Holmium laser enucleation of the prostate (HoLEP) is a method for treating benign prostatic hyperplasia, or BPH. Naren Nimmagadda, assistant professor of urology, explains the procedure, which uses a light beam called a holmium laser to remove the interior tissue of the prostate and relieve bladder obstruction.

What is HoLEP?

Holmium laser enucleation of the prostate is a minimally invasive procedure that uses pulses of laser beam to remove tissue from the inside of the prostate, which surrounds the urethra (the tube leading from the bladder to the urinary opening).

How does HoLEP compare with other procedures?

“Holmium laser enucleation of the prostate is very effective, with results comparable to those of simple prostatectomy, which is surgical removal of the prostate,” Nimmagadda says.

He explains: “The main advantage of HoLEP over some other methods is the large volume of prostate tissue that can be safely removed. The pulses of holmium laser help the surgeon push the tissue and separate the bulk of the interior prostate from its outer layer. HoLEP allows us to work from the outside of the prostate inward, toward the urethra, removing a very large volume of prostate tissue.”

Some of the other methods to reduce the size of the prostate remove only enough tissue around the urethra to restore the flow of urine. Nimmagadda says that prostate tissue left behind after treatment can cause post-procedure pain and irritation. It can also grow and cause a recurrence of symptoms. That is why the more prostate that can be removed, the higher the chance of a lasting good outcome for the patient.

In terms of effectiveness, practitioners report that holmium laser enucleation of the prostate has results comparable to those of simple prostatectomy but does not involve an invasive surgical procedure.

Is HoLEP procedure an option for me?

“HoLEP may be appropriate for those with signs of bladder obstruction, due to benign prostatic hyperplasia ― an enlarged prostate,” Nimmagadda says.

People who have BPP symptoms may notice recurrent problems, such as:

• Frequent urinary tract infections
• Blood in the urine
• Bladder stones
• Kidney problems

“The approach to treating BPH is individualized,” he says, noting that a range of procedures can relieve BPH symptoms. “You and your doctor will go over these issues with you and will recommend the surgery most appropriate for your situation.”

HoLEP Procedure: What to Expect

Before scheduling your HoLEP procedure, the doctor will conduct a thorough physical and medical history, including details about your symptoms and their impact on your life.

Screening Tests

Next, Nimmagadda says, you will likely be scheduled for one or more of the following tests:

• Surveys, where you can record your symptoms and rate their severity
• Ultrasound to see how much urine is retained in your bladder after urination
• A uroflowmetry test to assess the volume, speed and strength of the urine stream

Based on these results, your doctor may recommend medication as a first step to relieve your symptoms. If these preliminary tests show that you have an obstruction and may benefit from removal of all or part of the prostate to relieve your symptoms, the doctor will go over options with you and order further tests, which may include:

• Cystoscopy, which helps the practitioner look for signs of cancer, infection, narrowing, blockage or bleeding. After you have been given numbing medication, a long, flexible, lighted tube called a cystoscope is placed into the urethra and moved up into the bladder, so the practitioner can examine the inside of the urinary tract.
• Prostate exam
• Ultrasound (ultrasonography), CT scan or MRI to further estimate the size of the prostate

Preparing for HoLEP

“Before your surgery, you will need to get preoperative lab work completed. Your family doctor or primary care practitioner can help you set up these tests and further optimize you for surgery,” Nimmagadda says.

You may be staying overnight in the hospital, so you will want to bring your essentials with you. Make sure you have someone who can drop you off the day of your procedure and pick you up at the hospital when you are ready to come home.

In the days immediately preceding your HoLEP procedure, follow your urologist’s instructions regarding eating, drinking and taking your regular medications.

HoLEP: What Happens

Dr. Nimmagadda explains what you can expect on the day of your procedure and afterward.

• Holmium laser enucleation of the prostate takes about three hours, depending on the size of the prostate.
• Once you are asleep under general anesthesia, the surgeon inserts a narrow endoscopy tube, called a resectoscope, into the urethra.
• A laser fiber instrument inserted through the resectoscope pulses a beam of holmium laser to separate the core of the prostate from its outer border — “It is similar to spooning out the inside of an avocado or kiwi fruit from its outer peel,” Nimmagadda says. The resectoscope is also used to push and peel the tissue. The tissue is released into the bladder as two or three large pieces.
• A tool uses suction to pull the inner prostate tissue in, cut it into small pieces and remove it from the body. The pieces will be saved to send to pathology, who will look for any signs of prostate cancer. “Prostate cancer shows up in about 5% of people being treated with holmium laser enucleation and is typically a type that tends to be dormant and can be addressed through observation and monitoring,” he notes.
• Once the prostate has been hollowed out by the laser and the excess prostate tissue is removed, you will be transported to the recovery room for about two hours.
• You will have a special catheter, called a three-way catheter, in your bladder. This helps the nurses and technologists rinse the inside of the bladder with saline and ensures that the catheter stays open.
• You can expect to see blood-colored urine, especially during the first 24 hours the HoLEP procedure.
• The doctor may remove the catheter the next day, or let you go home with the catheter in place. In this instance, you return the next day to have the catheter removed.
• Before removing the catheter, the doctor may use it to fill the bladder and check how much fluid is left after urination.

HoLEP Recovery

• In many ways, the recovery from holmium laser enucleation of the prostate is similar to that of other procedures to remove or reduce the prostate.
• After HoLEP, the urethra will heal into the new space.
• You can expect some bleeding because the inside of the prostate has many small blood vessels. This may take eight to 12 weeks to resolve.
• Pain, burning sensations and discomfort in the one to three weeks following the procedure can be managed with over-the-counter pain relievers. Most patients can expect to have less pain with HoLEP than with other procedures that leave charred prostate tissue behind, which can lead to irritation.

Urinary Incontinence After HoLEP

When you have BPH, the bulk of extra tissue in the prostate gland can help retain urine in the bladder. As a result, the urinary sphincter, a ring of muscle around the urinary opening, can weaken over time because the excess prostate tissue is holding urine in the body rather than the sphincter. After a prostate treatment, the sphincter muscles must regain their strength, and in the meantime, urinary incontinence is a potential side effect.

When the extra prostate tissue is removed, the sphincter will need time to re-strengthen to the point where it can hold back urine flow. While this is happening, you might experience leaks or urine spurts requiring a pad.

Both stress incontinence (involuntary urination when lifting, coughing, sneezing or straining) and urge incontinence (inability to hold urine until you can get to the bathroom and are ready to urinate) may be part of the recovery process until your bladder and urinary sphincter regain their strength.

Kegel exercises can help strengthen the floor of the pelvic muscles and help resolve urinary leaks. If urinary incontinence continues, it may be due to a bladder dysfunction, which can occur in patients with or without BPH.

Holmium Laser Enucleation of the Prostate: Risks and Complications

Because HoLEP is minimally invasive, it may involve less risk of serious complications than open surgery procedures.

Retrograde ejaculation is a common side effect of HoLEP. “Retrograde” means backward. In retrograde ejaculation, semen travels up the urethra into the bladder instead of down the urethra out of the penis, and comes out in your urine. Retrograde ejaculation will not harm you.

Long-term urine leakage can affect up to 1% to 2% of patients who have had HoLEP. Older patients and those who have had removal of large volumes of prostate tissue are more at risk.

Blood loss that requires a blood transfusion is a rare side effect. The risk may be higher in older patients, especially those with lower blood levels from chronic bleeding due to prostate disease.

In very rare instances, the bladder may be injured by the device that cuts up the prostate tissue so it can be removed through the tube. Open surgery would be needed to repair the bladder.