Holmium Laser Enucleation of the Prostate After Prostatic Urethral Lift: The State of Bother

In the recent era, as treatment options expand for surgical management of benign prostatic hyperplasia (BPH), prostatic urethral lift (PUL) remains a popular and in-demand option for patients looking for a minimally invasive option while sparing antegrade ejaculatory function. However, PUL failure can occur in inappropriately counseled patients such as those with prostates larger than 80cc and those with the presence of a median lobe. Retreatment rates after PUL, including return to medication therapy and secondary surgical therapy, are as high as 33.6%.

Holmium laser enucleation of the prostate (HoLEP) has been shown to be a viable and safe option for BPH patients post-PUL. Anecdotally, we have noted a higher incidence of irritative lower urinary tract symptoms (LUTS) in patients undergoing HoLEP post-PUL. Therefore, the objective of this study was to perform a retrospective matched cohort analysis of individuals who underwent HoLEP with prior PUL. We were able to identify a total of 59 patients with prior PUL compared to a control cohort of 118 patients.

We found that morcellation efficiency was lower in the prior PUL cohort (9.8 vs 7.2 g/min (p ≤ 0.001)), likely due to the need to remove the PUL implants. We typically utilize a “catch-and-release” technique to dislodge the clip before it becomes wedged inside the morcellator blade. This minimizes blade malfunction and allows for usage of fewer blades.

More notably, we found that pre-operative Michigan Incontinence Symptom Index (M-ISI) severity scores were significantly higher in the PUL group (median 6 vs 3 (p = 0.011)). Prior PUL patients required more anticholinergic and beta-3 agonist medical therapy at 90 days post-op, though not statistically significant (8.5% vs 19%, p=0.084). These findings signify that this patient cohort may be more prone to irritative symptoms both before and after HoLEP.

While there were no significant differences in intra-operative and 90-day post-operative outcomes between groups, and patients with prior PUL appear to have just as good outcomes after HoLEP, clinicians should be aware that these patients may have more irritative LUTS both before and after HoLEP and ensure that they are counseled appropriately.

Written by: Amir Patel,¹ Jenny N. Guo,² Perry Xu,² Alyssa McDonald,² Allaa Fadl-Alla,² Amy Krambeck²

Department of Urology, Oregon Health and Science University, Portland, OR, USA.
Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

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