CHALLENGING CASE REPORT: HOLMIUM LASER ENUCLEATION OF THE PROSTATE IN THE RETREATMENT SETTING

By: Amy E. Krambeck, MD and Matthew Lee, MD

A 67-year-old man with a history of enlarged prostate and lower urinary tract symptoms was experiencing a weak stream and urinary frequency. His local urologist had initially treated him with Flomax (0.4 mg twice daily) and finasteride (5 mg daily), which he had been taking for two years.

His symptoms were somewhat controlled with medical management, but he developed urinary retention after he underwent elective laparoscopic gallbladder removal. He discussed surgical options with his local urologist and chose to proceed with UroliftÒ, which is a minimally invasive surgical treatment (MIST) that can be performed in the office and works by using surgical clips that mechanically retract prostate tissue open. The Urolift initially improved the patient’s symptoms, but after about one year, he developed worsening of his urinary frequency and urgency.

He was then referred to me for a second opinion. Many patients come to see me after previously undergoing MISTs such as Urolift or RezumÒ. Holmium laser enucleation of the prostate (HoLEP) is a surgical treatment for enlarged prostate that can be used for any prostate size and allows for maximum removal of excess prostate tissue. This means that the relief from HoLEP should be durable for the rest of the patient’s life, with no need for further medication or interventions.

HoLEP can be performed even if a man has undergone prior surgical treatment (including options such as Urolift, Rezum, microwave, TURP or Greenlight laser prostatectomy). For this patient, we discussed that because Urolift does not remove tissue, its benefits can be temporary, and some kind of prostate tissue removal is often required. We reassured this patient that his Urolift clips would be removed during the HoLEP. We discussed the risks and benefits of HoLEP as well as the alternatives. The patient agreed to proceed with surgery.

The HoLEP surgery went smoothly and all Urolift clips were removed during the operation. We observed him in the recovery area and confirmed there was minimal bleeding. His catheter was removed, and he was able to empty his bladder completely with a powerful stream. He was discharged the same day, only hours after his surgery. He was instructed to not exercise for one week after surgery.

Today, the patient is extremely happy that he went through with the HoLEP surgery. He is voiding better than he has in decades, and his urinary frequency has decreased. He wishes he had gotten his HoLEP sooner.

Listen to a recent Better Edge podcast featuring Dr. Krambeck on HoLEP >