Enucleation of the prostate: An anatomical perspective.

Among transurethral surgery for benign prostatic hyperplasia (BPH), anatomical endoscopic enucleation of the prostate (AEEP) differs from conventional transurethral surgery as it adopts the same enucleation principle as open surgery. AEEP is known as an effective and safe surgical method. However, the learning curve is steep because the surgical anatomy is different from that of conventional transurethral surgery. If information on surgical anatomy related to enucleation is enriched and surgical standardisation is achieved, the learning curve will be shortened and AEEP will become more widespread. The concept of AEEP has been developed based on the surgical techniques obtained from holmium laser enucleation of prostate (HoLEP). The original surgical technique of HoLEP is a three-lobe technique. At the 12 o'clock position at the prostatic apex, the boundary of the prostate capsule is unclear. Separating anterior prostatic tissue from the prostatic capsule while preserving the sphincter in the apical area is one of the biggest challenges in AEEP. During the AEEP procedure, an accurate understanding of the surgical anatomy of the capsular plane, bladder neck, apical sphincteric area and blood vessels is important. In this article, literature on the anatomy related to enucleation in AEEP, mainly HoLEP, is reviewed and discussed.

[A Case of Holmium: YAG Laser Resection of Superficial Bladder Tumor (HoLRBT)].

We present a case of holmium : YAG laser resection of superficial bladder tumor (HoLRBT). A 73-year-old male was referred to our hospital with elevated prostatic specific antigen. Due to difficulty of urination, holmium : YAG laser enucleation of the prostate was performed under the diagnosis of benign prostatic hyperplasia. During the surgery, superficial bladder tumor was incidentally identified, and HoLRBT was performed. After the operation, histopathological examination revealed urothelial carcinoma, G2 ＞ G1, pTa. The patient has been subsequently followed up for 9 months, and there areno evidence of recurrence. Changing the holmium : YAG laser energy setting can potentially be effective and safe to approach a superficial bladder tumor.

[Investigation of changes in sexual and ejaculatory functions after holmium laser enucleation of the prostate (HoLEP)].

Changes in sexual function and ejaculatory function in patients who had undergone holmium laser enucleation of the prostate (HoLEP) were investigated using questionnaires. In this study, 77 patients on whom HoLEP was performed at our department from July 2010 to December 2010 were included. Of the 77 patients, the number of patients who could achieve an erection increased from 36 (46.8%) preoperatively to 52 (67.5%) postoperatively after HoLEP. Although postoperative ejaculatory dysfunction was found in 38 (73%) of 52 patients, 47 (90%) experienced orgasms, regardless of ejaculation, which is a high rate. With respect to ejaculatory satisfaction, patients who experienced an ejaculation had significantly higher satisfaction levels than those who did not. These results suggest that changes in postoperative ejaculatory function might affect satisfaction levels of ejaculation.

Bone dissemination of prostate cancer after holmium laser enucleation of the prostate: a case report and a review of the literature.

We report a case of dissemination of prostate cancer after holmium laser enucleation of the prostate in an 80-year-old patient. The patient presented at hospital because of nocturia. Transrectal ultrasound-guided biopsy was carried out because of high serum prostate-specific antigen (3.55 ng/mL), but it showed no malignancies. Benign prostate hyperplasia was diagnosed, and he was started on an α1-blocker. Although the urinary symptom improved with silodosin, acute urinary retention occurred 3 years after therapy began. Holmium laser enucleation of the prostate for relief of bladder outlet obstruction enabled discharge of urine. Pathological examination of the resected tissue found adenocarcinoma with a high Gleason score, 4 + 5. Serum alkaline phosphatase increased rapidly after holmium laser enucleation, and bone scintigraphy confirmed multiple bone metastases. Prostate cancer, T1bN0M1b, was diagnosed.

[Relationship between morcellation efficiency and enucleated tissue weight in holmium laser enucleation of the prostate (HoLEP) for patients with benign prostatic hyperplasia].

OBJECTIVE: We examined the relationship between morcellation efficiency and enucleated tissue weight in holmium laser enucleation of the prostate (HoLEP) for patients with benign prostatic hyperplasia (BPH) retrospectively. METHODS: From January to December 2010, 140 patients with BPH were treated by HoLEP combined with mechanical morcellation with up side down technique by a single surgeon. RESULTS: The mean age was 70.6 years, and the mean enucleated tissue weight was 46.8 g. The mean morcellation time was 9.9 min, and the mean rate of morcellation was 6.7 g/min. No complications were reported relating to morcellation such as bladder injury. Although morcellation time and enucleated tissue weigh were proportionally related (Estimate equation: Y = - 1.186 + 0.813 * X, R^2: 0.814), larger glands with more than 80 g of tissue enucleated did not match this distribution map. Five cases with more than 100 g of enucleated tissue weight required much longer operation time (range 66-90 min) and were disproportioned to tissue weight. Morcellation efficiency tended to decrease when enucleated tissue weight exceeds 80 g and less than average in almost all cases. Morcellation efficiency significantly worsen when enucleated tissue weight exceeds more than 100 g. CONCLUSIONS: Morcellation efficency may decrease in larger gland exceeds 80 g.

[Holmium laser enucleation of the prostate (HoLEP) in patients with continuous oral anticoagulation: first reported cases in Japan].

Oral anticoagulation (OA) has been considered as a strict contraindication to transurethral resection of the prostate (TURP). In recent years, some studies have shown that holmium laser enucleation of the prostate (HoLEP) has less blood loss compared to TURP. Thus we have performed HoLEP in patients with benign prostatic hyperplasia (BPH) under continuous OA from September 2009, and herein we report our first nine cases. Patients received HoLEP by a single surgeon at our institution. HoLEP was performed successfully in all patients. The mean times to complete enucleation and morcellation were 48.2 and 5.1 minutes, respectively. The mean tissue weight of enucleation was 37 grams. The mean hemoglobin and sodium loss after HoLEP were 1.7 g/dl and 1.3 mEq/L, respectively, and the catheterization time was 1.6 days. Blood transfusion, clot retention or transurethral resection syndrome were not observed in any cases. HoLEP has excellent hemostatic properties, and is a safe and effective procedure for patients with symptomatic BPH under the condition of continuous OA.

[An effective method to shorten the learning curve of HoLEP].

Holmium laser enucleation of the prostate (HoLEP) is a safe and effective treatment for patients with symptomatic benign prostatic hyperplasia (BPH), but is a difficult operation. To shorten the learning curve, we evaluated the surgical outcome of successive bilateral lobe enucleations with HoLEP. Performed by an inexperienced endourologist and an expert. Between March and July on 2009, we evaluated 20 cases of HoLEP performed by a beginner who underwent successive bilateral lobe enucleations and 20 cases of HoLEP performed by an expert. Enucleation time was shortened when successive bilateral lobe enucleations were performed by the beginner using HoLEP (115 vs 92 minutes, p<0.05). The enucleation time was significantly shorter in the expert group than in the beginner group. However, there were no significant differences in morcellation time, enucleated tissue weight, hemoglobin decrease level, sodium decrease level, catheterization time or significant incontinence time between the two groups. The postoperative evaluations was excellent in both groups. We conclude that HoLEP is a safe and effective operation. However, close supervision by an expert is required. In addition, learning from the easier part of enucleation to elaborate skill sets required to perform HoLEP is prerequisite for success.

[Cases of bacillus Calmette-Guerin-induced granulomatous prostatitis and prostatic stromal invasion of the bladder carcinoma in situ, showing similar clinical findings].

Intravesical instillation of bacillus Calmette-Guerin (BCG) is the first-line therapeutic option for flat carcinoma in situ (CIS) of the bladder. Intravesical BCG instillation has been demonstrated to cause granulomatous prostatitis. Bladder CIS often also is known to show prostatic stromal invasion. We report a case of BCG-induced granulomatous prostatitis and a case of prostatic stromal invasion of bladder CIS accompanied by locally advanced prostate cancer, which showed similar clinical findings after the intravesical BCG therapy. In these 2 patients, urinary symptoms such as dysuria were prolonged regardless of anti-tuberculous medication, hard nodules were palpable at the prostate, and hypoechoic lesions were visualized by transrectal ultrasound. Both patients were treated by transurethral resection of the prostate, and the diagnoses were made by histopathological examination. Urinary symptoms were resolved in both patients after surgery, but the prostatic stromal tumor showed recurrence of growth. We report the usefulness of transurethral resection of the prostate for medication-resistant BCG-induced granulomatous prostatitis, and the importance of the correct diagnosis of prostatic stromal invasion of bladder CIS especially in the cases with concurrent prostate cancer.

Weekly paclitaxel plus estramustine combination therapy in hormone-refractory prostate cancer: a pilot study.

BACKGROUND: Paclitaxel used in combination with estramustine has been shown to exert synergistic cytotoxicity in patients with hormone-refractory prostate cancer (HRPC). There have been few reports of this therapy in an Asian male population. METHODS: Nine patients with progressive metastatic HRPC completed at least one cycle of combination therapy employing weekly paclitaxel plus estramustine. Paclitaxel was given weekly for 3 weeks as a 2-h intravenous infusion at a dose of 100 mg/infusion. The cycle was repeated every 4 weeks. A dose of 280 mg of oral estramustine was administrated twice daily for 21 days from the first day of each cycle. Both efficacy and toxicity were recorded. RESULTS: Grade 1 sensory neuropathy was seen in three patients (33%) and grade 4 thrombopenia/anemia was seen in one patient (11%). Performance status improved in three of seven patients (43%), while six patients (67%) showed a 50% or greater decline in prostate-specific antigen levels. Two of these patients experienced significant improvement in bone pain. One patient died of cardiac infarction during this trial and another died of disseminated intravascular coagulopathy subsequent to gastrointestinal bleeding. An additional patient suffered non-fatal pulmonary infarction. The one-year median survival rate was 22.2% and the overall survival period was 36 weeks. CONCLUSION: Although weekly paclitaxel plus estramustine may pose a significant risk, this combination may have a beneficial effect on the quality of life HRPC patients. A well-designed phase I-II trial in an Asian male population is highly recommended.

[Experience with the memotherm stent in high-risk urinary retention patients].

PURPOSE: We report on our experience with the Memotherm stent implanted in high-risk patients who had an indwelling catheter. PATIENTS AND METHODS: Seventeen patients (mean age 80.6 years, range 55 to 93) who had an indwelling catheter were treated by placement of the Memotherm stent. The mean duration time of indwelling catheter were 12.7 months (range 1 to 60). The methods of implantation was used the special delivery system and treatment can be done with the patient under local anesthesia with non-steroidal anti-inflammatory drug. To assess the efficacy of the treatment we measured urinary peak flow rate (ml/sec), residual urine volume (ml) and residual urine rate (residual urine volume/total urine volume: %). Subjective symptoms were evaluated using the International Prostate Symptom Score (I-PSS). The mean follow-up time was 3.3 months (range 1 week to 8 months). RESULTS: There were no severe medical problems associated with stent placement. Sixteen patients were able to void immediately after insertion of the stent. The remaining 1 required an indwelling catheter to 2 months, however, eventually able to void. Only 7 of the 17 patients can be evaluation for urinary flow and residual urine, nevertheless the mean urinary peak flow rate showed 9.7 ml/sec, the mean residual urine volume was 77.4 ml, and the mean residual urine rate was 27.5%. Also, average I-PSS showed 13.4 in these patients. CONCLUSIONS: As a results of this study, the Memotherm stent is good conservative therapy for high-risk urinary retention patients.