Need for upper urinary tract stenting in cases of ureteral orifice injury during laser enucleation of the prostate
We have read this article by Enikeev et al.  with huge interest and would like to compliment the authors for this wonderful study. We have few thoughts that we would like to share on this topic.
We have been performing holmium laser enucleation of prostate (HoLEP) for nearly 20 years with an experience of more than 1500 enucleation procedures. In our view, the 1.5% incidence of ureteric injury in this study is very high and probably unacceptable. Our incidence of ureteric orifice injury is extremely low. We feel it is related to few important precautions that we have incorporated in our HoLEP technique.
Always look for the orifice before you start the procedure.
See to it that the bladder neck incision does not enter the bladder or trigone.
The risk of injury is highest when the terminal disconnection of the median lobe is being performed. This is when the partially enucleated median lobe gets upturned in the bladder and blocks the view of the ureteric orifices making them prone to injury. At this time, when you are near the bladder neck, it is a good idea to let the bladder partially over fill. Reduce the outflow while maintaining the inflow. When the bladder fills, the orifice would move away from the bladder neck and the risk of injury would reduce.
Do not cut with the laser blindly. Keep the laser fiber continuously under vision. When disconnecting the terminal attachments of the median lobe from the bladder neck, cut towards the bladder neck and not towards the median lobe. This will again reduce the risk of inadvertent injury to the orifice.
At the end of the procedure, always look at the orifice to confirm that it has not been injured.
We have had two ureteric orifice injury in our experience and both have happened during the bladder neck incision done for post-TURP bladder neck stenosis (BNO). Here, the scarring may have changed the landmarks on the trigone and also, the bladder end of the cut is usually not taken under vision. To take care of this difficulty, we almost always take the initial part of the cut under vision using a ureteroscope. The thin ureteroscope can enter the bladder through the BNO, can identify the orifice, and then cut can be taken taking care to prevent injury. If that is not possible, then the first cut is taken at 6′o clock position where there would be no risk of injury to orifice.
Injury to ureteric orifice is a significant complication and all efforts should be done to prevent this complication.
Compliance with ethical standards
Conflict of interest
All authors declare that they have no conflict of interest.
Research involving human and animal participants
This article does not contain any studies with human participants or animals performed by any of the authors.
- 1.Enikeev D, Glybochko P, Rapoport L, Snurnitsyna O, Potoldykova N, Novoselova T, Laukhtina E, Taratkin M, Margulis V (2018) Need for upper urinary tract stenting in cases of ureteral orifice injury during laser enucleation of the prostate. Int Urol Nephrol. https://doi.org/10.1007/s11255-018-2007-6 PubMedGoogle Scholar