Holmium Laser Enucleation of the prostate (HoLEP) is a modern alternative to the standard Transurethral Resection of the Prostate (TURP) procedure for bladder outflow obstruction due to BPH. It requires a short period of hospitalisation and an anaesthetic. A catheter (a tube which drains the bladder) is also needed for 1-2 days until the urine clears. Patients are advised to take life quietly and to avoid straining or heavy lifting for four weeks after the surgery.

Who is it suitable for?

HoLEP can be performed on men of any age with urinary outflow obstruction caused by an enlarged prostate. It is particularly indicated in men with large prostates (over 60mls in size) and men on medications to thin the blood such as warfarin, aspirin or clopidogrel.

What are the advantages of HoLEP

There is no upper size limit of prostate that can be dis-obstructed – traditionally men with prostates over 100ml in size needed major open surgery

• There is often less bleeding than after a TURP
• Discharge is often quicker than after TURP at 1-2 days
• The chance of recurrence requiring further surgery is very low
• Unlike greenlight laser operations, large quantities of prostate tissue are sent for pathological analysis
• The PSA generally drops to very low levels after HoLEP operations

How does it work?

The aim of HoLEP is to relieve pressure on the tube through which the urine drains (urethra) by anatomically enucleating the majority of excess benign prostate tissue. This is done under a general anaesthetic with the help of a telescopic camera inserted through the penis. The three lobes of the prostate that are cored out intact are pushed into the bladder before being sucked up (morcellated) by a special instrument inserted through the telescopic camera. The pieces are sent for laboratory analysis just in case they might be found to be cancerous. A catheter is placed into the bladder to drain the urine while the raw surface heals, then left in place for around 24 hours before being removed on the day of discharge from hospital. Sterile saline fluid is also irrigated into the bladder through the catheter to dilute any blood in the urine and prevent clots from forming.

It is normal to have some blood in the urine after this operation, so it is advisable to drink plenty of water for a few days while it clears. Clots are sometimes passed 10-14 days afterwards; again, this is part of the healing process.

Apart from this and the risk of infection that accompanies any operation or invasive procedure, the only significant side-effect is the near certainty that normal ejaculation will cease. This is because the contraction that occurs during orgasm may not completely block the entrance to the bladder once some tissue has been removed, and the semen will flow back into the bladder (“retrograde” or “dry” ejaculation) rather than out through the penis. This is not harmful, but it does mean that future fertility is greatly reduced. The procedure does not generally affect erectile function or continence, although the urinary symptoms may take a few weeks to settle down afterwards.

Credit: The Prostate Centre