|Year : 2016 | Volume
| Issue : 1 | Page : 14-18
Precise Transurethral Enucleation of Prostate: New Surgery Treatment for Benign Prostate Hyperplasia
Huan Xu, Meng Gu, Qi Chen, Yan-bo Chen, Zhi-kang Cai, Zhong Wang
Department of Urology, The Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
|Date of Web Publication||1-Feb-2016|
Department of Urology, The Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai
Department of Urology, The Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai
Source of Support: None, Conflict of Interest: None
There have been many advances in the surgical treatment for benign prostate hyperplasia (BPH), moving from open surgery (retropubic and suprapubic open prostatectomy) to transurethral resection of the prostate (TURP, the historical gold standard and still the most commonly used approach), and onto endoscopic transurethral enucleation. The application of new laser and plasma technologies now allows the precise transurethral enucleation of the prostate (PTUEP). In our medical center, we have found great success using PTUEP. Many urologists have found that PTUEP reduces perioperative complications and risks during operation. It can be applied to all size prostates and can even be used with BPH patients taking anticoagulation medicine. PTUEP is quickly replacing TURP as an effective and less invasive approach to BPH surgery.
Keywords: Benign prostatic hyperplasia, enucleation, laser enucleation of the prostate, morcellation, plasma enucleation
|How to cite this article:|
Xu H, Gu M, Chen Q, Chen Yb, Cai Zk, Wang Z. Precise Transurethral Enucleation of Prostate: New Surgery Treatment for Benign Prostate Hyperplasia. J Integr Nephrol Androl 2016;3:14-8
|How to cite this URL:|
Xu H, Gu M, Chen Q, Chen Yb, Cai Zk, Wang Z. Precise Transurethral Enucleation of Prostate: New Surgery Treatment for Benign Prostate Hyperplasia. J Integr Nephrol Androl [serial online] 2016 [cited 2021 Oct 18];3:14-8. Available from: http://www.journal-ina.com/text.asp?2016/3/1/14/175395
| Introduction|| |
Benign prostate hyperplasia (BPH) is one of the most common causes of lower urinary tract symptom and bladder outlet obstruction in elderly men and is characterized by increased tissue mass in the prostate. After medical therapy, surgical treatment is often used to treat symptomatic BPH, but there are many different approaches. There has been a long history for the development of BPH surgery. Since Fuller performed the first "retropubic and suprapubic open prostatectomy" in 1894,  open operation remained the only option for patients for quite a long period.  Almost 100 years later, transurethral endoscopic surgery was applied and developed for the 1 st time. Since then, transurethral resection of the prostate (TURP) has been used widely all over the world due to its minimally invasive nature and low cost.  TURP has been considered as the gold standard to surgically alleviate the problem of obstructive voiding dysfunction due to an enlarged prostate. However, more recent technological advances have led to enucleation using transurethral technology, a technique allowing increased precision.  In this review, we for the 1 st time as we know, treat this great innovation as precise transurethral enucleation of prostate (PTUEP) and focus on the historical evolution of it.
| New prospective of precise transurethral enucleation of prostate|| |
For many years, retropubic and suprapubic open prostatectomy was used extensively in the clinic. In an open prostatectomy procedure, the hyperplastic prostate is removed through a single incision through the lower abdomen. There are two types of this open enucleation procedure, retropubic and suprapubic. A retropubic prostatectomy accesses the prostate by going through the lower abdomen behind the pubic bone. A suprapubic prostatectomy procedure enters through the lower abdomen and through the bladder via suprapubic pathway to access the prostate.  For many years, BPH was addressed by open surgery, though there were often adverse side-effects such as hemorrhage and these approaches often left large scars. In addition, patient recovery was often slow because of the highly invasive nature of the surgery. This is also a challenging procedure, as the operative field is limited due to the narrow space in pelvic cavity. 
With technological improvements allowing more facile use of an endoscope, transurethral resection of the prostate or TURP arose as the original micro and endoscopic operation for BPH. As the name indicates, this technique is performed by removing tissue by electrocautery dissection followed by the overall visualization of the bladder and urethra. TURP became the standard technique to which all surgical modalities for BPH were compared and had been studied the most though postoperative recurrence tended to be high. , TURP is a surgery of resection, not enucleation. TURP also requires general anesthetic and hospitalization and is limited in its applicability, as it is most successful with smaller enlargements. A further limitation is that bleeding may result from the repeated opening of blood vessels, adding to the challenge of this technique. ,
For years, urologists have been searching for a method to combine the previous two types of surgery. Fortunately, in the 1990s, Gilling et al. proposed enucleation using a holmium laser.  The use of laser and plasma enucleation for prostate treatment is now technologically feasible. , Though there remains a question of whether laser or plasma works best for BPH treatment, it is clear that transurethral enucleation of prostate is the superior approach to BPH treatment.  To some degree, it is an anatomic surgery for prostate hyperplasia. The procedure maintains the boundary of the transitional and peripheral zones and dissects the surgical capsule with high precision using a full understanding for prostate anatomy as the basis of transurethral enucleation.  Inaccurate placement within the prostate capsule can be a challenge for a surgeon, and precision is critical.
As first proposed by US in 2003, PTUEP allowed a new visual field independent of whether lasers or plasma were used. Initially, there were many obstacles preventing more widespread use of the proposed technique. The most serious one was hemorrhage that occurred with incorrect exposure of the surgical capsule. To deal with this problem, we improved the technique in which the direction of the tunnel to the surgical capsule was oriented in the 6 o'clock position. In this position, the transurethral tissue is weak and facilitates accurate capsule finding. Now, to a great extent, PTUEP is safer and more efficient than TURP. , PTUEP is more hemostatic with less active bleeding, partly because the blood vessel is opened only once and sealed from the root on the capsule during enucleation, as reported by US in 2012. In contrast, during resection, a loop is used to cut the prostate back and forth, and the vessels are opened repeatedly, which increased the risk of bleeding, especially for surgeries of large prostates.  Afterward, we performed long-term follow-up to observe the efficiency of PTUEP. As a minimally invasive operation, it reduced the risk of injury to the bladder and shortened the catheter duration and decreased hospital stay. Moreover, in our and others' studies, PTUEP has been applied to all size prostates, and it can be used to treat BPH patients taking anticoagulation medicine preoperatively. , Recently, we developed a laser handpiece combined with a 30 scope to allow better handling and control enabling better precision. The precision is additionally enhanced in the overall and thorough view of the urethra, bladder, and prostate, which allows the laser PTUEP to smash the calculus and avoid severe complications. We have found this technique applicable to men with BPH combined with other complications and high risks.
The PTUEP, on any kind of energy platform being used, has become the new gold standard for BPH surgery.
| Technological advances in precise transurethral enucleation of prostate appliances|| |
There has been significant appliance development during the past 20 years, allowing more accurate prostate enucleation.  The endoscopic use of lasers has evolved for a range of urological diseases. Four contemporary laser technologies are currently used: Holmium:yttrium-aluminum-garnet, thulium:yttrium-aluminum-garnet lasers, potassium titanyl phosphate: Neodymium:yttrium-aluminum-garnet (Nd:YAG), and lithium borate:Nd:YAG lasers. Enuleation allows the best surgical outcome, through three potential modes of laser usage: Vaporization (removal of tissue), resection (excision of small chips and wash them out from the bladder), and enucleation (removal of the adenoma from the surgical capsule and subsequent morcellisation).  With the combination of tissue resection and hemostasis, laser enucleation is possible for any size of the prostate and allows urologists to reach the surgically restricted area.  There has also been recent interest in the use of bipolar electrosurgery "plasma kinetic" technology for prostate enucleation as the first bipolar endoscopic enucleation was reported by Gillings' et al. group in 2006.  From then on, different shapes of electrodes have been used to meet diverse clinical needs. Surgeons must know the differences, advantages, and disadvantages of different endoscopic energy sources and techniques to maximize surgical efficacy and minimize the relative postoperative morbidity.
For laser enuleation, performance and efficiency rely on two critical steps, namely enucleation and tissue morcellation.  The latter process depends mainly on the prostatic tissue mass, visualization, and the type of morcellator used. Lumenis VersaCut, as a first-generation instrument, has a reciprocating blade mechanism causing prostate tissue to be moved back and forth during morcellation. Further improvement was made for the Richard Wolf Piranha, which has a rotating blade in which prostatic tissue is moved from side to side. This system was reported to be superior to previous methods and more efficient and safe for tissue removal. ,
Enucleation can also be performed using a laser. The holmium laser has been developed as a simple tool for treating BPH, by combining it with a 30° cystoscope, improving observation, and a laser fiber-restraining device which conferred better control and precision to the laser operation. The proper use of the resectoscope beak during enucleation is important to minimize the surgery risk, and our improved handpiece has a steady beak and laser holder. Together, this improved technology allows increased precision for TUEP.
| The reform of precise transurethral enucleation of prostate skills|| |
Innovative technology of enucleation
There are three anatomical lobes of the prostate. The traditional step of the procedure is to create bladder neck incisions at the 5 and 7 o'clock positions down to the surgical capsule, allowing the enucleation. Urologists have developed variations of the enucleation procedure, including the two-lobe method, the three-lobe method, and the tunnel method. We developed a four-step retrospective tunnel enucleation in which the prostate is cut from 6 to 12 o'clock, and then the adenoma is enucleated.  This method begins from the verumontanum and the prostate is separated from the apex retrospectively. The enucleated prostate tissue is put into the bladder for further morcellation, are shown in [Figure 1]. The no-touch laser firing phase facilitates the ability to stop bleeding quickly. The no-touch lasing of fibers can be done using the effect of the bubble at the tip of fiber, with no direct contact to the capsule. In this method, the surgical capsule is relatively easy to spot and less time is required for hemostasis. The data from the use of this improved enucleation surgical method is presented in [Table 1] and were collected from 422 patients during a 6-year period.
|Figure 1: (a) Schematic of our improved method. (b) A short horizontal incisionis made beneath the median lobe along the surgical capsule to make a tunnel into bladder. (c) Enucleation is performed of the left and right lateral lobes from 6 to 12 o'clock. (d) The entire prostate is pushed off and subject to morcellation|
Click here to view
The PTUEP process requires initial training, and there have been efforts made to shorten the learning curve. For example, a plasticine model of a prostate is used to elucidate prostatic anatomy.  The learning curve depends on adequate training.  The method of four-step retrospective tunnel enucleation is more easily learned than previous methods. To facilitate learning of the process, we developed our own training method, during which harvest cutting or capsule separation could be performed by junior staff with the help of the experienced surgeon. Owing to the improvement of surgery technology and tools, the PTUEP is not impossible for beginners. As was reported by Shah et al.,  an endourologist inexperienced with holmium laser enucleation of the prostate (HoLEP) tends to reach the reasonable level comparable to that of experts after about 50 cases. With our training process, the necessary number decreases to about 30, based on unpublished data collected from 2012 to 2014, during which time the trainees performed 142 HoLEP procedures independently.
Innovative technology of morcellation
There are various techniques for the removal of floating prostate tissue from the bladder following the enucleation procedure. Morcellation of isolated prostate adenoma inside the bladder is currently the standard step following transurethral enucleation. The most common method of tissue removal after holmium laser enucleation uses the mechanical tissue morcellator introduced by Gilling et al.  The morcellator causes the floating tissue to be morcellated into small pieces that are suctioned through a hand piece held within a collection device.
The duration of the morcellation procedure is dependent on the prostate size and tissue quality. Morcellation can be efficiently and safely performed in patients with prostates of all kinds of size. ,, The morcellator action can be summarized as "suck-cut-out." However, some studies have reported the so-called "crazy ball" or "beach ball" effect, which is caused by small round tissue fragments that may persist after morcellation and that are difficult to morcellate because they could dislodge from the morcellator blades. , The crazy ball tissue complicates morcellation and can increase the time required for the process. The most serious potential complication during this procedure is an accidental injury of bladder or bladder perforation. Most mechanical problems are related to suction. Because the crazy ball tissue resists suction, this process may need to be repeated up to many times, increasing the duration of the overall procedure. To address this issue, we developed some techniques to reduce morcellation time and increasing safety.  The first trick is executed during the enucleation phase, just before the gland is pushed into the bladder. The surgeon should evaluate the gland tissue texture. The loose and soft tissue can be easily vaporized and cut by laser, but more firm tissue cannot. If the texture of the gland is determined to be firm tissue or a smooth surface, it may present a problem for morcellation. In this case, the laser should be used to roughen the surface and dig several holes in the gland. This loosens the gland tissue and roughens the surface, making it easier for the floating tissue to be removed by suction. Another skill developed by a surgeon in our center is executed during the suck phase. If the prostate tissue is loose and soft, the conventional upward method can be used for morcellation. Otherwise, when operating on large volume glands or crazy ball with fibrotic, smooth surfaces, and firm tissue, an inverse technique could be applied. Our methods for overcoming these challenges are to grab the tissue, drag it to the prostatic fossa, and then perform suction. The stabilized prostate fossa will greatly reduce the motion of the gland and can increase the contact of the gland with the blade. If the method of digging holes and roughening surface of the tissue fails, surgeons should use the holmium laser to cut the firm tissue into small pieces and repeat the previous steps. The instrument is one of the important factors in morcellation, and the reciprocating blades can be replaced to maintain as sharp a cutting tool as possible and reduce morcellation-correlated complications.
| Conclusion|| |
PTUEP, as we first proposed, is an excellent alternative to TURP or open prostatectomy which shows equivalent or superior postoperative outcomes. Current advances in technology have allowed the successful widespread application of this technique for the treatment of BPH. Accompanied by the fast fly of scientific technology, the golden standard belongs to the present and the past, but not the future. Inspite of this, PTUEP is no doubt a landmark of BPH surgery.
It is always a dream of us, of numerous urologists that PTEP has truly come of age.
We gratefully acknowledge the urologists making great contributions to TUEP, especially to Yinghao Sun, Peter Gilling, Chuanjun Du, and Chunxiao Liu. This study was funded by grants from the Pudong Health Bureau of Shanghai (Number PW2013D-3), the Key Disciplines Group Construction Project of the Pudong Health Bureau of Shanghai (PWZxq2014-11), and the fund of Shanghai Science and Technology (15DZ1941500). We would also like to acknowledge the reviewers for their helpful comments on this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Losh CW. Suprapubic prostatectomy with primary closure of the bladder. Miss Valley Med J 1950;72:99-102.
Millin T. Retropubic prostatectomy; a new extravesical technique; report of 20 cases. Lancet 1945;2:693-6.
Ramsey EW. Transurethral resection of the prostate: Still the gold standard? Can J Surg 1993;36:9-10.
Gilling PJ, Cass CB, Malcolm AR, Fraundorfer MR. Combination holmium and Nd:YAG laser ablation of the prostate: Initial clinical experience. J Endourol 1995;9:151-3.
Condie JD, Jr., Cutherell L, Mian A: Suprapubic prostatectomy for benign prostatic hyperplasia in rural Asia: 200 consecutive cases. Urology 1999;54:1012-6.
Michalak J, Tzou D, Funk J. HoLEP: The gold standard for the surgical management of BPH in the 21 st
Century. Am J Clin Exp Urol 2015;3:36-42.
Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP) - Incidence, management, and prevention. Eur Urol 2006;50:969-79.
Rigatti P, Cestari A, Gilling P. The motion: Large BPH should be treated by open surgery. Eur Urol 2007;51:845-7.
Montesi L, Quaresima L, Tiroli M, Lacetera V, Cantoro U, Sbrollini G, et al.
Improvement of lower urinary tract symptoms and sexual activity after open simple prostatectomy: Prospective analysis of 50 cases. Arch Ital Urol Androl 2014;86:353-5.
Dolowy L, Krajewski W, Dembowski J, Zdrojowy R, Kolodziej A. The role of lasers in modern urology. Cent European J Urol 2015;68:175-82.
Kahokehr AA, Gilling PJ. Which laser works best for benign prostatic hyperplasia? Curr Urol Rep 2013;14:614-9.
Chen YB, Chen Q, Wang Z, Peng YB, Ma LM, Zheng DC, et al.
A prospective, randomized clinical trial comparing plasmakinetic resection of the prostate with holmium laser enucleation of the prostate based on a 2-year followup. J Urol 2013;189:217-22.
Van Rij S, Gilling PJ. In 2013, holmium laser enucleation of the prostate (HoLEP) may be the new 'gold standard'. Curr Urol Rep 2012;13:427-32.
Naspro R, Suardi N, Salonia A, Scattoni V, Guazzoni G, Colombo R, et al.
Holmium laser enucleation of the prostate versus open prostatectomy for prostates >70 g: 24-month follow-up. Eur Urol 2006;50:563-8.
Elzayat EA, Habib EI, Elhilali MM. Holmium laser enucleation of the prostate: A size-independent new "gold standard". Urology 2005;66 5 Suppl:108-13.
Neill MG, Gilling PJ, Kennett KM, Frampton CM, Westenberg AM, Fraundorfer MR, et al.
Randomized trial comparing holmium laser enucleation of prostate with plasmakinetic enucleation of prostate for treatment of benign prostatic hyperplasia. Urology 2006;68:1020-4.
Chen Q, Chen YB, Wang Z, Peng YB, Zheng DC, Cai ZK, et al.
An improved morcellation procedure for holmium laser enucleation of the prostate. J Endourol 2012;26:1625-8.
Monn MF, El Tayeb M, Bhojani N, Mellon MJ, Sloan JC, Boris RS, et al.
Predictors of enucleation and morcellation time during holmium laser enucleation of the prostate. Urology 2015;86:338-42.
El Tayeb MM, Borofsky MS, Paonessa JE, Lingeman JE. Wolf piranha versus lumenis versacut prostate morcellation devices: A prospective randomized trial. J Urol 2015. pii: S0022-534704677-7.
Gu M, Cai ZK, Chen Q, Chen YB, Wang Z. Six-o'clock tunnel holmium laser enucleation of the prostate: A modified procedure for benign prostate hyperplasia. Zhonghua Nan Ke Xue 2015;21:132-5.
Gilling PJ, Aho TF, Frampton CM, King CJ, Fraundorfer MR. Holmium laser enucleation of the prostate: Results at 6 years. Eur Urol 2008;53:744-9.
Abdel-Hakim AM, Habib EI, El-Feel AS, Elbaz AG, Fayad AM, Abdel-Hakim MA, et al.
Holmium laser enucleation of the prostate: Initial report of the first 230 Egyptian cases performed in a single center. Urology 2010;76:448-52.
Elzayat EA, Khalaf I, Elgallad M, Hosny H, Elhilali M. Holmium laser enucleation of prostate in patients with prostate size </=60 cm3. Urology 2009;73:95-9.
Gupta N, Sivaramakrishna, Kumar R, Dogra PN, Seth A. Comparison of standard transurethral resection, transurethral vapour resection and holmium laser enucleation of the prostate for managing benign prostatic hyperplasia of >40 g. BJU Int 2006;97:85-9.
Scoffone CM, Cracco CM. The en-bloc no-touch holmium laser enucleation of the prostate (HoLEP) technique. World J Urol 2015; 97:85-9.
Rasch A, Gruber S, Perleth M. Learning curve in laser treatment of benign prostatic syndrome: A systematic review. Z Evid Fortbild Qual Gesundhwes 2013;107:335-43.
Shah HN, Mahajan AP, Sodha HS, Hegde S, Mohile PD, Bansal MB. Prospective evaluation of the learning curve for holmium laser enucleation of the prostate. J Urol 2007;177:1468-74.
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;12:457-9.
Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol 2008;53:160-6.
Vavassori I, Valenti S, Naspro R, Vismara A, Dell'Acqua V, Manzetti A, et al.
Three-year outcome following holmium laser enucleation of the prostate combined with mechanical morcellation in 330 consecutive patients. Eur Urol 2008;53:599-604.
Ritter M, Krombach P, Bolenz C, Martinschek A, Bach T, Haecker A. Standardized comparison of prostate morcellators using a new ex-vivo
model. J Endourol 2012;26:697-700.