Impact of Prior Prostate Intervention Type on Outcomes of Salvage Holmium Laser Enucleation of Prostate: Comparison of Prostatic Artery Embolization vs Transurethral Procedures

Objectives: Prostatic artery embolization (PAE) is a minimally invasive alternative to surgical benign prostatic obstruction (BPO) interventions, but durability is variable, and some patients ultimately require definitive surgery. Holmium laser enucleation of the prostate (HoLEP) is a size-independent, durable option with established efficacy in salvage settings. We evaluated outcomes of HoLEP in patients with prior PAE and compared them with surgery-naïve patients and those with prior transurethral BPO procedures to contextualize where PAE falls along the prior-intervention spectrum. Materials and Methods: We retrospectively reviewed a prospectively maintained HoLEP registry (July 2017 to August 2025) at a tertiary academic center. Patients undergoing HoLEP after prior PAE were compared with prostate procedures-naïve patients and those with prior transurethral BPO procedures. Outcomes and complications were compared among groups. Results: Among 856 HoLEP patients, 70 had prior PAE, 137 had prior transurethral BPO procedures, and 649 were surgery naïve. Baseline characteristics were largely comparable, although the prior transurethral cohort was older and had worse flow. All cohorts demonstrated marked postoperative improvement in functional outcomes. However, patients with prior transurethral surgery exhibited significantly lower postoperative flow. On linear regression, prior PAE was not independently associated with postoperative functional outcomes. Overall complication rates were low; major complications occurred in approximately 5% to 6%, and minor complications were largely driven by transient incontinence. Prior PAE was independently associated only with higher urinary tract infection (UTI) risk on multivariable analysis. Conclusions: HoLEP after prior PAE appears safe and effective with functional improvements comparable to primary HoLEP. Prior PAE was not associated with worse functional outcomes. The increased UTI risk in the prior PAE cohort warrants optimized perioperative care and further study.