Introduction & Objective :
HoLEP (Holmium Laser Enucleation of the Prostate) is a minimally invasive transurethral approach, relying on the anatomical enucleation of the obstructing prostatic adenoma. The totally en-bloc no-touch low-power approach is the result of our progressive modification of the traditional 3-lobe technique, successfully performed in its different versions since 2011 on more than 500 patients. Since 2015 we applied the low-power approach, with the intent to deliver less energy to the capsular plane and minimize early postoperative dysuria. Since 05/2017 we transformed the partially en-bloc enucleation of the adenoma (in a horseshoe-like piece with a single 5 o’clock incision) into the totally en-bloc one (removing the intact adenoma with no incisions at all), aiming at a further improvement of the enucleation efficiency and safety. 55 consecutive patients underwent totally en-bloc low-power en-bloc no-touch HoLEP in our Department. Here we present an illustrative video of the step-by-step procedure.
Patients suffering from symptomatic BPO (inclusion criteria: any prostate volume, normal PSA, Qmax 10) underwent totally en-bloc no-touch low-power HoLEP in our Department from 05/2017 to 03/2018. A 26F Storz continuous flow endoscope, a 12° degree optics, a 550 micron end-firing laser fiber, the 50W Auriga XL holmium laser device (Boston Scientific) (2.2 J energy, 18 Hz frequency, long pulse length, almost 40W power) and the Storz morcellator were used. This was a 75-year-old patient operated in 05/2017, with a urethral catheter for complete urinary retention and a 78 mm prostate at ultrasound.
Results : Enucleation lasted 33' requiring 44 kJ, morcellation of the 63 g adenoma lasted 7'. The postoperative period were uneventful. At the follow up the functional outcomes are optimal (IPSS 3, no dysuria). The low-power approach allowed to reproduce all the steps of the high-power one, being as safe and efficient. Energy consumption was reduced by nearly one third, the no-touch mode additionally contributing to deliver less energy to the capsular plane and minimizing intensity and duration of postoperative dysuria. Enucleation efficiency was optimal, with minimal traction on the presphincteric mucosa due to its early incision.
Totally en-bloc no-touch low-power HoLEP is a feasible, safe and effective approach, minimizing intensity and duration of postoperative dysuria and optimizing anatomical enucleation. Energy supply to the capsule, enucleation technique and surgeon’s experience seem to be relevant factors influencing HoLEP’s surgical outcomes.
Cesare Scoffone– M.D., Chief of the Department of Urology, Department of Urology, Cottolengo Hospital, Torino, Piemonte, Italy
Dario Del Fabbro– M.D., Resident, Department of Urology, Tor Vergata University Hospital, Roma, Lazio, Italy
Felipe Figueiredo– M.D., Urologist, Pompèia Hospital, Caxias do Sul, Rio Grande do Sul, Brazil
Cecilia Cracco– M.D., Ph.D., Urologist, Department of Urology, Cottolengo Hospital, Torino, Piemonte, Italy
M.D., Chief of the Department of Urology
Department of Urology, Cottolengo Hospital
Torino, Piemonte, Italy
Dr. Cesare Marco Scoffone has been working for two decades in the University Department of Urology of Orbassano (Torino, Italy), developing a wide experience in uro-oncologic and reconstructive surgery, retrograde ureteroscopic and percutaneous treatment of urolithiasis, miniinvasive approaches to BPO, holmium laser treatment of various pathologies. Since 2010 he is Chief of the Department of Urology of the Cottolengo Hospital of Torino (Italy). His personal case series include thousands of open, laparoscopic and endoscopic procedures (>750 ECIRS, >500 low-power (totally) en-bloc no-touch HoLEPs, thousands of RIRS) performed as first surgeon in all urologic fields, and during the last fifteen years he has been often invited for Live Surgeries (mainly RIRS, ECIRS, bipolar TURP, HoLEP) all over the world. He is author of many peer-reviewed publications, guidelines, book chapters (including one in the 4th edition of the Smith’s Texbook of Endourology on ECIRS), didactic videos, editor of a Springer book on ECIRS in 2014, reviewer for many international journals, editor for WJUrol, member of national and international urological societies, consultant and tutor for various companies, part of the EAU, CIE, WCE and SIU Faculties, director of Advanced Endourology Courses in his hospital (about 35/year, lessons in the afternoon, surgeries in the morning afterwards), chairman of the Technology and Training in Endourology congress in Torino (8th edition in 2018).
Department of Urology, Tor Vergata University Hospital
Roma, Lazio, Italy
Caxias do Sul, Rio Grande do Sul, Brazil
M.D., Ph.D., Urologist
Department of Urology, Cottolengo Hospital
Torino, Piemonte, Italy
§ 1989: Degree in Medicine and Surgery, Faculty of Medicine and Surgery, University of Torino (110/110 cum laude).
§ 1990 and 1996: attendance for 8 months at the Department of Anatomy and Developmental Biology, University College London, London, UK (supervisors prof. G. Gabella and prof. G. Burnstock), as guest researcher.
§ 1991-1994: PhD student in Ophtalmologic Sciences, University of Torino.
§ 1994-1999: Residency in Urology, Urological Clinic, University of Torino.
§ November 1999: Specialization in Urology, University of Torino (70/70 cum laude and “menzione onorevole”).
§ May 2000: Urologist (permanent position), Division of Urology, SS. Annunziata Hospital of Savigliano (Cuneo).
§ November 2002: transfer at the Urological Clinic, S. Luigi Gonzaga Hospital of Orbassano (Torino), position D, C2 from March 2007.
§ May 1st 2008: she won #1 position for researcher, MED24 Urology, University of Torino, Faculty of Medicine and Surgery, always working at the Urological Clinic at the S. Luigi Gonzaga Hospital of Orbassano (Torino). Position C1 from 2009.
§ February 2011: she won a position as Urologist at the Urology Department, Cottolengo Hospital of Torino (currently working there).
§ Member of many national and international urological societies, 12 prizes for videos, presentations and research, received research funding for many years, had a constant teaching activity since 1990 (Anatomy, Physiology, Urology) for University and Masterclasses courses.
§ She published more than 250 papers (95 indexed papers), invited book chapters and a Springer book on ECIRS in 2014, and is referee for many international journals.
§ Surgical activity: more than 1000 procedures as first surgeon, in particular bipolar TURP, URS and RIRS, Greenlaser vaporization of the prostatic adenoma, bipolar TURB, PDD and SPIES TURB, ECIRS, HoLEP, with some invited surgeries since 2013.