HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HoLEP)

HoLEP is used for the surgical treatment of urinary symptoms which are due to enlargement of the prostate.

These symptoms may include:

• Waking through the night to urinate.
• Needing to pass urine frequently throughout the day.
• Having to pass urine urgently.
• Reduced urine flow.
• Difficulty starting urination.
• Stop-start flow.
• Dribbling after passing urine.
• A feeling of incomplete bladder emptying.

HoLEP is an option for you if:

• You take blood thinning medication and can not have a transurethral resection of the prostate (TURP)
• Your prostate is larger than 80gms and;
• You do not want to take or are unable to take medications for prostate enlargement (such as prazosin, tamsulosin, silodosin, dutasteride or finasteride)
• Medications are no longer working
• You are catheter dependent due to urinary retention
• You have complications of your enlarged prostate including blood in the urine (haematuria), bladder stones, kidney failure or recurrent urinary tract infections.

HoLEP is a treatment for benign prostate enlargement. It is not a treatment for prostate cancer.

HoLEP is performed under a general anaesthetic, through a telescope introduced into your bladder through your urethra.
A laser is used to core out the obstructing adenoma of the prostate leaving the outer zone of the prostate behind (much like coring out the flesh of an orange and leaving the outer rind behind).
A morcellator is then introduced to chew up the prostate tissue so it can be removed via the urethra.
There are no abdominal incisions involved in the procedure.
You will generally be in hospital overnight.
A catheter will be left in your bladder at the end of the procedure with irrigating fluid to wash out any blood overnight.
The catheter is removed the day after surgery and you will have a “trial of void” which tests your ability to urinate.

HoLEP usually requires a one night stay in hospital.

You may have some discomfort when urinating for a couple of weeks. Some patients experience transient urinary incontinence (leakage of urine). This however usually resolves by three months.

Intermittent blood in the urine can occur.

Retrograde Ejaculation (ejaculate goes into the bladder rather than out) occurs > 80% of the time.

You can return to sedentary work approximately 4-5 days after the operation. If your job involves physical work, please discuss this with your doctor.

Avoid lifting more than 10kg for 2 weeks following surgery

Avoid constipation and straining on the pelvic floor.

It is usually safe to drive 48-72 after the procedure.

We strongly recommend you see a pelvic floor physiotherapist to learn pelvic floor muscle exercises prior to your HoLEP and commence these once your catheter has been removed.

Avoid sexual activity for two weeks.

Treatment of large glands (>80 grams) through an endoscopic technique – avoiding abdominal incisions.
Size independent treatment option for an enlarged prostate (BPH).
Short catheter duration (1-2 nights vs 7-10 days with an open or robotic procedure)
Shorter hospitalization than TURP or Simple Prostatectomy (open or robotic).
Low risk of bleeding or blood transfusion compared to a standard TURP.
Low/No risk of TUR Syndrome compared to TURP.
Ability to treat any stones in the bladder at the same time with the holmium laser.
Low long term retreatment rate (<4% at 10+years) compared to TURP (12-15% at 10 years).
A tissue sample is sent to pathology to be tested for cancer.

Very common risks (Most patients)

• Transient urinary frequency, burning and stinging
• Blood in urine intermittently.
• Retrograde ejaculation. 

Occasional risks (1/10 – 1/50)

• Transient urinary incontinence.
• Transient reduction in erectile function (normally resolves if good sexual function prior to surgery).
• Urinary tract infection.
• Inability to urinate after the catheter is removed following surgery, requiring the catheter to be reinserted.
• Failure of your urinary symptoms to improve.
• Worsening of “storage symptoms” (including frequency, urgency and nocturia) requiring further medication.
• Scarring of the urethra (urethral stricture) or bladder neck (bladder neck contracture) requiring further surgery.

Rare risks (1/50 – 1/250)

• Injury to the ureters.
• Injury to the bladder during morcellation – requiring open operation to repair or prolonged catheter for 10-14 days.
• Significant bleeding requiring a blood transfusion.
• Inability to complete the operation endoscopically or with laser which requires conversion to TURP or an open incision or delayed morcellation on another day.

 Theoretical risks

• Erectile dysfunction.
• Rectal injury.

The risks of anaesthesia have not been listed here.

• Surveillance – no treatment.
• Lifestyle changes.
• Medication.
• Open simple prostatectomy.
• Robotic simple prostatectomy.
• Prostate artery embolization.
• Transurethral resection of the prostate.

1. Guideline Statement 5.3.3, Management of Non-neurogenic Male LUTS, European Association of Urology Guidelines.

2. Guideline Statement 21, Benign prostate hyperplasia: Surgical Management of Benign Prostate Hyperplasia/Lower urinary symptoms

3. Holmium laser enucleation of the prostate for very large benign prostate hyperplasia (<200cc3)

4. Holmium laser enucleation of the Prostate – Outcomes independent of size?

5. Editorial: HoLEP is the complete technique for treating BPH.

6. Treating BPH: Comparing HoLEP, Rezum, Urolift and Aquablation.