Prior to the introduction of the holmium laser enucleation of the prostate (HoLEP) by Dr. Gilling’s group in 1996, the surgical management of large prostate glands was limited to the open simple prostatectomy, a procedure with significant morbidity, prolonged catheter time and hospital stays, and high rates of blood transfusion. While other approaches have been described in recent years, HoLEP remains the gold standard for endoscopic management of large glands. We sought to report our experience utilizing this approach for prostate glands over 200 cubic centimeters. Additionally, we analyzed the subset of these patients with glands over 300 cc in order to analyze the surgical outcomes of the truly massive gland population.
Our series adds to the evidence in the literature that without limitation of gland size, HoLEP presents a minimally invasive, natural orifice surgical option with demonstrable efficacy and a reasonable perioperative complication rate. Further, there was a low need for operation, low rates of permanent incontinence requiring later surgical intervention, and low rates of conversion to other surgical techniques. Excluding scope breakages, all glands were completely enucleated endoscopically with the exception of one patient with a 770 cc prostate. In this case, we were unable to advance our scope across the entirety of the prostatic urethra. Even in this case, the endoscopic approach proved beneficial as we performed the apical dissection using the scope and laser, while the remainder of the gland not reachable with our scope was completed using a traditional open approach. By using this combined technique, we were able to minimize the morbidity to the patient.
Early in our series, several glands were extracted through an open incision due to morcellator limitations; this has been obliviated by the use of the Wolf PIRANHA morcellator. Previous studies by Dr. McAdams et al. have demonstrated the superior morcellation efficiency of the PIRANHA, and since adopting this into our practice all glands have been morcellated within the bladder.
We analyzed the patients with glands over 300 cc separately and did not find any difference in operative parameters or perioperative outcomes with the exception of improved enucleation efficiency and longer morcellation times.
The median length of stay and catheter duration for our series was one night and one day, respectively, and did not vary by increasing gland size. With the exception of a higher transfusion rate, we did not observe any significant deviation from our usual postoperative course and complication rate. While these large glands do pose unique surgical challenges, it is our hope that this series demonstrates the utility and feasibility of HoLEP for all prostate sizes and encourages further adoption of this technique.
Written by: Michael Zell, MD, Twitter: @michaelzellmd and Haidar Abdul-Muhsin, M.B., Ch.B., Twitter: @h_abdulmuhsin, Department of Urology, Mayo Clinic Hospital-Phoenix
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