treatment options
 However, if retrograde ejaculation is truly being avoided, bladder neck
and complete capsular incision are avoided

Transurethral incision of
the prostate.
The incision is started at
the ureteral orifice and
carried through the
bladder neck up to the
verumontanum

Complications
 Hemorrhage should be controlled quickly, although significant bleeding
and transfusion are rare.
 In cases in which capsular perforation occurs, this can generally be treated
with prolonged postoperative catheterization.
 When compared with TURP, TUIP has a lower risk for retrograde
ejaculation but a higher risk for reoperation
 No difference between treatments with respect to ED ,urinary retention,
urinary infection, stricture, or incontinence

LASER Treatments
 LASER prostate treatments rely on the prostate interacting with the light
energy and converting it to local thermal energy.
 The ability to destroy tissue is important for prostate treatment but when
used errantly can lead to unintended consequences such as injury of the
patient or operating room personnel.
 Human eye is at the highest risk for accidental exposure because of the
lack of a protective layer

The portion of the eye that is injured depends on the
wavelength used.
 For lasers with a larger wavelength like the holmium or thulium, the
cornea is at greatest risk.
 The potassium-titnyl-phosphate (KTP), lithium-triborate (LBO),
Neodinium:yttrium-aluminum-garnet (ND:YAG) lasers are particularly
dangerous as this wavelength is focused on the retina.
 The lens of the eye focuses this energy on the retina causing an
increased intensity of up to a factor of 100,000

Holmium and Prostate Enucleation
 The Ho:YAG LASER 2140 nm: pulsed energy emission.
 Strongly absorbed by water-rich tissues and has an absorption length of
0.4 mm with excellent hemostatic properties
 The light is easily transmitted along flexible quartz fibers and creates a
high-energy density that leads to vaporization with a superficial
coagulation zone

Technique
 This technology uses an end-firing 550-micron fiber delivered through a
continuous-flow LASER resectoscope (usually 26 Fr in size).
 The LASER resectoscope has a modification in which the inner sheath
contains a fiber guide to stabilize and prevent fiber movement while in
use.
 A 6-Fr open-ended catheter may also be used as a fiber guide when placed
through the sheath.

Current surgical techniques of enucleation in
HoLEP
 The first attempt to use a holmium laser for transurethral
prostatectomy Gilling et al , who combined the use of a holmium
laser with an Nd:YAG laser to perform a so-called combined
endoscopic laser ablation of the prostate or CELAP.
 In 1996, Gilling et al developed a new surgical procedure, Holmium
Laser Resection of Prostate (HoLRP), which involved excising the
prostate with a holmium laser.

 Following the development of the morcellator, large prostatic
fragments could be pulled out of the bladder.
 HoLRP was no longer extended, and soon it was replaced with
HoLEP.
 This enucleation method has become a powerful method for treating
enlarged prostates of any size.

Various Surgical Techniques Of Enucleation In Holep
 CLASSIC GILLING’S THREE-LOBE TECHNIQUE
 ANTERO-POSTERIOR DISSECTION BY THE TOKYO GROUP
 MODIFICATION OF THE ORIGINAL THREE-LOBE TECHNIQUE BY THE XIAN
GROUP
 EN BLOCK METHODS

(1) CLASSIC GILLING’S THREE-LOBE TECHNIQUE
 Based on the enucleation of three lobes independently in retrograde
fashion by making three longitudinal incisions from the apex to the
bladder neck.
 The bladder neck at the 5 o’clock & 7 o’clock position is incised
vertically to the verumontanum; a further deep incision is made until
a surgical capsule is reached.
 If there is no discernable median lobe, only one longitudinal incision
may be made at the 6 o’clock position.

 Once the two incisions are complete, they are connected just above
the verumontanum to allow enucleation of the median lobe.
 The median lobe is completely separated from the bladder neck
before being placed into the bladder for later morcellation.
 The enucleation of the left lateral lobe is proceeded by sweeping
circumferentially until the 2 o’clock position is reached.

 longitudinal incision should be made at the 12 o’clock position of the
bladder neck, extended in the distal direction.
 The space between the adenoma and the capsule is developed
laterally and circumferentially with a sweeping motion.
 After further enucleating the left lateral lobe, it is placed into the
bladder, and the right lateral lobe is enucleated similarly to the left
lateral lobe.

(2) ANTERO-POSTERIOR DISSECTION BY THE TOKYO GROUP
 Endo et al modified Gilling’s technique to reduce the possibility of sphincter
damage.
 Performed similarly to the previous procedure in that the bottom edge of the lateral
lobe is enucleated from the surgical capsule throughout the apex and the bladder
neck.
 However, this procedure does not extend further upward, and stops just after
forming the edge.
 A longitudinal incision is made over the 12 o’clock direction from the bladder neck
to the sphincter level.
 The adenoma is then released from the surgical capsule in either side around the
12 o’clock position while pressing downward at the mid-portion of each lateral lobe

(3) MODIFICATION OF THE ORIGINAL THREE-LOBE
TECHNIQUE BY THE XIAN GROUP
 Enucleation starts by dissecting the left apical area after a small incision
is made at left lateral side of the verumontanum.
 The apical incision is extended circumferentially to the 3 o’clock position
in the left lateral lobe, and to the 9 o’clock position in right lateral lobe
through a transverse incision at the proximal part of the verumontanum.
 The apical dissection of the left lateral lobe is further extended along the
surgical capsule from the 3 o’clock position toward the 11 o’clock
position.

 Careful dissection of the urethral mucosal strip at the 1 o’clock and 12
o’clock position is carried out at the verumontanum level.
 The left lateral lobe is then separated from the right lateral lobe by
making an incision at the 12 o’clock position in a retrograde fashion.
 Enucleation of the right lateral lobe is accomplished in the same
manner as the left lateral lobe.

(4) EN BLOCK METHODS
• Two main reasons for attempting to remove the prostatic
adenoma with en bloc
• First: There is a concern that residual tissue may remain due to a
potential mismatch among the surgical planes due to the
conventional three longitudinal incisions.
• Second: There is a need to overcome problems with improper
incision length and depth when making longitudinal incisions at the 12
o’clock position from the bladder neck to the apex.

 If the incision is extended too distally, there is a risk of sphincter
damage, if the incision is too deep, there is a risk of bleeding due to
capsular perforation, and if the incision is too shallow, residual
tissue will remain.
 Depending on the en bloc surgical method, there is a difference in the
techniques of apical mucosal incision and enucleating the anterior
prostate at the 12 o’clock position of the apex.

(a) EN BLOC NO-TOUCH EUCLEATION BY THE TURIN
GROUP
 A small incision is made at the left lateral side of the verumontanum
and the surgical plane is widened in a retrograde manner.
 The left lateral lobe is longitudinally and retrogradely incised from the
apex to the bladder neck at the 5 o’clock position.
 The left lateral lobe is enucleated sideways and moved up to the 3
o’clock position from the 5 o’clock position.
 At the 3 o’clock position, enucleation proceeds further to the 12
o’clock position, then overpasses the anterior commissure from the 12
o’clock position to the 9 o’clock position of the right lateral lobe.

 After the return to the 5 o’clock position of the apex, the apex of
the right lateral lobe is approached by making a transverse
incision at the proximal verumontanum.
 The median lobe and the right lateral lobe are enucleated from the
5 o’clock position to the 9 o’clock position as a single lump.
 Enucleation of the prostatic adenoma ultimately results in a
horseshoe-shaped adenoma.

(b) En Bloc Enucleation With Early
Apical Release By The Milan Group
 Here the early release of the sphincter from the prostatic
capsule is a crucial step in sphincter preservation because it
prevents sphincter stretching.

a) The anatomy of the sphincter and prostatic urethra
b) The enucleation process is started at the apex of the prostate where an incision is
initiated from 11 to 1 o’clock by the proximal edge of the external sphincter.

(c) Then an incision is carried out parallel to the verumontanum down to the edge of the
sphincter; it is then joined to the previously performed anterior incision. The same process is
carried out on the contralateral side.
(d) This results in a complete demarcation of the apex from the sphincter.

(e) The tip of the scope is positioned laterally to the right of the verumontanum
and a gentle lateral tilt of the tip of the scope is performed to enter the plane
between adenoma and surgical capsule under direct visualization.
(f) A careful dissection of the apex is performed, by deepening the para-sphincteric
ridge from 6 to 12 o’clock. The same steps are carried out in the contralateral side
until the apex is completely freed from the sphincter anteriorly at 12 o’clock.

(g) Then, the crista urethralis is cut over the verumontanum to allow
circumferentially liberate the apex from the sphincter.
(h) The enucleation plane is followed circumferentially, progressively approaching the
bladder neck.

(i) Entry into the bladder is pursued anteriorly, between the adenoma and the surgical
capsule.
(j) The bladder neck is then cut circumferentially with care to protect the ureteral
orifices.

(k) At the end of the enucleation phase, the
adenoma is free and can be pushed into the
bladder.

INCISION EN BLOC Holep BY THE FREIBURG Group
 This surgical technique provided a simplified procedure for
HoLEP, and is likely to be standardized for beginners for training
purposes.
 They have used three inverted U - shaped incisions in this
technique and Unlike other en-bloc methods, this technique does
not apply longitudinal incisions.

(A) First, an inverted U-shaped incision is made
around the verumontanum and the median
lobe is lifted for enucleation.
(B) another inverted U-shaped incision is
performed from the 10 o’clock position to
the 2 o’clock position in order to release the
mucosal strip; now, the adenoma of both
lateral lobes is fully mobilized at the apex
site
(C) Third inverted U-shaped incision is made to
the bladder neck in order to partially detach
the adenoma from the bladder neck; both
lateral lobes are now circumferentially
enucleated

MOSES: A New Technology for HoLEP
 Lumenis developed a system capable of modify the production of
the Holmium laser pulse with the Moses technology in order to
optimize the laser to lithotripsy and enucleation of the prostate.
 The Moses technology allows to modify the shape of the laser pulse
and therefore of the plasma bubble produced by the interaction
between Holmium laser and water.

 The laser energy in HoLEP is used in two different ways…
(1) One is vaporization of prostate tissue
(2) Second is the "photoacoustic effect",due to the expansion of the plasma
bubble, resulting in a pressure wave that propagates to promote cleavage of
tissues in course of detachment of the adenoma from the capsule during
enucleation.

 The Moses technology makes the HoLEP :
 More effective when performed by an expert operator due to reduction of
incision and enucleation times
 Is able to simplify the learning curve for beginners due to the better
development and exposure of enucleation plans.

Complications
 Most studies either did not report, or did not have any intraoperative
complications.
 In a study using the morcellator for evacuation of prostate lobes, no
patients suffered from incomplete morcellation or ureteric orifice
injuries,however,1.3% had bladder wall injuries resulting from the
morcellator
 symptomatic UTI (6.8%), bleeding (5.6%), and immediate retreatment for
residual BPH (2.2%). Blood transfusion was required in 2.2% of patients,
Mild storage symptoms (27%)

Prostate Stents
 Classified into many categories temporary or permanent, epithelializing,
or nonepithelializing.
 Temporary varieties are used to combat the edema that accompanies
many of the minimally invasive treatment options and are removed when
the edema has resolved.
 Permanent stents have largely been relegated to use in older men with
medical comorbidities that severely restrict their treatment options
because of the inability to tolerate any level of anesthesia.

 Once in place in the prostatic fossa, pushes outward to open the prostatic lumen. In the
epithelializing version, the stent is incorporated into the urethra as the urothelium grows
into the stent, which should prevent encrustation or migration.
 Other indications include the treatment of detrusor-sphincter dyssynergia ,
postbrachytherapy obstruction , and complications of radical prostatectomy
 UroLume was an epithelializing permanent stent composed of alloy wire in a woven
shape that can expand to 42 Fr within the prostatic urethra.

Temporary Implantable Nitinol Device
 Developed to provide immediate relief from LUTS without the side effects
of a permanent urethral implant.
 The device is composed of elongated struts and an anchoring leaflet,
entirely composed of nitinol, which is a biocompatible superelastic shape-
memory alloy
 The total length of the device is 50 mm, and its outer diameter is 33 mm,
allowing the device to cover the entire length of the prostatic urethra

 Preloaded on a dedicated delivery system and deployed in a folded
configuration through a standard rigid cystoscope under light intravenous
sedation.
 The device is then manipulated under direct visualization so that the
anchoring leaflet slides into the 6 o’clock position distal to the bladder
neck.
 Once in place, the struts of the TIND expand and exert longitudinal
pressure on the obstructing portion of the prostatic urethra and the
bladder neck at the 12 , 5 , and 7 o’clock positions.

 The radial force exerted by the struts of the nitinol device is intended to
cause ischemia, necrosis, and scarring of the prostatic urethra to
“reshape” the prostatic urethra allowing urine to flow freely.
 On postoperative day 5, the TIND is retrieved in an outpatient setting
using a standard 22-Fr cystoscope
 Complications included infection (6.2%), urinary retention (3.1%), and
urinary incontinence 1 day after surgery (3.1%).

Aquablation (Aquabeam)
 This TRUS-guided technology utilizes a nonthermal high-velocity saline
water jet stream to ablate prostate tissue.
 A real-time TRUS probe defines the treatment area, and a robotically
guided transurethral system then quickly hydrodissects the target area.
 The treatment carefully carves out the transitional zone without possible
thermal or anatomic injury to the bladder neck, external sphincter, or
periprostatic nerves
 The effect on continence, errections, and antegrade ejaculation are
minimized.

The AquaBeam system console, pump
and articulating arm with Handpiece
High-velocity waterjet for
prostate ablation.

Prostate Embolization
 Access is generally gained at one of the femoral arteries, and pelvic
angiography is performed to evaluate the iliac tree and prostatic arteries.
 Once the catheter has been advanced into the prostatic arteries, an
embolizing agent (e.g., alcohol, microspheres) is then infused through the
catheter until stasis is seen in the prostatic vessels.
 Bilateral procedures incur better results
 Postembolization syndrome of pain and fever is customary.

Prostatic Injections
 An injectable is commonly administered via a transperineal or
transurethral approach into the prostatic parenchyma, with the injected
substance theoretically causing localized changes to reduce prostate
volume.
 Reported agents used in human studies include acid mixtures ,
pepsin/iodine concoctions , ethanol, botulinum toxin A (BONT-A)

Minimally invasive and endoscopic management of benign prostatic

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Minimally invasive and endoscopic management of benign prostatic