Holmium Laser Enucleation Of The Prostate (Holep)

• Typically outpatient admission for observation (< 24 hours), keep patients overnight to monitor for bleeding and make sure catheter does not clog by running irrigation through it.
• Check postoperative labs (blood counts, electrolytes, kidney function) as a precaution.
• Once fully awake can eat/drink, can walk with nurses assistance.
• On day after surgery as long as you are doing well, the nurses remove the catheter around 4-Sam in order to allow time for you to urinate. If the nurses have any concerns, they wait for me to see you in the morning before removing the catheter.
• With the catheter out, we ask that when you void you use a hand-held urinal so we can measure the volume voided and assess the color of the urine which gives an indication on how much bleeding there is. Typically, at least two bladder scans with relatively low volumes and good voided volumes meets discharge criteria.
• 90% of patients are discharged home on the day after surgery without a catheter.

• 2% complication rate - bleeding (blood transfusion or clot retention), infection (UTI), injury to nearby structures (urethra/bladder).
• Blood in the urine normal/expected postop, improves with time. If on blood thinners can take weeks/months to resolve.
• Burning with urination is common due to the raw surface in the prostatic urethra from the surgery and resolves with time, sometimes in days but can take weeks/months in some men.
• Urethral stricture/bladder neck contracture/regrowth of prostate requiring treatment 1-2%.
• Short term stress and/or urge incontinence 25-30%, long term 1%.
  • Stress: the urethral sphincter is a muscle that sits below the prostate and is responsible for continence.
    This muscle is weakened in men with large prostates because the prostate has limited the amount of lifting this sphincter has had to do to hold back the urine (prostate is an upstream dam). Once the prostate size is largely reduced, the sphincter has to do more work and is atrophy is significant there can be leakage until the pelvic floor regains strength.

  • Urgency: some patients get frequency/urgency after this operation. The bladder for years has had to squeeze very hard to get urine past the prostate. After the surgery, the bladder does not need to do this because the obstruction is gone, but the bladder nerves need time to adjust to this. Nerves heal slowly so this process can take several months.
  • On average, any postoperative urinary symptoms are improving by three months, only 1% chance the incontinence lasts more than one year.
• 90% chance of retrograde ejaculation
  • Could be diminished or absent ejaculated with orgasm/climax, not harmful, semen will go back into the bladder but then with the next void will empty in the urine.
  • Semen enters urethra below the prostate and after prostate surgery the path of least resistance is to go back into the bladder instead of out the small urethral channel.
  • Nerves that control erections are outside the prostate and not affected by the surgery, so erectile function does not typically change.

Less than 10 percent chance of incidental prostate cancer identified on pathology. This surgery does not preclude other treatments (radical prostatectomy, radiation, etc.).