Urethral Complications Post-Holmium Laser Enucleation of the Prostate (HoLEP), A Seven-Year Experience - Beyond the Abstract

HoLEP operative technique: Our routine technique in Holmium Laser Enucleation of the Prostate (HoLEP) procedure includes initial calibration of the urethra using the sequential Von-braun's dilators up to 28 fr. In the case of tight urethral meatus and fossa navicularis, Otis urethrotome was used to cut the fossa.

Enucleation is usually done in standard two lobe retrograde enucleation technique. Holmium laser energy settings of 80 and 40 W at a power setting of 2J and frequency of 40 and 20 HZ respectively are used through 550-micron laser fiber. Storz ™ laser resectoscope sheath of either 28 or 26 fr was often used Morcellation was performed for HoLEP using PiranhaTM morcellator system (Richard Wolf GmbH, Knittlingen, Germany). Three-way 22 fr Foley catheter was always inserted after surgery for continuous bladder irrigation.

Our results: Among 566 patients with at least follow up of 12 months included in the study, a total of 28 (4.94%) patients had urethral complications. Nineteen (3.3%) and eight (1.4%) patients suffered postoperative urethral stricture (US) and bladder neck contracture (BNC) respectively while one patient (0.17%) had both US and BNC complications. Among the 19 patients with US, 11 patients had denovo stricture while 8 patients had intraoperative diagnosed US.

US presentation and diagnosis were early at 6 weeks follow up visit in 10 (50%) patients, between 6-week and 6-month follow up in 6 (30%) patients, and late presentation after 6 months in 4 (20%) patients. BNC was diagnosed before 6 months follow up in 6 (66%) patients while it was later than 6 months in 3 (34%) patients.

Among the US patients, US was bulbar in 9 (45%) patients, penile in 6 (30%) patients, at the fossa navicularis at 3 (15%) patients and bulbo-membranous in 2 (10%) patients.

In patients with US, urethral dilatation under local anesthesia with Van Buren dilators was initially performed in 17 (85%) patients. With median follow up of duration of 11 months (range 6-30 months), dilatation was sufficient in 14 (70%) patients while 3 (15%) patients required internal endo-visual urethrotomy (DIVU) after failed dilatation. Other 3 (15%) patients had DIVU from the start. All of them had endoscopic bladder neck incisions (BNI) with satisfactory results.

Written by: Mohamed Elsaqa, MD & Marawan M. El Tayeb, MD, Baylor Scott & White Medical Center, Temple, Texas

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