Assessing the Outcome of Holmium Laser Enucleation of the Prostate by Age, Prostate Volume, and a History of Blood Thinning Agents: Report from a Single-Center Series of >1800 Consecutive Cases

Abstract

Purpose: To assess perioperative outcomes of holmium laser enucleation of the prostate (HoLEP) in a realworld scenario and with a focus on demanding patient factors, such as large prostate size, advanced patient age, and anticoagulation therapy (AT). Materials and Methods: We retrospectively analyzed HoLEP procedures at our institution between 2010 and 2016. After stratification by prostate volume, age, and AT, perioperative and early voiding characteristics were compared. A multivariable regression model was employed to identify predictors of prolonged time of catheterization (defined as being above group's median). Results: The study cohort consisted of 1816 men with a median age of 71 years (interquartile range [IQR]: 66-76), a median prostate volume of 80 mL (IQR: 58-105), and American Society of Anesthesiologists score ‡3 in 618 men (34%). Median time of enucleation and morcellation was 43 minutes (IQR: 31-60) and 10 minutes (IQR: 6-18), respectively. Perioperative blood transfusions were administered in 44 (2.4%) cases, severe postoperative complications (Clavien-Dindo grade ‡3b) occurred in 61 (3.3%) cases. The median time of catheterization was 2 days (IQR: 2-2), with prolonged catheterization occurring in 277 (15%) cases. After adjustment, large prostates (fourth volume quartile [106-280 mL]) (odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.3-2.6, p = 0.001), therapeutic low-molecular-weight heparin bridging regimen (OR: 2.2, 95% CI: 1.4-3.6, p = 0.037), low-dose acetylsalicylic acid (OR: 1.5, 95% CI: 1.0-2.2, p = 0.015), and a history of direct oral anticoagulation (OR: 2.3, 95% CI: 1.2-4.0, p = 0.022), but not patient age, were independently associated with prolonged catheterization. Conclusions: We confirm HoLEP as safe and efficient; however, patients with large prostates and patients with a history of AT are at risk of prolonged catheterization.

Evaluation of the short-term cessation and early initiation of antithrombotic therapy in high-risk patients undergoing HoLEP procedure for large prostates (> 100 mL): A critical evaluation

“…6 Although the surgical procedure ( HoLEP) could be performed under AT in patients with small-sized prostates, the performance of the procedure in large-sized prostates will certainly increase the risk of severe bleeding and associated problems. [11][12][13] Evaluation of our cases demonstrated that although cases undergoing AP ve AC treatment were older with associated co-morbid diseases, the efficiency of enucleation and morcellation procedures were similar in both groups. Bleeding in terms of Hb drop was evaluated with the postoperative Hb values obtained at two different time intervals (postoperative 12 hours and 1 week) after the procedure.…”

“…We compared our findings with the data of similar studies and found that the results were comparable. 12,13 Regarding prolonged catheterization issues in the three groups, we found that the results were different (p = 0.028, 3x2 chi-square test). Also, the AP and AC groups were compared with the NT group in terms of prolonged catheterization and our findings showed that catheterization time was significantly longer in cases undergoing AP treatment when compared with the ones without any treatment (AP vs NT; OR: 2.77, 95% CI: 1.28-5.96, p=0.007 and AC vs NT; OR: 1.67, 95% CI:0.61-4.55, p=0.391, 2x2 chi-square test).…”

Safety and Efficacy of Laser Enucleation of the Prostate in Elderly Patients – A Narrative Review

“…Clavien grade ≥ III complications was minimal in all groups (0%, 5.6%, 3.9% and 4.4% in groups). 60–69:91 N/A 28.9 ± 4.7 3.20 (0.28–21.74) 21.2 ±7.7 9.4 ±6.1 N/A 1.28 ±0.7 N/A 5 ± 4.4 24.7± 11 70–79:153 N/A 27.2 ± 3.9 4.63 (0.37–91.2) 19.5 ±6.6 9.7 ±6.3 N/A 1.26 ±0.9 N/A 5.7 ± 4.7 20.3 ± 8.9 ≥ 80:45 N/A 25.8 ± 3.2 6.20 (0.67–82.7) 23.3 ±7.3 9.1±5.0 N/A 1.68 ±2.1 N/A 8.7 ± 8.3 15.1 ± 6.7 Gild et al 2020 17 retrospective HoLEP ≤ 60: 134 71 (66–76) 80 (58–105) 5.3 (2.8–10) 19 (13–24) 10 (7–14) 4 (3–5) N/A N/A N/A Δ 18 (9–27) b The improvement in maximal flow rate was more pronounced in men under 60 years than in men over 80 [12 (IQR: 3.5–18) vs.18 mL/s (IQR: 9.0–27)]. The improvement in PVR was more pronounced in men aged 80 years and older than men<60 years [(100 mL (IQR: 34–233) vs 85 mL (IQR: 35–180)].…”

“… 6 , 22–24 Five studies focussed mainly on Holmium laser enucleation of the prostate (HoLEP). 6 , 17 , 20–22 One study focussed on comparing HoLEP to other laser prostatectomy procedures, 16 two studies examined Thulium laser enucleation of the prostate (ThuLEP) in more detail, 14 , 18 and two other studies focussed on the GreenLight XPS 180-W laser procedure, 19 , 23 one focussed on potassium-titanyl-phosphate (KTP) laser 24 and another compared laser prostatectomy to transurethral resection of the prostate (TURP). 15 …”

“…Gild et al performed a retrospective analysis including of 1816 men's perioperative outcomes after HoLEP. 17 Their study emphasises that the Qmax improvement was more pronounced in men aged under 60 years than in those over 80 [12 (IQR: 3.5–18) vs 18 mL/s (IQR: 9.0–27)], whereas the improvement in PVR was more pronounced in men aged 80 years and older than those <60 years [100 mL (IQR: 34–233) vs 85 mL (IQR: 35–180)]. Prolonged catheterisation was not associated with patient age.…”