Challenging scenarios in HoLEP

Introduction and objectives

Holmium laser enucleation of the prostate (HoLEP) is a gold standard treatment for benign prostatic hyperplasia (BPH). It provides robust symptom relief and low re-operative rates while being size independent. There are several challenging scenarios that can be encountered by surgeons that require a systematic approach to complete the procedure. We highlight our approach to difficult scenarios during HoLEP including: “beach ball” morcellation, prostatic urethral lift implants, equipment malfunction, and poor visibility.

Results

Vascular prostates are prone to intraoperative bleeding, which can lead to impaired visibility during enucleation. Surgeons should ensure good inflow and outflow as clots can form in the resectoscope. Deliberate hemostasis, working close to tissue, continued dissection, and potentially using alternative approaches allow the surgeon to reach the capsular plane and control prostatic vessels near their origin. The need to use bipolar cautery for hemostasis during HoLEP is rare but should be considered when other strategies are not successful.

It is crucial to recognize capsular perforations early to minimize complications. Most perforations can be managed by overcorrecting the plane of enucleation and using loop diuretics. These cases should be finished efficiently, as prolonged operative times can increase risk for volume overload. In rare scenarios, the case may need to be terminated or converted due to increased fluid absorption by the patient or loss of visibility.

Enucleated prostate adenoma is morcellated in the final step of HoLEP. Occasionally, very dense adenoma tissue will not morcellate creating “beach balls.” The first step to mitigating this issue is to slow down the morcellator speed. If this fails, the adenoma can be brought into the fossa where it is less likely to disengage from the morcellator blade. Next, grooves can be cut into the adenoma using the laser to improve tissue engagement. Finally, a bipolar loop may be used to break down the adenoma into smaller pieces that can be irrigated out. Small “beach balls” can also be removed using an atraumatic tipless percutaneous stone basket.

Prostatic urethral lift is a minimally invasive therapy for BPH. These implants may be encountered during enucleation and broken down with the laser. They can also jam or damage the blade during morcellation. If this occurs, the implant needs to be cleared from the blade, and if the blade is damaged a new morcellator blade should be used.

Scope breakage may occur during HoLEP. The beak of the resectoscope has been reported to detach in the bladder and can be retrieved using laparoscopic graspers. Excessive torque on the scope and lens during enucleation can lead to bending of the scope or lens. It is critical to have a backup set ready in the event of equipment malfunction.

Conclusions

HoLEP can present several challenges to surgeons. ​Difficult scenarios are likely to be encountered by surgeons with substantial case volume,so it is critical to be prepared with multiple troubleshooting strategies.