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Reevaluating ‘Top-Down’ HoLEP: the case for anterior fibromuscular stroma as a surgical landmark

Prostate Cancer and Prostatic Diseases (2023)Cite this article

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I was quite surprised by the recent publication from Elmansy et al. [1], especially considering their 2019 article which advocated the ‘Top Down’ surgical approach as being highly beneficial for the widespread adoption of prostate enucleation. They emphasized its efficiency and reduced operation time, although they did not report on postoperative urinary incontinence at the time. To discover now that this technique does not aid in reducing postoperative stress urinary incontinence (SUI), in contrast to the majority of reports starting from the anterior part, is indeed perplexing.

The hallmark of prostate enucleation surgery is its excellent efficacy, as evidenced by patient narratives and uroflowmetry post-surgery, which far surpasses the traditional transurethral resection of the prostate (TURP) results. This has led enucleation surgeons to be deeply enamored with the procedure. However, the occasional but troubling occurrence of postoperative SUI, despite most cases eventually resolving, continues to be a source of distress for both surgeons and patients. The uncertainty of recovery duration contributes to patients’ psychological torment and physicians’ stress, prompting many surgeons to develop various techniques in hopes of reducing postoperative SUI.

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References

  1. Elmansy H, Abbas L, Fathy M, Hodhod A, Shabana W, Alkandari A, et al. Top-down holmium laser enucleation of the prostate (HoLEP) versus traditional HoLEP for the treatment of benign prostatic hyperplasia (BPH): 1-year outcomes of a randomized controlled trial. Prostate Cancer Prostatic Dis. 2023. https://doi.org/10.1038/s41391-023-00730-x. Epub ahead of print.

  2. Endo F, Shiga Y, Minagawa S, Iwabuchi T, Fujisaki A, Yashi M, et al. Anteroposterior dissection HoLEP: a modification to prevent transient stress urinary incontinence. Urology. 2010;76:1451–5.

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Authors and Affiliations

  1. Department of Urology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan

    Yu-Hsiang Lin & Horng-Heng Juang

  2. School of Medicine, Chang Gung University, Taoyuan, 333, Taiwan

    Yu-Hsiang Lin

  3. Department of Anatomy, School of Medicine, Chang Gung University, Kwei-shan, Tao-Yuan, Taiwan

    Horng-Heng Juang

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  1. Yu-Hsiang Lin
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Concept and design: YHL and HHJ; drafting of the manuscript: YHL.; critical revisions to manuscript: YHL and HHJ.

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Correspondence to Yu-Hsiang Lin.

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Lin, YH., Juang, HH. Reevaluating ‘Top-Down’ HoLEP: the case for anterior fibromuscular stroma as a surgical landmark. Prostate Cancer Prostatic Dis (2023). https://doi.org/10.1038/s41391-023-00768-x

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