The reduction of long-term reoperation after Holmium laser enucleation of the prostate (HoLEP) for benign prostate enlargement would minimize the challenge of increased financial costs and optimize patients’ satisfaction.
In a single center large series including 1216 patients who underwent HoLEP and after a median follow-up of 7.6 years, we detected only 52 (4.3%) patients who needed reoperation for relief of recurrent bothersome lower urinary tract symptoms due to recurrent adenoma, bladder neck contracture (BNC) or de novo urethral stricture. Of interest, we observed that smaller prostate size was significantly associated with recurrence of adenoma and BNC. Most patients (71.4) who developed BNC had prostates smaller than 50 cc. In addition, previous prostate surgery was significantly associated with recurrence of obstructing adenoma.
The significantly lower percent (50%) of PSA reduction from its baseline value in those patients after 3-months may raise the possibility of residual adenoma with recurrence of obstruction after surgery. A possible explanation for this is probably relared to the observation that the plane of enucleation in such relatively smaller prostates is not always as obvious as in the case of larger glands. Furthermore, the enucleation may not be as complete in previously operated cases due to altered tissue consistency and adhesion which may necessitate the use of higher energy and more prolonged morcellation time.
The higher incidence of urethral strictures in longer procedures is understandable particularly if prolonged catheterization is required. This said the incidence of urethral stricture is still lower than monopolar transurethral resection of the prostate (TURP).
The question now is whether patients with relatively small prostate are not good candidates for HoLEP and if another laser ablation modality would be a better option for them. Considering the small number of patients who needed reoperation for recurrent adenoma or BNC, relatively smaller prostate should not be a limitation for HoLEP. However, the surgeon should be aware about the higher rate of reoperation in these patients so that more meticulous enucleation should be performed with potential care to maintain a widely opened bladder neck.
Written by:
Mohamed A. Elkoushy and Mostafa M. Elhilali
Department of Surgery, Division of Urology
McGill University Health Center,
Montreal QC, Canada