Inverted-T Incision With Early Apical Release vs. Three-Lobe in Holmium Laser Enucleation of The Prostate

Inverted-T Incision With Early Apical Release Technique vs. Three-Lobe Technique in Holmium Laser Enucleation of The Prostate: A Comparative Study

Aim of the work is to compare the surgical efficacy and perioperative outcomes of the inverted-T incision with early apical release technique versus the standard three-lobe technique in patients undergoing Holmium Laser Enucleation of The prostate for Benign prostatic hyperplasia .

Primary outcome :

• Technical operative time (started from the activation of the holmium laser for enucleation of the prostate lobes and ending after completion of morcellation )

Secondary outcome:

• Laser energy used.
• Intraoperative blood loss (change in hemoglobin level).
• Learning curve.

Benign prostatic hyperplasia is a histologic diagnosis that refers to the proliferation of smooth muscle and epithelial cells within the prostatic transition zone.

Treatment options for Benign prostatic hyperplasia range from watchful waiting and lifestyle changes for mild cases to medications that relax smooth muscles of prostatic urethra (alpha-blockers) or decrease the prostate size (5-alpha reductase inhibitors) .

Minimally invasive procedures or surgery (e.g. transurethral resection or anatomical endoscopic enucleation) are the treatment of choice for cases that don't respond to medical treatment and for more severe and complicated symptoms . Tailoring the treatment depends on individual factors like symptom severity, prostate size, age, and tolerance to side effects .

Holmium Laser Enucleation of the Prostate has been established as a gold standard surgical treatment for Benign prostatic hyperplasia of all prostate sizes due to its efficacy, durability, and low complication rates . Holmium Laser Enucleation of the Prostate involves enucleation of the adenoma from the surgical capsule using a holmium laser, followed by morcellation of the enucleated tissue . The standard technique typically involves identifying and dissecting three lobes (median and lateral lobes) .

While effective, the standard three-lobe technique can be technically demanding, particularly in larger glands or those with complex anatomy. Also, it involves multiple incisions which are associated with increased risk of complications. This may lead to longer operating times, increased laser energy usage, and a steeper learning curve .

Various modifications to the standard Holmium Laser Enucleation of the Prostate technique have been proposed to optimize outcomes and simplify the procedure. Inverted-T Incision with Early Apical Release technique aims to simplify the enucleation by creating an inverted T-shaped incision at the bladder neck and then performing early release of the apical attachments. This theoretically allows for easier visualization and dissection of the adenoma and decrease incidence of the sphincter injury, potentially reducing operative time and improving enucleation efficiency.

Although both techniques have shown efficacy in treating Benign prostatic hyperplasia, their comparative effectiveness in terms of enucleation quality, post-operative complications, operative time, and long-term outcomes is still a subject of debate. This study aims to directly compare these two techniques to identify which provides better clinical outcome .

Inclusion Criteria:

• Male patients aged 50-80 years.
• Prostate size ≥ 80 mL.
• Candidates for Holmium Laser Enucleation of the Prostate based on clinical and radiological evaluation

Exclusion Criteria:

• Suspected or confirmed prostate cancer.
• Previous prostate or urethral procedure (excluding prostate biopsy).
• Urethral stricture.
• Active urinary tract infection.
• Urinary bladder mass, stone or diverticulum.
• Severe coagulopathy or inability to discontinue anticoagulant/antiplatelet medications.
• Unwillingness to comply with follow-up protocol