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Urologist encourages consideration of early apical release HoLEP technique


"For those who do enucleations, I think I would encourage people to highly consider adopting an apical release technique if they haven't," says Daniel J. Heidenberg, MD.

In this video, Daniel J. Heidenberg, MD, shares the take-home message from the recent Urology paper, “The Impact of Standard vs Early Apical Release HoLEP Technique on Postoperative Incontinence and Quality of Life.” Heidenberg is an endourology fellow at Mayo Clinic in Phoenix, Arizona.


What is the take-home message for the practicing urologist?

For those who do enucleations, I think I would encourage people to highly consider adopting an apical release technique if they haven't. But if you don't, and you're doing what most practicing urologists are doing, like the TURPs, or GreenLights, and stuff like that, I think a lot of private practice people already do this to a degree. So I think that they've been really wise and learning from their experiences, but I think this just adds to the support that to open up a nice channel laterally and posteriorly is great, and then anteriorly, if you want to be conservative up there, with the counseling to the patients that that may mean you're coming back more, because with HoLEPs you get more tissue out, but if you're not an enucelator, and you're doing TURPs and GreenLights and those things, I think you're practicing great urology, and just knowing that anatomy of the sphincter as it pertains to BPH, that just helps people.

Is there anything you would like to add?

The tough part about enucleation...is everybody always talks about how many case numbers you need to become proficient. And I think that that's really tough in the setting of residency training and stuff like this, with apical release being such a critically important part of it. And so, I think at some point, we, as the people in academics, have to allow some hands-on experience for the people who are training in order for them to master the skill that they can take to help patients. And so going forward, we're working on a grading system right now of the apex, and I think we're not necessarily focusing on this particular thing, but with experience, of course, things are always better. We're working on trying to find a way that...if the sphincter kind of looks like this, maybe we need to know that this person probably ought to start pelvic floor PT and really get on it, or if it really does look great we can be maybe a little bit less proactive and just follow up and knowing with some sort of statistics that the odds of them having a stress incontinence issue at 6 weeks or 3 months are pretty low. So I think we're working on that as a way to help us counsel patients postoperatively. And then I think long term, I think more work, and a lot of great work is being done in this space, but the more we can do to try to figure out exactly how much that sphincter at the top is involved with the continence mechanism going forward, because what happens is the skeletal muscle—this is what I suspect; I don't have any pure anatomical models to tell people—but I think that that muscle and the interstitial tissue, and then the BPH all kind of starts to fuse. So in some people, especially as they age, it may become that it's all intertwined. I think this is a common talk that many people may suggest, I think it's totally valid, or they say, "in some of the older guys, the prostate's been doing the work of the sphincter for a lot of years, and then you un-obstruct them and the sphincter needs to put in some work to get strong again." I think that there's probably some merit to that, but also, there may be the idea that anteriorly they may have become a little bit more fused; how much, I don't know. And I think there's a lot we all could stand to learn in this space. But I think there's exciting research to be done ahead. And I look forward to learning from many of my other colleagues who I'm sure will have some great ideas down the road too.

This transcription was edited for clarity.

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