Holmium Laser Enucleation of Prostate HoLEP with Anatomical Bladder Neck Dissection

We describe our technique for HoLEP, with anatomical bladder neck dissection (“V-neck” bladder neck dissection), which we believe may improve postoperative urge incontinence.

We usually start with 1.5 Joules and 40 Hertz (using a 550 micrometers fiber) with mild variations throughout the surgery.

We start with bilateral longitudinal dissection, parallel to the verumontanum, usually beginning with the left side. We perform posterolateral dissection of the adenoma, following the plane between the adenoma and prostate capsule.

Once both lateral lobes are adequately dissected (approximately 50-60% prostate extension), we start with dissection of the mid prostatic lobe, proximal to the verumontanum, connecting both sides of the already dissected lateral lobes, along the adenoma-capsule plane that has already been exposed laterally.

We then perform apical prostatic release, with proper care, not to cause any injury to the sphincter. We do not start our procedures with the so called early apical release, since it has already been published its non-superiority when compared to the “delayed” apical release, and because the average time that we spent on the previously described steps, before apical release, is of approximately 10-15 minutes, depending on prostate size.

We continue with anterior prostatic dissection until bladder neck fibers are identified, then, we follow the medial edge of the bladder neck fibers, to begin bladder neck anatomical dissection.

Once bladder lumen is identified, adequate lateral dissection, following the anatomical plane between prostate adenoma and bladder neck muscle fibers is performed, until the previously dissected plane between posterior prostatic adenoma and capsule is reached. We then continue posteriorly to finish the correct plane between the proximal prostatic adenoma and the bladder neck.

This anatomical bladder neck dissection usually leaves a “V” shape bladder neck. We believe that it may improve postoperative urge incontinence severity and duration.

Alan de Jesus Martinez-Salas. Urology and Minimally Invasive Urological Surgery.