Endoscopic Removal of UroLume Urethral Stent Using High-Power Holmium Laser

Abstract

Introduction: The UroLume stent has been used for treatment of urethral stricture disease and benign prostatic hyperplasia since 1988.1 This procedure is not without complications, including migration, encrustation, epithelialization, pain, and irritative voiding symptoms.2 Holmium laser ablation of the prostate was introduced in 1994 by Gillings, Cass, and Cresswell.3 Multiple randomized studies have documented the safety and efficacy of laser ablation of the prostate.4 Only three cases in the literature document the use of the Holmium laser in the removal of a migrated UroLume stent.2,5 We present our experience with the removal of an infected, calcified UroLume stent using the Holmium laser. Materials and Methods: A 101-year-old male with a history of Guillain-Barre syndrome, gastroesophageal reflux disease, and hypertension underwent placement of a UroLume stent in 2006 for lower urinary tract symptoms. He had been voiding without difficulty and low postvoid residuals. However, over the past year he developed three prolonged admissions to the ICU for urosepsis. Cystourethroscopy revealed erosion and calcification at the 6 o'clock position of the urethral stent within the prostate. Using the 100 W Holmium laser, 550 nm end-fire laser fiber at settings of 2.5 J and 40 Hz, the UroLume stent was engaged with the laser. The stent was divided into four large sections by cutting at the 1, 5, 7, and 11 o'clock positions, extending from the bladder neck, where the proximal extent of the UroLume extended into the bladder, to just above the verumontanum. The median lobe was then enucleated. The end-fire fiber was then exchanged for a side fire DuoTome fiber and HoLAP of the remaining prostate tissue was performed. Residual fragments of the UroLume stent were retrieved with a rigid grasper. Results: The entire UroLume stent was removed without complications and the prostatic adenoma was successfully treated by HoLAP. Follow-up cystoscopy 6 weeks later revealed an open prostatic fossa with no evidence of any residual foreign body. Conclusion: Holmium laser excision is both safe and effective for the treatment of infected indwelling UroLume stents. The advantage of the Holmium laser in this setting is its unique combination of high-power energy delivery coupled with minimal depth of tissue penetration allowing cutting of metal over delicate tissues. Additionally, in the same setting, it serves the dual role of treating the prostatic adenoma underneath the UroLume stent using the HoLAP procedure. No competing financial interests exist. Runtime of video: 6 mins 49 secs