Holmium Laser Enucleation of the prostate (HoLEP) is a more precise alternative to the standard Transurethral Resection of the Prostate (TURP) procedure for urinary symptoms due to enlarged prostate/benign prostatic hyperplasia (BPH). It is done either as an outpatient, or may require a 1 night overnight stay, depending on the size of the prostate. A catheter (a tube which drains the bladder) is also needed for 1-2 days until all blood in the urine has stopped. Recovery period is 2-3 weeks. During the recovery period strenuous exercise and lifting more than 10-15 lbs is discouraged, as this can potentiate or restart bleeding in the urine.
Am I a candidate for HoLEP/ProLEP?
HoLEP can be performed on men with urinary outflow obstruction caused by an enlarged prostate/BPH. It can be done on men with chronic medical conditions, and of advanced age, as an alternative to more invasive robotic or open BPH surgeries. It is particularly indicated in men with large prostates (over 60-80 cubic centimeters in size) and men on medications to thin the blood such as warfarin, aspirin or Plavix/clopidogrel. HoLEP can be done on prostates of any size, including severely enlarged prostates where open or robotic abdominal surgery was the only prior option. Blood thinners such as aspirin, Plavix/clopidogrel, warfarin, Eliquis, and Xarelto are recommended to be held before the operation, and for a short period after the operation.
How is the HoLEP/ProLEP performed?
HoLEP unblocks the prostate by separation of the enlarged glandular prostate tissue from the fibrous peripheral covering of the prostate. This is done under a general anesthetic with a telescope through the penis. There are no incisions made in the skin. The obstructing prostate tissue is detached from the peripheral part of the prostate as shown below, and is pushed into the bladder. This is often compared to “peeling an orange from the inside”. A special instrument called a morcellator is then inserted through the telescope, and used to break up and suction out the tissue in pieces. The pieces are then sent for biopsy. A catheter is placed into the bladder to drain urine and allow for comfort for about 1 day.
What are the advantages of HoLEP/ProLEP relative to TURP and other techniques?
- Unlike TURP, HoLEP can be performed on prostates of any size
- There is less bleeding than after TURP and many other prostate resection techniques
- This is often an outpatient procedure, with occasional stay of 1 night overnight – TURP usually has a 1-2 night hospital stay.
- The HoLEP (illustrated below right) is a more complete resection of obstructing prostate tissue than TURP (illustrated below left), leaving very little chance of regrowth requiring further surgery.
- As such, the chance of recurrence requiring further surgery is very low – only 1% – substantially lower than TURP – 6-10%
- Like TURP, HoLEP also removes tissue which is sent to the pathologist for analysis to exclude prostate cancer
- The PSA generally drops substantially after HoLEP operations, reassuring many men that prostate cancer is not a potential issue
- The procedure does not affect erectile function aside from very rare cases
What are the disadvantages of HoLEP/ProLEP?
- The procedure takes slightly longer in the operating room than a TURP. Most urologists are not comfortable with the technique, and choosing a urologist who is comfortable with the technique is important.
- Like any surgical technique to resect tissue and unblock an enlarged prostate, most men will have retrograde ejaculation (a dry orgasm) after the procedure. This is usually permanent, but does not affect erections, or the ability to have an orgasm.
- Rate of incontinence is low but real(3%).