MP29-06: Initial Comparison of Technique Change from Three Lobe to Early Apical Release in Holmium Laser Enucleation of the Prostate in a High-Volume Center

Christian Ericson*, Bryce Baird, Chandler Dora, Jacksonville, FL

Introduction: Since the three-lobe technique of holmium laser enucleation of the prostate (HoLEP) was first described by Gilling in 1996, there have been multiple modifications described.  Recently, early apical release (EAR) has been promoted as a HoLEP technique to minimize mechanical force on the sphincter and keep the mucosa overlying the anterior sphincter intact.  A paucity of literature exists describing the impact of a wholesale change in technique for a high-volume HoLEP surgeon.  We describe the initial results comparing the three-lobe (TL) technique and the EAR technique.

Methods: 646 men underwent HoLEP at our institution between 2018 and 2021.  Beginning in June 2021 all procedures were performed using the EAR technique.  Pre, intra, and postoperative data was recorded in an IRB-approved database.  Patients were divided into two groups based on operative technique: TL or EAR. Preoperative ellipsoid prostate volume was obtained by computerized tomography (CT), magnetic resonance imaging (MRI), or transrectal ultrasound (TRUS). Perioperative outcomes including operative time, reinsertion of catheter after initial removal, enucleation ratio (specimen weight/preoperative volume), and specimen yield were compared.

Results: 573 and 73 men were included in the TL and EAR groups respectively. Median preoperative prostate volumes were 92 ml (range 17-366, interquartile range (IQR) 67-130) vs. 100 ml (range 32-266, IQR 69-124). Median specimen weight was 65 g (range 7-298, IQR 41-90) vs. 62 g (range 7-282, IQR 38-77). Median enucleation ratio was 0.69 (range 0.188-1.66, IQR 0.58-0.81) vs 0.59 (range 0.16-0.73, IQR 0.52-0.73). Median operative times were 85 min (range 33-405, IQR 68.5-105.5) vs 95 min (range 56-183, IQR 78-116.5. Catheter reinsertion was required in 63 of 573 (11.1%) vs. 7 of 73 (9.6%). RTOR occurred in 24 of 573 (4.3%) vs 1 of 73 (1.4%).

Conclusions: Conversion from TL to EAR technique by an experienced HoLEP surgeon resulted in longer operative times and lower specimen yield.  However, incising the mucosa circumferentially and developing the anterior plane meticulously pays dividends with a lower catheter reinsertion rate.  Subjectively, this technique has resulted in improved hemostasis and HoLEPs are currently being performed as same-day surgery.  We anticipate with increased experience using EAR technique the operative times and specimen yields will approach those of the TL cohort.

Source of Funding: NA