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Assessing Peri-Operative Outcomes Of Holmium Laser Enucleation Of The Prostate Following Prior Benign Prostatic Hyperplasia Procedures - A Video Demonstration Of Techniques Following Prostate Artery Embolization
Ankur U. Choksi, MD, Mursal Gardezi, BS, Michael Jalfon, BS, Christopher S. Hayden, MD, Tashzna Jones, MD, Syed N. Rahman, MD, Amir I. Khan, MD, Benjamin Press, MD, Gregory L. Lacy, III, MD, Daniel S. Kellner, MD
Yale School of Medicine, New Haven, CT, USA

Background: Holmium laser enucleation of the prostate (HoLEP) has been described for patients with recurrent lower urinary tract symptoms following other benign prostatic hyperplasia (BPH) procedures. In this study, we examine the peri-operative outcomes of patients who underwent HoLEP as a second treatment for BPH. We demonstrate cystoscopic findings and laser enucleation technique for a patient with persistent voiding symptoms following a prostate artery embolization. Methods: We retrospectively reviewed the peri-operative characteristics for the first 500 patients who underwent HoLEP between April 2019 and June 2022. Student’s t-test and Pearson chi-squared was used for statistical analysis. We performed univariate logistic regression to determine if a prior BPH procedure predicts a greater than 50% decrease in AUA Symptom Score or return to continence within 6 months of HoLEP. Results: A total of 50 patients (10.0%) of 500 patients undergoing HoLEP had been treated with a prior BPH procedure. There were no significant difference between patients that were and were not treated with a prior BPH surgery in terms of age, BMI, race, CCI, and prostate volume. Operative time, weight of enucleated tissue, length of hospitalization or post-operative catheter duration, and complication rates were similar (Table 1). On univariate logistic regression, being treated with a prior BPH procedure was not responsible for differences in improvement of AUA symptom score or return to urinary incontinence (Table 2).Conclusion: HoLEP can be performed in patients that have had prior BPH procedures with similar improvement in voiding symptoms and return to urinary continence as compared to patients that have never had any prior BPH procedures.

No Prior BPH Treatment(n = 450)Prior BPH Treatment(n = 50)p-value
Age 69.0 ± 8.1 years72.6 ± 7.4 years0.88
BMI28.3 ± 4.8 kg/m228.1 ± 5.1 kg/m20.99
Charlson Co-Morbidity Index3.1 ± 1.53.6 ± 1.60.91
Prior BPH Surgery
TURP26 (52.0%)
Greenlight PVP4 (8.0%)
UroLift11 (22.0%)
Prostate Artery Embolization4 (8.0%)
TUMT4 (8.0%)
Rezum1 (2.0%)
Prostate Volume (mL)98.3 ± 55.3 mL116.0 ± 69.4 mL0.92
Operative Time (mins)110.8 ± 52.3 mins112.2 ± 46.4 mins0.99
Tissue Enucleated (g)68.7 ± 57.1 g84.1 ± 58.0 g0.93
Length of Stay (days)0.5 ± 0.9 days0.5 ± 0.6 days1.00
Duration of catheterization (days)2.2 ± 1.7 days2.1 ± 2.1 days
Clavien Dindo Score0.82
0369 (82.0%)40 (80.0%)
128 (6.2%)3 (6.0%)
235 (7.8%)5 (10.0%)
315 (3.3%)1 (2.0%)
43 (0.7%)1 (2.0%)
Change in AUA Symptom Score-16.7 ± 9.7-14.1 ± 9.50.93
Return to Continence0.98
1 month253 (56.2%)30 (60.0%)
3 months49 (10.9%)5 (10.0%)
6 months21 (4.7%)3 (6.0%)
12 months9 (2.0%)0
> 12 months or insufficient follow up118 (26.2%)12 (24.0%)

Table 1: Pre-operative characteristics and peri-operative outcomes for patients undergoing HoLEP, stratified by those that had prior BPH surgery

Decrease in AUA SS > 50%Continence within 6 months
Odd’s Ratio95% Confidence Intervalp-valueOdd’s Ratio95% Confidence Intervalp-value
No Prior Surgery1.001.00
Any Prior BPH Surgery0.780.35 – 1.740.541.250.63 – 2.450.53
TURP1.010.31 – 3.270.981.070.44 – 2.600.89
Greenlight PVP1.001.180.12 – 11.450.89
UroLift0.340.08 – 1.400.131.050.27 – 4.010.95
Prostate Artery Embolization1.001.00
TUMT0.170.02 – 1.900.151.180.12 – 11.450.89

Table 2: Univariate logistic regression of whether a patient was treated with a prior BPH procedure predicts a greater than 50% decrease in AUA Symptom post-operatively or return to urinary incontinence within 6 months following HoLE
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