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Updated: Nov 2, 2025
Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate HoLEP.
Published on: March 6, 2018
'Top-Down' holmium laser enucleation of the prostate. Report of initial cases performed by a single surgeon
Amr Hodhod1, Fabiola Oquendo1, Thomas Tablowski1
1Department of Urology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada.
Insights
The Top-Down holmium laser enucleation of the prostate (HoLEP) shows comparable 12-month outcomes to traditional HoLEP. This technique may reduce operating time and stress urinary incontinence rates.
Area of Science:
- Urology
- Minimally Invasive Surgery
Background:
- Benign prostatic hyperplasia (BPH) management often involves surgical intervention.
- Holmium laser enucleation of the prostate (HoLEP) is an effective BPH treatment.
- The 'Top-Down' HoLEP technique is a modification aiming for improved efficiency and outcomes.
Purpose of the Study:
- To evaluate the 12-month clinical outcomes of the 'Top-Down' holmium laser enucleation of the prostate (HoLEP) technique.
- To compare the efficacy and safety of Top-Down HoLEP with traditional HoLEP.
- To assess the impact of Top-Down HoLEP on urinary symptoms, quality of life, and incontinence rates.
Main Methods:
- Retrospective chart review of prospectively collected data from patients undergoing Top-Down HoLEP (2017-2018).
- Standardized data collection including enucleation/morcellation times, complications, International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax), and post-void residual (PVR).
- 12-month follow-up assessments to evaluate long-term efficacy and safety.
Main Results:
- 60 patients were analyzed with a median prostatic volume of 124 mL and resected weight of 90 g (76% of tissue).
- Median enucleation and morcellation times were 80 and 14.5 minutes, respectively.
- Significant improvements in IPSS (P=0.045) and QoL (P=0.04) were observed. Postoperative incontinence rates were low, with 5% experiencing stress urinary incontinence (SUI) and 13.3% urge urinary incontinence (UUI) at 3 months, decreasing to 1.7% SUI and 5% UUI at 12 months.
Conclusions:
- The Top-Down HoLEP technique demonstrates comparable 12-month outcomes to traditional HoLEP.
- This approach may offer benefits in reducing procedural complexity and operating time.
- The Top-Down technique shows potential for lower rates of stress urinary incontinence post-procedure.
Objectives:
To present the 12-month outcomes of 'Top-Down' holmium laser enucleation of the prostate (HoLEP).
Patients And Methods:
We retrospectively reviewed the charts of prospectively collected patients who underwent Top-Down HoLEP between 2017 and 2018. All cases were operated upon by a single urologist (H.E), using a 100-W holmium:YAG laser with a 550-μm laser fibre. We recorded the enucleation time, morcellation time, intraoperative, and postoperative complications. All patients had postoperative follow-up visits at 1, 3, 6 and 12 months. The evaluation included the International Prostate Symptom Score (IPSS), quality-of-life (QoL) assessment, measurement of maximum urinary flow rate (Qmax) and the post-void residual urine volume (PVR).
Results:
A total of 60 consecutive patients were recruited. The median (range) prostatic volume, resected prostatic weight, and percentage of resected prostatic tissue were 124 (70-266) mL, 90 (44-242) g and 76 (46-97)%, respectively. The median (range) enucleation and morcellation times were 80 (25-200) and 14.5 (4-58) min, respectively. One patient had a simple bladder mucosal injury and another developed clot retention. At 3 months, three patients (5%) had stress urinary incontinence (SUI) and eight patients (13.3%) presented with urge UI (UUI). At the last follow-up visit, one patient (1.7%) presented with persistent SUI, while three patients (5%) presented with UUI. The IPSS and QoL significantly improved during the follow-up period (P = 0.045 and P = 0.04, respectively).
Conclusion:
The results of the Top-Down technique are comparable to those of traditional HoLEP. However, the Top-Down technique may reduce the complexity, operating time, and SUI rates.
Abbreviations:
BN: bladder neck; HoLEP: holmium laser enucleation of the prostate; PVR: post-void residual urine volume; Qmax: maximum urinary flow rate; QoL: quality of life; TOV: trial of voiding; (S)(U)UI: (stress) (urge) urinary incontinence.
