HoLEP: your expert guide

We hear expert insight from Mr Matthew Liew, a leading consultant urologist, on the HoLEP (Holmium laser enucleation of the prostate) procedure which is performed to treat benign prostate hyperplasia. He sheds light on how the procedure is performed, associated risks, and the recovery period to follow in this informative guide for patients preparing for HoLEP treatment, often referred to as Holmium laser prostate surgery.

What is the aim of the HoLEP procedure?

HoLEP (Holmium laser enucleation of the prostate) is an alternative to conventional transurethral resection of the prostate (TURP) for the treatment of bladder outflow obstruction. It is a modern highly-effective prostate operation to treat men with obstructing bladder symptoms or retention of urine.

Who is an ideal candidate for HoLEP treatment?

Candidates for HoLEP treatment include men who are generally fit and well but are experiencing urinary symptoms or retention, have an enlarged prostate, and have found no relief from lifestyle changes or medical treatment. The procedure is predominantly used to treat benign prostate enlargement rather than cancerous glands.

Though HoLEP treatment is used for prostates of all sizes, it is the most effective approach for men with larger prostates (more than 80 grams). This is because the procedure offers the greatest amount of tissue removal, without the risk of serious complications associated with more traditional operations. For this reason, it is the first-line treatment for these men. For men with smaller prostate glands, there are a number of beneficial approaches, including HoLEP treatment.

How is it performed?

HoLEP is not a very major operation. Similar to TURP (transurethral resection of the prostate), it is performed either under general anaesthetic or spinal anaesthetic. In the procedure, an instrument is inserted down the penis, allowing a laser to ‘shell out’ the prostate. The operation takes around two hours, depending on the size of the prostate gland.

The holmium laser used in the procedure is very safe, and enables a large amount of obstructing prostate gland tissue to be removed. This tissue is then evacuated from the bladder via the urethra (within the penis). This leaves a cavity within the prostate, allowing rapid flow of urine through the prostate when the catheter is removed, usually the following day. It is important to have a urine flow rate test and a measurement of the prostate size, in order to help decide the best type of prostate operation.

Is HoLEP surgery risky?

A key advantage of HoLEP over conventional TURP is that it is less risky. The risk of bleeding is reduced, which generally makes for a safer procedure and can translate into a shorter hospital stay. In the long term, the only real complication is a two per cent chance of a stricture, where a scar tissue forms in the urethra, which in turn results in a restricted flow at a later stage (often within the first year).

What are the advantages of this type of procedure?

HoLEP treatment is safer than other procedures because of the reduced risk of bleeding. Additionally, doctors are able to remove more of the central part of the prostate with HoLEP, compared to other treatment approaches. This means that HoLEP tends to be more durable in the long term and the risk of requiring a repeat operation at a later stage is much less. It is recommended in Getting it Right First Time (GIRFT) guidelines.

What is the recovery period like after HoLEP treatment?

Most people take things easy in this early stage of the recovery process. However, the majority of men don’t require need any pain relief in this period and symptoms will settle on their own.

Most men have some burning and stinging when urinating for a few days after surgery. They may also pass urine relatively frequently while the bladder adjusts to the surgery. This usually settles within the first few weeks but it can take up to three months to get the full benefit from the operation. The majority of men don’t require need any pain relief in this period and symptoms will settle on their own.

How effective is the procedure?

The prostate is shaped like a doughnut with a hole in the centre. It wraps around the water pipe (urethra) at the exit of the bladder. As we age, the prostate grows, meaning the central hole gets tighter and obstructs the bladder when it tries to empty. This causes a range of symptoms and occasionally, total blockage (acute retention), bladder stones or even kidney failure, resulting from back pressure.

There are several types of operation which can be performed to treat obstruction, with some involving removal of tissue and others shrinking the tissue or using implants to hold the prostate open. All surgical approaches may be successful in the short term (for five years) but as the remaining prostate gland continues to grow, obstruction can recur. HoLEP is the most effective procedure in terms of providing a long-term positive outcome (over 25 years) as more tissue is removed as compared to other approaches.

 

What are the side effects of HoLEP?

Compared with traditional options for large prostate glands, (including the open enucleation (Millin) procedure), HoLEP is much safer and less complex. Instead of spending five nights in the hospital with a catheter and a high chance of needing a blood transfusion, a stay in hospital is often not required or just one night.

HoLEP rarely causes significant bleeding, although anticoagulants should be stopped beforehand. In addition, the bloodstream’s electrolyte composition is not disturbed. Occasionally, urinary infection can occur following HoLEP, requiring a course of antibiotics.

Temporary incontinence necessitating pads occurs in 3/100, which rarely persists. Persisting symptoms and stricture are mentioned above. I always counsel my patients on the possibility of intermittent shows of blood, urgency to get to the toilet and leaks, which can occur in the few weeks following HoLEP. This occurs because the cavity is healing, while the bladder becomes accustomed to no longer being obstructed.

What happens to the prostate after HoLEP surgery?

We use a special device to chop up the shelled out prostate in the bladder, and suck it out through the penis, and then we send it to the laboratory. In the laboratory, they establish whether there was anything untoward in the prostate tissue, (i.e. cancer).

A big wall cavity is then left on the inside, which takes about six weeks to three months to heal. Once healed, the patient will have a good flow and won't suffer from any urine urgency.

If you require treatment for benign prostate hyperplasia and wish to schedule a consultation with Mr Matthew Liew, visit his Top Doctors profile today.