The likelihood of converting from holmium laser enucleation of the prostate (HoLEP) to an open procedure for the surgical management of benign prostatic hyperplasia depends on the size of the prostate, according to a recent study.

Larger prostates increased the odds of conversion. Each 10 mL increase in prostate size was significantly associated with a 1.2-fold increase in the odds of conversion, Asaf Shvero, MD, from Sheba Medical Center in Ramat-Gan, Israel, and colleagues reported in Urology. A 100 mL increase in prostate size was significantly associated with 6.7-fold increased odds.

The study included 807 patients with a median age of 71 years who underwent HoLEP from 2013 to 2020. In 20 cases (2.4%), surgeons had to convert to open procedures. The median preoperative estimated prostate size was significantly larger for conversation cases than for nonconversion cases (228 vs 95 mL). Dr Shvero’s team observed no conversions for prostates smaller than 150 grams.

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“The risk for conversion to open prostatectomy/cystotomy must be communicated to patients who choose HoLEP to improve the informed consent process and provide the highest quality of patient care and transparency,” Dr Shvero and colleagues concluded.

The authors noted that one of the biggest advantages of HoLEP is its ability to treat large prostates (100 grams or more), and thus replace open prostatectomy. In addition, HoLEP is associated with lower complication rates, shorter hospital stays, and shorter catheterization times compared with open prostatectomy. But they added, “Certain technical challenges can occur during HoLEP procedures and can hamper the ability to complete the enucleation or morcellation endoscopically.”

In the current study, the reasons for conversion were anatomical in 8 cases and bleeding that was difficult to control endoscopically in 4 cases, according to the investigators. In 6 cases, surgeons expected the procedure to be too long because of large prostate size. In one case, morcellation technical malfunction occurred, and in another case, the patient had very large bladder stones not suitable for endoscopic treatment.


Shvero A, Han TM, Salib A, Shenot PJ, Das A. Conversion of holmium laser enucleation of prostate to open prostatectomy. Urology. 2022;161:100-104. doi:10.1016/j.urology.2021.12.010