In this descriptive study of 173 patients who underwent HoLEP, we found that this technique was associated with significant Qmax improvement, short bladder catheterization, hospital stay, and could be used independently of prostate size. The rate of complications was relatively high in our study in the first two years following the introduction to our institution and further decreased as much as experience was gained.
Holep is a mini invasive surgical technique indicated in men with moderate to severe LUTS due to benign prostatic hyperplasia, unresponsive to conventional medical treatment [14]. Several lines of evidence have established that Holep is a safe and effective procedure, enabling complete removal of the prostatic adenoma as with prostatectomy, in patients with voluminous prostate size [5,6,7]. Similarly, it is equally effective as TURP for smaller prostates with the lowest complications rates [10, 15, 16]. Holep significantly improves Qmax and reduces LUTS, all of which have been proven in many reports [17,18,19]. As a result of the learning curve, Holep-associated complications such as prostate capsular perforation or bladder mucosal damage are likely to occur more frequently when the procedure is newly implemented, but decrease with time and experience [7, 16]. For example, bladder injury and bladder trigone detachment occurred within the first two years of Holep commencement in our institution (Fig. 1), and became less common in the subsequent years. There have been instances in which Holep had to be converted to TURP (1.1% in our study) to complete the surgery, due to the inability to obtain a good cleavage plane between the adenoma and the prostate shell, although Holep conversion to TURP remains a rare occurrence.
One patient (0.58%) underwent an open cystotomy in order to remove a bulky prostate tissue weighing 330 g that had been enucleated in one piece. In that particular situation, open cystotomy is not only faster but also reduces the risk of morcellation injury since, after enucleation, the bulky prostate tissues that have been released into the bladder completely occlude the bladder lumen, challenging the vision and ultimately not allowing a safe fragmentation of the enucleated prostate. Therefore, an open cystotomy is sometimes necessary to facilitate the retrieval of the enucleated tissue, because the morcellation of enucleated adenoma could be unsafe if performed under impaired vision [16].
Bladder injury during morcellation is one of the most feared intraoperative complications, with cumulative incidence ranging from 2.9 to 3.6% [7]. In our study, bladder injury appeared superficial and distant from ureteral meatus. It is well known that superficial bladder injuries display a better prognostic compared to bladder rupture which requires open surgical repair [7]. One of the key elements to prevent bladder injury remains effective and careful hemostasis and fully distended bladder [20], all of which provide a clear vision during enucleation/morcellation, and allow a minimally continuous bladder irrigation postoperatively [10]. It is apparent, however, that a hyperinflated bladder required during morcellation may have been a contributing factor to the extra peritoneal extravasation of the irrigation liquid that we encountered in this series. While it is often challenging to identify this complication intraoperatively [21], the diagnosis was made afterward in our series, as patients experienced abdominal discomfort, meteorism, and had ultrasound signs. Bladder injury as well as capsular perforation didn’t prolong the duration of catheterization.
The blood transfusion rate in our series (3.5%) is comparable to that of the rates reported during TURP in the literature [7]. Post-Holep hematuria increases the length of catheterization and hospital stay, as it requires more frequent irrigations, blood transfusion, and often reoperations. Patients taking anticoagulation medication seemed to be more at risk of this complication during Holep surgery, and therefore represent a dilemma for clinicians [22, 23]. In fact, clinicians may be able to benefit from discontinuing anticoagulation medications prior to Holep, since this ensures better control over hemorrhagic complications. However, it is often impossible to do in real practice, especially in patients with heart valves replacement, as doing so greatly increases the risk of thromboembolic complications [23]. In addition to anticoagulation medication, Prostate volume is another contributing factor to the risk of hemorrhagic complications because surgery for large adenomas increases the time for enucleation and hemostasis [10].
Transient urinary incontinence is common within the first 3 months following Holep, and numerous factors have been implicated, including advanced age, large prostate volume, obesity, traction of the urethral sphincter during the enucleation procedure or tissue damaged by laser energy near the prostatic apex [7, 24, 25]. A meta-analysis reported that the rate of persistent urinary incontinence (after 3 months) is comparable to that of TURP and roughly ranged between 1.5 and 2% [7, 26]. Furthermore, the rate of persistent urinary incontinence despite bladder and pelvic floor rehabilitation in our series (3.5%) is similar to that reported by Ye et al. (3.2%) [27].
Urethral strictures and bladder neck sclerosis are complications associated with prostate surgery, and not specific to HoLEP [7]. The postoperative decrease in the PSA level confirms almost complete elimination of the adenoma after surgery [16, 28].
This study presents several limitations that should be highlighted. Given its descriptive nature, numerous variables were not accounted for in the assessment of Holep safety and effectiveness, including concurrent comorbidities, Holep indications, or sexual function post Holep. While we found a higher rate of hemorrhagic complications in patients who did not discontinue their anticoagulation treatment, we didn’t compare these findings to patients who did. In addition, the absence of control group further limits the interpretation of these findings.
