SUFU 2020: Initial Experience of Holmium Laser Enucleation of the Prostate Following Previous Prostatic Urethral Lift for Management of Benign Prostatic Hyperplasia

Scottsdale, Arizona ( This was a retrospective study for a database of all patients that underwent holmium laser enucleation of the prostate (HoLEP) at a single institute between January 2013 and September 2019. The authors in this study determined the incidence of patients who receive HoLEP following previous prostatic urethral lift (PUL) and to assess the benefits and pitfalls of HoLEP in these patients at our institution. PUL has become a commonly performed procedure for symptomatic benign prostatic hyperplasia (BPH). The current recommendation for PUL is for a patient with a prostate size of <80 grams. Additionally, despite more recent updates in guidelines, patients with enlarged median lobes have not always achieved desirable outcomes with PUL. In patients who fail PUL, HoLEP is a viable and effective option but presents its own unique challenges.

Six hundred and thirty-seven consecutive HoLEP cases in 670 patients were identified, with all cases performed by one surgeon. Data collected included demographics, the prostate size on pre-operative assessment, the time elapsed since previous PUL procedure, and complications.

Eleven of the patients (1.6%) had hade previous PUL procedures. The time between HoLEP and previous PUL ranged from 2.9-48.7 months (mean=17.7 months, median=12.6 months). Pre-operative prostate size ranged from 80-180 grams (mean=116.1 g, median=107.0 g). In one of these cases, the PUL implant prevented effective prostate adenoma morcellation, requiring the patient to return seven days later to complete the case and recover the remaining chip fragment. No complications occurred intra-operatively in the other 10 patients with previous PUL. All patients experienced an improvement in symptoms following HoLEP.

The authors reported that while HoLEP can be performed safely and effectively in the PUL failure population, unique challenges arise. Defining the true sulcus of the prostate lobes may be lost after PUL, making enucleation more challenging as the anatomy is distorted. Additionally, jamming of morcellator blades from the remaining implants may occur. Considering these challenges coupled with current guidelines suggesting laser enucleation as the endoscopic procedure of choice in patients with prostate sizes >80 grams, a thorough discussion with patients considering PUL regarding interventional alternatives should be encouraged, especially in patients with larger prostate sizes (>80 grams) on pre-operative assessment.

Presented by: Timothy Han, MD, Lydia Glick, MD, Thomas Hardacker, MD, Tomy Perez, MD, Patrick Shenot, MD, Akhil Das, MD, Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania

Written by: Bilal Farhan, MD, Assistant Professor, Division of Urology, University of Texas, Medical Branch, Texas; Twitter: @BilalfarhanMD, at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting, SUFU 2020, February 25 - 29, 2020, Scottsdale, AZ