HoLEP: Holmium Laser Enucleation of the Prostate

HoLEP stands for holmium laser enucleation of the prostate. It is a surgical treatment for men whose urinary symptoms are caused by an enlarged prostate, a common condition also called benign prostatic hyperplasia, or BPH.

The prostate sits just below the bladder and wraps around the urethra, the tube that carries urine out of the body. As the prostate grows, it can squeeze that tube and make it harder to empty the bladder. That is what causes symptoms like a weak stream, straining, dribbling, getting up several times at night, or feeling like the bladder never fully empties.

During HoLEP, your surgeon uses a laser to separate the inner portion of the prostate — the part pressing on the urethra — from the outer shell, and then removes it. Think of it as coring out the inside of an orange and leaving the peel intact. The result is a wide-open channel for urine to pass through.

HoLEP is done through the urethra. There are no incisions on the outside of the body.

One of its main advantages is that it works well regardless of how large the prostate is. Many other procedures are best suited to smaller prostates, and men with very large glands were historically offered open surgery. The American Urological Association’s BPH guideline lists HoLEP as a size-independent option that clinicians should consider for men with these symptoms.

Because the obstructing tissue is removed rather than just shrunk, trimmed, or held open, results tend to last. Studies following patients for ten years or more have shown lasting improvement in symptoms and urine flow, with a low rate of needing another procedure later.

HoLEP is often a reasonable choice for men who:

• Have a large prostate
• Have not gotten enough relief from medication, or want to stop taking it
• Are in urinary retention and dependent on a catheter
• Have had repeated urinary tract infections, bladder stones, or bleeding related to the prostate

Your urologist will talk with you about how HoLEP compares to other options, including medication, TURP, and less invasive in-office procedures. Every option has trade-offs, and the right choice depends on your prostate size, your symptoms, your other health conditions, and what matters most to you.

You will be asleep under general anesthesia, or numb from the waist down with spinal anesthesia. Your care team will discuss which is right for you.

A thin scope is passed through the urethra so the surgeon can see the prostate. The laser is used to peel the inner prostate tissue away from the outer capsule and to seal blood vessels as it goes, which keeps bleeding low. The freed tissue is pushed into the bladder, then a second instrument breaks it into small pieces and suctions them out.

The tissue that is removed is sent to the lab and examined for any sign of prostate cancer. This is routine, and it is one benefit of a procedure that removes tissue rather than destroying it in place.

The operation usually takes somewhere between one and three hours, depending mostly on the size of the prostate.

A catheter is placed at the end of surgery to drain the bladder and to flush it with sterile fluid while any minor bleeding settles. The catheter is removed the day after surgery. You may stay overnight or go home after the procedure depending on your surgeon’s preference.

The first week or two. It is normal to see blood in the urine on and off, and to feel burning or urgency when you urinate. You may need to get to the bathroom quickly, and some men leak a little urine at first. This is common and usually temporary. Drinking plenty of water and avoiding heavy lifting and strenuous activity for the first few weeks helps.

Bladder control. Most men regain full control, but it can take weeks to a few months for the bladder to settle down after years of working against a blockage. Pelvic floor exercises help, and your care team can show you how to do them. A small number of men have longer-lasting leakage.

Getting back to normal. Most men notice a stronger stream soon after the catheter comes out, with symptoms continuing to improve over the following weeks. If there is no blood in your urine after 2 weeks, there are no restrictions.

No surgery is without risk. The ones to discuss with your urologist include:

• Retrograde ejaculation. After HoLEP, semen usually travels backward into the bladder instead of out through the penis. This is expected in most men and is not harmful, but it does affect fertility. It does not cause erectile dysfunction, and HoLEP is not generally expected to change your ability to get an erection.
• Temporary burning, urgency, and leakage, as described above.
• Bleeding. Serious bleeding is uncommon with HoLEP, but a small number of men need a return trip to the operating room or, rarely, a transfusion.
• Urinary tract infection.
• Scar tissue in the urethra or at the bladder neck, which can narrow the channel and occasionally needs a minor procedure to correct.
• Ongoing bladder symptoms. If the bladder has been overworked for a long time, urgency and frequency may persist even after the blockage is relieved.

If you are dealing with urinary symptoms from an enlarged prostate, we can review your options and help you decide whether HoLEP makes sense for you. Call us at 704-752-3730.