Better Stream: HOLEP Laser Surgery for Treating Urinary Symptoms of BPH

Better Stream: HOLEP Laser Surgery for Treating Urinary Symptoms of BPH Listen To This Episode on Apple Podcasts

In this episode, we discuss a type of laser surgery called HOLEP as an option for men with urinary symptoms caused by an enlarged prostate – a condition called BPH that we discussed in a previous episode. Historically, when men either no longer benefited from prostate medication or could not tolerate the side effects of these medications, the next step would be a TURP surgery, otherwise known as the “Roto-Rooter”. Recently, however, new surgical options have been developed which are believed to provide results that are similar to or better than TURP and that are potentially safer and have less side effects. One of these newer procedures is a laser surgery called HOLEP which stands for holmium enucleation of the prostate.

This Episode's Guest:
Amy Krambeck, MD

Joining us to help us better understand the risks and benefits of HOLEP is Dr Amy Krambeck. Dr Krambeck is a Professor of Urology at Northwestern Medical in Chicago, Illinois. Her Urology residency was completed at the Mayo Clinic in 2008 and she subsequently completed an Endourology fellowship at the Methodist Institute for Kidney Stone Research in Indianapolis, Indiana. Dr Krambeck worked as an endourologist at the Mayo Clinic from 2009-2016 at which time she joined the staff at Indiana University and ran the benign urologic diseases division until 2020. Dr Krambeck specializes in the surgical and medical management of stone disease and BPH and has performed approximately 3000 HOLEP procedures. Who better to help us understand this procedure. And now, without further ado, I bring you our conversation with Dr Amy Krambeck about HOLEP as a surgical option for BPH.

Better Stream: HOLEP Laser Surgery for Treating Urinary Symptoms of BPH Transcript:

Better Man Clinics  

What is BPH (benign prostatic hypertrophy) and what is HoLEP treating exactly?

Dr Krambeck  

BPH is something that occurs naturally as men age. Just as our noses and ears get bigger every year, so does your prostate, unfortunately.  As it enlarges, in some men, it can constrict the urethra. The urethra is the tube that you urinate through, and it connects the bladder to the tip of the penis. The prostate acts like a doughnut around the urethra. As it enlarges, it can squeeze down on that tube, just like kinking off a water hose, and can make it very difficult to urinate. HoLEP is a surgical procedure that uses a scope. With the man asleep, we use the scope and a laser to core out the inside of the prostate through the urethra and to open up that channel. By coring out all of that tissue, I can get you back to where you were when you were a teenager.  You will urinate again like that and urination will no longer be something that you’re worried about doing or planning your day around. It will just become a natural function again,

Better Man Clinics  

When does surgery become a consideration for men that are bothered by BPH symptoms?

Dr Krambeck  

There are really two kinds of men that are bothered by BPH. There is the guy that is slowly retaining urine and just doesn’t notice it, and then ends up unable to urinate and maybe even has kidney damage. Then there is the man who has a lot of symptoms- they’re urinating often and they might be leaking urine. They are just going every few minutes and their bladder is very irritated. Surgery comes into play when you have one of the following situations- you’re unable to urinate, you’re retaining large amounts of urine, you’re developing stones in your bladder, you have blood in the urine, your kidney function is damaged. Those are absolute indications for surgery. Relative indications for surgery include having bothersome symptoms but not wanting to take BPH medications due to not liking the side effects or due to cost considerations, or just being a person that doesn’t like taking medication. So, really, any man who is significantly bothered by their urination, and doesn’t want to take medication, is a candidate for surgery.

Better Man Clinics  

The traditional surgery for BPH has been TURP(Transurethral Resection of the Prostate) – colloquially called a “roto-rooter”.  Is HoLEP the same as a TURP or is it different? If different, how so?

Dr Krambeck  

Most people know someone who had a TURP, or “roto rooter”.  There are similarities between TURP and HoLEP. They’re both done with a scope through the penis. They both remove prostate tissue. But beyond that, that’s it.  With the TURP, you go in with a cutting blade, usually using electrocautery, and you just slowly shave out the inside of the prostate. I liken it to like a deli shaver- you’re just shaving off layers of the prostate, until you get the channel open enough so that it looks like there’s no more blockage, and then you stop.  With a HoLEP you also use the scope, but you’re using a laser that goes through the middle of the scope, and it cuts like a knife. It is like a very precise knife. With the laser, I’m able to cut down to the capsule of the prostate and then just peel out the center of the prostate. The prostate is a lot like an orange- it has a pulpy center and an outer rind.  With HoLEP, I can just completely peel out all of the pulpy center, leaving you only a thin rind behind. There is no judgment on my part.  I’m not looking at it and wondering if it looks “good enough.” There is only one way to do it. And it’s just like peeling an orange- there’s really only one way to peel an orange. You get a lot more tissue out with the HoLEP than you do with a TURP.  Also, when you’re going in and shaving with a TURP, you’re shaving through a lot of little blood vessels. As a result, you can get quite a bit of bleeding with a TURP. With the HoLEP, I am getting down to those blood vessels where they enter the capsule, so I’m able to control them with the laser in a pinpoint fashion. There is much less bleeding and a faster recovery with the HoLEP as opposed to the TURP.

Better Man Clinics  

You mentioned that the urethra goes from the bladder all the way to the tip of the penis and that the “doughnut” is surrounding it. If you’re going to shave away the doughnut (or cut away the pulp), where is the urine going to go?  Isn’t the urine just going to go all over the place because your urethra is not there anymore?

Dr Krambeck  

I get that question every day. I tell my patients to think about the urethra like skin.  It is just a thin cell layer that runs through the middle of the prostate.  I’m actually cutting the urethra out in that portion and then you have the raw surface area of the prostate and the urine runs through it. As it heals, the urethra will fill in over that new surface. It’s a lot like, if you skin your knee, you have a big patch of skin that’s gone. And then the new skin grows in from the edges and resurfaces that area.

Better Man Clinics  

Got it. And I guess the difference is that instead of peeing through a pinhole formed by that doughnut, you’re peeing through a much bigger space, but it’s still lined by the appropriate surface and the urine is not going everywhere. Now, that would be pretty bad. I’m glad we can provide that reassurance to our listeners. One thing you mentioned is that the HoLEP is done with a laser. Now there’s another BPH procedure called the greenlight laser. Can you explain what the difference between the two?

Dr Krambeck  

There are two types of laser procedures ablative procedures and enucleation procedures. Ablative procedures include HoLAP, greenlight ablation, and ThuLAP (thulium ablation). What they do with the laser in those scenarios is, for lack of a better term, burn the surface of the prostate and cause the tissue to evaporate. This is technically not that difficult to do and there’s not a lot of bleeding. But again, it’s a judgment call. You’re burning tissue until you think it looks open enough. And then you stop and there’s a limit to how much tissue can be burned or ablated in one setting. So that’s the green light or HoLAP or ThuLAP procedures. In contrast, there is HoLEP or other enucleation procedures.  With enucleation procedures, we’re using the laser at different settings to cut. It is basically just a knife that cuts the tissue and we use the scope to core out and push out the tissue. It is technically much more difficult but you get a much better outcome because you’re there’s no judgment call.  You’re just coring out that pulp until you get down to the rind. And then we have another device called a morcellator that chews up that pulp and removes it from the body. It is then sent to the pathologist so we can look for cancer or any other conditions that may be in that tissue. So, basically, one type of procedure physically removes tissue and the other one just burns it.

Better Man Clinics  

It sounds like the HoLEP is much more definitive based on what you’re saying because there is no gray zone.  No question of whether it is done completely or not. You keep working until basically it’s just the rind that’s there.

Dr Krambeck  

Exactly. There was a great study that was done in Canada, one one of the first places to ever do HoLEP. The procedure has been around since the late 90s, actually. The study followed men for 18 years after HoLEP and found that 1% of the men needed a repeat prostate surgery. That is pretty significant if you think about the fact that your prostate grows at least 2% per year throughout the course of your lifetime. That data shows that if you get enough tissue out, you should never need another treatment.

Better Man Clinics  

Who is the candidate for a HoLEP procedure?

Dr Krambeck  

A great thing about HoLEP is that it is non-discriminatory. Your prostate can be 20 grams or it can be 500 grams and you will get the same outcome. The HoLEP can be applied to any patient. As long as you have symptoms related to an enlarged prostate, you’re a candidate for HoLEP. It’s safe and men who have bleeding disorders or take blood thinners don’t have to stop the medication. It can be done under a spinal anesthetic in case someone is too ill to have general anesthetic. It is widely utilized and it is highly unusual that we find a man who cannot undergo the procedure.

Better Man Clinics  

So, generally speaking, if a man is eligible for a TURP or UroLift or a Rezum, is he eligible for a HoLEP as well? 

Dr Krambeck  

On a general level, yes. A lot of the other procedures require pretty extensive testing before you decide to do it. That is not the case with HoLEP because we don’t care about the size. As a result, we don’t need an ultrasound or an MRI or anything along those lines. The bladder function can be very weak and you can still urinate after the procedure because we are removing so much tissue. So we don’t do urodynamic testing or pressure flow testing. Also, it doesn’t matter what the configuration of the prostate is, so we generally never do a cystoscopy. So, we have men come in and we assess their symptoms. We also screen them for prostate cancer because we clearly do not want to miss an undiagnosed prostate cancer. As long as there’s no risk for prostate cancer and their prostate is enlarged and they have significant symptoms, then we can go forward with surgery.

Better Man Clinics  

Are there any contraindications to HoLEP?  Any situations in which HoLEP cannot be performed?

Dr Krambeck  

There are no contraindications, but there are situations that make it a little bit more difficult. For example, if someone has undergone surgery for erectile dysfunction and have a penile prosthesis, that makes it difficult.  We usually have to perform those surgeries through an incision in the perineum behind the scrotum. That requires an incision. Also, if patients are really obese, that can make it difficult, and we have to perform the surgery through the perineum in that situation as well. But really, you can get the HoLEP done on almost anyone. Perhaps if someone has so much cardiac disease that they are not even a candidate for a spinal anesthetic because of the concerns of fluid shifts, that patient would not be a good candidate for HoLEP.

Better Man Clinics  

Can you perform a HoLEP procedure on someone who has already undergone a TURP, UroLift, or Rezum procedure?

Dr Krambeck  

I do a lot of HoLEP procedures after someone has had a previous procedure, whatever that might be. I’ve done a HoLEP procedure after every type of BPH surgery, except another HoLEP.  But TURP, UroLift,  Rezum, TUNA, microwave ablation,  Aquablation- I’ve done HoLEP procedures after all of those procedures. Surprisingly, they rarely make it any more difficult because they’re not getting down to the capsule with those procedures so the surgical plane is really undisturbed. So it is very easy to go ahead and do the HoLEP in these patients. We’ve studied these patients and they have similar outcomes as to someone who has never had a prior surgery. You can still get a great outcome even if you’ve had a prior procedure. 

Better Man Clinics  

What are the risks of the HoLEP procedure?

Dr Krambeck  

There are three main risks I always talk to my patient about. The first one is bleeding. It is almost unheard of that you would ever need a blood transfusion with this surgery, but you are going to have blood in the urine for a period of time. For most people, it’s three to five days.  However, it can last up to a month if you’re taking blood thinners. You have to know that that you will have some bleeding; you will have blood in the urine- it will go away but that is a risk. The second risk is urinary leakage. Because I’m taking out so much tissue, there’s nothing really holding it in other than the muscle called the sphincter. A lot of men haven’t used their sphincter in years because their prostate has been acting like a plug. For some people, the sphincter kicks in really quickly and they have no issues while other men do have temporary leakage. About 30% of men will have temporary urinary leakage or incontinence after the procedure that goes away as they heal. For most men, it is gone by three months. The likelihood of it being permanent is 1%. So there is a very low risk of permanent leakage. But you may experience that temporary leakage. The one thing that I say is the true drawback to the HoLEP is retrograde ejaculation. Any procedure that is going to “open you up” fully is going to run the risk of causing that. Just to clarify for the listeners, retrograde ejaculation means that you still have erections-those are not affected, they are not worsened. Also, you still climax and orgasm. However, you’re not going to see the semen come out. That is an adjustment for a lot of men and they have to be willing to accept that going into the surgery. It’s irreversible. We have quite a few men already experiencing that with the prostate medications so they have an idea of what they’re looking at. But it is something that I take a lot of time counseling them about.

Better Man Clinics  

Why does retrograde ejaculation occur with HoLEP?

Dr Krambeck  21:24

That is actually quite an area of debate. We don’t completely know what leads to it. Based on what things look like after HoLEP I can tell you that there is nothing blocking the bladder neck after the procedure. Semen comes in through the ejaculatory ducts, which sit right in the middle of the prostate. The bladder is right there and there’s nothing blocking the bladder anymore after the procedure so there is no longer anything preventing the semen from going into the bladder. As a result, the semen just takes the path of least resistance and goes into the bladder.  There is no longer that obstructing prostate tissue that creates that pressure difference and forces the semen up to the tip of the penis The next time you urinate, the semen comes out with the urine. It doesn’t hurt you and doesn’t really make any difference to your overall health.

Better Man Clinics  

Are men with retrograde ejaculation after HoLEP effectively infertile? Do they still need to use some sort of contraception for birth control?

Dr Krambeck  

Three to 4% of men still can produce some ejaculate after surgery. Some men may go a year and not see any ejaculate and then, all of a sudden, they see some. This surgery is not done to create infertility. When you’re relying on a side effect of a surgery for your outcome, that’s never a good thing. You cannot consider yourself infertile after the procedure.  You still need to use protection because there is still a risk of fertility. 

Better Man Clinics  

What is the difference between HoLEP and surgery performed for prostate cancer?

Dr Krambeck  

Surgery for prostate cancer requires that you remove all of the prostate.  In order to remove all of the prostate, you have to take off or move away the nerves that control erections that run to the penis and sit on the surface of capsule of the prostate. There is quite a dense nerve network that sits right over the surface of the prostate. Because it’s cancer and cancer is life threatening, we accept the risks and we move the nerves, we take the prostate out, and then we sew everything back together. With BPH, there’s no real risk of death. It is a lifestyle surgery so we don’t want to take those risks. As a result, we just carve out the center of the prostate and leave the capsule. And what does that do? Well, that spares all of those nerves that control your erections.  There is no injury to the nerves and, hence, no effect on your erections.

Better Man Clinics  

So, using your own example, for prostate cancer, instead of just taking out the pulp, you’re removing the entire orange, and that is a much more involved procedure. Is that correct?

Dr Krambeck  

Much more involved. In the same vein, I do treat quite a few men with HoLEP who do have prostate cancer and are on active surveillance protocols. These men have a low grade prostate cancer and have decided to just monitor it.  These men can still go on and have a HoLEP if they have difficulty urinating.

Better Man Clinics  

Does performing a HoLEP in such men with prostate cancer raise the concern of spreading the cancer?

Dr Krambeck  

That has come up as a big concern, especially with what we’ve seen in gynecology and their issues with their morcellators. Many men with active prostate cancer who are on active surveillance have undergone HoLEP and we’ve not seen any evidence to indicate that it worsens the prostate cancer or that the prostate cancer will spread into the bladder or the urethra.  It really just does not appear to cause an issue. I think that is because we’re keeping the urinary tract intact. Everything is kept inside the bladder and urethra and those areas are already exposed to the prostate cancer anyway, because it’s all connected.

Better Man Clinics  

Is any preparation required prior to a HoLEP procedure?

Dr Krambeck  

Prior to the surgery, I would require that you have a urine culture. You may need to take a week of antibiotics prior to the procedure, depending on if you have a catheter in place or if your urine culture is positive or if you have a history of urinary tract infections. The night before surgery, we would ask you not to eat or drink any anything after midnight. Then you would come in for your procedure. The way I do HoLEP is different than other surgeons across the United States. I send my patients home that same day without a catheter. My patients come in, they have their procedure, and they wake up with a catheter in their bladder. We watch them in our extended recovery area for two hours. If the urine color is light enough, then we take their catheter out, let them urinate and go home. About 85% of the men that I treat can go home the same day without a catheter. We ask them to not do anything strenuous for one week and to drink plenty of fluids to make sure that the bleeding stops within that week.  If they don’t have any bleeding for a week and they’re feeling well, then I will let them go back to half their normal exercise regimen. If they usually walk five miles, they can walk two and a half. If they lift heavy weights, we have them lift half of what they normally do for another week. Then, after two weeks, they can do everything you want.

Better Man Clinics  

Sounds like a pretty quick recovery. I assume that most guys with desk jobs are going back to work pretty soon after surgery.

Dr Krambeck  

Yes, they’re back to their desk job within 24-48 hours. It is variable as to how much discomfort you will have, but you shouldn’t have a throbbing or aching pain. About 12% of men will have burning with urination. It can feel like pins and needles or burning when they urinate. That can last for several weeks. There are medications we can give to help with that. However, patients don’t require narcotic medications. They really feel quite good. 

Better Man Clinics  

How long does the procedure usually take to perform?

Dr Krambeck  

It all depends on the patient’s prostate size. For smaller prostates, less than 80 grams, its maybe a 35-40 minutes surgery. If you have a very large prostate, like 300 grams or more, it could be three and a half hours. I tell my schedulers to use a mean of an hour and a half of our time, and that will just encompass the small and the large and everything in between.

Better Man Clinics  

What is the typical prostate size for a man.

Dr Krambeck  

If you were to look in a textbook, it would say 20 to 30 grams, but that’s a younger man. As you age, that goes up to 40 to 50 grams. My practice is a little bit different because I do HoLEPS so most of the prostates I treat are around 100 150 grams because they’re referred to me by other urologists.

Better Man Clinics  

Historically, really large prostate required open surgery, correct?

Dr Krambeck  

Yes, when I was training, I did quite a few open prostate surgeries for BPH.  Simple prostatectomy is  what you did because once you got above 80 grams, most of the less invasive procedures either don’t work as well or you could have significant bleeding complications because the prostate is so vascular (has a lot of blood vessels in it).  So, once you got above 80 grams, your options were limited. Nowadays, we have HoLEP, robotic simple prostatectomy, and prostatic artery embolization as options for really large prostates. 

Better Man Clinics  

If a man has a 200 gram prostate, is it reasonable for his urologist to still recommend an open prostatectomy? Or, if I’m told I should get an open prostatectomy, should I seek another opinion?

Dr Krambeck  

I would suggest seeking another opinion in that scenario.  Open prostatectomy involves cutting your abdomen open, cutting open your bladder, coring out the inside of the prostate and then sewing everything back up. You’re looking at a minimum of a six week recovery time. You are going to have a catheter for seven to 14 days and you have a real risk of significant blood loss during that procedure. It’s a big surgery. And nowadays, there are other options. There’s not a lot of surgeons who do HoLEP, but there a lot of surgeons who do robotic simple prostatectomy, and that’s at least less morbid than an open prostatectomy. Due to this, I think that, if it’s suggested that you have an open simple prostatectomy, I think it’s just worth your time to step back, slow down and get a few other opinions.

Better Man Clinics  

HoLEP appears to be a very specialized procedure.  Do a lot of urologists in the US offer it?

Dr Krambeck 

It is actually becoming more and more common. There are more surgeons like me that are training fellows. We are also training residents so that when they leave their training, many people understand how to do it and can adopt it. So we’re seeing a big uptick right now. 

Better Man Clinics  

How do you vet a urologist that offers you a HoLEP? What kind of questions do you ask? What are the criteria that make you comfortable that the surgeon knows what he or she is doing?

Dr Krambeck  

I would ask them how many procedures they have done. You really don’t want someone who’s in their first 100 cases. It is beyond that 100th case when you start to plateau and start getting really standardized outcomes. You also want to know what their average operative time is. You don’t want to be asleep for four to five hours having your prostate treated. This should be an hour long surgery, maybe an hour and a half to two hours. I think is a reasonable amount of time. And then ask what is their blood transfusion rate? And how long is the catheter left in place after the procedure? These are all legitimate questions that they should be able to answer.

Better Man Clinics  

Does it matter how many HoLEP procedures a prospective surgeon performs every year?

Dr Krambeck  

Yes, the number of procedures they do every year and how frequently they do them is important. There was a really interesting study done which looked at surgeons who performed HolEP and their outcomes. They found that if a particular surgeon had several breaks from the procedure (like they had a baby or moved practices or took some time off to do research), the patient’s temporary leakage went up. It is a highly skilled procedure that requires that you do a lot of surgery consistently. 

Better Man Clinics  

You had mentioned that you don’t routinely include catheters after surgery, but you said that one of the questions to ask prospective surgeons is about catheter rates and catheter times. What parameters can you give us in terms of catheters? How long should a catheter reasonably remain in place after a HoLEP?

Dr Krambeck  38:29

I would say 24 hours of catheter time is a normal range for a HoLEP. So if they say that they keep the catheter in overnight and take it out the next day, that is truly the normal range. I think I’m outside the normal because I’ve just done so many of these procedures, I can get the bleeding down to a point where can take the catheter out the same day. There are a few other surgeons that do that, but the vast majority of people will leave it in overnight. In contrast, if they say that you have to be on bed rest after the procedure and that they don’t take it out for three days, that’s abnormal. That would probably not be the person to do the procedure.

Better Man Clinics  

How does HoLEP compare with minimally invasive procedures such as UroLift or Rezum?  Why would I go under general anesthesia or even spinal when I can have a procedure done in the office? What would you say to men asking you those questions?

Dr Krambeck  

First, the catheter is actually left in for a shorter period of time with a HoLEP than with Rezum for most patients. Second, you have to think about what you’re actually experiencing while you’re awake and undergoing UroLift or Rezum in the office.  Most people would choose to be asleep for that. Here is what I tell patients:  you can get a Rezum or UroLift, but you have to think about either of these procedures as a bridge to something else. It is not a definitive therapy. If you don’t want to take medication but are just not ready for the big procedure and understand that you are probably going to need another surgery in a few years, it is fine to get a Rezum or Urolift.  You will likely come back to see me in a couple of years and we’ll do the definitive procedure. The benefit of UroLift and Rezum is that they do not cause retrograde ejaculation at the higher rates that you see with HoLEP. So if you have a patient who just cannot accept retrograde ejaculation, then that might be a nice bridge for a few years for them. But the vast majority of the time, men just want this fixed and they want it fixed for good. And because of the low retreatment rates for HoLEP and the minimal downtime, they almost invariably just choose HoLEP in the first place.

Better Man Clinics  

Similarly, how does HoLEP compare to a TURP?

Dr Krambeck  

We are very fortunate that HoLEP was developed in New Zealand, because it’s a country where they could do prospective randomized studies. They can just bring patients in and tell them that they will be getting a HoLEP or a TURP.  We have a lot of data from New Zealand and, in those studies, TURP didn’t do poorly, HoLEP just did better. HoLEP patients had less blood loss, shorter hospitalization time, and shorter catheterization time. There was no difference in urinary leakage, no difference in scar tissue formation, and no difference in erectile dysfunction. So, immediately after surgery, the patients did better with HoLEP.  Then they followed them for seven years. At each time point after surgery, the patients who had the HoLEP had a better flow rate (their urine flowed out faster) and their symptom scores (a survey that we have patients fill out to get a quantification as to how bad their symptoms are), were better at each time point as compared with patients that had a TURP. Furthermore, none of the patients in the HoLEP group needed a retreatment versus three patients in the TURP group over the seven year period, showing that it is just more definitive. I am not going say that a roto rooter is bad. I’m just going to say that the HoLEP does better.