Feasibility of holmium laser enucleation of the prostate (HoLEP) for recurrent/residual benign prostatic hyperplasia (BPH)

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? The major advantage of holmium laser enucleation of the prostate (HoLEP) depends on the ability to use the native anatomical plane between the prostate adenoma and surgical capsule, peeling each prostatic lobe from the capsule. HoLEP is associated with less catheterisation time, hospital stay and blood loss than transurethral resection of the prostate (TURP) or open prostatectomy. Urodynamic relief of obstruction has been reported to be better with HoLEP than TURP. However, surgical treatment of recurrent prostatic obstruction after previous transurethral surgery for symptomatic benign prostatic hyperplasia is more challenging because of loss of anatomical landmarks resulting in either incomplete removal or incontinence. HoLEP for recurrent symptoms due to residual or re-growing prostatic adenoma seems to be as safe, feasible and efficient as HoLEP for de novo cases. The surgical plane between the adenoma and the surgical capsule was still accessible resulting in a durable long-term outcome with minimal side-effects. Previous transurethral prostatic surgery is not a contraindication for HoLEP.

Objective: • To assess the technical feasibility, functional outcome and morbidity of holmium laser enucleation of the prostate (HoLEP) for symptomatic benign prostatic hyperplasia (BPH) in patients with previous transurethral prostate surgery. 'Redo' surgery for recurrent or residual BPH poses a technical challenge with uncertain outcome as a result of disturbed anatomical landmarks with no clear surgical limits.

Patients and methods: • We retrospectively reviewed 1054 patients who underwent HoLEP for symptomatic BPH. • Patients were stratified into two groups, group-I with no previous prostate surgery or primary-HoLEP (978 patients) and group-II with history of previous prostate surgery or secondary-HoLEP (76). • All patients' variables as well as follow-up data were assessed and compared.

Results: • There were no significant differences in baseline criteria between the two groups (P > 0.05). • In group-II, HoLEP was done after a median (range) of 66 (13-121) months from previous prostate surgeries, including transurethral resection of the prostate (48 patients), HoLEP (eight), transurethral incision of the prostate (nine), photoselective vaporization of the prostate (four) and other procedures (seven). • In both groups, routine HoLEP technique was adopted, the plane of enucleation could be identified without extra difficulty. However, more energy per gram of prostate tissue was needed in group-II (P < 0.05). • Operative auxiliary procedures were indicated in 1.9% of group-I, and 1.3% of group-II (P > 0.05). There were no operative complications or blood transfusion in group-II. The mean hospital stay and catheter time was similar in both groups. Early and late postoperative complications were not statistically different (P > 0.05). • At 1 month the mean maximum urinary flow rate (Q(max) ) was 22.3 and 18.8 mL/s, postvoid residual urine volume (PVR) was 46 and 45 mL, International Prostate Symptom Score (IPSS) was 7.04 and 7.08, and the health-related quality of life (HRQL) score was 1.57 and 1.56, in group-I and II, respectively. At 1 year the mean Q(max) was 23.4 and 25.9 mL/s, PVR was 32.5 and 24.1 mL, IPSS was 4.5 and 4.4, and the HRQL score was 1.2 and 1.1,) in group-I and II, respectively (P > 0.05). • Reoperation for recurrent obstruction was indicated in 4% in group-I and 5.2% in group-II (P > 0.05).

Conclusion: • Secondary-HoLEP procedures seem to be safe and technically feasible with comparable functional outcomes as those of primary-HoLEP.