Men with a very large prostate have not always had many good surgical options. Standard TURP works best for small and medium glands, and open surgery was often needed for larger ones. Holmium laser enucleation of the prostate, or HoLEP, changed this. It can treat prostates of almost any size through the urethra, without cuts on the skin.
What HoLEP involves
HoLEP uses a holmium laser to separate the inner part of the prostate, which causes the blockage, from the outer capsule. The surgeon works along the natural plane between them, much like peeling a segment from an orange.
The freed tissue is pushed into the bladder. A second instrument, called a morcellator, then cuts it into small pieces and removes it. The tissue is sent to the laboratory, which also allows any unexpected cancer to be found. This is an advantage over treatments that vaporise or reshape tissue, where no sample is available to examine.
The procedure is done under general or spinal anaesthetic. It usually takes between one and two hours, depending on the size of the prostate.
Why it suits larger prostates
HoLEP has several advantages for large glands:
- Size is rarely a limit: it can treat prostates that would otherwise need open surgery.
- Thorough removal: it removes most of the obstructing tissue, which gives long-lasting results.
- Less bleeding: the laser seals blood vessels as it works, which is helpful for men taking blood thinners.
- Short hospital stay: many men go home after one night.
Recovery
After the operation, a catheter drains the bladder, usually for a day or two. Once it is removed, most men notice a much stronger flow straight away.
During recovery, it is common to have:
- some burning when passing urine
- urgency and frequency for a few weeks
- a little blood in the urine on and off
Temporary leakage, especially when coughing or lifting, affects some men in the first weeks. It usually improves steadily, and pelvic floor exercises help. Most men return to normal activities within two to four weeks. It is wise to avoid heavy lifting, cycling and strenuous exercise during this time, and to drink plenty of water to keep the urine clear.
Results
HoLEP gives a marked improvement in symptoms and flow. Because so much tissue is removed, the need for repeat treatment is low. NICE guidance on urinary symptoms in men includes HoLEP among the recommended surgical options.
Side effects
Possible side effects include:
- Retrograde ejaculation: very common after HoLEP, as with TURP. Semen goes back into the bladder rather than out.
- Temporary stress incontinence: usually short-lived.
- Urethral narrowing: uncommon.
- Erection problems: uncommon.
How it compares with other options
HoLEP is a demanding technique with a long learning curve, so it is not available everywhere, and results depend on the experience of the surgeon. Other options for larger prostates include Aquablation therapy, which uses a waterjet and aims to preserve ejaculation for more men, and prostate artery embolisation, which avoids surgery through the urethra. Our guide to TURP explains the traditional operation. The British Association of Urological Surgeons has a patient leaflet on HoLEP.
Is HoLEP right for you?
HoLEP may be a good choice if you have a large prostate, have had urinary retention or take blood-thinning medicines. It is less suitable if preserving ejaculation is a high priority. Your urologist will measure your prostate and discuss which procedure best fits your priorities. Our page on benign prostatic enlargement gives an overview of all the treatments.
Professor Prokar Dasgupta can review the options for a large prostate with you at The London Clinic. Please contact the clinic to arrange a consultation.