Laser Enucleation of the Prostate (HoLEP and ThuLEP)

Anatomy and Physiology

The anatomy of the prostate was first described in detail by Andreas Vesalius in 1543, followed by more advanced studies, including McNeal's classification of prostate zones in 1968.[2] McNeal divided the prostate into four distinct zones: peripheral, anterior fibromuscular, central, and transitional zones. The transitional zone, which comprises approximately 10-15% of the prostate’s total volume, is of primary interest when discussing benign prostatic hyperplasia (BPH), as it is the zone most commonly affected by hyperplasia.[1][2][10] Within the prostate, important structures include the internal sphincter muscle, the prostatic urethra, the capsule, and the ejaculatory ducts, which open into the urethra from the verumontanum.[3]

Embryologically, the prostate originates from the urogenital sinus and develops just below the bladder under the influence of androgens secreted by the Leydig cells.[11][12] Androgens, particularly testosterone and its more potent derivative, dihydrotestosterone (DHT), play a central role in prostate development and maintenance.

The primary blood supply to the prostate is derived from the inferior vesical artery, which branches into the prostatic artery, further dividing into capsular and urethral arteries. The urethral artery gives rise to Flock’s branches at the 1 and 11 o’clock positions and Badenoch’s branches at the 5 and 7 o’clock positions, which are critical anatomical landmarks during procedures like HoLEP and ThuLEP.[3][12] 

The venous drainage of the prostate flows into the internal iliac veins, and the gland is innervated by sympathetic and parasympathetic fibers from the hypogastric and pelvic nerves, respectively.[3][10] For more information on the Anatomy of the Prostate, see the companion StatPearls review at www.statpearls.com/point-of-care/27831.[3]

The pathophysiology of BPH is influenced by a balance between prostatic cell proliferation and apoptosis (programmed cell death). As men age, a decrease in apoptosis results in an overall increase in prostatic cell mass, contributing to the enlargement of the gland.[4][13] Dihydrotestosterone (DHT), which is synthesized from testosterone by intracellular 5-alpha-reductase, has a significant effect on prostatic development and growth, maintaining and promoting the hyperplastic process later in life.[14][15] There are two types of 5-alpha-reductase enzymes (Type 1 and Type 2) located in the liver, skin, scalp, and prostate.[16] The prostate contains predominantly 5-alpha-reductase type 2 located predominantly in the stromal cells.[10][16]

As the transitional zone expands, it compresses the prostatic urethra, leading to obstructive symptoms such as decreased urine flow and increased frequency of urination.[4] The resulting symptoms are not solely dependent on the size of the prostate but rather on the degree of obstruction and the functional response of the bladder to increased outflow resistance.[1][4][1][10][13] For more information on Benign Prostatic Hyperplasia, see the companion StatPearls' reference review at www.statpearls.com/point-of-care/18212.[4]

Indications

Laser enucleation procedures are particularly advantageous for patients with an increased risk of bleeding or those on anticoagulation therapy, as the laser’s coagulative properties can effectively manage hematuria during surgery, making it a safer alternative compared to conventional methods like monopolar or bipolar TURP. For these patients, the option to continue anticoagulation during surgery may be considered, although those who can safely hold their anticoagulants are generally advised to do so according to the half-life of their specific medication, overall health, and specific bleeding risk.[17][18]  For those unable to temporarily discontinue anticoagulation due to underlying conditions (e.g., mechanical heart valves or recent thromboembolic events), laser enucleation provides a safer option compared to TURP or open prostatectomy.

Prostate volume assessment is critical for planning the intervention and determining the most appropriate surgical approach. This can be estimated by prostatic imaging as follows:

• Transrectal ultrasound (TRUS) remains the standard for prostate size measurement, offering better detail than abdominal ultrasound.
• Magnetic resonance imaging (MRI) provides the most precise volume measurement and excellent anatomical visualization, particularly valuable when prostate cancer is suspected, although it is less commonly used in BPH assessments.
• TRUS-based formulas, such as height × width × length × 0.52, are widely used to estimate the overall prostate volume and can be integrated into automated calculations on ultrasound machines.
• Unlike most other surgical treatments for BPH, Holep and Thulep are size-independent procedures suitable for prostates of any size.
• The inability of a patient to come off anticoagulation is not necessarily an absolute contraindication to the procedure, although it is recommended when possible.[13][19]
• For more information on Prostate Imaging, see the companion StatPearls' reference review at www.statpearls.com/point-of-care/36530.[19]

Laser enucleation of the prostate, encompassing HoLEP and ThuLEP, is primarily indicated for patients with larger prostate volumes (greater than 80 cc) and those whose symptoms have not responded to maximal tolerable medical therapy, as recommended by guidelines from the National Institute for Health and Care Excellence (NICE), American Urological Association (AUA), and European Association of Urology (EAU).[20][21][22] However, laser enucleation is technically suitable for prostates of any size, providing a highly effective option even for smaller glands if patient-specific factors, such as significant comorbidities, warrant a minimally invasive approach and the patient can safely tolerate the required anesthesia.

Laser enucleation is typically offered after the failure of medical management, which includes an adequate clinical trial of maximally tolerable alpha-blocker therapy to relax the smooth muscle in the bladder neck and prostate, as well as 5-alpha reductase inhibitors for patients with prostates larger than 40 cc and a prostate-specific antigen (PSA) greater than 1.4 ng/ml.

The broader indications for surgical intervention include recurrent urinary tract infections (UTIs), persistent hematuria, bladder stones, high-pressure chronic urinary retention, and recurrent episodes of acute urinary retention secondary to BPH, especially when medical therapy has failed. Laser enucleation offers a less invasive alternative to open or robotic prostatectomy in these scenarios, minimizing the risks associated with more invasive surgeries and providing long-term relief of obstructive symptoms.[23][24][25]

Patients should undergo a thorough preoperative evaluation, including a urinalysis, flow rate study, post-void residual measurement, and completion of the International or AUA Prostate Symptom Score (IPSS) questionnaire. Flexible cystoscopy is usually performed for patients with severe symptoms or hematuria and to directly visually assess the prostatic urethra and bladder anatomy.[8][23][26]

Contraindications

There are no absolute contraindications specific to HoLEP and ThuLEP beyond those that would prevent a patient from safely undergoing anesthesia. However, considerations for the patient’s overall health and ability to tolerate a prolonged surgical procedure are critical, as laser enucleation typically requires 2-3 hours under general or spinal anesthesia. Patients with severe cardiopulmonary comorbidities or those classified as high anesthetic risk may be better suited to alternative treatments that require shorter operative times or staged procedures.[27]

For patients with a history of severe urethral stricture disease or bladder neck contractures, laser enucleation may be challenging due to difficulty in advancing the endoscopic instruments into the bladder and exacerbating any pre-existing strictures. Dealing with urethral strictures will certainly extend the operative time for the surgery and the duration of the anesthesia required. These conditions should be carefully evaluated during preoperative planning, and alternative approaches should be considered if the risks outweigh the benefits of proceeding with laser enucleation.

An inability of a patient to safely stop anticoagulation is not necessarily an absolute contraindication to laser enucleation of the prostate. When anticoagulation can be paused, it is recommended to do so according to the specific pharmacokinetics of the anticoagulant medication, such as stopping direct oral anticoagulants 24-48 hours before the procedure, depending on renal function.

In addition to medical contraindications, patient preferences and goals should be considered, especially for those concerned about potential side effects such as retrograde ejaculation or stress urinary incontinence. While these outcomes are common with most BPH surgical treatments, informed discussions about the risks and benefits of laser enucleation versus other procedures are essential for shared decision-making and informed consent.

Equipment

Laser technology has significantly advanced urological interventions, particularly in procedures like Holmium Laser Enucleation of the Prostate (HoLEP) and Thulium Laser Enucleation of the Prostate (ThuLEP). These procedures necessitate specialized equipment to enable precise tissue ablation, coagulation, and resection.[28][29]

The laser generator is the primary component of the setup, which delivers high-energy laser beams for tissue ablation and coagulation.

• For HoLEP, a holmium laser operates at a wavelength of 2140 nm, producing pulsed energy with a pulse duration of approximately 350 microseconds.[28][29] This pulsed nature allows for rapid heating and controlled ablation, making it effective for cutting through prostatic tissue with minimal thermal spread to surrounding structures. The penetration depth of 0.4 mm ensures precise targeting, while the coagulation zone is limited to 0.5 to 1 mm, helping to maintain hemostasis during enucleation.[30][31] The typical energy settings for HoLEP are 50 Hz and 2 Joules for tissue resection, while hemostasis and apical dissection are performed at 30 Hz and 2 Joules.[30][31]

• The thulium laser, used in ThuLEP, operates at a wavelength of 2013 nm, emitting energy as a continuous wave. This continuous emission enables consistent tissue vaporization, with a shorter wavelength resulting in a shallower penetration depth of around 0.25 mm, which facilitates rapid vaporization and enhanced hemostasis.[30][31] The continuous-wave nature allows for smoother ablation and more consistent visibility during surgery, which is particularly advantageous for procedures requiring detailed visualization of tissue planes.[30][31] Surgeons may use power settings up to 150-200 W in ThuLEP to accommodate different tissue types and prostate sizes.[30][31]

Both holmium and thulium lasers are delivered through end-firing laser fibers, typically with a diameter of 550 microns, designed to direct laser energy accurately while maintaining flexibility for maneuvering through the resectoscope.[31] For both HoLEP and ThuLEP, the laser fiber is integrated into a 26-28 French continuous flow resectoscope equipped with a laser bridge, providing stability and precision during enucleation. The resectoscope facilitates continuous irrigation, ensuring a clear operative field throughout the procedure.[30]

Advanced morcellation devices are commercially available to facilitate prostatic tissue removal from the bladder after enucleation. Morcellation devices quickly fragment the freed prostate tissue into smaller pieces for evacuation. Effective morcellation is critical for minimizing operative time and reducing the risk of postoperative retention due to retained tissue fragments.[30][31]

Advanced morcellators are essentially equivalent, although each offers unique features claimed to enhance efficiency.[30][31] One device is known for its ergonomic design and efficiency, using oscillating blades that produce microbursts of suction, aiding in the safe and efficient removal of tissue fragments.[31] This design helps minimize the risk of bladder wall injury, a potential complication during morcellation, especially in cases involving large tissue volumes.[30][31]

Maintaining a filled bladder during morcellation is crucial for optimal visualization and to prevent damage to the posterior bladder wall.[18] Gravity-assisted irrigation during this phase is generally used to maintain a steady flow of saline, helping to clear blood and debris from the surgical field.[30]

Fluid management is essential during HoLEP and ThuLEP, requiring continuous irrigation with normal saline (3-liter bags) to maintain a clear operative field during both enucleation and morcellation.[30][31] Saline is preferred over hypotonic solutions used in traditional monopolar transurethral prostate resections because it reduces the risk of TURP syndrome, a potentially life-threatening condition of sudden, severe dilutional hyponatremia caused by the absorption of large volumes of hypotonic fluid.[30][31] Saline’s isotonic nature helps maintain the patient’s electrolyte balance throughout the procedure.[30][31]

The continuous flow resectoscope is designed with separate inflow and outflow ports to manage irrigation. The inflow port is connected to the saline reservoir, while the outflow relies on gravity or controlled suction to ensure a constant fluid turnover. This system allows the surgeon to adjust the flow rate as needed, depending on visibility and the extent of bleeding encountered during the procedure.[31]

Supporting surgical instruments are necessary for successful laser enucleation. Van Buren sounds are used for initial dilation of the urethra, facilitating the smooth insertion of the resectoscope.[31] An Ellik evacuator or Toomey syringe may be employed to remove small tissue fragments not effectively captured by the morcellator.[30][31] These instruments provide additional options for clearing the operative field and ensuring the bladder is free of residual debris.

Catheterization is typically performed using a 20, 22, or 24 French, 2-way Foley catheter with a 30 cc balloon, inserted postoperatively to ensure bladder drainage and tamponade of the prostatic fossa to control bleeding. This catheter helps prevent clot retention by allowing continuous outflow of urine, minimizing the risk of acute urinary retention immediately after surgery.[30][31] In cases with more than average bleeding requiring more aggressive bladder irrigation to prevent clot formation, a 3-way Foley catheter may optionally be used, allowing simultaneous irrigation and drainage.[30]

Understanding specialized laser physics is crucial for understanding their different clinical applications. Laser light is characterized by being monochromatic (single wavelength), collimated (parallel waves), and coherent (waves in phase).[30][31] These properties ensure precise energy delivery to the target tissue, making laser energy ideal for ablation with minimal damage to surrounding structures.[30]

Absorption of laser energy by water molecules in the tissue is key to the function of both holmium and thulium lasers.

• In holmium lasers, most of the energy is absorbed in a thin layer of tissue, converting to heat, which causes the vaporization of the target cells. This controlled process is beneficial for the simultaneous coagulation of small and medium blood vessels, providing effective hemostasis during tissue cutting.[30] The thermal energy generated helps limit the depth of thermal injury, preserving surrounding structures during the enucleation process.[18][27]

• Thulium lasers, with their continuous-wave emission, provide a smoother energy delivery, ensuring consistent tissue vaporization and enhanced visualization throughout the procedure. Their shorter wavelength allows for more efficient water absorption, which is advantageous when maintaining a consistent enucleation plane.[30]

Achieving surgical proficiency in HoLEP and ThuLEP requires a prolonged learning curve, particularly for HoLEP. Studies indicate that inexperienced surgeons need to perform around 50 cases to reach a level of competence characterized by decreased operative time and improved morcellation efficiency.[30] For ThuLEP, the learning curve may be shorter, with studies suggesting that experienced endourologists can become proficient after performing about 30 cases, especially with prior simulator training.[30] 

Saredi’s assessment of surgeons trained on a simulator demonstrated that 30 cases were sufficient to achieve competence in ThuLEP.[30] Regular practice in high-volume centers is essential for maintaining surgical skills, reducing operative time, and ensuring optimal outcomes in laser enucleation of the prostate.[30]

Performing Holmium Laser Enucleation of the Prostate (HoLEP) requires a range of specialized equipment to ensure precision, efficiency, and patient safety. Below is a comprehensive list of the necessary tools and devices: [30][31][32][33]

• Video and Imaging Equipment:
  • Video Tower and Camera: Provides high-definition visualization during the procedure.

• 30 Degree Cystoscope Lens: Provides a wide-angle view of the prostate and surrounding tissues.

• Laser and Associated Tools:
  • Holmium / Thulium Generator Laser Unit: Must have In Holmium 80–100 watt maximum power to ensure effective tissue ablation, IN Thulium 150-200 watt
  • 550 μ Laser Fiber: Delivers the laser energy to the prostate tissue.
  • 550 μ Laser Fiber Stripper: Prepares the laser fiber for use.

• Resectoscope and Stabilizing Instruments:
  • 26 to 28 F Continuous Flow Resectoscope Sheath: With a modified inner sheath containing a laser fiber stabilizing bridge.
  • 7 F Laser Fiber Stabilizing Catheter: Ensures the laser fiber remains stable during the procedure.

• Supportive Surgical Instruments:
  • Van Buren Sounds: Used for urethral dilation.
  • Ellik Evacuator: For the removal of tissue fragments.

• Morcellation Equipment:
  • Offset Rigid Nephroscope: Facilitates the visualization and removal of enucleated tissue.
  • Morcellator: Fragments and removes the enucleated prostate tissue.

• Irrigation and Catheterization Supplies:
  • Normal Saline for irrigation (3-liter bags): Maintains clear visualization and flushes out debris.
  • 20 F, 2-Way, or 3-way Foley Catheter (30 cc balloon): Used immediately postoperatively to facilitate urine drainage, prevent clot retention, and tamponade the prostatic fossa to minimize bleeding.
  • Catheter Guide: Assists with the placement of the Foley catheter.
  • Lubricant for transurethral instruments and Foley catheter

Effective utilization of this equipment is critical for achieving optimal outcomes in HoLEP and ThuLEP procedures. This underscores the importance of clinicians' proficiency in equipment selection, operation, and troubleshooting to ensure the safe and effective treatment of patients with benign prostatic hyperplasia (BPH).

Technique or Treatment

Before discussing the specific techniques of HoLEP and ThuLEP, it is essential to understand the general steps involved in both procedures, which are summarized below. These steps provide the foundational approach to enucleating the prostate using laser technology, which is largely shared between the two methods, as summarized in Table 1.[30][31][32][33]

Basic Steps in Laser Prostate Enucleation:

1. Preoperative Preparation:

   • Anesthesia: Both HoLEP and ThuLEP can be performed under general or spinal anesthesia, depending on patient preference and medical history. The patient is positioned in a lithotomy position.
   • Equipment Setup: High-powered lasers (100W-120W for HoLEP and 150W-200W for ThuLEP) are used. An end-firing 550-micron laser fiber is typically employed for precision. Additionally, a continuous-flow resectoscope with a laser bridge is used for visualization and tissue removal.
   • Patient Positioning: The patient is placed in the dorsolithotomy position.

2. Fluid Management:

   • Continuous saline irrigation is essential to maintain visibility during the procedure. The inflow is provided by gravity or pumps, and large volumes of saline may be required due to the fluid outflow during tissue resection.

3. Insertion of the Resectoscope:

   • The resectoscope is inserted into the urethra and advanced to the level of the prostate. This device allows the surgeon to visualize the obstructive prostatic tissue and access the area for laser enucleation.

4. Capsular Plane Identification:

   • The key to successful enucleation is identifying and staying within the capsular plane. The laser is used to create initial incisions in the urethral mucosa to expose the plane between the prostate tissue and the capsule.

5. Enucleation:

   • The enlarged portions of the prostate (adenoma) are enucleated, either lobe by lobe or in one piece, depending on the selected technique.
   • The laser is used for cutting, and its coagulative properties are critical for minimizing intraoperative and postoperative bleeding.
   • Dissection is often performed with an early release of the ventral urethral mucosa and using apical mucosal-sparing incisions to minimize postoperative incontinence.

6. Morcellation:

   • Once the prostate tissue is enucleated, it is pushed into the bladder. A morcellator (a device that fragments the tissue) is then used to suction the tissue out of the bladder, ensuring complete removal of the adenoma.

7. Residual Adenoma and Hemostasis:

   • Surgeons should thoroughly inspect the surgical site to ensure no residual adenomatous tissue remains. Residual tissue may cause persistent urinary symptoms and necessitate repeat surgery.
   • Both holmium and thulium lasers provide excellent hemostasis, allowing for real-time coagulation of blood vessels as the tissue is cut. This minimizes the risk of bleeding, even in patients on anticoagulants.

8. Post-Procedure Catheterization:

   • A urinary catheter is typically inserted at the end of the procedure to facilitate postoperative drainage and monitor for any excessive bleeding.
   • The catheter is usually removed within 24-48 hours, depending on the patient’s speed of recovery.

THULIUM LASER ENUCLEATION OF THE PROSTATE (ThuLEP) TECHNIQUES

Once the general steps are completed, specific variations in the ThuLEP procedure can be applied, depending on the surgeon’s preference and the patient’s prostate anatomy. The thulium laser provides precise cutting ability with superior coagulation, making it an ideal choice for laser enucleation.[34]

Classic Three-Lobe Enucleation Technique:

• Approach:
  • Begin by making two mucosal incisions at the 5 o’clock and 7 o’clock positions, extending from the bladder neck to the verumontanum.
  • Enucleate the median lobe first in a retrograde manner (from the prostate apex to the bladder neck).
  • The lateral lobes are then enucleated separately by widening the incisions to free the lobes from the surgical capsule.

• Usage: The traditional three-lobe technique is commonly used in ThuLEP, providing a clear step-by-step approach, especially for less experienced surgeons.

Two-Lobe Enucleation Technique (Wolters’ Modification): [35]

• Approach:
  • Enucleation starts with the left lateral lobe, which is removed first.
  • Afterward, the median and right lateral lobes are enucleated together as a single piece.
• Advantages: This method reduces the number of incisions required, which can shorten operative time.

Median Lobe First (Dallabella and Castellani Approach):[36]

• Approach:
  • The enucleation begins with the removal of the median lobe.
  • This allows for better visualization and easier access to the lateral lobes, which are then enucleated and joined anteriorly.
• Application: This technique improves exposure to the lateral lobes, making the procedure easier to complete.

En-Bloc Enucleation Technique (Kim et al.):[37]

• Approach:
  • A U-shaped incision is made above the verumontanum, followed by a circular incision at the prostate apex to define the distal boundary of enucleation.
  • The entire transitional zone is enucleated as one piece in a circumferential retrograde manner, working from the apex to the bladder neck.
• Advantages: The en-bloc method improves efficiency by reducing tissue fragmentation, facilitating easier morcellation.

Saredi's Modification of the En-Bloc Technique:[38]

• Approach:
  • An antegrade incision is made at the 5 o’clock position, starting from the bladder neck and extending to the prostate apex.
  • This incision serves as a landmark for maintaining the correct capsular plane.
• Benefits: This modification helps avoid discrepancies in the enucleation planes, ensuring consistent tissue removal while preventing damage to surrounding structures.

HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HoLEP) TECHNIQUES

Specific HoLEP techniques are employed to enucleate the prostate using a holmium laser MORE effectively. HoLEP is highly regarded for its precision in enucleating large prostates and its excellent long-term results.

Classic Three-Lobe Enucleation Technique:[39]

• Approach:

  • Make incisions at the 5 o’clock and 7 o’clock positions from the bladder neck to the verumontanum.
  • Enucleate the median lobe first, proceeding retrograde from apex to bladder neck.
  • A third incision at the 12 o’clock position separates the lateral lobes, which are then enucleated individually.

• Usage: This technique is commonly employed by surgeons with varying levels of experience and is ideal for large prostates.

Two-Lobe Technique:

• Approach:
  • The median and lateral lobes are enucleated together as one unit, similar to the two-lobe technique in ThuLEP.
• Advantages: Reduces operative time by simplifying the number of cuts and lobes to be removed.

Retrograde Enucleation:

• Approach:
  • Start the enucleation at the bladder neck and proceed antegrade toward the apex of the prostate.
• Advantages: This technique offers better visualization of the prostate capsule, making it ideal for complex cases or large prostates.

Midline Incision Technique:

• Approach:
  • A midline incision is made near the verumontanum, and the lateral lobes are enucleated individually.
• Application: This technique is useful for surgeons who prefer more control over the enucleation process and is effective for dealing with larger prostates.

Complications and How to Avoid Them

Identifying and maintaining the capsular plane is essential for complete enucleation. For beginners, the classic three-lobe technique offers clear anatomical guidance, reducing the risk of moving out of the correct plane. Careful attention during distal dissection is critical to avoid damage to the external urinary sphincter, which could result in postoperative stress incontinence. A circular incision at the apex helps preserve sphincter integrity. Both holmium and thulium lasers provide excellent hemostasis. Surgeons should focus the laser on blood vessels during tissue cutting, especially in patients taking anticoagulants.

Table 1. A comparison between Holep and Thulep

Complications

General complications associated with HoLEP and ThuLEP include anesthetic and cardiovascular risks. These procedures, like many other surgeries, can lead to complications such as chest infections, pulmonary embolism, stroke, deep vein thrombosis, heart attack, and in rare cases, death. Such complications emphasize the importance of a thorough preoperative assessment and close intraoperative monitoring, particularly in patients with pre-existing conditions. Intensive care may be necessary for patients who develop severe cardiovascular or respiratory issues during or after surgery.

Intraoperative complications are also a concern, with severe hemorrhage or hematuria being one of the most notable. According to the British Association of Urological Surgeons (BAUS), significant bleeding occurs in 10-50% of cases. A study by Chang et al. showed that 3.2% of HoLEP patients and 4.34% of ThuLEP patients required blood transfusions.[40] Hemorrhage can be diagnosed either intraoperatively or postoperatively when the urine color fails to clear. When this happens, the surgeon can reinsert the resectoscope to perform additional coagulation, either with the laser or the rollerball of the resectoscope. If significant bleeding occurs in the recovery room, it can be managed with a bladder washout and gentle traction on the catheter against the bladder neck, although traction should not be applied for too long to avoid ischemia and potential bladder neck stenosis. Blood tests and close monitoring of hemoglobin levels and vital signs are essential during this time. In rare cases where these measures do not control the bleeding, the patient may need to return to the operating room for further hemostasis. Studies suggest that ThuLEP is associated with less hemoglobin reduction than HoLEP, although the data on this is heterogeneous.

Bladder wall injury is another potential intraoperative complication, usually caused during the morcellation phase when the enucleated prostate tissue is fragmented and suctioned out. The bladder mucosa can be trapped in the morcellator, leading to hematuria or injury to the bladder wall, which can be identified by endoscopic visualization. In these cases, achieving hemostasis and leaving the catheter in place for a longer period can aid healing. Surgeons must also take special care around the ureteric orifices (U.O.) during enucleation. The dissection should stay distal to the U.O. to avoid injury, and standard practice includes inspecting the U.O. before and after the procedure to ensure they are unharmed. If the U.O. cannot be identified, the anesthetist may administer diuretics to encourage urine efflux and help locate the orifices. In cases where injury is suspected, postoperative monitoring of renal function through ultrasound is required, and nephrostomy or antegrade stenting may be necessary if hydronephrosis develops.

Prostate capsule penetration can occur during the procedure and is typically identified by the appearance of a fat plane. When this happens, the surgeon should immediately stop the procedure, achieve hemostasis, and postpone further intervention until the patient is stabilized. If the procedure’s results are not satisfactory, the patient may need further treatment after being counseled.

In the early postoperative period, infection and fever are notable risks. A 2023 study found that 12.4% of patients developed fever following HoLEP, which led to early clinic visits or emergency department admissions in 7.4% of cases.[41] Positive postoperative urine cultures were recorded in 13.5% of patients. Studies comparing HoLEP and ThuLEP showed that the incidence of urinary tract infections (UTI) is comparable, with UTI rates of 11.5% in HoLEP and 13.5% in ThuLEP. Acute urinary retention or residual obstructive symptoms are less common. In one study involving 50 patients, retention occurred in 2% of ThuLEP cases and 0% in HoLEP. Another larger study of 246 patients showed retention in only 1.2% of cases.[42] Urge incontinence, particularly in patients with overactive or neurogenic bladders, is another possible complication.[43] Urodynamic studies are typically recommended preoperatively for these patients. Postoperatively, 2% of HoLEP patients required antimuscarinic medications, compared to 0% of ThuLEP patients. Additionally, 3.9% of HoLEP patients were advised to perform pelvic floor muscle exercises to manage incontinence, compared to 0% of ThuLEP patients.[44]

Retrograde ejaculation is a well-known and common side effect of laser enucleation procedures, affecting up to 75% of patients. Both HoLEP and ThuLEP have been associated with high rates of retrograde ejaculation, reaching up to 92%.[45] However, only 26% of patients reported finding this side effect bothersome, and 10% considered it severely distressing. Additionally, moderate erectile dysfunction was reported in about 19% of patients.[46] Since retrograde ejaculation is difficult to preserve during laser enucleation, it is important to counsel patients about this outcome before surgery.

Later postoperative complications include persistent stress urinary incontinence (SUI). This is not uncommon following bladder outlet obstruction surgeries, as these procedures can disrupt the mechanisms that maintain urinary continence. SUI is defined as involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing or lifting. In most cases, symptoms improve over weeks or months. However, if the incontinence persists and significantly affects the patient’s quality of life, options like an artificial urinary sphincter may be considered. Before proceeding with surgical intervention, a urodynamic study should be conducted to fully assess the patient's condition. Urethral strictures may also develop, requiring surgical treatment in the long term.[35] The reoperation rate for urethral strictures is estimated to be around 5% over five years, highlighting the importance of long-term follow-up for patients.[47]

Clinical Significance

The clinical significance of Holmium Laser Enucleation of the Prostate (HoLEP) and Thulium Laser Enucleation of the Prostate (ThuLEP) lies in their role as highly effective, minimally invasive surgical techniques for treating benign prostatic hyperplasia (BPH). BPH is a prevalent condition among aging men, characterized by prostate gland enlargement that leads to lower urinary tract symptoms (LUTS). Both HoLEP and ThuLEP offer several significant clinical benefits that enhance patient outcomes and quality of life.

Efficacy: Numerous studies have demonstrated that both HoLEP and ThuLEP provide superior or comparable results to traditional BPH treatments, such as transurethral resection of the prostate (TURP), in terms of symptom relief, urinary flow improvement, and reduction in prostate volume. These procedures effectively address LUTS caused by BPH and are associated with sustained improvements in patient quality of life. Long-term data support their effectiveness, with a low incidence of retreatment and durable symptom relief over time.[30][31][32]

Safety: HoLEP and ThuLEP have been associated with lower intraoperative and postoperative complication rates compared to TURP. This includes a reduced risk of bleeding, fluid absorption issues, and sexual dysfunction.[30] These advantages make these laser-based techniques a safer alternative for patients with comorbidities or those on anticoagulant therapy.[30][31]Furthermore, studies have shown a lower incidence of urethral strictures following HoLEP and ThuLEP compared to TURP in saline (TURis), with rates of 2.6% versus 4.4% respectively (38), and lower infection rates, particularly in larger European studies.[30]

Minimal Blood Loss: The precision of laser technology used in HoLEP and ThuLEP allows for exact tissue removal while minimizing blood loss. This significantly reduces the need for blood transfusions, particularly beneficial for patients with bleeding disorders or those at risk of excessive bleeding.[30][31] Such precision improves intraoperative control, making these procedures ideal for patients with coagulopathies.[30]

Shorter Hospital Stay and Recovery: One of the significant advantages of HoLEP and ThuLEP is the shorter hospital stay and quicker recovery compared to open surgical approaches. These procedures can often be performed on an outpatient basis or with a short hospital stay, reducing the burden on healthcare resources and treatment costs.[30] Faster recovery allows patients to return to their daily activities more quickly, further enhancing the overall appeal of these techniques.[30][31]

Durability: Long-term studies have shown that both HoLEP and ThuLEP provide durable outcomes, with sustained improvements in urinary flow and symptom relief over time. The low retreatment rates observed in these procedures reinforce their efficacy as definitive treatments for BPH.[30][31] Both techniques offer long-lasting results, ensuring that patients benefit from fewer complications or the need for additional interventions in the years following the procedure.[30]

Applicability to Various Prostate Sizes: Unlike some surgical approaches that are less effective for larger prostates, HoLEP and ThuLEP are versatile and can be applied to prostates of all sizes, including large glands (>80 mL). This adaptability makes these techniques suitable for a broader range of patients, including those with very large prostates, where traditional methods may be less effective or technically challenging.[30][31]

Preservation of Sexual Function: One of the key clinical advantages of HoLEP and ThuLEP is their ability to minimize the risk of sexual dysfunction, including retrograde ejaculation and erectile dysfunction. Studies have shown that these procedures can preserve ejaculatory function in up to 46% of cases.[30] Furthermore, long-term assessments indicate that HoLEP has a better outcome in maintaining erectile function compared to TURP, as measured by the IIEF-5 questionnaire.[30] Several studies also suggest that ThuLEP may be more favorable than TURP in preserving erectile function, further highlighting the sexual health benefits of these techniques (11, 40).[30][31]

Low Reoperation Rates: The reoperation rates for HoLEP and ThuLEP are significantly lower compared to other BPH treatment options. Long-term studies report reoperation rates of around 5% over a five-year period, making these procedures reliable long-term solutions for BPH management.[30]

In summary, the clinical significance of HoLEP and ThuLEP lies in their ability to provide effective, safe, and durable treatment for BPH, while minimizing the risk of complications such as bleeding, strictures, and sexual dysfunction. These procedures represent important advancements in urological surgery, offering significant benefits to patients with symptomatic BPH and improving their quality of life.

Enhancing Healthcare Team Outcomes

Holmium Laser Enucleation of the Prostate (HoLEP) and Thulium Laser Enucleation of the Prostate (ThuLEP) represent advanced surgical techniques for treating benign prostatic hyperplasia (BPH), offering the potential to significantly improve healthcare outcomes. Success in these procedures requires the involvement of a well-coordinated interprofessional healthcare team, consisting of surgeons, advanced practitioners, nurses, anesthesiologists, pharmacists, and allied health professionals. This team ensures a patient-centered approach, optimizing both outcomes and patient safety throughout the perioperative process.

Healthcare professionals involved in HoLEP and ThuLEP must possess specialized expertise. Surgeons need precise surgical skills to effectively enucleate obstructive prostate tissue while preserving surrounding structures. Anesthesiologists are responsible for the safe administration of anesthesia, taking into account each patient’s unique medical needs, especially in cases with comorbidities. Nurses play a critical role in preoperative, intraoperative, and postoperative monitoring, ensuring early detection of complications and providing essential patient care. Pharmacists contribute by managing medications, ensuring compatibility, and supporting perioperative pain management and anticoagulant protocols.

A strategic approach to HoLEP and ThuLEP is essential for optimizing outcomes and minimizing complications. Evidence-based treatment plans are collaboratively developed, integrating feedback from the surgical team, nursing staff, pharmacists, and advanced practitioners. These plans focus on delivering individualized care that respects the patient's autonomy and ensures informed consent is obtained prior to surgery. Tailoring each procedure to the patient’s specific needs, while also adhering to ethical standards, is critical for enhancing treatment success.

Each member of the healthcare team has defined responsibilities in the care of patients undergoing HoLEP and ThuLEP. Surgeons lead the operative team and oversee the technical execution of the procedure. Nurses ensure thorough preoperative preparation, assist in intraoperative care, and provide postoperative monitoring and patient education. Pharmacists ensure proper medication management, particularly for patients on anticoagulants or those requiring pain management. Advanced practitioners, such as physician assistants or nurse practitioners, contribute to patient assessments, develop preoperative plans, and facilitate postoperative care, ensuring the overall care delivery is comprehensive and seamless.

Effective communication among team members is key to facilitating smooth patient care and achieving successful outcomes. Regular interprofessional meetings allow team members to discuss patient progress, share observations, and collaborate on decision-making. This ensures that the treatment plan is continuously refined and aligned with the patient’s goals of care. Clear communication channels, such as electronic medical records and verbal briefings, ensure that all healthcare professionals are fully informed and able to contribute to the patient's care plan.

Care coordination plays a pivotal role in ensuring that all aspects of the patient’s journey, from preoperative assessments to postoperative follow-up, are well-managed. This collaboration minimizes the risk of errors, enhances patient safety, and supports optimal recovery. Patient education is also a vital part of care coordination. Engaging patients in their own treatment decisions and educating them on self-management strategies postoperatively empower them to take an active role in their recovery, thus improving long-term outcomes.

By leveraging the collective expertise, strategic planning, ethical considerations, effective communication, and care coordination among the interprofessional team, HoLEP and ThuLEP procedures can provide high-quality, patient-centered care. This not only enhances patient outcomes but also improves the overall performance of the healthcare team in the management of BPH. Through these collaborative efforts, patients can benefit from reduced complications, faster recoveries, and improved quality of life following surgery.