Holmium Laser Enucleation of the Prostate After Failed UroLift: Surgical Considerations for the Management of Nonabsorbable Implants.

OBJECTIVE

To demonstrate the surgical considerations for managing retained UroLift implants when performing HOLEP. Prostatic Urethral Lift via the UroLift System has become a common treatment modality to manage symptoms associated with benign prostatic hyperplasia. The UroLift procedure uses nonabsorbable implants to retract obstructing prostate lobes. Retreatment rates following UroLift have been reported at 13.6% over 5 years.1 We anticipate an increasing number of men seeking definitive surgical management after failed UroLift. There have been reports in the literature of UroLift implants causing morcellator device jams when attempting holmium laser enucleation of the prostate (HOLEP).2

METHODS

From August 2018 to April 2019, we reviewed 118 consecutive patients who underwent HOLEP by a single surgeon. Three men were identified who had previously undergone UroLift. Video footage was obtained. As demonstrated in the video, during enucleation, the metallic clip of the UroLift implants were incorporated in the adenoma specimen. For morcellation, we use the Piranha morcellator (Richard Wolf, Knittlingen, Germany). Morcellation was carried out in a slow and controlled manner. When the metal clip comes into contact with the morcellator, a catch and release is performed by releasing the morcellator pedal and withdrawing the morcellator into the nephroscope to release the adenoma. Remnant clips and sutures can be retrieved with a grasper. We perform a 3 month follow-up cystoscopy in the office to exclude any remnant implant material in the prostatic urethra or bladder.

RESULTS

Procedures were completed uneventfully. In developing this technique, we experienced jamming of the morcellator blades in 2 cases requiring replacement of the disposable blades. Follow up in-office cystoscopy did not reveal any remnant implant material that needed to be removed.

CONCLUSION

HOLEP can be performed safely in the UroLift failure patient population. Careful morcellation techniques can decrease the risk of costly morcellator blade replacement.