Holmium Laser Enucleation of the Prostate (HoLEP) is the only transurethral enucleation technique that remains effective regardless of prostate size in the treatment of benign prostatic hyperplasia (BPH). This video showcases a HoLEP procedure performed on a 79-year-old patient with a 210-gram prostate, who also has chronic kidney disease (CKD) and heart disease. The surgery was conducted by Dr. Hemendra Shah, Professor and Endourology Program Director at the Desai Sethi Urology Institute, a part of the University of Miami Health System. A pioneer in HoLEP, Dr. Shah has successfully performed over 2,500 HoLEP surgeries.
OK, so we have a 71 year old gentleman with a 220 g prostate. He's diagnosed of Gleason 6 prostate cancer involving 2 out of 12 courses and active surveillance, his PSA is between 6 and 7. we are doing a whole lot for him because he's on recurrent retention of urine. And it's different catheter since the last 5 months. So we did an initial cystoscopy and we found this big prostate, which is very vascular with a lot of versaal hemorrhoids, you know, huge veins around in the urethra. We are using a Moses 2.0 laser today for the procedure. The procedure starts with the initial incision in front of the very mountanum, and the goal is to cut the mucosa. And once you cut the mucosa, you should be able to enter the plane of innucleation. In bigger process, we expect them to be more vascular. So once I take the incision, I've I've now entered the plane of nucleation here. OK, you can identify it very clearly. And once you are in the right plane, the Atima usually separates on its own. So you can see once you get on the right plane, the tissues will separate on its own. You see this beautifully. So in a big process that's our advantage it's very, you know, it's easy to get a plane and separate them mechanically, provided you are in the right one. If you're not, you know, you can see now this is a capsule clearly seen. This is adenoma. The adenoma looks white. capsule looks little pale, you know, there is a clear cut this, uh, tissue demarcation in between these two planes. Uh, in a big process, the capsule gets thinned out, you know, so it's really very thin, and you will see all these big vessels which will be entering and supplying adenoma through the capsule. So as you are dissecting, you fire on the capsule and making sure that you take care of all the breeders. You can see separating before you can actually reach, and then I'm firing with a laser to just get around it and uh. If you keep coming out, so when you do panorama, you will see whether everything is OK or not, you know. So now you can see from the lateral I'm going untely. This is the anterior part which I'm separating it and from an here I'm going on the right side now. So you can see this globe is separated, the vessels are here. You defocus the laser beam, you stop the bleeders, and in the same way you keep separating it. So the tissues keep separating even before you go there and use the laser to just paint the wall of the capsule so that the bleeders are taken care of, you know. This bluish shoe, you see, this is mucosa on the other side, and I'm in the bladder. When you see a bluish shoe, and this is an intra vertical extension of the lobe, so there is no, this is the area which is going beyond the bladder neck on the on the to do of bladder, you know, and the bladder neck is somewhere here, you see. This is the bladder neck. This is a part of your introvert extension of the lateral lobe and the median lobe, so you won't see any bladder neck area here. You'll only see prostate tissues. So you can keep cutting the prostate tissues and the when you see this glistening. You see this white shiny fibers is a bladder neck. So all this area is beyond the bladder neck, you know, this is a bulge. If you do a retroflex maneuverstoscopy, you will see the bulge in the bladder, you know, that is what it is this part. You can see this thing fibers now the bladder fibers. But you are going around and you are Turning the lobe, so you have this lobe. You have already gone in the bladder here. You coagulate the vessels again. Now you will do the same thing for the other lobe, you know. So here you go like this. Cut the bladder next. The prostate tissue here. You clean this from the bladder neck completely. This is a plane near from here. You connect this So you'll have a single plane. And you keep separating it. This is a plane. We have to separate this from here. So we get the later los out. So you use your right hand. See my movements of the right hand. You are using like a finger and you know, separating the adenoma from the lateral lobe up and down like this, you know. And you fire more on the capsule, so as you, if you fire in the capsule should turn red, you know, very white, so you tend to have hemoses at the same time as the nuliating. Bladder is lifted up. So intermittently what we do is once we are separated a lot of prostate, we go back again, see the capsule, and if you find any bleeders, anything which is red or pink, we try to turn it white, you know, because otherwise, you know, then what will happen is our entire forsa is going to wooze everywhere and your vision will be so bad that you'll have problem, you know. Intermittently keep coagulating again, go back again, see the bleeders. If you see something. Spend some time calculating them. This is a small t. You can just vaporize it, burn it. You can clearly see this is yellow, this is white, you know. The yellow is a little small plaque the tissue, you know, which is left, you can simply cate like this. And get rid of it. So all the intracocci are currently going in the circulation through that vein. On similar veins, you know. Yeah, fluid absorption will happen and because this period is high, we have to be careful about it. So once I'm I'm almost done with the other lobe, which should happen in 10 minutes, you will ask them. So you can see the right lobe of the prostate is completely separated. We are separated and nearly everything, OK. So actually I can go around and, uh, separate the right lobe, sorry, left uh right lobe of the patient now we separate the left lobe, we are doing right now. Like this little tissue, this is little pros of tissue which is attached to the bladder neck. You can see as I'm cutting it, I'm separating it, you know, because yellow is a prostate tissue. These the bladder neck fibers. This is prostate tissue. So now what I do is, you can see this is all separated. So now I'm going to go and take the incision on the right side near the Vantanum. If I do this, it's easy for me to identify the apical mucosa and preserve the mucosa near the apex, you know. OK, and now here in the way it goes about, you know, so you have to go around this area, it will change the shape, you know, like a bumper. You go in front of this and put all this mucosal fibers. And then I walk on the plane. And I keep going, keep going, keep going like this, little movements. I mean, and I joined the plane here, you see. So both the planes are joined now. So all I have to do is I had to keep coming out now that I did it mechanically, I must have had some bleeders which might be bleeding, OK, so I will come out. You know, and I will be. Taking care of all the bleeder as I come out, you can see. Bleeder, yeah, er, yeah. You joined the plains. We are not separating the right love of the patient completely. You can see there is a small plaque of adenoma left ear, but I won't really bother to remove it right now. What I'll do is I'll remove the remaining prostate first and then, uh, if it really shows up easily, I will remove that little plaque, you know. And you coagulate it very well so it doesn't open up. If you don't really hit it well, it's going to open up again, you know, and then you have to keep coagulating it again and again throughout your surgery. OK, we have a good hemostasis. The slope is getting separated beautifully. We'll meet in the midline somewhere. Once we join both the prostate and the midline, then we will go for the apical mucosa. So if you want to do ejaculation preservation, you just leave one cen tissue here and then he will have anti ejaculation preserved, you know, so it's all separated except for the floor now. And so the last time you to just go around, go all around and keep separating it. When we are here at the level of ragon, we should see the. This is raglu We're almost done with the indication here. So you know there are 2 planes. You can see this. It needs to come out. It's a compressed. I I Because Yeah, yeah, yeah. The adenoma is gone in the bladder. Then I just check yours both the sides. You can see even if we were getting a good emotion throughout when the animal goes in completely they can carry it to collapse, you know, and then you will see that some bleeders might open up so you go systematically all across the fossa and once again, uh, you know, calculate everything. Make sure bladder is all clear, you know, and I'll go more unclearly and see if there's anything unclearly. So you know, this is the last step, which is mulation. So what we did is we separated the process, we push it back in the bladder, and now we are using this machine, which is called mulator to break it into very small pieces and suck everything out, you know. Usually it will take half an hour or so for a 200 g prostate, and now we'll monitor for cardiac issues, uh, at least for one night in the ICU. Make sure everything is OK. And now you try to go in. And see your it's a very relaxed open area, although the mucosal strip is pretty good, you know, we are, we are adenomy extending up to this area. We are preserved mucosa here, uh, but, uh, yeah, you will need some Kegels. We are done. OK, we are just putting a foley and then that's it.
