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    AVANTGARDE UROLOGY
    Center of Minimally Invasive Surgery

Holmium Laser (HoLEP)

What is BPH?

The gradual enlargement of the prostate is a non-cancerous disease common among aging men. The enlarged prostate can intrude into the urethra causing partial or complete obstruction of urine flow. This condition is referred to as benign prostatic hyperplasia, or BPH. While BPH is usually not life threatening, it can cause considerable discomfort, with complete obstruction leading to emergency surgery for resolution. Over half of all men over 50 have BPH symptoms, with the percentage growing to 80% of men over 80. Due to the overall aging of society, the number of men seeking treatment over the next 20 years is expected to increase. (holep 3)
Newer procedures that use laser technology can be performed on an outpatient basis.


Holmium Enucleation of the Prostatic Adenoma (HoLEP)



This is a Laser based application that consists in drilling around the adenoma of prostate, separate in from the capsule and push it in the bladder using a modified cystoscope (operation performed through the urethra). Then a special instrument called morcellator is introduced always through the urethra in order to remove in small pieces the adenoma. A catheter is introduced for a few hours. For further information please visit the www.lumenis.com website and the article guide (holep 1 and holep 2)

Why Holmium?

Tissue Removal
The holmium laser is ideal for precisely and cleanly ablating without charring or overheating tissue. Since the holmium absorption depth is only 0.5 mm or less, tissue is ablated faster than heat is conducted into surrounding tissue. Holmium energy is delivered in a pulsed mode with each pulse containing enough energy to vaporize the tissue. The vaporized tissue is removed before it can conduct heat, which minimizes thermal damage. The resulting “what-you-see-is-what-you-get” effect contrasts to the coagulating effects of Nd:YAG and KTP lasers whose wavelengths penetrate deeper and extend below the visible tissue surface.


Hemostasis
Hemostasis with holmium is remarkably good. Its localized coagulation effect ‘seals’ the tissue and provides hemostasis superior to electrocautery instruments without producing deeper thermal injury associated with Nd:YAG or KTP lasers. The holmium coagulating effect minimizes fluid absorption better than electrocautery.


The ablating and hemostasis features of holmium make it an excellent energy choice for BPH treatment. When stone fragmentation benefits are considered, the holmium laser is the best and most cost effective choice for treating both stone disease and BPH—two of the most common reasons patients visit the urologist.

Holmium Prostate Treatments
Since its introduction, holmium laser prostatectomy has undergone rigorous scientific studies that substantiate its surgical equivalence to the traditional electrocautery procedure (TURP) with fewer patient complications and faster patient return to normal activities. Whether performing holmium laser enucleation (HoLEP) or holmium laser ablation (HoLAP) of the prostate, the procedure can be done as a day case or in a 23-hour facility. HoLEP and HoLAP treatments offer many benefits including:

  • Immediate removal of tissue and symptoms.
  • Virtually bloodless and minimally invasive technique.
  • Short catheterization time.
  • Few complications.
  • Short convalescence.
  • Cost-effective solutions—hospitals gain unmatched economic benefits by utilizing the multipurpose holmium laser for stones, strictures, tumors AND BPH treatment.


Virtually bloodless view immediately post op. Clear channel 3 months post op

Q: What are the disadvantages of HoLEP?
A: There are several disadvantages to HoLEP. Clinically, there is a higher incidence of stress urinary incontinence for HoLEP (10-15%) as compared to TURP, especially in patients with larger prostates (>,,,,,,,,100 gm). However, this problem is virtually resolved in all patients after 6 weeks. Second, there is a high learning curve for HoLEP (approximately 15 to 20 cases) before the surgeon becomes efficient with this technique. This equates to an investment in time and equipment for the surgeon to learn HoLEP.
Q: What are the advantages of HoLEP over TURP?
A: The benefits of HoLEP include shorter catheter time, shorter hospital stay, minimal risk of blood transfusion, the rare need for perioperative bladder irrigation and quicker return to full activity.
Q: Can you use the holmium laser to coagulate specific areas of bleeding during the enucleation of the prostate?
A: Yes, by placing the fiber tip 2-3 mm away from the bleeding point and then activating the laser for 8-10 seconds. This is also known as defocusing the laser beam.
Q: How often do you see TURP syndrome with holmium laser prostatectomy?
A: Almost never. The holmium laser coagulates as it cuts tissue, which minimizes fluid absorption. In addition, normal saline, which is more physiologic, is used during holmium laser prostatectomy.

Your Recovery after Surgery in the Hospital
The amount of time you will stay in the hospital depends on the type of surgery you had and how quickly you recover.

At the end of surgery, a special catheter is inserted through the opening of the penis to drain urine from the bladder into a collection bag. Called a Foley catheter, this device has a water-filled balloon on the end that is put in the bladder, which keeps it in place.

This catheter is usually left in place overnight. Sometimes, the catheter causes recurring painful bladder spasms the day after surgery. These spasms may be difficult to control, but they will eventually disappear.

You may also be given antibiotics while you are in the hospital. Many doctors start giving this medicine before or soon after surgery to prevent infection. However, some recent studies suggest that antibiotics may not be needed in every case, and your doctor may prefer to wait until an infection is present to give them.

After surgery, you will probably notice some blood or clots in your urine as the wound starts to heal. If your bladder is being irrigated (flushed with water), you may notice that your urine becomes red once the irrigation is stopped. Some bleeding is normal, and it should clear up by the time you leave the hospital. During your recovery, it is important to drink a lot of water (up to 8 cups a day) to help flush out the bladder and speed healing.

Do`s and Don`ts
Take it easy the first few weeks after you get home. You may not have any pain, but you still have an incision that is healing, even with transurethral surgery where the incision can`t be seen. Since many people try to do too much at the beginning and then have a setback, it is a good idea to talk with your doctor before resuming your normal routine. During this initial period of recovery at home, avoid any straining or sudden movements that could tear the incision.

Here are some guidelines:

  • Continue drinking a lot of water to flush the bladder.
  • Avoid straining when having a bowel movement.
  • Eat a balanced diet to prevent constipation. If constipation occurs, ask your doctor if you can take a laxative.
  • Don`t do any heavy lifting.
  • Don`t drive or operate machinery.

Getting Back to Normal After Surgery
Even though you should feel much better by the time you leave the hospital, it will probably take a couple of months for you to heal completely. During the recovery period, the following are some common problems that can occur.

Problems Urinating
You may notice that your urinary stream is stronger right after surgery, but it may take awhile before you can urinate completely normally again. After the catheter is removed, urine will pass over the surgical wound on the prostate, and you may initially have some discomfort or feel a sense of urgency when you urinate. This problem will gradually lessen, and after a couple of months you should be able to urinate less frequently and more easily.

Incontinence
As the bladder returns to normal, you may have some temporary problems controlling urination, but long-term incontinence rarely occurs. Doctors find that the longer problems existed before surgery, the longer it takes for the bladder to regain its full function after the operation.

Bleeding
In the first few weeks after transurethral surgery, the scab inside the bladder may loosen, and blood may suddenly appear in the urine. Although this can be alarming, the bleeding usually stops with a short period of resting in bed and drinking fluids. However, if your urine is so red that it is difficult to see through or if it contains clots or if you feel any discomfort, be sure to contact your doctor.

Sexual Function After Surgery
Many men worry about whether surgery for BPH will affect their ability to enjoy sex. Some sources state that sexual function is rarely affected, while others claim that it can cause problems in up to 30 percent of cases. However, most doctors say that even though it takes a while for sexual function to return fully, with time, most men are able to enjoy sex again.

Complete recovery of sexual function may take up to 1 year, lagging behind a person`s general recovery. The exact length of time depends on how long after symptoms appeared that BPH surgery was done and on the type of surgery. Following is a summary of how surgery is likely to affect the following aspects of sexual function.

Erections
Most doctors agree that if you were able to maintain an erection shortly before surgery, you will probably be able to have erections afterward. Surgery rarely causes a loss of erectile function. However, surgery cannot usually restore function that was lost before the operation.

Although most men are able to continue having erections after surgery, a prostate procedure frequently makes them sterile (unable to father children) by causing a condition called retrograde ejaculation or dry climax.

During sexual activity, sperm from the seminal vesicles enters the urethra near the opening of the bladder. Normally, a muscle blocks off the entrance to the bladder, and the semen is expelled through the penis. However, the coring action of prostate surgery cuts this muscle as it widens the neck of the bladder. Following surgery, the semen takes the path of least resistance and enters the wider opening to the bladder rather than being expelled through the penis. Later it is harmlessly flushed out with urine. In some cases, this condition can be treated with a drug called Pseudoephedrine, found in many cold medicines, or imipramine. These drugs improve muscle tone at the bladder neck and keep semen from entering the bladder.

Orgasm
Most men find little or no difference in the sensation of orgasm, or sexual climax, before and after surgery. Although it may take some time to get used to retrograde ejaculation, you should eventually find sex as pleasurable after surgery as before.

Many people have found that concerns about sexual function can interfere with sex as much as the operation itself. Understanding the surgical procedure and talking over any worries with the doctor before surgery often helps men regain sexual function earlier. Many men also find it helpful to talk with a counselor during the adjustment period after surgery.

BPH and Prostate Cancer: No Apparent Relation
Although some of the signs of BPH and prostate cancer are the same, having BPH does not seem to increase the chances of getting prostate cancer. Nevertheless, a man who has BPH may have undetected prostate cancer at the same time or may develop prostate cancer in the future. For this reason, the National Cancer Institute (http://www.cancer.gov/cancertopics/screening/prostate) and the American Cancer Society (http://www.cancer.org/docroot/home/index.asp) recommend that all men over 40 have a rectal examination once a year to screen for prostate cancer.

After BPH surgery, the tissue removed is routinely checked for hidden cancer cells. In about one out of 10 cases, some cancer tissue is found, but often it is limited to a few cells of a non aggressive type of cancer, and no treatment is needed.

Attention! The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with your physician for further evaluation.

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