HoLEP is at least as effective as other surgical therapies, including TURP, OP and other laser modalities, with fewer complications, shorter hospital stays, and decreased catheter time. These benefits make HoLEP the procedure of choice for men seeking surgical relief for BPH related LUTS and the gold standard for the 21st Century.

1. Presenter :Dr. Manjul Maurya

2. Introduction
• TURP is the historical gold standard to which all surgical modalities for BPH
are compared.
• Other interventions, such as OP, PVP, and various laser therapies have
demonstrated efficacy in relieving BPH related LUTS.
• HoLEP is poised to replace all of these modalities as the new standard,
based on nearly two decades of data that consistently demonstrate its
superior outcomes and lower morbidity.

3. • This review article summarizes the available literature comparing HoLEP and
traditional therapies for BPH that are widely used and have long-term
efficacy.
• Patients undergoing HoLEP have greater improvements in
1. post-operative Q-max
2. post-operative subjective symptom scores,
3. lower rates of repeat endoscopic procedures
4. significantly shortened catheterization times
5. decreased length of hospital stay.

4. • Various RCTs have demonstrated that HoLEP can enucleate adenomas
greater than 100 grams with similar efficacy as open prostatectomy, but
with radically decreased hospitalization stay, catheterization times, blood
loss, and transfusion rates.

5. HoLEP vs TURP
• There is an abundance of level 1 data directly comparing outcomes and
complications for HoLEP andTURP.

7. • Based on these studies, it was suggested that HoLEP was the only procedure
that did not require re-operation for adenoma regrowth within 5 years.
• An argument against HoLEP is that operative times are significantly longer
than withTURP.
• However, Ahyai also found that the mean tissue resection rate (g/ min) for
HoLEP and TURP was statistically similar (0.52 g/min vs 0.57 g/min), making
them equally time-efficient procedures.
• Post-ope-rative complications tend to be lower for HoLEP compared to TURP,
and post-HoLEP TUR syndrome has never been reported-even for adenomas
hundreds of grams in size.

8. HoLEP vs Open prostectomy
• Contrary to TURP, HoLEP is a size-independent procedure and the
consequence of this is that HoLEP will eventually make OP all but a
historical operation for even the largest of prostates.
• HoLEP has been used to successfully enucleate adenomas as large as 800 g .

10. • HoLEP and OP outcomes have been directly compared in multiple,
well-designed, RCTs.
• These studies found almost equivocal functional outcomes but a
lower transfusion rate , decreased catheterization time, and shorter
hospital Length of stay in patients who underwent HoLEP as
compared to Open prostectomy.

11. • In addition to HoLEP and TURP, numerous other minimally invasive therapies
exist for the treatment of symptomatic BPH, including ….
1. Greenlight PVP
2. PKRP
3. ThuLEP
• Greenlight PVP is the most well established laser alternative to traditional
TURP that allows for quick and efficient vaporization of prostatic
adenoma.Recent advances in the PVP laser have allowed for the treatment of
larger adenomas .
• PKRP is similar to bipolar TURP. Chen, et al compared HoLEP and PKRP in a
RCT and found HoLEP procedures had significantly more tissue resected and
shorter hospital LOS and catheter time.

12. • The thulium:YAG laser (ThuLEP) works at a wavelength of 2013 nm
in continuous wave mode, and boasts excellent vaporization and
hemostatic capabilities with outcomes and complication rates similar
to that of HoLEP. However, as a pulsed laser, HoLEP offers greater
versatility to the urologic surgeon .

13. HoLEP and sexual function`
• Regarding sexual function, HoLEP appears to offer no distinct advantage
overTURP .
• Retrograde ejaculation was equally common after HoLEP (50-96%) and
TURP (50-86%).
• Various studies suggested that HoLEP did not significantly affect libido,
erections, or sexual satisfaction.

14. Cost effectiveness
• Regarding cost-effectiveness, it seems obvious that HoLEP patients
would generate decreased hospital bills, based purely on shorter
average LOS.
• Several studies have attempted to compare the cost-effectiveness of
HoLEP withTURP.
• When comparing HoLEP to OP, Salonia, et al found that average
costs were $2,919 vs. $3,556, respectively .

15. Current surgical techniques of
enucleation in HoLEP
• Historically, urologists in New Zealand have made significant contributions to
BPH surgeries using a holmium laser.
• The first attempt to use a holmium laser for transurethral prostatectomy was
made by 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, HoLRP, which
involved excising the prostate with a holmium laser.
• HoLRP was later applied to BPH surgery, which became the precursor

16. • HoLRP was later applied to BPH surgery, which became the
precursor surgery of HoLEP.
• 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.

17. (1) CLASSIC GILLING’S THREE-LOBE
TECHNIQUE
• Gilling’s method is based on the enucleation of three lobes, where the
median and both lateral lobes are enucleated independently in
retrograde fashion by making three longitudinal incisions from the apex
to the bladder neck.
• After the morcellator became available, this HoLRP surgical technique
evolved into HoLEP.
• Similar to HoLRP, the bladder neck at the 5 o’clock position and 7
o’clock position is incised vertically to the verumontanum; a further
deep incision is made until a surgical capsule is reached.

18. (1) CLASSIC GILLING’S THREE-LOBE
TECHNIQUE
• 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.
• Next, both lateral lobes are enucleated.
• the medial edges of both lateral lobes, formed by the previous step for
removing the median lobe, are extended to the apex to more clearly define
the apical anatomy.

19. (1) CLASSIC GILLING’S THREE-LOBE
TECHNIQUE
• 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 incision should be
deepened until the underlying capsular plane is reached.
• The space between the adenoma and the capsule is developed
laterally and circumferentially with a sweeping motion.
• The enucleation from the upper and lower parts is connected to each
other at the 2 o’clock position of the apex.

20. (1) CLASSIC GILLING’S THREE-LOBE
TECHNIQUE
• 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.
• Kuo et al. [33] described a few additional technical details. They
explained that enucleation of the right lateral lobe should precede the
left lobe.
• They also suggested that a lower power setting (2 J, 40 Hz) during
apical dissection is needed to reduce thermal injury to the sphincter.
• They emphasized that the dissection should begin at a point slightly
proximal to the apex to preserve the apical fat pad, so as to protect

21. (2) ANTERO-POSTERIOR DISSECTION BY THE TOKYO
GROUP
• In 2008, Endo et al modified Gilling’s three lobe technique to further
reduce the possibility of sphincter damage.
• The enucleation method on the middle lobe remained the same, but the
method of enucleating the lateral lobes was modified.
• This new procedure is performed similarly to the previous procedure in
that the bottom edge of the lateral lobe was enucleated from the surgical
capsule throughout the apex and the bladder neck.
• However, this procedure did not extend further upward, and instead
stopped just after forming the edge.

22. (2) ANTERO-POSTERIOR DISSECTION BY THE
TOKYO GROUP
• A longitudinal incision was made over the 12 o’clock direction from the
bladder neck to the sphincter level.
• In detail, the urethral mucosa at the 12 o’clock point opposite the
verumontanum was first vaporized to reach the surgical capsule, which
was extended to the bladder neck in a retrograde fashion.
• The adenoma was 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.

23. MODIFICATION OF THE ORIGINAL THREE-
LOBE TECHNIQUE BY THE XIAN GROUP