Presented by: Tomer Hasdai MD
Institute of Urology, Rabin Medical Center - Hasharon Hospital

Introduction

Holmium laser enucleation of the prostate (HOLEP) is a commonly performed procedure for the treatment of benign prostatic hyperplasia (BPH), particularly in cases involving large prostates. Compared to open prostatectomy, HOLEP has demonstrated advantages such as less complications, shorter hospital stays, reduced bleeding, and faster recovery. However, HOLEP is associated with a steep learning curve and potential complications that may necessitate a conversion to an open surgical procedure. This study aimed to present HOLEP cases which underwent conversion to open approach in our institution.

 

Materials

We conducted a retrospective analysis of patients who underwent HOLEP at our institution and required conversion to open surgery. We collected demographic and clinical data, as well as intraoperative and postoperative characteristics.

Results

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Among 890 patients who underwent HOLEP surgery at our institution between 2016 and 2023, 6 patients (0.67%) required conversion to open surgery. The mean age at the time of surgery was 75 years (range: 70-87), and the mean body mass index (BMI) was 30. Five patients were referred for surgery due to intractable lower urinary tract symptoms (LUTS), while one patient had obstructive uropathy. The mean prostate size was 101 cc (range: 80-174). The indication for conversion included bladder perforation during morcellation (2 cases), operational difficulties (2 cases), uncontrolled arterial bleeding (1 case), and a narrow urethra impeding resectoscope insertion (1 case). In patients with bladder perforation, exploration and cystotomy suturing were performed, while the remaining patients underwent standard Suprapubic prostatectomy (SPP) with hemostasis as needed. No correlation was observed between surgeon experience and the need for conversion to open. The mean duration of the operation was 221 minutes (range: 141-253), and the average length of hospital stay was 8.5 days (range: 5-11). Two patients experienced urinary tract infections during the postoperative period, two patients required intensive care unit admission, and one patient needed drainage of a contaminated collection. No patient required reoperation.  

Conclusion

Although the risk of conversion to open surgery during HOLEP is low, it does exist. HOLEP surgeons should be aware of this potential complication and acquire proficiency in the open surgical approach for situations when it is necessary.

Funding

non

Co-Authors

Tomer Hasdai, MD
Institute of Urology, Rabin Medical Center - Hasharon Hospital

Abed El-halim Darawsha, MD
Institute of Urology, Rabin Medical Center - Hasharon Hospital

David Lifshitz,
Institute of Urology, Rabin Medical Center - Hasharon Hospital

Yaron Ehrlich, MD
Institute of Urology, Rabin Medical Center - Hasharon Hospital