Holmium Laser Enucleation of the Prostate (HoLEP)

What is the evidence base for this information?

This leaflet includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence based sources; it is, therefore, a reflection of best practice in the UK. It is intended to supplement any advice you may already have been given by your Urologist or Nurse Specialist, as well as the surgical team at Addenbrooke’s. Alternative treatments are outlined below and can be discussed in more detail with your Urologist or Specialist Nurse.

What does the procedure involve?

This operation involves the telescopic removal of obstructing prostate tissue using a laser and temporary insertion of a catheter.

What are the alternatives to this procedure?

Drugs, use of a catheter/stent, observation, conventional transurethral resection or open operation.

What should I expect before the procedure?

If you are taking a prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban or clopidogrel, ticagrelor or blood thinning medication you should ensure that the Urology staff are aware of this well in advance of your admission.

You will usually be admitted on the day of your surgery. If not done on the day of your Urology clinic appointment, you will normally undergo pre-assessment on the day of your clinic or an appointment for pre-assessment will be made from clinic, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the Medical team which may include the consultant, junior urology doctors and your named nurse.

You will be asked not to eat or drink for six hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

Please be sure to inform your Urologist in advance of your surgery if you have any of the following:

• an artificial heart valve
• a coronary artery stent
• a heart pacemaker or defibrillator
• an artificial joint
• an artificial blood vessel graft
• a neurosurgical shunt
• any other implanted foreign body
• a prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban or clopidogrel, ticagrelor or blood thinning medication
• a previous or current MRSA infection
• high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

What happens during the procedure?

Either a full general anaesthetic (where you will be asleep throughout the procedure) or a spinal anaesthetic (where you are awake but unable to feel anything from the waist down) will be used. All methods minimise pain; your anaesthetist will explain the pros and cons of each type of anaesthetic to you.

The operation, on average, takes 45 to 90 minutes, depending on the size of your prostate.

You will usually be given an injectable antibiotic before the procedure after checking for any drug allergies.

The laser is used to separate the obstructing prostate tissue from its surrounding capsule and to push it in large chunks into the bladder. An instrument is then used through the telescope to remove the prostate tissue from the bladder. A catheter is normally left to drain the bladder at the end of the procedure.

What happens immediately after the procedure?

There is always some bleeding from the prostate area after the operation. The urine is usually clear of blood within 12 hours, although some patients lose more blood for longer. It is very unusual to require a blood transfusion after laser surgery.

It is useful to drink as more fluid than normal in the first week after the operation because this helps the urine clear of any blood more quickly.

Sometimes, fluid is flushed through the catheter to clear the urine of blood.

You will be able to eat and drink on the same day as the operation when you feel able to.

Most patients can be safely discharged on the same day as the surgery with the catheter left in for up to one week to allow any internal swelling related to the surgery to resolve. When you return to the ward after surgery, the nurse will show you how to look after the catheter at home. The colour of urine draining through the catheter will be monitored by the nurse and any temporary fluid running through the catheter will be adjusted and stopped as appropriate. Once we know that you can eat and drink without feeling sick, that you can get out of bed and walk safely, and that you know how to look after the catheter at home, you can be discharged.

Before you leave the hospital you will be given written information on who to contact if you have any questions or problems after you leave the hospital. You will also be given information on who will remove the catheter for you and when. Sometimes we arrange for catheters to be removed at your home by your local district nurse, and sometimes you will be asked to return to the hospital for catheter removal. Full instructions will be given to you about what has been arranged in your case.

Before you come in for surgery please ensure you have made arrangements for the following:

• Someone is able to drive you home on the day of your surgery.
• Someone will be able to stay with you the first night after surgery.

For some patients, going home on the same day as the surgery is not appropriate or feasible. The final decision on whether you are suitable for same day discharge is made on the day of surgery. Please come prepared to stay one night in hospital in case this might be necessary.

What to expect the day after your catheter is removed

After your catheter is removed, it may at first, it may be painful to pass your urine and it may come more frequently than normal. Any initial discomfort and frequency of urination usually improves steadily within a few days. Some of your symptoms, especially frequency, urgency and getting up at night to pass urine, may not improve for several months because these are often due to bladder over activity (which takes time to resolve after prostate surgery) rather than prostate blockage. Since a large portion of prostate tissue is removing with the laser technique, there may be some temporary loss of urinary control until your pelvic floor muscles strengthen and recover. Pelvic floor exercises before and after surgery help to decrease the chance of any temporary loss of urinary control (incontinence).

It is not unusual for your urine to turn bloody again for the first 24 to 48 hours after catheter removal. Some blood may be visible in the urine even up to six weeks after surgery but this is not usually a problem.

Are there any side effects?

Most procedures have a potential for side effects. You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

Common (greater than one in 10)

• Temporary urethral burning, blood in the urine and frequency/urgency of urination after the procedure.
• No semen is produced during an orgasm in almost all men if the prostate is fully enucleated. An ejaculation-sparing HoLEP decreases this risk to 20%. Although a pleasurable sensation of climax is still expected with retrograde ejaculation, most men report the feeling at climax is less pleasurable than with normal ejaculation.
• In around 15% of men HoLEP does not relieve all the urinary symptoms within the first couple of months. If the persistent symptoms are a nuisance a temporary bladder calming medication (usually taken for three months) virtually always improves them.
• Infection of the bladder or testes requiring antibiotics (approx 10-15%).
• Failure to pass urine before hospital discharge, requiring re-placement of a catheter which is then removed (almost always successfully) within a week (10-15%).

Occasional (between one in 10 and one in 50)

• Loss of complete urinary control (incontinence) which normally resolves within six weeks (less than 10%); this can usually be resolved by doing pelvic floor exercises
• Weaker or no erections. Several published studies have shown no significant difference in ability to have an erection in men before and after HoLEP surgery but there is still a small risk (probably less than 5%) of a decreased ability to have an erection. Some men’s erections improve after surgery.
• Injury to the urethra causing delayed scar formation (urethral stricture), requiring further minor surgery (4%).
• Finding unsuspected cancer in the removed prostate tissue which may need further treatment (8%).

Rare side-effects (between 1 in 50 and 1 in 1,000)

• Need for further prostate surgery due to regrowth of the prostate (less than 1% in the first 10 years after HoLEP).
• Failure to relieve urinary retention requiring long-term catheterisation (1%).
• Persistent loss of urinary control (urinary incontinence) requiring further surgery (0.5%).
• Retained prostate tissue fragments requiring a minor surgical procedure (less than 0.5%).
• Bleeding requiring blood transfusion (less than 0.5%).
• Recurrent urethral stricture requiring major reconstructive urethral surgery (urethroplasty). 0.1%.
• Blood clot in a blood vessel (DVT) or lung vessel (PE) requiring treatment

Extremely rare side-effects (less than 1 in 1,000)

• Extensive urethral stricture requiring more than one major reconstructive urethral surgery (urethroplasty).
• Perforation of the bladder requiring open surgical repair.
• Bleeding requiring return to the operating theatre.
• Persistent overactive bladder symptoms (urgency, frequency and waking to urinate overnight), unresponsive to medication and requiring bladder BoTox injection.
• Inability to access the prostate adequately enough to perform HoLEP.

What should I expect when I get home?

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation.

If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

Most patients feel pretty much back to normal within a week. Apart from some burning on urination you should not be in any pain. You may notice that you pass very small flecks of tissue in the urine at times within the first month as the prostate area heals. This does not usually interfere with the urinary stream or cause discomfort. It is normal to pass some blood in the urine (usually intermittently) for up to six weeks after surgery.

What else should I look out for?

If you experience increasing frequency, burning or difficulty on passing urine or worrying bleeding, contact your GP.

In the event of severe bleeding, passage of clots or sudden difficulty in passing urine, you should contact your GP immediately since it may be necessary for you to be readmitted to hospital.

Are there any other important points?

Removal of your prostate should not adversely affect your sex life provided you are getting normal erections before the surgery. Sexual activity can be resumed as soon as you are comfortable, usually after three to four weeks.

It is often helpful to continue with pelvic floor exercises as soon as possible after the operation since this can improve your control when you get home.

The symptoms of an overactive bladder may take three months to resolve whereas the flow is improved immediately.

If you need any specific information on these exercises, please contact the ward staff or the specialist nurses. The symptoms of an overactive bladder may take three months to resolve whereas the flow is improved immediately.

The results of any tissue removed will be available after 14 to 21 days and you and you and your GP will be informed of the results by letter.

Around three months after surgery you will be reviewed in the outpatient clinic and several tests repeated (including a flow rate, bladder scan and symptom score) to help assess the effects of the surgery. Please come to your clinic appointment prepared to pass urine for a flow test.

Most patients require a recovery period of one to two weeks at home before they feel ready for work. You should avoid any heavy lifting or physical straining during this time. You should not drive until you feel fully recovered; one to two weeks is the minimum period that most patients require before resuming driving.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery.

You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than three months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and/or specialist one to one care is required.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team need to see or reach your skin and if this is necessary they will use an electric hair clipper with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself or use a razor to remove hair, as this can increase the risk of infection. Your healthcare team will be happy to discuss this with you.

References

NICE clinical guideline No 74: Surgical site infection (October 2008); Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August 2007)

Is there any research being carried out in this field at CUH?

Yes. We are currently assessing the effectiveness and safety of HoLEP. This involves a number of detailed tests performed before surgery which are then repeated several weeks after the procedure.

This is part of the ongoing audit process for developing technologies recommended by the National Institute of Health and Clinical Excellence (NICE).

Who can I contact for more help or information?

Oncology nurses

Uro-oncology nurse specialist
01223 586748

Bladder cancer nurse practitioner (haematuria, chemotherapy and BCG)
01223 274608

Prostate cancer nurse practitioner
01223 274608 or 01223 216897

Surgical care practitioner
01223 348590 or 01223 256157

Non-oncology nurses

Urology nurse practitioner (incontinence, urodynamics, catheter patients)
01223 274608

Urology nurse practitioner (stoma care)
01223 349800

Urology nurse practitioner (stone disease)
07860 781828

Patient advice and liaison service (PALS)

Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS

Mail: PALS, Box No 53
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

Chaplaincy and multi faith community

Telephone: 01223 217769
Email the chaplaincy

Mail: The Chaplaincy, Box No 105
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

MINICOM System ("type" system for the hard of hearing)

Telephone: 01223 217589

Access office (travel, parking and security information)

Telephone: 01223 596060

What should I do with this leaflet?

Thank you for taking the trouble to read this patient information leaflet. If you wish to sign it and retain a copy for your own records, please do so below.

If you would like a copy of this leaflet to be filed in your hospital records for future reference, please let your urologist or specialist nurse know. If you do, however, decide to proceed with the scheduled procedure, you will be asked to sign a separate consent form which will be filed in your hospital notes and you will, in addition, be provided with a copy of the form if you wish.

I have read this patient information leaflet and I accept the information it provides.

Signature……………………………….……………Date…………….………………….