Prostate Enucleation with Holmium Laser (HoLEP)
When is this procedure indicated?
Enucleation of prostate adenoma with Holmium laser (HoLEP) consists in the surgical treatment with endoscopic approach of benign prostatic hyperplasia (BPH) with cervical-urethral obstruction and consequent dysuric symptoms during emptying and/or filling. Compared to TURP, this procedure can also be used in patients with larger prostate volume.
How is it performed?
Holmio laser enucleation of prostate adenoma (HoLEP) is performed under locoregional or general anesthesia according to the judgment of the anesthesiologist. This surgical technique is used to remove the inner portion of the prostate (the so-called prostate adenoma) leaving the outer prostate capsule in place. This method involves the use of an endoscopic instrument introduced inside the urethra up to the level of the prostatic loggia. The procedure takes about 1 hour and involves the use of laser technology (Holmium laser) to enucleate (remove completely) the inner portion of the prostate. Subsequently, the enucleated adenoma is reduced into frustules (morcellation), aspirated outside the bladder and sent to Pathology for histological examination. In cases of very bulky prostates (>200 grams) it may be necessary to make a small abdominal median suprapubic incision and, through a cystostomy, manually remove the endovesical prostate lobes previously enucleated. This occurs in about 2% of cases. This does not lead to any anatomical or functional consequences, but it may be necessary to maintain the bladder catheter for a longer period (usually 3-4 days).
At the end of the surgery a bladder catheter is placed for a period usually varying from 1 to 3 days unless complications occui.
The hospitalization has a variable duration generally conditioned by the days of permanence of the bladder catheter, usually from 1 to 3 days. Once the catheter is removed, resumption of spontaneous urination may be characterized by the presence of bloody urine and the need to urinate frequently (usually this situation improves considerably during the first postoperative month).
- Transient dysuric symptoms (burning on urination).
- Transient stress urinary incontinence. Present when abdominal pressure increases, such as during a cough or when lifting weights.
- Acute urinary retention on bladder catheter removal.
- Postoperative fever for urinary tract infection.
The most common long-term complication in patients undergoing this type of surgery is retrograde ejaculation. This condition, which occurs in about 90% of cases, consists in the disappearance of seminal fluid discharge during orgasm, while maintaining orgasmic sensitivity and erectile function. Seminal fluid collected in the bladder is subsequently expelled with the first urination. The rest of the long-term complications consist of rare events and are essentially represented by:
- Stenosis of the urethra or bladder neck with need for re-intervention.
- Definitive urinary incontinence.