Endoscopic enucleation of the prostate (EEP) is an established, safe and effective alternative to TURP and open prostatectomy for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). All EEP procedures, regardless of the source of energy used (holmium, thulium, green laser and bipolar energy), require a steep learning curve (LC) and during this LC the risk of stress urinary incontinence (SIU) could be increased. It’s very important to know the surgical anatomy of the male external urethral sphincter (EUS) well to avoid SUI. The morphology of the male EUS can be assessed by various types of diagnostic imaging: MRI and transrectal ultrasonography (TRUS).
1) To review the surgical anatomy of the male EUS by microscopic tissue sections of cadaveric specimens and by MRI and TRUS images.
2) To evaluate the intraoperative TRUS images of the male EUS during laser EEP and report the morphological changes before and after the surgery.
We reported a summary of the topographic anatomy of the male EUS based on microscopic tissue sections from male cadaveric specimens, TRUS images and MRIs. Eleven patients underwent EEP, five of which were "en bloc" holmium laser enucleation of the prostate (HoLEP) and six which were green laser enucleation of the prostate (GreenLEP). All patients' EUS were studied by intraoperative TRUS using a linear probe before and after surgery. However, in this video only the results of one case have been presented. Morphological parameters of the EUS (shape, length echo-pattern and thickness) were evaluated. Postoperative follow-up at 1, 3 and 6 months with IPSS, QoL, Qmax, PSA levels, IIEF-5 and SIU were assessed at each follow-up appointment.
A detailed topographic anatomical study of the male EUS has been presented. The male EUS was easily detectable by TRUS as a hypoechoic circular shaped structure surrounding the membranous urethra, that remained unchanged before and after the EEP procedure. The patient was discharged 24 hours postoperative without complications. The bladder catheter was removed at 24 hours after surgery and three months later all the parameters showed significant improvement. There was no SUI as a result of the procedure.
First and foremost it is imperative that the surgeon has a complete understanding of the EUS surgical anatomy before performing EEP in order to avoid SUI during the learning curve.
As demonstrated previously in the literature, EEP represents an established safe and effective technique for the complete removal of the adenomatous prostate tissue. This is not an easy procedure and requires a steep learning curve. During "en bloc" EEP carefully dissecting the apical lobes from the EUS is fundamental in preventing SUI, as it protects the sphincter from mechanical dissection damage.