Holmium Laser Enucleation of the Prostate Following Previous Prostatic Urethral Lift

To determine the feasibility and operative challenges of holmium laser enucleation of the prostate (HoLEP) in patients with previous prostatic urethral lift (PUL) procedure. A retrospective review was performed on files of all patients that underwent HoLEP at our institution between 2013 and 2021. Seven hundred ninety-three consecutive HoLEP cases were identified. Data collected included demographics, the time elapsed since previous PUL, number of PUL implants, preoperative prostate size, intraoperative complications/challenges, and postoperative follow-up. Twenty-two men with a mean preoperative prostate size of 90 g (range 32-180 g) underwent HoLEP at a median of 14.4 months (range 2.8-48) after PUL. 63.6% (14/22) of cases involved prostates with preoperative sizes ≥80 g. Three cases involved PUL implant jamming of morcellator blades, which required replacing the blades. Fifteen cases (68.2%) required using a grasper or a basket device to remove free PUL implants or adenoma parts with PUL implants embedded in them. One patient needed a second procedure to remove a relatively large piece of calcified adenoma. Nonpost-PUL HoLEP was more time efficient than post-PUL HoLEP (0.77 vs 0.55 mL/minute respectively). There was no difference in functional outcome between post-PUL and nonpost-PUL HoLEP cases. While HoLEP can be performed safely and effectively in the PUL failure population, unique challenges arise. PUL implants may distort prostate anatomy, jam morcellator blades, and may be encountered in aberrant locations. Patients with borderline indications for PUL should be aware of the possibility of performing HoLEP in case of PUL failure.