HoLEP (Holmium Laser Enucleation of the Prostate)
HoLEP is an advanced laser-based procedure for managing benign prostatic hyperplasia (BPH). It uses the holmium laser’s localized effect to precisely remove the obstructing prostate tissue, providing excellent hemostasis without transmitting energy to the rest of the body.
Unlike traditional resection, HoLEP involves en-bloc removal of the prostate adenoma, which is then fragmented and evacuated from the bladder. The procedure offers a minimally invasive alternative to open surgery, especially effective in men with very large prostate sizes.
While HoLEP requires specialized training and equipment, it has become a reliable option for patients who are at higher risk of bleeding or those unsuitable for conventional TURP.
Method
The laser works locally, producing high heat that cuts and coagulates tissue simultaneously. This ensures excellent hemostasis, with no interference to cardiac pacemakers and no risk of obturator nerve reflex.
Procedure Highlights
- Performed as an en-bloc enucleation of the prostate
- Rare risk of TUR syndrome compared to traditional TURP
- More instrumentation is required, which may slightly increase the chance of complications such as stricture
- Lesser control in limiting resection strictly within the capsule compared to TURP
- Particularly useful in very large prostates as an alternative to open surgery
Irrigation During HoLEP
Normal saline (iso-osmolar and non-hemolytic) is typically used as irrigation fluid, which lowers the risk of TUR syndrome. However, care is still needed to avoid excessive fluid absorption and overload.
Advantages of HoLEP
- Excellent laser cutting precision with good hemostatic effect
- Lower intraoperative bleeding compared to conventional methods
- Effective for patients with very large prostates
- No interference with pacemakers
- Preferred option in patients on blood thinners or with recent cardiac procedures
Limitations
- Procedure time may be longer compared to TURP
- Independent coagulation is slower
- Slightly higher risk of stricture and incontinence than TURP
- Bleeding, if present, may not always be effectively controlled with laser alone and might need conversion to conventional methods
Patient Selection & Alternatives
HoLEP can be performed in almost all cases of prostate enlargement, but it is particularly beneficial for:
- Very large prostate size (alternative to open prostatectomy)
- Patients on anticoagulants or with cardiac conditions
- Men requiring minimally invasive approaches with durable outcomes
Alternative techniques like TURP, Bipolar TURP, ThuLEP, or GreenLight PVP provide comparable results and may be considered based on patient health and risk factors.