V404: Holmium Laser enucleation prostatectomy in very large prostates

Video

Introduction and Objectives
The clinical efficacy of Holmium Laser Enucleation of Prostate (HoLEP) has been reported to be comparable to open prostatectomy. There are few reports regarding enucleation of large prostates. However, there are no technical guidelines for HoLEP in prostates larger than 200mL. We aimed to describe the surgical difficulties in HoLEP in very large prostates and to share useful findings.

Methods
We reviewed the surgical HoLEP video database of our hospital from August 2010 to June 2012. The three operations introduced in this video (prostate sizes 201, 209, 357ml each) were performed by a single surgeon (SJO), and two independent reviewers (SHK, HEL) reviewed the videos.

Results
The total operation time ranged from 105 to 210 minutes. The intraoperative difficulties we encountered with such large prostates were as following. When introducing the scope into the prostate, the scope length was insufficient and therefore there was penile urethral compression. Severe intravesical protrusion of the enlarged prostate not only made inspection of the bladder difficult but also made the bladder walls extremely vulnerable to injury with the laser during incision of the prostate-bladder margin. The bottleneck-shaped bladder neck made it difficult to move the enlarged adenoma into the bladder after enucleation. In addition, there was a high distribution of bleeding arteries, and there were multiple satellite nodules which made the surgical planes complex and diverse. The morcellation time was prolonged due to abundant hard and compact nodules which was resistant to morcellation. At average, the Foley catheter was removed at the first or second postoperative day, and the patients were discharged uneventfully. There were no major postoperative complications.

Conclusions
HoLEP with very large prostates presented more technical difficulties than moderately enlarged prostates. Such difficulties should be kept in mind when performing HoLEP in larger prostates. Despite difficulties when enucleating huge adenomas, HoLEP is a feasible method for even very large prostates.

Funding: None