Laser prostatectomy
(HoLEP, ThulVEP)

Benign prostatic hyperplasia (BPH) or benign prostatic hypertrophy is an enlargement of the prostate gland. The word “benign” means non-cancerous. “Hyperplasia” means an increased number of cells. It occurs in part because of the effects of testosterone on prostate cells over many years.

The prostate gland encircles the urinary outflow pipe (urethra), so problems with urination can occur if the gland enlarges, restricting urine flow by compression like a kink in a garden hose. This causes urinary symptoms which can be relieved by the removal of the obstructing tissue.

Long regarded as the standard treatment for BPH, TURP (transurethral resection of the prostate) involves passing a cystoscope with a working electric cutting wire to trim away the central prostatic tissue. TURP represented a significant advance from open surgery for this problem and is still widely practised. It avoids the need for an external wound and the longer recovery time associated with that. The main drawbacks of TURP are that it can cause a significant amount of blood loss and TURP syndrome, in which the irrigating fluid used disrupts blood salt and fluid levels.

Laser prostatectomy is in many ways similar to TURP in that it is performed using a cystoscope with no external incision required. The point of difference is that this technique uses laser energy to dissect the tissue.

Laser prostatectomy can be performed under general anaesthetic (fully asleep) or regional anaesthetic (an injection in the back makes the lower half of the body numb). Using a lubricating anaesthetic gel an endoscope is introduced up the urethra (outflow pipe). The scope has a light and camera technology so that structures can be seen, an irrigating system to wash away blood and debris and a working channel through which the laser fibre is directed.

Tissue is vapourised at the point of contact with the laser fibre giving a generally less bloody result and avoiding some of the potential problems with salt and fluid imbalance that occasionally happen with TURP.

Once the prostate fragments have been removed and sent for microscopic inspection, a catheter is placed for irrigation of the bladder. The catheter usually stays in place for 1-2 days and discharge from the hospital occurs following removal of the catheter once voiding.

There are different lasers that can be used for this operation. The two most common are the Holmium YAG laser (HoLEP stands for Holmium Laser Enucleation of the Prostate) and the Thulium YAG laser (ThuLVEP stands for Thulium Laser VapoEnucleation of the prostate). There are minor differences between the lasers which have different characteristics, but nothing that is noticeable to the man having the procedure.

As with any surgery, there are risks with laser prostatectomy. Even with the natural blood vessel sealing properties of laser energy, bleeding occurs to some extent. In a very small number of men, particularly if they already have a low blood count before the operation, a blood transfusion may be necessary. Blood in the urine after the operation is common and it is important to maintain a good fluid intake (around 2 litres/day of mostly water) to flush this through. Avoiding strenuous exercise for the first 4 weeks after the operation will help prevent this.
Antibiotics are routinely given during the operation to reduce the chances of infection.
There may be some temporary discomfort with the catheter and following its removal which can usually be managed effectively with medicines and lubricating gel. Burning when passing urine is due to the acidic urine coming into contact with inflamed tissues and is helped by taking Ural sachets (which remove the acid from the urine) and by drinking around 2 litres a day to dilute the urine.
Urinary symptoms progressively improve over the first 6 to 8 weeks after surgery. Going frequently and urgently is common early on. Leakage of urine (incontinence) can sometimes happen but usually also improves. This can be helped by practising pelvic floor exercises and avoiding caffeine (coffee, tea and energy drinks) in the early postoperative period.
Occasionally men are unable to void after surgery. This is often temporary and results from bladder stretching during the operation, however for some men their bladder is no longer strong enough to empty even when all the obstructing tissue downstream has been removed. In this situation, there is a range of other methods which may be used to empty the bladder.
Men are often concerned that they may lose sexual function after surgery however the risk of this with laser prostatectomy is much less than that seen with prostate cancer surgery. The vast majority of men remain able to achieve an erection and reach climax. The change in sexual function that is much more common (around 75% of the time) is retrograde ejaculation. This is an expected outcome as the bladder neck muscle that prevents it from happening is resected routinely during the surgery. The result is a dry ejaculation where the sperm travel back into the bladder and are flushed out in the urine. This isn’t harmful or painful however it may impair fertility and can therefore be of concern for men planning on having further children.
Following any procedure, the tissue heals with a degree of scarring. For some men, scarring can be excessive leading to impeded urine flow and resulting in symptoms similar to those caused by prostate enlargement. In this situation, a laser bladder neck incision (for bladder neck stenosis) or urethrotomy (for urethral stricture) may be necessary as a later procedure.