Holmium laser enucleation of the prostate, or HoLEP, is a minimally invasive surgical procedure used to treat urinary symptoms caused by an enlarged prostate, also known as benign prostatic hyperplasia (BPH).

The prostate is a gland that sits below the bladder and in front of the rectum. It surrounds the urethra, the tube that carries urine from the bladder through the penis and out of the body. The prostate enlarges as a man ages, which can result in BPH.

In BPH, the enlarged prostate physically presses against the urethra, either blocking it or causing it to narrow. This can cause problems with urination, including increased urinary frequency and/or urgency and an inability to fully empty the bladder. Over time, it can also result in a weakened bladder, which also makes it more difficult to empty, as well as kidney damage.

HoLEP is used to treat people with these and other bothersome urinary symptoms caused by BPH. In the procedure, a laser is used to remove the excess prostate tissue that presses against the urethra, allowing the urethra to open more fully, thereby improving urine flow.

“HoLEP is a minimally invasive procedure that can be used to treat patients with any size prostate,” says Yale Medicine urologist Daniel Kellner, MD. “It is also effective in treating patients who have already failed other less effective procedures.”

BPH is a condition in which the prostate becomes enlarged. As it grows larger, it presses against and narrows the urethra, obstructing the flow of urine. In some cases, BPH does not cause any symptoms. When it does cause symptoms, however, they may include:

• Urinary hesitancy, or difficulty starting urination
• A weak urinary stream
• A need to strain muscles to begin urine flow
• A urinary stream that starts and stops one or more times
• An inability to completely empty the bladder
• An increased urinary frequency (when it occurs at night, it is called nocturia)
• An increased urge to urinate
• An involuntary loss of urine (known as urge incontinence)
• Urine that dribbles toward the end of urination

BPH can also result in certain complications, such as kidney damage, bladder stones, blood in the urine (hematuria), urinary tract infections (UTIs), and acute urinary retention, a condition marked by the inability to urinate accompanied by pain in the lower abdomen.

BPH most commonly affects men ages 40 or older, and its prevalence increases as men age. For example, around 50% of men ages 31 to 40 have BPH, and around 90% of men ages 81 to 90 are affected.

Treatment for BPH includes lifestyle changes, such as cutting back on certain drinks and diuretics (drugs that increase the excretion of urine, causing the body to get rid of water during urination) including caffeine and alcohol; medications that help relax bladder and urethral muscles; and surgery.

Traditional surgical procedures for symptoms caused by BPH include:

• Transurethral resection of the prostate (TURP), a widely used procedure in which prostate tissue is removed with an electric current that passes through a loop of wire.
• Transurethral incision of the prostate (TUIP), a procedure in which small incisions are made in the prostate where it joins the bladder, widening the urethra and improving urine flow.
• Open or Robotic simple prostatectomy, a procedure in which prostate tissue is removed through one or more incisions in the lower abdomen.

In addition to HoLEP, other minimally invasive surgical procedures include:

• Prostatic urethral lift (UroLift), a procedure in which permanent implants are placed into the urethra. The implants lift excess prostate tissue away from the urethra, improving urine flow.
• Photovaporization of the prostate (PVP), a procedure in which a green light laser vaporizes excess prostate tissue.

HoLEP is a minimally invasive procedure in which a laser is used to remove excess prostate tissue around the urethra, thereby improving urine flow and relieving urinary symptoms of BPH.

To understand HoLEP, it might be helpful to define the words that make up its name, holmium laser enucleation of the prostate:

• Holmium laser. A special laser, called holmium:yttrium-aluminum-garnet (Ho:YAG), removes excess prostate tissue.
• Enucleation of the prostate. The prostate is surrounded by a capsule of fibrous tissue. Enucleation means to surgically remove tissue as a single piece from its surrounding capsule, like peeling away an orange from the rind. In HoLEP, a holmium laser separates—or enucleates—excess prostate tissue from the capsule. The enucleated prostate tissue is then pushed into the bladder and removed from the body with a process called morcellation.

After diagnosing BPH, your urologist will discuss treatment options, such as lifestyle changes, medications, and/or surgical options, including HoLEP.

Often, people initially try medication and lifestyle changes to treat their symptoms. For those who continue to have urinary symptoms or who experience side effects from medication, surgery, including HoLEP, may be recommended.

If surgery is recommended, your urologist will typically order tests to evaluate the prostate and your urinary symptoms, as well as determine the best course of treatment. These tests may include:

• Imaging tests to determine the size and shape of the prostate. Imaging tests may include a magnetic resonance imaging (MRI) scan, a computed tomography (CT) scan, a transrectal ultrasound (in which an ultrasound probe is inserted into the rectum), an abdominal ultrasound, or a cystoscopy, a test in which a cystoscope—a thin tube equipped with a camera—is inserted into the urethra to allow doctors to visually assess the prostate.
• Post-void residual (PVR) test, a test that measures the amount of urine that remains in the bladder after urination.
• Uroflometry, a test that measures how much urine is released during urination, the speed of its release, and how long it takes to release the urine.

In BPH, the size of the prostate enlargement varies from person to person. In some cases, it is greatly enlarged, while in others, it is only slightly larger than normal. HoLEP can be used to treat enlarged prostates of any size that cause symptoms.

HoLEP is performed using a resectoscope and a morcescope. These are two types of endoscopes (thin tubes equipped with a light and a camera that transmits video signals to a monitor in the procedure room) through which surgical tools can be passed. These endoscopes are inserted through the urethra (though not at the same time), and the surgeon performs the procedure using tools passed through them. No skin incisions are needed in HoLEP.

Before the procedure, the patient is given anesthesia and an antibiotic to reduce the chances of infection.

The surgeon begins the procedure by inserting a resectoscope into the patient’s urethra. The holmium laser is then sent through the resectoscope. The surgeon uses the laser to separate excess prostate tissue from the prostate capsule and then pushes large pieces of the tissue into the bladder. (As the holmium laser separates tissues, it coagulates it—meaning it stops blood vessels from bleeding, helping to lessen blood loss during the procedure.) When all excess prostate tissue has been enucleated and pushed into the bladder, the laser and resectoscope are removed from the urethra.

The surgeon then inserts a morcescope into the urethra and bladder, followed by a device called a morcellator. Once in the bladder, the morcellator suctions large pieces of prostate tissue to its tip, where blades cut the tissue into smaller pieces. The small pieces are then suctioned out of the bladder with the morcellator.

At the end of the procedure, a catheter is inserted to flush the bladder with sterile fluid and to allow it to drain.

Immediately after the procedure, patients will have a catheter in place to drain the bladder. Urine typically contains some blood after the procedure due to bleeding from the prostate. In most cases, the urine is free of blood within a day, though blood may continue to appear in the urine for several weeks after the procedure. Drinking plenty of fluids after the procedure can help clear blood from the urine. Usually, the catheter is removed the day after the procedure. Most people go home the same day as the procedure.

After the catheter is removed, there may be some mild temporary burning with urination. Usually, these symptoms resolve within a few days. Other BPH symptoms, such as urinary frequency, urgency, and nocturia, are due to bladder overactivity and may take several weeks to improve.

People may also have transient incontinence (difficulty controlling urination) after HoLEP. Pelvic floor exercises (such as Kegels) before and after the procedure can strengthen muscles involved in bladder control and can help prevent incontinence. If incontinence occurs, it typically resolves within three months.

In general, patients should avoid lifting anything over 20 pounds for a week after the procedure. Sexual activity can typically be resumed about two weeks after the procedure.

Possible complications of HoLEP include:

• An injury to the bladder, ureters, and/or urethra
• Urinary retention
• Hematuria
• UTI
• Urinary incontinence
• Urethral stricture (narrowing of the urethra) or bladder neck contracture (narrowing of the bladder where it meets the urethra)
• A need for reoperation due to ongoing symptoms of BPH
• Retrograde ejaculation (when semen travels backward into the bladder rather than out of the penis)
• Feeling an urgency to urinate
• Frequent urination
• Pain or discomfort during urination

Most complications from HoLEP are temporary.

HoLEP is a safe and effective treatment for people who have bothersome lower urinary tract symptoms due to BPH. It can be used to treat people with an enlarged prostate of any size—big or small.

Clinical trials have shown that HoLEP is effective in relieving bothersome urinary symptoms caused by BPH, that the reduction in symptoms is long-lasting, and that the procedure is safe, with a low rate of complications. Studies that compare HoLEP to other common surgical treatments for symptomatic BPH, including TURP (often referred to as the “gold standard” of BPH treatment) and open simple prostatectomy, have found that HoLEP is at least as effective as these other treatments and has fewer complications. For example, less blood is lost during HoLEP, and the rate of blood transfusion is lower for HoLEP than for TURP and open simple prostatectomy. Similarly, studies have shown that compared to TURP, HoLEP requires a shorter hospital stay and less time with a catheter inserted.

“Yale Urology was the first center in Connecticut to offer HoLEP,” says Dr. Kellner. “We take pride in attracting patients not only from Connecticut but from across the nation and around the world. Patients are drawn to our expertise and cutting-edge services, and our tailored approach to patient care.”