Introduction: Morbidly enlarged prostate (MEP) >400g due to benign prostatic hypertrophy (BPH) can result in significant lower urinary tract symptoms that are refractory to standard medical and surgical management. While the vast majority of large glands are amenable to either Holmium laser enucleation (HoLEP) or robotic simple prostatectomy (RSP), each of these procedures has drawbacks that limit effective management of MEP. Namely, accessing the apex is difficult from the robotic approach; for HOLEP, base access and morcellation are challenging for glands of this size and perineal urethrostomy is often required. We sought to develop a safe procedure combining the strengths of HoLEP and RSP.
Methods: Patients with MEP and bothersome LUTS underwent a combined HoLEP and RSP procedure between 2017-2019. Patient charts were retrospectively reviewed.
Results: Three patients were identified with a mean prostate volume of 498g (range 400-600g) all of whom required self catheterization to empty their bladders preoperatively. Operative time ranged from 270-384 minutes. Mean drop in hematocrit was 8%. An average of 64% of the gland was removed (range 275-330g). All patients were discharged on postoperative day 2 with a mean time to catheter removal of 10 days. One patient required an intraoperative blood transfusion and was found to have high risk prostate cancer in the specimen requiring further treatment. All patients were able to void at the time of followup (mean 8.5 months) with a mean PVR of 64cc. None of the patients have developed a urethral stricture and all have excellent continence.
Conclusions: Combined HoLEP and RSP is a safe procedure for MEP that may not be adequately treated by either procedure alone. By combining these approaches, the need for perineal urethrostomy and morcellation is obviated, endoscopic time is decreased, thereby potentially lowering the risk of urethral stricture formation, and apical dissection is substantially simplified. Source of
