Extensive Free Air After Thulium Laser Enucleation of the Prostate Without Rectal Injury: A Case Report

INTRODUCTION: Free intraperitoneal or extraperitoneal air detected after transurethral prostate surgery may mimic catastrophic gastrointestinal perforation. Following thulium laser enucleation of the prostate (ThuLEP), such findings can prompt urgent surgical evaluation. CASE PRESENTATION: A 75-year-old man underwent ThuLEP for symptomatic benign prostatic hyperplasia. Early postoperative computed tomography demonstrated extensive intravesical, periprostatic, and combined intra- and extraperitoneal free air highly suggestive of rectal perforation. Despite alarming radiological findings, the patient remained hemodynamically stable, afebrile, and without peritoneal signs. Laboratory parameters, including inflammatory markers, were within normal limits. Contrast-enhanced CT with oral and rectal contrast showed no evidence of contrast extravasation or rectal wall defect. Conservative management with close observation was pursued. Serial imaging confirmed spontaneous regression of free air, and the patient remained asymptomatic at 2-week follow-up. CONCLUSION: Extensive postoperative free air after ThuLEP may represent a benign phenomenon rather than true rectal injury. Careful clinicoradiological correlation is essential to prevent unnecessary surgical exploration in clinically stable patients.