Various techniques can be employed in Holmium Laser Enucleation of the Prostate (HoLEP) based on the surgeon's preference, patient anatomy, and the extent of prostate enlargement.

HoLEP En Bloc Technique

The en bloc technique is a surgical approach used in HoLEP to remove the prostate adenoma as a single piece or “en bloc”. This technique involves enucleating the entire prostate adenoma from its surrounding capsule in one piece rather than fragmenting it into smaller pieces for removal. 

En bloc Surgical Approach

The en bloc technique involves meticulous dissection and enucleation of the entire prostate adenoma from its surrounding capsule in a single piece.

The surgeon starts the enucleation process at the bladder neck and progresses distally towards the prostatic apex, gradually separating the adenoma from the capsule using the holmium laser.

Special attention is paid to preserving the integrity of the prostate capsule and avoiding injury to surrounding structures, such as the sphincter muscle, bladder neck, and neurovascular bundles.

The en bloc technique allows for efficient and complete removal of the prostate adenoma while minimising the risk of intraoperative complications and ensuring optimal clinical outcomes for patients with BPH.

HoLEP Early Apical Release Technique

Early Apical Release is a surgical technique employed during HoLEP to facilitate enucleation and improve surgical outcomes. This technique involves releasing the apical portion of the prostate gland early in the HoLEP procedure before proceeding with the enucleation of the rest of the prostate adenoma. 

Early Apical Release Surgical Approach

The Early Apical Release technique involves accessing the prostate gland transurethrally using a laser cystoscope.

After accessing the prostate, the surgeon identifies and dissects the urethra from the apex (the lowermost part) of the prostate gland.

Once the sphincter is dissected free from the apical portion of the prostate, the surgeon proceeds with the enucleation of the prostate adenoma.

The Early Apical Release technique in HoLEP allows for better exposure of the surgical plane and facilitates the enucleation process, leading to improved surgical outcomes, including postoperative urinary incontinence. 

HoLEP Two-lobe Technique

The two-lobe technique is a surgical approach used in HoLEP to remove the prostate adenoma in two separate lobes. This technique involves enucleating the prostate adenoma from its surrounding capsule in two lobes, typically the left and right lobes. 

Two-lobe Technique Surgical Approach

The two-lobe technique involves accessing the prostate gland transurethrally using a laser cystoscope.

The surgeon identifies and dissects the urethra from the prostate adenoma, creating a plane between the adenoma and the surrounding capsule.

The enucleation process begins with the left lobe of the prostate adenoma, followed by the right lobe.

The two-lobe technique allows for the complete removal of the prostate adenoma under good vision, allowing continual progress. It can be useful in much larger glands where vision is suboptimal. 

HoLEP Three-lobe Technique

The three-lobe technique is a surgical approach used in HoLEP to remove the prostate adenoma in three separate lobes: the left, right, and middle lobes. This technique involves enucleating the prostate adenoma from its surrounding capsule in three distinct lobes. 

Three-lobe Technique Surgical Approach

The three-lobe technique involves accessing the prostate gland transurethrally using a laser cystoscope.

The surgeon identifies and dissects the urethra from the prostate adenoma, creating a plane between the adenoma and the surrounding capsule.

The enucleation process begins with the left lobe of the prostate adenoma, followed by the right lobe. Subsequently, the middle lobe is enucleated separately.

The three-lobe technique is particularly useful in cases where the middle lobe of the prostate is significantly enlarged and requires separate enucleation.