Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive treatment for benign prostatic hyperplasia (BPH). With the patient under general anesthesia, the surgeon uses the laser to enucleate the prostate gland tissue, leaving just the capsule in place. The surgeon pushes the excised prostate gland tissue into the bladder and then uses a morcellation device to grind up and remove the tissue.
A simple analogy would be if you scooped out the inside of an orange and just left the rind, that is what the HoLEP procedure does to a prostate.
So what are the advantages?
The HoLEP procedure can treat any size prostate gland. Other transurethral surgeries (through the penis with no incision) cannot treat the prostate gland effectively once it reaches a certain size. In these cases, urologists will often recommend a more invasive procedure (simple prostatectomy).
The HoLEP procedure completely excises the obstructing prostate tissue down to the prostate’s encapsulating structures, resulting in a re-treatment rate of less than 2 percent. Although other transurethral surgeries have the ability to do this, in my hands, I feel that I can more reliably remove all of the obstructing tissue with the HoLEP.
The HoLEP procedure provides early, immediate symptom relief and fast return to normal activity . Next-day catheter removal with limited swelling generally allows patients to void painlessly and immediately. Same-day or next-day hospital discharge is possible.
The HoLEP procedure preserves tissue for pathologic examination . Because the tissue is excised rather than ablated, surgeons can examine specimens for prostate cancer or other abnormalities. Not all transurethral surgeries can offer this . Overall, cancer is found in about 10 percent of HoLEP procedures, even in patients previously screened. In many cases, the cancer identified is of low malignant potential.
The HoLEP procedure has fewer potential complications . The low depth of penetration of the holmium laser causes little damage to healthy tissue, and the risk of excessive bleeding and erectile dysfunction associated with traditional surgical approaches is reduced.
In my opinion, HoLEP is the best surgery for BPH because it is minimally invasive, treats all size prostates, and completely removes the obstructing tissue. So you might ask, why are there not more urologists doing it? The reason is that it is a specialized procedure that requires mentored training during a residency or fellowship.
Are there any side-effects of the operation?
Common side-effects (greater than 1 in 10)
Patients usually experience temporary mild burning, bleeding and frequency of urination after the procedure. This is common for all transurethral prostate surgeries and not unique to HoLEP.
No semen is produced during an orgasm in approximately 75% of patients (retrograde ejaculation). Instead, the semen is ejected into the bladder and then comes out when you urinate. This is common for all transurethral prostate surgeries, EXCEPT, the Urolift. If this is important to you, discuss with your surgeon whether you would be a candidate for the UroLift, or another procedure known as TUIP (transurethral incision of the prostate) .
Treatment may not relieve all the urinary symptoms, but, if this is the case, a medication can sometimes help. The bladder often remains overactive for some time after the procedure. I commonly see persistence of urgency, frequency, and nighttime voiding for up to 3 months after surgery. During the three month healing period however, most patients improve as time goes on. Long term, 90% of patients report complete resolution or great improvement in their urinary symptoms.
10% of men are unable to urinate the first day after surgery. If this is the case, they have the catheter replaced, are discharged from the hospital, and then come back to the office a few days later to have it removed again. With few exceptions, men are then able to urinate at that time.
Finally, but most importantly, leakage of urine (incontinence) is very common immediately after surgery. In fact, 30% of men wear a pad for protection during the first 6 weeks after surgery. The degree of leakage varies from person to person. If a man experiences severe leakage during the first few days, then tends to improve quickly over the following weeks. Often times, the leakage is experienced when a man stands, strains, laughs, coughs, or sneezes. This type of leakage is referred to as stress urinary incontinence, and it can be improved by doing Kegel Exercises. Long term incontinence is much less common. Only 1% of men experience severe incontinence permanently. (Severe incontinence refers to poor urinary control and continual usage of a pad or Depends to manage.) 5-10% of men experience mild levels of incontinence permanently. Mild incontinence refers to light leakage that occurs on occasion. It is not a lot of leakage but it is enough that men often wear a light pad for protection when they go into public.
Occasional side-effects (between 1 in 10 and 1 in 50)
You could experience weaker or no erections. Two recent studies have shown no significant difference in ability to have an erection in men before and after HoLEP surgery, but there is still a small risk (1%) of a decreased ability to have an erection. Interestingly, some report improvement in the quality of their sex life after surgery. From a physiologic perspective, the laser’s depth of penetration is so shallow that it should be impossible for it to impact the nerves (which lie outside the prostate) that go to the penis to assist with erection.
Some patients have injury to the urethra causing delayed scar formation (urethral stricture) requiring further minor surgery ( 5% )
Some patients get an infection of the bladder, testes or kidney requiring antibiotics.
Rare side-effects (less than 1 in 50)
Rarely patients need to repeat treatment later due to re-obstruction from prostate regrowth (approx 1% in the first 7 years after surgery). This is significantly less than the reported regrowth rate from other transurethral surgeries (10-20% in the first 10 years after surgery).
Rarely patients are completely unable to urinate. Self-catheterization or permanent catheter may be needed to empty bladder if the bladder is weak (1%). There is research to suggest that patients with very poor bladder function are still able to urinate after a HoLEP procedure. With my own patients, I have found that >95% of men with no bladder function are able to void after a HoLEP procedure.
Persistent and severe loss of urinary control which may require a further operation (less than 1%). This is an unusual but a significant complication.
Retained tissue fragments floating in the bladder which may require a second telescopic procedure for their removal (less than 1%).
A perforation of the bladder that requires a temporary urinary catheter or open surgical repair can occur (less than 0.5%).
Bleeding requiring return to the operating room and/or blood transfusion (less than 0.5%). This is in contrast to other procedures for BPH, including TURP and open simple prostatectomy, which have a higher rate of return to the operating room to remove blood clots.
So what’s the take home message?
Surgery usually is not required to treat BPH , although some men may choose it because their symptoms bother them so much. Choosing surgery depends mostly on your preferences and comfort with the idea of having surgery.
Things to think about include your expectation of the results of the surgery, the severity of your symptoms, and the possibility of having complications from the surgery. Men who have severe symptoms often have a great improvement in their quality of life following surgery. Men whose symptoms are mild may find that surgery does not greatly improve their quality of life. Men with only mild symptoms may want to think carefully before deciding to have surgery to treat BPH .
Besides your urinary symptoms and overall level of bother, the situations in which I will strongly recommend prostate surgery include:
- The inability to urinate
- Recurrent urinary tract infections
- Recurrent blood in the urine
- Damage to your kidneys as a result of bladder outlet obstruction
If you are at the point where a BPH surgery is advised, most commonly performed procedures do an effective job at relieving your symptoms. The main advantage for the HoLEP is its ability to remove all BPH tissue in a minimally invasive fashion. In comparison to other treatments, this translates to a lower surgical risk and a decreased need for repeat operations.