>> HoLEP is spelled out
holmium laser in nucleation of the prostate.
If you were to simplify to one word it would be enucleation,
and in this sense, we use a holmium laser to do that enucleation.
What an enucleation is,
is basically finding the very edge
of the prostate at the very start of
the surgery and then following
the tissue plane all the way around the prostate,
left side to right side, top to bottom,
front to back, and staying in that tissue plane,
and that is what an enucleation is separating
all that tissue from the peel of
the prostate or the casing of the prostate.
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>> The HoLEP procedure would be good for anybody
with obstruction from their prostate,
and that might come across for
some patients as a lot of urinary frequency,
meaning going to the bathroom more often or urgency
or they can't hold their urine or postpone their urination.
In addition, other men
present more with your classic plumbing problem.
Weak stream, you have to strain to empty urine,
might start and stop.
For either of those men, HoLEP could be
a potentially excellent option.
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>> There are lots of different procedures
that you can have for your prostate.
The benefit of a HoLEP is that it's a comprehensive surgery.
You're removing all the prostate tissue in one setting,
which then minimizes the risks that you might need
some future procedure for the same problem.
After a HoLEP, your risk of needing
another procedure in 10 years is about one or two percent,
so 99, 98 percent of patients
are a one-and-done thing after a HoLEP.
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>> HoLEP procedure is done through the *****,
insert a telescope into the urethra,
and go through the prostate and into the bladder,
and at that point, it typically divide
the prostate into two or three pieces.
I use a laser to cut into the prostate and get to
the very edge of the prostate or
the capsule of the prostate, so to say.
Then use a combination of some mechanical force
using the edge of the scope almost like a pry bar.
In addition, use the holmium laser to push the tissue away,
so that way I can see exactly where I need to
go next in this spherical space that I'm in.
If you think of the prostate like an orange,
and basically staying between the fruit and the peel of
that orange and working all the way around front-to-back,
and I take that tissue and push it all into the bladder.
Now, with other surgeries,
the pieces are smaller and it's easy
to pull those pieces through the scope.
Or if you were to have
a simple prostatectomy where
it's done through the abdominal cavity,
we would take all that prostate tissue and
put it in a bag and pull the bag out.
With a HoLEP, you could imagine
these two big pieces or three big pieces can be pretty large,
and so I use a different device called a morcellator.
Essentially, a long wand with
suction and some tiny blades on it that section
onto the tissue chump off the pieces and pull
all the pieces out without needing any incisions.
Because it's all done through the urethra,
through a telescope,
there are no incisions at all related to
holmium laser or enucleation in the prostate.
The equivalents can be done
through the abdominal cavity with incisions,
and that's called a simple prostatectomy.
But again, I'm essentially doing
the same thing just through the urethra
where we stay confined to the very edge of
the prostate and work all the way
around the casing of the prostate.
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>> After a man goes through a HoLEP,
the cavity is pretty large or can be,
and it does take some time for the urinary system to
re-grow the lining that makes
up the urinary tract through that area.
Essentially, recarpet that area.
That's the period of time that men are mostly looking
at for symptoms of the surgery.
They might pie a little bit more frequently than normally.
They might have to go to the bathroom more often or more
urgently than before surgery just as at area is healing.
They might also see some more blood in
their urine on and off during that period of time.
It's usually the same timeframe that we tell
people to avoid getting constipated or
lifting something heavy because if they strain they might bleed
and that could put them into retention temporarily.
While that healing is happening,
that urge can be quite intense, and urea's sphincter,
the gasket mechanism that keeps you in control of your urine
may not be strong enough immediately to
compensate for that intense urge,
so men may leak a little bit of
urine in the first several weeks after the surgery.
They might also leak a little bit of
urine when they cough or sneeze
or lift something heavy because again,
the sphincter might not be strong enough.
All these years the prostate has been in the way,
and presumably, we think that
the sphincter weakens to some extent.
It's a muscle, so if it's not used as much it weakens,
but once it start seeing work to do,
it'll get stronger again.
We actually help people regain that urinary control
a little faster by teaching them
exercises called Kegel exercises,
and so with those interventions,
most men are able to regain their urine control.
Somewhere between a few weeks,
sometimes even three months,
10 percent of men might still have some leakage at three months,
but the leakage rate at one year is about two percent,
two people out of 100.
Another side effect that is really common well
beyond the recovery period is retrograde ***********,
so men might have
this condition on certain medicines that they're taking
right now for an enlarged prostate or for prostate obstruction.
After surgery, there's no backdoor that can
close off to keep sperm going
forward out of the ***** during sexual activity,
and so instead what happens is it just goes
backwards and mixes with the urine.
You don't feel it, essentially nothing will come out.
The rest of sexual activity is the same,
erections are the same, the sensations of same,
but you should just know that after
a HoLEP procedure and frankly a lot of
other procedures too men will
probably experience retrograde ***********.
Retrograde *********** should it occur,
is usually permanent,
and that's essentially a main function that
prostate to help direct sperm outwards.
But if we remove the prostate tissue
relative to resolve a blockage situation,
then it's a long-term side effect of the surgery.
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>> I think there are lots of urologists out there and urologists,
as long as they can do a top or simple prostatectomy,
they should be able to handle the wide spectrum of
BPH problems or prostate obstruction problems.
The benefit of coming to Hopkins is that this is
a very non-invasive surgery, no incisions,
and it's able to take care of a prostate of any size as opposed to
just small prostates for a term
or simple prostatectomy for large prostates.
I'm the only fellowship-trained HoLEP surgeon in the area,
so there's a lot of interest in learning the HoLEP technique.
It is a enjoyable operation and it's an efficient operation,
and so there's motivations for
the surgeon and patients to seek the surgery out,
but there is a learning curve
for first surgeons to have good outcomes.
I did fellowship specifically in this for two years
and I helped to bring the skill
set to help my patients in this area.
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