Bleeding after holmium laser enucleation of the prostate: Lessons learned the hard way

What's known on the subject? and What does the study add? Holmium laser enucleation of the prostate is rapidly gaining popularity as an alternative and in some institutions a replacement for standard transurethral resection of the prostate. It has been proven to have at least equivalent outcomes to the TURP and noted to be exceptionally hemostatic. This study shares some caveats regarding bleeding after HoLEP. OBJECTIVE To examine specific causes of postoperative bleeding requiring transfusion after holmium laser enucleation of the prostate (HoLEP) in order to enhance preoperative screening and counseling. MATERIALS AND METHODS After Institutional Review Board (IRB) approval, a retrospective review of a single surgeon's experience of 130 consecutive HoLEPs was performed to specifically examine patients requiring perioperative blood transfusions. All patients from August 2007 to April 2009 who underwent a HoLEP at our institution since its inception were included. These patients' charts were reviewed to gain insight into their bleeding diathesis. A case series report was compiled and compared with the relevant published literature. RESULTS Of the 130 patients, eight (6.7%) were found to require transfusion postoperatively. Four of these patients required a second operation for completion. These patients had a variety of causes for increased bleeding and subsequent transfusion including: chronic anticoagulation (n = 1), significant cardiac disease requiring maintenance of hemoglobin (n = 4), sepsis with secondary disseminated intravascular coagulation (n = 1), large prostate size (> 150 g) (n = 4), underlying prostate cancer (n = 1) and inadequate anesthesia during the procedure leading to patient movement (n = 1). All patients made a full recovery with satisfactory urinary symptom improvement except for one patient with residual incontinence at last follow-up. CONCLUSIONS Despite the many benefits of holmium laser enucleation, all patients should be counseled regarding the real potential for postoperative blood transfusion. When feasible, any known bleeding risk should be minimized by the surgeon as long it is done safely for the benefit of the patient considering their co-morbidities.