Holmium Laser Enucleation of the Prostate after Prostatic Urethral Lift Surgery: Feasibility and Technical Considerations from a Multi-Institutional Case Series

Introduction and Objective: Ten percent of patients undergoing prostatic urethral lift (PUL) require repeat surgical treatment within 3 years. We describe the feasibility and considerations of performing holmium laser enucleation of the prostate (HoLEP) as a salvage therapy after previous PUL. Methods: Men who had undergone HoLEP after PUL were retrospectively identified from three institutions with surgeons experienced in HoLEP. Subjects were characterized by age, time from PUL procedure (months) to HoLEP surgery, indication for retreatment, and pre-operative prostate volume by ultrasound. Outcomes of interest included enucleation time, morcellation time, morcellator type, weight of tissue resected, and Clavien complications. We also summarize findings related to the location of PUL device implants, and the effect of the implants on the enucleation and morcellation portions of the procedure. Results: From December 15, 2015 to October 31, 2016, seven men aged 51-78 years underwent HoLEP at a median of 8.6 months (range 3-18) after PUL. The median prostate volume by transrectal ultrasound was 80 cm³ (range 56-160 cm³). For the 7 patients, 6 out of the 22 device implants were found in aberrant locations. Auxiliary maneuvers were required in five cases. Morcellation devices tended to jam with each implant, requiring a pause for withdrawal of the morcellator and manual removal from the blade or requiring grasper retrieval of device components. There were no Clavien complications. Conclusions: HoLEP can be performed safely and effectively post-PUL; however, device implants may be found in areas other than the intended location, and morcellation of the adenoma tissue is complicated by metallic implants of the PUL device.