HoLEP- Diagnosis, Procedure, Benefits, Complications & Recovery

What is HoLEP surgery?

HoLEP, or Holmium Laser Enucleation of the Prostate, is a minimally invasive laser surgery for the treatment of lower urinary tract symptoms (LUTS) caused due to benign prostatic hypertrophy (BPH). It can be used to treat severe cases of BPH by removing entire sections of the prostate gland to ease the urinary symptoms.

What is BPH?

BPH, also known as benign prostatic hyperplasia, is the non-cancerous enlargement of the prostate gland. The prostate gland naturally enlarges in men due to hormonal changes. There are two main growth periods of the prostate gland- during puberty, when the gland doubles in size and after the age of 40, as the prostate gland gradually increases in size little by little. 

This is why prostate enlargement is very common among men. 50% of men between the ages of 51 and 60 have urinary problems due to enlarged prostate (or BPH) gland while more than 90% of men above the age of 80 exhibit symptoms of the condition.

How does HoLEP surgery work?

HoLEP surgery is performed using a modified resectoscope. The resectoscope for a HoLEP procedure has an attached camera lens, a light, and a laser device (instead of an electric loop). The surgeon inserts the resectoscope through the urethra and chips away the excess part of the prostate pressuring the urethra using a high-powered laser beam.

What are the indications and contraindications of HoLEP surgery?

What are the preoperative tests and procedures carried out before HoLEP surgery?

Before the surgery, the patient undergoes a thorough examination to evaluate the severity of their symptoms, their prostate size, etc. The diagnostic tests required for BPH diagnosis before HoLEP surgery are:

• Physical workup: The pre-operative workup for BPH includes a detailed medical history, along with a physical exam, including a digital rectal exam. For a digital rectal exam, the surgeon uses a finger to palpate and examine the size of the prostate gland.
• Laboratory tests: The patient is given a complete blood workup, including a PSA test and a urinalysis. PSA, or prostate-specific antigen, is a protein made by the prostate gland. If the level of PSA in the blood is too high, it may be indicative of prostate cancer.
• Transrectal ultrasound: A transrectal ultrasound helps to visualize and assess the prostate gland size and shape. It is more accurate than a digital exam and even helps assess the amount of urine retained by the bladder after urination.
• Cystoscopy: A cystoscopy is performed to examine the lining of the bladder and the urethra using a camera lens. It is especially necessary for repeat procedures to evaluate the amount of scar tissue present on the urethra, bladder, and prostate gland and to rule out urethral strictures.
• Urodynamics: Urodynamics is a series of tests that are performed to evaluate the functioning of the bladder, sphincters, and urethra and determine their ability to hold and release urine. It helps assess whether the urinary symptoms are due to prostate enlargement or other urinary problems.

Once the diagnostic tests are completed and the treatment procedure has been determined, the patient is given specific instructions such as:

• The patient cannot take any blood thinners for up to 10 days before the surgery to prevent hemorrhage during or after the surgery.
• The patient should not partake in any foods or drinks starting midnight before the day of the surgery.
• The patient should have a urine culture within 2-4 weeks of the surgery to minimize the risk of infection after the treatment.

What happens during a HoLEP surgery?

The steps during a HoLEP surgery are:

• HoLEP surgery can be performed under either general or local anesthesia, depending on the patient’s and surgeon’s preference. Once the patient is given anesthesia, they are laid in the proper posture for the surgery, i.e., on their back with legs raised.
• The modified resectoscope is inserted through the urethra. The surgeon then uses the laser to enucleate the enlarged prostate tissue through its capsule, i.e. to chip the extra prostate gland tissue through its outer layer.
• The incisions are sealed back using the laser itself to prevent bleeding and the removed prostate tissue is deposited inside the urinary bladder. 
• The resectoscope is removed from the urethra and is replaced by a morcellator, which is used to suction out the removed tissue from the urinary bladder. 

Once the procedure is complete, a catheter is placed inside the urethra to aid urination as the urethra may be swollen due to the surgery. It also helps flush out blood clots from the bladder after the surgery.

What happens after HoLEP surgery?

• Most patients are admitted to the hospital for overnight observation and catheter care. The patient may have a little bleeding after the surgery, but it usually resolves within 12 hours after the surgery.
• Patients are able to eat and drink without any complications on the same day as the surgery.
• If the amount of bleeding is normal and manageable, the catheter is removed and the patient is discharged within 24 hours after the surgery. Sometimes patients may need to be catheterized for up to 7 days after the surgery if there is too much swelling or if the patient is unable to urinate without the catheter.
• There may be a little pain and discomfort while urinating right after the surgery but it can be easily managed through pain medications and anti-inflammatories. Patients are also encouraged to drink more fluids during this period to help clear the blood more efficiently and quickly.

The urinary symptoms that were caused due to BPH may take a little while to resolve as the bladder and urethra readjust themselves to the reduced amount of prostate tissue.

What are the benefits of receiving HoLEP surgery over other treatments?

HoLEP surgery is one of the best and most effective treatments for benign prostate enlargement. As the entire surgery is performed entirely through laser, it is very safe and can even be used to treat severe cases of BPH with very few risks.

As there is very little bleeding in the surgery, the potential risk of heavy bleeding after the surgery is very low, which decreases the chances of the patient needing blood transfusions. HoLEP also necessitates a very short hospital stay and recovery period after the surgery. The recurrence rate of BPH after HoLEP surgery is also very low.

What are the after-effects of HoLEP surgery?

Common after-effects/side effects of HoLEP surgery are:

• Temporary bleeding and burning sensation during urination: They are not indicative of any serious problems and resolve on their own within a few days.
• Temporary urinary incontinence: It takes a little time for the urinary bladder muscles and strictures to get used to the reduced amount of prostate tissues, which makes it a little harder to control urination in the days following the surgery. 

You can also improve urinary control by performing pelvic floor strengthening exercises such as Kegel exercises.

• Retrograde/Backward ejaculation: In over 75% of the cases, the patient may experience dry orgasms for a few days after the surgery, i.e. there is no semen after ejaculation.
• Erectile dysfunction: Generally erectile function is not affected. In very rare cases, the patient may have erectile dysfunction for a little while.

What are the potential complications associated with HoLEP surgery?

• Injury to the surrounding structures such as the urinary bladder, prostate capsule, and urethra accompanied by extensive scarring
• Infection
• Recurrence of the condition
• Hemorrhage
• Prolonged catheterization due to extensive swelling in the urethra
• Complications associated with anesthesia

How long does it take to recover from HoLEP surgery?

After HoLEP surgery, most patients are discharged within 24 hours of the surgery. People with desk jobs can return to work within 3-4 days of the surgery, however, people who have to perform strenuous physical activity daily may need to rest for about 1-2 weeks before returning to work.

Tips to improve recovery after HoLEP surgery

• Avoid any strenuous activity for at least two weeks after the surgery
• Wait at least 2 weeks or get approval from your urologist before driving
• Maintain your fluid intake as it helps flush out blood from the operative site
• Eat healthy to avoid constipation during the recovery period
• Avoid caffeine as it increases the urge and frequency of urination
• Consult your prostate doctor before resuming sexual activity
• Perform kegel exercises and other pelvic floor strengthening exercises to improve urinary control after the surgery

If you notice any symptoms such as high fever, bleeding, abdominal swelling, persistent vomiting, chills, etc., contact your prostate surgeon immediately as they may be a sign of a serious postoperative complication.

Alternative treatments for prostate enlargement

Based on the severity of the urinary symptoms, size of the prostate gland, patient’s budget, insurance coverage, etc., there are a few other treatments that can serve as alternatives for HoLEP surgery for BPH.

These include TURP surgery, TUIP, TUMT, HoLVP, etc. However, among all these, HoLEP surgery is considered to be the best as it has a shorter hospital stay, fewer postoperative complications and a much quicker recovery period after the surgery.

Overall, HoLEP is among the safest and most recommended treatments for BPH patients.