V5-12: Holmium Laser Enucleation of the Prostate After Prostatic Urethral Lift
Prostatic urethral lift (PUL) has emerged as a minimally invasive option for treatment of benign prostatic hyperplasia (BPH) and bothersome lower urinary tract symptoms (LUTS) especially in young males who would like to avoid sexual and ejaculatory dysfunction. To date, there is no long-term data concerning the durability of the PUL in the management of LUTS. The bladder outlet is opened by placement of retention devices which effectively lift the lateral lobes towards the prostatic capsule. This device consists of a nitinol capsular anchor attached to a non-absorbable suture which spans the prostate tissue and is anchored by a stainless steel urethral end piece. Patient selection is critical, and PUL should be avoided in those with obstructing bladder necks, large median lobes or with glands larger than 100g. Holmium laser enucleation of the prostate (HoLEP) is a safe, effective and durable option for management of BPH in any size gland. Also, the powerful cutting effects of the holmium laser and visualization afforded to the surgeon with HoLEP make it an excellent surgical option to deal with urethral foreign bodies after failed PUL.
A 51 year old male presented with persistent lower urinary tract symptoms after two prior PUL procedures and urodynamic evidence of obstruction. Cystoscopy showed a high bladder neck. The patient chose to undergo HoLEP, and this was performed using Storz 28 French sheath and 550 micron Boston Scientific holmium laser fiber at 80 watts. Hemostasis was achieved at 40 watts. Morcellation was carried out using the Storz offset nephroscope and the Wolf Piranha morcellator.
The enucleation time was 23 minutes. Four stainless steel urethral end pieces were removed. 5g of prostate tissue was morcellated in 7 minutes. A urethral end piece did bind the morcellator momentarily, however at this point, the prostate tissue was small enough to be grasped and removed through the scope. The catheter was removed after one day. At four months follow-up, the patient had a post-void residual of 0 mL and subjective improvement in his symptoms with International Prostate Symptom Score of 4 and Quality of Life score of 0.
HoLEP is an effective option for managing the unique situation of BPH and urethral foreign bodies after failed PUL.