Safety and feasibility of En-bloc holmium laser enucleation for very large prostates (> 200 cc) with trainee involvement

Objectives: To evaluate the safety and feasibility of "en-bloc" Holmium Laser Enucleation of the Prostate (HoLEP) with trainee involvement in patients with prostates larger than 200 cc. Patients and Methods: A retrospective analysis was conducted on patients undergoing HoLEP using the "en-bloc" technique for prostate sizes > 200 cc between July-2017 and December-2023 at an academic teaching hospital. Perioperative data was collected, including patient demographics, clinical parameters, operative details and functional outcomes. Patients who continued to experience incontinence at 1 year were further followed up at 2 years to update their continence status. Sub-group analysis was performed to compare outcomes between patients with preoperative prostate size of 200-300 cc and > 300 cc. Results: The analysis included 89 patients with a mean age of 73.12 +/- 8.10 years. Preoperative prostate weight ranged from 200 to 401 cc with a median of 245 cc, and median PSA was 7.71 ng/ml. Median operative time was 218.5 minutes, and median enucleated prostate volume was 164.2 cc. Median postoperative PSA was 0.4 [0.21-0.78] ng/ml. At 1-year follow-up, mean IPSS was 1 +/- 2.4, Qmax was 27.03 +/- 11.57 ml/s and PVR was 21.6 +/- 28.6 ml. Postoperative complications included blood transfusion (5.6%), acute renal injury (4.5%), urinary tract infection (2.2%), postoperative urinary retention (2.2%) and urethral stricture (5%). Although transient urinary incontinence was noted in 41.6% at 1-3-months, complete continence was achieved in 83.3% and 96.3% at 1 and 2 years postoperatively, respectively. Subgroup analysis showed significant differences in operative time and enucleated weight between prostates 200-300 cc and > 300 cc, but no significant differences in postoperative IPSS, PVR or Qmax at 3-months. Conclusion: "En-bloc" HoLEP is a feasible and safe procedure for prostates larger than 200 cc, demonstrating favourable perioperative and functional outcomes despite the extended operative times and involvement of trainees.