Abstract
The biomedical industry is working full-time to get to the urologists better but miniaturized equipment with an aim to provide improved results with reduced complications. No wonder our percutaneous tracts, flexible ureteroscope size and port sizes are all steadily reducing. It would then be logical to assess if better holmium laser enucleation of prostate (HoLEP) can be achieved through a smaller resectoscope sheath.
The study by Dean et al. have prospectively looked at the impact of the resectoscope sheath size on the intraoperative and immediate postoperative results of HoLEP. 1 They observed that the larger (28F) sheath provided better irrigation leading to better vision, hence, better hemostasis and lesser hematuria. This led to early catheter removal, shorter length of stay, and higher possibility of same-day discharge from hospital. As the sheath size did not impact emergency room presentations, re-admissions, complications, or functional outcomes, the authors have, contrary to expectations, concluded that smaller sheath provided no clear advantage in the early outcomes, rather led to reduced possibility of ambulatory HoLEP.
The authors, in their short 90-day follow-up, did not find any patient with urethral stricture or bladder neck contracture (BNC) in this study. They propose a secondary analysis with a longer follow-up to assess if sheath size impacted these complications. It is a classical teaching that larger sheath and longer procedure could lead to higher incidence of urethral stricture, hence, such analysis would be very important and interesting to see if smaller size reduces these complications. It is unlikely for the BNC to be related to sheath size. None of the studies looking at the etiology of BNC after transurethral BPH procedures mention scope size as a risk factor. 2 –4 Even Felipe de Figueiredo and Teloken who described minimally invasive laser enucleation of the prostate 5 have not mentioned about the reduction of BNC by reducing the size of the resectoscope sheath.
One more basic question needs to be pondered upon. Is pushing for same day discharge after HoLEP really necessary? A lot of the patients undergoing HoLEP have large adenomas, are in older age bracket, and may have a higher risk of associated comorbidities. Apart from few countries, ambulatory HoLEP may not be a fascinating concept in most of the world. Keeping the patient under observation for 24 hours would surely be much safer. Also, the 13%–18% risk of emergency room visit is far higher than the common experience (<2%) when patient is observed in-hospital for a longer duration.
Smaller sheath may have a small disadvantage during morcellation as the irrigation may be compromised and risk of mucosal injury may be higher. Apart from this, smaller sheath would reduce the need for urethral dilatation or urethrotomy, may reduce the risk of incontinence, and logically should reduce the risk of urethral stricture on longer follow-up. 4 With improvements in morcellation technology, miniaturization may still be a way to go even for HoLEP.