HoLEP Surgery for Prostate Enlargement

What is HoLEP surgery?

HoLEP surgery is an effective and new method. Benign prostatic hyperplasia (benign prostate hyperplasia, BPH) is one of the most common urological diseases in elderly men. BPH is a benign disease of the prostate that does not turn into cancer. In the beginning, if the complaints are not too much, drug treatment is sufficient, the patients are relieved with drug treatment. However, over time, complaints increase and drug treatment becomes ineffective and surgery is required.

HoLEP is a benign prostate surgery performed with a laser. HoLEP is the abbreviation of the phrase “Holmium Laser Enuclation of Prostate” (removal of the enlarged part of the prostate using a holmium laser).

How is HoLEP surgery performed?

The HoLEP method is a procedure performed by entering the urethra with special endoscopic instruments (optical and illuminated system) and pushing the parts of the prostate (adenoma) that press on the urethra (urinary duct) to the bladder by laser by separating them from the capsule (prostate membrane), and then separating the prostate pieces into very small pieces with a system called morcellator. is surgery.

In this system, there are no incisions or surgical scars in the body. Postoperatively, a Foley catheter is inserted in the patients and remains for 2 days. The procedure is performed with general or spinal anesthesia.

Is Prostate Biopsy Required for Every Patient for HoLEP Surgery?

Prostate surgery with the HoLEP method is performed in benign prostatic enlargement. However, it is important to determine in advance that the patients who will undergo this surgery do not have prostate cancer. Because if cancer comes out, the type of surgery changes.

Most of our patients are wondering whether preoperative prostate biopsy will be necessary with this method. In patients who will undergo surgery for benign prostatic hyperplasia (BPH), it should be demonstrated that they do not have prostate cancer.

Investigations to find out if there is prostate cancer before HoLEP surgery

• PSA test: Normal PSA values ​​are between 0-4 ng/ml, if it is above this, it is necessary to differentiate cancer with other methods.
• Prostate examination: The rectal examination of the prostate with fingers gives general information about whether there is prostate cancer.
• Prostate multi-parametric MR film: This is a special MR method and gives high information if there is cancer in the prostate. Here, the suspicious lesion in the prostate is evaluated on a scale of 1-5 with a scoring method called the PIRAD system. If the result is PIRAD 4-5, the probability of cancer is high and a biopsy should be taken. At values ​​below this, there is no need for biopsy as the probability of cancer will be low.
• Prostate biopsy: The definitive diagnosis of prostate cancer is made by biopsy. The biopsy (part) taken from the suspected cancer is examined pathologically and it is clearly understood whether there is cancer or not.

In a study conducted in 2021, 397 patients who would undergo HoLEP surgery were examined, and as a result of the analysis of the data obtained from them, it was explained in detail which patients would be required to undergo further study for prostate cancer.

The patients were examined in 2 groups: Patients who underwent standard examination: Here, only finger examination was performed and PSA test was requested. The patients in the second group were classified as the advanced study group patients. Multiparametric prostate MRI and biopsy were performed on patients in the advanced research group.

Based on the data from this study, the authors came to some conclusions about pre-HoLEP biopsy. We can summarize them as follows.

Conditions for prostate biopsy before HoLEP

• Prostate biopsy is not required for every patient who will be treated with the HoLEP surgery method due to BPH.
• If patients have high PSA values, prostate multiparametric MRI should be requested. If the PI-RADS value is 4/5 as a result of MRI, prostate biopsy should be taken because the risk of cancer in these patients will be high. A biopsy is not required if there are lower PIRADS scores.
• In addition, if 2 or more biopsies have been taken beforehand due to PSA elevation and no prostate cancer has been found as a result of these, the risk of cancer in these patients is also very low and biopsy is not required.

HoLEP surgery is performed in three main ways!

• Removal of the prostate in three parts (Three lobar prostatectomy): With this method, an incision (incision) is made from the urethra, starting from the bladder side at the 5 and 7 o’clock positions in the prostatic urethra, to the lower part of the prostate, called the verumontanum, and up to the prostate capsule, by entering through the urethra. Then the middle lobe of the prostate from the verumontanum to the bladder is separated from the capsule and pushed into the bladder. Then the right and left prostate lobes are separated from the capsule (dissection) and pushed into the bladder in the same way. In this method, because the prostate is dissected from the capsule in 3 parts (separation from the prostate capsule) and pushed into the bladder, it is called “three lobar prostatectomy” in English (in 3 parts). These pieces, which are thrown into the bladder, are then taken out in very small pieces with a device called a “morcellator”.
• The second method is “two lobar prostatectomy: In this method, the enlarged prostate adenoma is separated from the prostate membrane in 2 pieces and thrown into the bladder, and from there it is fragmented with a morcellator and taken out in very small pieces without making any incisions in the body.
• Another method is “en block prostatectomy” (separating the enlarged prostate adenoma from the capsule of the prostate and throwing it into the bladder). Here, the benign prostate tissue, which makes urination difficult, is separated from the capsule as a whole and thrown into the bladder, and then it is broken up with a “morcellator” and taken out in very small pieces.

After the prostate is taken out with all three methods, bleeding is controlled with laser energy, small vessels are burned, and finally, the patient is terminated by placing a catheter in the urinary canal called a Foley catheter.

All three methods have no superiority or advantage over each other. The process is exactly the same. The choice is all about the surgeon’s habit.

BPH and HoLEP laser therapy

BPH (benign prostate hyperplasia), benign prostatic enlargement, is a disease seen in more than 40 percent of patients aged 60 years and older. BPH is a benign disease and its treatment is different from prostate cancer. Benign prostatic enlargement in older men usually presents with urinary complaints.

Urinary complaints due to prostate enlargement are as follows:

HoLEP surgery in urology is a laser surgical method that is effective in benign enlargement of the prostate. Common complaints in elderly male patients with benign prostatic enlargement:

• Frequent urination, especially at night
• Difficulty urinating, needing to strain
• Drops of urine at the end of urination
• Forked urination
• Urinary incontinence before reaching the toilet with the feeling of sudden urination
• The need to urinate again after urinating
• Feeling of incomplete emptying of the bladder after urinating

Which patients need HoLEP surgery?

There is no need for surgery for every patient with prostate enlargement. Some of the men with enlarged prostate usually respond well to drug treatments called alpha blockers if their complaints are not too severe and do not need surgery. However, over time, patients begin to not benefit much from these drugs, and in such cases, we have no more options than surgical treatment.

The most commonly used methods in the surgical treatment of benign prostate enlargement: Open prostate surgery, TUR-P (transurethral resection of the prostate), and Plasmakinetic are known surgical methods. However, with the advancement of technology, serious progress has been made in prostate surgeries performed with laser. In recent years, holmium laser closed surgery of the prostate (HoLEP) has been used as an effective treatment method in developed western countries.

Patients requiring HoLEP therapy

In some cases with prostate enlargement, drugs are insufficient and surgical treatment is absolutely necessary. We can summarize the situations that absolutely require surgery (including HoLEP surgery) as follows:

• Patients for whom drug therapy is not effective: Previously, patients benefited from drug therapy, but with time and age, these drugs become ineffective and surgery is required. In elderly patients, the effect of drugs may be less, in these patients, if drug therapy is not effective and the general condition of the patient is suitable for surgery, surgery should be performed.
• Serious diabetes patients: In time, nerve damage called neuropathy develops in diabetic patients and these patients cannot see the expected benefit from drug treatments as the bladder neck and bladder nerves will be damaged.
• Enlargement of the prostate: In some patients, the prostate grows into the bladder. This is called median or middle lobe hyperplasia, and in these patients, medications are often not effective and surgery is required.
• Patients who urinate frequently at night: Since patients urinate frequently at night, their sleep patterns are disrupted and this reduces the quality of life of people in their normal daily lives. For this reason, it is appropriate for patients who suffer from insomnia due to prostate enlargement and whose daily social life and work life are adversely affected to undergo surgery.
• Excess urine remaining in the bladder after urination: Inability to empty the bladder completely after urination, excess urine in the bladder is another reason for surgery. Normally, after urinating, the bladder, that is, the urinary bladder, should be completely emptied, if 100-150 cc or more of urine remains in the bladder, this is a reason for surgery.
• Frequent recurrent urinary tract infections: Patients cannot fully empty their bladders due to pressure on the urinary tract (urethra) due to prostate enlargement, and as a result, residual urine remains in the bladder, which leads to recurrent urinary tract infections. The definitive solution for such infections that cannot be controlled with antibiotics is prostate surgery.
• Bladder stones: Incomplete emptying of the bladder and excess urine remaining in the bladder after micturition cause stone formation in the bladder over time. Stones can be numerous. Removing the stones in the treatment is not the solution, the definitive solution is prostate surgery.
• Inability to urinate: In some prostate patients, the urinary canal (urethra) is completely closed due to the prostate and patients cannot urinate, a catheter must be inserted. In these patients, the definitive treatment is surgery instead of medication.
• Bleeding from the bladder: There is enlargement of the veins in the bladder neck due to prostate enlargement. In some cases, these enlarged veins open and cause serious bleeding. In such patients, drug therapy is not effective as a treatment method.
• Deterioration in kidney functions (kidney failure): In patients with long-term prostate enlargement and severe obstruction, enlargement of the ureter and kidneys (hydroureteronephrosis) develops over time, if these patients lose more time and if surgery is not performed, kidney failure may develop as a result.
• Bladder diverticulum: In patients with BPH, in case of incomplete emptying of the urinary bladder and the progression of obstruction, outward herniation in the urinary bladder occurs over time, these are called “diverticulum”. These diverticula may be numerous and of varying sizes. In such patients, the definitive treatment is surgery instead of drug therapy.

Patients who will not undergo HoLEP

HoLEP surgery is an operation that can be performed on any patient with benign prostatic enlargement, provided that it is very careful. However, in some cases, it is necessary to be more careful and prepare accordingly.

• Patients with serious bleeding problems: It is more appropriate to perform the procedure after the necessary treatments (if surgery is required) in patients with serious bleeding problems.
• Patients who have had prostate surgery before: The HoLEP method is performed in patients who have had prostate surgery and whose prostate cannot be completely removed, but if the remaining piece is very small and the patient has a high cost with this method, the remaining small pieces can be removed with other methods (such as TUR). Prior surgery is not a definite obstacle. We have patients that we have successfully treated in this way.
• Patients who cannot be positioned for surgery: Operations such as TUR, HoLEP, plasmatinetics are difficult for technical reasons in patients who have problems in the leg joints and cannot be positioned appropriately for surgery. Because in these surgeries, the patient must be in a special position, if there is a serious problem in the hip joints and the joints cannot be broken, there will be difficulty in the surgery.

Pre-HoLEP preparation

HoLEP surgery is a surgical procedure like other surgeries. It is done in operating room conditions. Patients who are decided to have surgery are evaluated in detail by the anesthesiologist.

Urological evaluation of patients

Patients who will undergo HoLEP surgery undergo a detailed urological examination. For this purpose:

• Prostate examination is done from the anus with fingers
• Prostate cancer must be differentiated.
• PSA (prostate specific antigen) test should be done, if it is high, further research should be done in terms of cancer. For this purpose, multiparametric MRI and prostate biopsy should be performed according to the result.
• Kidneys and bladder should be evaluated: Information about kidneys and bladder can be obtained by performing ultrasonography and kidney function tests.
• If necessary, tests showing bladder functions such as urodynamics may be ordered.
• Uroflow test showing the urine flow gives an idea about the urine flow.
• Determination of residual urine after micturition in the bladder: Normally, there should be no urine left after urinating in the bladder, but if there is an obstruction, urine will remain in the bladder in varying degrees.
• Urinalysis should be done: If there is an infection, it should be treated with appropriate antibiotics before surgery.

General assessment of the patient

Patients who will undergo HoLEP surgery undergo a general evaluation before surgery. For this purpose, patients are asked for routine blood tests, where:

• Liver-kidney function tests are requested
• Whether bleeding and coagulation tests are normal,
• Routine blood count is done, blood group is determined. If the blood values ​​are insufficient, the patient is made suitable for anesthesia by giving blood beforehand.
• Lung X-ray
• ECG is taken to find out whether the lungs and heart are normal, and if necessary, necessary precautions are taken in advance.
• If an anesthesiologist deems it necessary, consultation is requested from the relevant departments for patients with chronic problems such as heart, lung or diabetes, and necessary treatments are performed according to the recommendations received from these departments.
• If patients are taking blood thinners before, they are usually stopped one week before surgery or replaced with more suitable ones.
• If patients are using diabetes medication, blood pressure medication or chronic medication due to neurological disorders, it would be beneficial for the anesthesiologist to know these before the operation. It is recommended to take blood pressure and diabetes medications in the same way. Or other drugs may need to be discontinued before surgery.

What patients should do before surgery

• Patients are hungry after 24.00 the night before the surgery, they do not eat or drink anything by mouth (at least 5-6 hours before the surgery).
• If there are blood pressure and diabetes medications that he used before, they are used in the same way if deemed appropriate by the relevant specialist or anesthesiologist.
• Before the operation, sedative drugs can be given to the patients to relax and enter the operation without stress.
• Daily hospital clothes (slippers, pajamas, etc.) to be used before coming to the hospital are provided,
• After the pre-operative identity check and hospitalization, an “informed consent form” regarding the operation is signed,
• It is recommended to have as few visitors as possible, short visits and only one accompanying person.

Information about the surgery

• The surgery is performed under general or spinal anesthesia in the supine position of the patients.
• After the surgery, a Foley catheter is inserted through the urinary tract to the patient.
• The duration of the operation varies according to the size of the prostate, if it is not very large, it may end in 1-2 hours, in large prostates the duration may be longer.

Postoperative

• After the surgery, patients are kept in the operating room for 20-30 minutes until they feel well, then they go to their room.
• Patients are not given oral food or drink for 4-5 hours after the operation. During this period, only serum is given intravenously.
• To relieve the patient’s pain, painkillers and antibiotic prophylactic treatment against infection are started (intravenously or by injection).
• After 5 hours, the patient is evaluated and if there is no problem, he starts to take water and watery foods by mouth, gets up slowly and walks. If he has received spinal anesthesia, he will be able to walk later.
• On the first day after the operation, the patient is evaluated, the vascular access is cut, oral nutrition is started, and the drugs are given orally in the form of pills instead of the veins.
• Patients are advised to drink plenty of water after starting to take it orally. Drinking at least 2-3 liters of fluid per day is beneficial, in this way the color of the urine becomes lighter and there is no bleeding inside.
• If the general condition of the patients is good and there is no problem in the urine, they are discharged on the first or second day.
• Painkillers and antibiotic treatment are started for the discharged patients to take them orally.
• We usually pull the urinary catheter on the 2nd day, if the patients also have urethral stricture and it has been treated, or sometimes in oily patients, the catheter can be removed in the later days.

Advantages of prostate surgery with the HoLEP method compared to other methods

There are prostate TUR, plasmakinetic, rectum surgeries and open prostate surgery similar to HoLEP surgery, but HoLEP surgery has many advantages over these surgeries. Due to these advantages, this method in the surgical treatment of benign prostate enlargement is currently considered as the “gold standard treatment method”. In other words, it is a surgical method with the best effectiveness and the least side effects.

• With this method, bleeding is less compared to other methods.
• After HoLEP surgery, patients stay in hospital less and are discharged sooner.
• Postoperative patients return to their normal lives earlier
• Patients remain less catheterized after the procedure
• More prostate tissue is removed in the surgery performed with this method.
• Since more prostate tissue is removed, the probability of catching prostate cancer is higher as a result of the examination of the removed parts.
• With this method, there is no recurrence rate of the prostate, it is extremely low.
• “TUR syndrome” seen in TUR surgery is not seen in HoLEP surgery
• Post-operative sexual functions are not affected by the laser method. Because laser energy does not penetrate very deeply, damage to the erectile nerves of the penis is less likely. However, in other methods, various degrees of sexual dysfunction are seen.
• It can be applied to prostates of all sizes.
• With this method, postoperative bladder neck stenosis is less common than other methods.
• Due to all these advantages, the HoLEP method is accepted as the “gold standard” treatment method in the treatment of benign prostate.

Surgical treatment of benign prostate disease with the HoLEP method is very popular today. For a long time, transurethral resection of the prostate (TUR-P) was the gold standard method for the surgical treatment of benign prostatic enlargement. Today, HoLEP is accepted as the gold standard treatment method in the treatment of prostate enlargement. While other methods vary according to the size of the prostate, HoLEP is a method applied to prostates of all sizes.

Although HoLEP surgery has been popular in the last few years, it is not actually a new method. It is a well-known technique that has been used for nearly 20 years. The first prostate surgery was performed with this method in the late 1990s. With the advancement of the technique over time, it has become popular only today. Another reason why the method has not become widespread is the long learning curve. Besides the long learning time, the expensiveness of the system is another reason why HoLEP is not widely used.

There have been significant advances in laser technology in the nearly 20 years since it was first implemented. The procedure after pushing the prostate tissue into the bladder is a very important step as well as separating the prostate tissue from the capsule with the laser. The disintegration of the tissues in the bladder, that is, the “morcellation” process, requires a separate system. Prostate tissues in the bladder are broken down by a system called “morcellator”. This system is very developed today, and in this way, the prostate, which is thrown into the bladder, is quickly divided into small pieces and removed.

The duration of the operation varies from patient to patient. The larger the prostate, the longer the operation time. In patients with large prostates, the operation time takes longer for two reasons. First, the separation of the prostate from the capsule takes a long time. Another is the disintegration process of the prostate thrown into the bladder, that is, morcellation takes a long time. Apart from these, sometimes in small prostate patients, if a biopsy has been done before or if there is an infection, adhesions may occur due to these and the surgery may be prolonged.

One of the frequently asked questions by patients is whether HoLEP surgery is associated with prostate size. I will describe the summary of an article published in the Canadian Urology journal about the HoLEP method. Various techniques applied in the study, safety, efficacy, complications, etc. have been extensively studied.

The prominent findings of the study can be listed as follows:

• HoLEP can be applied to prostates of all sizes.
• Large or small prostate is not an obstacle for surgery.
• Bleeding is very less in this method
• Patients are hospitalized less
• They remain with shorter probes after surgery
• They return to their daily lives earlier
• Rapid improvement is seen in urine flow
• Recurrence is extremely low

In conclusion, the HoLEP method is an extremely safe and effective method in the treatment of benign prostate enlargement. It is suitable for prostates of all sizes.

Prostate size or smallness is not an obstacle for surgery. The American and European Associations of Urology (AUA, EAU) have accepted the HoLEP method as the gold standard method in prostate treatment.

HoLEP surgery cost (fee)

Benign prostatic hyperplasia (BPH, benign prostate hyperplasia) is a common disease in elderly men and can be treated with surgery. The incidence of the disease increases with advancing age. Today, thanks to the improvement in health conditions, life expectancy has increased and in parallel, the number of BPH patients has increased.

Patients with benign prostatic enlargement initially respond well to drug therapy, but over time, these patients’ complaints increase and surgical treatment (surgery) may be required. In the drug treatment of BPH, the group of drugs called “alpha blockers” is most commonly used.

Although drugs that reduce the testosterone hormone (antiandrogens) shrink the prostate, they are not preferred because they need to be used for a long time and negatively affect sexual functions. While open surgery methods were used in the treatment of benign prostate enlargement, today endoscopic or minimally invasive surgical methods are widely used.

Today, the most commonly used surgical methods in the treatment of BPH are:

• TUR (transurethral resection of the prostate) surgery
• Plasmakinetics –ENG
• bipolar TUR
• Monopolar ENG
• Open prostate surgery in very large prostates
• HoLEP
• Other less frequently used surgical methods

As in all fields, new techniques and methods in medicine are changing rapidly day by day. HoLEP (holmium laser enucleation of the prostate) method, which is accepted as the newest and “gold standard” in the surgical treatment of benign prostate disease, is one of the newest surgical methods in the field of Urology.

Here, prostate tissue, which has enlarged by using laser and makes it difficult to urinate by pressing on the urinary canal, can be entered through the urinary canal and removed without any incision.

The reflection of these advances in technology to medicine and the cost of endoscopic prostate surgeries also vary. Patients are rightfully wondering about the cost (price) of the HoLEP surgery and the total price including the hospital.

A study was conducted in 2020 comparing the costs of Open prostate surgery, which is widely used in the surgical treatment of BPH, and TUR and HoLEP surgery. According to this research, the costs of these 3 surgeries are stated at different rates.

While the prices of surgery are higher in developed countries such as European countries and the USA, treatment is offered at lower fees in our country. In HoLEP surgery, the cost is reasonable compared to the open method, as the bleeding is less and the hospital stay is shorter.

The HoLEP device and supplies, and personnel training are feature-required. When performed by experienced surgeons, the HoLEP method is the most appropriate treatment method. TURP (TUR) method is slightly cheaper than HoLEP, but there is a possibility of recurrence in TUR surgery.

SSI covers a small portion of benign prostate surgeries (BPH) in our country, and all private hospitals charge additional fees from patients at different rates. In other words, patients with SSI cannot have open prostate, TUR and HoLEP surgeries performed at hospitals that have an agreement with SSI without paying any difference.

To summarize briefly: Since patients with open prostate stay in the hospital longer, the price is higher for them. Bleeding and the need for blood transfusion are absent or extremely rare in HoLEP surgery compared to TUR and open prostate surgeries.

HoLEP patients stay on catheters for less time and stay in hospital for less time compared to other methods.

Reasons that increase the cost of HoLEP surgery

• Expensive equipment and consumables used
• It can’t be done in every hospital, it can be done in certain centers.
• Long learning curve
• Reasons such as the limited number of people who are trained and do this job.
• Patients with chronic diseases such as heart, lung and diabetes

What should be considered after HoLEP?

HoLEP is a benign prostate enlargement (BPH) surgery performed with a laser by entering through the urinary canal with a closed method. In this surgery, there is no incision or scar on the body, it is an endoscopic or closed method. Although there is no incision in the body in HoLEP surgery, there is an operation area made with laser in the prostate region. A Foley catheter is inserted after the surgery, and this catheter is removed after 1-2 days, and the patients begin to urinate normally.

As in every surgery, there are some points to be considered after the surgery in HoLEP surgery. By paying maximum attention to these situations, possible complications, that is, side effects, are reduced. Bleeding is one of the most important issues to be considered after HoLEP and other closed prostate surgeries. We can list the points that need to be considered in order to minimize or not at all the possibilities such as bleeding, inability to urinate, urinary tract infection:

• Sitting on a hard floor should be avoided as much as possible in the early postoperative periods,
• Do not sit for a long time, especially on hard ground,
• Care should be taken not to become constipated,
• In the first days after surgery, patients should urinate frequently without waiting for urination,
• After the catheter is removed, it should be seen whether the patients urinate normally or not. Sometimes patients may not be able to urinate due to edema and small blood clots at the surgery site. In this case, the doctor should be informed and a catheter should be inserted if necessary. Such conditions can occur, albeit very rarely, especially in the very old and those with diabetes. By inserting the catheter, patients remain with the catheter for a few days and then urinate normally.
• After the catheter is taken at first, especially in elderly patients, urinary incontinence may occur while moving, sitting and getting up and working. This situation is temporary and will mostly improve over time.
• Do not strain too much while urinating or making bowel movements.
• Hot and spicy foods and drinks should be avoided
• Heavy physical activity should not be done, excessive weight should not be lifted.
• It should be protected from extreme cold for the first 2-3 weeks and rested in a warm environment.
• Burning while urinating and dark urine may be possible in the early periods after the catheter is taken, and these conditions are improved by increasing fluid intake.
• Constipation may occur due to the effect of anesthesia after prostate surgeries, as in all post-operative surgeries. This situation is temporary, returns to normal in a few days. During this period, patients should be careful and do not strain too much, otherwise bleeding may occur due to excessive straining. In the early stages, drugs can be given to help patients perform defecation more easily.
• Fluid intake should be increased: Daily fluid intake should be kept around 2-3 liters.
• Antibiotics and other drugs given should be used regularly.
• Blood thinners should not be used unless necessary
• Since there is no incision or wound in the patients, they can take a bath with warm water after the catheter is removed after the surgery.
• Car should not be used for the first 7-10 days after the operation, especially on long journeys.
• Alcohol and excessive coffee consumption should be avoided
• Urinary tract infections can be seen in patients. If there are complaints such as burning, turbid urine during urination, the patient should definitely consult his doctor or a urologist.

Benign prostate enlargement (BPH) surgery with the HoLEP method is a gold standard method. In recent years, this method has become more widespread. One of the questions frequently asked by patients is “Does the prostate recur or recur after HoLEP surgery?” is the question. I will also summarize the recurrence of the disease after surgery in comparison with commonly used methods.

Commonly used surgical methods in the treatment of BPH: Open prostatectomy, TUR, Greenlight

Open prostate surgery (open prostatectomy) and TUR surgery are two commonly used methods for surgical treatment in BPH patients. The most important negative aspect of these surgeries is the inability to completely remove the enlarged parts of the prostate that press on the urinary canal, that is, recurrence.

In some patients, prostate surgery is performed with the closed method using the greenlight laser method. In this method, enlarged prostate tissues are not removed, only vaporized. Since only the parts that close the urinary canal are evaporated with the evaporation method, a large part of the prostate remains and recurrence is frequent. Since the prostate is not removed, the complaints begin again in the future.

Another disadvantage of prostate surgery with greenlight laser is that tissue cannot be taken for pathological examination after surgery. Since a piece is not taken and sent to pathology with this method, if the patient has prostate cancer, this cancer is overlooked. However, in the HoLEP technique, the entire prostate is taken and sent to pathology for cancer analysis. Thus, if the patients have prostate cancer, it is revealed in the pathological examination.

Open prostate surgery is an old method used in the treatment of benign prostate enlargement. Open prostate surgery is a frequently preferred surgical method in patients with very large prostates. With this method, prostate adenoma (prostate part that presses on the urinary canal, with the prostate capsule around the urinary canal) is completely removed.

If open prostate surgery is performed very well, the entire bleeding adenoma can be removed and there will be no recurrence. If it is not done well, the part may remain and cause problems in the future. Other disadvantages of open surgery are bleeding, prolonged catheterization and prolonged hospitalization.

Another frequently used surgical method in BPH patients is transurethral prostate resection (TUR, TUR-P, closed prostate surgery). In this surgery, prostate adenoma is removed with a closed method by entering through the urinary canal. In patients with very large prostates, it is not possible to remove the entire prostate with the TUR technique.

Especially in TUR operations performed by surgeons who are not very experienced, recurrence is common. Prostate enlargement complaints begin again in patients who relapse, and some require reoperation.

However, with the HoLEP method, enlarged prostate tissues can be completely removed by separating them from the prostate capsule (the membrane surrounding the prostate). In this way, as a result of the complete removal of the prostate adenoma (enucleation), there is no recurrence or recurrence, or it happens very often. In addition, with the HoLEP method, bleeding is less and the patient is hospitalized less often.

In summary: During HoLEP surgery, the prostate adenoma is completely stripped from the prostate capsule, as in open prostate surgery. Therefore, there is no recurrence. In addition, all the removed parts are sent for pathological examination and if there is cancer, it will be revealed.

Prof. Dr. Emin ÖZBEK

Urology Specialist

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