En-Bloc Holmium Laser Enucleation of the Prostate with Early Apical Release: Are We Ready for a New Paradigm?

Abstract

Background:

Holmium laser enucleation of the prostate (HoLEP) is considered a safe and effective treatment in case of bladder outlet obstruction (BOO). Despite technical execution has evolved over time, from the standard three-lobes to the more recent en-bloc approaches, data comparing these two techniques are missing. The aim of the present study was to describe our en-bloc HoLEP with early apical release technique and compare peri- and postoperative results with the classical three-lobe approach in a single referral center.

Materials and Methods:

We prospectively analyzed all consecutive cases between 2017 and 2019 divided according to the type of approach. Patients were preoperatively studied through instrumental assessment and clinical evaluation, using validated questionnaires and then postoperatively at specific time frames. Linear regression analysis was performed to evaluate possible predictor of continuous variables. All the procedures were carried out by one single expert surgeon.

Results:

Overall, 168 patients were included, of which 81 were treated with classical three-lobes and 87 with en-bloc with early apical release technique. The two cohorts were comparable related to preoperative features and postoperative complication rate. Mean enucleation time (ET), lasing time, amount of energy delivered, and overall operative time were significantly lower in en-bloc procedures (p < 0.05). Stepwise multivariable linear regression showed that en-bloc strategy can significantly predict shorter ET and lower energy delivered. Stress incontinence rate at 1-month follow-up was found to be significantly reduced in the en-bloc group, compared with the counterpart.

Conclusions:

Both techniques are effective and safe treatment options for BOO, since peri- and postoperative surgical and functional outcomes were favorable. En-bloc strategy may significantly decrease ET and the amount of energy delivered leading to a reduced early stress incontinence rate compared with the standard approach.

Introduction

Laser technology is nowadays adopted within the main surgical treatments for benign prostatic hyperplasia (BPH) and, according to the latest European guidelines on non-neurogenic male low urinary tract symptoms¹ and on laser technologies,² holmium:YAG (Ho:YAG) laser enucleation of the prostate (HoLEP) can be offered to any patient with bladder outlet obstruction and BPH, regardless of the prostate volume.

The potential advantages of Holmium laser rely on mirroring the general principles of the open simple prostatectomy (OSP), thanks to the steam bubble emitted from the pulsed laser energy,³ together with the minimal invasiveness and better hemostasis of the transurethral resection of the prostate (TURP).⁴

In 1998 HoLEP was first introduced in its classical three-lobe technique⁵ and, in few years, has been shown to be equivalent in terms of safety and efficacy to OSP⁶ and TURP⁷ with superior urodynamic relief of obstruction.⁸

Nevertheless, it requires a relevant endoscopic experience, a non-negligible steep learning curve⁹ and seemed to be burden by relevant urinary incontinence (UI) rate, ranging between 1.3% and 44% among the available studies.^10,11

More recently, the “en-bloc” techniques have emerged. Theoretical advantages of such approach reside in a faster identification of the surgical capsule and the plane to dissect, thus reducing the operating time (OT), the amount of energy delivered, and bettering the sphincter preservation.^4,12

–16 Despite several en-bloc variants have progressively been proposed, still no authors compared surgical and functional outcomes between the en-bloc and the standard three-lobe technique.

To fill this gap, we aimed to compare our en-bloc laser enucleation of the prostate to the classical three-lobe technique in a single referral center, focusing on early and mid-term surgical and functional outcomes.

Materials and Methods

Development of the holmium laser technology program

Since Ho:YAG laser was first introduced in our center in 2017, we developed an institutional structured laser technology program for BPH, including one surgeon (A.T.), highly skilled in endoscopic prostatic surgery (>500 procedures); a mentor; and a nursing staff, trained on laser technology. The program followed a step-by-step approach to familiarize with laser technology. Namely, the first phase consisted in observing 10 procedures executed by an expert HoLEP surgeon (mentor). Twenty consecutive standard three-lobe procedures were then performed under the supervision of the dedicated mentor (second phase). Subsequently, our surgeon started carrying out the surgeries alone and collected 101 three-lobe prostate enucleations. The en-bloc enucleation principles were initially acquired from the experience with Green-light laser enucleation of the prostate. Finally, in 2018, he moved to en-bloc HoLEP performing 87 consecutive cases. A structured training program for the en-bloc approach was not followed and the surgeon progressively increased his experience as self-thought, relying on the general surgical principles described by Saitta and colleagues.¹⁷

Population data

After internal Review Board approval was obtained, we retrospectively reviewed our prospectively collected data on all patients submitted to HoLEP. Criteria for laser surgery were: (1) symptomatic BPH not responsive to medical therapy, according to EAU guidelines¹; (2) preoperative max flow rate (Q _max) at flowmetry <15 mL/sec and/or postvoid residual (PVR) >100 mL; (3) prostate volume >60 cc according to abdominal/transrectal ultrasound (US); and (4) availability of the dedicated surgeon.

History of previous acute urinary retention, indwelling catheter at surgery, high comorbidity burden, and antiplatelet/anticoagulant therapy were not considered exclusion criteria.

Conversely, we excluded the first 40 cases considered as surgeon's learning curve phase, according to previous available evidence.⁹ Other exclusion criteria were the concomitant diagnosis of bladder tumor, history of TURP, presence of large bladder calculi (>5 cm) unmanageable endoscopically.

Finally, we analyzed all consecutive cases from August 2017 to October 2019 divided into two groups according to the type of approach (three-lobe vs en-bloc).

All patients underwent a preoperative laboratory and imaging analysis, including uroflowmetry with PVR urine examination, prostate-specific antigen (PSA), and abdominal US. Clinical evaluation and symptoms were assessed using validated questionnaires: The International Prostate Symptom Score (IPSS) questionnaire, the International Index of Erectile Function (IIEF), the International Consultation on Incontinence Modular Questionnaire (ICIQ-UI), the Overactive Bladder questionnaires (ICIQ-OAB), and the Quality of Life index were used. Patients revealing incontinence symptoms were not investigated with urodynamic study since the difference between urgency urinary incontinence (UUI) and stress urinary incontinence (SUI) was based on the abovementioned questionnaires.¹⁸

Postoperative complications were registered using the modified Clavien–Dindo classification scale¹⁹ and divided in “early” and “late” since they occurred before or after the 30th postoperative day.

All patients were assessed at 1-, 3-, 6-, and 12-month postoperatively and therefore annually with uroflowmetry, PVR urine examination, PSA and creatinine measurement, and symptomatologic assessment (using the abovementioned questionnaires).

At the third month follow-up, Patient Global Impression of Improvement (PGI-I) scale were submitted to all patients.

Urinary incontinence was defined as any involuntary urine leak, including postvoid dribbling, regardless the number of pads used.

Surgical technique

Surgical instrumentation

All procedures were carried out under general anesthesia using the 120 W VersaPulse Holmium Laser Machine (Lumenis, Yokneam, Israel). Five hundred fifty micrometer caliber end-firing laser fibers were adopted and laser energy was set at 2 J × 45 Hz, 90 W for enucleation, and 2 J × 30 Hz, 60 W for coagulation. Continuous flow 26F resectoscope (Karl Storz, Tuttlingen, Germany) and classical 30° optic were employed. A mechanical transurethral morcellator (Versacut; Lumenis) inserted by means of a nephroscope sheath was used in all procedures.

Three-lobe technique

Classical three-lobe technique was performed in accordance to Gilling and colleagues' approach.⁵

Briefly, the bladder neck is incised deeply at 5 and 7 o'clock with the incisions brought to the level of the verumontanum on each side. If present, the median lobe is enucleated first moving toward the bladder neck after joining the two incisions distally. The two lateral lobes are dissected separately in a backward fashion and pushed into the bladder.

En-bloc technique

A detailed description of surgical steps is depicted in Figures 1 and 2. At preliminary cystoscopy, the identification of the external sphincter's wrinkle (Nesbit sign) is considered a crucial landmark, defining the limit between the prostatic adenoma and the urethral sphincter (Fig. 1a, b). The procedure starts with a circular incision at the level of the apex near the proximal edge of the external sphincter, using low-power emission (60 W) (Figs. 1c and 2a). Subsequently, two semicircular incisions are performed laterally on both sides, at the level of the Nesbit sign, from the verumontanum up to 12 o'clock (Figs. 1d, e, and 2b). The two incisions are deepened and merged cutting horizontally the crista urethralis resulting in a complete demarcation of the apex from the sphincter (Fig. 1f). The tip of the scope is placed between the verumontanum and the lateral lobe and the dissection plane is conducted firing the laser beam into the adenoma. As such, the apex is gradually freed leaving a slight edge of soft tissue to minimize any possible mechanical traction on the sphincter (Fig. 2c). Once the apex is released, the enucleation is completed circumferentially toward the bladder neck. The median lobe, if present, is enucleated together with the lateral lobes. The entry to the bladder is pursued anteriorly, between the adenoma and the capsule (Fig. 2d). The bladder neck is then cut circumferentially until the adenoma can be flipped and pushed into the bladder (Fig. 2e). Then, if necessary, an accurate hemostasis is performed with bipolar energy and the adenoma is morcellated following the standard precautions.

FIG. 1.

Intraoperative surgical phases of the early apical release: (a) and (b) identification of the Nesbit Sign; (c) semilunar incision at12 o'clock; (d) and (e) lateral semicircular incisions at the level of the Nesbit sign; (f) completion of the dissection of the prostate apex from the sphincter. Color images are available online.

FIG. 2.

Surgical steps of the en-bloc with early apical release technique: (a) incision at the apex at 12 o'clock and laterally at the Nesbit Sign; (b) Incision of the crista urethralis; (c) circumferential dissection of the apex from the sphincter leaving a slight edge of soft tissue; (d) entry into the bladder; (e) completion of the en-bloc enucleation. Color images are available online.

Statistical analysis

Data were recorded using Microsoft Excel and analyzed using SPSS^® 26.0 (IBM Corporation, Armonk, NY). Categorical, continuous parametric, and nonparametric variables were reported as frequencies and proportions, mean and standard deviation, or as median and interquartile range (IQR), respectively. Unpaired t-test, Mann–Whitney and Pearson's chi-square tests were used to compare variables, as appropriate. To evaluate possible predictors of surgical outcomes (such as OT), multivariable linear regression analysis was performed using stepwise regression method to determine the best-fitting model. Statistical significance in this study was set as p ≤ 0.05.

Results

Overall 168 patients were included for quantitative analysis and divided in 81 patients treated with standard three-lobe technique (group A) and the 87 with en-bloc approach (group B).

The two cohorts were found mostly comparable relatively to preoperative characteristics (Table 1).

Table 1.

Patient's Preoperative Characteristics

	Standard three-lobe technique (Group A), n = 81	En bloc technique (Group B), n = 87	p
Age, median (IQR), years	69 (64–74)	70 (64–74.5)	0.5
ASA score, n (%)
1	2 (2.4)	5 (5.5)	0.5
2	72 (88.9)	77 (88.5)
3	7 (8.6)	6 (6)
CCI age adjusted ≥5, n (%)	14 (17.3)	18 (20.7)	0.4
BMI, median (IQR)	26.1 (24.5–28.6)	26.3 (24.2–28.7)	0.5
PSA preop, median (IQR), ng/mL	5.8 (2.8–7.4)	3.8 (2.3–6.8)	0.6
Major CV disease, n (%)	21 (26)	25 (28.7)	0.2
BPH therapy, n (%)
α-Blocker	35 (43.2)	45 (51.7)	0.06
5-α-Reductase inhibitor	4 (5)	2 (2.3)
Both	25 (30.8)	34 (39)
AP/AC therapy at surgery, n (%)
Single AP	7 (8.6)	12 (13.7)	0.2
Double AP	0 (0)	0 (0)
AC	2 (2.4)	0 (0)
Bridging to LMWH	1 (1.2)	5 (9.1)
AUR, n (%)	40 (49.3)	39 (44.8)	0.8
Indwelling catheter, n (%)	22 (27.1)	23 (26.4)	0.5
Prostate volume preop, median (IQR), mL	102.5 (80.5–130)	100 (76.5–120)	0.3
Bladder diverticula, n (%)	4 (4.9)	6 (6.9)	0.8
Bladder stones, n (%)	12 (13.8)	6 (6.9)	0.1
Creatinine serum level preop, median (IQR)	1 (0.9–1.2)	0.9 (0.9–1.1)	0.9
HB blood level preop, median (IQR)	14 (13.1–15.2)	14.9 (13.7–15.3)	0.03
Preoperative functional features
Q _max preop, median (IQR), mL/s	8.4 (7–9.8)	8.2 (7–10)	0.3
PVR preop, median (IQR), mL	200 (105–445)	100 (50–200)	0.1
UUI preop, n (%)	4 (5)	15 (17.2)	0.01
IPSS preop, median (IQR)	24 (22–27.5)	24.5 (20–28)	0.4
QoL preop, median (IQR)	4 (3–5)	4 (3–5)	0.8
OAB-q SF preop, median (IQR)	40 (27–55)	50.5 (35.8–65)	0.01
ICIQ-SF preop, median (IQR)	0 (0–0)	0 (0–0)	0.1
IIEF preop, median (IQR)	17 (12–20)	16 (8–21)	0.6

Bold values indicate statistically significant p-values (p < 0.05).

AC = anticoagulant; AP = antiplatelets; AUR = acute urinary retention; BMI = body mass index; BPH = benign prostate hyperplasia; CCI = Charlson comorbidity index; CV = cardiovascular; HB = hemoglobin; IIEF = international index of erectile function; IPSS = international prostate symptom score; IQR = interquartile range; PVR = postvoid residual; QoL = quality of life; UUI = urge urinary incontinence.

Perioperative complication rates were similar between the cohorts, whereas mean enucleation time (ET), lasing time (LT), amount of energy delivered, and overall OT were significantly lower in en-bloc procedures (p < 0.05) (Table 2). Stepwise linear regression models (Table 3) showed that en-bloc technique was associated with shorter ET (coefficient β −12.1; 95% CI −16.7 to 8.7) and lower amount of energy released (coefficient β −4.8; 95% CI −9.3 to 1.4); surgeon's experience (namely the increasing number of procedures conducted) and larger prostate volume were found to positively affect shorter overall OT (coefficient β −0.1; 95% CI −0.2 to 0.05 and coefficient β 0.4; 95% CI 0.3–0.5, respectively) and ET (coefficient β −5.3; 95% CI −9.6 to 3.4 and coefficient β 0.17; 95% CI 0.1–0.2, respectively); using of anticoagulants or antiplatelet therapy were associated with higher amount of energy delivered (coefficient β 3.9; 95% CI 1.3–8.2) (all p < 0.05).

Table 2.

Peri- and Postoperative Results

	Standard three-lobe technique (Group A), n = 81	En bloc technique (Group B), n = 87	p
Intraoperative features
Overall operative time mean (SD), minutes	102.7 (±35.1)	84.5 (±29.4)	0.001
Enucleation time, mean (SD), minutes	55.2 (±16.2)	43.2 (±14)	0.001
Morcellation time, mean (SD), minutes	26.2 (±17.5)	20.9 (±15.9)	0.06
Lasing time, mean (SD), minutes	36.9 (±10.5)	32.1 (±8)	0.02
Energy delivered, mean (SD), kJ	146.2 (±37.9)	122.6 (±44.6)	0.01
Intraoperative complication, n (%)	11 (13.6)	5 (5.7)	0.2
Postoperative features
Catheterization time, mean (SD), days	3.6 (±2.8)	3 (±0.9)	0.07
Hospitalization time, mean (SD), days	4.4 (±1.6)	4.1 (±1.1)	0.2
Δ decreasing creatinine, mean (SD)	0.4 (±0.1)	0.0 (±0.2)	0.3
Δ decreasing HB, mean (SD)	1.4 (±2.3)	1.8 (±2.7)	0.4
Early Postop complications ≤30 days, n (%)	9 (11.1)	16 (18.2)	0.3
Clavien–Dindo classification, n (%)
2	8 (10):6 atb for UTI; 2 catheter replacement for clots retention	14 (16):12 atb for UTI; 2 transfusion for hematuria
3a	0 (0)	0 (0)
3b	1 (1.2):Reintervention for clots removing	1 (1.1):Reintervention for clots removing
4	0 (0)	1 (1.1):Sepsis
Late Postop complication >30 days, n (%)	2 (2.5)	3 (3.5)	0.8
Clavien–Dindo classification, n (%)
2	0 (0)	2 (2.2):Progressive urethral dilatation for urethral stenosis
3a	0 (0)
3b	2 (2.5):Reintervention for persistent LUTS; urethrotomy for urethral stenosis	1 (1.1):Urethrotomy for urethral stenosis
4	0 (0)	0 (0)
Incidental pCa at histopathological examination, n (%)	4 (4.9)	4 (4.6)	0.9
Functional outcomes (at 3-month follow-up)
Δ increasing Q _max, mean (SD)	15 (±7.3)	16 (±10.1)	0.4
Δ decreasing PVR, mean (SD)	209.4 (±170.5)	133.1 (±167.7)	0.2
Δ decreasing PSA, mean (SD)	4.8 (±5.2)	3.5 (±3.4)	0.3
Δ decreasing IPSS, mean (SD)	19.1 (±5.2)	18 (±7.1)	0.3
Δ decreasing QoL, mean (SD)	3.1 (±1.6)	2.7 (±1.7)	0.1
Δ decreasing OAB-q SF, mean (SD)	25.8 (±19.3)	30.8 (±20.1)	0.1
Δ decreasing ICIQ-SF, mean (SD)	0.4 (±4.4)	0.3 (±5.4)	0.9
Δ increasing IIEF, mean (SD)	0.3 (±3.3)	0.6 (±3.9)	0.2
PGI postop, n (%)
1 extremely improved	31 (38.2)	33 (38)	0.2
2 very improved	39 (48.1)	43 (49,4)
3 slightly improved	7 (8.6)	6 (6.9)
4 no improvement	3 (3.7)	5 (5.8)
5 slightly worsened	0 (0.0)	0 (0.0)
6 very worsened	1 (1.2)	0 (0.0)
7 extremely worsened	0 (0.0)	0 (0.0)
UI at 1-month FU, n (%)
UUI	13 (16)	7 (8)	0.1
SUI	11 (13.5)	4 (4.5)	0.03
UI at 3-months FU, n (%)
UUI	5 (6.1)	3 (3.5)	0.6
SUI	4 (4.9)	2 (2.3)
UI at 6-months FU, n (%)
UUI	2 (2.7)	3 (3.5)	0.6
SUI	4 (4.9)	2 (2.3)
Follow-up, mean (SD), months	18.6 (7.3)	9.7 (6.2)

Bold values indicate statistically significant p-values (p < 0.05).

ATB = antibiotics; UTI = urinary tract infection; LUTS = low urinary tract symptoms; PCa = prostate cancer; PGI = patient global impression of improvement; PSA = prostatic-specific antigen; SD = standard deviation; SUI = stress urinary incontinence; UI = urinary incontinence.

Table 3.

Multivariable Regression Model for Variables Included Following Stepwise Method

Variables	Overall operative time				Enucleation time				Amount of energy delivered
Variables	Coefficient β	Standard error	95% CI	p	Coefficient β	Standard error	95% CI	p	Coefficient β	Standard error	95% CI	p
Surgical technique (three-lobes vs en-bloc)	−2.9	6.2	−15.3 to 9.4	0.6	−12.1	2.01	−16.7 to −8.7	0.001	−4.8	6.3	−9.3 to −1.4	0.001
Prostate volume	0.4	0.05	0.3 to 0.5	0.004	0.17	0.02	0.1 to 0.2	0.001	0.15	0.1	−0.05 to 0.37	0.1
Consecutive procedures conducted	−0.1	0.05	−0.2 to −0.05	0.004	−5.3	0.4	−9.6 to −3.4	0.02	−0.5	0.1	−0.85 to 0.20	0.3
AC/AP at surgery (vs not-users)	8.1	6.4	−4.5 to 20.7	0.2	6.1	2.9	−0.2 to 11.9	0.1	3.9	12.7	1.3 to 8.2	0.002

Bold values indicate statistically significant p-values (p < 0.05).

Regarding functional results, while UUI was found similar at first month after surgery (16% vs 8%, p = 0.1), SUI rate showed a significant difference between the two cohorts at the first assessment. In fact, based on clinical evaluation, 11 (13.5%) and 4 (4.5%) patients referred stress involuntary urinary leak, in standard and en-bloc approach, respectively (p = 0.03). SUI rate progressively decreased in both groups and settled at 4.9% vs 2.3% at the third and sixth month follow-up (p > 0.05).

At the third month follow-up, PGI-I attested an overall strong perceived benefit in 87% of the population, in both cohorts (p > 0.05).

Discussion

To the best of our knowledge, the current article is the first comparing standard three-lobe and en-bloc HoLEP.

The three-lobe technique is still recognized as the standard for holmium prostate enucleation, but its main pitfall remains the correct identification of the surgical capsule. Developing “false planes,” in fact, often impairs the completeness of the enucleation itself and causes postoperative complication such as UI.¹⁷

UI after HoLEP is often cited as a concerning impairment as it decreases patients' quality of life,²⁰ despite the extremely variable rate reported in literature.^10,21 Several mechanisms have been proposed to explain the occurrence of early postoperative incontinence. Related to urgency UI, the healing of the fossa associated with urinary tract infection and the possible thermal injuries of the prostatic capsule by laser exposure are the most quoted causes.^22
–24 Regarding SUI, possible explanations include the prolonged stretching of the sphincter and tractions needed to reach the capsule during the classical three-lobe technique, which may damage the musculus sphincter urethrae glaber (lissosphincter) running underneath the striated sphincter closely related to the mucosa.¹⁷

To exceed such inconvenience, several en-bloc techniques have progressively emerged^17,25,26 aiming to facilitate crucial surgical steps and reducing the risk of mismatching the surgical plans.

Our findings showed a significant lower OT, ET, LS, and amount of energy delivered during en-bloc procedures compared with the standard three lobes, confirming the likely easier identification of the surgical plane and the faster achievement of a complete enucleation, as proposed by previous authors.^17,27

Linear regression models substantiated that the surgical strategy (en-bloc vs three-lobe) can predict lower ET and amount of energy released while, on the other hand, the overall OT has shown to be most affected by prostate volume and surgical experience since a consistent part of it is determined by the need time for morcellation.

Moreover, we believe that starting the dissection at the level of the apex had also a relevant impact on these surgical outcomes. Namely, preserving the bladder neck and incising its fibers last helped in maintaining a laminar irrigation as both, inflow and outflow, occurred in the small space between the capsule and the adenoma. This aspect, avoiding losing irrigation and reducing bleeding from the neck, significantly improved the visualization during the procedures and thus the ET.

Related to functional outcomes, our findings confirmed those available in literature in particular in terms of improving outlet obstruction, reducing urgency, and bettering sexual functions.^28,29

Interestingly, our evidence showed a significant decrease of SUI rate in patients submitted to en-bloc technique compared with those submitted to standard method, at 1-month follow-up (13.5% vs 4.5%; p = 0.03).

Again, the early apical release, performed during our en-bloc procedures, has positively affected this finding. In particular, this step is crucial to preserve the sphincter competence through three concepts: (1) it avoids traction to the sphincter during the anterior and lateral enucleation; (2) it avoids tearing the sphincteric mucosal ring on each side of the verumontanum during upward dissection of the apex; (3) it keeps the anterior mucosa of the sphincter attached to the capsule avoiding it to unstick from the striated sphincteric muscle.³⁰

Moreover, lowering the amount of energy delivered to the prostatic capsule during en-bloc surgeries (p < 0.05) may have reduced potential thermal injuries to the sphincter mucosa, participating to the faster continence recovery in this group.

The gap in terms of SUI rate, however, decreased with time up to become comparable between the two groups at the 3- and 6-month follow-up confirming the transitory nature of the most incontinence events, according to previous reports.^14,25,26

Based on our experience, we also recognized two main surgical drawbacks related to en-bloc technique with early apical release: First, in prostate with long anteroposterior diameter, this step may leave a slight amount of adenomatous tissue at 12 o'clock, proximate to the sphincter. This remnant can be removed in a succeeding step or maintained, whereas not bulky. Second, when facing with high-volume prostate with no intravesical protrusion and predominant posterior growing, a considerable strain may be necessary to expose the surgical plane during the dissection at the level of the bladder neck.

Our study is not devoid of limitations: (1) since we analyzed consecutive cases in two different time frames, skill acquisitions and the improved expertise of the surgeon may have partially biased the results; (2) our results are related to a single surgeon and referral center. This might potentially limit the generalizability of the findings; (3) the difference in follow-up length between the two cohorts may have prevented assessment of possible late complications, especially in the en-bloc group.

Acknowledging these limitations, the current study is the first comparing standard three-lobe and en-bloc HoLEP aiming to provide useful evidence on surgical, postoperative, and functional outcomes, at specific time frames. Furthermore, through linear regression models, the present study showed a positive impact of en-bloc strategy on reducing ET and the amount of energy delivered. We strongly believe that the early apical release added further benefits to this technique: through an improved anatomical dissection of the prostatic apex and a better preservation of urethral integrity, this surgical step may ultimately lead to a lower transient urinary incontinence rate.

As such, if confirmed by larger prospective series, these evidences may contribute to a changing in HoLEP trend, moving beyond the standard approach toward a new paradigm.

Conclusions

Both en-bloc and standard HoLEP techniques are effective and safe treatment options for BPH since surgical and functional outcomes, as well as complication rates were favorable. By the adoption of structured and well-defined surgical principles, particularly the early apical release, the en-bloc strategy may significantly shorten the OT and the amount of energy delivered leading to a reduced early stress incontinence rate, as compared with the standard technique.

Footnotes

Author Contributions

A.T.: Project development and article writing; A.A.G.: Article writing and analysis; F.S.: Data collection and analysis; M.S.: Data collection; R.T.: Data collection and analysis; A.C.: Data collection and analysis; L.V.: Data collection; P.V.: Data collection; M.D.C.: Data collection; F.D.M.: Data collection and analysis; A.M.: Article editing and analysis; M.C.: Project development and article editing; A.M.: Project development and article editing.

Acknowledgment

The authors would like to thank Lorenzo Leccese for the technical steps' illustration.

Informed Consent

Informed consent was obtained from all individual participants included in the study. All the procedures were in accordance with the ethical standards of the Institutional and National Research Committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Availability of Data and Materials

Dataset in which data have been collected and employed for the present study is available to the corresponding author

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Abbreviations Used

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