In a man with symptomatic benign prostatic hyperplasia and a prostate larger than 30 cc who has failed medical therapy, when is Holmium laser enucleation of the prostate (HoLEP) appropriate, and what are its indications, contraindications, pre‑operative assessment, and postoperative course?

HoLEP for Benign Prostatic Hyperplasia

HoLEP is the size-independent endoscopic gold standard for surgical treatment of symptomatic BPH in men who have failed medical therapy, particularly for prostates larger than 30 cc, and should be strongly considered as the preferred surgical option over traditional TURP. 1, 2

Indications for HoLEP

Primary indications include:

• Moderate to severe LUTS (IPSS >8) with failed medical therapy in men with prostates >30 cc who desire definitive surgical treatment 1

• Any prostate size, but particularly advantageous for glands >80 cc where traditional TURP becomes less effective and open prostatectomy was historically required 1, 2

• Very large prostates (>175 cc) where HoLEP provides endoscopic tissue removal comparable to open prostatectomy with significantly lower morbidity 3

• Patients on anticoagulation or antiplatelet therapy where HoLEP's superior hemostasis provides a safety advantage over TURP 1, 4

• Urinary retention requiring catheterization despite medical management 4, 3

• Recurrent gross hematuria from prostatic bleeding refractory to medical therapy 1

• Bladder stones secondary to bladder outlet obstruction from BPH 1

• Recurrent urinary tract infections attributable to elevated post-void residual volumes 1

Contraindications

Absolute contraindications:

• Active urinary tract infection (must be treated prior to surgery) 1

• Inability to tolerate general or spinal anesthesia due to severe cardiopulmonary disease 1

Relative contraindications:

• Suspected prostate cancer (should undergo biopsy confirmation first, though HoLEP tissue can be sent for pathology) 1

• Bladder pathology requiring separate surgical intervention 1

• Severe urethral stricture disease that would prevent passage of resectoscope 5

Pre-operative Assessment

Essential pre-operative evaluation includes:

• IPSS symptom score and quality of life assessment to document baseline symptom severity 1, 6

• Uroflowmetry with post-void residual measurement to objectively document obstruction (typical findings: Qmax <10-12 mL/sec, elevated PVR) 4, 6

• Prostate size estimation via transrectal ultrasound or MRI to plan operative approach and counsel regarding operative time 4, 3

• PSA measurement to establish baseline (expect 75-90% reduction post-operatively) 4, 3

• Urinalysis and urine culture to rule out active infection 1

• Assessment of anticoagulation status - HoLEP can be safely performed on anticoagulation, but this should be documented and discussed 1, 4

Optional but valuable studies:

• Urodynamic testing in patients with unclear diagnosis, suspected detrusor underactivity, or neurogenic bladder to confirm bladder outlet obstruction 6

• Cystoscopy if bladder pathology is suspected or to assess urethral anatomy 1

Expected Outcomes and Postoperative Course

Immediate postoperative period:

• Catheterization time averages 17-18 hours (significantly shorter than TURP's 45 hours) 4, 6

• Hospital stay averages 24-28 hours, with many patients discharged same-day or next morning 4, 3

• Minimal blood loss with transfusion rates of 1-2% (primarily in anticoagulated patients) 4

• No risk of TUR syndrome due to saline irrigation 5

Functional outcomes at 6-12 months:

• 200% increase in peak flow rate (from ~8 mL/sec to 18-20 mL/sec) 4, 6

• 75% improvement in IPSS (from ~19 to 6-7) 4, 6

• Significant improvement in quality of life scores comparable to or better than TURP 6

• 90% reduction in detrusor pressure at maximum flow, demonstrating superior relief of obstruction compared to TURP 6

• Durable results extending beyond 10 years of follow-up 2

Complications and Management

Common early complications:

• Transient irritative voiding symptoms (frequency, urgency, dysuria) occur in 9.4% of patients and typically resolve within 4-6 weeks 4

  • Manage with anticholinergics (oxybutynin) only if urge incontinence or persistent irritative symptoms develop, not as routine prophylaxis 7
  • Avoid oxybutynin in patients with narrow-angle glaucoma, impaired gastric emptying, or urinary retention risk 7

• Transient stress incontinence occurs in 4.2% early postoperatively but resolves in most patients, with only 1.5% experiencing long-term incontinence (similar to TURP) 1, 4

  • Do not treat stress incontinence with anticholinergics - this is contraindicated and will worsen symptoms 7
  • Recommend pelvic floor exercises and behavioral modifications first 7

Late complications:

• Bladder neck contracture occurs in 1.3% of patients 4

• Urethral stricture occurs in 1.3% of patients 4

• Retreatment rate is extremely low (<2% at 5-7 years) due to complete adenoma removal 1, 2

Sexual function:

• Retrograde ejaculation occurs in the majority of patients (similar to TURP and open prostatectomy) 1

• Erectile function is generally preserved, with no significant difference compared to TURP 1

Critical Advantages Over Alternative Procedures

HoLEP vs TURP:

• More complete tissue removal (mean 40-52 g vs 25 g with TURP) resulting in lower retreatment rates 4, 6

• Superior hemostasis with lower transfusion rates, especially important for anticoagulated patients 1, 6

• Shorter catheterization time and hospital stay 6

• No TUR syndrome risk 5

• Size-independent efficacy - can treat any size prostate endoscopically 2, 3

HoLEP vs Open Prostatectomy:

• Equivalent tissue removal and functional outcomes for large glands (>80-100 cc) 1, 3

• Dramatically shorter hospital stay (27 hours vs 5-7 days) 1

• Lower morbidity and complication rates 1

• Faster recovery and return to normal activities 1

Common Pitfalls to Avoid

• Do not routinely prescribe anticholinergics post-HoLEP - reserve for documented urge incontinence or persistent irritative symptoms beyond 4-6 weeks 7

• Do not confuse transient stress incontinence with urge incontinence - anticholinergics will worsen stress incontinence 7

• Do not delay surgery in patients with retention or recurrent UTIs - these complications indicate absolute need for intervention 1

• Recognize the learning curve - HoLEP requires specialized training and 20-50 cases to achieve proficiency, so ensure the surgeon has adequate experience 5

• Do not assume small prostates are contraindications - HoLEP is effective for prostates as small as 20 cc, though TUIP may be considered for glands <30 cc 1, 4