Update on HoLEP: Fast relief and maximum benefit for patients with benign prostatic hyperplasia

The challenge

For decades, transurethral resection of the prostate (TURP) has been the gold standard surgical treatment for benign prostatic hyperplasia (BPH). However, depending on surgeon experience, up to 25 percent of patients may experience some type of complication after TURP, including bleeding, hyponatremia, urinary incontinence and erectile dysfunction. TURP also subjects patients to risks inherent in any surgical procedure, as well as a hospital stay of one to four days and recovery time of four to six weeks.

Although laser ablation can provide swift symptom relief and quick recovery and minimize the risk of damage to healthy tissue, impotence or prolonged incontinence, some procedures may result in prostate swelling with temporary need for catheterization. Additionally, the long-term durability of ablative procedures has not been widely assessed, and there is a risk of prostate regrowth requiring repeat surgical intervention in some cases.

Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive treatment for BPH. With the patient under general anesthesia, the surgeon uses the laser to enucleate the prostate gland tissue, leaving just the capsule in place. The surgeon pushes the excised prostate gland tissue into the bladder and then uses a morcellation device to grind up and remove the tissue.

HoLEP offers some distinct advantages:

  • Treatment of any size prostate gland.
  • Complete excision of the obstructing prostate tissue down to the prostate's encapsulating structures, resulting in a re-treatment rate of less than 2 percent.
  • Early, immediate symptom relief and fast return to normal activity. Next-day catheter removal with limited swelling generally allows patients to void painlessly and immediately. Same-day or next-day hospital discharge is possible when the procedure is performed in a 23-hour observation setting.
  • Tissue preservation for pathologic examination. Because adenomatous tissue is excised rather than ablated, surgeons can examine specimens for prostate cancer or other abnormalities. Cancer is found in about 10 percent of HoLEP procedures, even in patients previously screened. In many cases, the cancer identified is of low malignant potential.
  • Fewer potential complications. The low depth of penetration of the holmium laser causes little damage to healthy tissue, and the risk of excessive bleeding and erectile dysfunction associated with traditional surgical approaches is reduced.

Some studies have shown that patients who underwent HoLEP actually had improved erectile function after surgery, but almost all had retrograde ejaculation. All patients experience hematuria for one to two weeks after the procedure, but the need for blood transfusion is low, around 1 percent. Since normal saline irrigation is used for the procedure, there is no risk of hyponatremia, regardless of prostate size. Transient urinary incontinence is common, but permanent incontinence at one year after the procedure occurs in approximately 1 to 2 percent of patients, depending on the definition and type of incontinence.

Ongoing HoLEP research

Detrusor acontractility is viewed as a relative contraindication to surgical intervention for men with bladder outlet obstruction secondary to BPH. Mayo Clinic researchers are testing the use of HoLEP for men with hypocontractile or acontractile bladders.

In a prospective trial of men ages 53 to 85 years, Mayo urologists performed HoLEP on 15 participants with evidence of BPH and bladders that had very little function or contraction ability. Preoperatively, all participants had catheter-dependent urinary retention for a median of five months (range: three to 60 months). Postoperatively, all men were able to void spontaneously without need for intermittent catheterization, with 13 participants displaying a return of detrusor contractility, and two participants voiding exclusively by Valsalva efforts. At their six-month postoperative follow-up, all participants were still able to urinate. Although these findings are preliminary, they suggest that HoLEP may be a viable treatment option for men with BPH and hypocontractile or acontractile detrusor muscle.

Widely acknowledged as a benchmark BPH procedure, HoLEP requires specialized skills and training. Mayo Clinic is among the few medical centers in the United States that performs HoLEP procedures at its campuses in Minnesota and Arizona.

Points to remember

  • Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive treatment for benign prostatic hyperplasia (BPH). Its short- and long-term outcomes are superior to those associated with transurethral resection of the prostate and suprapubic prostatectomy.
  • HoLEP is performed transurethrally, using a holmium laser to separate the plane between the prostate gland tissue and the prostate capsule. This procedure allows complete resection of all adenomatous tissue, minimizing the need for future re-treatment.
  • Mayo Clinic researchers are testing the use of HoLEP for men with hypocontractile or acontractile bladders and BPH.