Operative note 41 Advanced
HoLEP
What it does: laser the adenoma off its capsule, then morcellate it in the bladder.
- Calibrate the meatus. Dilate to 28 to 30 Fr. Landmarks first: both orifices, veru, sphincter. Read the lobes.
- Laser (owner's settings): 100 to 120 W platform. About 2 J at 40 to 50 Hz to enucleate. 550 micron fibre, held by a laser bridge or a 6 Fr stabilising catheter. 26 to 28 Fr continuous-flow laser scope, 30 degree lens. Saline.
- Grooves at 5 and 7 o'clock. Bladder neck to just above the veru. Deepen till the white capsular fibres show.
- Join the grooves above the veru.
- Median lobe: work distal to proximal. Beak lifts, laser cuts the bands. Coagulate the vessels as they come.
- Coagulate: lower energy, longer pulse, or pull the fibre back a little. Defocused.
- Free it at the bladder neck. Push it into the bladder. Do not undermine the trigone.
- Early apical release: inverted U lateral to the veru, each side. Low power. No traction.
- Divide the 12 o'clock apical mucosal strip early. The sphincter mucosa is never stretched.
- 12 o'clock incision, bladder neck to apex. Defines the top of each lateral lobe.
- Lateral lobes: in at the apex, sweep laterally and up, retrograde. Beak retracts. Peel round till it hangs at the bladder neck. Divide. Into the bladder. Other side the same.
- Haemostasis: turn the flow down to see the bleeders. Coagulate each one. Orifices intact?
- Morcellation: swap to the nephroscope (about 26 Fr) and morcellator. Full bladder, dual inflow. Window up, away from the wall. Suck, then cut. Tip central. Bring the tissue to it. Chips to the trap.
- View lost or bladder empties? Stop the blades. Mushroom at the neck: trim it with a loop.
- 3-way catheter, 20 to 22 Fr. Continuous irrigation. Traction only for bladder-neck bleeding.
- Watch: The plane is the operation. Leave the capsule: sinuses. Stay in adenoma: tissue left. Laser settings are the owner's typical values.
From the UroRef Operative Quick Guide.