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"The process of laser enucleation is similar to peeling an orange but leaving the peel behind," Dr. Mansour says. The removed tissue is then pushed into the bladder in a single piece. Once the prostate tissue has been relocated to the bladder, a morcellator is introduced through the cystoscope. The morcella- tor grinds up the excised prostate tissue and suctions it out of the body, where it can be examined for cancer and other conditions. The entire laser enucleation procedure takes 90 to 150 min- utes to complete and requires general or spinal anesthesia. No abdominal incisions are made, and after a 23-hour period of observation with a catheter in place, patients are usually free to leave the hospital. In comparison, procedures such as open or robotic prostatectomy can require three to four days of hospitalization and up to a week of catheterization. REPLACING OPEN PROSTATECTOMY Due to the aging population, more patients are presenting with larger prostate glands simply as a result of longevity. Furthermore, the success of medical treatment in improving symptoms typically delays the time of surgery by 10 years or more. "As a result, we have to operate on bigger prostates in comorbid patients," Dr. Mansour says. Traditionally, enlarged prostate glands that are over 100 grams in weight require open or robotic prostatectomy for removal. Because laser enucleation is a size-independent procedure, ThuLEP has been used to successfully remove up to 300 grams of enlarged prostate tissue — potentially allowing patients who might not be eligible for open surgery to find relief from BPH symptoms. "The procedure can also be used in patients who are maintained on blood thinners and anticoagulants," Dr. Mansour says. THULEP VS. HOLEP The only major dierence between ThuLEP and HoLEP lies in the type of laser that is used for the procedure. Holmium and thulium lasers have dierent wavelengths and are thus absorbed by dierent substances in the body. Holmium lasers are mainly absorbed by hemoglobin, while thulium lasers are mostly taken Michael Liss, MD, Director of Clinical Research at University Hospital and Assistant Professor of Urology at UT Health San Antonio. Dr. Liss offers fusion-guided prostate biopsy. Robotic surgery in by water. Holmium lasers are pulsed lasers; thulium lasers are continuous. " Thulium provides a knife-like action as opposed to hol- mium's pulse laser," Dr. Mansour says. "Theoretica lly, thulium lasers a re associated with improved hemostasis a nd control of blood vessels, a nd while we've persona lly perceived these improvements, ongoing clinica l tria ls will shed light on the clinica l sig nif ica nce." ADOPTION OF L ASER ENUCLEATION PROCEDURES D e s p i t e t h e e f f e c t i v e n e s s a n d e f f i c i e n c y o f l a s e r enucleat ion ,¥ Un iver sit y Hea lt h S y s t em i s ju s t one of a ha ndf u l¥ of¥ medica l instit utions in t he countr y t hat of fer pro c e du re s¥ s uch a s T hu L E P. D ue t o a l a ck of t r a i n i n g oppor tunities for¥ current a nd soon-to-be surgeons, la ser enucleat ion¥ h a s¥ yet¥ t o receive w idesprea d a dopt ion by the medica l communit y.¥ Universit y Hea lth System hopes to reverse t h is¥ trend by¥ prov id i ng tra i n i ng prog ra ms i n la ser enucleation¥ for surgeons both w ithin a nd outside of the orga nization. " La ser enucleation is perceived a s a dif f icult procedure to lea r n, but t hat 's not wel l-suppor ted in t he¥ literat ure," Dr. Mansour says. "We are one of the few centers¥in¥which¥HoLEP a nd ThuLEP tra ining is being¥incorporated in our residency prog ra m with objective assessments¥tools for¥performa nce metrics. We are in the¥process of developing¥a¥program where M D N E W S . C O M /// M D N E W S S A N A N T O N I O ■ 2 018 0 7