Minimally-invasive endoscopic enucleation of the prostate with a Holmium laser, or HoLEP, has become a reference in the treatment of large symptomatic prostate adenomas. However, it is a difficult technique, and potentially dangerous without initial coaching.
The ureteral meatuses and the striated sphincter are the main anatomical structures at risk during enucleation. Meatus lesions can be caused by incision of the neck at 5 o’clock and 7 o’clock with a back-and-forth movement of the endoscope along the axis of the meatus with an axial-shooting laser fiber and by retrograde enucleation of the lobes without neck visibility.
In order to protect the ureteral meatuses, the initial transversal and longitudinal incision of the bladder neck at 5 o’clock and 7 o’clock, or T-incision, moves the meatuses away from the enucleation zone and avoids trigonal detachment during retrograde enucleation of the prostatic lobes.
Loss of verumontanum visibility during apical enucleation of the lateral lobes can cause striated sphincter lesions, by excessive backward movement of the endoscope.
To protect the striated sphincter, we prepare apical dissection of the adenoma with an inverted T incision at 12 o’clock directly above the verumontanum before starting the enucleation plane in contact with the capsule across from the verumontanum. The removal of the apex is then made possible by a superficial hemi-circumferential incision, linking the inverted T incision at 12 o’clock with the hockey stick incision lateral to the verumontanum.
Preparation of the bladder neck and of the adenoma apex by appropriate incisions at the beginning of prostatic enucleation by Holmium laser seems fundamental in protecting the ureteral meatuses and the striated sphincter.