Holmium laser enucleation of the prostate for prostates of >125 mL


James E. Lingeman, Methodist Hospital Institute for Kidney Stone Disease, 1801 North Senate Boulevard, Suite 220, Indianapolis, IN 46202, USA.
e-mail: jlingeman@clarian.org



To examine a group of patients treated with holmium laser enucleation of the prostate (HoLEP) and with the bladder outlet obstructed by an exceptionally large (>125 mL) prostate, as such men are often not considered candidates for endoscopic treatments and historically have required open surgery.


We analysed retrospectively all patients with prostates of > 125 mL on transrectal ultrasonography (TRUS) who underwent HoLEP between January 2000 and January 2005.


Eighty-six patients were identified; their mean (range) age was 72.6 (48–90) years and prostate volume 170.2 (125–309) mL. Their mean preoperative prostate-specific antigen (PSA) level was 9.82 ng/mL and preoperative American Urologic Association symptom score (AUA-SS) was 19.6. The mean operative duration and hospital stay were 128.1 min and 26.1 h, respectively. The mean weight of tissue enucleated was 140.2 g. At the 1-month follow-up the mean AUA-SS (63 men) was 8.4 and at 6 months (35 men) it was 6.4. The mean serum PSA level in 48 patients was 0.96 ng/mL, a reduction of 90%. TRUS measurements in 20 patients gave a mean prostate volume of 30.8 mL, a reduction of 82%. At the 1-year follow-up the mean AUA-SS of 22 patients was 5.1.


The present report details the largest series of patients, with the largest mean prostate size, treated by any endoscopic surgical method. HoLEP may be the ideal treatment for men with prostates of > 125 mL with symptoms of bladder outlet obstruction.


holmium laser enucleation of the prostate


AUA Symptom Score.


Suprapubic prostatectomy has traditionally been the treatment of choice for men with the symptoms of BOO caused by an extremely large prostate. However, this procedure can be associated with considerable morbidity, including blood transfusion, prolonged convalescence, and even mortality [1]. Increasing experience with holmium laser enucleation of the prostate (HoLEP) has allowed the treatment of patients with progressively larger prostates. Gilling et al.[2] originally described the successful treatment by HoLEP of patients with prostates of > 100 mL on TRUS. Kuntz et al.[3] reported favourable results when comparing HoLEP to open surgical prostatectomy for patients with prostates of > 100 g, as did Moody and Lingeman [4]. In the former study, a mean of 83.9 g of tissue was retrieved, and in the latter study only 10 patients were treated with HoLEP. Thus we evaluated the outcomes in a larger series of patients who had enucleation of much more adenoma by HoLEP.


We analysed retrospectively all patients undergoing HoLEP between January 2000 and January 2005; patients were excluded from analysis if they had been previously diagnosed with adenocarcinoma of the prostate. All HoLEP procedures were performed by one surgeon (J.E.L.), using a 100 W Ho:YAG laser source, configured with a 550-nm end-fire laser fibre (Lumenis, Santa Clara, CA, USA). A 28 F continuous-flow resectoscope (Karl Storz Endoscopy, Culver City, CA, USA) with a laser bridge housing a 7 F stabilizing catheter (Cook Urologic, Spencer, IN, USA) was used to enucleate the prostate. A standard video camera system was used to optimize visualization and maintain a safe working distance from the laser fibre. Normal saline was used as the irrigant in all cases.

The HoLEP procedure was as previously described [5]; briefly, the enucleation requires laser settings of 2 J and 50 Hz for the lateral lobes, 2 J and 40 Hz for the apical dissection, and 2 J and 20 Hz to divide the apical mucosal bridges. Bleeding points are fulgurated by de-focusing the laser several millimetres from the open vessel. Optimal haemostasis can be achieved by adjusting the laser setting to 2.5 J and 40 Hz. The enucleated prostatic tissue is evacuated from the bladder with a VersaCut morcellator (Lumenis). After enucleation, morcellation, and evacuation of the prostate, a 20 F three-way catheter is secured in the bladder with a 60 mL balloon. If necessary, the catheter is placed for continuous bladder irrigation; the catheter is typically removed early in the morning of the first day after surgery.


In all, 86 consecutive patients were identified with preoperative TRUS as having a prostate volume of > 125 mL, and who had HoLEP. The mean (range) age of the patients was 72.6 (48–90) years; 47 (55%) had urinary retention before surgery and 10 of these used clean-intermittent catheterization, whereas the remainder managed their bladder with an indwelling Foley catheter. Six patients had a history of urinary retention but were not in retention at the time of surgery.

The mean (range) enucleation and morcellation times were 94.7 (27–263) and 33.4 (7–120) min, respectively, and the mean weight of resected tissue was 140.2 (30.7–312) g. The mean rate of tissue retrieval for the procedure overall was 1.09 g/min. Six patients (7%) were also found to have bladder calculi, which were treated with the Ho:YAG laser in the same setting as HoLEP. A pathological evaluation of the tissue retrieved showed BPH in 83 and adenocarcinoma in three patients. Two of these patients had Gleason 3 + 3 disease and one Gleason 4 + 5 disease. These patients had all had a previous prostate biopsy, with benign results. The mean duration of postoperative catheterization was 15.1 (2–48) h and the mean hospital stay 26.0 (5–144) h. Excluding the patient with a 144-h stay, the next longest stay was 72 h. The mean haemoglobin levels before and after surgery were 14.1 and 12.0 g/dL, respectively.

The standard follow-up regimen entailed office visits at 1, 6 and 12 months after HoLEP. Due to the referral nature of our practice, 30 of the 86 patients (35%) were from outside the state of Indiana, representing eight additional States and Canada. As a result, we were unable to obtain follow-up data in all cases. Table 1 details the TRUS-calculated prostate volume and serum PSA levels before and after HoLEP, and Table 2 lists the AUA Symptom Score (SS) and peak urinary flow rate during the follow-up. The SS and urine flow rates were not obtained before surgery in those patients with urinary retention, as accurate scores could not be assessed.

Table 1.  The TRUS-calculated prostate volume and serum PSA levels before and after HoLEP
VariableN patientsBeforeAfter% Reduction
Mean (range):
Prostate volume, mL20170.2 (125–309)30.8 (12.1–74.2)81.9
Serum PSA level, ng/mL48  9.82 (0.60–43.09) 0.96 (0.01–6.42)90.2
Table 2.  The SS and peak urinary flow rate during the follow-up
VariableBaseline1 month6 months12 months
N patients86633522
Mean (range):
SS19.6 (4–35) 8.4 (1–29) 6.4 (0–28) 5.1 (0–19)
Peak urinary flow rate, mL/s 9.1 (5.1–16.3)24.5 (11.9–54.8)22.9 (4.3–47.5)24.9 (16.7–33.7)

Two patients required open cystotomy to complete the HoLEP procedure. In both cases, the enucleated prostate adenoma occupied such an extent of the bladder volume that safe morcellation was impossible. In both of these patients the Foley catheters were removed 48 h after cystotomy, and they were subsequently able to void and were discharged from the hospital. One patient, who had urinary retention managed with a Foley catheter and had bladder calculi with recurrent UTI, developed sepsis after surgery, despite being treated with appropriate antibiotic therapy beforehand. One patient developed clot urinary retention in the recovery room after surgery, requiring an unplanned secondary procedure on the same day as the initial one. No discrete bleeding vessel was identified at the secondary procedure, and once the clot was evacuated from the bladder the haematuria resolved. This patient was the only one who required a blood transfusion. One patient, whose preoperative prostate volume was 309 mL and from whom 284 g of tissue was retrieved, required a perineal urethrostomy at the time of surgery, as the resectoscope was not sufficiently long to effectively perform the procedure. One patient had a minor bladder mucosal injury during the morcellation process, which was fulgurated with the Ho:YAG laser and required no further treatment. One patient, with a history of hypertension and coronary artery disease, had a non-Q wave myocardial infarction after surgery, necessitating a prolonged hospital stay (144 h); his cardiac condition was determined to require medical therapy only.


Historically, open prostatectomy has been considered the standard surgical treatment for men with BOO from an extremely large prostate [6]. However, an open simple prostatectomy is often not so simple, and can be a rather morbid procedure. Serretta et al.[1] reported a contemporary series of 1804 patients with a median prostate volume of 70 mL who had an open prostatectomy for BPH. The median hospital stay after surgery was 7 days. The authors reported that severe bleeding occurred in 11.6% of patients, and 8.2% required a blood transfusion. Sepsis occurred in 8.6% of cases, and within 2 years, 3.6% of patients required re-operation, mainly to treat bladder neck contracture. Others have reported even greater rates of blood transfusion for patients undergoing open prostatectomy. Moody and Lingeman [4] reported that three of 10 patients in the open prostatectomy arm of their retrospective analysis required a blood transfusion, compared to none requiring a transfusion in the HoLEP arm. Mearini et al.[7] reported in 1998 that, of 380 patients who had open prostatectomy, 102 (26.5%) received a blood transfusion.

The haemostatic nature of the Ho:YAG laser is responsible for the lower complication rate, and in particular the markedly lower transfusion rate in the present series. As the prostate can be enucleated with little blood loss, the transfusion requirement is much less. We encountered only one episode of sepsis in the series, probably caused by either an inability to completely sterilise the patient's bladder calculus even with appropriate preoperative antibiotics, or to endotoxin release during litholapaxy of the bladder calculus [8]. One possible explanation for the low incidence of infectious complications may be our practice of placing all patients on either culture-specific or broad-spectrum antibiotics for 1–2 weeks before surgery. We have had no patients with bladder neck contracture after surgery in the present series, another advantage over open prostatectomy.

TURP, a minimally invasive alternative treatment, is the most common surgical method for BPH [9]. However, patients with very large prostates are often not considered as candidates for this therapy, as there is a greater incidence of adverse events, such as blood transfusion. Mebust et al.[10] retrospectively analysed 3885 patients undergoing TURP, with a mean of 22 g resected, and found that the risk of blood transfusion was 2.5% and the risk of TUR syndrome was 2%. Importantly, the authors noted that patients with prostates of > 45 g had a significantly higher incidence of intraoperative bleeding and TUR syndrome. Muzzonigro et al.[11] prospectively analysed a cohort of patients with TRUS-calculated prostate volumes of 70–150 mL and who had TURP. These patients had an 8.9% incidence of blood transfusion, which although not significantly different from a similar cohort of men with prostates of < 70 mL, is still a clinically meaningful value, and greater than the rate of transfusion in the present series (1.1%). Furthermore, when considering this transfusion rate and comparing it to the one patient in the present series who required a blood transfusion, it must be recognized that the mean weight of tissue resected in the earlier series was 41 g, whereas the present mean was 140.2 g of tissue retrieved. The rate of retrieval in the TURP series was 0.63 g/min, compared to 1.09 g/min in the present HoLEP series. Although the mean operative duration may be less for patients undergoing TURP, HoLEP is better when assessing both operative efficiency and morbidity. Also, although two patients required a cystotomy to complete the HoLEP procedure, due to the volume of prostate tissue enucleated, in both cases their catheters were removed 48 h after surgery. The median catheter removal in the series by Muzzonigro et al. in men with large prostates treated by TURP was 3 days after surgery. Saline is used as the irrigant during HoLEP and we had no episodes of TUR syndrome.

Ablation techniques have been used to treat men with large prostates in an effort to minimize the risk of untoward events such as blood transfusion. Sandhu et al.[12] recently reported a series of 64 men with large prostates (defined as TRUS-estimated volumes of > 60 mL) who were treated with high-power KTP photoselective laser vaporization of the prostate. The mean operative duration in that series, 122.9 min, was comparable to the mean of 128.1 min in the present HoLEP series. Unfortunately, prostate tissue cannot be retrieved with the KTP procedure, which is important, as three of the present patients (3.5%) were found to have adenocarcinoma of the prostate on pathological evaluation of retrieved tissue, despite each having a complete evaluation before surgery that included serum PSA assay and, if indicated, a prostate biopsy. Although there were decreases in both the IPSS and postvoid residual urine volume in the KTP series, two patients (3%) developed bladder neck contracture, both requiring a second procedure to treat this complication. Bladder neck contracture is also a well known complication after open prostatectomy, but no patient in the current HoLEP series developed it, representing a possible advantage of HoLEP over other treatments [3]. Also, one patient (2%) in the KTP series developed urinary retention 9 months after surgery, due to ‘re-growth’ of prostatic tissue, and required a second treatment. In the present series, no patient required a secondary procedure, probably because of the complete enucleation achieved with HoLEP.

HoLEP has been previously applied to men with large prostates but these reports have included fewer patients, with smaller prostates, than reported here. Hettiarachchi et al.[13] reported a series of 18 patients with preoperative TRUS-calculated prostate volumes of > 100 mL who had HoLEP. A mean of 82.7 g of tissue was retrieved, the mean duration of catheterization was 23.8 h and the mean hospital stay was 24 h. No patient required a blood transfusion. The results reported in the present series of 86 patients are similar to those from the 18 reported in Hettiarachchi et al. Tan et al.[14] reported a larger, prospective, randomized trial of 61 men with prostates of 40–200 g; 31 had HoLEP and 30 TURP. The authors reported that HoLEP was better than TURP for the mean catheter time and hospital stay. More prostate tissue was retrieved during HoLEP, with a mean of 40.4 g reported; the present mean tissue weight retrieved was more than three times (140.2 g) that but the present complication rates and outcomes were similar. These data support the assertion of Kuntz et al.[15], that peri-operative morbidity and voiding improvement after treatment for patients treated with HoLEP do not depend on prostate size.

We previously reported a series of patients from whom > 75 g of tissue was retrieved by HoLEP [16]. For these 108 patients the mean operative duration was 166.8 min and the mean enucleated tissue weight 120.6 g, producing a rate of tissue retrieval of 0.72 g/min. The overall complication rate between this and the present study was similar, but the present mean duration was > 30 min less and the mean tissue retrieved ≈ 20 g greater. The rate of tissue retrieval in the current series was 1.09 g/min, i.e. 34% greater. We think that these data are representative of our increasing experience with HoLEP; as we have done more HoLEPs the efficiency has also increased. Our particularly unique experience with HoLEP in patients with such exceptionally large prostates confirms that the only constraint on the size of prostate that can be treated with HoLEP is that imposed by the physical space within the bladder that can accommodate the enucleated tissue. Even for those patients whose prostate is so large that it does not permit safe morcellation, an open cystotomy can be used to retrieve the specimen and, as supported by the present data, the catheter can still be removed and the patient can void at 48 h after surgery.

The current report represents the largest series of patients, with the largest prostates, who have undergone HoLEP. The present safety, morbidity, and outcome data are better than those for both open suprapubic prostatectomy and TURP for patients with exceptionally large prostates. We think that HoLEP is the ideal treatment for such patients, and particularly those who have bladder calculi, which can be expeditiously fragmented with the Ho:YAG laser. Furthermore, although suprapubic prostatectomy has been historically reserved for larger prostates, and TURP and other ablative technologies reserved for smaller prostates, HoLEP can be used to treat patients with prostates of any size, making this the most versatile surgical therapy currently available for patients with BPH.


Ramsay L. Kuo is a meeting participant and lecturer for Lumenis, Boston Scientific and Karl Storz. James Lingeman is a consultant/advisor and meeting participant/lecturer for Lumenis; an investor, meeting participant/lecturer and is involved in a scientific study/trial for Boston Scientific; a consultant/advisor for Olympus; and a meeting participant/lecturer for Karl Storz.