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What is the prostate?

Your prostate is part of your reproductive system. It is a plum-sized gland and is only found in men. It lies at the base of your bladder and surrounds your urethra (the tube that takes urine from the bladder, along the penis and out of your body). Your prostate produces nutrients for your sperm, which makes most of the milky fluid (semen) when you ejaculate.

Why has my prostate enlarged?

As men get older, due to hormonal changes, the cells of the prostate begin to swell, which increases the size of the prostate. This is called benign prostatic enlargement (BPE), based on extra growth of benign and normal (non-cancerous) prostate cells. 

This usually isn’t serious, but sometimes the prostate grows so large that it puts pressure on the tube you pass urine through (urethra). 

It can cause difficulty to pass urine and may cause other urinary symptoms such as:

  • not being able to empty your bladder completely, so you may need to go to the toilet more often (referred to as frequency)
  • sometimes you may develop an extreme urge to urinate or even lose some urine (referred to as urgency or urge-incontinence)
  • having a weak urine flow
  • having to strain to pass urine
  • Because of the squeeze on your urethra, the bladder may have to use a lot of pressure to pass urine. In the long term, this can damage your bladder and kidneys

 When do I need treatment?

Not everyone who develops an enlarged prostate will need treatment. Whenever you are bothered by your complaints, discuss them with your GP. 

Initially your GP will start treatment with medications. They can reduce complaints significantly for several months and even years. 

Whenever symptoms become bothersome again or in case you experience troublesome side effects of medications, your GP will usually refer you to a urologist for further treatment.

The urologist will perform additional investigations to judge how severe your complaints are and if the bladder is obstructed by the enlarged prostate. When this is the case, he will discuss surgical options with you.

Holmium Laser Enucleation of the Prostate (HoLEP)

Holmium Laser Enucleation of the prostate (HoLEP) is a modern alternative to the standard TransUrethral Resection of the Prostate (TURP) procedure for bladder outflow obstruction due to Benign Prostate Enlargement (BPE). It requires a short period of hospitalisation and an anaesthetic.

After surgery, a catheter (a tube which drains the bladder) is also needed for 1-2 days until the urine clears and will be removed. You then can return to your home.

Patients are advised to take life quietly and to avoid straining or heavy lifting for six weeks after the surgery.

Who is it suitable for?

  • HoLEP can be performed on men of any age with urinary outflow obstruction caused by an enlarged prostate. 
  • It is particularly indicated in men with large prostates (over 50mls in size) and men on medications to thin the blood such as warfarin, aspirin or clopidogrel.

What are the advantages of HoLEP?

  • There is no upper size limit of prostates that can be dis-obstructed – traditionally men with prostates over 100ml in size need major open surgery
  • There is less bleeding than after a TURP
  • Discharge is quicker than after TURP at 1-2 days
  • The chance of recurrence requiring further surgery is very low
  • Removed prostate tissue can be sent for pathological analysis
  • The PSA generally drops to very low levels after HoLEP operations

What are the disadvantages of HoLEP?

  • The procedure takes slightly longer than a TURP and requires specialist training.

How does it work?

The aim of HoLEP is to relieve pressure on the tube through which the urine drains (urethra) by anatomically enucleating / removing the excess and obstructive benign prostatic tissue. This is done under a general anaesthetic with the help of a telescopic camera inserted through the penis. 

The enucleated lobes of the prostate, that are cored out intact, are pushed into the bladder before being sucked up and cut into small pieces (morcellated) by a special instrument (morcellator) inserted through the telescopic camera. The pieces are sent for pathologic analysis just in case they might be found to be cancerous. 

After surgery, a catheter is placed into the bladder to drain the urine while the raw surface heals, then left in place for around 24 hours before being removed on the day of discharge from hospital. Sterile saline fluid is also irrigated into the bladder through the catheter to dilute any blood in the urine and prevent clots from forming. 

It is normal to have some blood in the urine after this operation, so it is advisable to drink plenty of water (at least 1,5 to 2 litres) for a few days while it clears. Clots are sometimes passed 10-14 days afterwards; again, this is part of the healing process.

Apart from this and the risk of infection that accompanies any operation or invasive procedure, the only significant side-effect is the near certainty that normal ejaculation will cease. This is because the contraction, that normally occurs during orgasm, may not occur anymore once prostate tissue has been removed. This leads to an orgasm without ejaculation (”dry ejaculation”). 

This is not harmful, but it does mean that future fertility is greatly reduced. The procedure does not generally affect erectile function or continence, although the urinary symptoms may take a number of weeks to settle down afterwards.

What are the risks of after-effects after HoLEP surgery? 

The possible after-effects and your risk of getting them are shown below. 

Most of them are self-limiting and reversible, some are not. The impact of these after-effects can vary a lot from patient to patient; you should ask your surgeon’s advice about the risks and their impact on you as an individual

Temporary mild burning, bleeding and frequent urination

Almost all patients in the first few weeks

No semen is produced

In 9 out of 10 patients (90%)

Continuing blood in your urine for several days

Between 1 in 2 & 1 in 10 patients

Temporary loss of urinary control

In 1 in 10 patients

Permanent loss of urinary control

Less than 1 in 50 patients

Treatment may not relieve all your symptoms

Between 1 in 50 & 1 in 250 patients

Bleeding requiring a blood transfusion or re-operation

Between 1 in 50 & 1 in 250 patients

Anaesthetic or cardiovascular problems

Between 1 in 50 & 1 in 250 patients

Injury to the urethra causing narrowing which may require further surgery

Between 1 in 100 & 1 in 250 patients