What is HoLEP and how does it work?

Holmium laser enucleation of prostate (HoLEP) is a minimally invasive procedure developed in the 1990s to remove large amounts of prostate tissue in men with obstructive symptoms from benign prostate enlargement. The procedure is done in the operating room under general anesthesia using a scope and no incisions are made on the skin.

Removal of the prostate for urinary obstruction has been performed for >100 years, originally being done through an open abdominal incision, and then evolving into scope based procedures that remove or destroy tissue through the urethra. Transurethral surgeries are less invasive than the abdominal approach, but until the development of HoLEP, transurethral surgery did not remove as much prostate tissue and often repeat treatments were common when prostate tissue grew back. Borrowing principles from open surgery, HoLEP approaches the prostate through the urethra and uses a high-powered holmium laser to core out or “enucleate” the obstructing lobes of the prostate along the prostatic capsule. This approach allows for removal of 80-90% of the prostate tissue, resulting in the lowest retreatment rate of any BPH treatment currently available.

Emory Urology is excited to be the first department in Atlanta and the state of Georgia to offer HoLEP for men with urinary symptoms related to prostate enlargement.

Who would benefit from HoLEP?

HoLEP is ideally suited for patients with large obstructing prostates that cause bothersome urinary symptoms (including slow or intermittent urinary stream, difficulty starting urination or incomplete emptying of the bladder) that are not controlled with medical therapy. Urinary symptoms can arise in men with any size prostate, and HoLEP is best employed for men with larger prostates. Men with severe urinary symptoms, particularly catheter dependent, recurrent UTIs from poor bladder emptying, or formation of bladder stones, could achieve the most significant benefits from HoLEP, which maximally opens the bladder outlet to facilitate optimal bladder emptying. Additionally, the surgical dissection follows a path with less blood vessels and thus men on anticoagulation for other medical problems could also be candidates for HoLEP.

While urinary obstruction is often associated with benign prostate enlargement, many men with prostate cancer will also develop bothersome urinary symptoms. Men with very low risk prostate cancer who are established on active surveillance programs may be candidates for HoLEP. While HoLEP is not curative for prostate cancer, it can improve urination while not compromising the potential for curative cancer treatment in the event of cancer progression. The prostate tissue removed during HoLEP can be evaluated under a microscope to look for evidence of prostate cancer.

The procedure can be more challenging in patients who have had previous prostate treatments (e.g. TURP, laser surgery, microwave, biopsy, radiation, etc.) so let your doctor know if you have had a prior procedure done on your prostate.

Procedure In Detail

Pre-Op

Prior to moving forward with surgery, it is essential to ensure that a patient has the appropriate indications. The work-up may include:

  • Medical history to assess degree of symptoms, prior medical or surgical treatments, history of infections, and other details
  • Physical exam including digital rectal exam to approximate the size of the prostate and evaluate for nodules that could suggest prostate cancer
  • Urine flow rate and post-void residual (amount of urine remaining in the bladder after urinating to completion) to objectively assess degree of obstruction
  • Urine sample to ensure no evidence of infection or blood that could indicate other diseases in the urinary tract
  • Bloodwork to evaluate baseline blood counts, clotting capacity as well as screening for prostate cancer with PSA in appropriate patients.
  • Imaging is helpful to evaluate the size of the prostate and decide whether it is large enough to require HoLEP, or if the prostate is small enough to be adequately treated with TURP or other minimally invasive options available at Emory. CT scan, MRI or ultrasound that includes the bladder/prostate/pelvis completed within the past year may be adequate and would not need to be repeated. If you have any imaging done within the past year outside of Emory please bring the images on a disc for us to review.
  • Cystoscopy (a procedure where a small scope is passed through the urethra into the bladder) can be helpful to directly examine the anatomy of the prostate and the bladder.
  • Urodynamics is a test done in the clinic that measures the strength of the bladder muscle contraction. This test is helpful for patients who are catheter-dependent or who have neurologic conditions to ensure that the bladder will be able to contract and empty after the obstructing prostate is removed.
  • If a patient has an elevated PSA, a nodule on exam or a suspicious lesion on prostate MRI then they may require a prostate biopsy to look for evidence of prostate cancer. If we identify prostate cancer then we can discuss the next steps.
Days leading up to surgery:
  • Urine culture approximately one week prior to surgery to treat any bacteria and reduce risk of significant urinary tract infection cause by surgery
  • If you take anticoagulation medications (e.g. aspirin, plavix, coumadin, xarelto, etc.) we will determine a specific plan for when to stop your medications based on your individual risk factors and conversation with your physician who prescribes/monitors that medication
  • Nothing to eat or drink after midnight the night before surgery

Intra-Op

HoLEP is performed in the operating room under general anesthesia (completely asleep with a breathing tube). Antibiotics are given to reduce the risk of infection prior to starting the procedure. A scope is passed through the urethra to the level of the prostate. Using a high power laser, incisions are made down to the level of the prostate capsule and then carried circumferentially around to free up the prostate lobes and push them into the bladder. Any bleeding is stopped using the laser or electrocautery. Finally, the prostate lobes in the bladder are sucked out of the bladder with an instrument called a morcellator, which captures the prostate tissue for examination under a microscope. A foley catheter is then placed to irrigate and drain the bladder and the patient is awoken for transport to the recovery room.

Hospital Stay

The vast majority of patients remain in the hospital for only one night of observation to ensure there are no problems with bleeding or bladder spasms. Patients are allowed to eat and drink following surgery as long as they are doing well after anesthesia. Depending on preoperative bladder function as well as the anatomy dissected during the operation, most men will have their foley catheter removed the day after surgery and a trial of urination prior to discharge that day. If you are unable to urinate after catheter removal then a catheter will be replaced prior to discharge. If you have a catheter replaced or if your surgeon feels you should keep the catheter for a few days of bladder rest then we can arrange for the catheter to be removed in our clinic postoperatively.

Benefits and Risks

HoLEP has an established track record as a safe and effective treatment for prostate enlargement over thousands of cases. However, as with every surgical procedure, there are associated risks and benefits that you should consider before moving forward with surgery. Discuss any questions or concerns with your physician to best understand your personal risks and decide if HoLEP is right for you.

Benefits:

  • HoLEP provides the optimal combination of maximal prostate tissue removed with minimally invasive, transurethral approach, not requiring any skin incisions.
  • Significant improvement in urinary flow, reduction in post-void residual urine, and improvement in urinary symptoms
  • Largest amount of prostate tissue resected of any transurethral BPH treatment option
  • Shorter hospital stay and shorter catheter duration than TURP or robotic simple prostatectomy
  • Decreased blood loss and blood transfusion rates '
  • Lowest rates of retreatment among BPH treatments (0.7% after 10 years, compared with 15% at 5 years for TURP, Rezum and Urolift)

Risks:

  • Bleeding: small amounts of blood in the urine is normal, but in rare cases patients will require a blood transfusion, usually if their blood count is lower before the start of the procedure.
  • Urinary tract infection resulting from passing instruments into the bladder
  • Retrograde ejaculation (~80% of patients): with orgasm, instead of passing out the tip of the penis, semen will pass up into the bladder. This is not dangerous and will not result in stones or infection, but it is common to notice decreased volume or absent ejaculation post-operatively. Studies have not shown any decreased erectile function or orgasm after HoLEPsince the dissection is inside the capsule and away from the nerves that control erections.
  • Urethral stricture: scar tissue in the urethra that obstructs urine flow downstream from the prostate, often will not develop until months to years after the surgery.
  • Damage to prostate capsule or bladder: most often treated with urinary catheter drainage for several weeks to allow the tissue to heal.
  • Urinary incontinence: usually in the form of dribbling after urination, but can be more pronounced, especially in men who have urge-type leakage prior to the procedure. Incidence is approximately 12% six weeks postoperatively, and decreases to 1% at six months postop as the bladder muscle re-equilibrates. Urge related incontinence can be treated with medications once the obstructing prostate has been removed.
  • Incidental prostate cancer (10%): even after normal screening evaluation, it is possible to find prostate cancer when the removed prostate tissue is examined under the microscope. Most of this incidental prostate cancer is low risk and can be monitored moving forward. If you are found to have incidental prostate cancer, we will discuss the steps moving forward.
  • Standard risks associated with general anesthesia include pneumonia, blood clot, heart attack, to name a few. These will be reviewed with your anesthesiologist prior to surgery.

Recovery

We will see you in clinic approximately six weeks after the procedure to see how the recovery is progressing. This can include measuring your urinary flow and residual urine.

Returning to your normal activities after surgery is influenced by many factors, including age, preoperative urinary symptoms, as well as other health conditions and medications. Recovery can be different for each individual. Here we listed general expectations, but before the procedure discuss with your surgeon any specific concerns about your medical history, or if your work/activities are particularly strenuous.

  • In the first few days, you may feel some burning with urination, which is related to urine passing over the freshly operated prostate bed. This does not always indicate urinary tract infection, but let us know if you also develop any of the symptoms listed below under “When to Call”. 
  • This urinary discomfort or mild penile/pelvic pain is normal and should not reach significant levels of pain. It should be manageable with short-term use of over-the-counter pain medications (e.g. acetaminophen/Tylenol or phenazopyridine/Azo/Pyridium).
  • It is normal to see some blood in your urine after this surgery while the prostate bed heals, and this can come and go for up to eight weeks after surgery. It is also normal to see some clots in your urine, which should pass easily. If you feel the clots are increasing in volume or if they grow larger than the size of a dime, you should call the clinic.
  • Symptoms of urinary urgency, frequency, and urinary leakage may not initially improve (and in a few cases get temporarily worse as the large obstructing prostate has now been removed). Over the months after surgery your bladder will re-equilibrate and these symptoms should improve. If there is not significant improvement, discuss with your doctor possibly starting medications that can reduce bladder spasticity now that the prostate has been treated.

During the first few weeks after surgery, drink large amounts of liquids to produce ample urine and flush your urinary tract of any small amounts of blood or tissue. It is OK to resume your normal diet when you return home.

Kegels are an exercise with repeated squeezing of the pelvic floor muscles to increase strength and muscle tone. These exercises can help with urinary control, particularly if you notice urinary leakage after the procedure. Complete ten squeezes in a row at three times per day for the first two weeks after surgery to help strengthen your pelvic floor.

Returning to work and exercise depend on the level of exertion that your activities entail. You will likely feel fatigued for about 1-2 weeks after surgery as your body recovers and heals. Please continue to move and walk short distances everyday, you should not spend all day in bed. It would be appropriate to resume exercise at two weeks provided you are doing well and there is minimal blood in your urine. Returning to work depends on your job and feel free to discuss with your surgeon. If you work at a desk with minimal exertion it may be possible to return sooner than other jobs that require heavy lifting or other activity.

When To Call The Clinic

  • Fever >101 degrees F
  • Bloody urine red wine colored or darker, or passing clots larger than a dime
  • Difficulty with urination, sensation that you are not emptying your bladder
  • Increased urinary frequency with small volume urinations
  • Significant increase in pain