Category: BPH

VS3-2 - Top down technique Holmium laser enucleation of the prostate: A step-by-step approach

Fri, Sep 21
10:00 AM - 12:00 PM

Introduction & Objective :

Holmium Laser Enucleation of the Prostate (HoLEP) is widely regarded as a challenging procedure to perform. Its prolonged learning curve, in comparison with TURP, has limited its acceptance in urological clinical practice. The Top Down Enucleation Technique aims to simplify the HoLEP procedure while simultaneously reducing operative time and shortening the learning curve.


Methods :

Between October 2017 and April 2018, 40 patients with symptomatically enlarged prostate underwent HoLEP with the Top Down Technique. All cases were operated upon by a single urologist (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, Germany). Enucleated tissue was morcellated using a Karl Storz Morcellator.


A video of step by step surgical technique was provided with narration.


Results :

We demonstrate our version of this technique and present early operative outcomes. One posterior groove is used allowing simultaneous enucleation of median lobe with attached lateral lobe. Top down Enucleation started at 12 o’clock which is extended anteroposteriorly and downwardly toward the apical adenoma in the 6 o’clock position. The mucosal strip is easily visualized as the apical dissection is performed from top down. This eliminates the need to encircle the mucosal strip reducing enucleation time. The median enucleation and morcellation time were 91 and 15 minutes respectively, with a morcellation rate of 5.6 g/ min. There were no reported intraoperative complications during morcellation.


Conclusions :

We expect that this new technique may reduce the complexity, operating time of HoLEP. Further studies are required to determine the effect of this technique on HoLEP’s steep learning curve.

Hazem Elmansy

Assistant Professor
North Ontario School of Medicine
Thunder Bay, Ontario, Canada

Hazem Elmansy, MD, FRCSC, Assistant Professor Urology, Northern Ontario School of medicine Ontario, Canada. Dr. Hazem Elmansy, , joined Thunder Bay Regional Health Sciences Centre’s Urology department in May 2017. He completed his Urology residency at McGill University and has training in endourology (including Percutaneous Nephrolithotomy for complex stone management, laser surgery for the prostate and metabolic work-up to prevent stone disease recurrence). He has a strong passion for research and has co-authored 16 peer- reviewed publications, as well a chapter in Smith’s Textbook of Endourology.
His research contributions were recognized and awarded at both the American and Canadian Urological Association annual conferences.

Ahmed Kotb

Assistant Professor
North Ontario School of Medicine
Thunder Bay, Ontario, Canada

Owen Prowse

Assistant Professor
North Ontario School of Medicine
Thunder Bay, Ontario, Canada

Walid Shahrour

Assistant Professor
North Ontario School of Medicine
Thunder Bay, Ontario, Canada