Challenging Case of Holmium Laser Enucleation of the Prostate after Prior Prostatic Focal Laser Ablations and Rezum.

Background Holmium laser enucleation of the prostate (HoLEP) is an effective, size independent procedure for management of benign prostatic hyperplasia (BPH) 1 . Additionally, HoLEP is able to be performed successfully after prior surgical BPH treatments without complication and a low rate of long term retreatment 2 . Objectives To demonstrate challenging case of HoLEP in a patients with multiple, prior ablative BPH surgeries. Material A 63 year old male with refractory lower urinary tract symptoms (LUTS) after two focal laser ablations (FLA), one Rezum treatment, and medications (silodosin 8 mg and tadalfil 5 mg) presented to our clinic with obstructive lateral lobe BPH. The prostate was approximately 50 ml on digital rectal exam and preoperative cystoscopy demonstrated prostatic urethral calcifications and lateral lobe hypertrophy. Preoperative AUA symptom score (AUAss) was 12, peak urinary flow was 5.3 ml/s. A HoLEP was performed to alleviate the patients LUTS and allow him to stop his medications. Results Total procedure time was 44 minutes, with enucleation time of 20 minutes and morcellation time of one minute. The HoLEP was started as a two-cut technique, however due to poor surgical planes we changed to top-down technique 3 . There was a small, posterior, non-clinically significant capsular perforation. Five grams of benign adenoma were removed. Patient was discharged on the day of surgery. Catheter was removed on postoperative day four due to patient desiring to return home (over 150 miles away) for catheter removal, instead of having it done in our clinic on postoperative day one. At most recent follow-up, AUAss was 5 and peak urinary flow was 13.2 ml/s. Conclusion HoLEP can be performed after prior, multiple BPH treatments successfully. These can prove to be more challenging cases. Prior ablative techniques can lead to fibrosis of transition zone tissue and distort the natural plane between adenoma and surgical capsule.