Ongoing HoLEP Research

Detrusor acontractility is viewed as a relative contraindication to surgical intervention for men with bladder outlet obstruction secondary to BPH. Mayo Clinic researchers are testing the use of HoLEP for men with hypocontractile or acontractile bladders.

In a prospective trial of men ages 53 to 85 years, Mayo urologists performed HoLEP on 15 participants with evidence of BPH and bladders that had very little function or contraction ability. Preoperatively, all participants had catheter-dependent urinary retention for a median of five months (range: three to 60 months). Postoperatively, all men were able to void spontaneously without need for intermittent catheterization, with 13 participants displaying a return of detrusor contractility, and two participants voiding exclusively by Valsalva efforts. At their six-month postoperative follow-up, all participants were still able to urinate. Although these findings are preliminary, they suggest that HoLEP may be a viable treatment option for men with BPH and hypocontractile or acontractile detrusor muscle.

What should I expect before the procedure?

If you are taking any blood thinners, please notify me well in advance prior to your surgery. These drugs can cause increased bleeding after prostate surgery. Based on your specific situation, I will make a recommendation on when to safely hold and restart your medication. In general, these medications are held about 1 week prior to and 1 week after your surgery.

Examples of Blood Thinners Include: Aspirin, Plavix (Clopidogel), Coumadin (Warfarin), Argatroban, Pradaxa (Dabigatran), Xarelto (Rivaroxaban), Eliquis (Apixaban), Edoxaban

You will usually be admitted on the day of your surgery. You will normally receive an appointment for preassessment before your admission, to assess your general fitness and to perform some baseline blood and urine tests. After admission, you will be seen by members of the medical team who will include your anesthesiologist and nurse.

You will be asked not to eat or drink for at least 8 hours before surgery and, immediately before the operation, you may be given a pre-medication by the anesthesiologist which will make you dry-mouthed and pleasantly sleepy.

What happens during the procedure?

Either a full general anesthetic (where you will be asleep throughout the procedure) or a spinal anesthetic (where you are awake but unable to feel anything from the waist down) will be used. All methods minimize pain; your anesthesiologist will explain the pros and cons of each type of anesthetic to you. The operation usually takes 60-180 minutes, depending on the size of your prostate.

You will usually be given an injectable antibiotic before the procedure after checking for any drug allergies.

The laser is used to separate the obstructing prostate tissue from its surrounding capsule and to push it in large chunks into the bladder. An instrument is then used through the telescope to remove the prostate tissue from the bladder. A catheter is normally left to drain the bladder at the end of the procedure.

What should I expect after surgery?

There is always some bleeding from the prostate area after the operation. The urine is usually clear of blood after 24 hours, although it is quite common to see some blood in the urine, often intermittently, for even up to 6 weeks after surgery. This is not a concern surgically, and although blood in the urine may seem alarming to some people it is usually only a small amount of blood that is lost. It is very unusual to require a blood transfusion after laser surgery (1-2%).

It is useful to drink more fluid than normal in the first 24 hours after the operation because this helps the urine clear of any blood more quickly. Sometimes, fluid is flushed through the catheter to clear the urine of blood.

Many men are surprised at how comfortable they are after laser prostate surgery. Apart from some minor discomfort from the catheter irritating the penis and bladder, it is usual not to have any pain as such.

You will be able to eat and drink on the same day after the operation.

The catheter is generally removed the morning after surgery. At first, it may be painful to pass your urine and it may come more frequently than normal. Any initial discomfort can be relieved by tablets or injections and the frequency usually improves within a few days. Some of your symptoms, especially frequency, urgency and getting up at night to pass urine, may not improve for several months because these are often due to bladder overactivity (which takes time to resolve after prostate surgery) rather than prostate blockage.

Since a large portion of prostate tissue is removing with the laser technique (which means you

will have excellent relief of prostate blockage and have a very low risk of ever needing a repeat prostate operation), there may be some temporary loss of urinary control until your pelvic floor muscles strengthen and recover.

I have attached some information on pelvic floor, or kegel, exercises. If you do these exercises as advised, the risk or urinary incontinence after surgery is low, and if it does occur it normally resolves completely within a few months (often within a few days). Any incontinence is normally managed by wearing a pad inside the underpants. The need to use pads beyond 3 months occurs in less than 2% of men.

Let your nurse know if you are unable to pass urine and feel as if your bladder is full after the catheter is removed. Some patients, particularly those with small prostate glands, are unable to pass urine at all after the operation due to temporary swelling of the prostate area. If this should happen, we normally pass a catheter again to allow the swelling to resolve and the bladder to regain its function. Usually, patients who require re-catheterization go home with a catheter in place and then return within a week for a second catheter removal which is successful in almost all cases.

The average hospital stay is one day.

What should I expect when I get home?

Most patients feel tired and below par for a week or two because this is major surgery. You may notice that you pass very small flecks of tissue in the urine at times within the first month as the prostate area heals. This does not usually interfere with the urinary stream or cause discomfort.

What else should I look out for?

If you experience increasing frequency, burning or difficulty in passing urine or worrying bleeding, please contact your doctor.

About 1 man in 5 experiences bleeding some 10-14 days after getting home; this is due to scabs separating from the cavity of the prostate. Increasing your fluid intake should help stop this bleeding within 24 hours but, if it does not, you should contact your urologist or your GP who may prescribe some antibiotics for you.

In the unlikely event of severe bleeding, passage of clots or sudden difficulty in passing urine, you should contact me immediately since it may be necessary for you to be re-admitted to hospital.

Are there any other important points?

Removal of your prostate should not adversely affect your ability to have an erection provided you are getting normal erections before the surgery. It is very common not to be able to ejaculate any semen at the point of orgasm after prostate surgery. This is because after surgery it is much easier for the semen to travel back into the bladder than down and out through the penis. This is not an uncomfortable or harmful consequence of surgery, and most men say the experience of orgasm remains a pleasurable sensation. This is only a major issue if you intend fathering children in future. Sexual activity can be resumed as soon as you are comfortable, usually after 3-4 weeks.

It is often helpful to recommence pelvic floor exercises as soon as possible after the operation since this can improve your control when you get home. The symptoms of an overactive bladder may take 3 months to resolve whereas the flow is improved almost immediately.

The results of any tissue removed will be available after 7-14 days and I will inform you of the results. If any results are best discussed with you in person, an appointment will be made for you to be seen in the clinic soon after the results become available.

If you are doing well after surgery, I will see you in about 6 weeks for a checkup. At that time several tests will be repeated (including a flow rate, bladder scan & symptom score) to help assess the effects of the surgery.

Most patients require a recovery period of 1-2 weeks at home before they feel ready for work. We recommend 2 weeks’ rest before resuming any job, especially if it is physically strenuous and you should avoid any heavy lifting during this time. You should not drive until you feel fully recovered; 1 week is the minimum period that most patients require before resuming driving.

Are there any side-effects of the operation?

Common side-effects (greater than 1 in 10)

· Temporary mild burning, bleeding and frequency of urination after the procedure

· No semen is produced during an orgasm in approximately 75% if the prostate is fully enucleated (retrograde ejaculation)

· Treatment may not relieve all the urinary symptoms, but if this is the case a medication can sometimes help if required

· Failure to pass urine immediately after surgery requiring placement of a new catheter which is then removed (almost always successfully) within a week (10-15%)

Occasional side-effects (between 1 in 10 and 1 in 50)

· Loss of complete urinary control (incontinence) which normally resolves within 6 weeks (less than 10%); this can usually be improved with pelvic floor exercises

· Weaker or no erections. 2 recent studies have shown no significant difference in ability to have an erection in men before and after HoLEP surgery but there is still a small risk (probably less than 5%) of a decreased ability to have an erection. Some men’s erections improve after surgery

· Injury to the urethra causing delayed scar formation requiring further minor surgery (5%)

· Finding unsuspected cancer in the removed tissue which may need further treatment (5%)

· Infection of the bladder, testes or kidney requiring antibiotics

Rare side-effects (less than 1 in 50)

· Need to repeat treatment later due to re-obstruction from prostate regrowth (approx 1% in the first 7 years after surgery)

· Self-catheterization or permanent catheter to empty bladder if the bladder is weak (1%)

· Persistent loss of urinary control which may require a further operation (less than 1%)

· Retained tissue fragments floating in the bladder which may require a second telescopic procedure for their removal (less than1%)

· Very rarely, perforation of the bladder requiring a temporary urinary catheter or open surgical repair (less than 0.5%)

Bleeding requiring return to theatre and/or blood transfusion (less than 0.5%)

Summary

Surgery usually is not required to treat BPH, although some men may choose it because their symptoms bother them so much. Choosing surgery depends mostly on your preferences and comfort with the idea of having surgery. Things to think about include your expectation of the results of the surgery, the severity of your symptoms, and the possibility of having complications from the surgery. Men who have severe symptoms often have great improvement in quality of life following surgery. Men whose symptoms are mild may find that surgery does not greatly improve quality of life. Men with only mild symptoms may want to think carefully before deciding to have surgery to treat BPH.

Besides your urinary symptoms and overall level of bother, the situations in which I will strongly recommend prostate surgery include:

1. The inability to urinate

2. Recurrent urinary tract infections

3. Recurrent blood in the urine

4. Damage to your kidneys as a result of bladder outlet obstruction

If you are at the point where a BPH surgery is advised, most commonly performed procedures do an effective job at relieving your symptoms. The main advantage that I see for HoLEP is the ability to remove all BPH tissue in a minimally invasive fashion. In comparison to other treatments, I think that this translates to a lower surgical risk and a decreased need for repeat procedures.