Extensive Free Air after Thulium Laser Enucleation of the Prostate without Rectal Injury: A Case Report

Extensive intra- or extraperitoneal free air after transurethral prostate surgery may mimic gastrointestinal perforation and lead to unnecessary surgical intervention. Although thulium laser enucleation of the prostate (ThuLEP) is considered safe, alarming postoperative imaging findings may create diagnostic uncertainty.

A 75-year-old man underwent ThuLEP for benign prostatic hyperplasia. Shortly after surgery, he developed lower abdominal pain and catheter dysfunction due to catheter malposition. Computed tomography revealed extensive intravesical, periprostatic, and combined intra- and extraperitoneal free air, raising suspicion of rectal perforation. However, the patient remained hemodynamically stable, afebrile, and without peritoneal signs. Laboratory findings were within normal limits. Contrast-enhanced computed tomography with oral and rectal contrast demonstrated no contrast extravasation or rectal wall defect. Conservative management with close observation was pursued. Serial imaging showed spontaneous regression of free air, and the patient recovered without complications.

Extensive postoperative free air after ThuLEP may represent a benign phenomenon rather than true rectal injury. In clinically stable patients, contrast-enhanced imaging and careful clinicoradiological correlation are essential to avoid unnecessary surgical exploration.