HoLEP patient selection and the technical error most surgeons make past training

There is no prostate too large or too small for holmium laser enucleation when treating benign prostatic hyperplasia (BPH)—but patient selection and apical technique separate surgeons who consistently achieve excellent outcomes from those who do not, according to Amy E. Krambeck, MD, a professor of urology at Northwestern University Feinberg School of Medicine and one of the highest-volume HoLEP surgeons in the United States.

On candidacy, Krambeck described her position as a true believer in the broad applicability of enucleation—from 20-g to 600-g prostates—while being precise about the clinical scenarios that warrant caution or outright redirection. Morbidly obese patients represent the most technically demanding cases and should not be among the early cases for surgeons building their experience. Patients who have undergone prior radiation therapy are poor candidates because healing is compromised. Those with neurologic conditions affecting pelvic floor or lower extremity musculature are unlikely to achieve continence. Patients with dementia present a different but equally important concern: "They probably won't urinate even with an enucleation because it's a cognitive issue," Krambeck said. Extremely large prostates, like morbidly obese patients, are generally best referred to enucleation specialists.

On the other side of the selection question, Krambeck challenged what she sees as a pattern of inappropriate exclusion.

"I do think enucleation is suitable for most patients who are good candidates for BPH therapy," she said. The technical demands of the procedure should not translate into unnecessary restriction of access for patients who would benefit—they should translate into appropriate channeling toward surgeons with sufficient experience for complex cases.

The most consistent technical error Krambeck observes when proctoring surgeons who have completed their initial learning curve is insufficient tissue removal at the apex. The root of the problem is discomfort with proximity to the sphincter.

"They err inwards and leave significant tissue around the sphincter," she said. The consequence is self-compounding: failing to establish the correct plane at the apex—near the verumontanum—makes it nearly impossible to find that plane anywhere else in the dissection.

"If you don't find the plane there, you're not really going to find it well elsewhere," Krambeck said.

Her coaching approach is direct. Surgeons need to pull the scope back far enough to execute complete turns around the apex, commit to working close to the sphincter, and take the time to find the anterior plane after those turns before accelerating.

"Spending a little bit of time there, really finding the plane, then you can speed through the rest of it," she said. The apical dissection is the investment that enables efficiency for the remainder of the case—and avoiding it in the name of sphincter preservation paradoxically makes both continence outcomes and operative efficiency worse.