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Holmium laser enucleation of the prostate is an effective and popular method of treating benign hyperplasia (BPH, prostate adenoma), which is based on the removal of altered tissue with a special laser. Laser radiation in this method is generated by a holmium crystal, a rare earth element, the unique properties of which make it possible not to resect the tissue in small parts, but to remove it along the anatomical capsule of the gland.
Benign prostatic hyperplasia (BPH) or prostate adenoma is a problem for most men over 40 years of age. A healthy prostate in men is the size of a walnut and is divided into four main anatomical zones: transitional, central, peripheral and anterior fibrovascular stroma. At about 40 years of age, the prostate transition zone begins to grow slowly at 1.6% per year and this figure gradually increases with age. Enlargement of the transition zone of the prostate leads to obstruction (narrowing) of the urinary tract and, in the absence of timely treatment, to further progression of symptoms and worsening of the problem.
Currently, there are many ways to treat prostate adenoma, both surgical and conservative. Unfortunately, approved conservative methods, which include the use of alpha-adrenergic receptor blockers and alpha-reductase inhibitors, can only slightly reduce the severity of symptoms.
Surgical treatment of prostate adenoma.
The most common types of surgical treatment for prostate adenoma are open prostatectomy and transurethral resection of the prostate (TURP).
Despite overall promising long-term results and low reoperation rates, this method has many unpleasant side effects:
- dysuria; — difficulty urinating
- frequent urination;
- sexual dysfunction;
- long recovery period;
- frequent relapses of the disease.
In order to reduce these side effects, experts have proposed other surgical methods, but with the same functional results, including plasmakinetic resection or enucleation of the prostate gland, as well as holmium resection of the prostate gland.
Holmium laser enucleation of the prostate (HoLEP).
The holmium laser is a pulsed solid laser with a wavelength of 2140 nm and a small depth of penetration into tissue (less than 3 mm). Depending on the distance between the laser tip and the prostate tissue, the surgeon has the ability to homeostasis or cut and evaporate the prostate tissue. These properties make the laser an ideal device for enucleation of the prostate lobes. Additionally, lower energy settings reduce the likelihood of damage to the external urethral sphincter.
Advantages of using holmium laser in surgery:
- formation of sutures without abscesses;
- laser gives control of hemostasis;
- does not penetrate deeper than the zone of visually altered tissue, which is safe for the patient;
- after using the laser, rapid tissue restoration is observed, which reduces the patient’s time in the hospital.
For the purpose of treating prostate adenoma directly, the HoLEP technique was proposed about 20 years ago, and made it possible to enucleate or enucleate the adenoma lobes.
This laser is widely used in other operations, including operations for urolithiasis, bladder tumors, and skin lesions of the genital organs.
How is laser enucleation of prostate adenoma performed?
In the case of using a holmium laser, two techniques have been described: three-band and two-band techniques. The choice of type of laser enucleation of the prostate is determined in accordance with the individual anatomy of the patient’s prostate gland.
This is a technically complex, step-by-step operation that should be performed by experienced urologists and in well-equipped centers.
The technique itself consists of several steps:
Step 1. First, the urethra is calibrated.
Step 2. Insertion of a continuous resectoscope and visualization of the anatomical structure.
Step 3. Enucleation of the prostate lobes. In the case of hypertrophy of three lobes, the middle lobe is enucleated first.
Step 4. Inspection of the prostate bed. After enucleation is completed and the lobules are pushed into the bladder, the surgeon examines the prostatic fossa and performs complete hemostasis.
Step 5. The surgeon inserts a morcellator into the bladder through the outer shell of the resectoscope and performs morcellation (removal) of the prostate lobes, and the fragmented tissue is sucked out with a vacuum pump.
Postoperative period.
As a rule, after surgery, a flushing system is connected to the urethral catheter for 4–12 hours, which is removed after 2 days, after which the patient can be discharged home.
Benefits of holmium enucleation of the prostate.
HoLEP has a number of advantages compared to other treatment methods:
- It can be used for any prostate size.
- Causes less blood loss.
- Short residence time of the catheter in the bladder.
- After holmium laser, there is a lower incidence of postoperative complications and reoperations (the probability of relapse is less than 2%).
- Fast recovery after surgery (on average 2–3 days), while after TUR, recovery takes 5–7 days.
- The possibility of using the method in patients who take anticoagulants and are at higher risk of bleeding during operations.
- It should be noted that after treatment, stress urinary incontinence is observed in 4.9–12.5% of cases, but restoration of function occurs within one year, which is considered a good result.
- This method allows you to reduce the frequency of retrograde ejaculation.
Flaws.
- The technique of mastering the holmium laser for prostate adenoma requires more time compared to other surgical methods.
- Due to the highly technical technique, the operation takes more time than with a standard TUR.
Despite the existing disadvantages of the method, such as the requirement of special equipment, holmium laser enucleation of the prostate gland is an effective surgical approach in the treatment of prostate adenoma.
What is the difference between HoLEP and TOUR?
Holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TUR) have some differences regarding the risks of postoperative complications.
- Bleeding: TUR may have a higher incidence of bleeding compared to HoLEP. Statistics indicate that the bleeding rate of TURBT is around 5-15%, while the bleeding rate of HoLEP is around 1-2%.
- Strictures: The risk of developing urethral strictures after TUR is estimated to be around 3-12%, while after HoLEP this risk is reduced to around 1-5%.
- Retrograde ejaculation: This complication can occur after both procedures. TUR can cause retrograde ejaculation in approximately 70-90% of patients, while in HoLEP this percentage may be lower at around 10-30%.
- Urethral strictures (narrowing of the urethra): a very common occurrence in patients undergoing TURP. HoLEP has virtually no such complications.
Strictures (narrowings of the urethra) occur after transurethral resection of the prostate (TURP) much more often than after holmium laser enucleation of the prostate (HoLEP), for several reasons:
- Urethral trauma: During a TURP, an instrument called a resectoscope is used to remove parts of the enlarged prostate. During the process of inserting it and moving it through the urethra, trauma can occur, which can put you at risk of developing strictures.
- Heat Injury: The TURP process uses electrical current to resect the prostate. Sometimes this can cause heat damage to surrounding tissues, including the urethra, increasing the likelihood of developing strictures.
- Wound healing: After a TUR, wounds are formed in the area of the removed prostate tissue. As the wound heals, scar tissue can form, which can cause the urethra to narrow and develop a stricture.
On the other hand, holmium laser enucleation of the prostate (HoLEP) is associated with a lower incidence of strictures. This is due to more precise removal of prostate tissue using a laser beam, which reduces trauma and thermal damage to the urethra. HoLEP also allows for more complete tissue removal, which reduces the risk of stricture formation.
The price for prostate enucleation in Germany is from 6000 Euro.
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