Introduction: The 2021 American Urological Association benign prostate hyperplasia (BPH) guideline recommends several alternative minimally invasive surgeries. We describe outcomes of holmium laser enucleation of the prostate (HoLEP) after failing an alternative surgery, specifically water vapor thermal therapy (WVTT), prostatic urethral lift (PUL), robotic waterjet treatment (RWT), or prostatic artery embolization (PAE). 

Methods: We retrospectively examined patients within our institution review board-approved clinical database that underwent HoLEP (March 2021 to September 2021) with a prior history of WVTT, PUL, RWT, or PAE. Continuous variables were expressed as mean (range) with heteroscedastic two-tailed T-test and Fisher's exact test (p<0.05).

Results: We identified 17 patients that underwent PUL (n=8), PAE (n=4), WVTT (n=3), and RWT (n=2) an average 28.5 months prior to HoLEP (range 10–83 months). Average age was 71 (60–81) years, with preoperative prostate size of 95.3 mL (range 31–191) (magnetic resonance imaging: 8, computed tomography: 7, transrectal ultrasound: 1, digital rectal exam: 1), intraoperative specimen weight of 59.7 g (15–125), and body mass index of 28 (21–35). Pre-HoLEP urinary incontinence (UI) was present in 8/17 (47%), with patients using alpha-blockers (n=14), 5-alpha-reductase inhibitors (5-ARIs) (n=6), anticholinergics (n=3), and beta-3 agonists (n=1) following their alternative BPH surgery. Post-HoLEP, only two patients required anticholinergic medications at three months (alpha-blockers: 0, 5-ARIs: 0, beta-3 agonists: 0). International Prostate Symptom Score improved post-HoLEP (20.0 [6–30] vs. 8.9 [2–21], p=0.0043). Michigan Incontinence Symptom Index bother scores improved post-HoLEP (5.5 vs. 1.2, p=0.028). No patients required indwelling catheters at three months post-HoLEP.

Conclusions: In patients that have undergone alternative minimally invasive BPH surgeries (PUL, WVTT, RWT, PAE) with persistent lower urinary tract symptoms, UI, or need for medical management, our single-center six-month series shows IPSS and UI bother score improvements post-HoLEP. All patients were able to discontinue alpha-blockers, 5-ARIs, and beta-3 agonists at three-month followup.