Holmium laser enucleation of the prostate (HoLEP)

What is this?

This operation involves the telescopic removal of obstructing prostate tissue using a laser and temporary insertion of a catheter for bladder irrigation

What alternatives are there?

Drugs, use of a catheter/stent, observation,, conventional transurethral resection or open operation.

What to expect before procedure

If you are taking Clopidogrel on a regular basis, you must stop 10 days before your admission. This drug can cause increased bleeding after prostate surgery. Treatment can be re-started safely about 10 days after you get home. If you are taking Warfarin to thin your blood, you should ensure that the Urology staff are aware of this well in advance of your admission. You will usually be admitted on the day before your surgery. You will normally receive an appointment for pre-assessment, approximately 14 days before your admission, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the Consultant, Specialist Registrar, House Officer and your named nurse. You will be asked not to eat or drink for 6 hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

What happens during the procedure?

Either a full general anaesthetic (where you will be asleep throughout the procedure) or a spinal anaesthetic (where you are awake but unable to feel anything from the waist down) will be used. All methods minimise pain; your anaesthetist will explain the pros and cons of each type of anaesthetic to you. The operation, on average, takes 60-120 minutes, depending on the size of your prostate. You will usually be given an injectable antibiotic before the procedure after checking for any drug allergies. The laser is used to separate the obstructing prostate tissue from its surrounding capsule and to push it in large chunks into the bladder. An instrument is then used through the telescope to remove the prostate tissue from the bladder. A catheter is normally left to drain the bladder at the end of the procedure.

After the procedure

There is always some bleeding from the prostate area after the operation. The urine is usually clear of blood after 12 hours, although some patients lose more blood for longer. It is unusual to require a blood transfusion after laser surgery. It is useful to drink as much fluid as possible in the first 12 hours after the operation because this helps the urine clear of any blood more quickly. Sometimes, fluid is flushed through the catheter to clear the urine of blood. You will be able to eat and drink on the same day as the operation when you feel able to. The catheter is generally removed at midnight on the first night after surgery. This allows your bladder to fill overnight so that, in the morning, the doctors can decide whether you may go home without the catheter. At first, it may be painful to pass your urine and it may come more frequently than normal. Any initial discomfort can be relieved by tablets or injections and the frequency usually improves within a few days. Some of your symptoms, especially frequency, urgency and getting up at night to pass urine, may not improve for several months because these are often due to bladder overactivity (which takes time to resolve after prostate surgery) rather than prostate blockage. Since a large portion of prostate tissue is removing with the laser technique, there may be some temporary loss of urinary control until your pelvic floor muscles strengthen and recover. It is not unusual for your urine to turn bloody again for the first 24-48 hours after catheter removal. Some blood may be visible in the urine even several weeks after surgery but this is not usually a problem. Let your nurse know if you are unable to pass urine and feel as if your bladder is full after the catheter is removed. Some patients, particularly those with small prostate glands, are unable to pass urine all after the operation due to temporary swelling of the prostate area. If this should happen, we normally pass a catheter again to allow the swelling to resolve and the bladder to regain its function. Usually, patients who require re-catheterisation go home with a catheter in place and then return within a week for a second catheter removal which is successful in almost all cases. The average hospital stay is 1-2 days.

Potential side effects