Latest Technology in Benign Prostate Enlargement: HoLEP Surgery

HoLEP surgery, performed using laser energy in the treatment of benign prostatic hyperplasia (BPH), is a minimally invasive surgical method where the prostate tissue blocking the urinary tract is completely removed. Eliminating the need for open surgery, especially for large-volume prostates, this innovative procedure allows patients to return to their daily lives much faster. By resolving quality-of-life issues such as difficulty urinating, frequent trips to the bathroom, and interrupted night sleep, this method stands as one of the most successful treatment options in modern urology.

• It is performed endoscopically (closed method) without any incisions.
• It boasts a high success rate, particularly for large prostates weighing 80 grams or more.
• Catheterization time is remarkably short, averaging just 3 to 5 days.
• The risk of bleeding is significantly lower compared to traditional methods.
• Negative impacts on sexual function (erections) are kept to an absolute minimum.
• The removed tissue can be sent to pathology for detailed cancer screening.

What is Laser Treatment for Prostate Enlargement?

Holmium Laser Enucleation of the Prostate (HoLEP) is a procedure in which the adenoma tissue—the part of the prostate gland that grows inward and narrows the urinary tract (urethra)—is separated from its capsule and removed using laser energy. You can think of this process like carefully peeling an orange from the inside, removing the fruit whole without damaging the outer rind. While the outer capsule of the prostate is left in place, the inner tissue blocking the urine flow is completely cleared away.

Prostate gland enlargement is a natural part of the aging process for older men. However, when this growth begins to press on the urinary canal, medical intervention becomes necessary. Because this minimally invasive laser method separates rather than cuts the tissues, it minimizes damage to surrounding areas. Consequently, the recovery process is accelerated, and the risk of post-operative complications is drastically reduced.

Symptoms and the Decision for Surgery

Benign prostatic hyperplasia often progresses quietly, with symptoms worsening over time. In the early stages, you might notice a slight slowdown in your urine flow rate. As time goes on and the bladder cannot empty completely, much more frustrating symptoms emerge. Waking up frequently during the night to urinate is the most common complaint, directly impacting a patient's energy levels and overall quality of life.

In the advanced stages of the condition, you may experience difficulty starting urination, a need to strain, or a weak, interrupted, or split urine stream. Additionally, a sudden and urgent need to go, leaking urine before reaching the toilet, and a constant feeling of fullness in the bladder can occur. These signs indicate that the bladder muscles are exhausted and struggling to push the urine out. For patients whose symptoms persist despite medication or whose kidney function is at risk, surgical intervention is planned.

Who is HoLEP For?

This operation can be safely performed on male patients of almost any age who have been diagnosed with benign prostatic hyperplasia and require surgical treatment. It is the ideal choice, especially for patients with a large prostate volume where traditional closed methods fall short. It is also a primary preference for cardiovascular patients who must take blood thinners, thanks to its low risk of bleeding.

Assoc. Prof. Dr. Yasin Yitgin, a Urology Specialist at BHT CLINIC İstanbul Tema Hastanesi, shares the following important insight regarding who this method is applied to:

"Looking at broad screenings, we see symptomatic benign prostate enlargement in one out of every two men aged 50 and over. We particularly prefer this surgery for prostates weighing 80 grams and above, and in patient groups that are resistant to medical treatment."

Pre-Operative Preparation and Diagnosis

At our hospital, patients presenting with prostate complaints first undergo a detailed urological examination. During the diagnostic process, an ultrasound is performed to evaluate the size and structure of the prostate. The degree of blockage is objectively determined using a uroflowmetry test, which measures the urine flow rate. Additionally, the PSA (Prostate-Specific Antigen) level in the blood is always checked to rule out the possibility of prostate cancer.

Once the decision for surgery is made, a pre-operative evaluation is conducted by our anesthesia specialists. Routine screenings such as blood tests, an ECG, and a chest X-ray are completed. The operation is typically performed under general anesthesia or regional (spinal/epidural) anesthesia, which numbs the body from the waist down. Patients are asked to stop eating and drinking from midnight the night before the surgery. The intake of regularly used blood pressure or diabetes medications is adjusted under the guidance of our physicians.

How is the Operation Performed?

After anesthesia is administered, the procedure begins by entering the patient's urinary tract (urethra) with a special endoscopic camera. No incisions are made on the body. Thanks to the camera, the prostate tissue and bladder are displayed on a screen in high resolution. Using the fine fiber of the holmium laser, the enlarged prostate tissue (adenoma) is separated from the outer capsule with millimeter precision.

The large prostate tissues, once completely separated from the capsule, are pushed into the bladder. Inside the bladder, these large pieces of tissue are broken down into smaller fragments using a special device called a 'morcellator,' then vacuumed and removed from the body. These extracted fragments are sent to the pathology laboratory to be examined at a cellular level. At the end of the procedure, bleeding control is meticulously performed, and a urinary catheter is inserted for the first stage of the recovery process, concluding the operation.

Comparison with Traditional Methods

In past years, open prostate surgery or the traditional closed method, TURP (Transurethral Resection of the Prostate), were frequently used to treat large prostates. Because open surgery required an incision in the lower abdomen, the hospital stay was longer, and the risks of infection and bleeding were higher. In the TURP method, tissues were burned and cut using electrical energy, which prolonged the procedure time and increased the risk of bleeding, especially for large prostates.

Laser technology eliminates the disadvantages of both methods. Like open surgery, the entire enlarged tissue of the prostate is removed, but this procedure is done completely endoscopically, like TURP. The penetration depth of the holmium laser into the tissue is only 0.4 millimeters. This shallow area of effect prevents the nerves that run just around the prostate and control sexual functions from being damaged by heat. Furthermore, the laser's ability to simultaneously seal blood vessels reduces bleeding during surgery to an almost negligible level.

Advantages and the Recovery Process

The biggest advantage of this laser intervention is that patients can quickly return to their normal lives. The hospital stay is generally limited to 1 or 2 days. The catheter is typically removed within 3 to 5 days, once the urine color clears up. After the catheter is removed, patients begin to urinate comfortably and can return to work shortly after.

One of the biggest concerns for male patients before prostate surgery is the potential negative impact on their sexual life. Assoc. Prof. Dr. Yasin Yitgin reassures patients on this matter:

"Its superiority over other closed prostate surgeries lies in the fact that the laser energy does not penetrate deeper tissues, resulting in less tissue damage. Thanks to this, we rarely see erectile dysfunction. Ejaculation dysfunction is also encountered much less frequently compared to other prostate surgeries."

Precautions and Risks

The first few weeks after discharge are critical for a healthy recovery. Patients are advised to drink at least 2-3 liters of water a day to naturally flush their urinary tracts. It is important to avoid constipation, refrain from heavy lifting, and steer clear of strenuous physical activities. Experiencing a slight pinkish tint in the urine or a mild burning sensation during the first few days is expected and temporary.

The risk of the disease recurring and the development of cancer are often confused. Assoc. Prof. Dr. Yasin Yitgin summarizes this critical distinction:

"Because we completely remove the obstructive adenoma portion, we theoretically do not expect prostate blockage to occur again. However, we do not eliminate the risk of prostate cancer after surgery. This is because the cells in the peripheral zone—the capsule part of the prostate where prostate cancer develops with an 85-90 percent probability—still remain in the patient."

For this reason, it is vital not to neglect annual urological check-ups in the post-operative period.

When Should You See a Doctor?

If you are experiencing symptoms of prostate enlargement, you should see a urologist before your bladder muscles become permanently exhausted. Assoc. Prof. Dr. Yasin Yitgin recommends that men over 40-45 with a family history, or all men aged 50 and over, have a prostate exam once a year, even if they have no urinary complaints. In symptomatic patients, surgical treatments performed after bladder dysfunction has become permanent may not yield the desired results.

If you experience any of the following emergency symptoms, you should immediately visit the emergency department of the nearest healthcare facility or call 112:

• Inability to urinate at all (acute urinary retention) and resulting severe lower abdominal pain.
• Heavy, clotted, and dark red bleeding in the urine.
• Unbearable burning sensation while urinating, accompanied by a high fever and chills.
• Sudden and severe pain developing in the kidney areas (on both sides of the lower back).

The Process at BHT CLINIC

At the BHT CLINIC İstanbul Tema Hastanesi Urology Department, personalized plans are created using the latest technologies in the diagnosis and treatment of prostate diseases. From your detailed pre-operative tests to the operation and post-discharge follow-up process, every step is meticulously managed by our expert medical staff. For any potential emergencies, our 24/7 emergency department is always by your side.

When you visit our hospital for your prostate check-ups, you can also undergo a comprehensive health screening by booking an appointment with our Ophthalmology department for conditions like cataracts or glaucoma, which are common in older age groups. If you would like detailed information about these silently progressing eye diseases, you can review our related guide. To avoid delaying your health and to consult with our specialist doctors, you can visit our online appointment page.

Frequently Asked Questions

How long does HoLEP surgery take?

While the operation time varies depending on the size of the prostate, it is typically completed in about 1 to 2 hours. For patients with a very large prostate volume, this duration may be slightly longer.

Is sexual life affected after surgery?

Because the laser energy only penetrates 0.4 millimeters into the tissue, it does not damage the nerves responsible for erections. As a result, the risk of losing erectile function is almost non-existent. Only the backward flow of semen into the bladder (retrograde ejaculation) might occur, which is not harmful to your health.

How many days does the catheter stay in?

While a catheter can remain for weeks in traditional open prostate surgeries, with this modern laser method, the patient's catheter is usually removed within 3 to 5 days. Once the catheter is taken out, the patient can urinate comfortably on their own.

Will the prostate grow back?

In this surgical technique, the inner tissue of the prostate (adenoma) that blocks the urinary tract is completely separated from its capsule and removed. Since no obstructive tissue is left behind, the possibility of the disease recurring and causing another blockage is theoretically not expected.

Will there be urinary incontinence after surgery?

The sphincter muscles that control urine retention are clearly seen with high-resolution cameras during the operation and are therefore protected. Although slight dripping is considered normal for the first few days after the catheter is removed, permanent urinary incontinence is an extremely rare occurrence.

This article is for informational purposes only; please be sure to consult your doctor for diagnosis and treatment.