It has traditionally been believed that endoscopic surgery becomes more difficult as the prostate enlarges. However, recent clinical reports suggest that even extremely large cases of benign prostatic hyperplasia can be safely treated using holmium laser enucleation of the prostate (HoLEP) when performed by experienced surgeons.
Benign prostatic hyperplasia (BPH) is a common condition that occurs as men age. A normal prostate typically measures about 20–30 cc in volume, but it gradually enlarges over time. When the prostate exceeds 80 cc, it is generally classified as a large prostate, and when it exceeds 150 cc, it is considered a “giant” or extremely large prostate.
It is often assumed that the larger the prostate becomes, the more severe urinary symptoms such as difficulty urinating, residual urine, or acute urinary retention will be. In reality, the severity of symptoms varies depending on bladder function. However, when long-term urinary obstruction leads to complications such as bladder stones or impaired kidney function, surgical treatment becomes necessary.
Traditional prostate surgery typically involves shaving away enlarged prostate tissue using a loop-shaped electrical electrode. The larger the area that must be removed, the greater the risk of bleeding. In cases of extremely large prostates, complete removal of the obstructing tissue can also be technically challenging.
In contrast, HoLEP uses a holmium laser to carefully separate the enlarged prostate tissue from the surrounding capsule. This technique allows the surgeon to remove the obstructing tissue along the natural anatomical plane between the prostate capsule and the enlarged tissue. Because the laser simultaneously cuts and coagulates blood vessels, bleeding is significantly reduced. Even when large volumes of tissue are removed, the procedure can generally be performed safely, which is why HoLEP has become widely used for treating enlarged prostates.
A notable case involved a patient in his 60s with extremely large benign prostatic hyperplasia. He had received medication therapy for more than five years, but urinary retention symptoms continued to recur. At a university hospital, ultrasound examination revealed that his prostate measured approximately 220 grams. Because of the size, open abdominal surgery under general anesthesia was recommended.
However, the patient was concerned about undergoing general anesthesia and the cost of open surgery. Instead, he sought treatment from a surgeon experienced in advanced endoscopic prostate surgery.
Preoperative ultrasound showed that the enlarged prostate was significantly protruding into the bladder. After confirming the anatomical structure with endoscopic evaluation, HoLEP surgery was performed. During the procedure, the holmium laser was used to separate the enlarged prostate tissue from the capsule, minimizing bleeding. The removed tissue was then safely fragmented and extracted through a morcellation process, allowing the entire surgery to proceed smoothly.
Following surgery, the prostate size was reduced from approximately 220 grams to about 25 grams. The patient was able to urinate normally without residual urine. His peak urinary flow rate improved to more than 40 mL/s, indicating excellent urinary function. Remarkably, the patient was able to be discharged on the same day.
One advantage of HoLEP surgery is that it can be performed under spinal anesthesia rather than general anesthesia, and it does not require abdominal incisions. Recovery is typically faster, and hospital stays are shorter. In addition, HoLEP is recognized as a standard treatment covered by national health insurance in Korea, making it possible to perform complex prostate surgery while reducing financial burden for patients.
However, HoLEP is known for having a long learning curve. As the prostate becomes larger, the procedure can take more time, and surgeons with limited experience may encounter challenges such as bleeding or incomplete tissue removal. For this reason, when considering surgery for extremely large prostate enlargement, it is important to choose a medical center with both experienced urology specialists and appropriate surgical equipment.
Treatment decisions for benign prostatic hyperplasia should not be based solely on prostate size. Symptoms, bladder function, and anatomical characteristics must all be evaluated together. The most appropriate treatment option should be determined through careful consultation with an experienced specialist.
Today, advances in surgical technology allow even extremely large prostate enlargement to be treated safely without open abdominal surgery and often without general anesthesia. Ultimately, the most important factor is not simply which procedure is performed, but where and by whom the surgery is carried out. With skilled specialists, advanced equipment, and a well-structured surgical system, even extremely large benign prostatic hyperplasia can be treated safely and effectively.