Outcomes of Holmium Laser Enucleation of the Prostate in the Re-Treatment Setting

Salvage holmium laser enucleation of the prostate after previous interventions: a systematic review

OBJECTIVE

To investigate the feasibility, safety and efficacy of holmium laser enucleation of the prostate (HoLEP) in the re-treatment setting (salvage HoLEP) and compare it to the primary HoLEP procedure that is commonly used for the treatment of benign prostate hyperplasia (BPH).

MATERIALS AND METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, PubMed, Scopus, and Cochrane databases were systematically screened, from inception to 8 August 2022. Other potentially eligible studies were retrieved using the reference lists of the included studies. Retrospective and prospective studies, both comparative and non-comparative, were included.

RESULTS

A total of 12 studies met the inclusion criteria and were included in the final qualitative synthesis. One study was prospective comparative (non-randomised), seven studies were retrospective comparative, and four studies were retrospective non-comparative or case series. In total, 831 patients were treated with salvage HoLEP in the above studies. Previous intervention before salvage HoLEP ranged among studies. The most commonly performed was transurethral resection of the prostate. Intraoperative parameters of salvage HoLEP were comparable with those reported during primary HoLEP, while all postoperative outcomes were significantly improved after salvage HoLEP and were similar with those observed after primary HoLEP. No major complications were noted after salvage HoLEP according to Clavien-Dindo classification.

CONCLUSIONS

Salvage HoLEP after previous interventions for treating recurrent or residual BPH is a feasible, safe, and efficient procedure. Data presented in selected studies, along with the holmium laser's physical properties to resect more tissue and to dissect along the true anatomical plane of BPH, render HoLEP an ideal salvage treatment modality for recurrent or residual BPH symptoms.

Same-day catheter removal after holmium laser enucleation of the prostate (HoLEP): a systematic review

PURPOSE

To summarize all existing evidence regarding the feasibility, safety, and efficacy of same-day trial of void and catheter removal after Holmium Laser Enucleation of the Prostate (HoLEP). Although there have been many reports of the safety and efficacy of same-day discharge from the hospital for selected patients undergoing HoLEP, in most of these reports, patients return to the hospital, usually on postoperative day one, to undergo a trial of void and catheter removal.

METHODS

PubMed®, Scopus®, and Cochrane® primary databases were systematically screened, from inception to 17 January 2023. The search strategy used the PICO (Patient, Intervention, Comparison, Outcomes) Framework. We followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

Six studies met all the predefined criteria and were included in the final qualitative synthesis. Four studies were retrospective and two were prospective. Four studies were non-comparative, while two were comparative ones. The same-day catheter removal success rate ranged from 85.5 to 90% among studies, while only one grade-IIIb Clavien-Dindo complication was reported, which was unrelated to surgery.

CONCLUSION

Same-day catheter removal is a feasible, safe, and efficient approach for selected patients undergoing HoLEP. Certain factors, such as intraoperative furosemide administration, were found to improve same-day catheter-free rates, while preoperative PVR and urinary retention were independent predictive factors of same-day trial of void failure.

Enucleation of the prostate as retreatment for recurrent or residual benign prostatic obstruction: a systematic review and a meta-analysis

BACKGROUND

Anatomical endoscopic enucleation of the prostate (AEEP) is recommended for first line surgical treatment of benign prostatic obstruction (BPO) caused by moderate and large prostatic adenoma. However, its role in the retreatment setting after failed previous surgical treatment for BPO remains uncaptured. In this scope, we performed a systematic review and meta-analysis aiming to assess the safety and efficacy of AEEP in the retreatment setting.

METHODS

We searched PubMed, Cochrane Library and Embase databases from inception to March 2022 for prospective or retrospective studies involving patients undergoing prostatic enucleation for recurrent or residual BPO after previous standard or minimally invasive surgical treatments for BPO. Based on data availability, we performed a meta-analysis comparing AEEP in patients with recurrent or residual BPO versus AEEP for primary BPO.

PROSPERO

CRD42022308941).

RESULTS

We included 15 studies in the systematic review and 10 in the meta-analysis (6553 patients, 841 with recurrent or residual BPO and 5712 with primary BPO). All included studies involved patients undergoing HoLEP or ThuLEP. In terms of Qmax, post-void residual, International Prostate Symptom Score, removed adenoma, operative time, duration of catheterization and hospital stay, as well as complications, HoLEP for recurrent or residual BPO was equally effective compared to HoLEP for primary BPO up to 1 year postoperatively. Importantly, the beneficial effect of HoLEP on the retreatment setting was observed after previous standard or minimally invasive surgical treatments for BPO. The overall strength of evidence for all outcomes was deemed very low.

CONCLUSIONS

HoLEP may be safely and effectively used in experienced hands for the surgical treatment of recurrent or residual BPO in patients with large or moderate prostates following previous open, endoscopic or minimally invasive surgical treatment for BPO.

Outcomes of robotic modified Freyer's prostatectomy in an Australian patient cohort

Introduction

The study aims to demonstrate the feasibility, safety and efficacy of robotic simple prostatectomy (RSP) using the modified Freyer's approach in an Australian patient cohort. Although RSP is performed in several Australian centres, there is a paucity of published Australian data.

Methods

We reviewed prospectively collected perioperative and outcomes data for patients who underwent a robotic modified Freyer's prostatectomy (RMFP) from June 2019 to March 2022. Statistics were completed using SPSS statistics v27.0 and reported as mean and range with a p value of <0.05 considered statistically significant.

Results

There were 27 patients who underwent RMFP over the study period with a mean age of 67 years and prostate volume of 159.74 cc (100-275). The mean console time was 168 min (122-211), blood loss of 233 ml (50-600) and average length of hospital stay of 3.8 days (3-8). The preoperative versus postoperative outcome means were as follows: serum prostate-specific antigen was 9.69 versus 1.2 ng/mL, IPPS score was 17.1 versus 1.25, quality of life (QOL) score 3.4 versus 0.4, postvoid residual volume: 223.6 versus 55.9 ml, Q-max 7.86 versus 29.6 ml/s. These were all statistically significant (p < 0.001). The mean weight of resected tissue was 74 g (43-206) with 25 patients having benign histopathology and two being diagnosed with prostate cancer (Gleason 3 + 3 = 6 and 3 + 4 = 7). No patients returned to theatre or required a blood transfusion.

Conclusions

Data from our patient cohort demonstrate the feasibility, safety and efficacy of RMFP for benign prostatic hyperplasia in an Australian patient cohort. Our outcomes compare favourably with published studies on RSP.

Outcomes of Robotic Simple Prostatectomy After Prior Failed Endoscopic Treatment of Benign Prostatic Hyperplasia

BACKGROUND

We compared outcomes of robotic simple prostatectomy (RASP) in patients with and without a history of prior prostate surgery for management of symptomatic benign prostatic hyperplasia.

METHODS

We retrospectively reviewed our multi-institutional database for all consecutive patients who underwent RASP between 05/2013 and 01/2021. Postoperatively, urinary function was assessed using the American Urological Association Symptom Score (AUASS) and Quality of Life (QOL) score.

RESULTS

Overall, 520 patients met inclusion criteria. Among the 87 (16.7%) patients who underwent prior prostate surgery, 49 (56.3%), 26 (29.9%), 8 (9.2%), 3 (3.4%) and 1 (1.1%) patients underwent transurethral resection of the prostate, photoselective vaporization of the prostate, transurethral microwave therapy, prostatic urethral lift or water vapor thermal therapy, respectively. There was no difference in mean prostate volume (p=0.40), estimated blood loss (p=0.32), robotic console time (p=0.86) or major 30-day postoperative (Clavien>2) complications (p=0.80) between both groups. With regards to urinary function, the mean improvement in preoperative and postoperative AUASS (p=0.31), QOL scores (p=0.11) and continence rates were similar between both groups.

CONCLUSION

For management of patients with BPH and LUTS, RASP is associated with an improvement in urinary function outcomes and a low risk of postoperative complications. Perioperative outcomes of RASP are similar in patients who underwent prior prostate surgery versus those that did not undergo prior prostate surgery.

Robot-Assisted Simple Prostatectomy: A Comparison of Primary Simple Prostatectomy Versus Salvage Simple Prostatectomy in Treatment of Lower Urinary Tract Symptoms

Purpose: Simple prostatectomy is indicated in patients with enlarged glands (>80 g) who present with lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia. Salvage robotic simple prostatectomy (SSP) is defined as simple prostatectomy after failed transurethral procedure. The aim of this study is to evaluate the efficacy of primary robotic simple prostatectomy (PSP) vs SSP in ameliorating LUTS. Materials and Methods: We retrospectively reviewed 124 patients who underwent RSP between 2013 and 2021. Indications for surgery were enlarged prostate, bothersome LUTS, or symptoms refractory to medical management and/or previous prostate surgery. PSP and SSP preoperative, perioperative, and postoperative variables were recorded. The severity of LUTS was assessed using the International Prostate Symptoms Score (IPSS). Two-tailed t-tests were performed to compare primary vs salvage RSP cohorts at a p-value of 0.05. Results: Of 124 patients who underwent RSP, 98 were primary and 26 were in the salvage setting with 19 patients undergoing prior transurethral resection of the prostate, 3 status post-transurethral microwave therapy, 1 status post-transurethral needle ablation of the prostate, and 3 status post-UroLIFT. Mean length of stay following RSP was 1.87 (days). At mean follow-up of ∼12 months, no patient required reoperation for LUTS. Preoperative IPSS for primary and salvage RSP was 18.56 and 16.25, respectively (p = 0.36), and postoperative IPSS for primary and salvage RSP was 5.33 and 8.00, respectively (p = 0.38). Conclusion: Regardless of primary or salvage indication, RSP remains a highly efficient and durable procedure for improvement in LUTS. RSP performed in the salvage setting greatly improved urinary function outcomes in patients after failure of previous transurethral procedures.

Evaluating Surgical Outcomes of Robot Assisted Simple Prostatectomy in the Retreatment Setting

OBJECTIVE

To report perioperative and postoperative outcomes in men who undergo salvage RASP (sRASP) following some other endoscopic outlet procedure for benign prostate enlargement (BPE) compared to those undergoing RASP for primary treatment (pRASP).

METHODS

A prospectively maintained database consisting of all RASP surgeries (December 2014 - October 2019) performed at our institution by three different urologists was used. Patients who had received an endoscopic procedure for BPE prior to their RASP (sRASP) were compared to those who had not had a prior outlet procedure (pRASP).

RESULTS

In total, 310 men underwent RASP during the study period. Of those, 30 (9.7%) had undergone an endoscopic procedure prior to surgery. There were no significant differences in age, race, ASA, BMI, prostate volume, PSA or rates of preoperative retention (p>0.05 for all). Men who were treatment-naive had significantly higher preoperative International Prostate Symptom Scores (IPSS) than men who had a prior procedure (18.3 ±7.7 vs. 13.6 ±6.2, p=0.008). However, there were no significant differences in functional or quality of life outcomes between the two groups (p>0.05 for all). There were no significant differences in perioperative or post-operative outcomes between the two groups. Furthermore, rates of post-operative complications and incontinence were similar between groups (11% vs. 10%, p=0.9 and 2% vs. 0%, p=1 respectively).

CONCLUSION

Performing a RASP after prior endoscopic procedure for BPE was found to be safe and effective. Success and complication rates were similar to patients with no prior procedures.

Salvage versus primary holmium laser enucleation of the prostate: trends, outcomes and safety analysis

PURPOSE

To study the safety, efficacy and trends in index procedures leading to salvage holmium laser enucleation of the prostate (S-HoLEP).

METHODS

This was a single-institution retrospective review of HoLEPs performed between 2006 and 2020. Patients who underwent S-HoLEP were compared to those undergoing primary holmium laser enucleation of the prostate (P-HoLEP). The endpoint of primary interest were functional outcomes. Changes in index procedures over the study period were analyzed.

RESULTS

A total of 633 HoLEPs were performed during the study, with 217 being S-HoLEP. The S-HoLEP cohort was older than P-HoLEP cohort, 71.2 years vs 68.8 years (p = 0.03). All other factors were well matched. The most common index procedures prior to S-HoLEP included transurethral resection of the prostate (TURP) (87, 40.1%), transurethral microwave thermotherapy (TUMT) (44, 20.3%), photoselective vaporization of the prostate (PVP) (24, 11.1%) and prostatic urethral lift (PUL) (24, 11.1%). Preoperative prostate volume, IPSS and Q_max were similar between groups. Intra-operatively, S-HoLEP had longer procedure and morcellation times (p = 0.01 and 0.007). Postoperatively, the S-HoLEP cohort had longer catheter duration and hospitalization (both p < 0.001). Postoperative Q_max, IPSS and 90-day complication rates were similar. On temporal analysis, minimally invasive surgical therapies (MIST) have become more prevalent as index procedures.

CONCLUSION

S-HoLEP is safe and efficacious for patients requiring additional BPH surgical intervention. S-HoLEP patients had longer operative times and hospital stays but equivalent postoperative functional outcomes compared to P-HoLEP. As MIST mature and gain traction, it is expected that rates of S-HoLEP will continue to rise.

Does prior transurethral resection of prostate have a negative impact on the outcome of holmium laser enucleation of prostate? Results from a prospective comparative study

Objectives

To prospectively evaluate safety and efficacy of holmium laser enucleation of prostate (HoLEP) for surgical treatment of recurrent symptoms due to prostatomegaly after prior transurethral resection of prostate (TURP).

Materials and Methods:

We prospectively evaluated 43 patients with a history of TURP who underwent HoLEP (study group). Patients in chronological order who underwent HoLEP without prior TURP were included in the control group. We hypothesized that prior TURP would increase technical difficulties, thereby leading to a reduction in procedure efficiency by 25%. Patients’ demographic, intraoperative, and postoperative data were compared, and statistical analysis was performed.

Results:

Demographic data in both groups were comparable. The average interval between past TURP and HoLEP was 4.22 years. There was no difficulty in identifying the dissection plane in the study group and the difference in the procedure efficiency between the study and the control groups were statistically insignificant (0.75 ± 0.31 g/min-study group vs. 0.69 ± 0.36 g/min-control group; P = 0.665). The intraoperative parameters and postoperative outcomes were comparable in both groups.

Conclusions:

Prior TURP does not negatively impact the outcome of HoLEP in treating symptomatic recurrence for enlarged prostate after initial TURP.

Robotic-Assisted vs. Open Simple Prostatectomy for Large Prostates: A Meta-Analysis

Purpose: To compare the efficacy and safety of robotic-assisted simple prostatectomy and open simple prostatectomy for large benign prostatic hyperplasia. Methods: We systematically searched the Cochrane Library, PubMed, Embase, and Science databases for studies published through December 2020. Controlled trials on RASP and OSP for large prostates were included. The meta-analysis was conducted with the Review Manager 5.4 software. Results: A total of seven studies with 3,777 patients were included in the analysis. There were no significant differences in IPSS (WMD, 0.72; 95%CI: -0.31, 1.76; P = 0.17), QoL (WMD, 0.00; 95%CI: -0.39, 0.39; P > 0.99), Qmax (WMD, 1.88; 95% CI: -1.15, 4.91; P = 0.22), or PVR (WMD, -10.48; 95%CI: -25.13, 4.17; P = 0.16) among patients undergoing RASP and OSP. However, compared with patients who underwent OSP, patients who underwent RASP had a shorter LOS (WMD, -2.83; 95%CI: -3.68, -1.98; P < 0.001), less EBL (WMD, -304.68; 95% CI: -432.91, -176.44; P < 0.001), a shorter CT (WMD, -2.61; 95%CI: -3.94, -1.29; P < 0.001), and fewer overall complications (OR, 0.30; 95% CI: 0.16, 0.57; P < 0.001). Nevertheless, RASP was associated with a longer OT (WMD, 59.69, 95% CI: 49.40, 69.98; P < 0.001). Conclusion: The results of the current study demonstrated that RASP provided similar efficacy to those of OSP in the treatment of large prostate, while maintaining better security. Our findings indicate that RASP is a feasible and effective alternative to OSP.

From open simple to robotic-assisted simple prostatectomy (RASP) for large benign prostate hyperplasia: the time has come

PURPOSE

Robotic-assisted simple prostatectomy (RASP) has recently been studied as an alternative to open simple prostatectomy or endoscopic treatment options. At present, there is no defined recommendation for a robotic procedure as a standard surgical technique to treat large benign prostate hyperplasia.

METHODS

Several robotic techniques have been described since 2007. Contemporaneously, multiple endoscopic enucleation techniques have been proposed. Nevertheless, open simple prostatectomy still remains a mainstay of therapy. We aimed to evaluate the development of robotic-assisted prostatectomy for large benign prostatic obstruction, thus comparing the technical aspects and clinical outcomes with open and endoscopic enucleation.

RESULTS

Robotic-assisted simple prostatectomy provides significantly less blood loss and shorter hospital stay but longer operative time compared to open simple prostatectomy. Compared to endoscopic treatments, robotic approaches have a similar perioperative outcome, but cause less urethral trauma or potential bladder neck strictures. Moreover, concomitant bladder pathologies can be treated within the same setting.

CONCLUSION

Robotic-assisted simple prostatectomy is an effective and safe technique, and can hence be considered to become the preferred first-line therapy to treat patients with obstructive large prostate glands.

Retrospective Assessment of Endoscopic Enucleation of Prostate Complications: A Single-Center Experience of More Than 1400 Patients

Introduction: Endoscopic enucleation of the prostate (EEP) is a safe method of treating benign prostatic hyperplasia, regardless of prostate volume and type of applied energy. To date, however, there has been no study that examines complication rates with respect to the type of applied energy. This study aims to address this problem by providing a retrospective analysis of >1400 patients who have undergone prostate enucleation. Materials and Methods: We performed a retrospective analysis of all patients undergoing EEP between 2013 and 2018 at a single tertiary institution. This analysis included patients who had undergone one of three forms of EEP: holmium laser enucleation of the prostate (HoLEP), thulium fiber laser enucleation of the prostate (ThuFLEP), or monopolar enucleation of the prostate (MEP). We compared intraoperative and early postoperative complications, as well as complications at 3 and 6 months follow-up. Results: A total of 1413 patients were included in this study; 36% patients underwent HoLEP, 57.5% had ThuFLEP, and 6.5% MEP. The most frequent complication in the early postoperative period was a mild fever (2.76% of the cases). The morcellation was delayed to a separate stage because of intensive hemorrhaging in 1.4% of the cases. Bladder tamponade was found in 1.1% of the cases. We found no correlation between complication rate and either prostate volume or energy source. Stress urinary incontinence was found in 3.9% of patients at 3 months and in only 1.4% of patients at 6 months after the operation. Urethral stricture at 6 months after the surgery was found in 1.4% of patients, whereas bladder neck sclerosis was found in only 0.9% of these cases. No significant difference was observed between these complication frequencies and any preoperative factors or energy source. Conclusions: All EEP types are safe with equal rates of complications intraoperatively, postoperatively, and at 6 months follow-up.

Challenging Case of Holmium Laser Enucleation of the Prostate after Prior Prostatic Focal Laser Ablations and Rezum

BACKGROUND

Holmium laser enucleation of the prostate (HoLEP) is an effective, size independent procedure for management of benign prostatic hyperplasia (BPH).¹ Additionally, HoLEP is able to be performed successfully after prior surgical BPH treatments without complication and a low rate of long term retreatment.² OBJECTIVES: To demonstrate challenging case of HoLEP in a patient with multiple, prior ablative BPH surgeries.

MATERIAL

A 63 year old male with refractory lower urinary tract symptoms after 2 focal laser ablations, one Rezum treatment, and medications (silodosin 8 mg and tadalfil 5 mg) presented to our clinic with obstructive lateral lobe BPH. The prostate was approximately 50 ml on digital rectal exam and preoperative cystoscopy demonstrated prostatic urethral calcifications and lateral lobe hypertrophy. Preoperative AUA symptom score (AUAss) was 12, peak urinary flow was 5.3 ml/s. A HoLEP was performed to alleviate the patients lower urinary tract symptoms and allow him to stop his medications.

RESULTS

Total procedure time was 44 minutes, with enucleation time of 20 minutes and morcellation time of 1 minute. The HoLEP was started as a 2-cut technique, however due to poor surgical planes we changed to top-down technique.³ There was a small, posterior, nonclinically significant capsular perforation. Five grams of benign adenoma were removed. Patient was discharged on the day of surgery. Catheter was removed on postoperative day four due to patient desiring to return home (over 150 miles away) for catheter removal, instead of having it done in our clinic on postoperative day one. At most recent follow-up, AUAss was 5 and peak urinary flow was 13.2 ml/s.

CONCLUSION

HoLEP can be performed after prior, multiple BPH treatments successfully. These can prove to be more challenging cases. Prior ablative techniques can lead to fibrosis of transition zone tissue and distort the natural plane between adenoma and surgical capsule.

Rapid Prostatic Regrowth and a Free-Floating Necrotic Bladder Mass Serving as a Nidus for Infection Following ThuLEP: Management With Morcellation and HoLEP

We present a question regarding the management of a patient with recurrent urinary tract infections (UTIs) following multiple procedures for benign prostatic hyperplasia (BPH).

Robotic Simple Prostatectomy: Why and How?

Increasingly many studies have presented robotic simple prostatectomy (RSP) as a surgical treatment option for large benign prostatic hyperplasia (BPH) weighing 80-100 g or more. In this review, some frequently used RSP techniques are described, along with an analysis of the literature on the efficacy and complications of RSP and differences in treatment results compared with other surgical methods. RSP has the advantage of a short learning curve for surgeons with experience in robotic surgery. Severe complications are rare in patients who undergo RSP, and RSP facilitates the simultaneous treatment of important comorbid diseases such as bladder stones and bladder diverticula. In conclusion, RSP can be recommended as a safe and effective minimally invasive treatment for large BPH.

Is Holmium Laser Enucleation of the Prostate a Good Surgical Alternative in Benign Prostatic Hyperplasia Management? A Review Article

Several therapeutic approaches such as holmium laser enucleation of the prostate (HoLEP) have been introduced to relieve bladder outlet obstruction caused by benign prostatic hyperplasia (BPH). Compared with other techniques including the transurethral resection of the prostate (TURP) and simple open prostatectomy, HoLEP results in a shorter hospital stay and catheterization time and fewer blood loss and transfusions. HoLEP is a size-independent treatment option for BPH with average gland size from 36 g to 170 g. HoLEP is a safe procedure in patients receiving an anticoagulant and has no significant influence on the hemoglobin level. Also, HoLEP is an easy and safe technique in patients with a prior history of prostate surgery and a need for retreatment because of adenoma regrowth. The postoperative erectile dysfunction rate of patients treated with HoLEP is similar to TURP or open prostatectomy and about 77% of these patients experience loss of ejaculation. Patients with transitional zone volume less than 30 mL may suffer from persistent stress urinary incontinence following HoLEP so other surgical techniques like bipolar TURP are a good choice for these patients. In young patients, considering HoLEP with high prostate-specific antigen density and a negative standard template prostate biopsy, multiparametric MRI needs to be considered to exclude prostate cancer.

[Endoscopic enucleation of the prostate]

The spectrum of surgical procedures for the minimally invasive treatment of benign prostatic hyperplasia (BPH) has significantly increased over the last two decades. The simple suprapubic prostatectomy (subtotal prostatectomy, SP) has largely lost relevance in current practice. On the other hand, transurethral resection of the prostate (TURP) has been further standardized and potentially made safer by the introduction of the bipolar technique and low-pressure systems.Transurethral (endoscopic) enucleation techniques (endoscopic enucleation of the prostate, EEP) are increasingly competing with the current gold standard TURP and are replacing SP for treatment of larger adenomas. This approach is especially related to the rapid development of laser technology, which has sustainably changed the face of modern BPH treatment in a similar way to stone therapy. This has been incorporated in the clinical patient management, clinical studies and standardization of numerous surgical techniques that are systematically described in this article. Additionally, efforts have also been made to use other energy sources, such as bipolar current in EEP. With respect to scientific objectivity, high-quality clinical trials are regularly published which further strengthen the position of EEP.

Evidence-based outcomes of holmium laser enucleation of the prostate

PURPOSE OF REVIEW

Holmium laser enucleation of the prostate (HoLEP) has been a mainstay therapy for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostate hyperplasia (BPH) for nearly 20 years. We briefly review current and sentinel publications that provide outcomes data after HoLEP.

RECENT FINDINGS

Current literature continues to support HoLEP as a versatile and durable surgical option for men with LUTS secondary to BPH. Despite evidence supporting durable symptom relief beyond 10 years even in large prostate glands, HoLEP is still not widely available to all patients. Concerns surrounding the learning curve of the procedure, high rates of retrograde ejaculation, and transient urinary incontinence seem to persist and limit the adoption of HoLEP by established urologists and residency training programs.

SUMMARY

Recent publications continue to show excellent short-term and long-term outcomes after HoLEP, in the categories of voiding function and patient satisfaction. Continued attempts to demonstrate equivalent outcomes of alternate-BPH surgical techniques are being met with renewed efforts by those performing HoLEP to demonstrate equivalent outcomes and patient safety during the learning phase of HoLEP for both mentored and self-directed surgical training.

Holmium Laser Enucleation of the Prostate: Patient Selection and Outcomes

PURPOSE OF REVIEW

Holmium laser enucleation of the prostate (HoLEP) is a proven technique to alleviate bladder outlet obstruction (BOO) from benign prostatic hyperplasia (BPH). Herein, we review factors relevant to selecting patients who will benefit from this procedure and expected outcomes.

RECENT FINDINGS

New randomized trials have validated the excellent outcomes achieved by HoLEP in the management of BOO from BPH. Its success has been reproduced in a diverse array of patients including those on anticoagulation, with detrusor underactivity/acontractility, prostate cancer, and in the retreatment setting. HoLEP can be applied to the majority of patients with BOO from BPH regardless of prostate size, previous operations, or the condition of the detrusor. HoLEP can also be carefully considered in patients requiring anticoagulation or who are undergoing active surveillance for low-risk prostate cancer. Immediate complication rate is low and incontinence is rare. Retrograde ejaculation occurs in approximately 75% patients. Furthermore, the retreatment rate for HoLEP is lower than reported for other endoscopic BPH procedures demonstrating its durability.