Safety and efficacy of concomitant holmium laser enucleation of the prostate with transurethral endoscopic management of symptomatic large bladder diverticulum: revisiting a historical technique in the modern era with literature review.

Introduction: Acquired bladder diverticulum (BD) is typically managed using open, laparoscopic, or robotic approaches. Although transurethral techniques demonstrated favorable outcomes in the 1970s and 1980s, they have largely fallen out of favor. This study revisits transurethral endoscopic management of large, symptomatic BD, combined with Holmium laser enucleation of the prostate (HoLEP) for patients with benign prostatic obstruction (BPO) and coexisting BD.

Methods: We retrospectively reviewed patients who underwent combined HoLEP with transurethral endoscopic management of bladder diverticulum (C-HoLEP-TUBD) between May 2017 and January 2025. Following HoLEP, the diverticular neck was circumferentially resected, and the diverticular mucosa was fulgurated using bipolar cautery. Follow-up cystography was obtained 6-12 weeks postoperatively and perioperative data were collected and analyzed.

Results: Six patients (mean age: 72 + 7.46 years) underwent the procedure. The mean prostate volume was 91 ± 43 cc, and mean BD size was 8.57 ± 5.28 cm. Preoperative Qmax averaged 4.76 ml/s, and mean post-void residual (PVR) was 372.8 cc. At 3-month follow-up, Qmax improved to 25.74 ± 22.4 ml/s, and PVR decreased to 22 ± 23.24 cc. Mean diverticulum size reduced to 1.7 ± 1.19 cm, representing an of 81.89 ± 15.09% reduction. No patient had a residual diverticulum > 2 cm or developed related symptoms during follow-up.

Conclusion: C-HoLEP-TUBD is a safe and effective technique for managing large, symptomatic bladder diverticula in patients with BPO. This combined approach offers significant improvements in urinary function and diverticulum size. Further multi-institutional studies are warranted to confirm these findings and evaluate long-term outcomes.