Pacchetti Andrea, Pirola Giacomo Maria, Berti Lorenzo, Palumbo Mara, Ietto Giuseppe, Carcano Giulio, Terrone Carlo, Saredi Giovanni
Department of Urology, University of Genoa, Genoa, Italy.
Department of Urology, San Donato Hospital, Arezzo, Italy.
Urology. 2019 Feb;124:307. doi: 10.1016/j.urology.2018.11.006. Epub 2018 Nov 16.
To present a reproducible step-by-step approach to en bloc thulium laser enucleation of the prostate (ThuLEP) for benign prostatic hyperplasia surgical treatment. Laser adenoma enucleation is nowadays a recognized surgical treatment for benign prostatic enlargement. Some variants to the classical 3-lobes laser technique have been proposed, in order to overcome the main concerns regarding the original procedure. After a vast experience with the 3-lobes ThuLEP, we developed our own en bloc enucleation technique.
The capsular plane is identified only once, at the level of the prostatic apex, at 5 o'clock; this plane is followed ascending towards the bladder neck, separating the left lobe from the prostatic capsule from 5 to 11 o'clock. The right and median lobes are then enucleated following the same plane clockwise and the 2 planes are joined anteriorly at 11 o'clock. Finally, enucleation is completed by incising the remaining mucosal flap from 10 to 2 o'clock. We have already proved the clear advantages provided by this technique compared to the "3-lobes" enucleation. RESULTS: Our single-center experience with this technique includes 140 procedures performed up to June 2018. Mean prostatic adenoma volume was 66.7 mL (range 20-220 ± 32.85 standard deviation [SD]). Mean total surgical time was 60.93 minutes (25-133 ± 23.6 SD); mean enucleation time was 18.3 minutes (8.2-36.53 ± 5.62 SD), mean enucleation time normalized per adenoma gram was 0.32 min/g (0.12-0.8 ± 0.15 SD) and mean energy needed for the enucleation normalized per adenoma gram was 1852.13 J/g (689-6129 ± 862.4 SD). Only 1 case of reintervention for clot evacuation (Clavien grade IIIb) was necessary.
En bloc ThuLEP provides an anatomical approach for endoscopic enucleation of prostatic adenoma. We believe that this sequence optimizes efficiency and efficacy in a reproducible way.
介绍一种可重复的、逐步进行的整块铥激光前列腺剜除术（ThuLEP）用于良性前列腺增生手术治疗的方法。激光腺瘤剜除术如今是一种公认的治疗良性前列腺增生的手术方法。为了克服对原始手术方法的主要担忧，人们提出了一些经典三叶激光技术的变体。在对三叶ThuLEP有丰富经验后，我们开发了自己的整块剜除技术。
仅在前列腺尖部5点钟位置识别一次包膜平面；沿此平面向上朝着膀胱颈分离，从5点钟至11点钟将左叶与前列腺包膜分开。然后沿同一平面顺时针方向剜除右叶和中叶，两个平面在11点钟位置前方汇合。最后，通过从10点钟至2点钟切开剩余的黏膜瓣完成剜除。我们已经证明了该技术与“三叶”剜除术相比具有明显优势。
我们单中心应用该技术的经验包括截至2018年6月进行的140例手术。前列腺腺瘤平均体积为66.7 mL（范围20 - 220，标准差[SD]为±32.85）。平均总手术时间为60.93分钟（25 - 133，SD为±23.6）；平均剜除时间为18.3分钟（8.2 - 36.53，SD为±5.62），每克腺瘤的平均归一化剜除时间为0.32分钟/克（0.12 - 0.8，SD为±0.15），每克腺瘤的平均归一化剜除所需能量为1852.13 J/克（689 - 6129，SD为±862.4）。仅1例因血凝块清除需要再次干预（Clavien IIIb级）。
整块ThuLEP为前列腺腺瘤的内镜剜除提供了一种解剖学方法。我们认为这种手术步骤以可重复的方式优化了效率和效果。
