HOLEP Surgery: Holmium Laser Enucleation of the Prostate

Benign prostatic hyperplasia (benign prostate hyperplasia, BPH) is one of the most common urological diseases in elderly men. Medication is helpful in the initial phase, but over time, drugs do not help and surgery is required. HoLEP surgery has been widely used in the surgical treatment of BPH in recent years. In this article, I will talk about the HOLEP method.

What is HOLEP surgery?

HOLEP is a benign prostate enlargement surgery performed with a laser. As an abbreviation, HOLEP is the abbreviation of the phrase “Holmium Laser Enuclation of Prostate” (removal of the enlarged part of the prostate using a holmium laser). It is also known as “endoscopic prostate surgery with laser” among the people.

HOLEP surgery is currently accepted as the “gold standard treatment method” in the treatment of prostate enlargement. We are the first clinic in Istanbul to purchase the special HOLEP device and perform this surgery (HOLEP Istanbul).

Preoperative Urological examination

Patients who will undergo HoLEP treatment are first subjected to a detailed urological examination. To this end:

• Prostate examination is done from the anus with fingers
• Prostate cancer must be differentiated.
• The size (weight) of the prostate should be determined.
  • PSA (prostate specific antigen) test should be done, if it is high, further research should be done in terms of cancer. For this purpose, multiparametric MRI and prostate biopsy should be performed according to the result.
  • Kidneys and bladder should be evaluated: Information about kidneys and bladder can be obtained by performing ultrasonography and kidney function tests.
  • If necessary, tests showing bladder functions such as urodynamics may be ordered.
  • Uroflow test showing the urine flow gives an idea about the urine flow.
  • Determination of residual urine after micturition in the bladder: Normally, there should be no urine left after urinating in the bladder, but if there is an obstruction, urine will remain in the bladder in varying degrees.
  • Urinalysis should be done: If there is an infection, it should be treated with appropriate antibiotics before surgery.

Preparation before HOLEP surgery, what should be done?

Patients who will undergo HOLEP surgery undergo a general evaluation before surgery. For this purpose, patients are asked for routine blood tests, where:

• Liver-kidney function tests are requested
• Whether bleeding and coagulation tests are normal,
• Routine blood count is done, blood group is determined. If the blood values ​​are insufficient, the patient is made suitable for anesthesia by giving blood beforehand.
• Lung X-ray
• ECG is taken to find out whether the lungs and heart are normal, and if necessary, necessary precautions are taken in advance.
• If an anesthesiologist deems it necessary, consultations are requested from the relevant departments for patients with chronic problems such as heart-lung or diabetes, and necessary treatments are performed according to the recommendations received from these departments.
• If patients are taking blood thinners before, they are usually stopped one week before surgery or replaced with more suitable ones.
• If patients are using diabetes medication, blood pressure medication or chronic medication due to neurological disorders, it would be beneficial for the anesthesiologist to know these before the operation. It is recommended to take blood pressure and diabetes medications in the same way. Or other drugs may need to be discontinued before surgery.
• Patients are hungry after 24.00 at night before the surgery, they do not eat or drink anything by mouth (at least 5-6 hours before the surgery).
• If there are blood pressure and diabetes medications that he used before, they are used in the same way if deemed appropriate by the relevant specialist or anesthesiologist.
• Before the operation, sedative drugs can be given to the patients to relax and enter the operation without stress.
• Daily hospital clothes (slippers, pajamas, etc.) to be used before coming to the hospital are provided,
• After the pre-operative identity check and hospitalization, an “informed consent form” regarding the operation is signed,
• It is recommended to have as few visitors as possible, short visits and only one accompanying person.

How is HOLEP surgery performed?

The HOLEP method is a procedure performed by entering the urethra with special endoscopic instruments (optical and illuminated system) and pushing the parts of the prostate (adenoma) that press on the urethra (urinary canal) from the capsule (prostate membrane) by laser and pushing them into the bladder, and then separating the prostate pieces into very small pieces with a system called morcellator. is surgery. In this system, there are no incisions or surgical scars in the body.

Technically, HOLEP surgery is performed with 3 main methods, these methods are:

• Removal of the prostate in three parts (Three lobar prostatectomy): With this method, an incision (incision) is made from the urethra to the prostate capsule, starting from the bladder side at the 5 and 7 o’clock positions in the prostatic urethra by entering the urethra, and cooling down to the lower part of the prostate called the verumontanum. Then the middle, right and left prostate lobes are separated from the capsule (dissection) to the bladder. In this method, the prostate is dissected from the capsule in 3 parts (separation from the prostate capsule) and pushed into the bladder, it is called “three lober prostatectomy” in English (in 3 parts). These pieces, which are thrown into the bladder, are then taken out in very small pieces with a device called a “morcellator”.
• The second method is “two lobar prostatectomy”: In this method, the enlarged prostate adenoma is separated from the prostate membrane in 2 pieces and thrown into the bladder, and from there it is fragmented with a morcellator and taken out.
• Another method is “en block prostatectomy” (separating the enlarged prostate adenoma from the prostate capsule and throwing it into the bladder).

All three methods have no superiority or advantage over each other. The procedure is exactly the same. The choice is all about the surgeon’s habit.

Are surgically removed parts sent to pathology?

HOLEP is not a prostate cancer surgery, although it is very unlikely, all surgically removed parts are sent to pathology in case of cancer.

What is the type of anesthesia, length of hospital stay, and length of catheterization?

Patients who will undergo HOLEP surgery are given general anesthesia or spinal anesthesia (numbing from the waist down). The probe remains in the patient for 1 or 2 days.

What are the advantages of HOLEP surgery?

There are prostate TUR, plasmakinetic, rectum surgeries and open prostate surgery similar to HOLEP surgery, but HOLEP surgery has many advantages over these surgeries. Due to these advantages, this method in the surgical treatment of benign prostate enlargement is currently considered as the “gold standard treatment method”. In other words, it is a surgical method with the best effectiveness and the least side effects. It is possible to list the advantages of HOLEP surgery (advantages over other surgeries) as follows;

• Bleeding is less with HOLEP compared to other methods
• After HOLEP surgery, patients stay in hospital less and are discharged earlier.
• Postoperative patients return to their normal lives earlier
• Patients remain less catheterized after the procedure
• More prostate tissue is removed in the surgery performed with this method.
• Since more prostate tissue is removed, the probability of catching prostate cancer is higher as a result of the examination of the removed parts.
• With this method, there is no recurrence rate of the prostate, it is extremely low.
• “TUR syndrome” seen in TUR surgery is not seen in HOLEP surgery
• Post-operative sexual functions are not affected by the laser method. Because laser energy does not penetrate very deeply, damage to the erectile nerves of the penis is less likely. However, in other methods, various degrees of sexual dysfunction are seen.
• It can be applied to prostates of all sizes.
• With this method, postoperative bladder neck stenosis is less common than other methods.

Due to all these advantages, the HOLEP method is accepted as the “gold standard” treatment method in the treatment of benign prostate.

Does HOLEP surgery affect sexual functions negatively?

Since the laser energy used in the HOLEP method penetrates to a depth of 0.4 mm, there is no negative effect on the nerves passing outside the prostate and adjacent to the prostate capsule, and as a result, erection problems are not seen in HOLEP patients.

Retrograde ejaculation (retraction of the semen) is seen in all prostate surgeries. It is possible to reduce this situation by applying some protective methods in HOLEP surgery, but it is not a hundred percent guarantee.

What is the price of HOLEP surgery?

The cost of HOLEP is slightly higher than other methods, the reasons for this are:

• Expensive equipment and consumables used
• It can’t be done in every hospital, it can be done in certain centers.
• Long learning curve
• Reasons such as the limited number of people who are trained and do this job.

Matters that patients should pay attention to after surgery

We can list some of the points that patients should pay attention to after the surgery as follows;

• After the surgery, patients are kept in the operating room for 20-30 minutes until they feel well, then they go to their room.
• Patients are not given oral food or drink for 4-5 hours after the operation. During this period, only serum is given intravenously.
• Pain reliever and antibiotic prophylactic treatment against infection is started (intravenously or by injection) to relieve the patient’s pain.
• After 5 hours, the patient is evaluated and if there is no problem, he starts to take water and watery foods by mouth, gets up slowly and walks. If he has received spinal anesthesia, he will be able to walk later.
• On the first day after the operation, the patient is evaluated, the vascular access is cut, oral nutrition is started, and the drugs are given orally in the form of pills instead of the veins.
• Patients are advised to drink plenty of water after starting to take it orally. Drinking at least 2-3 liters of fluid per day is beneficial, in this way the color of the urine becomes lighter and there is no bleeding inside.
• If the general condition of the patients is good and there is no problem in the urine, they are discharged on the first or second day.
• Painkillers and antibiotic treatment are started for the discharged patients to take them orally.
• We usually pull the urinary catheter on the 2nd day, if the patients also have urethral stricture and it has been treated, or sometimes in oily patients, the catheter can be removed in the later days.
• After 2 weeks, the patients are called for control, and then the patients are evaluated at regular intervals.

In summary; HoLEP surgery is the most effective and the most effective surgical method in the surgical treatment of benign prostate enlargement (BPH). There is no recurrence after the surgery, sexual functions are not affected. It is the gold standard treatment method in the treatment of BPH. We have been successfully performing HOLEP surgery for a long time and our results are quite successful.

To get more information about HOLEP surgery, you can get more information by visiting mail or phone.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul-  TURKEY

You can make an online appointment with our doctor via the panel below.