Mediclinic hosts renowned expert on anatomical enucleation of the prostate
Posted on 18 December 2017
On Monday 27 November 2017, urologists gathered at Mediclinic Durbanville for a workshop on using the latest laser surgical techniques for benign prostatic hyperplasia. Internationally renowned Prof Thomas Herrmann joined Dr Gawie Bruwer, a urologist practicing at Mediclinic Durbanville and well recognized for his cutting-edge treatment approach, for a live demonstration on using the Revolix laser for anatomical enucleation of the prostate.
While minimally invasive laser techniques for benign prostatic hyperplasia (BPH) are well-established in South Africa, Prof Herrmann, associate professor and vice chairman of the Department of Urology at Hanover Medical School and chairman elect of Urological Clinic in Frauenfeld, STGAG, Switzerland, demonstrated and presented the refined laser surgery techniques he has developed. Called the Thulep procedure (Thulium Revolix laser enucleation of the prostate), this technique offers additional benefits to an already-minimally-invasive surgery: fewer symptoms of irritation and stress urinary incontinence after surgery and a preservation of ejaculatory function in the majority of patients.
Transurethral laser prostatectomy is an already-accepted alternative for the management of benign prostate enlargement. Since the start of laser prostatectomy with the development of the holmium lasers in the 1990s, varying procedures were introduced. Generally speaking, these include vaporizing, resecting, and enucleating approaches.
Vaporizing techniques are now used largely to resolve urinary symptoms for small and medium prostate volumes, while enucleating techniques, such as holmium laser enucleation of the prostate and thulium enucleation of the prostate, are often the preferred methods for large-volume glands (over 70 grams).
The transurethral laser enucleation of the prostate or HoLEP procedure uses a laser to remove tissue that is blocking urine flow through the prostate. A separate instrument is used to cut the prostate tissue into fragments which are ground up inside the bladder (morcellation) for easy extraction. As the entry point is through the urethra, the surgery is performed without incisions.
Between 2013 and 2017, over 300 of Dr Bruwer’s patients have benefitted from his introduction of a Thulium laser into his practice, namely early discharge, significantly less blood loss, and a lowered need for open surgery in patients with large prostates.
With the learnings applied from Prof Herrmann’s workshop, Dr Bruwer and fellow attendees will be able to limit blood loss and complications as well as refine their techniques further. More specifically by:
1) Excising the entire transitional zone
‘Prof Herrmann demonstrated how to lift off the shell of the prostate and remove it along its natural plane using the scope on the laser rather than cutting through the tissue unnecessarily,’ says Dr Bruwer.
Citing a paper published in the World Journal of Urology in 2014, Dr Herrmann demonstrated how he localizes the capsule at the apex of the adenoma by carrying out a bilateral incision lateral to the veru montanum and then using the tip of the resectoscope to push laterally and find the connection between the capsule and adenoma. Dissection of the plane with the resectoscope toward the bladder neck at 6 o’clock follows, alternating with low-power coagulation of capsular bleeding.
2) Using ejaculation-sparing techniques
There are muscles around the veru montanum where the seminal ducts enter, that is pulled down the veru below the prostatic portion of the urethra during ejaculation. After that the semen is transported with pumping contracting from the upper to the lower urethra and externally.
‘Prof Herrmann showed us that if we cut higher on the lateral lobes using the laser, break it with the scope, and then leave tissue on the floor around the ducts, we can preserve ejaculation function in about 60-70% of cases,’ explains Dr Bruwer.
As compared with other techniques described in the literature so far with around 48% this is another step towards functional preservation using extended ejaculation sparing technique for ThuLEP whilst other techniques of endoscopic management of BPH (e.g. transurethral resection of the prostate) cause retrograde ejaculation in most patients.
Furthermore, if sexual function is of utmost importance ‘Prograde ejaculation can virtually be conserved if the median lobe only is removed by ThuLEP technique – of course in this modification tissue removal is less radical but functional results can be secured, if this is the special intent of the patient,’ says Prof. Herrmann.
3) Minimising stress urinary incontinence
According to the EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms (LUTs) including benign prostatic obstruction published in 2016, laser enucleation of the prostate is the first choice for men with large prostates (over 70 grams) and moderate to severe LUTs.
During the workshop at Mediclinic Durbanville, Prof Herrmann further demonstrated how to preserve sensation in the mucosa of the bladder to indicate that urine has entered the cavity near the urethra.
Dr Bruwer emphasizes that only about 15 urologists in South Africa currently perform laser enucleation, admitting that a steep learning curve makes it difficult for some surgeons to make the transition.
‘Most urologists still use the well-established transurethral resection or ablation of the prostate for BPH. Unfortunately, the morbidity and hospital stay is significantly longer and the complications more numerous’.
Prof Herrmann explains that for surgeons to become completely proficient in the enucleation techniques, they need to perform between 60 and 80 of these surgeries.
Over time, however, theatre time is equivalent to other methods, according to Bruwer, who emphasizes the benefits:
1) At least 80% of patients go home the next day, whereas it takes 3 – 4 days with the traditional methods
2) Bleeding is significantly less
3) Large prostates otherwise requiring open surgery with marked morbidity can be done with the laser and patients can go home sooner without a stay in intensive care
In short, enucleation of the prostate using a Thulium Yag laser is an increasingly well-established and lasting procedure with opportunity to further refine techniques.