A 68-year-old male patient visited the outpatient clinic after experiencing acute urinary retention last fall, when he suddenly became unable to urinate. A transrectal prostate ultrasound examination showed that his prostate size had enlarged to approximately 120 grams. After additional diagnostic evaluation, holmium laser enucleation of the prostate (HoLEP) surgery was recommended. Following the procedure, the urethral passage was successfully restored. One week after surgery, a uroflowmetry test showed a clean bell-shaped flow curve, and the patient’s peak urinary flow rate improved to 29.1 mL/sec, indicating a return to normal urinary function. Even three months after the surgery, the peak flow rate remained stable at 26.9 mL/sec, demonstrating a favorable outcome. This case illustrates that even very large prostates exceeding 80 grams can be effectively treated with HoLEP surgery.
Benign prostatic hyperplasia (BPH) refers to enlargement of the prostate gland, a male reproductive organ that produces part of the seminal fluid. In younger men, the prostate is approximately the size of a walnut, but it gradually enlarges with age. As the prostate grows, it can compress the urethra and interfere with the normal flow of urine, leading to various urinary symptoms. This condition is known as benign prostatic hyperplasia. BPH typically begins to develop after the age of 40, affecting approximately 60–70% of men in their 60s and nearly all men in their 70s.
When symptoms of BPH become severe, treatment usually begins with medication therapy. If symptoms do not improve sufficiently with medication, surgical treatment may be considered. In the past, the most commonly used surgical method was transurethral resection of the prostate (TURP). TURP involves using an electrical loop to shave away the enlarged prostate tissue from inside the urethra through an endoscope. However, TURP carries a relatively higher risk of bleeding and may leave residual prostate tissue behind, which has led to the gradual adoption of newer surgical techniques.
One of the surgical methods that has emerged as a replacement for TURP is holmium laser enucleation of the prostate (HoLEP). HoLEP uses a holmium laser to separate the enlarged prostate tissue from the surrounding capsule and remove the entire enlarged portion of the prostate. This process can be compared to removing the inner segments of an orange while leaving the peel intact. Because HoLEP removes the enlarged prostate tissue completely, the risk of recurrence is relatively low. In addition, the holmium laser allows simultaneous cutting and coagulation, which significantly reduces bleeding compared with traditional TURP surgery.
As demonstrated in the case described earlier, HoLEP surgery can also be performed effectively in patients with very large prostates exceeding 80 grams. In the past, prostates larger than 80 grams were considered extremely large and often required open surgery. Performing TURP in such cases could take more than two hours and might result in significant bleeding, sometimes requiring blood transfusion. In contrast, HoLEP surgery does not necessarily take longer simply because the prostate is larger. Even for prostates exceeding 100 grams, the procedure can often be completed in less than two hours.
At the hospital where I currently practice, recent analysis of the most recent 100 HoLEP surgeries showed that the average decrease in hemoglobin levels was less than 1 mg/dL. This amount of blood loss is smaller than the volume contained in a single unit of red blood cells used for transfusion. In fact, none of these patients required blood transfusion. For this reason, HoLEP surgery can be considered a safe and effective option even for patients with very large prostates.
According to data from the Health Insurance Review and Assessment Service (HIRA), the number of HoLEP procedures (R3977) increased from 4,983 cases in 2021 to 5,944 cases in 2022, representing an increase of approximately 20% within a single year. In contrast, the number of transurethral resection of the prostate procedures (TURP, R3975) has steadily decreased by about 20% since 2019. This trend indicates that HoLEP has become the dominant surgical treatment for benign prostatic hyperplasia.
In the past, patients with very large prostates often had to undergo open surgery, which placed significant strain on the body. Today, however, HoLEP surgery allows these cases to be treated more safely and effectively. For patients with very large prostates, consulting a urology specialist about the possibility of HoLEP surgery is strongly recommended.
As men enter middle age and beyond, urologic conditions become increasingly common. By providing useful information about urinary diseases that interfere with daily life, the goal is to help individuals maintain a healthier and more comfortable quality of life.