Anatomical Control of Adenoma Technique: An Accurate Surgical Approach to Thulium Laser Enucleation of the Prostate

OBJECTIVE: To present our 2-lobe technique of thulium laser transurethral enucleation of the prostate. Transurethral resection of prostate and open prostatectomy have been traditionally considered as the gold standard for benign prostatic enlargement surgical treatment. Laser has been recently made available for benign prostatic enlargement surgery to minimize morbidity of traditional surgery.1 In 2009, Bach et al introduced the use of thulium laser,2 describing the 3-lobe technique, which overlaps open prostatectomy but with a greater control of hemostasis.3 Two techniques have been recently published that differ from the original one.4,5 Kim et al described the "All-in-One" technique,4 whereas Wolters et al described a 2-lobe enucleation (left lobe first, then combined enucleation of the right and median lobe).5 We developed a different en block enucleation technique. METHODS: In our 2-lobe enucleation technique, the median lobe is enucleated first, whereas the lateral lobes are dissected and enucleated en bloc. Once the medial lobe is moved into the bladder lumen, the dissection is carried out at 4-o'clock position toward the bladder neck, enucleating the left lobe in an anticlockwise direction. At 12-o'clock position, dissection keeps going beneath the right lobe toward the 9-o'clock position. At this point, an incision is made at 8-o'clock position and enucleation is completed in a clockwise direction toward the 9-o'clock position. The 2 enucleated tissues are finally morcellated. RESULTS: Preoperative prostate volume was 55 cc. Operative time was 36 minutes. The decrease in hemoglobin was 1.1 g/dL 24 hours after surgery. Catheter was removed in first postoperative day and the patient was discharged home. Removed tissue weighed 45 g and showed <5% Gleason score 3 + 3 adenocarcinoma. CONCLUSION: Our enucleation technique may offer perioperative outcomes comparable with other approaches in medium-sized prostates (up to 100 mL), and we believe that is helpful in following correctly the surgical capsule plane. This technique speeds up the procedure and helps to leave no tissue behind.