Top-down Holmium Laser Enucleation of the Prostate: Technical Aspects and Early Outcomes

To clarify the key steps and evaluate the early results of the recently introduced top-down holmium laser enucleation of the prostate (HoLEP).^1,2 This technique was developed to shorten the steep learning curve associated with the conventional approach.

Sixty patients with a median age of 73 years (54-88) underwent HoLEP between 2017 and 2018. The top-down technique was performed by 1 surgeon (H.E). We used a 100-W holmium: YAG Laser (VersaPulse PowerSuite, Lumenis, Yokneam, Israel) with a 550 μm laser fiber and a 28 Fr continuous flow resectoscope (Karl Storz, GmbH, Tuttlingen, Germany). In this video, we clarified the stages of enucleation: posterior groove incision, 12-o'clock urethral mucosa incision, top-down dissection (anteroposterior direction), apical tissue dissection, bladder neck dissection. We collected data related to prostate size, enucleation time, morcellation time, perioperative complications, and early outcomes.

Fifty-seven percent of patients presented with acute urine retention and the remaining had severe obstructive lower urinary tract symptoms. The median Transrectal Ultrasound (TRUS) prostatic volume was 124 mL (70-266). The median resected volume was 90 g (44-242) with a median enucleation time of 92 minutes (42-131). At 3 months follow-up, we observed that the urine stream significantly improved with a median Qmax 23.6 mL/s (17-42). Two patients (3.3%) had urge incontinence, and 2 other patients (3.3%) had stress incontinence at 3 months follow-up. There were no reported intraoperative complications. We noticed that performing apical dissection from top-down resulted in easy visualization of the mucosal strip. This approach eliminates the need to encircle the mucosal strip reducing enucleation time.

The top-down HoLEP technique has emerged as a novel modification to conventional HoLEP. The preliminary results are comparable to the original approach.^3,4 In our opinion, the top-down method may reduce the complexity, operating time, and the learning curve for urologists performing the HoLEP procedure.