Holmium Laser Enucleation of the Prostate (HoLEP)
Holmium laser enucleation of the prostate (HoLEP) is a treatment for men with benign prostatic hyperplasia (BPH). The laser surgery removes blockages of urine flow. This treatment is done without any incisions on the body.
Holmium laser enucleation of the prostate (HoLEP) is a type of laser surgery used to treat obstruction (blockage) of urine flow as a result of benign prostatic hyperplasia (BPH). In men with BPH, the prostate gland is not cancerous but has become enlarged. An enlarged prostate can result in a number of urinary tract symptoms such as frequent urination, inability to urinate, difficulty in starting urination, or loss of bladder control.
HoLEP was developed in the 1990s as a more effective and potentially less costly surgery for urinary obstruction due to BPH, as compared to other surgical options such as laser vaporization and transurethral resection of the prostate.
How does holmium laser enucleation of the prostate (HoLEP) work?
The holmium laser is a surgical laser that has been found particularly effective in performing several types of urological surgeries. In the case of HoLEP, the laser is used to cut and remove the bulky prostate tissue that is blocking the flow of urine.
Who needs to have holmium laser enucleation of the prostate (HoLEP)?
BPH occurs in more than 40 percent of men over the age of 60 and is a leading cause of urination symptoms, including difficulty in passing urine. As men age, the symptoms of this condition can worsen. Although many cases of urinary obstruction from BPH can be treated without surgery, patients who do not benefit from such medical treatments may eventually need surgery to avoid or deal with long-term problems such as retention of urine, urinary tract infections, and bladder stones. Patients who are appropriate for HoLEP are typically symptomatic due to very large prostates.
Patients may not be candidates for HoLEP if:
- They have bleeding problems.
- They have had certain types of prior prostate treatments.
- They cannot lie on their back with their legs raised. This position is necessary for the procedure.
What happens before holmium laser enucleation of the prostate (HoLEP)?
- A pre-operative (before surgery) work-up will include a detailed medical history as well as a physical exam to determine the severity of symptoms, a digital rectal exam (using a finger to feel the prostate), a measure of urinary flow rate, and a test to see how much urine remains in the bladder after urinating. These will help determine the level of obstruction of the urinary tract.
- Laboratory tests will include blood work, possible PSA (prostate-specific antigen) level, and urinalysis. For high PSA levels, a biopsy (tissue sample) may be taken to ensure no cancer is present.
- To measure the amount of enlargement in the prostate gland, a transrectal ultrasound may be performed. This test is more accurate than a digital (finger) rectal exam, and helps the medical team estimate how much time will be needed to perform surgery. The larger the size of the prostate, the more surgery time required.
- Cystoscopy (looking inside the urethra, prostate and bladder with a camera) will be performed in the clinic to evaluate the prostate and bladder anatomy and to rule out urethral strictures (scar tissue).
- Depending on a patient’s symptoms, a test called urodynamics may be performed to evaluate how the bladder is working and determine if removal of the prostate tissue would likely decrease the symptoms. This is a diagnostic test done in the clinic involving a catheter in the bladder and various pressure sensors.
- Before surgery is performed, use of blood-thinning drugs needs to be discontinued for up to 10 days to prevent excessive bleeding during and after the procedure.
- No food or drink is allowed starting at midnight before surgery.
- Patients must have a urine culture in the two to four weeks prior to surgery to minimize risk of infection after the operation.
What happens during a holmium laser enucleation of the prostate (HoLEP) procedure?
- HoLEP requires the patient to be under general anesthesia (“asleep” throughout the procedure). If a patient cannot have general anesthesia for some reason, a spinal anesthetic can be used—this allows him to remain awake but blocks all feeling from the waist down.
- An injection of an antibiotic is given to reduce the chances of infection.
- The patient is placed on his back with the legs raised during the procedure.
- A surgical instrument called a resectoscope is inserted through the urethra (the channel that carries urine from the bladder). The resectoscope includes a camera that allows the surgeon to view the internal structure of the prostate gland, and to see where incisions are being made during surgery.
- The laser is inserted into the resectoscope and is used to enucleate (free up) the enlarged prostate tissue from the capsule (outer shell)and then to seal up any blood vessels. The tissue that has been removed is deposited in the bladder.
- The laser is removed from the resectoscope and is replaced by a morcellator. This device is used to suction out the tissue that was left behind in the bladder.
- When tissue removal is complete, the resectoscope is withdrawn and a urinary catheter is put in place.
What happens after a holmium laser enucleation of the prostate (HoLEP) procedure?
- The patient is admitted to the hospital overnight for observation and catheter care.
- Some bleeding from the prostate is to be expected following surgery. For most patients this will clear in about 12 hours. The need for a blood transfusion due to excessive bleeding following HoLEP surgery is rare.
- Fluid will be flushed through the catheter to clear blood from the urine after the surgery.
- Eating and drinking are permitted the same day of the procedure as soon as the patient is able to do so safely.
- The catheter is usually removed the morning after surgery if there is no excessive bleeding. If the patient is able to urinate well at least two to three times after the catheter is removed, then he can go home without the catheter. If he is unable to urinate, then the catheter is replaced and will be removed again in one week. In certain cases, such as scar tissue in the urethra, the catheter may just be left in for one week after surgery and then removed in clinic.
- At first, passing urine may be painful and more frequent than usual. Medications may be used to relieve symptoms until some improvement is noted within a few days. Patients are encouraged to drink plenty of fluids once the catheter is removed. This fluid helps clear the urine of blood more efficiently.
- Symptoms such as frequency, urgency, and waking up at night to urinate may take several months to permanently improve because the bladder must adjust to the removal of the prostate tissue and muscle control in the pelvic area can be weakened by the surgery.
How long is the recovery process?
Most patients need at least one to two weeks of rest at home before they can return to work. Some patients may require three to four weeks of recovery time before going back to work, especially if the job is physically strenuous. No heavy lifting should be attempted during the recovery period; however, patients are expected to walk and do light activities.