Borrowing Laser Enucleation of the Prostate Techniques to Manage Eroded Urethral Bulking Agent

Objectives: Urethral bulking agents are a minimally invasive treatment option for stress urinary incontinence, however they are not without risk. Erosion of bulking agent into the urethra is one known complication of this procedure. Traditional transurethral loop resection of eroded bulking agent risks a large defect and worsened incontinence. We describe laser enucleation as an alternative technique for precise removal of eroded urethral bulking agent.

Methods: A 47-year-old female with history of urethral bulking agent for primary treatment of stress urinary incontinence presented with gross hematuria. She was found to have eroded urethral bulking agent with overlying stone formation.

We used a 21-French rigid cystoscope and a 550-micron Holmium laser fiber with Moses technology within a laser stabilizing catheter. The laser was set at 1 joule and 10 hertz. The stone overlying the eroded bulking agent was lasered off the bladder neck and irrigated from the bladder. The bulking agent protruding into the urethral lumen was then enucleated using the holmium laser. Given the small scale of this enucleation, morcellation was not needed.

After enucleation, flexible cystoscopy with retroflexion demonstrated the bulging nodule of eroded bulking agent and overlying stone was removed entirely. The patient was discharged on the same day with Foley catheter in place which was removed on post-operative-day two. At six week follow-up she was doing well with no further hematuria, and six month cystoscopy demonstrated well-healed surgical site. She reported no urinary incontinence.

Clinical Relevance: Urethral bulking agent complications do occur and are likely underreported. Much of the limited literature about complications, particularly those that require additional procedures, come from case reports. The optimal management strategy remains to be determined.

Holmium laser enucleation of the prostate (HoLEP) is a newer, versatile option for management of benign prostatic hyperplasia which has been gaining traction in recent years. We perform a high volume of HoLEP procedures at our institution, and thus applied those techniques for precise bulking agent enucleation. Here, we describe laser enucleation as an alternative technique for precise removal of eroded urethral bulking agent.