What Happens During HoLEP Procedure?

The Holmium Laser Enucleation of the Prostate (HoLEP) procedure involves meticulous planning and preparation, as well as the use of various techniques to ensure the safe and effective removal of obstructive prostate tissue. 

Planning & Preparation

Before the procedure, the patient undergoes a comprehensive evaluation to assess prostate size, configuration, and suitability for HoLEP. This includes a medical history review, physical examination, urinalysis, blood tests, and imaging studies.

The surgical team prepares the operating room with the equipment and ensures all instruments are sterile and functional.

Anaesthesia, typically general or spinal anaesthesia, is administered to ensure patient comfort and safety during the procedure.

Apical Release

Apical release involves early dissection and release of the apex of the prostate gland to facilitate better access to the surgical plane, improve visualisation and minimise incontinence.

This step helps create a clear delineation between the prostate adenoma and the surrounding capsule, making subsequent enucleation easier and safer.

Sphincter Preservation

Sphincter preservation is crucial for maintaining urinary continence postoperatively. Careful dissection and preservation of the urethral sphincter complex are essential to minimise the risk of urinary incontinence.

Special attention is paid to preserving the integrity of the bladder, neck and urethra during the enucleation process.

Anterior Zone Dissection

Anterior zone dissection involves careful separation of the anterior portion of the prostate gland from the surrounding capsule.

This step can be challenging due to difficult surgical planes. Meticulous dissection is required to avoid injury to these structures and ensure complete removal of anterior prostate tissue.

Lateral Lobe Dissection

Lateral lobe dissection entails separating the lateral lobes of the prostate gland from the surrounding capsule, usually carrying the most prostate tissue.

This step is critical for accessing and enucleating the lateral lobes of the prostate adenoma while preserving adjacent structures such as the neurovascular bundles.

Tissue Morcellation

After enucleation, the prostate adenoma is fragmented into smaller pieces using a morcellator device.

The morcellator consists of rotating blades that cut the prostate tissue into small fragments, which are then suctioned out of the bladder.

Continuous irrigation maintains a clear surgical field and facilitates the morcellation process.

Bladder Inspection and Hemostasis

Once tissue morcellation is complete, the surgeon inspects the bladder using the cystoscope to ensure the complete removal of prostate tissue and the absence of any retained fragments.

Any bleeding points are addressed using the holmium laser to achieve haemostasis and ensure a clear surgical field.

Catheter Insertion

A catheter will be inserted into the bladder to allow drainage and healing of the urinary tract.

The catheter helps maintain urinary flow and minimises the risk of blood clots during the immediate postoperative period.

Postoperative Monitoring

The patient is transferred to the recovery area to closely monitor vital signs and postoperative recovery.

Nurses and medical staff monitor the patient's condition, including vital signs, urine output, and pain levels.

Recovery and Discharge

The patient remains in the hospital for one or two nights. Bladder irrigation will run, and laxatives are given to avoid straining in the immediate postoperative period.

Once the patient meets discharge criteria, the catheter will be removed, and the patient can be discharged home.

Instructions are provided to the patient and their caregiver regarding postoperative care, including activity restrictions, medication management, and signs of potential complications.

Follow-up Care

Follow-up appointments are scheduled to monitor the patient's progress, assess urinary symptoms, and address postoperative concerns.

Patients may undergo further evaluation, such as uroflowmetry or cystoscopy, to assess urinary function and ensure optimal outcomes.

What Happens to the Urethra During HoLEP Surgery?

During HoLEP surgery, the urethra, a crucial part of the urinary system, plays a central role. Here's what happens to the urethra during HoLEP surgery:

• Accessing the Prostate: To perform HoLEP, the surgeon inserts a cystoscope through the urethra into the bladder. This scope allows visualisation of the prostate gland, which surrounds the urethra like a doughnut around a straw.
• Enucleation of Prostate Tissue: Once the surgeon has visualised the prostate gland, a laser fibre is inserted through the cystoscope. The laser is used to carefully separate and remove excess prostate tissue that is causing urinary obstruction. This process is called enucleation.
• Clearing the Urethra: As the excess prostate tissue is removed, the urethra within the prostate is also removed. The goal is to create a wide and clear passage for urine flow through the urethra.
• Closure and Recovery: Once the enucleation is complete, any bleeding is carefully controlled, and the surgical site is inspected to ensure no damage to surrounding structures. The urethra lining then heals by extending over the remaining prostate capsule and rejoining the bladder, allowing for normal urinary function post-surgery. Patients typically experience relief from urinary symptoms as the obstructing prostate tissue is removed and urine flow improves.

How Much Tissue Is Removed in HoLEP?

On average, HoLEP procedures remove a substantial amount of tissue, often exceeding 70% of the whole gland. In comparison, TURP normally removes 50% of prostate tissue. 

The ability of HoLEP to remove large volumes of prostate tissue is one of its key advantages over other surgical techniques for BPH, such as transurethral resection of the prostate (TURP) or GreenLight laser therapy. This extensive tissue removal contributes to the procedure's efficacy in relieving urinary obstruction and improving urinary symptoms.

The precise amount of tissue removed during HoLEP is typically determined intraoperatively based on the size and configuration of the prostate gland and the surgeon's assessment of the patient's needs and clinical presentation. Additionally, postoperative assessments may include measuring the weight of the resected tissue to evaluate the extent of tissue removal and the procedure's success.