Holmium laser enucleation of the prostate, what is HoLEP?

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Holmium laser prostate enucleation, HoLEP; Benign prostatic hyperplasia (Benign prostatic hyperplasia) is a type of laser surgery used to treat obstruction of urinary flow as a result of BPH. An enlarged prostate can cause a number of urinary tract complaints such as frequent urination, inability to urinate, and difficulty urinating.

HoLEP was developed in the 1990s as a more effective and potentially less costly alternative for urinary obstruction, urinary obstruction due to BPH, compared to other closed surgical options such as laser vaporization and transurethral resection of the prostate.

How does holmium laser enucleation of the prostate (HoLEP) work?

Holmium laser is a surgical laser that has been used for many years to perform kidney stones, tumors and many other urological surgeries. When a Holmium-type laser is used in benign prostate enlargement, it is called HoLEP, and in this technique, the HOLEP laser is used to cut and remove the prostate tissue that blocks urine flow.

Who needs holmium laser enucleation of the prostate (HoLEP) and when?

1. BPH mainly affects men over 50, but affects more than 40 percent of men over 60 and is the leading cause of urination complaints, including difficulty urinating.
2. Although most cases of urinary obstruction due to BPH can be treated without surgery, patients who do not benefit from drug treatments may need surgery when problems such as urinary retention (inability to urinate), recurrent bleeding and urinary tract infections and bladder stones occur.
3. HoLEP can be applied to almost any type of patient and any size and weight.
4. Patients may not be candidates for HoLEP if:

Patients with diseases that cause bleeding problems, patients who have undergone prostate surgery and some types of treatment before, patients with serious orthopedic problems who cannot take the lithotomy position

How is the preparation before holmium laser enucleation of the prostate (HoLEP)?

1. A physical examination and digital rectal examination and uroflowmetry test to determine the severity of symptoms and, if necessary, multiparametric prostate MRI are performed along with a medical history for preoperative preparation. The amount of urine remaining after postvoiding residual-voiding should also be measured.
2. Blood creatinine and PSA (prostate specific antigen) and urinalysis should be checked.
3. If there are high PSA levels or if there is any doubt on Examination and MRI, a biopsy (tissue sample) may be taken to make sure there is no cancer.
4. The larger the size of the prostate, the longer the operation time. Cystoscopy (looking at the urethra, prostate and bladder with a camera) can be performed in the clinic to evaluate prostate and bladder anatomy and to rule out urethral strictures (scar tissue).
5. To prevent excessive bleeding before and after surgery, blood thinners should be discontinued for up to 7-10 days.
6. It is necessary not to consume any food or drink, like fasting, from midnight the night before the surgery.
7. In order to minimize the risk of infection after the surgery, urinalysis and urine culture should be performed from the patients before the surgery, and antibiotic therapy should be given if necessary.

How is holmium laser enucleation of the prostate (HoLEP) procedure performed?

1. HoLEP can be performed under general anesthesia or, if the patient cannot receive general anesthesia for any reason, under spinal anaesthesia.
2. Due to the risk of infection, an antibiotic injection is given during the operation in accordance with the patient’s findings.
3. During the procedure, the patient is placed on his back with his legs elevated (lithotomy position).
4. HOLEP IS A COMPLETELY CLOSED SURGERY. ANY INJECTION IS NOT MADE. A surgical instrument called a resectoscope is inserted through the urethra (the channel that carries urine from the bladder). The resectoscope contains a camera that allows the surgeon to see the internal structure of the prostate gland and where incisions were made during surgery.
5. The laser is inserted into the resectoscope and used like a knife to remove the enlarged prostate tissue from the capsule (outer shell). The removed tissue is deposited in the bladder.
6. The laser is removed from the resectoscope and replaced with a morcellator. This device is used to break up the tissue left behind in the bladder to expel it.
7. When tissue collection is complete, the resectoscope is withdrawn and a urinary catheter is inserted.

How is the follow-up after the prostate (HoLEP) holmium laser enucleation surgery?

1. The patient is hospitalized for 1-3 nights. A reasonable amount of bleeding can be expected after surgery. For most patients, this will resolve in about 12 hours. The need for blood transfusions due to excessive bleeding following HoLEP surgery is rare.
2. After the operation, washing is done from the catheter and probe to clean the blood in the urine. Eating and drinking is allowed on the same day of the procedure.
3. If there is no excessive bleeding, the catheter is usually removed on or 2nd day after surgery. After the catheter is removed, the patient can go home without the catheter if he or she can urinate easily. In patients with ongoing bleeding or additional disease, the catheter may remain for 3-7 days after surgery.
4. Urinating may be painful and more frequent than usual for a few weeks after catheter removal, and medications may be used to relieve symptoms until improvement is seen. Permanent resolution of symptoms may take several months because it may take time for the bladder to adjust to the removal of prostate tissue.

What are the advantages of holmium laser enucleation of the prostate (HoLEP)?

HoLEP is a safe and effective procedure. Although there are many types of BPH surgery available, HoLEP reduces the risk of bleeding and allows tissue removal for pathology, offering the advantage of being able to remove a large amount of tissue without making any incisions in the body, even in very large prostates. This means that the need for blood transfusions during surgery is very low and the hospital stay is short. The need for retreatment is low.

What are the side effects of holmium laser enucleation of the prostate (HoLEP)?

The most common side effects are:

1. Temporary burning and bleeding while urinating. Some blood may be seen in the urine for weeks after surgery. This is usually not an indication of anything serious, just that the healing process is not yet complete.
2. Some patients may have urinary incontinence (inability to control the flow of urine) immediately after surgery and may need to use pads for the first few days/weeks. This usually heals completely in a few weeks. Doing Kegel exercises such as breech squeeze and release can help reduce urinary problems.
3. The risk of urge incontinence may depend on a variety of factors such as age, prostate size, symptoms and other medical problems such as diabetes, and is easy to treat with medication.
4. Retrograde ejaculation or “retrograde ejaculation”. It is seen in 75 percent of the cases, it does not affect orgasm and sexual life, except for patients who want to have children.
5. Erection is usually not significantly affected. A small percentage of patients reported improved erection quality, while a small percentage reported decreased erectile function.

What are the risks or potential complications of holmium laser enucleation of the prostate (HoLEP)?

1. Urethral stricture, rarely seen
2. Injury of the prostate capsule (typically treated with longer catheterization)
3. Injury of the bladder or ureteral orifices (where urine from the kidneys flows out)
4. Resistant urinary tract infection.
5. Re-operation requirement, return of urinary obstruction (1-2 percent) at a later date requiring another operation.
6. Need for transfusion or repeat surgery due to bleeding.
7. Failure to relieve all symptoms after surgery and/or the need for prolonged catheterization.
8. Five to 15 percent of patients are found to have previously undiagnosed prostate cancer in prostate samples. Prostate cancer is curable after HoLEP.
9. Standard anesthesia risks

What happens after holmium laser enucleation of the prostate (HoLEP)?

1. Tissue removed during surgery will be analyzed in the PATHOLOGY section for any abnormal findings.
2. After surgery, the patient is called for examination at 3 months to monitor recovery and repeat tests such as urine flow rate, bladder scan, and symptom score
3. Using pelvic floor, breech exercises (also known as Kegel exercises) as soon as possible can help improve problems with urinary incontinence.
4. Most patients need at least a week of rest at home before returning to work.
5. No heavy lifting should be attempted during the recovery period; however, patients are expected to walk and do light activities.

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