What are the considerations for Holmium Laser Enucleation of the Prostate (HoLEP) or Robotic-assisted HoLEP for a patient with a 150g prostate and symptoms of Benign Prostatic Hyperplasia (BPH)?

HoLEP for Large Prostates (150g)

For a patient with a 150g prostate and BPH symptoms, HoLEP is the optimal surgical choice and should be strongly recommended as the preferred treatment over robotic-assisted simple prostatectomy or other alternatives. 1, 2

Why HoLEP is the Best Option for This Patient

Size-Independent Gold Standard

• HoLEP is explicitly recommended by both the AUA and EAU as a size-independent treatment option for moderate-to-severe LUTS, meaning it can be performed on prostates of any size without limitation, including very large prostates >80g like this 150g gland. 1, 2, 3
• The EAU guidelines specifically state that HoLEP should be offered as an alternative to TURP or open prostatectomy with a strong recommendation for men with moderate-to-severe LUTS. 1
• At 150g, this prostate is nearly double the threshold where traditional TURP becomes problematic, making HoLEP particularly advantageous. 1

Superior Long-Term Outcomes

• HoLEP demonstrates durable symptomatic improvement with long-term data extending beyond 10 years, showing superior outcomes compared to TURP including greater Qmax improvement (4.36 mL/s better at 7 years) and lower reoperation rates. 4, 3
• The reoperation rate for HoLEP at 3 years is 7.2%, comparable to TURP's 6.6%, but HoLEP's ability to completely enucleate all adenomatous tissue provides better durability for large prostates. 5
• Patients achieve significant IPSS reduction and Qmax improvement that is sustained long-term, directly impacting quality of life. 4, 6

Safety Profile and Recovery

• HoLEP offers excellent hemostatic properties, making it the safer choice for patients with high bleeding risk or those on anticoagulation/antiplatelet therapy. 1, 2
• Patients benefit from significantly shorter catheterization times (median 2 days vs 5 days for robotic prostatectomy) and reduced hospital stay (median 3 days vs 4 days). 7, 8
• The complication profile is favorable compared to open or robotic approaches, with lower rates of serious perioperative complications. 4, 6

What About Robotic-Assisted Simple Prostatectomy?

When RASP Might Be Considered

• Robotic-assisted simple prostatectomy (RASP) is recommended by the AUA for large prostates when providers lack access to or expertise with HoLEP technology. 1
• For extremely large prostates ≥200cc, RASP and HoLEP show similar functional outcomes with comparable improvements in Qmax (+10.6 vs +10.7 mL/s) and IPSS reduction. 7

Why HoLEP Still Wins at 150g

• Despite similar efficacy, HoLEP provides shorter hospital stays and catheterization times even in prostates ≥200cc, making it preferable for this 150g prostate. 7, 8
• A propensity-matched analysis showed that while trifecta outcomes (continence, Qmax >15, no complications) were similar between HoLEP (71.25%) and RASP (63.75%), HoLEP patients had significantly shorter postoperative stay and catheterization time. 8
• The amount of tissue resected is actually greater with HoLEP (180g vs 134.5g in one study), suggesting more complete adenoma removal. 7

Robotic-Assisted HoLEP: Not Ready for Prime Time

• There is no guideline support or high-quality evidence for robotic-assisted HoLEP in the provided literature. [1-8]
• The established robotic approach for large prostates is RASP (simple prostatectomy), not robotic HoLEP. 1, 7
• Standard HoLEP performed transurethrally remains the evidence-based approach with the most robust long-term data. 4, 3, 6

Clinical Algorithm for This Patient

Step 1: Confirm HoLEP Availability and Expertise

• Verify that your institution has HoLEP capability and an experienced surgeon (the learning curve is steep but outcomes are superior once mastered). 4, 6
• If HoLEP is available, proceed directly to recommending it as first-line surgical treatment. 1, 2

Step 2: If HoLEP Unavailable

• Consider RASP as the next best alternative for this 150g prostate, given the size exceeds what is reasonable for TURP. 1, 7
• Open simple prostatectomy remains an option but has higher morbidity than either HoLEP or RASP. 1

Step 3: Patient-Specific Considerations

• If the patient is on anticoagulation or has high bleeding risk, HoLEP is strongly preferred over RASP due to superior hemostasis. 1, 2
• If the patient prioritizes rapid recovery and shorter catheterization, HoLEP provides measurable advantages. 7, 8
• Counsel regarding similar rates of retrograde ejaculation with both procedures (this is expected with complete adenoma removal). 4

Common Pitfalls to Avoid

Don't Default to RASP Just Because It's "Robotic"

• The robotic platform does not confer superiority over standard HoLEP for BPH treatment. 7, 8
• RASP requires longer catheterization and hospitalization without providing better functional outcomes. 7, 8

Don't Attempt TURP on This Size Prostate

• At 150g, TURP would require prolonged resection time with increased complications and incomplete tissue removal. 1
• The AUA guidelines acknowledge that while some providers achieve good results with transurethral approaches in prostates >60g, this requires specific expertise with bipolar TURP or HoLEP. 1

Don't Overlook the Learning Curve

• HoLEP has a steeper learning curve than TURP, but appropriate mentoring and training overcome this barrier. 4, 6
• Outcomes at high-volume centers with experienced surgeons are consistently superior to alternatives. 3, 6