Morcellator safety in HoLEP: Owning the checklist and recognizing early warning signs

The benign prostatic hyperplasia treatment holmium laser enucleation of the prostate has undergone a quiet but consequential evolution since its introduction in 1998—and surgeons performing the procedure today are operating in a substantially different technical environment than even a decade ago, according to Amy E. Krambeck, MD, a professor of urology at Northwestern University Feinberg School of Medicine and one of the highest-volume HoLEP surgeons in the United States.

Krambeck described the cumulative effect of improvements across laser technology, morcellator performance, scope design, and anesthetic approach as compounding gains that have transformed the procedure's efficiency and patient experience.

"I am probably twice as fast as I was when I first started," she said, attributing the acceleration not only to technical experience but to industry advances in the tools themselves. Laser technology has reduced intraoperative bleeding substantially, and newer morcellators have delivered two- to threefold improvements in tissue removal speed compared with earlier-generation devices. Better inflow and outflow characteristics in current scopes have also contributed.

One change with broad implications for workflow is the shift away from general anesthesia. Krambeck noted that sedation now suffices for the majority of cases, improving hemodynamic stability—and with it, bleeding control—while enabling same-day catheter removal and discharge in most patients.

"It's a significantly different procedure over my career," she said.

Pearls on morcellation during HoLEP

On morcellation — the step that generates the most anxiety among surgeons learning HoLEP—Krambeck identified surgeon accountability as the most fundamental safety principle.

"The most common error that occurs during morcellation is the surgeon not owning every role in the room," she said. Nurses, scrub technicians, and anesthesiologists rotate, but the surgeon is the only constant. Her approach mirrors an aviation checklist: Before initiating morcellation, she verbally confirms that irrigation bags are unclamped, the roller is unobstructed, and inflow is properly connected to the scope.

"I am assured that every piece of the morcellation—the inflow of the fluid, the outflow of the fluid—is hooked up correctly," she said, adding that the checklist should be revisited periodically throughout the morcellation until it is complete.

The second most common error Krambeck sees when proctoring other surgeons is rushing into morcellation before achieving adequate hemostasis.

"People are so excited that they completed the enucleation that they just want to go straight to morcellation," she said. Spending 3 to 5 minutes controlling bleeding with the laser and confirming clear visualization before initiating tissue removal pays dividends during the morcellation itself—because visual clarity is the earliest warning sign of impending trouble.

“If it starts to get murky looking, or you start to see more blood while you're morcellating, that means you have a flow problem," Krambeck said. Decreasing pressure signals compromised inflow, and the first visual indication of that deterioration—murkiness or increased bleeding—is the moment to stop and reassess the system before an injury occurs.

"If you are hyper vigilant to every role, morcellator injury is extremely rare," she said.