What is a Laser Prostatectomy (HoLEP)?
A laser prostatectomy is a minimally invasive operation that uses a laser to remove the obstructing part of the prostate gland that is causing your urinary symptoms. The type of laser prostatectomy Dr Nathan usually performs is referred to as a Holmium Laser Enucleaton of Prostate - HoLEP for short. This procedure is performed to allow a free flow of urine and improved bladder emptying.
The potential advantages of HoLEP over conventional surgery (TURP) are:
- reduced bleeding
- a shorter hospital stay
- a safer and more complete removal of the obstructing part of the prostate especially in larger glands > 80cc.
What is the Prostate?
The prostate is a walnut-sized gland that sits at the base of the bladder surrounding the urethra, the tube through which you urinate. As you get older, the prostate gland grows and can cause an obstruction to the flow of urine leaving the bladder, thus causing problems urinating.
Why do I need a Laser Prostatectomy?
You are having significant problems or bother passing water, and may have stopped passing water altogether (urinary retention).
How is a Laser Prostatectomy performed?
The operation is performed under general or spinal anaesthesia. It is performed through as specialised telescope called a laser resectoscope which is passed up the pipe of the penis (urethra), and therefore there are no external cuts or scars.
A laser beam is directed onto the prostate through a fibre optic cable passed up the resectoscope, and used to core out (enucleate) the central portion of the prostate gland, until there is a wide channel with no obstructing tissue. The prostate tissue that is cored out is then chopped up into smaller pieces by a device called a morcellator and removed through the resectoscope. The procedure usually takes 60-90 min.
When I have finished the operation, I pass a catheter into the bladder, which drains the urine and helps to wash away any blood. This catheter usually stays in overnight and will be removed before you go home, usually on the day after surgery.
What are the risks, consequences and alternatives associated with having a laser prostatectomy?
Most procedures are straightforward; however as with any surgical procedure there is a chance of side effects or complications.
Serious or frequently occurring risks
Common (greater than 1 in 10)
- Temporary mild burning, bleeding or frequency of urination after the procedure - it can take a few weeks for the internal wound from the operation to heal.
- No semen is produced during orgasm in 80% of patients after the procedure. The semen passes into the bladder during orgasm and mixes with the urine. This is not harmful and does not prevent you having an orgasm but it will be a dry orgasm. This is referred to as retrograde ejaculation
- The operation may not relieve some of your symptoms.
Occasional (between 1 in 10 and 1 in 50)
- Temporary loss of urinary control (incontinence) which improves over time.
- Urine infection requiring antibiotics.
- Bleeding requiring return to theatre and / or blood transfusion.
- Possible need to re-operate in future due to recurrent obstruction.
- Failure to pass urine after surgery requiring another catheter.
Rare (less than 1 in 50)
- Permanent loss of urinary control (incontinence) which may require additional corrective surgery 1%.
- Impotence – difficulty in achieving a satisfactory erection.
- The need to self-catheterise after the procedure to fully empty the bladder.
- Delayed scar formation in the urethra or opening into the bladder which can cause recurrent obstruction (urethral or bladder neck stricture)
- Very rarely perforation of the bladder requiring temporary insertion of a catheter or open surgical repair.
Alternatives to laser prostatectomy
- Medication – medication is usually not as effective as surgery, can have side effects, and you will need to take it for the rest of your life.
- Ejaculation preserving procedures including Urolift procedure, Rezuum, and Prostatic Arterial Embolisation. These procedures do not cause retrograde ejacultion but are not as effective as a Laser Prostatectomy and may not provide durable relief of symptoms
- Transurethral Prostatectomy (TURP) is the standard operation for prostate enlargement. Laser Prostatectomy has similar effectiveness to TURP in published studies. TURP has a higher risk of bleeding compared to laser prostatectomy so you may need to stay in hospital a day or two longer with a catheter
- Transurethral Incision of Prostate (TUIP) - also sometimes called Bladder Neck Incision. May be recommended for small prostates
- Open prostate operation – higher risk of complications and longer recovery so only recommended in really large glands, that are too big to manage with minimally invasive surgery
- Long-term catheter – can cause significant discomfort and complications, so only recommended if you are not fit for an operation
- Intermittent self-catheterisation
- Observation of symptoms – is a good option if your symptoms are mild and don’t trouble you
What type of anaesthetic will I have?
The anaesthetist will see you before your operation to discuss the alternatives. The anaesthetist will also check that you are fit enough for the anaesthetic.
Getting ready for your operation
If you smoke, try and cut down or preferably stop, as this reduces the risks of heart and chest complications during and after the operation. If you do not exercise regularly, try and do so for at least half an hour per day e.g. brisk walk or swimming.
You may be sent an appointment to visit the pre-assessment clinic a few days before your operation date. This is a general health check to ensure you are fit for surgery. The pre-assessment nurse will organise for you to have bloods taken and have an ECG (electrocardiogram - heart tracing), and answer any questions that you may have.
Please let Dr Nathan know well in advance of your surgery (at least 2 weeks) if you are taking any blood thinners such as aspirin, Assasantin, Plavix, Iscover, Brilinta, Warfarin, Pradaxa, Xarelto etc.
What should I expect after the operation?
After your operation you will normally go back to the surgical ward. You can start eating and drinking as soon as you recover from the anaesthetic.
Because there are no external cuts, this procedure is relatively pain free. You may experience some discomfort from the catheter, but this is usually easily treated with mild painkillers.
A urinary catheter is a tube that runs from the bladder out through the tip of the penis and drains into a bag. It is important to drain the urine in this way until the urine is clear. Your catheter is usually removed on the day after your operation.
Before you are allowed home
- You must be passing water without difficulty.
- Mild painkillers such as Paracetamol and Voltaren must adequately control any pain.
- Your temperature must be normal.
Discharge information and home advice
It is quite normal to see an occasional show of blood in your urine during the first month after surgery because it takes time for the internal operation site to heal. If you see blood in the urine, simply increase your fluid intake and rest. Avoid strainging and make sure you don't become constipated. If you have prolonged heavy bleeding (>24 hours), significant pain or increasing difficulty passing water, please contact my rooms. Outside of office hours if you are experiencing heavy bleeding or difficulty passing urine you should attend the Emergency Centre at Buderim Private Hospital which is open 24/7.
Mild painkillers such as Paracetamol, and/or an antiinflammatory such as Mobic should be enough to deal with any post-operative discomfort
It is important that you do not get constipated. There are no dietary restrictions but you should try and eat plenty of fruit and vegetables and wholemeal bread. If you feel that you may be constipated, see your GP. Try an drink 2-3 litres of fluid a day.
You should take it easy for a month, although it is important to take some gentle exercise like walking, to reduce the risk of developing a blood clot in your legs.
During the first 2 weeks you should not:
- Lift or move heavy objects.
- Dig the garden.
- Carry shopping.
You can resume normal sexual activity 2 weeks after your operation.
Recovery takes 4-6 weeks from your operation date; I will be able to advise you when it will be safe to return to work as this depends on your occupation – you may be able to resume a sedentary office job after only a week or two but may need to take a month off if you have a strenuous job. A sick note for your hospital stay and recovery period can be obtained from your family doctor or my rooms.
You may resume driving a motor vehicle after 1-2 weeks if you feel well and do not have significant pain or discomfort. You should initially commence this with short trips. You should avoid any long car trips for at least four weeks.
This information is intended as a general educational guide and may not apply to your situation. You must not rely on this information as an alternative to consultation with your urologist or other health professional.
Not all potential complications are listed, and you must talk to your urologist about the complications specific to your situation.