Holmium Laser Enucleation Of The Prostate (HoLEP)

This publication includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence-based sources. It is, therefore, a reflection of best urological practice in the UK. It is intended to supplement any advice you may already have been given by your GP or other healthcare professionals. Alternative treatments are outlined below and can be discussed in more detail with your Urologist.

What does the procedure involve?

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

The standard surgical treatment of Benign Prostatic enlargement causing bladder outflow obstruction leading to retention of urine or other urinary symptoms is transurethral resection of the prostate (TURP). However, relatively high morbidity associated with TURP has led to the development of a range of minimally invasive techniques, some of which use thermal energy. One such minimally invasive technique is the use of holmium: yttrium-aluminium-garnet (YAG) laser which is the only laser treatment approved by the National Institute for Health and Clinical Excellence.

The most evolved Holmium laser procedure on the prostate is Holmium laser enucleation of prostate (HoLEP). It utilises the holmium laser as a precise cutting instrument to enucleate the lobes of prostate. Initially a bilateral bladder neck incision is made to define the margins of resection. The median and lateral lobes are then individually undermined and peeled off the prostate capsule in a retrograde direction. HoLEP is performed with a modified continuous flow resectoscope that has a circular fibre guide in the tip of the scope. An end-firing laser fibre is used as a precise cutting instrument by which the intact prostatic lobes are removed with the holmium laser and then passed into the bladder where they are cut into smaller pieces, before removal.

A primary advantage of HoLEP over other laser prostatectomy techniques is that it can rapidly create a large ‘TURP-like’ cavity by immediately removing obstructing tissue, rendering it suitable for large prostates of up to 100 grams. The coagulative ability of the holmium laser effectively seals tissue planes as the operation progresses, which makes HoLEP a relatively bloodless operation with a concomitant reduction in transfusion requirement, and also avoids the dangers of systemic fluid absorption.

Other postulated advantages include a reduced need for bladder irrigation, shorter postoperative catheterisation period and length of hospital stay, and the ability to retrieve tissue for histological examination.

What are the alternatives to this procedure?

Alternative to the procedure include, drugs, use of a catheter/stent, observation, conventional transurethral resection or open operation.

What should I expect before the 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 is aware of this well in advance of your admission.

You will usually be admitted on the day before your surgery although some hospitals now prefer to admit patients on the day of surgery. You will normally receive an appointment for pre-assessment 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.

You will be asked not to eat or drink for 6 hours before surgery and, immediately before the operation.

Please be sure to inform your surgeon in advance of your surgery if you have any of the following:

• An artificial heart valve
• A coronary artery stent
• A heart pacemaker or defibrillator
• An artificial joint
• An artificial blood vessel graft
• A neurosurgical shunt
• Any other implanted foreign body
• A regular prescription for Warfarin, Aspirin or Clopidogrel (Plavix®)
• A previous or current MRSA infection
• A high risk of variant-CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human-derived growth hormone).

At some stage during the admission process, you will be asked to sign the second part of the consent form giving permission for your operation to take place, showing you understand what is to be done and confirming that you wish to proceed. Make sure that you are given the opportunity to discuss any concerns and to ask any questions you may still have before signing the form.

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 60-150 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.

What happens immediately after the procedure?

In general terms, you should expect to be told how the procedure went and you should:

• Ask if what was planned to be done was achieved
• Let the medical staff know if you are in any discomfort
• Ask what you can and cannot do
• Feel free to ask any questions or discuss any concerns with the ward staff and members of the surgical team
• Ensure that you are clear about what has been done and what is the next move

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 over-activity (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.

Are there any side-effects?

Most procedures have a potential for side-effects. You should be reassured that, although all these complications are well-recognized, the majority of patients do not suffer any problems after a urological procedure.

Common (greater than 1 in 10)

• Temporary mild burning, bleeding and frequency of urination after the procedure
• No semen is produced during an orgasm in approximately 75% If the prostate is fully enucleated
• Treatment may not relieve all the urinary symptoms
• Poor erections (impotence in approx approximately 14%)
• Infection of the bladder, testes or kidney requiring antibiotics
• Possible need to repeat treatment later due to re-obstruction (approx 10%)
• Injury to the urethra causing delayed scar formation
• Loss of urinary control (incontinence) which reduces within 6 weeks (10-15%);
• this can usually be improved with pelvic floor exercises

Occasional (between 1 in 10 and 1 in 50)

• May need self-catheterisation to empty bladder fully If bladder weak
• Failure to pass urine after surgery requiring a new catheter
• Bleeding requiring return to theatre and/or blood transfusion (less than 2%)

Rare (less than 1 in 50)

• Finding unsuspected cancer in the removed tissue which may need further treatment
• Retained tissue fragments floating in the bladder which may require a second telescopic procedure for their removal
• Very rarely, perforation of the bladder requiring a temporary urinary catheter or open surgical repair
• Persistent loss of urinary control which may require a further operation (1- 2%)

Hospital-acquired infection

• Colonization with MRSA (0.9% – 1 in 110)
• Clostridium difficile bowel infection (0.01% – 1 in 10,000)
• MRSA bloodstream infection (0.02% – 1 in 5000)

The rates for hospital-acquired infection may be greater in high-risk patients e.g. with long-term drainage tubes, after removal of the bladder for cancer, after previous infections, after prolonged hospitalisation or after multiple admissions.

What should I expect when I get home?

By the time of your discharge from hospital, you should:

• Be given advice about your recovery at home
• Ask when to resume normal activities such as work, exercise, driving, housework and sexual intimacy
• Ask for a contact number if you have any concerns once you return home
• Ask when your follow-up will be and who will do this (the hospital or your GP)
• Ensure that you know when you will be told the results of any tests done on tissues or organs which have been removed

When you leave hospital, you will be given a “draft” discharge summary of your admission. This holds important information about your inpatient stay and your operation. If you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

Most patients feel tired and below par for a week or two because this is major surgery. You may notice that you pass very small flecks of tissue in the urine at times within the first month as the prostate area heals. This does not usually interfere with the urinary stream or cause discomfort.

What else should I look out for?

If you experience increasing frequency, burning or difficulty on passing urine or worrying bleeding, contact your GP.

About 1 man in 5 experiences bleeding some 10-14 days after getting home; this is due to scabs separating from the cavity of the prostate. Increasing your fluid intake should stop this bleeding quickly but, If it does not, you should contact your GP who will prescribe some antibiotics for you. In the event of severe bleeding, passage of clots or sudden difficulty in passing urine, you should contact your GP immediately since it may be necessary for you to be re-admitted to hospital.

Are there any other important points?

Removal of your prostate should not adversely affect your sex life provided you are getting normal erections before the surgery. Sexual activity can be resumed as soon as you are comfortable, usually after 3-4 weeks.

It is often helpful to start pelvic floor exercises as soon as possible after the operation since this can improve your control when you get home. The symptoms of an overactive bladder may take 3 months to resolve whereas the flow is improved immediately.

If you need any specific information on these exercises, please contact the ward staff or the Specialist Nurses. The symptoms of an overactive bladder may take 3 months to resolve whereas the flow is improved immediately.

The results of any tissue removed will be available after 14 – 21 days and you and You and your GP will be informed of the results by letter.

You will be reviewed in the outpatient clinic and several tests repeated (including a flow rate, bladder scan & symptom score) to help assess the effects of the surgery.

Most patients require a recovery period of 1-2 weeks at home before they feel ready for work. We recommend 3-4 weeks’ rest before resuming any job, especially If it is physically strenuous and you should avoid any heavy lifting during this time.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery. You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than 3 months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

What should I do with this information?

Thank you for taking the trouble to read this publication. If you wish to sign it and retain a copy for your own records, please do so below.

If you would like a copy of this publication to be filed in your hospital records for future reference, please let your Urologist know. However, if you do agree to proceed with the scheduled procedure, you will be asked to sign a separate consent form that will be filed in your hospital. You will, if you wish, be provided with a copy of the consent form.

Disclaimer

While every effort has been made to ensure the accuracy of the information contained in this publication, no guarantee can be given that all errors and omissions have been excluded. No responsibility for loss occasioned by any person acting or refraining from action as a result of the material in this publication can be accepted