Holmium Laser Enucleation of the Prostate (HoLEP)

Overview

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

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.

Procedure Details

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.

Risks / Benefits

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

Use of HoLEP in many different parts of the world has shown it to be a safe and effective procedure. Although there are many types of BPH surgeries available, HoLEP offers a unique advantage in being able to remove a large amount of tissue without any incisions on the body, even in very large prostates, while decreasing the risk of bleeding and providing tissue for pathology (to look for cancer). This decreases the need for blood transfusions during surgery, minimizes the time of stay in the hospital to one or two days, and reduces the risk of needing repeat treatment.

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

The most common side effects include:

  • Temporary burning and bleeding during urination. Some blood may be seen in the urine for weeks after surgery. This is usually not an indication of anything serious, only that the healing process is not yet finished.
  • Urinary incontinence (inability to control urine flow) is expected in all patients immediately after surgery and they should wear pads for the first few days/weeks. This typically improves over the course of several weeks. Performing Kegel exercises can help decrease leakage from stress maneuvers such as coughing, sneezing, or lifting. The rate of long term leakage from stress maneuvers is low. Patients may also have leakage with urgency and this may be treated with medication. The risk of urge incontinence can be dependent on several factors including age, prostate size, symptoms, and other medical problems.
  • Retrograde ejaculation or “backwards ejaculation.” In 75 percent of cases, the patient will not see any fluid during ejaculation during sexual activity after surgery.
  • Erectile function is generally not significantly affected. A small percentage of patients have reported improved erectile function while a small percentage have reported decreased erectile function.

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

  • Injury to the urethra or development of scar tissue at a later date.
  • Injury to the capsule of the prostate (typically treated with longer catheterization).
  • Injury to the bladder or ureteral orifices (where urine from the kidneys drains out).
  • Infection of the bladder, testes or kidneys.
  • Return of urinary obstruction at a later date requiring another operation (1 to 2 percent).
  • Need for transfusion or reoperation due to bleeding.
  • Failure to relieve all symptoms and/or need for prolonged catheterization after surgery.
  • Five to 15 percent of patients are found to have previously undiagnosed prostate cancer in their prostate specimen. Prostate cancer can be treated after HoLEP.
  • Standard risks of anesthesia including blood clots, heart attacks, etc.

Recovery and Outlook

What happens after holmium laser enucleation of the prostate (HoLEP)?

  • Tissue removed during surgery will be tested in the laboratory for any abnormal findings.
  • The patient will be seen by the doctor following surgery to monitor recovery and to repeat tests, such as urinary flow rate, bladder scan, and symptom score. These tests gauge the effectiveness of the surgery. Typically, patients are seen at six weeks and six months after surgery.
  • The use of pelvic floor exercises (also known as Kegel exercises) as soon as possible can help improve problems with urinary incontinence.

How long is the healing 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.

When to Call the Doctor

When should I call my doctor?

Call your doctor if:

  • You experience increasing urinary frequency, pain or sudden difficulty passing urine.
  • You have severe bleeding or passage of blood clots.
  • You have fevers higher than 101 degrees.

Last reviewed by a Cleveland Clinic medical professional on 10/15/2018.

References

  • Kuo RL, Paterson RF, Kim SC, et al. . World J Surg Oncol. 2003; 1: 6. Accessed 10/9/2018. Holmium Laser Enucleation of the Prostate (HoLEP): A Technical Update (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC165416/)
  • Aho TF. . Ther Adv Urol. 2013 Oct; 5(5): 245-253. Accessed 10/9/2018. Holmium laser enucleation of the prostate: a paradigm shift in benign prostatic hyperplasia surgery (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3763780/)
  • Nam JK, Kim HW, Lee DH, et al. . World J Mens Health. 2015; Aug; 33(2): 88-94. Accessed 10/9/2018. Risk Factors for Transient Urinary Incontinence after Holmium Laser Enucleation of the Prostate (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4550601/)
  • Gilling PJ, Wilson LC, King CJ, et al. Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. BJU Int. 2012 Feb;109(3):408-11. Accessed 10/9/2018.
  • The British Association of Urological Surgeons. . Accessed 10/9/2018.Holmium Laser Enucleation of the Prostate (HoLEP). Procedure Specific Information (https://www.ouh.nhs.uk/urology/services/documents/holep.pdf)

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