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Since its introduction in the late 1990s, Holmium Laser Enucleation of the Prostate (HoLEP) has gained traction and popularity for the management of benign prostatic hyperplasia (BPH), or enlarged prostate. The principles behind the HoLEP procedure are to provide patients with the fastest relief coupled with the most optimal outcomes when it comes to prostate symptoms.

What Is the HoLEP and How Is It Performed?

Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive treatment for BPH. It is all done through a natural urinary orifice (through the penis) without the need for any incisions. Utilizing general or spinal anesthesia, a holmium laser is used to dissect, enucleate, and peel the prostate gland tissue, leaving only the capsule (outer layer) of the prostate in place. The enucleated prostate gland tissue is then pushed into the bladder under complete endoscopic vision and extracted through a morcellator device. The extracted tissue is then sent to a pathology lab for further analysis, ensuring other conditions such as prostate cancer are not present. An analogy that is often used: If the prostate is an orange, the HoLEP removes the "fruit" and leaves the "peel."

Why Aren't All Urologists Performing the HoLEP?

HoLEP is an extremely specialized procedure that requires intensive mentored training during a urology residency or fellowship. Due to the difficult and steep learning curve, there are very few urologic surgeons and institutions in the United States who are currently teaching and performing this procedure. Dr. Tsai has been very fortunate to train under one of these highly skilled mentors who has passed his technique for this unique and game-changing procedure onto him.

The HoLEP Advantage

HoLEP offers some unique advantages:

  • Ability to treat any size prostate gland with minimal bleeding
  • Complete cleaning of the enlarged prostate tissue down to the prostatic capsule,resulting in a re-treatment rate of less than 2 percent and high durability rate.
  • Since normal saline is used for irrigation, no risk of hyponatremia is encountered
  • Early, immediate relief of symptoms and fast return to normal activity Back to work within 2-3 days and can resume physical exercise within 2 weeks
  • Next-day catheter removal in most of the cases with less than 24 hours hospital stay
  • Minimal pain with minimal pain medication requirement
  • Tissue available for pathologic examination to check for malignancy or cancer.
  • The holmium laser technology offers a low depth of tissue penetration, less than half of 1 mm which causes less damage to the underlying tissue healthy tissue, minimizing excessive bleeding
  • There is no to minimal effect on sexual function, erections, climax.

Evidence-Based Outcomes

Multiple studies suggest that HoLEP provides superior outcomes in treating men with BPH compared to procedures such as transurethral resection of the prostate (TURP) and open simple prostatectomy, regardless of prostate size.

The TURP procedure is effective for only small to moderate sized prostate glands (0-60 grams) with results varying with surgeon experience and involvement. It may also lead to significant complications including hyponatremia (low sodium), significant bleeding, prolonged hospitalization, risk of urinary incontinence, higher risk of returning to the hospital or emergency room, or higher risk of postoperative urinary retention. The HoLEP in comparison effectively treats prostates of all sizes with fewer complications.

When compared to the open simple prostatectomy, HoLEP offers similar efficacy but without any incisions. There are also less morbidities such as bleeding, decreased hospital stay and better postoperative course. HoLEP is also suggested to decrease hospital costs when compared to open prostatectomy.

Another similar but different procedure, laser ablation, may provide symptom relief, fast recovery, and fewer risks compared to the two above mentioned procedures. However, ablation may result in postoperative prostate tissue edema and resulting urinary retention. Additionally, the long-term durability of ablative procedures is questionable, and there is a risk of prostate regrowth especially with larger glands that may require repeat surgical procedures.

Who Is the HoLEP for and Is It Right for Me?

BPH occurs in more than 40% of men over the age of 60 and is a leading cause of urination symptoms, including difficulty passing urine and weak urine stream. As men age, these symptoms may worsen, sometimes to the point where they are unable to urinate at all. Although BPH can be treated without surgery, many patients eventually fail conservative options and ultimately require surgical intervention.

HoLEP has been recommended by the American Urological Association (AUA) as a safe and effective treatment for men with BPH and prostate symptoms. It may be used to treat a wide range of men with prostates of all sizes. It is especially advantageous in treating patients with severely enlarged prostates who do not wish to undergo traditional open surgery requiring incisions. Men who wish to stop taking medications may also consider surgery. You may not be a candidate for HoLEP if you have prostate cancer, bleeding problems, have had prior certain prostate procedures, or if you cannot lay on your back with raised legs for a prolonged period of time as this is the necessary surgical position.

What To Expect Before and After Your HoLEP Procedure?

Before (Pre-op)

Prior to proceeding with the HoLEP, the doctor will perform a series of testing including obtaining urine samples(to assess for active infection or bacterial organisms), cystoscopy (bladder camera to assess your lower urinary tract and anatomy), bladder scan (to assess for residual urine after voiding), testing for the strength of your urine stream.

If you are on any blood thinners you will be instructed to hold them approximately a week prior to surgery.

There is a risk for bleeding after the HoLEP procedure. This risk increases more if you currently have a foley catheter, a history of urinary tract infections, or if youíve been on anticoagulation (blood thinners).

Like most prostate surgeries, a majority of patients will experience retrograde ejaculation after surgery. This does not affect your overall long term health nor does it have any effect on your ability to climax or your sexual performance.

Urinary incontinence (stress and urge) is common and often transient. Symptoms should usually subside by 2 weeks. The risk increases marginally with larger prostates.

After (Post-op)

DIET:

  • Return to the diet you were on before surgery.
  • Continue to drink lots of fluids.
  • Alcohol is okay in moderation.

ACTIVITY:

  • Lift nothing over 10 lbs (i.e. 1 gallon of milk) for the first 2 weeks following your discharge.
  • It is EXTREMELY important to minimize the amount of straining you are doing post-operatively, whether it is in the form of physical activity or with having bowel movements. If you have constipation, take scheduled miralax daily to ensure that you do not strain or push with bowel movements.
  • After 2 weeks, you may gradually resume your usual activity.
  • Walking, even up and down stairs, is encouraged and will not disturb your postoperative healing process. Start slow and build up your activity every day.
  • No driving for 48 hours after your catheter has been removed.
  • Gradually build up your activity a little each day.

THINGS TO LOOK FOR:

  • Healing after your procedure can take up to 3 months, although the average healing process is 6 weeks.
  • Frequency, urgency, pain at the tip of your urethra and where you urinate is typical, expected, and usually transient after your procedure. These symptoms usually improve by 2-3 weeks post-op.
  • Blood that appears transparent (fruit punch, koolaid) is typically normal. If your urine begins to look opaque (ketchup-like), please notify our office.
  • If you do notice blood in your urine, stay off your feet and drink plenty of fluids.
  • If you have trouble urinating, please call our clinic for further guidance.

WHEN TO CALL THE DOCTOR:

  • If your temperature is 101° or higher, please call the office number provided.
  • If you develop a rash (breaking out), stop your medicine and call our office number.
  • If your urine becomes too bloody (opaque, ketchup-like) or if you are unable to urinate at all, please notify our office.
  • Above all else, if there are any concerns or questions, please do not hesitate to call or ask.