HoLEP: How We treat benign prostatic hyperplasia?


In the Hospital San Raffaele Turro, at the Urology Division, in the first years of the new millennium, our experience has led us to abandon traditional surgical techniques mentioned above in favor of this new method. Currently, the overall operating series boasts several thousand patients, since the procedure has become part of daily practice of our team. The real benefits of this type of methodology are identified in the great advantages of the Holmium laser:


§  It is able to cut and coagulate

§  It is effective on prostates of large volumes

§  The patient benefits from the removal of the bladder catheter only 24 hours after surgery

§  Important reduction of postoperative bleeding


This technique consists of administering anesthesia to the patient (usually spinal i.e. without the need to completely numb the patient) and introducing a thin instrument that contains an optical fiber for vision and the Holmium laser fiber.


The urethra is lifted up to the level of the prostate, where the laser enucleates its central portion (called adenomas – the main cause of symptoms), which is then reduced into small fragments (morcellation) and removed through the same tool.


After the procedure, which lasts an average of 45-60 minutes (relative to the prostate volume), a bladder catheter is placed, which is usually removed the next morning. The patient is then able to leave the hospital as early as the same day.


The Scientific Institute San Raffaele in Milan contributed to the completion and publication in prestigious international journals of numerous studies comparing the new endoscopic technique performed using the Holmium laser (HoLEP) and the traditional endoscopic resection technique, defined usually with the Anglo-Saxon abbreviation TURP (Trans Urethral Resection of the Prostate).


The result of these studies, as mentioned above, showed that both methods are effective in curing the patient from his disturbed state. However, for the benefit of the laser technique, the result is the early removal of the bladder catheter in the postoperative time combined with the absence of pain/discomfort and a shorter hospital stay. In addition to the method with Holmium laser, it allows to minimize the intraoperative blood loss completely avoiding the need for subsequent blood transfusions.


The HoLEP method solves prostatic obstruction even in cases of very massive prostates, completely endoscopically and without making any incisions. Therefore, it is considered a minimally invasive, painless technique that is well tolerated by the patient. The Holmium laser also provides the great advantage of being able to be used effectively for the treatment of prostatic adenomas that are very voluminous (over 100 grams of weight) for which, in the absence of the laser method, the only solution would be the traditional open surgery (i.e. with surgical incision of the abdomen). In these cases, the advantages of the Holmium laser are even more evident since with the traditional intervention the catheter must be maintained for 4-5 days, necessarily entail a longer hospitalization and definitely a more bothersome post-operative course for the patient.


In patients treated with HoLEP one can always run a precise examination of the removed prostate tissue. Considering the progressive increase of cases of prostate cancer in the last twenty to thirty years, the great advantage of the opportunity to always perform the histological examination is immediately evident. It is important to point out that similar laser methods available today, in addition to providing functional results decidedly inferior to those of the Holmium laser, they do not allow an analysis of the removed tissue, with the consequent risk of not recognizing cases of occult prostate cancer.


After discharge, the patient can see almost immediate improvement in the quality of their urinary stream and the disappearance of the sense of incomplete emptying of the bladder (obstructive symptoms). The irritative symptoms (small heartburn, moderately increased micturition frequency) and small traces of blood in the urine tend to disappear usually within two to four weeks after the procedure.


The onset of the classic traditional post surgery complications (TURP) such as urinary tract infections, hematuria, and acute retention of urine may still occur even after laser method (HoLEP) but with much lower incidence and are still easily manageable and solvable.


Retrograde ejaculation (i.e. the non-issuance of sperm during orgasm) tends to occur after HoLEP, which is not dissimilar than the traditional TURP procedure. It should be stressed that this issue is often already present in simple medical therapy patients. One possible way to overcome this disadvantage is the use of cryo-preservation of the seed prior to the intervention. It is also important to highlight how the erectile and orgasmic function are not at all influenced according to studies that suggest steps such as improving urinary symptoms in some patients may be related to a better sexual function. More severe complications, such as the onset of a modest urinary incontinence, are described in the literature but are limited to less than 1% of patients.


The patient is then monitored at Our Division with initial check ups of three-six times a month and then yearly, which usually entail blood tests (PSA), Uroflowmetry with evaluation of post-void residual and Ultrasound of the Lower Abdomen. All exams and post-operative visits can be organized at Our Facility.


Finally, the Holmium laser and the HoLEP method are therefore the less invasive and more effective treatment option for patients with benign prostatic hyperplasia with obstructive symptoms, which do not respond or only partially respond to drug treatment.