Name: surgical treatment for benign prostatic hyperplasia: holmium laser enucleation of the prostate (holep).
Uploaded: 2018-03-06T12:30:00.000+00:00
Duration: 6 min 4 s
Description: Watch this Scientific Journal Video about Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate HoLEP. at JoVE.com

The authors have nothing to disclose.

Ethical approval was obtained from the Ethics Committee of Shanghai Ninth People&#39;s Hospital and the written informed consent of each patient were obtained in our study.
1. Patients and Surgical Materials
Notes: Patients diagnosed with BPH and need surgical treatment in accordance with the European Association of Urology (EAU) guidelines can be included10. This surgical procedure requires experience and a long learning curve. The experience of the surgeon is one of the most important factors to accomplish this technique, specifically for prostate with a volume exceeding 100 g. The micro explosion effect of holmium laser is suitable for enucleation.
<ol>
	<li>Pre-surgical preparation
	<ol>
		<li>Assess patients with BPH who require surgical treatment in accordance with the EAU guidelines10.</li>
		<li>Exclude those with the following conditions: severe urinary infection, severe pulmonary or heart disease, impairment of renal function, severe bleeding disorder, poor blood pressure control, neurogenic bladder dysfunction, bladder cancer, previous prostate surgery, prostate cancer, urethral stricture, and other surgical contraindications mentioned in our previous reports11.</li>
		<li>Perform preoperative evaluations and conduct certain perioperative treatment according to the results.</li>
		<li>Administer lumbar or general anesthesia to the patient and place the patient in the lithotomy position.</li>
	</ol>
	</li>
	<li>Pre-surgical evaluation 
	Notes: For the preoperative evaluation, perform the followings analyses including the regular surgery check: urinary flow dynamics analysis, prostatic ultrasound analysis, analysis of the prostate specific antigen (PSA) level and the urethroscopy analysis.
	<ol>
		<li>Perform HoLEP using a 550 &#181;m end-firing laser fiber and a 100 W Versa Pulse holmium laser, with power settings of 80-100 Wat 1.6-2 J/s and 40-50 Hz. Perform transurethral morcellation with a 26 F nephroscope using a mechanical morcellator. Use about 1 L of normal saline (0.9%) as the irrigation &#64258;uid.</li>
	</ol>
	</li>
</ol>
2. Enucleation Procedures
Notes: Use plasma sterilization to sterilize the instruments and put the instruments in aseptic packages until used. Administer lumbar or general anesthesia to the patients and place the patient in the lithotomy position during surgery.
<ol>
	<li>Observation of the prostate and the urethra
	<ol>
		<li>Insert continuous-flow cystoscope, ensuring minimal tissue damage and observing the prostate, the urethra, and the bladder carefully.</li>
		<li>Locate the ureteral orifices with the use of a visual obturator for a general assessment, including the median lobe volume and the amount of intravesical tissue.</li>
		<li>Identify the verumontanum which is one of the most important landmarks for enucleation. Insert the handpieces with a laser fiber connected to the laser machine with the power of the laser machine set to 80-100 W at 1.6-2 J per second and 40-50 Hz.</li>
	</ol>
	</li>
	<li>Tunnel the incision around the 6 o&#39;clock position of the prostate with the patients in the lithotomy position.
	<ol>
		<li>Using a holmium laser, make a short horizontal incision around the 6 o&#39;clock position in front of the verumontanum (as shown in Figure 1A) to locate the surgical capsule of the prostate.</li>
		<li>Expose the prostate surgical capsule from the verumontanum to the bladder neck. On the layer of the surgical capsule, create a tunnel from the apex toward the back of the bladder neck, as shown in Figure 1A and 1D.</li>
		<li>When the operation is close to the bladder neck, ensure that the mucosa and the muscle are protected to facilitate efficient urinary control.</li>
	</ol>
	</li>
	<li>Lateral lobe removal 
	Notes: The capsule is characterized by a smooth white tissue with sufficient blood vessels on the surface. Bleeding vessels can also be sealed off by using the laser with a bit further distance than that used in enucleated process (greater distance is suitable for hemostasis, while smaller distance is suitable for cutting). During the procedure, return to the prostatic apex without hesitation to ensure that the exact surgical capsule is located, which is helpful to avoid getting lost in the procedure, when the operator cannot find the clear view.
	<ol>
		<li>First, enucleate the left lateral lobe from the 6 o&#39;clock to the 12 o&#39;clock position at the level of the surgical capsule and then enucleate the other lateral lobe similarly.</li>
		<li>During the procedure, use blur separation by using a scope sheath combined with laser cutting.</li>
		<li>Hang the enlarged prostate in the 12 o&#39;clock position of the bladder neck without cutting down.</li>
		<li>Cut the tissue off from the bladder neck and push it into the bladder at the end of the enucleation procedure.</li>
		<li>Recheck the prostate capsule to ensure no active bleeding occurs. Remove all enlarged glands and stop the severe bleeding points (illustrated in Figure 1A-1F).</li>
	</ol>
	</li>
</ol>
3. Morcellation
Notes: There are two gears in the morcellator, which can be shifted according to the foot pressure applied. The first gear uses light pressure to absorb tissue and water, whereas the second gear is used for morcellation. To prevent complications and improve the efficiency of the procedure, we have developed traditional morcellation skills and procedures. The approach to implement in this case is discussed in detail in our previous study12. The tissue taken out of the bladder is shown in Figure 2.
<ol>
	<li>Morcellation procedure
	<ol>
		<li>Equip the morcellator and the match tube according to the morcellator instruction, regardless of the kind of morcellator used. Remove the prostate tissue from the bladder by using a morcellator efficiently.</li>
		<li>During the procedure, treat the bladder tissue with great caution13. Maintain sufficient irrigation water in the bladder to keep the bladder engorged, thus avoiding bladder injury and to keep the morcellator away from the bladder wall remaining within the bladder, for maximum protection the bladder wall.</li>
		<li>Finally, observe the general condition of the bladder and ensure that no reserved tissue is left in the bladder.</li>
	</ol>
	</li>
	<li>Morcellation skills
	<ol>
		<li>As reported in our earlier study12, prior to morcellation, evaluate the texture of the gland tissue.</li>
		<li>Dig holes by using laser to provide friction to the surface of the gland and thus obtain a smooth surface.</li>
		<li>Use the inverse technique to morcellate the large and firm tissues as well as fibrotic, spherical glands with smooth surfaces and firm tissues. During the process invert the morcellator for its opening to face downward in the bladder. Ensure that the circulating water is unobstructed, and constantly feel the bladder pressure during morcellation.</li>
	</ol>
	</li>
</ol>
4. Post-operative Treatment
<ol style="margin-left: 40px;">
	<li>After surgery, insert the catheter and then irrigate normal saline into the bladder until the irrigation water is clear or only slightly reddish.</li>
	<li>Remove the catheter until the urine becomes clear without gross hematuria.</li>
	<li>If no obvious retention is observed and the patient can urinate without assistance after catheter removal, discharge the patient from the hospital14,15.</li>
</ol>
5. Follow-up Observation
<ol>
	<li>After hospital discharge, examine the follow-up data of the patient for 1, 6, and 12 months, which include the international prostate symptom score (IPSS), over-active bladder scoring system (OABSS), quality of life (QoL), and Qmax. If post-operative complications occur, apply further treatment14.</li>
</ol>

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M., Borofsky, M. S., Paonessa, J. E., Lingeman, J. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Wolf+Piranha+Versus+Lumenis+Versacut+Prostate+Morcellation+Devices:+A+Prospective+Randomized+Trial.">Wolf Piranha Versus Lumenis Versacut Prostate Morcellation Devices: A Prospective Randomized Trial.</a> J Urol. , (2015).</li><li>Gilling, P. J., Aho, T. F., Frampton, C. M., King, C. J., Fraundorfer, M. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Holmium+laser+enucleation+of+the+prostate:+results+at+6+years.">Holmium laser enucleation of the prostate: results at 6 years.</a> Eur Urol. 53 (4), 744-749 (2008).</li><li>Shah, H. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+evaluation+of+the+learning+curve+for+holmium+laser+enucleation+of+the+prostate.">Prospective evaluation of the learning curve for holmium laser enucleation of the prostate.</a> J Urol. 177 (4), 1468-1474 (2007).</li><li>Gratzke, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EAU+Guidelines+on+the+Assessment+of+Non-neurogenic+Male+Lower+Urinary+Tract+Symptoms+including+Benign+Prostatic+Obstruction.">EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction.</a> Eur Urol. 67 (6), 1099-1109 (2015).</li><li>Vincent, M. W., Gilling, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=HoLEP+has+come+of+age.">HoLEP has come of age.</a> World J Urol. 33 (4), 487-493 (2015).</li><li>Qian, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+outcomes+and+complications+following+B-TURP+versus+HoLEP+for+the+treatment+of+benign+prostatic+hyperplasia:+a+review+of+the+literature+and+Meta-analysis.">Functional outcomes and complications following B-TURP versus HoLEP for the treatment of benign prostatic hyperplasia: a review of the literature and Meta-analysis.</a> Aging Male. 20 (3), 184-191 (2017).</li><li>Xu, H., Chen, Y. B., Gu, M., Chen, Q., Wang, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+noise+hazard+during+the+holmium+laser+enucleation+of+prostate.">Evaluation of noise hazard during the holmium laser enucleation of prostate.</a> BMC Urol. 17 (1), 71 (2017).</li><li>Gilling, P. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+results+of+a+randomized+trial+comparing+holmium+laser+enucleation+of+the+prostate+and+transurethral+resection+of+the+prostate:+results+at+7+years.">Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years.</a> BJU Int. 109 (3), 408-411 (2012).</li></ol>

This research was supported by Key Disciplines Group Construction Project of Pudong Health Bureau of Shanghai (PWZxq2014-11), Program for Outstanding Medical Academic Leader, and Special Construction of Integrated Traditional Chinese Medicine and Western Wedicine in Shanghai General Hospital (ZHYY-ZXYJHZX-1-03).

In this protocol, we introduce a procedure for the surgical treatment of BPH. HoLEP can be employed in daily clinical practice. As mentioned, the development of BPH surgery includes three landmarks. The first is the open surgery. Retropubic prostatectomy and suprapubic open prostatectomy have extensively been employed in the clinical setting for a long time. Despite this, the technique involves severe adverse side effects, which are often observed during the perioperative period. These side effects include hemorrhage, large scars after surgery, and slow patient recovery. Moreover, the operative field is limited to the pelvic cavity. The second significant period is the development of TURP along with the advances in endoscopic techniques, which is still regarded as the gold standard for the surgical treatment of BPH. However, TURP is still not considered an anatomical surgery, and it is difficult to find the surgical capsule to resect all the hyperplastic prostate tissue. The method is low-efficient for prostate resection because the tissue can only be cut down when the loop passes. Moreover, as the loop cuts tissues back and forth until the blood vessel is sealed, the vessels tend to open up repeatedly, causing bleeding during surgery. Thus, TURP is not suitable for extremely large prostate, particularly when the prostate exceeds 100 g. In the EAU guidelines, TURP is suggested if the prostate volume is less than 80 g16. On the basis of TURP, HoLEP was improved in the 1990s and continues to be important in the development of surgery for BPH4. Plasma kinetic resection of the Prostate (PKRP) and HoLEP data were compared in our prospective study in 20126. Obstructive symptoms are significantly improved compared with the preoperative examination. Patients who underwent HoLEP showed better efficiency and postoperative recovery results, compared with those who received TURP17.
Main complications include: urinary incontinence, urinary retention, hematuresis and urethral stricture18. Careful operative and preoperative assessment can prevent complications at some degree. In any case, treatments for complications are available. For post-surgical urinary incontinence, functional recovery training (such as Levator Ani Sports), medical treatment and pelvic muscle exercise can be used. Most patients with post-surgical urinary incontinence recover without surgery. For those with genuine stress incontinence, surgery may be the remedy. Post-surgical urinary retention can be caused by the poor function of the detrusor muscle. Thus, pre-operative assessment is important to discover these patients. Once this complication occurs, an indwelling catheter can help. Pipe clipping training and a muscarinic receptor agonist can also be used. Hematuresis can be caused by bleeding vessels of the prostate. Thus, for severe bleeding with clots, surgical hemostasis should be applied. For many, continuous bladder irrigation can sufficiently provide hemostasis. Urethral stricture can also occur in a small number of patients, which can be remedied by urethral dilatation. In case the procedure fails to address the problem, transurethral incision is suggested. 
This method has certain limitations, including a long learning curve, high cost of the laser machine and noise19. However, HoLEP has been increasingly used in clinical practice to treat enlarged prostate. Urologists may vary in their skills, but the main technical process remains the same. For the prostate with three lobes, a tunnel can be made between the lateral lobe and the median lobe. This position is not exactly in the 6 o'clock but around 5 or 7 o'clock maybe. Regardless, the use of tunnel can still be a good choice for the surgeon as it provides convenience in performing enucleation. Holmium is pulsed solid-state laser with a wavelength of 2140 nm. Although numerous types of laser can be used in prostate surgery, holmium provides advantages, including the preservation of sexual function, efficiency, hemostasis, and lithotripsy. In our department, the skills required for enucleation and morcellation have improved. In our clinic report mentioned in the results section of this passage, as a flaw, no post-surgical PSA was recorded because of the loss to follow-up; otherwise, doctors are suggested to record post-surgical PSA for their clinical follow-up work. For the complications, one patients needed recatheterization because of urine retention after catheter removal. No transfusions were required. Stress incontinence to a certain degree was present in five patients after HoLEP, but these patients recovered within 6 months post-surgically. During follow-up, no patient required repeat surgery due to recurrence.
HoLEP is widely regarded as a suitable procedure for extremely large prostate. The method provides ease in locating the capsule, rendering it more efficient than other methods. HoLEP is more hemostatic and during enucleation the blood vessel could be opened only once at the bottom of the vessel. Compared with TURP, HoLEP is more thorough because the hyperplasic tissue can be separated anatomically. Long-term follow-up analysis indicates that the outcomes are considerable. As reported in a randomized trial in 2012, HoLEP is at least equivalent to TURP with respect to postoperative outcomes, such as erectile function, Qmax, and American Urological Association (AUA) scores in the long run (7 years), with fewer re-operations necessary20. Thus, owing to its efficiency and safety, HoLEP may become the good choice and an excellent surgical treatment for the surgical treatment of BPH.

Benign prostatic hyperplasia (BPH), which is hyperplasia of the prostate gland, occurs in elderly males. This condition starts at approximately 40 y old, and morbidity can reach 50%-60% for men in their 60s and 80%-90% for men in their 70s and 80s1. BPH causes progressive obstruction, lower urinary tract symptoms, retention and its complications, and even renal failure, all of which lower the quality of life of the elderly male. After medical therapy, surgical treatment is often used as the most efficient treatment for symptomatic BPH.
Various types of surgery have been developed to treat the symptoms of BPH, including the first open prostatectomy introduced in 18942 and transurethral endoscopic surgery (TURP) a century later. Since its development, TURP has been regarded as the gold standard to surgically alleviate prostate enlargement.
The holmium laser operates at a wavelength of 2120 nm, which is similar to that of the tissue water3, which induces vaporization of water. Tissue penetration reaches 0.4 mm, and coagulation can also be operated with it. The process was first introduced for BPH in 19944. In 1998, Peter Gilling used the device to perform enucleation application5. As proposed by Peter Gilling et al. in the 1990s4, holmium laser enucleation of the prostate (HoLEP) is used to treat BPH by combining the two earlier types of surgery, including the open enucleation and the TURP4. With the development of the hyperplasia process, the prostatic peripheral zone is compassed by the transitional zone (TZ) to form a so-called surgical capsule. HoLEP allows the removal of the hyperplasic part of the prostate, the TZ, which separates the prostate capsule. Thus, HoLEP, as the anatomical surgery, can enucleate the enlarged prostate zone from the formed separation between TZ and capsule. Compared with the traditional surgical method, HoLEP may be safer, more efficient, and thorough with durable outcomes. Compared with TURP, holmium reduced the duration, irrigation time, and catheter time of the procedure and shortened hospital stay.6,7,8 The technique can also be performed safely on patients who are on anticoagulant therapy or with bleeding disorders9. Though there are different kinds of procedures for HoLEP, the main procedure is the same as mentioned in the following. We also introduce our own experiences and the innovation for this method in order to make it easier to accept and shorten the learning curve. The procedure is particularly suitable for large prostates and those combined with bladder stones, given that the holmium laser can also be used for lithotripsy8. This article introduces this technique and the detailed procedure.

<table><tbody><tr><td>holmium laser</td><td>Lumenis, USA</td><td></td><td>PowerSuite 100W</td></tr><tr><td>mechanical morcellator</td><td>Lumenis, USA</td><td></td><td>VersaCut</td></tr><tr><td>27Fr continuous flow resectoscope</td><td>Storz, Tuttlingen, Germany</td><td></td><td></td></tr></tbody></table>

surgical treatment for benign prostatic hyperplasia: holmium laser enucleation of the prostate (holep).

Benign prostatic hyperplasia (BPH) commonly occurs among elderly males. The condition causes symptoms in the lower urinary tract, thereby reducing the quality of life. BPH includes 2 major treatments: medication and surgery. Surgical treatment is often the most effective and final intervention. Holmium laser enucleation of the prostate (HoLEP), one of the most efficient surgical procedures for BPH, is conducted transurethrally. During surgery, the most important and most difficult part is to locate the surgical capsule of the prostate, which is consistent to the idea of anatomic surgery. Different skills may be needed in treating different parts of the prostate. HoLEP tends to be efficient and safe with good hemostatic properties, and able to treat bladder calculus, which may be the complications of BPH. The technique is particularly suitable for prostate of varying volumes and sizes. Indeed, HoLEP also presents certain disadvantages, such as a long learning curve and costly equipment. Regardless, this method may be the "new standard" and the excellent method for the surgical treatment of BPH.

Retrospective data, collected from 2015 to 2016, were obtained from the clinical database of our department. A total of 100 patients treated for BPH were enrolled in the study. Perioperative outcomes were included: operation time (OT), hemoglobin decrease after surgery, Na+ variation, hospital stay duration, bladder irrigation duration and following-up data. Basic patient characteristics were also collected during our study. In addition, the catheterization time and hospitalization time were noted. Follow-up data and post-operative urinary complications were collected at 1, 4 and 24 weeks after surgery. All data are shown in Table 1.
The prostate tissue can be removed from the bladder by morcellation, as shown in Figure 1C and 1F. Figure 2 shows the prostatic tissue after morcellation. The tissue can be analyzed pathologically after surgery. For prostate exceeding 120 g combined with multiple bladder calculi, making a small suprapubic incision is suggested to remove the enucleated prostate and stones from the bladder. This method can shorten the operating time and provide safety for some patients with poor general condition11.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/56683/56683fig1.jpg" /> 
Figure 1: Schematic of the process of HoLEP. (A, D) Tunnel should be made through the prostatic apex to the bladder neck in the 6 o&#39;clock position. (B, E) Lateral lobes should be enucleated from 6 to 12 o&#39;clock position. (C, F) The entire prostate should be pushed into the bladder for the following morcellation. (G) Sketch of the laser handpiece used in HoLEP. P: prostate tissue, V: verumontanum, TZ: transitional zone, S: surgical capsule, M: morcellator <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56683/56683fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/56683/56683fig2.jpg" /> 
Figure 2: Tissue harvested after enucleation and morcellation.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Median 
			(first quartile, third quartile)</td>
			<td>Numbers</td>
		</tr>
		<tr>
			<td>Pre-surgical data</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Age</td>
			<td>70.00 (64.00-66.00)</td>
			<td>100</td>
		</tr>
		<tr>
			<td>Prostate volume (ml)</td>
			<td>54.15 (35.80-70.03)</td>
			<td>100</td>
		</tr>
		<tr>
			<td>PSA (ng/ml)</td>
			<td>3.62 (1.64-7.28)</td>
			<td>94</td>
		</tr>
		<tr>
			<td>Pre-surgical IPSS</td>
			<td>23.00 (20.00-26.00)</td>
			<td>100</td>
		</tr>
		<tr>
			<td>Post-surgical data</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Operation time</td>
			<td>75.00 (55.00-105.00)</td>
			<td>100</td>
		</tr>
		<tr>
			<td>Hemochrome decrease (gm/dl)</td>
			<td>1.20 (0.91-1.69)</td>
			<td>100</td>
		</tr>
		<tr>
			<td>Na+ changes (mmol/l)</td>
			<td>3.26 (2.11-4.33)</td>
			<td>100</td>
		</tr>
		<tr>
			<td>Hospital stay (day)</td>
			<td>4.00 (3.00-5.00)</td>
			<td>100</td>
		</tr>
		<tr>
			<td>Bladder irrigation time (hours)</td>
			<td>17.00 (12.00-29.00)</td>
			<td>83</td>
		</tr>
		<tr>
			<td>IPSS 1 week</td>
			<td>7.00 (2.75-8.25)</td>
			<td>54</td>
		</tr>
		<tr>
			<td>IPSS 4 weeks</td>
			<td>4.00 (0.00-6.00)</td>
			<td>47</td>
		</tr>
		<tr>
			<td>IPSS 24 weeks</td>
			<td>0.00 (0.00-5.00)</td>
			<td>47</td>
		</tr>
		<tr>
			<td colspan="3">The sample median (first quartile, third quartile) is shown as the above.</td>
		</tr>
		<tr>
			<td colspan="3">IPSS= international prostate symptom score</td>
		</tr>
		<tr>
			<td colspan="3">PSA= prostate specific antigen</td>
		</tr>
	</tbody>
</table>
Table 1: Perioperative data and pre-surgical characteristics of patients

Watch this Scientific Journal Video about Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate HoLEP. at JoVE.com

Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate HoLEP.

Here we present a safe and efficient protocol, holmium laser enucleation of the prostate, to treat benign prostatic hyperplasia.

Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate (HoLEP).

Benign prostatic hyperplasia (BPH) commonly occurs among elderly males. The condition causes symptoms in the lower urinary tract, thereby reducing the ...

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Nanyang Technological University

Research

JoVE Journal

Medicine

16.8K Views.  Shanghai Jiaotong University School of Medicine. Here we present a safe and efficient protocol, holmium laser enucleation of the prostate, to treat benign prostatic hyperplasia.

Video: Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate HoLEP.

Improved Protocol For Laser Microdissection Of Human Pancreatic Islets From Surgical Specimens

Laser microdissection (LMD) is a technique that allows the recovery of selected cells and tissues from minute amounts of parenchyma 1,2. The dissected cells can be used for a variety of investigations, such as transcriptomic or proteomic studies, DNA assessment or chromosomal analysis 2,3. An especially challenging application of LMD is transcriptome analysis, which, due to the lability of RNA 4, can be particularly prominent when cells are dissected from tissues that are rich of RNases, such as the pancreas. A microdissection protocol that enables fast identification and collection of target cells is essential in this setting in order to shorten the tissue handling time and, consequently, to ensure RNA preservation. 
Here we describe a protocol for acquiring human pancreatic beta cells from surgical specimens to be used for transcriptomic studies 5. Small pieces of pancreas of about 0.5-1 cm3 were cut from the healthy appearing margins of resected pancreas specimens, embedded in Tissue-Tek O.C.T. Compound, immediately frozen in chilled 2-Methylbutane, and stored at -80 &deg;C until sectioning. Forty serial sections of 10 &mu;m thickness were cut on a cryostat under a -20 &deg;C setting, transferred individually to glass slides, dried inside the cryostat for 1-2 min, and stored at -80 &deg;C. 
Immediately before the laser microdissection procedure, sections were fixed in ice cold, freshly prepared 70% ethanol for 30 sec, washed by 5-6 dips in ice cold DEPC-treated water, and dehydrated by two one-minute incubations in ice cold 100% ethanol followed by xylene (which is used for tissue dehydration) for 4 min; tissue sections were then air-dried afterwards for 3-5 min. Importantly, all steps, except the incubation in xylene, were performed using ice-cold reagents - a modification over a previously described protocol 6. utilization of ice cold reagents resulted in a pronounced increase of the intrinsic autofluorescence of beta cells, and facilitated their recognition. For microdissection, four sections were dehydrated each time: two were placed into a foil-wrapped 50 ml tube, to protect the tissue from moisture and bleaching; the remaining two were immediately microdissected. This procedure was performed using a PALM MicroBeam instrument (Zeiss) employing the Auto Laser Pressure Catapulting (AutoLPC) mode. The completion of beta cell/islet dissection from four cryosections required no longer than 40-60 min. Cells were collected into one AdhesiveCap and lysed with 10 &mu;l lysis buffer. Each single RNA specimen for transcriptomic analysis was obtained by combining 10 cell microdissected samples, followed by RNA extraction using the Pico Pure RNA Isolation Kit (Arcturus). This protocol improves the intrinsic autofluorescence of human beta cells, thus facilitating their rapid and accurate recognition and collection. Further improvement of this procedure could enable the dissection of phenotypically different beta cells, with possible implications for better understanding the changes associated with type 2 diabetes.

Laser microdissection is a technique that allows the recovery of selected cells from minute amounts of parenchyma. Here we describe a protocol for acquiring human pancreatic islets from surgical specimens to be used for transcriptomic studies. Our protocol improves the intrinsic autofluorescence of human beta cells, thus facilitating their collection.

Laser microdissection (LMD) is a technique that allows the recovery of selected cells and tissues from minute amounts of parenchyma 1,2. The dissected ...

Renal Capsule Xenografting and Subcutaneous Pellet Implantation for the Evaluation of Prostate Carcinogenesis and Benign Prostatic Hyperplasia

New therapies for two common prostate diseases, prostate cancer (PrCa) and benign prostatic hyperplasia (BPH), depend critically on experiments evaluating their hormonal regulation. Sex steroid hormones (notably androgens and estrogens) are important in PrCa and BPH; we probe their respective roles in inducing prostate growth and carcinogenesis in mice with experiments using compressed hormone pellets. Hormone and/or drug pellets are easily manufactured with a pellet press, and surgically implanted into the subcutaneous tissue of the male mouse host. We also describe a protocol for the evaluation of hormonal carcinogenesis by combining subcutaneous hormone pellet implantation with xenografting of prostate cell recombinants under the renal capsule of immunocompromised mice. Moreover, subcutaneous hormone pellet implantation, in combination with renal capsule xenografting of BPH tissue, is useful to better understand hormonal regulation of benign prostate growth, and to test new therapies targeting sex steroid hormone pathways.

We describe the manufacture of compressed hormone pellets, as well as subcutaneous surgical implantation into mice. This strategy can be combined with the growth of cell and tissue xenografts under the renal capsule of athymic nude mice to evaluate hormonal carcinogenesis and regulation of benign prostate growth.

New therapies for two common prostate diseases,  prostate cancer (PrCa) and benign prostatic hyperplasia (BPH), depend  critically on experiments ...

Laser-capture Microdissection of Human Prostatic Epithelium for RNA Analysis

The prostate gland contains a heterogeneous milieu of stromal, epithelial, neuroendocrine and immune cell types. Healthy prostate is comprised of fibromuscular stroma surrounding discrete epithelial-lined secretory lumens and a very small population of immune and neuroendocrine cells. In contrast, areas of prostate cancer have increased dysplastic luminal epithelium with greatly reduced or absent stromal population. Given the profound difference between stromal and epithelial cell types, it is imperative to separate the cell types for any type of downstream molecular analysis. Despite this knowledge, the bulk of gene expression studies compare benign prostate to cancer without micro-dissection, leading to stromal bias in the benign samples. Laser-capture micro-dissection (LCM) is an effective method to physically separate different cell types from a specimen section. The goal of this protocol is to show that RNA can be successfully isolated from LCM-collected human prostatic epithelium and used for downstream gene expression studies such as RT-qPCR and RNAseq.

The goal of this protocol is to use laser-capture micro-dissection as an effective method to isolate pure populations of cell types from heterogeneous prostate tissues for downstream RNA analysis.

The prostate gland contains a heterogeneous milieu of stromal, epithelial, neuroendocrine and immune cell types.  Healthy prostate is comprised of ...

Murine Prostate Micro-dissection and Surgical Castration

Mouse models are used extensively to study prostate cancer and other diseases. The mouse is an excellent model with which to study the prostate and has been used as a surrogate for discoveries in human prostate development and disease. Prostate micro-dissection allows consistent study of lobe-specific prostate anatomy, histology, and cellular characteristics in the absence of contamination of other tissues. Testosterone affects prostate development and disease. Androgen deprivation therapy is a common treatment for prostate cancer patients, but many prostate tumors become castration-resistant. Surgical castration of mouse models allows for the study of castration resistance and other facets of hormonal biology on the prostate. This procedure can be coupled with testosterone reintroduction, or hormonal regeneration of the prostate, a powerful method to study stem cell lineages in the prostate. Together, prostate micro-dissection and surgical castration opens up a multitude of opportunities for robust and consistent research of prostate development and disease. This manuscript describes the protocols for prostate micro-dissection and surgical castration in the laboratory mouse.

This manuscript describes the protocols for prostate micro-dissection and surgical castration in the laboratory mouse. We also depict representative results produced by these protocols. Finally, we discuss the advantages and utilization of these protocols.

Mouse models are used extensively to study prostate cancer and other diseases. The mouse is an excellent model with which to study the prostate and has ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Transcanalicular Diode Laser-assisted Dacryocystorhinostomy for the Treatment of Primary Acquired Nasolacrimal Duct Obstruction

Today&#39;s gold standard in the treatment of infrasaccal primary acquired nasolacrimal duct obstruction (PANDO) is external dacryocystorhinostomy (DCR), a relatively invasive procedure that can be performed after failure of recanalizing treatments. However, with progress in the field of diode laser technology, new approaches have emerged. Laser-assisted transcanalicular DCR with subsequent bicanalicular silicon intubation is a new option showing great promise as a viable minimally invasive procedure. Under permanent endoscopic visual control from the nasal cavity, a diode laser fiber is inserted into the lacrimal sac and laser energy is applied to create a bony ostium between the lacrimal sac and the nasal cavity. Since no skin incision needs to be made, advantages of this method comprise the sparing of the skin as well as the medial palpebral structures and the physiological palpebral-canalicular pump mechanism. The duration of surgery as well as reconvalescence is generally shorter than with external DCR. Complications include silicon tube prolapse, mild swelling and, rarely, canalicular infection and thermal injury. One-year functional success rates, defined as complete resolution of symptoms and ostium patency, are high, yet still range behind those of external DCR. However, secondary external DCR after failure of laser-assisted DCR can be performed without difficulty. Thus, laser-assisted transcanalicular DCR is a valid option that should be considered as a second-step procedure after failure of recanalization procedures and before external DCR.

The goal of this protocol is to present transcanalicular laser-assisted dacryocystorhinostomy as a minimally invasive approach in the treatment of primary acquired nasolacrimal duct obstruction.

Today&#39;s gold standard in the treatment of infrasaccal primary acquired nasolacrimal duct obstruction (PANDO) is external dacryocystorhinostomy (DCR), ...

Photoselective Vaporesection of the Prostate via an End-firing Lithium Triborate Crystal Laser

The occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem with a high incidence in the aging male population. Although it is not a life-threatening disease, BPH causes problems that seriously impact the quality of life. Here, we introduce a new technique called photoselective vaporesection of the prostate (PVRP) in treating BPH, which can be seen as a variation of photoselective vaporization of the prostate (PVP). This procedure presents several advantages compared to the PVP technique including less laser energy loss, less intraoperative complications as well as more tissue resection rate.

Here we present a protocol to perform Photoselective Vaporesection of the Prostate (PVRP) for benign prostatic hyperplasia (BPH) treatment.

The occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem with a high incidence in the aging ...

Enucleation of the Prostate for the Treatment of Benign Prostatic Hyperplasia Using a 980 nm Diode Laser

In the aging male population, the occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem. Here, we introduce a new technique called 980 nm diode laser enucleation (DiLEP) to treat BPH1. Diode lasers can absorb both water and hemoglobin at the same time, so they are good for cutting and hemostasis2. The diode laser was approved by the FDA in 2007, and has been used in the treatment of BPH because of its effective cutting and hemostasis effect3. DiLEP presents several advantages over other techniques, such as TURP, HoLEP, and PVP. During the procedure, we define the boundary of a high-volume prostate and separate it into three lobes with a diode laser by burning two rings and one groove (like a Cupid&#39;s arrow). Compared to other procedures, mDiLEP has fewer intraoperative complications, a shorter learning curve, and achieves more tissue resection.

Here, we present a protocol for modified 980 nm diode laser enucleation to treat large volume benign prostatic hyperplasia.

In the aging male population, the occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem. ...

Focal Laser Ablation of Prostate Cancer: An Office Procedure

In this article, we describe and illustrate an outpatient procedure for focal laser ablation (FLA) of prostate cancer (PCa). The procedure is conceptually similar to a fusion biopsy and is performed under local anesthesia in a clinic setting; treatment time is usually less than one hour. Laser insertion is guided by ultrasound; lesion targeting is via magnetic resonance imaging-ultrasound (MRI/US) fusion, as in targeted prostate biopsy. Real-time ablation monitoring is achieved utilizing a thermal probe adjacent to the laser fiber. The video demonstrates procedure planning, patient preparation, various steps during the procedure, and treatment monitoring. Safety, feasibility, and efficacy of this approach have been established during a previous trial. Outpatient FLA under local anesthesia is an option for management of intermediate risk prostate cancer.

This article presents and describes an outpatient treatment for prostate cancer using focal laser ablation. Laser catheter placement is guided by MRI-ultrasound fusion imaging in a fashion similar to prostate needle biopsy. Treatment is monitored in real-time with a thermal probe, placed adjacent to the laser fiber.

In this article, we describe and illustrate an outpatient procedure for focal laser ablation (FLA) of prostate cancer (PCa). The procedure is conceptually ...

Seminal Vesiculoscope Laser-Assisted Surgery to Treat Ejaculatory Duct Blockage

Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory duct cyst. Intraoperative excision of the verumontanum is usually required to expose the ejaculatory ducts. However, preserving the verumontanum structure allows for a better simulation of normal physiological anatomy. Maintaining the verumontanum may increase the risk of postoperative distal ejaculatory duct scarring, leading to recurrent obstruction or reduced semen volume. Therefore, we attempted a novel technique that preserves the verumontanum, which is relatively easier and safer compared to TURED. The following were the procedural steps: 1. A 6F seminal vesiculoscope was introduced through the external urethral orifice to the vicinity of the verumontanum, locating the opening of the affected-side ejaculatory duct and introducing a guidewire into the cyst. This successful step preserved the verumontanum, maximizing the retention of the anti-reflux mechanism in the distal ejaculatory duct. 2. The holmium laser enlarged the affected-side ejaculatory duct opening to 5 mm, decreasing the likelihood of postoperative closure of the ejaculatory duct opening and simplifying the procedure. 3. A window was created within the cyst to access the contralateral seminal vesicle, and then a holmium laser was used to burn and dilate the opening to 5 mm, redirecting the contralateral ejaculatory duct into the cystic cavity. This modification preserved the opening of the healthy-side ejaculatory duct and provided a new outflow passage for semen, reducing the risk of decreased semen volume postoperatively. The patients experienced no complications postoperatively, had shorter hospital stays, and showed improvement in semen volume. Hence, this surgical approach is simple yet effective.

Author Spotlight: Advanced Treatment of Seminal Duct Blockage Employing Endoscopy-Mediated Semen Channel Refluviation 

This protocol introduces the clinical application of seminal vesicle endoscopy combined with holmium laser in the treatment of ejaculatory duct obstruction caused by ejaculatory duct cyst.

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory ...