Tev Aho Urology Tev Aho Urology
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Holmium Laser Enucleation of the Prostate

Introduction

Holmium Laser Enucleation of the Prostate, otherwise known as HoLEP, is a surgical technique for the treatment of urinary symptoms due to benign enlargement of the prostate (BPH). It is the only laser technique recommended by NICE (National Institute for Health and Clinical Excellence) for the treatment of BPH in the UK outside of clinical trials, and is recommended for men with prostates of any size. NICE recommends that HoLEP should be performed by a surgeon specialising in the technique.

History

HoLEP was developed by 2 New Zealand Urologists, Peter Gilling and Mark Fraundorfer, in the 1990′s. Since then it has been extensively researched and a large number of published clinical trials support it as the new “Gold Standard” for treating BPH. Mr Aho trained with Messrs Gilling and Fraundorfer for a year and has been performing HoLEP since 2002. He is the most experienced HoLEP surgeon in the UK with experience of more than 1,300 HoLEP procedures.

What does HoLEP involve?

HoLEP is normally done under general anaesthetic. The prostate is approached internally (endoscopically), through the urethra, without any cuts on the skin. The Holmium laser is used to peel out the obstructive core of the prostate in its entirety. This leads to maximal relief of prostate obstruction and a man will usually only require one HoLEP procedure in his lifetime as it is very unlikely that the prostate will regrow after HoLEP (0.7% need a re-operation up to 10yr after HoLEP (1) compared to 10-15% after TURP, and more after green light laser surgery).

Complete removal of the obstructive inner part of the prostate with HoLEP

Diagram showing the complete removal of the obstructive inner part of the prostate that is achieved with HoLEP

After HoLEP, the area of the prostate that is removed is sent for microscopic analysis. Cancer that would otherwise be undetected is found in 8%.

Advantages of HoLEP

HoLEP was developed to improve the effectiveness, safety and durability of surgery for BPH. The main advantages of HoLEP over Transurethral Resection of the Prostate (TURP) which has been in use for the past 80 years include:

  • More tissue removed, leading to better relief of prostate obstruction, symptoms and urinary flow rate
  • Less blood loss
  • Shorter hospital stay. 90% of men stay just 1 night in hospital after HoLEP, whereas the average hospital stay after TURP in the UK is 3 days
  • More durable. The need for redo prostate surgery is 15% for TURP compared to 0.7% for HoLEP within the first 10 years of surgery. The benefits of HoLEP can be expected to last a lifetime.
  • Unlike TURP, HoLEP is suitable for men with any size prostate. Mr Aho has successfully performed HoLEP on men with prostate volumes up to 650g.
  • HoLEP is more effective at treating men who are in urinary retention. At 5 years after surgery, 98% of men who had been catheter dependent before HoLEP remained catheter-free compared to 70% of men who had TURP (Mr Aho’s own data).
  • Can be used in men who have bleeding disorders or are on blood thinners (eg. Aspirin, clopidogrel and warfarin).

What does research show about HoLEP?

HoLEP is one of the most extensively researched procedures for BPH. 16 HoLEP randomised trials (the highest quality of clinical trial) have been published up to Dec 2014. (2) The clinical trials comparing it to the previous “gold standard” of TURP, consistently show advantages for HoLEP that include: Less bleeding, fewer blood transfusions, shorter time with a catheter in place after surgery, and shorter hospital stay (90% of men having HoLEP are able to leave the hospital without a catheter the day after surgery, and in some cases there is no need to stay in hospital overnight). Meta-analyses which are studies analysing the results of large numbers of randomised trials, suggest that HoLEP relieves urinary symptoms and improves urinary flow rates more effectively than all other endoscopic procedures for BPH (3). The average symptom score improvement after HoLEP is 70-80% and flow rate improvements of up to 600% have been reported. (4) Recent studies have shown that HoLEP is extremely effective at treating men in urinary retention (5). 98% of men with catheters before surgery are freed from their catheter dependence after HoLEP. This compares to 70% with green light laser and TURP surgery. (6) Unlike all other endoscopic procedures for BPH, HoLEP is suitable for men with any size prostate. (7+8)

references

  1. Holmium laser enucleation of the prostate: long-term durability of clinical outcomes and complication rates during 10 years of followup.
    Elmansy HM, Kotb A, Elhilali MM.
    J Urol. 2011 Nov;186(5):1972-6. doi: 10.1016/j.juro.2011.06.065. Epub 2011 Sep 23. PMID: 21944127 [PubMed - indexed for MEDLINE].
    Reoperation rate due to regrowth of the prostate after HoLEP is 0.7% at up to10 years after surgery
  2. Holmium laser enucleation of the prostate: a paradigm shift in benign prostatic hyperplasia surgery.
    Aho TF.
    Ther Adv Urol. 2013 Oct;5(5):245-53. doi: 10.1177/1756287213498923
    http://www.ncbi.nlm.nih.gov/pubmed/24082919
    HoLEP literature review
  3. A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update.
    Cornu JN, Ahyai S, Bachmann A, de la Rosette J, Gilling P, Gratzke C, McVary K, Novara G, Woo H, Madersbacher S.
    Eur Urol. 2014 Jun 24. pii: S0302-2838(14)00538-7. doi: 10.1016/j.eururo.2014.06.017. [Epub ahead of print] Review.
    PMID: 24972732 [PubMed - as supplied by publisher]
    http://www.ncbi.nlm.nih.gov/pubmed/24972732
    Meta-analysis showing superior results for HoLEP compared to TURP and green light laser vaporisation
  4. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial.
    Kuntz RM, Lehrich K, Ahyai SA.
    Eur Urol. 2008 Jan;53(1):160-6. Epub 2007 Aug 28.
    PMID: 17869409 [PubMed - indexed for MEDLINE]
    HoLEP achieves equivalent flow rate improvement to open prostate removal
  5. Holmium Laser Enucleation and Photoselective Vaporization of the Prostate for Patients with Benign Prostatic Hyperplasia and Chronic Urinary Retention.
    Jaeger CD, Mitchell CR, Mynderse LA, Krambeck AE.
    BJU Int. 2014 Feb 19. doi: 10.1111/bju.12674. [Epub ahead of print]
    PMID: 24552209 [PubMed - as supplied by publisher]
    HoLEP is very effective at relieving urinary retention
  6. Holmium Laser Enucleation and Photoselective Vaporization of the Prostate for Patients with Benign Prostatic Hyperplasia and Chronic Urinary Retention.
    Jaeger CD, Mitchell CR, Mynderse LA, Krambeck AE.
    BJU Int. 2014 Feb 19. doi: 10.1111/bju.12674. [Epub ahead of print]
    PMID: 24552209 [PubMed - as supplied by publisher]
    HoLEP is more successful than green light vaporisation for relieving urinary retention
  7. Holmium laser bladder neck incision versus holmium enucleation of the prostate as outpatient procedures for prostates less than 40 grams: a randomized trial.
    Aho TF, Gilling PJ, Kennett KM, Westenberg AM, Fraundorfer MR, Frampton CM.
    J Urol. 2005 Jul;174(1):210-4.
    PMID: 15947629 [PubMed - indexed for MEDLINE]
    HoLEP is effective for small prostates and can be done as a day surgery procedure
  8. Holmium laser enucleation of the prostate for prostates larger than 175 grams.
    Krambeck AE, Handa SE, Lingeman JE.
    J Endourol. 2010 Mar;24(3):433-7. doi: 10.1089/end.2009.0147.
    PMID: 19852722 [PubMed - indexed for MEDLINE]
    HoLEP is safe and effective for men with very large prostates. There is no size limit for HoLEP

I am interested in HoLEP for treating my urinary symptoms. I don’t have a catheter. What is the next step?

If you live in the UK or Ireland we prefer either a GP or urologist referral letter with details of your PSA, rectal examination and dipstick urine test results if available. We also need a list of your current medications and a summary of your medical history.

If you are unsure about this please contact Mr Aho directly here

Please print the International Prostate Symptom Score, fill it out according to the instructions and bring this with you to your first appointment. If you have seen a urologist previously it would be helpful if you could provide your flow rate and bladder scan (post void residual volume) measurements as well as your estimated prostate volume if available.

If you are an international patient please contact Mr Aho directly here sending as much of the above information as possible.

Please send referral letters and other information to:
Fax: 01223 281271
Email

Mr Aho will assess the information you have submitted and respond to your enquiry. If deemed suitable, a clinic appointment will be booked to discuss HoLEP, arrange preassessment tests and a date for surgery.

If you will be travelling from more than 2 hours drive away it is recommended that you arrange to spend at least 1 night in London after discharge from hospital before travelling home. A clinic follow up is usually booked 3 months after surgery.

For international patients it is recommended to stay a minimum of 1 week in the UK after surgery.

I am interested in HoLEP to free me from the need for catheterisation, what is the next step?

If you live in the UK or Ireland we prefer either a GP or urologist referral letter with details of your current medications and a summary of your medical history. If you have seen a urologist previously it would be helpful if you could provide any letters from them

If you are an international patient please also send as much of the above information as possible.

Please fax or email your information to:
Fax: 01223 281271
Email

Mr Aho will assess the information you have submitted and respond to your enquiry. If deemed suitable, a clinic appointment will be booked to discuss HoLEP, arrange preassessment tests and a date for surgery.

If you will be travelling from more than 2 hours drive away it is recommended that you arrange to spend at least 1 night in London after discharge from hospital before travelling home. A clinic follow up is usually booked 3 months after surgery.

For international patients it is recommended to stay a minimum of 1 week in the UK after surgery.

HoLEP information sheet

Download the HoLEP info sheet

HoLEP videos

Link to HoLEP videos.