Early anterior detachment of the adenoma: a novel approach for en bloc thulium laser enucleation of the prostate

The procedure starts with a circular incision of the apical mucosa at the level of the seminal colliculus. The main novelty is the first identification of the capsular plane on the anterior aspect of the adenoma at the 12 o’clock position, starting from the prostatic apex and reaching the bladder neck. Then, the early detachment of the anterior plane is carried out in the direction of the two lobes at 10 o’clock and 2 o’clock positions. Afterwards, the enucleation is completed dissecting all the posterior aspect of the adenoma with a lateral dissection of the lobes from the early incision of the mucosa above the seminal colliculus towards the previously identified planes. The left lobe is enucleated by developing the surgical plane from 5 o’clock to 2 o’clock position and the right lobe enucleation is carried out following the plane from 5 o’clock to 10 o’clock position.

Tissue morcellation is then carried out using a mechanical morcellator inserted into a nephroscope sheath.

The first identification of the capsular plane in the anterior aspect of the adenoma at the level of the apex allows a better preservation of the mucosa adjacent to the external urethral sphincter, which has a known ‘omega’ shape. Moreover, as the detachment of the anterior plane can be difficult at the end of enucleation, this problem is avoided and enucleation time is reduced.

The novel totally ‘en bloc’ thulium laser enucleation of the prostate (ThuLEP) with early anterior detachment of the adenoma (EADA) may represent a fast, anatomic and safe surgical technique prompting the widespread adoption of laser enucleation for benign prostate enlargement.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

Video can be found at http://ceju.online/journal/2020/thulium-laser-enucleation-of-the-prostate-en-bloc-enucleation-2075.php