What are the surgical options for a patient with a 140g prostate, severe Lower Urinary Tract Symptoms (LUTS) and failed medical therapy, who wants to avoid sexual side effects?

Surgical Options for Large Prostate with Severe LUTS While Preserving Sexual Function

For a patient with a 140g prostate, severe LUTS, and failed medical therapy who wants to avoid sexual side effects, Holmium Laser Enucleation of the Prostate (HoLEP) or Thulium Laser Enucleation (ThuLEP) are the most appropriate surgical options. 1

First-Line Surgical Options for Large Prostates (>80g)

Laser Enucleation Procedures

• HoLEP (Holmium Laser Enucleation of the Prostate)

  • Strongly recommended by European Association of Urology for prostates >80g 1
  • Excellent efficacy in symptom relief
  • Lower rates of sexual dysfunction compared to traditional procedures
  • Requires specialized equipment and surgeon expertise

• ThuLEP (Thulium Laser Enucleation)

  • Specifically recommended for patients concerned about sexual function 1
  • Offers good balance between symptom relief and preservation of sexual function
  • Better safety profile than traditional TURP with fewer bleeding complications
  • Common side effects include temporary hematuria, dysuria, and transient incontinence

Second-Line Option

• Prostatic Artery Embolization (PAE)
  • Specifically studied in prostates >80g 1, 2
  • Less effective symptom relief than surgical options but better preservation of sexual function
  • Good option when laser technology is unavailable or patient is not a surgical candidate
  • Particularly suitable for patients with very large prostates (>80-120g) who cannot undergo surgery 2
  • Clinical success rates of 72% maintained at 36-month follow-up 3

Unsuitable Options for This Patient

• Prostatic Urethral Lift (UroLift)

  • Only recommended for prostates <70g without middle lobe obstruction 1, 4
  • Patient's 140g prostate exceeds size limitations for this procedure

• Traditional TURP

  • Higher risk of sexual side effects (65% ejaculatory dysfunction, 10% erectile dysfunction) 1
  • Not ideal for preserving sexual function

• Simple Prostatectomy (open, laparoscopic, or robotic)

  • While indicated for very large prostates (>80g), carries higher risk of sexual side effects 1
  • Should be considered only if maximum symptom relief is prioritized over sexual function

Procedure Selection Algorithm

1. First assess surgical expertise and equipment availability:

   • If laser enucleation expertise is available → HoLEP or ThuLEP
   • If laser expertise is unavailable → Consider PAE

2. If patient prioritizes sexual function preservation:

   • HoLEP/ThuLEP (first choice) → PAE (second choice)

3. If patient prioritizes maximum symptom relief regardless of sexual effects:

   • Simple prostatectomy (open, laparoscopic, or robotic)

Important Considerations

• Preoperative Assessment:

  • Confirm prostate size and shape via ultrasound or cross-sectional imaging 1
  • Evaluate for middle lobe enlargement which affects procedure selection

• Sexual Side Effect Comparison:

  • Laser procedures: 42% ejaculatory dysfunction vs. 65% with TURP 1
  • Erectile dysfunction: 7% with laser procedures vs. 10% with TURP 1
  • PAE and UroLift have minimal impact on sexual function but UroLift is contraindicated for this patient's prostate size 4

• Common Pitfalls to Avoid:

  • Selecting procedures based solely on availability rather than appropriateness for prostate size
  • Underestimating the importance of surgeon experience with laser procedures
  • Failing to properly counsel patients about realistic expectations regarding symptom improvement and potential side effects

For this patient with a 140g prostate and concern for sexual function, HoLEP or ThuLEP represents the optimal balance between efficacy and preservation of sexual function, with PAE as a reasonable alternative if laser technology is unavailable.