Laser prostatectomy (HoLEP): a modern approach to prostate surgery

Holmium laser enucleation of the prostate (HoLEP) is an advanced surgical technique used to treat men with urinary problems caused by prostate enlargement. As a minimally invasive procedure, HoLEP offers a number of advantages over traditional surgery. In this article, a consultant urologist gives us an overview of HoLEP, how it works, and what patients can expect before, during, and after treatment.

What is HoLEP?

HoLEP stands for holmium laser enucleation of the prostate. It is a type of laser prostatectomy that uses a high-powered laser to precisely remove obstructing or overgrown tissue from the prostate. The procedure is carried out through the urethra so there are no external cuts or incisions.

HoLEP is primarily used to treat benign prostatic hyperplasia (BPH), which is a non-cancerous enlargement of the prostate. BPH is a very common condition in older men and can cause a range of urinary symptoms, including:

A weak urine stream
Difficulty starting or stopping urination
Frequent or urgent need to urinate, especially at night
Feeling that the bladder hasn’t fully emptied

HoLEP may also be appropriate for men who are retaining urine and have developed complications such as bladder stones or kidney problems. In some cases, it may be used in men who are on long-term catheters.

What happens during a HoLEP procedure?

During HoLEP, a thin telescope-like instrument is inserted into the urethra. The surgeon uses the holmium laser to separate the enlarged prostate tissue from the outer shell of the gland. Once freed, the tissue is pushed into the bladder, where it is then broken up and removed.

HoLEP is performed under general or spinal anaesthetic and typically takes between 60 and 90 minutes, depending on prostate size. It typically requires an overnight stay. A urinary catheter is inserted to help drain the bladder and is usually removed the following day. Patients are closely monitored for urine flow and any bleeding before discharge.

Benefits of HoLEP compared to other prostate surgery options

There are several surgical options for BPH, including transurethral resection of the prostate (TURP) and open prostatectomy, but HoLEP offers several key benefits:

More complete tissue removal: HoLEP removes more of the obstructing tissue than TURP, which can lead to longer-lasting relief of symptoms.
Lower risk of bleeding: The laser seals blood vessels as it cuts, making it especially suitable for patients on blood-thinning medication.
Shorter hospital stay: Most patients are able to go home the next day, and some may even be discharged the same day.
Lower risk of needing repeat surgery: HoLEP has one of the lowest retreatment rates of any BPH procedure.
Can be used for larger prostates: Unlike TURP, HoLEP is suitable for prostates of any size, including those over 100 grams.

Recovery after a HoLEP

Most men recover quickly following HoLEP. It is common to experience mild discomfort, urgency, or frequency of urination for a few weeks as the body heals. Small amounts of blood in the urine can also be expected during this period. Patients are usually advised to:

Drink plenty of fluids to help flush the bladder
Avoid strenuous activity for 2–3 weeks
Refrain from sexual activity for 3–4 weeks

Many men notice a significant improvement in their urinary symptoms within days to weeks after the procedure. Full recovery usually occurs within four to six weeks.