HoLEP surgery: A modern solution for enlarged prostates
Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive surgical procedure that permanently removes the obstructing part of an enlarged prostate using a laser, offering a highly effective alternative to traditional open surgery with shorter recovery times.
Mr Harshawardhan Godbole, leading consultant urological and laparoscopic surgeon practising in central, north, and east London, discusses HoLEP in expert detail.
What exactly is HoLEP surgery?
HoLEP is a technique where a surgeon uses a high-powered laser fibre inserted through the urethra to precisely peel away the enlarged inner portion of the prostate gland. Unlike older methods that cut or burn tissue, this method enucleates, or shells out, the entire adenoma in one go, which is then removed and fragmented inside the bladder. This approach is considered the "gold standard" for very large prostates because it leaves no residual tissue to cause future blockages.
Precision of the laser allows for complete removal of the obstruction while sparing the surrounding sphincter muscles, which is crucial for maintaining urinary continence after the operation.
How does HoLEP differ from other treatments?
The primary difference lies in the durability and effectiveness of the outcome compared to medication or less invasive therapies like TURP (Transurethral resection of the prostate). Medications often lose their efficacy over time or fail to manage severe symptoms, whereas HoLEP provides a permanent solution by physically removing the problematic tissue. Traditional TURP can be risky for larger glands due to bleeding and fluid absorption issues, but HoLEP effectively handles prostates of any size with minimal blood loss.
According to recent clinical data, patients undergoing HoLEP experience a significantly lower rate of re-operation compared to those having TURP. Studies indicate that less than 1 per cent of HoLEP patients require a second procedure within ten years, demonstrating its long-term reliability. The laser also coagulates blood vessels simultaneously, making it safer for patients on blood-thinning medications who aren’t able to stop treatment before surgery.
What are the immediate benefits for patients?
Patients benefit from a much quicker hospital stay and faster return to normal daily activities compared to traditional open prostate surgery. Most individuals are discharged within 24 hours if there are no complications, provided they pass urine successfully after the catheter is removed. The risk of significant bleeding is low, meaning transfusions are rarely required even in complex cases involving very large glands.
Common improvements observed post-surgery include:
- A dramatic increase in maximum urine flow rates, often doubling pre-operative levels.
- Near-total resolution of night-time urination (nocturia), allowing for uninterrupted sleep.
- Significant reduction in the urgency and frequency of bathroom visits during the day.
- Elimination of the need for lifelong medication to control benign prostatic hyperplasia (BPH) symptoms.
What should you expect during recovery?
Recovery involves managing temporary discomfort and monitoring the urine as the bladder heals from the trauma of tissue removal. Patients will typically have a catheter for one to two days post-procedure to allow the bladder to rest and to clear any blood clots. During this time, drinking plenty of water helps flush the system and prevents clot retention, which is a common minor complication.
It's normal for urine to appear pink or red for up to three weeks following the surgery. Patients should avoid heavy lifting and strenuous exercise for about two weeks to prevent secondary bleeding. By six weeks, the vast majority of men report full functional recovery and a substantial improvement in their quality of life, with many describing the result as life-changing compared to their previous state of chronic obstruction.
References
- American Urological Association. AUA Guideline: Surgical Management of Benign Prostatic Hyperplasia. 2023 Update.
- NICE Guidelines. Transurethral microwave thermotherapy and laser prostatectomy for the treatment of lower urinary tract symptoms caused by benign prostatic obstruction. NG115. National Institute for Health and Care Excellence, 2020.
- Gilling P, et al. "Long-term results of holmium laser enucleation of the prostate for the treatment of benign prostatic hyperplasia." Journal of Endourology, 2019.
- British Association of Urological Surgeons (BAUS). Patient Information: Laser Surgery for an Enlarged Prostate. 2024.
- Cornford P, et al. "EAU Guidelines on the Treatment and Follow-up of Non-neurogenic Male Lower Urinary Tract Symptoms Including BPH." European Urology, 2023.
