Holmium Laser Enucleation of the Prostate (HoLEP)

This card explains what holmium laser enucleation of the prostate, known as HoLEP, is and what health bodies say about how it is done, recovery and risks. It is meant for patients, families and students. Individual plans differ, and the treating urologist decides what is suitable in each case.

What it is

HoLEP is a treatment for benign prostatic hyperplasia (BPH), in which the prostate grows larger than usual and presses on the urethra, the tube that carries urine out of the body. Mayo Clinic describes it as a minimally invasive procedure that uses a laser to remove prostate tissue so urine can flow freely. The British Association of Urological Surgeons (BAUS) explains that a telescope passes through the urethra and the laser peels the central part of the gland away from its surrounding capsule, leaving a wider channel.

Cleveland Clinic says HoLEP was developed in the 1990s and involves no cuts in the skin. The glossary defines related terms, and TURP is a related operation that uses an electrical loop and is often compared with HoLEP.

Why it is done

Mayo Clinic says HoLEP is used to improve urinary symptoms of BPH, including a frequent need to urinate, difficulty emptying the bladder, a slow stream, infections and night-time urination. It may be recommended if a person cannot empty the bladder fully, has bladder stones, kidney failure or blood in the urine that does not improve, gets infections often, or has not improved on medicines.

Not everyone with BPH needs surgery. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says BPH can be managed with watchful waiting, medicines, minimally invasive therapies or surgery, and BAUS lists observation, medicines, catheters and other procedures as alternatives to HoLEP. The bladder and prostate procedures page compares the options in this drawer.

How it is done, in outline

Cleveland Clinic says HoLEP is generally done under general anesthesia, with spinal anesthesia used if general is not possible. The surgeon passes a resectoscope, a scope with a camera, through the urethra and uses the laser to separate the obstructing tissue and seal blood vessels. The freed tissue falls into the bladder.

A tool called a morcellator then chops the tissue into smaller pieces and suctions them out, and BAUS says the pieces are sent to a laboratory for analysis. Cleveland Clinic gives a typical operating time of one to three hours, and BAUS says about two hours on average depending on prostate size. A catheter is placed at the end, and fluid is usually flushed through it for a short time to clear blood and clots.

Recovery

Mayo Clinic says some people go home after the procedure while others stay overnight, and the catheter is usually taken out a day or two later. BAUS says one night in hospital is usual. If a person cannot pass urine after the catheter comes out, BAUS says a catheter is temporarily replaced to let swelling settle. See urinary catheters after surgery for general catheter care.

Urination may be painful and more frequent at first. Cleveland Clinic says blood in the urine can persist for several weeks, burning for several weeks, and urgency or night-time urination may take several months to settle. The same source says walking is possible from the day after surgery and suggests avoiding strenuous activity for at least two weeks. BAUS notes that some people have bleeding two to three weeks later when scabs separate, and that most need two to three weeks at home before returning to work.

Leaking can occur early because the laser removes a lot of tissue. BAUS says urinary control often improves as the pelvic floor muscles recover and recommends starting pelvic floor exercises as soon as possible. The pelvic floor muscle training card covers these exercises, and recovery and rehabilitation offers wider guidance.

Risks

Mayo Clinic lists bleeding (with a risk lower than traditional surgery), trouble urinating right after the procedure, leaking urine, infection, retrograde ejaculation and narrowing of the urethra. Retrograde ejaculation means semen flows backward into the bladder. Sources give different figures for how often it occurs: Cleveland Clinic says about three in four people, while BAUS says about nine in ten.

Cleveland Clinic also lists injury to nearby structures, anesthesia risks and the need for a transfusion, and notes that the tissue removed may show previously unknown prostate cancer. Mayo Clinic advises getting medical help right away for lightheadedness, fever, chills, or bleeding thick enough to block urine flow. Cleveland Clinic adds passing clots, a fever above 101 degrees Fahrenheit (38 degrees Celsius), pain that does not ease with medication, or being unable to urinate.

Questions to ask your clinician

• Is HoLEP suitable for the size of my prostate, and how does it compare with TURP for me?
• Which anesthesia will be used, and will I stay overnight?
• How long should I expect to have a catheter, and what happens if I cannot pass urine afterward?
• How likely is leaking, and how can I prepare my pelvic floor muscles?
• Will my ejaculation change, and does that matter for my plans?
• Do I need to stop blood thinners or other medicines before surgery?
• Will the removed tissue be tested, and how will I receive the results?