Holmium Laser Enucleation of the Prostate (HoLEP)

What is holmium laser enucleation of the prostate (HoLEP)?

Holmium laser enucleation of the prostate (HoLEP) is a type of laser surgery that treats benign prostatic hyperplasia (BPH). BPH is a condition that causes your prostate to get larger (enlarged prostate). It makes your prostate press against your urethra, which prevents pee from passing through freely. HoLEP is a minimally invasive procedure that uses a laser beam to remove the tissue from your prostate that’s blocking the flow of pee.

HoLEP was developed in the 1990s as a more effective and potentially less costly surgery for urinary obstruction due to BPH. HoLEP offers faster recovery times and requires no incisions (cuts).

What does HoLEP treat?

The holmium laser is a surgical laser that surgeons use to remove the bulky prostate tissue that’s blocking the flow of pee. The most common cause of urinary obstruction (blocked pee) is BPH. BPH causes your prostate to enlarge. Your prostate pushes against your urethra and blocks pee from leaving your bladder.

Some common signs of BPH are:

• Difficulty peeing.
• A weak urine stream.
• Having a urine stream that starts and stops a lot.
• Burning when peeing.
• Having to pee very frequently.
• Peeing urgently or leaking pee because you can’t get to the bathroom fast enough.

How common is HoLEP surgery?

BPH occurs in more than 60% of men and people assigned male at birth (AMAB) over 60. As you age, the likelihood of developing BPH increases. Symptoms of BPH can also worsen over time. Not everyone with BPH needs surgery. Many people find success with medication and other treatments. But, if your symptoms are bothersome or you’re at risk for complications like urinary tract infections (UTIs) and bladder stones, your healthcare provider may recommend HoLEP.

Is HoLEP a major surgery?

HoLEP is minimally invasive and carries a low risk of complications compared to other surgeries that treat the same condition. But, as with most surgeries, there are risks. Be sure to talk to your healthcare provider about any concerns you have about the procedure and your recovery afterward.

What happens before HoLEP surgery?

Your healthcare provider will take your medical history and perform a physical examination to assess the severity of your condition. This could involve things like a prostate exam and tests to see how much pee remains in your bladder after you use the bathroom. Laboratory tests could include blood work, like the PSA (prostate-specific antigen) test and urinalysis.

Some other tests that may happen before HoLEP surgery include:

• Tests that assess the volume and flow of your pee.
• Imaging tests like a transrectal ultrasound or CT scan (computed tomography scan) to help your provider determine the size of your prostate.
• Cystoscopy (looking inside your urethra, prostate, and bladder with a camera) to evaluate your prostate and bladder for signs of cancer, infection or blockage.
• A urodynamics test to evaluate how your bladder is working and determine if removing the prostate tissue may help decrease symptoms. This is a diagnostic test involving a catheter in your bladder and various pressure sensors.

Let your healthcare provider know what medications you take. They may ask you to stop using certain medications up to 10 days before surgery. You won’t be allowed to eat or drink after midnight before your surgery.

How is a holmium laser enucleation of the prostate (HoLEP) procedure performed?

HoLEP requires general anesthesia (you’re asleep throughout the procedure). If you can’t have general anesthesia for some reason, you may get a spinal anesthetic to block all feeling from your waist down. Your healthcare provider may also give you an injection of an antibiotic to reduce your risk of infection.

HoLEP surgery generally follows these steps:

• Once you’re asleep, your healthcare team places you on your back and raises your legs.
• Your surgeon inserts a surgical instrument called a resectoscope through your urethra. The resectoscope includes a camera that allows the surgeon to view your prostate gland.
• Your surgeon inserts a laser into the resectoscope. It pulses laser beams into your prostate to cut the tissue that’s blocking the flow of pee (a process called enucleation). Then they seal up the blood vessels with the laser.
• They take the laser out from the resectoscope and replace it with a morcellator. This device suctions out the prostate tissue left behind in your bladder and removes it from your body. Your surgeon will send pieces of prostate tissue to the lab for analysis to check for any abnormalities like prostate cancer.
• Once the tissue removal is complete, your surgeon takes the resectoscope out and puts a urinary catheter in place.

How long does surgery take?

You can expect HoLEP surgery to take from one to three hours, but this varies depending on your condition.

What happens after you have HoLEP surgery?

Most people go home after spending a few hours in a recovery room. A few people may need to stay in the hospital if there are concerns for bleeding or other issues.

Here are some things you can expect after HoLEP surgery:

• A healthcare provider will flush fluid through the catheter to clear blood from your pee after the surgery. As long as the pee is a clear pink or clear red color, you’ll be allowed to go home. You’ll go home with a catheter.
• Your healthcare provider removes your catheter the day after surgery unless you’re bleeding excessively (which is rare) or there are other concerns. If you can pee two to three times after the catheter removal, then you can go home and pee as you normally would. If you can’t pee after your catheter comes out, your provider will replace your catheter and remove it in a few days.
• At first, peeing may be painful and more frequent than usual. Medications can relieve symptoms. Expect to have blood in your urine for several weeks. This will vary by your activity level and how much fluid you drink. Your healthcare provider will encourage you to drink plenty of fluids once the catheter comes out. This fluid helps clear your pee of blood more efficiently.
• Symptoms such as peeing more frequently, feeling the sudden urge to pee and waking up at night to pee may take several months to improve. This is because your bladder must adjust to the removal of the prostate tissue and muscle control in the pelvis can be weak after surgery.
• Feeling burning for several weeks after surgery is normal. You can take over-the-counter (OTC) pain relievers for discomfort.
• It’s normal to experience light bleeding from your prostate for several weeks and even a couple of months.

Your healthcare provider will want to see you after surgery to monitor your recovery and to repeat tests, such as urinary flow rate, bladder scan and others. These tests gauge the effectiveness of the surgery and possible complications.

Your provider may also recommend doing pelvic floor exercises (Kegel exercises) as early as the day after surgery to improve symptoms of urinary incontinence. Performing Kegel exercises can help decrease leakage from stress maneuvers such as coughing, sneezing or lifting.

What are the side effects of holmium laser enucleation of the prostate (HoLEP)?

The most common side effects include:

• Temporary burning and bleeding when you pee. It’s also normal to see blood in your pee for up to three months after surgery. This usually just means you haven’t completely healed from surgery.
• You may need to wear pads in your underwear for a few days as you may be unable to control your pee. This typically improves after a few weeks. The rate of leaking pee long-term is low. Your risk for long-term incontinence depends on several factors including age, prostate size, symptoms and other medical conditions.
• Retrograde ejaculation or “backwards or dry ejaculation.” In 75% of cases, you won’t see any fluid during ejaculation during sexual activity after surgery.
• Lack of semen during orgasm. Getting an erection is usually not an issue.

What percentage of the prostate is removed in HoLEP?

How much of your prostate your surgeon removes depends on how large the blockage is or how much your prostate is pressing on your urethra. Typically, your surgeon removes about 50% to 60% of the total prostate volume.

What are the advantages of HoLEP?

HoLEP is a safe and effective procedure with a quick recovery when compared to similar types of surgery. Although there are many procedures to treat BPH, HoLEP offers the following advantages:

• Surgeons can remove a large amount of prostate tissue without any incisions on your skin.
• HoLEP is excellent in treating large prostates but can be effective for any size prostate.
• Minimal or no hospital stay.
• Decreased risk of bleeding and blood transfusions.
• Lower risk of needing repeat procedures.

What are the risks and complications of holmium laser enucleation of the prostate (HoLEP)?

As with most surgeries, HoLEP has some risks. Some of the most common risks include:

• Injury to your prostate, urethra, bladder or ureters.
• Urinary incontinence lasting longer than three months.
• Infection in your bladder, testicles or kidneys.
• Risks of anesthesia, including blood clots, heart attacks or aspiration.
• Need for blood transfusion due to excess bleeding.
• Needing to use a catheter for longer than 24 hours (prolonged catheterization).

About 5% to 15% of people learn they have prostate cancer after HoLEP. Having HoLEP doesn’t affect your ability to get treated for prostate cancer if you have it or develop it in the future. Less than 2% of people have symptoms of urinary obstruction in the future and require a second surgery.

What is the recovery time?

You can walk and drive starting the day after surgery. You should avoid strenuous activities (running, lifting heavy objects, etc.) for at least two weeks and straddle activities (riding a bicycle, lawnmower, motorcycle, etc.) for six weeks. Most people can go back to work in one to two weeks. People with physically strenuous jobs may need longer. You shouldn’t lift anything heavier than 10 pounds for at least two weeks.

When should I call my healthcare provider?

Your healthcare provider will let you know what to expect while you recover. Some symptoms are normal and expected in your recovery. After HoLEP surgery, you should contact your healthcare provider if you:

• Pass blood clots or are peeing bright red blood that looks like tomato soup.
• Have fevers higher than 101 degrees Fahrenheit (38 degrees Celsius).
• Experience pain that doesn’t subside with medication.
• Are unable to pee.

What is the difference between HoLEP and TURP?

TURP stands for transurethral resection of the prostate (many people consider this like a roto-rooter). Like HoLEP, it’s a surgery to remove part of your prostate if you have BPH. The main difference between the two procedures has to do with how the prostate tissue is removed, which then affects recovery time, risks and costs. For example, HoLEP is less likely to require a blood transfusion or additional surgery in the future because your prostate grows back. Only you and your healthcare team can decide which type of prostate surgery is best for you, depending on your condition.

A note from Cleveland Clinic

HoLEP is an effective treatment for BPH or an enlarged prostate. It uses a laser to gently remove the prostate tissue that’s causing an obstruction. If your healthcare provider recommends this procedure, be sure to discuss the risks and benefits with them as well as what you can expect. Everyone is different. Your healthcare provider is the best person to discuss your questions and concerns with based on your unique situation.