Key information about prostate removal using a holmium laser ( HoLep)
What is HoLEP (Holmium Laser Enucleation of the Prostate)?
Holmium Laser Enucleation of the Prostate (HoLEP) is a type of laser surgery used to treat benign prostatic hyperplasia (BPH). BPH is a condition that causes the prostate gland to enlarge, which can put pressure on the urethra and make it difficult to urinate. HoLEP is a minimally invasive procedure that uses a laser beam to remove the prostate tissue that is blocking the flow of urine.
Developed in the 1990s, HoLEP was introduced as a more effective and potentially less costly surgery to treat urinary tract obstruction caused by BPH. This procedure offers faster recovery times and does not require large incisions.
What does HoLEP treat?
The holmium laser is a surgical laser used by surgeons to remove enlarged prostate tissue that is blocking the flow of urine. The most common cause of urinary tract obstruction (blocked urine flow) is benign prostatic hyperplasia. BPH causes the prostate gland to grow in size. The enlarged prostate puts pressure on the urethra and prevents urine from flowing out of the bladder.
Common Symptoms of Benign Prostatic Hyperplasia (BPH)
Some common signs and symptoms of BPH include:
- Difficulty urinating.
- Weak urine stream.
- A frequent need to urinate, especially at night.
- Feeling like you can’t empty your bladder completely.
- Leaking urine.
How Common is HoLEP Surgery?
Benign prostatic hyperplasia affects more than 60% of men over the age of 60. As men age, the risk of developing BPH increases. While the symptoms of BPH may worsen over time, not all men with BPH need surgery.
Many find relief with medications or other treatments. However, if symptoms are bothersome or you’re at risk for complications like urinary tract infections (UTIs) or bladder stones, your healthcare provider may recommend HoLEP.
Is HoLEP a Major Surgery?
HoLEP is considered a minimally invasive procedure with a lower risk of complications compared to other surgeries for BPH. However, as with any surgery, there are risks. Be sure to talk to your healthcare provider about any concerns you may have about the procedure and recovery.
What Happens Before HoLEP?
Your healthcare provider will take a medical history and perform a physical exam to assess the severity of your condition. This may include a digital rectal exam and tests to measure how much urine is left in your bladder after urinating. Lab tests may include a PSA (prostate-specific antigen) test and urine analysis.
Other tests that may be conducted before HoLEP (Holmium Laser Enucleation of the Prostate) surgery include:
- Tests to evaluate urine flow and bladder capacity.
- Imaging tests, such as transrectal ultrasound or computed tomography (CT) scans, to help the healthcare provider assess the size of the prostate.
- Cystoscopy (using a camera to view inside the urethra, prostate, and bladder) to evaluate the prostate and bladder for signs of cancer, infection, or obstruction.
- Urodynamic testing to assess how well the bladder functions and determine whether removing prostate tissue would help alleviate symptoms. This diagnostic test involves inserting a catheter into the bladder and using various pressure sensors.
Inform your healthcare provider about any medications you are taking. You may be asked to stop taking certain medications up to 10 days before surgery. You will not be allowed to eat or drink after midnight before the surgery.
How is Holmium Laser Enucleation of the Prostate (HoLEP) performed?
HoLEP requires general anesthesia (you will be asleep throughout the procedure). If you cannot undergo general anesthesia for any reason, spinal anesthesia may be administered to numb the body from the waist down. Your healthcare provider may also give you an injection of antibiotics to reduce the risk of infection.
Typical HoLEP Procedure
Here’s a breakdown of what typically happens during a HoLEP surgery:
- Preparation: Once you’re asleep, the healthcare team will position you on your back and elevate your legs.
- Scope Insertion: A surgical instrument called a resectoscope is inserted through the urethra. This instrument contains a camera that allows the surgeon to see the prostate gland.
- Laser Removal: A laser is inserted into the resectoscope. The laser fires pulsed beams at the prostate to cut away the tissue blocking urine flow (a process called enucleation). The surgeon then uses the laser to seal blood vessels.
- Tissue Removal: The laser is removed from the resectoscope, and a device called a morcellator is inserted. This device sucks up the remaining prostate tissue in the bladder and removes it from the body. The surgeon will send pieces of the prostate tissue to a laboratory for analysis to ensure there are no abnormalities such as prostate cancer.
- Catheter Placement: After all the tissue has been removed, the surgeon will remove the resectoscope and insert a urinary catheter.
How Long Does the Procedure Take?
A HoLEP surgery typically takes between one and three hours, but this can vary depending on your individual case.
What Happens After HoLEP?
Most people go home after spending a few hours in the recovery room. However, some may need to stay in the hospital if there are concerns about bleeding or other complications.
Here are some things you can expect after surgery:
- Catheter: A healthcare provider will flush fluid through the catheter to remove blood from the urine after surgery. As long as the urine is clear pink or red, you will be allowed to go home with the catheter.
- Catheter Removal: The healthcare provider will remove the catheter the day after surgery unless there is excessive bleeding (which is rare) or other concerns.
- If you can urinate two to three times after the catheter is removed, you can go home and urinate normally. If you cannot urinate after the catheter is removed, your doctor will reinsert the catheter and remove it again in a few days.
- Urination Changes: Initially, urination may be painful and more frequent than usual. Medications can help alleviate these symptoms. It is expected to have blood in your urine for several weeks. This will vary depending on your activity level and how much fluid you drink. Your healthcare provider will encourage you to drink plenty of fluids after the catheter is removed. This helps to flush the blood from your urine more effectively.
- Symptom Improvement: It may take several months for symptoms such as frequent urination, urgency, and waking up at night to urinate to improve. This is because the bladder needs to adjust to the removal of prostate tissue, and the control of the muscles in the pelvic area may be weak after surgery.
- Other Symptoms: Feeling a burning sensation for a few weeks after surgery is normal. You can take over-the-counter pain relievers to ease discomfort. It is normal to have some light bleeding from the prostate for several weeks or even a few months.
- Follow-up: Your healthcare provider will want to see you after surgery to monitor your recovery and repeat tests such as urine flow rate, bladder scans, and other tests. These tests help assess the effectiveness of the surgery and monitor for potential complications.
- Pelvic Floor Exercises: Your doctor may also recommend doing pelvic floor exercises (Kegel exercises) early after surgery to improve urinary incontinence symptoms. These exercises can help reduce leaking during activities such as coughing, sneezing, or lifting weights.
Common Side Effects of HoLEP
The most common side effects include:
- Temporary burning sensation and bleeding when urinating. It is also normal to see blood in the urine for up to three months after surgery. This usually indicates that you have not fully recovered after surgery.
- You may need to wear pads in your underwear for a few days because you may not be able to control urination. This usually improves after a few weeks. The long-term urine leakage rate is low.
- The risk of developing long-term urinary incontinence depends on several factors including age, prostate size, symptoms, and other medical conditions.
- Dry ejaculation: in 75% of cases, you will not see any liquid during ejaculation during sexual activity after surgery.
- Lack of semen during orgasm. There is usually no problem getting an erection.
What percentage of the prostate is removed in this surgery?
The amount of prostate removal depends on the size of the blockage or how much the prostate presses on the urethra. The surgeon usually removes about 50% to 60% of the total prostate volume.
What are the advantages of prostatectomy surgery using a holmium laser?
Prostatectomy with a holmium laser is a safe and effective procedure with a quick recovery period compared to similar surgeries. Although there are many procedures for the treatment of benign prostatic hyperplasia, prostatectomy with a holmium laser offers the following advantages:
- Surgeons can remove a large amount of prostate tissue without any incisions in the skin.
- Prostatectomy with a holmium laser is excellently effective in the treatment of a large prostate, but it is also effective with any prostate size.
- Short stay or no need to stay in the hospital.
- Reduced risk of bleeding and the need for blood transfusion.
- Reduced risk of the need for repeated further operations.
What are the risks and complications of prostatectomy surgery using a holmium laser?
Like most surgeries, prostatectomy surgery with a holmium laser carries some risks. The most common risks include:
- Injury to the prostate, urethra, bladder or ureters.
- Urinary incontinence that lasts more than three months.
- Infection in the bladder, testicles or kidneys.
- Risks of anesthesia, including blood clots, heart attacks or suffocation.
- The need for blood transfusion due to excessive bleeding.
- The need to use a catheter for more than 24 hours (prolonged catheter use).
About 5% to 15% of people discover that they have prostate cancer after surgery to remove the prostate using a holmium laser.
A prostatectomy with a holmium laser does not affect your ability to receive treatment for prostate cancer if you have it or develop it in the future. Less than 2% of people experience symptoms of urinary obstruction again and need a second surgery.
How long is recovery after prostatectomy surgery using a holmium laser?
You can walk and drive the day after surgery. Stressful activities (such as running, lifting heavy objects and others) should be avoided for at least two weeks, and activities that require a frequent sitting position (such as riding a bicycle, lawn mower, motorcycle, etc.) for six weeks.
Most people can return to work within one to two weeks. As for people with physically demanding jobs, they may need a longer period. Anything weighing more than 10 pounds should not be lifted for at least two weeks.
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