An insight into HoLEP – minimally invasive prostate surgery

Mr Andrew Ballaro is a Consultant Urological Surgeon who practices at our hospital.

He is highly experienced in the management of all general urological problems and is an expert in laser prostate surgery. We spoke to him about HoLEP (Holmium Laser Enucleation of the Prostate), which is particularly good for people who have very large prostates.

What is the prostate?

The prostate is a small gland about the size of a walnut. It’s divided into two lobes and is surrounded by an outer layer called the capsule. The prostate gets bigger as you get older.

The prostate sits below the bladder and surrounds the first part of the urethra – the tube that carries pee from the bladder.

What does the prostate do?

The prostate produces a fluid that mixes with sperm to make semen. It also produces a protein called prostate-specific antigen (PSA). A blood test can measure your PSA levels and is used to help diagnose different prostate problems, including cancer.

How to tell you might have an issue with your prostate

As men get older the prostate can grow larger, or become tighter, and this can constrict the flow of urine from the bladder out of the body. The symptoms of a prostate problem can be extremely troublesome. They may even need to have a catheter fitted in order to pee, which many find uncomfortable and embarrassing.

Obviously this causes many problems, such as:

• Straining when you pee
• Pain or burning when you pee
• Poor urinary flow
• Having to pee often or at night
• Having to rush to the loo
• Sudden painful inability to pass urine

What is HoLEP?

HoLEP is a laser surgery which I offer to men who have a very large prostate. If you think about the prostate like an orange, then the core through the middle of the orange would be the channel through which the urine flows, the orange flesh would be the obstructing prostate tissue constricting the flow, and the rind would be the prostate capsule.

The procedure is minimally invasive and uses a high-powered laser to detach the ‘flesh’ of the prostate from the capsule. This is then transferred to the bladder and suctioned out. The major advantage of this procedure is that you can treat prostates too large to be operated on safely using other methods.

What other options are there?

Depending on the severity of the symptoms and the size of the prostate (some can swell to the size of a grapefruit) different treatment approaches can be taken.

Should someone come to me and it turns out they have a large prostate, surgery would be needed to remove the enlarged section that’s causing issues.

When the prostate hasn’t swelled too much, we can do a standard prostate resection (TURP). This procedure involves resecting the prostate flesh bit by bit from the inside towards the capsule using a electrosurgical loop, leaving more space for the urethra and freeing up the flow of urine.

Whilst this procedure is highly effective for smaller and mid sized prostates, it isn’t recommend for very large ones. This is because as the tissue is shaved away, it bleeds, and will carry on bleeding until the capsule is reached. If there is a lot of tissue to shave away, the blood loss can be significant and could result in needing a blood transfusion.

There are other procedures available, which don’t remove as much obstructing prostate tissue as HoLEP and TURP, and as such may not produce as good a result, although there is certainly a role for them.

The bigger the prostate, the better it is to use the HoLEP method.

HoLEP is more efficient for larger prostates as the laser technique allows the obstructing prostate tissue to be separated from the capsule more efficiently in one chunk instead of multiple pieces, by cutting into the tissue plane just next to the capsule. This significantly reduces blood loss and removes the maximum amount of tissue possible, preventing regrowth of the prostate. The laser light is exceptionally good at stopping bleeding, so much so that the procedure can also be done on patients taking blood-thinning medications.

What are the benefits of HoLEP?

HoLEP is an established, safe and effective procedure that offers the unique advantage of being able to remove a large amount of prostate tissue with minimal blood loss without needing to make any incisions on the body, even when the prostate is very large. The recovery time is fast, meaning most people only need to stay overnight in hospital and can get home the next day passing urine well. It doesn’t affect the ability to have an erection, and minimises the risk of needing a repeat procedure in the future, which can occur with larger prostates when not all the tissue is removed.

HoLEP isn’t offered at many places as it’s difficult to do and surgeons need to do additional training, which involves doing at least 50 cases before being fully qualified. Whilst it’s offered at some NHS hospitals, waiting lists are currently very long due to the COVID backlog and cancer patients needing to be given priority treatment.

Some patients that come to me have previously been told that their prostate is too large to be operated on and there’s nothing that can be done. For them, HoLEP is the perfect solution.

A HoLEP procedure is safe and effective, even for the largest of prostates, and has a faster recovery time than other prostate procedures.

If you’re worried you might have an issue with your prostate, book an appointment with Mr Ballaro at our hospital. He runs clinics every Wednesday evening and Friday morning in our outpatients department. To book, call our Urology Clinic on 020 7432 8297 or fill out an enquiry form on his profile page.