Holmium Laser Enucleation of the Prostate

(HoLEP)

Holmium Laser enucleation of the prostate, or HoLEP, is a highly effective procedure for many patients suffering from moderate to severe benign prostatic hyperplasia (BPH). It is just one of the many treatment options experienced urologic practices like Georgia Urology offer.

Key Points About HoLEP

A minimally invasive procedure that does not require incisions in the abdomen or groin
It is ideal for patients with larger prostates – over 80 grams, but effective for all sizes.
Uses laser energy to cut out a significant portion of the pulp of the prostate
Performed under general anesthesia in a hospital setting.
Straightforward recovery with no overnight stays for most patients, less than 24 hours duration catheter placement, and mild, manageable symptoms for up to three weeks.
Some relief is expected immediately, with full results at about 3 months and lasting for around 10+ years.

Understanding BPH

To appreciate a treatment like HoLEP, it’s important to understand BPH first. BPH, or benign prostatic hyperplasia, refers to the excessive growth of prostate cells, which often causes lower urinary tract symptoms (LUTS). Imagine the prostate as a walnut-shaped gland wrapped around the urethra, the tube through which urine passes. As this gland grows, it presses on the urethra, slowing the urinary stream. Men with symptomatic BPH commonly experience a weak urine stream, incomplete emptying, urgency, frequency, and waking up multiple times at night to urinate.

If left untreated, the obstruction caused by an enlarged prostate can lead to urinary retention, which increases the risk of bladder and kidney failure. Even before reaching that stage, severe BPH can significantly raise the chances of overactive bladder, urinary tract infections, kidney stones, and bladder stones.

Comprehensive Treatment for BPH

Experienced practices like Georgia Urology offer a wide range of BPH procedures that can be performed in the office, a surgery center, or a hospital, depending on the patient’s needs and prostate size. HoLEP is an excellent choice for all prostates, including large prostates (over 80 grams) or patients with unusual anatomy, such as a large bladder neck.

The HoLEP procedure, performed under anesthesia, requires around three hours of operative time. During the procedure, a catheter is inserted into the urethra up to the level of the prostate. A specialized laser fiber is deployed, and holmium laser energy (holmium: yttrium aluminum-garnet (Ho: YAG)) is then used to remove much of the adenoma or internal tissue of the prostate – this is the excess prostatic tissue causing symptoms – relieving the obstruction and allowing urine to flow freely. Think about removing the pulp from an orange but keeping the skin.

At the end of the procedure, much of the prostatic tissue is removed from the body, at which point it is sent to pathology to check for possible signs of prostate cancer. A small percentage of patients will come back positive for prostate cancer, but rest assured that BPH does not cause this. Instead, these conditions can manifest concurrently. Fortunately, most cases of prostate cancer are low-grade and may only require active surveillance. Some patients who wish to treat their low-grade prostate cancer may benefit from a new and exciting procedural option known as NanoKnife. Higher-grade cancers can be treated with one of the many effective therapeutic options available today.

Since much of the prostatic tissue is cut away, patients immediately notice improved urination.

If this sounds like a simple prostatectomy, you would be correct. Both procedures are suitable for patients with larger prostates, and both cut away significant amounts of prostatic tissue safely and effectively. However, HoLEP does not require external cuts to access the prostate.

Georgia Urology Doctors Performing HoLEP

Kanika Searvance, MD, is a leading urologic surgeon in the Atlanta area. She specializes in treating BPH using HoLEP surgery. In her words, “HoLEP is a tried-and-true technology for all prostates, including larger prostates. that has been around for over 2 decades. While it does not have the visibility that many newer BPH procedures do because of the marketing behind them, it remains an exceptionally effective and safe procedure for men with severe BPH. It should be a consideration for any patient with significant prostatic enlargement.”

What Does Recovery Look Like?

Patients are either sent home same day, or kept overnight at the hospital for observation and may need a catheter for a day or two. They should have someone available to help them with their early recovery, including driving them home from the hospital.

Most patients will see blood in their urine for a few days to a week or two. Some may also see small pieces of tissue or scabs during urination. This may be accompanied by a burning sensation, which is managed using medication you may need to take for a week after surgery. You may also be instructed to take antibiotics for some time after the procedure.

Over the next several weeks, as bladder function adjusts to the reduced obstruction, patients experience progressively better urination. The full benefits of HoLEP are usually felt around three months after the procedure and can last for ten years or more.

Considerations for the HoLEP Procedure

The patient’s response to anesthesia is the most critical consideration for any surgical procedure. Patients undergoing HoLEP may undergo cardiovascular and pulmonary evaluations to ensure they are good candidates for surgery.

While the holmium laser is effective for most enlarged prostates, it’s typically recommended for larger prostates. Prolonged obstruction from BPH can cause bladder concerns, and some patients may continue experiencing lower urinary tract symptoms post-procedure—not due to the obstruction but rather residual bladder irritation, which generally resolves within three months.

Another consideration is retrograde ejaculation, a common side effect of HoLEP. This occurs when semen flows backward into the bladder during ejaculation instead of exiting through the urethra. For most BPH patients, especially those not planning to have children, this is not a significant concern. However, younger patients or those wishing to preserve ejaculation should consider other options, such as Aquablation, which uses a targeted water jet instead of heat, or robotic simple prostatectomy, a minimally invasive surgical procedure.

FAQ

Can You Have HoLEP After a Minimally Invasive BPH Procedure?

The answer is yes. For patients who do not achieve sufficient relief from conservative therapies like Rezum or UroLift, HoLEP remains an option. Its flexibility makes it a reliable solution even for those who have tried other minimally invasive BPH procedures without success.

Does HoLEP cause Significant Bleeding?

Like other BPH procedures, bleeding is very common after a HoLEP. Patients with bleeding disorders or who are taking anticoagulant medication should speak to their urologist to learn how to manage bleeding before and after the procedure. However, with improvements in technique and technology over the past few decades, bleeding issues have become less problematic. It is considered first line treatment for patients on blood thinners, due to the hemostatic capabilities of the laser.

The Bottom Line

We always counsel our patients to seek treatment for their BPH as early as possible to enjoy the benefits of less invasive and complex BPH treatments. However, if the prostate has grown very large, HoLEP is an excellent option to discuss with your urologist. As with all the BPH procedures we offer at Georgia Urology, HoLEP is a safe and effective option for selected patients.

If you are experiencing any lower urinary tract symptoms, we encourage you to make an appointment online with our self-service appointment system.