A call for HoLEP: AEEP for mega-prostates (≥ 200 cc)

Influence of preoperative indwelling urinary catheter on outcomes of high-power holmium laser enucleation for very large prostate (≥ 200 mL)

PURPOSE

to evaluate the impact of Indwelling Urinary Catheters (IUC) on perioperative and functional outcomes, as well as the safety profile, of High-Power HoLEP for the treatment of prostate gland volumes exceeding 200 cc.

METHODS

A retrospective analysis was conducted on 237 patients with prostate volumes > 200 cc who underwent HoLEP between January 2016 and December 2022. Patients were included based on specific criteria, such as an International Prostate Symptom Score (IPSS) > 7 and a maximum urinary flow rate (Qmax) < 15 mL/s. Patients were categorized into two groups: Group 1 included those with IUC prior to surgery, while Group 2 comprised patients without it.

RESULTS

A total of 237 patients with prostate volumes exceeding 200 cc underwent HoLEP, and were categorized into Group 1 (n = 63) and Group 2 (n = 174), with Group 1 exhibiting higher Charlson Comorbidity Index and BMI. Postoperative outcomes indicated a higher incidence of urinary tract infections in Group 1, as well as worse IPSS, Qmax, and PVR at 3 months; however, by the 1-year follow-up, both groups demonstrated comparable results. Longitudinal analysis revealed that both groups experienced significant functional and symptomatic improvements over time, with Group 2 showing rapid early gains that stabilized, whereas Group 1 exhibited continuous improvement from 3 months to 1 year.

CONCLUSION

HoLEP is an effective treatment for very large prostate volumes in patients with IUC. Although these patients are at a higher risk for UTI and initial lower Qmax, these outcomes improve by one year.

Benign prostate hyperplasia over 150cm3: Should we perform an endoscopic enucleation of the prostate or robotic-assisted simple prostatectomy?

INTRODUCTION

Benign prostatic hyperplasia (BPH) is a prevalent condition in ageing men, often resulting in significant lower urinary tract symptoms (LUTS) that impact quality of life. For patients with huge prostate volumes (>150mL), surgical management presents challenges. Traditionally, open simple prostatectomy (OSP) was the gold standard; however, minimally invasive approaches such as robotic-assisted simple prostatectomy (RASP) and endoscopic enucleation of the prostate (EEP), especially holmium laser enucleation of the prostate (HoLEP), offer similar or superior outcomes with reduced morbidity.

METHODS

This review analyzed studies comparing the perioperative, functional, and complication outcomes of RASP and HoLEP in treating very large prostates (>150mL). A comprehensive literature search was performed to evaluate evidence on surgical efficacy, complication rates, and recovery profiles.

RESULTS

Both RASP and HoLEP demonstrated excellent perioperative outcomes, with HoLEP providing reduced operative time and hospital stays. HoLEP also showed lower blood loss and a reduced need for transfusions, while RASP offered advantages in terms of precision and surgeon control, especially for anatomically complex cases. Functional outcomes, including improvement in urinary flow and symptom scores, were comparable between the two techniques. However, complications such as transient incontinence were more commonly reported with HoLEP.

CONCLUSION

Both RASP and HoLEP are effective and safe for the management of very large prostates. HoLEP offers significant advantages in perioperative recovery and reduced morbidity, whereas RASP provides excellent outcomes in complex cases requiring precise dissection. The choice between these techniques should be guided by patient-specific factors and surgical expertise. Future studies should focus on long-term functional outcomes to refine surgical recommendations further.

HoLEP versus ThuFLEP in men with very large prostates (> 175 ml)

PURPOSE

We aimed to demonstrate and compare the efficacy and safety of HoLEP and ThuFLEP procedures in patients with very large prostates (> 175 ml).

METHODS

Patients with prostates larger than 175 ml who underwent HoLEP (Group 1, n = 72) and ThuFLEP (Group 2, n = 85) for benign prostatic obstruction (BPO) were retrospectively analysed. Perioperative, postoperative functional outcomes and complications were analysed and compared.

RESULTS

Significant improvements were observed in functional parameters related to IPSS, Qmax, PVR and quality of life in all groups compared to baseline values at 1, 6 and 12 months postoperatively. Except for IPSS at the first postoperative month (3.22 ± 1.77 vs. 2.07 ± 1.11; p = 0.001), no difference was observed between the groups in terms of quality of life, IPSS, Qave and PVR at the sixth and twelfth months. There was no significant difference between the laser sources in terms of urge urinary incontinence (UUI) and stress urinary incontinence (SUI) at 1 month postoperatively, and no UI was observed in any patient at 6 and 12 months. No significant difference was observed between laser types in terms of postoperative complications.

CONCLUSION

HoLEP and ThuFLEP are safe and effective minimal invasive surgical methods in very large prostates with improvement in postoperative functional parameters and low perioperative complication rates. Since there are no significant differences in outcomes between these laser sources, they can be employed as alternative surgical techniques for BPO in patients with very large prostates.

Safety and feasibility of En-bloc holmium laser enucleation for very large prostates (> 200 cc) with trainee involvement

Objectives

To evaluate the safety and feasibility of "en-bloc" Holmium Laser Enucleation of the Prostate (HoLEP) with trainee involvement in patients with prostates larger than 200 cc.

Patients and Methods

A retrospective analysis was conducted on patients undergoing HoLEP using the "en-bloc" technique for prostate sizes > 200 cc between July-2017 and December-2023 at an academic teaching hospital. Perioperative data was collected, including patient demographics, clinical parameters, operative details and functional outcomes. Patients who continued to experience incontinence at 1 year were further followed up at 2 years to update their continence status. Sub-group analysis was performed to compare outcomes between patients with preoperative prostate size of 200-300 cc and > 300 cc.

Results

The analysis included 89 patients with a mean age of 73.12 ± 8.10 years. Preoperative prostate weight ranged from 200 to 401 cc with a median of 245 cc, and median PSA was 7.71 ng/ml. Median operative time was 218.5 minutes, and median enucleated prostate volume was 164.2 cc. Median postoperative PSA was 0.4 [0.21-0.78] ng/ml. At 1-year follow-up, mean IPSS was 1 ± 2.4, Qmax was 27.03 ± 11.57 ml/s and PVR was 21.6 ± 28.6 ml. Postoperative complications included blood transfusion (5.6%), acute renal injury (4.5%), urinary tract infection (2.2%), postoperative urinary retention (2.2%) and urethral stricture (5%). Although transient urinary incontinence was noted in 41.6% at 1-3-months, complete continence was achieved in 83.3% and 96.3% at 1 and 2 years postoperatively, respectively. Subgroup analysis showed significant differences in operative time and enucleated weight between prostates 200-300 cc and > 300 cc, but no significant differences in postoperative IPSS, PVR or Qmax at 3-months.

Conclusion

"En-bloc" HoLEP is a feasible and safe procedure for prostates larger than 200 cc, demonstrating favourable perioperative and functional outcomes despite the extended operative times and involvement of trainees.

Comparison of Perioperative Outcomes of Holmium Laser Enucleation of the Prostate for Standard (≤149 ml) Versus Very Large (≥150 ml) Prostate Glands: Retrospective Analysis of a Propensity Score Matched Cohort of 326 Patients

Background and objective

Our objective was to evaluate whether a very large prostate volume significantly affects the incidence of perioperative complications and compromises outcomes among patients undergoing holmium laser enucleation of the prostate (HoLEP).

Methods

We retrospectively analyzed data for 1815 adult patients who underwent HoLEP at Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin, between January 2019 and May 2024. Patients were divided into two groups according to their prostate volume: ≤149 ml (group A) and ≥150 ml (group B). Propensity score matching on age, body mass index, American Society of Anesthesiologists physical status, and the presence of an indwelling catheter was used to balance baseline differences. A Mann-Whitney U test was used for comparison of continuous variables between the groups, and a χ2 test for comparison of categorical variables, with p < 0.05 considered statistically significant. Postoperative complications were assessed according to the Clavien-Dindo classification.

Key findings and limitations

After propensity score matching, 163 matched cases per group were analyzed. Group B had significantly longer median total operative time (76 vs 47 min; p < 0.001), enucleation time (42 vs 26 min; p < 0.001), coagulation time (11 vs 6 min; p < 0.001), and morcellation time (15 vs 7 min; p < 0.001). Clavien-Dindo grade ≥IIIb complications (8.7% vs 1.2%; p = 0.02) and blood transfusion (2.5% vs 0%; p = 0.045) were significantly more frequent in group B. Catheterization time (1.9 vs 2.0 d; p = 0.01) and the proportion of patients with postoperative residual urine volume ≤50 ml (85.2% vs 80.2%; p = 0.18) were comparable between the groups. Limitations include the retrospective and single-center study design.

Conclusions and clinical implications

Prostate volume ≥150 ml is associated with a longer operative time, a higher rate of major complications, and a more frequent need for blood transfusion. Therefore, HoLEP for prostate glands ≥150 ml should be performed in experienced high-volume centers.

Patient summary

We compared outcomes of laser surgery for enlarged prostate glands of different sizes. We found that while the surgery is generally effective for very large prostates, it takes longer and has a higher risk of complications in comparison to more typical prostate sizes. However, this procedure is still the best treatment available for prostate enlargement and should be carried out in high-volume hospitals specializing in this treatment.

[Prostate Surgery for Benign Prostatic Syndrome >200 ml: Endoscopic, Robotic, or Open Approach]

Surgical approaches for benign prostatic hyperplasia have evolved and diversified over the past decades. While numerous studies document the efficacy of surgical procedures for moderate prostate sizes, there remains insufficient data for large prostate volumes >200 ml, leaving important questions unanswered regarding their effectiveness and safety. Consequently, selecting and adapting suitable therapeutic options for this specific patient group often poses a significant challenge. In this context, this review comprehensively summarizes and discusses current insights into surgical treatment options for large prostate volumes (>200 ml) following an extensive literature review.In summary, the surgical treatment of prostate volumes >200 ml is a challenge regardless of the chosen surgical method. Minimally invasive approaches should be considered standard practice today. Anatomical endoscopic enucleation of the prostate is a size-independent method and has the lowest morbidity. As it may be performed in spinal anaesthesia, endoscopic enucleation is feasible in patients with an increased anaesthetic risk. In extremely large prostate glands, the procedure poses challenges even for highly experienced surgeons. Especially in obese patients, the surgeon should be familiar with different exit strategies. Robot-assisted simple prostatectomy provides a minimally invasive alternative that may also treat pathologies such as diverticula or large bladder stones in the same surgical session. Due to its transabdominal approach, the morbidity and anaesthetic risk is comparatively higher. Each centre and surgeon should individually decide in which method they have the greatest expertise and which option is best suited for the specific case. In cases of limited expertise, it is advisable to refer patients to a centre with appropriate specialization.

Revisiting the issue of "beach balls" in holmium laser enucleation of prostate: clinical and histological characterization

PURPOSE

To clinically and histologically characterize prostatic nodules resistant to morcellation ("beach balls," BBs).

PATIENTS AND METHODS

We reviewed a consecutive cohort of 559 holmium laser enucleation of the prostate (HoLEP) procedures performed between January 2020 and November 2023. The BBs group comprised 55 men (10%) and the control group comprised 504 men (90%). The clinical, intraoperative, outcome, and histologic data were statistically processed for the prediction of the presence of BBs and their influence on the perioperative course and outcome.

RESULTS

The BBs group in comparison to the controls was older (75 vs 73 years, respectively, p = 0.009) and had higher rates of chronic retention (51 vs 29%, p = 0.001), larger prostates on preoperative abdominal ultrasound (AUS) (140 vs 80 cc, p = 0.006E-16), longer operating time (120 vs 80 min, p = 0.001), higher weights of removed tissue (101 vs 60 gr, p = 0.008E-10), higher complication rates (5 vs 1%, p = 0.03), and longer hospitalization (p = 0.014). A multivariate analysis revealed that larger prostates on preoperative AUS and older age independently predicted the presence of BBs which would prolong operating time. ROC analyses revealed that a threshold of 103 cc on AUS predicted BBs with 94% sensitivity and 84% specificity. BBs were mostly characterized histologically by stromal component (p = 0.005).

CONCLUSIONS

BBs are expected in older patients and cases of chronic retention. Prostatic volume is the most reliable predictor of their presence. They contribute to prolonged operating time and increased risk of complications. The predominantly stromal composition of the BBs apparently confers their resistance to morcellation.

Is Holmium Laser Enucleation of the Prostate Truly Size-Independent? A Critical Evaluation at the Extreme Ends of the Spectrum

OBJECTIVE

To assess the outcomes of holmium laser enucleation of the prostate (HoLEP) at the extremes of the size spectrum, comparing whether the results are consistent for very large and small prostates.

METHODS

A retrospective review of 402 patient charts was conducted to compare the outcomes of HoLEP in patients with prostate size ≤40 g (group 1), 41-200 g (group 2), and >200 g (group 3). Various preoperative, perioperative, and postoperative variables were collected.

RESULTS

HoLEP showed comparable voiding outcomes among all 3 groups, although patients with small prostates had a higher International Prostate Symptom Score during follow-up (P = .022). We noted a higher rate of perioperative blood transfusion in patients with very large prostates (P = .019) and a higher rate of transient acute urinary retention (AUR) in group 1 when compared to group 3 (P = .048). Patients with smaller prostates had a higher rate of bladder neck stenosis and urethral strictures, but the differences were not found to be statistically significant. The incidence of other complications, length of hospital stay, and catheterization duration did not differ significantly among the groups.

CONCLUSION

HoLEP has consistent and safe outcomes across a wide range of prostate sizes. Although, the risk of blood transfusion is higher in patients with very large prostates and the risk of transient AUR is greater in patients with small glands, the overall efficacy and safety of HoLEP are not significantly influenced by prostate size.

Holmium Laser Enucleation of the Prostate vs Transvesical Single-port Robotic Simple Prostatectomy for Large Prostatic Glands

OBJECTIVE

To compare the perioperative outcomes of transvesical single-port robotic simple prostatectomy (SP-RASP) and holmium laser enucleation of the prostate (HoLEP).

MATERIALS AND METHODS

A retrospective review was performed of patients undergoing SP-RASP and HoLEP from 2019 to 2022 with preoperative prostatic volume (PPV) >80 cm3. Percent of prostate adenoma removed (%PAR) was estimated by specimen weight normalized by PPV. Univariate analysis was performed using chi-square, Fisher exact, and Wilcoxon rank-sum tests. A subgroup analysis with 1:1 matching for PPV was also performed.

RESULTS

A total of 50 SP-RASP and 90 HoLEP cases were analyzed. The median (interquartile range) PPV was 169 (128-244)cm3 for SP-RASP and 129 (100-150)cm3 for HoLEP, (P < .01). The median (interquartile range) %PAR was 57(44-68) for SP-RASP vs 51(42-62) for HoLEP (P = .10). Overall, 11(12%) HoLEP and 5(10%) SP-RASP patients experienced complications (P = .51). Same-day discharge occurred in 24(48%) SP-RASP vs 7(8%) HoLEP patients (P < .01). Median foley catheter duration was longer in SP-RASP (6 vs 1 day, P < .01) and trial of void was successful at first attempt in >94% (P = .68). Transient de novo incontinence was reported in 24(28%) HoLEP vs 2(5%) SP-RASP (P < .01). No differences in voiding parameters were observed at latest follow up. Subgroup postmatched analysis revealed analogous findings.

CONCLUSION

SP-RASP and HoLEP have similar favorable perioperative outcomes for management of large prostatic adenomas. SP-RASP may be considered in patients unwilling to accept the risk of transient incontinence and in those with unfavorable urethral access, large bladder stone burden, or diverticula.

Predictive factors affecting morcellation efficiency in holmium laser enucleation of the prostate

PURPOSE

To determine the factors affecting morcellation efficiency in holmium laser enucleation of the prostate (HoLEP) surgery.

MATERIALS AND METHODS

Patients who underwent HoLEP surgery by a single surgeon between 2018 and 2022 were included in the study. Our primary outcome of interest in this study was morcellation efficiency. The effect of preoperative and perioperative variables on morcellation efficiency was evaluated with linear regression analysis.

RESULTS

A total of 410 patients were included in the study. The mean morcellation efficiency was 6.95±1.70 g/min. Univariable and multivariable linear regression analysis was performed to identify factors affecting morcellation efficiency. Presence of the "beach ball" effect (small, round prostatic tissue fragments that are fibrotic and difficult to morcellate), the learning curve, resectoscope sheath type, prostate-specific antigen (PSA) density, morcellated tissue weight, and the presence of prostate calcification were found to be independent predictive factors (β=-1.107, 95% CI: -1.59 to -0.55, p<0.001; β=-0.514, 95% CI: -0.85 to -0.17, p=0.003; β=-0.394, 95% CI: -0.65 to -0.13, p=0.003; β=-0.302, 95% CI: -0.59 to -0.09, p=0.043; β=0.062, 95% CI: 0.05 to 0.06, p<0.001; β=-0.329, 95% CI: -0.55 to -0.10, p=0.004; respectively).

CONCLUSIONS

This study reports that presence of the beach ball effect, the learning curve, small resectoscope sheath, PSA density, and presence of prostate calcification negatively affect morcellation efficiency. On the contrary, morcellated tissue weight has a linear relationship with morcellation efficiency.

En Bloc enucleation with early apical release technique using MOSES (En Bloc MoLEP) vs. classic En Bloc HoLEP: a single arm study comparing intra- and postoperative outcomes

BACKGROUND AND PURPOSE

We aimed to describe the technique and outcomes of En-Bloc MOSES laser enucleation of the prostate (En-Bloc MoLEP) with early apical release comparing it to En-Bloc HoLEP (non-MOSES).

PATIENTS AND METHODS

This is a single-arm prospective study, using a historical control. n = 80 patients were enrolled to the En Bloc MoLEP group and compared to a retrospective group of n = 137 patients treated by En Bloc HoLEP (non-MOSES), in total n = 217 patients.

RESULTS

En-Bloc MoLEP, showed to significantly improve the surgical time by 32% compared to non-MOSES HoLEP (32.16 ± 14.46 min, 47.58 ± 21.32, respectively; P = 0.003). Enucleation time, ablation rate and hemostasis time were also significantly improved (P < 0.001, for all three parameters). Enucleation time was 22.10 ± 9.27 min and 31.46 ± 14.85 min (P < 0.001), ablation rate 4.11 ± 2.41 and 2.54 ± 1.31 gr/min (P < 0.001), Hemostasis time 3.01 ± 2.50 and 8.35 ± 5.38 min (P < 0.001), for En Bloc MoLEP and En Bloc HoLEP, respectively. Q-max, PVR, PSA and IPSS showed significant improvement, however, at 12 months no significant differences were observed comparing both groups.

CONCLUSIONS

En-Bloc MoLEP was significantly better than En-Bloc HoLEP in terms of surgical time, enucleation time, ablation rate and hemostasis time. However, large comparative RCT with long-term follow-up are needed.

Laser enucleation of the prostate in men with very large glands ≥175 ml: A systematic review

Background

Surgical treatment options for lower urinary tract symptoms can differ according to prostate size. There are few studies on the efficacy and safety of endoscopic enucleation of prostate (EEP) in patients with very large prostates focusing on laser as energy source. In this systematic review, we aimed to examine the efficacy and safety of laser-based EEP on prostate glands ≥150 ml.

Methods

A systematic search was conducted using Web of Science, PubMed-MEDLINE, Wiley Online Library and Cochrane Library databases with the following search terms solely or in combination: "large prostate", "laser enucleation", "laser prostatectomy"by combining PICO (population, intervention, comparison, and outcome) terms. Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed.

Results

We retrieved 6 studies included 375 patients with prostate sizes ≥175 ml treated with laser-based EEP for symptomatic benign prostatic obstruction. Three studies examined Holmium laser enucleation of prostate (HoLEP) outcomes with a prostate volume (PV) >200 ml, one evaluated HoLEP outcomes with a PV of 200–299 and ≥ 300 ml, two studies evaluated HoLEP outcomes with a PV > 175 ml. We observed improvement in postoperative functional outcomes in patients with a PV > 175, >200 and >300 ml. The retreatment rate was 0–1.3% in all studies involving prostate size ≥175 ml. Most of the complications were Clavien-Dindo I (%0–9) and II (%12.7–16.6).

Conclusions

Laser-based EEP is an efficient, safe and feasible procedure even in very large prostates with good functional outcomes, low perioperative complication and retreatment rates.

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We observed better postoperative functional outcomes in prostates with a volume of ≥175, >200 and >300 ml in the present study.

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The retreatment rate was 0–1.3% in all studies involving prostate size ≥175 ml.

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Laser-based- endoscopic enucleation of the prostate is an efficient, safe and feasible procedure even in very large glands.