Holmium laser prostate surgery (HoLEP)

Overview

Holmium laser prostate surgery, also known as holmium laser enucleation of the prostate (HoLEP), is a minimally invasive laser surgery developed in the 1990s to treat benign prostatic hyperplasia (BPH). HoLEP uses a laser to remove obstructive prostate tissue.

HoLEP allows the removed tissue to be examined for other issues, such as prostate cancer. Compared to traditional prostate surgery, HoLEP offers quicker recovery and faster relief from symptoms. However, in rare cases, additional HoLEP treatments might be necessary for urinary symptoms.

Reasons for undergoing the procedure

Holmium laser prostate surgery is commonly used to treat benign prostatic hyperplasia (BPH). Over 60% of people over the age of 60 experience benign prostatic hyperplasia, and the likelihood of developing this condition increases with age.

BPH enlarges the prostate, pressing against the urethra and hindering urine flow. Signs and symptoms of BPH include:

• Frequent urination
• Urgent or leaking urination
• Difficulty urinating
• Burning sensation during urination
• Weak or intermittent urine stream

If symptoms become troublesome or there is a risk of complications like urinary tract infections (UTIs) and bladder stones, a healthcare provider might suggest HoLEP as a treatment option.

Risk

HoLEP carries potential risks, just like with any surgical procedure. However, less than 2% of people experience urinary obstruction symptoms again and need a second surgery, and 5% to 15% of people may also discover they have prostate cancer.

Potential risks of HoLEP include:

• Extended catheterization, or necessity for a catheter use exceeding 24 hours
• Requirement for blood transfusion because of significant bleeding
• Urinary incontinence persists beyond three months
• Infections in the bladder, testicles, or kidneys
• Anesthesia risks, such as blood clots, heart attacks, or aspiration
• Damage to the prostate, urethra, bladder, or ureters

Before the surgery

It is generally advised to refrain from eating or drinking after midnight before the surgery. In some cases, taking certain medications may need to be discontinued up to 10 days before surgery.

Several tests may be required prior the procedure, such as:

• PSA test
• Urinalysis
• Cystoscopy, which involves inspecting the urethra, prostate, and bladder with a camera to check for cancer, infection, or blockage
• Evaluations measuring urine volume and flow
• Imaging tests such as a transrectal ultrasound or CT scan to assess prostate size
• A urodynamics test to assess bladder function and determine if removing prostate tissue could alleviate symptoms, which involves using a catheter in the bladder along with various pressure sensors

The healthcare provider will also review the one’s medical history and conduct a physical examination, including a prostate exam and tests to measure residual urine in the bladder.

During the surgery

HoLEP typically lasts one to three hours, depending on the one’s condition. An antibiotic injection may be given to reduce infection risk.

The amount of prostate tissue removed during surgery varies based on the size of the blockage or the pressure on the urethra caused by the prostate. Generally, approximately 50% to 60% of the total volume of the prostate gland is removed to alleviate symptoms and improve urine flow.

The surgery proceeds as follows:

• Anesthesia is administered, and the individual is positioned on their back with legs raised
• A resectoscope is inserted through the urethra, equipped with a camera to visualize the prostate
• Using a laser through the resectoscope, the healthcare provider removes obstructive prostate tissue and seals blood vessels
• A morcellator replaces the laser to suction out and remove prostate tissue from the bladder
• The extracted tissue is then sent to a lab for analysis to check for abnormalities like prostate cancer
• The healthcare provider removes the resectoscope and inserts a urinary catheter

HoLEP requires general anesthesia, keeping the patient asleep during the procedure. If general anesthesia is not possible, a spinal anesthetic may be used to numb the lower body.

After the surgery

After surgery, the healthcare provider will schedule follow-up appointments to track one’s recovery and repeat tests like urinary flow rate and bladder scans to assess the surgery’s effectiveness and check for complications.

After the surgery, some individuals might need to stay in the hospital if there are worries about bleeding or other complications. However, in most cases, after spending a few hours in a recovery room, most people go home.

Pelvic floor exercises, also known as Kegel exercises, may be suggested soon after surgery to improve urinary incontinence symptoms. These exercises can help reduce leakage during activities like coughing, sneezing, or lifting.

Other recommendation post-surgery include:

• Symptoms like increased urination frequency, sudden urges, and nighttime waking may take months to improve as the bladder adjusts post-surgery
• Mild burning sensations for several weeks are common and can be managed with over-the-counter pain relievers.
• A catheter will be used to flush fluid and clear blood from the urine following surgery. If the urine appears clear pink or red, one can typically go home with the catheter in place
• The catheter is usually removed the day after surgery unless there are concerns like excessive bleeding. After removal, one should urinate two to three times normally to be discharged. If they cannot urinate, the catheter may need to be reinserted temporarily
• Light bleeding from the prostate can continue for several weeks to a couple of months following surgery

Outcome

Since HoLEP carries some risks, it is crucial to be vigilant for potential complications. Seek immediate medical attention if you experience any of the following symptoms:

• Difficulty urinating
• Persistent pain despite medication
• Fevers above 38 degrees Celsius
• Passing blood clots or urinating bright red blood resembling tomato soup

Healthcare providers will explain the expected recovery symptoms. General reminders may include:

• Walking and driving are permitted starting the day after surgery.
• Avoid strenuous activities (such as running or heavy lifting) for at least two weeks.
• Straddle activities (like biking or using lawnmowers) should be avoided for six weeks.
• Returning to work may be allowed within one to two weeks, but more time may be needed for those with physically demanding jobs.
• Refrain from lifting anything heavier than 10 pounds for at least two weeks to facilitate recovery.

HoLEP is a safe and effective procedure with a faster recovery compared to similar surgeries for treating BPH. It offers several advantages, including:

• Reduced risk of bleeding and the need for blood transfusions
• Lower likelihood of requiring additional procedures
• Minimal or no hospitalization
• Significant amounts of prostate tissue can be extracted without making any cuts in the skin
• Highly effective for treating large prostates but also suitable for any prostate size