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About HoLEP

Frequently Asked Questions about HoLEP

Superior relief of obstructive symptoms, average of 19 hours with a catheter, and maintenance of baseline erectile function. Learn more about HoLEP surgery recovery time and other common questions here.

FAQs about HoLEP

HoLEP Vs TURP: Which is Better?

Less bleeding, shorter catheter time, more complete removal of tissue, and a track record of effectiveness. Because HoLEP is practiced by relatively few urologists, the results have been rigorously studied and published. Published results indicate no change in postoperative erectile function from baseline and dramatically improved urination compared to baseline.

If HoLEP is better than TURP, why is it not offered by all urologists?

HoLEP requires training and proctoring by someone experienced in HoLEP. Because there are relatively few urologists in residency programs training subsequent generations of urologists in HoLEP, the procedure is offered by a small number of practicing urologists. Also, HoLEP has a reputation amongst urologists of being difficult and time consuming to learn.

Why do I have a difficult time finding information on HoLEP?

Once the large equipment for HoLEP is purchased (laser and morcellator), the disposable cost for each case is relatively low and the fibers can be purchased from multiple vendors. Lumenis (company that manufactures the laser and morcellator) has a small marketing force primarily designed for selling large capital equipment such as the laser and not for marketing and promoting HoLEP. The laser is used in most institutions primarily for treatment of kidney stones so HoLEP is a secondary usage. Lumenis revenue for 2013 was $265 million. In contrast, procedures such as the Greenlight PVP have a proprietary single use disposable fiber which is more expensive and promoted by much larger companies with much larger marketing forces. All this adds up to little fanfare and exposure for HoLEP. However, if you search the medical literature through publically available databases such as pubmed you will see that HoLEP has a robust literature documenting its efficacy, safety, and superiority over other BPH procedures.

Is HoLEP only for very large prostates?

No. The same technique used for very large prostates can also be applied to smaller prostates with some minor modifications. Since 2011, I have used HoLEP for all BPH procedures regardless of prostate size.

What if I have an elevated PSA and I might have prostate cancer?

All tissue removed at the time of HoLEP is sent for analysis by a pathologist. In 100 consecutive men undergoing HoLEP by Dr. Dora, 7 had incidentally discovered prostate cancer. Five of the 7 men had low risk low volume cancers that were managed with surveillance and have not required treatment to date. Two of the 7 men had intermediate risk cancer that required treatment. Previous HoLEP does not eliminate any future treatment options for prostate cancer.

If I have had radiation for prostate cancer and have urinary symptoms can I have a HoLEP?

No. Unfortunately once the prostate has been radiated BPH procedures of any kind should be avoided. This is because the prostate does not heal properly after radiation and non-healing necrotic tissue is created in the prostate lining. Post radiation urinary symptoms are best managed non-operatively.

I cannot urinate at all and have a catheter in place or self-catheterize. Am I a candidate for HoLEP?

Yes. In 100 consecutive men undergoing HoLEP by Dr. Dora, 11 were catheter dependent before surgery and could not urinate. In a recent study with 24 month follow-up, 18 of 19 men who were catheter dependent and without a measurable contraction in their bladder muscle were able to urinate after HoLEP. However, these were patients with bladder failure from BPH without other associated neurologic conditions such as parkinson’s, spinal cord injury, multiple sclerosis, or dementia. If you cannot urinate at all it is always a leap of faith to undergo a BPH procedure. Outcomes are less predictable in these cases but according to the data and my personal experience it is reasonable to offer HoLEP and expect most patients to resume spontaneous voiding.

My only urinary problem is that I get up frequently at night to urinate (nocturia). During the day I am fine. Will HoLEP fix this problem?

Isolated nocturia is a very complex and frequently frustrating problem for the patient and the urologist. Night time urination can be caused by an overproduction of urine by the kidneys at night (nocturnal polyuria), bladder storage problems, sleep apnea, or problems with sodium and fluid balance in the body from a variety of medical conditions. Patients with isolated nocturia may benefit from HoLEP if they also have an enlarged and obstructing prostate and none of the other conditions previously mentioned but these patients should exhaust medication options first and be counseled that the nocturia may persist after HoLEP.

Can I stop my prostate medications after HoLEP?

Yes. 5 alpha reductase inhibitors finasteride (Proscar) and dutasteride (Avodart) may be stopped immediately after HoLEP. The alpha blockers such as tamsulosin, alfuzosin, silodosin, terazosin, or doxazosin are typically continued for one week and then stopped.

What if I wet my pants on the way to the bathroom (urge incontinence)?Am I still a candidate for HoLEP?

Yes. Most men who have urge incontinence caused by an enlarged prostate will experience resolution of this symptom after HoLEP. However, some men will experience persistent urge incontinence symptoms after HoLEP and need overactive bladder medications. There is no test which will accurately predict which category men will fall in to.

Will my erections change after HoLEP?

No. A recent study followed 393 patients for 3 years after HoLEP with validated questionnaires to assess erectile function. No adverse impact on sexual functioning was noted.

What long term sexual side effects will occur after HoLEP?

Decreased semen production or dry ejaculation occurs in almost all men who have undergone HoLEP and is a permanent side effect of the procedure and most BPH medications and procedures including TURP. The orgasm or pleasurable sensation which accompanies climax is unchanged and the muscle contractions which would normally expel the semen still occur.

Will my insurance company pay for HoLEP?

Yes. HoLEP has a CPT code that is paid for by all insurers including medicare. The reimbursement to the surgeon for HoLEP is comparable to what is paid for a TURP. The cost to insurance companies for HoLEP in general is less compared to TURP because of reduced hospital stay, negligible transfusion rate, and minimal disposable costs.

Does Dr. Dora accept my insurance?

Dr. Dora accepts most insurance plans including Medicare. Dr. Dora is part of a larger group called Florida Urology Partners, LLP which has contracts with most major insurance companies. Dr. Dora does not accept Medicaid or any Medicaid replacement plans. If you have an HMO or Medicare replacement product you will need to obtain a referral to see Dr. Dora. The office staff can assist you with these questions.

What to expect after HoLEP

Will I have a catheter when I wake up?

Yes. A catheter is placed at the end of the surgery while you are still asleep and a slow continuous drip of saline solution is used to keep the urine free of any clots immediately after the HoLEP. The drip is shut off in the hours following the surgery and the catheter is removed the morning after surgery. The average time with catheter is 19 hours. In 100 consecutive men undergoing HoLEP by Dr. Dora, 93 men were able to urinate when the initial catheter was removed and left the hospital without a catheter. The 7 who could not had a small catheter reinserted and were sent home with the catheter and had it removed a day or two later in the office.

What will urination be like immediately after the operation?

Most men report immediate improvement in their urine flow. Because of the raw surfaces inside the prostate, men have urgency to urinate where they have to get to the bathroom quickly. This gradually resolves over the first few months after surgery. Because of salts in the urine and raw surfaces inside the prostate, most men will have a mild burning sensation at the end of urination and it will typically be referred out to the tip of the penis. A medicine called phenazopyridine will be prescribed for this to be used only if needed. Adequate hydration with water will also help dilute the salts in your urine and decrease burning. Opiate pain medications are not prescribed after this operation and are not necessary. Some men experience some minor leakage of urine after the surgery which resolves within the first few months. Permanent leakage of urine is extremely rare after HoLEP and did not occur in 100 consecutive men who underwent HoLEP by Dr. Dora and was seen in <1% of men in a published study containing over 1,000 men.

Will I have blood in the urine?

Yes. Most men experience a small amount of blood in the urine for 1-2 weeks after HoLEP. Typically it is at the beginning of the stream from a small amount of blood that has collected in the part of the prostate that was removed. A very small percentage of patients will have a delayed bleed where they pass substantial clots. If this occurs it typically resolves with rest and increasing fluid intake. In very rare instances a catheter may be temporarily inserted to flush out the clots and then removed. If this occurs please contact Dr. Dora for instructions. Seeing blood in the urine is very alarming to people but rarely results in anemia or any life-threatening consequences.

When can I resume physical activity?

Once released from the hospital, you can walk, shower, and eat and drink regular food. You should not walk long distances for about one week. You should not lift weights, ride a bicycle, or engage in strenuous exercise for 4 weeks. You can chip and putt in 2 weeks and resume a full golf swing in 4 weeks. Violation of these rules will not permanently injure you but may result in increased blood in the urine and slow your recovery.

When can I drive?

Since you are not on any pain medications you can resume driving once your reaction time is back to normal but no sooner than 24 hours after anesthesia.

When can I have sex?

Four weeks is recommended.

When can I return to work?

If you have a desk job or a job requiring light physical activity you may return in 3-5 days. If your job requires moderate to strenuous physical activity 2 weeks is generally recommended.