Bening prostatic hyperplasia (BPH, benign prostatic enlargement) is a disease whose incidence increases with age. Endoscopic treatment methods are generally used in surgical treatment. Among these, transurethral resection of the prostate (TURP, TURPP) is a common operation. In recent years, laser prostate treatment has gained more popularity. We have been using the laser method for BPH patients for a long time. In this article, I will talk about who and which patients will undergo laser prostate surgery.

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.

HOLEP (holmium laser enucleation of the prostate) means laser removal of the prostate. In patients with benign prostatic enlargement, the camera is entered through the urinary canal and the enlarged part of the prostate that presses on the urinary canal is separated from the prostate muscle and thrown into the bladder. These pieces, which are thrown into the bladder, are then separated into small pieces by a process called morcellation and taken out of the urinary canal.

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 (terminal dribling)
• 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 laser prostate 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.

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 treatment is not effective: While patients benefit from drug treatment in the past, these drugs become ineffective as time progresses 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 diabetics: In time, nerve damage called neuropathy develops in diabetics and these patients cannot see the expected benefit from drug treatments as the bladder neck and nerves of the bladder will be damaged. In these patients, there may also be damage to the bladder muscle and the contraction of the bladder muscle may be impaired. The risks that may occur after the surgery should be explained to the patients. Frequent urination is common in diabetics. This complaint will not disappear after prostate surgery.
• 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. The ingrowth of the prostate can be easily seen on ultrasound of the bladder. These patients show significant relief after surgery.
• 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. If the complaints of frequent urination at night do not improve with drug treatment and this is due to prostate enlargement, prostate surgery should be performed.
• 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. If surgery is not performed, problems such as recurrent urinary tract infections and bladder stones occur in these patients.
• 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. If the patient has an active urinary tract infection, the infection must be treated with an appropriate antibiotic. After the infection is treated, prostate surgery is performed.
• 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 are not operated, kidney failure may develop as a result.
• Bladder diverticulum: In patients with BPH, when the bladder is not fully emptied and the obstruction progresses, outward herniation occurs in the urinary bladder 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. Bladder diverticula that develop due to prostate enlargement are different from congenital diverticula. Since bladder muscle is present in congenital diverticula, there is no excess urine in the diverticula, and urine is emptied by contraction of the muscle. There is no muscle in the biverticula, which is subsequently formed due to the prostate, only a mucous layer. Since these diverticula do not have muscle, there is no complete ejaculation.
• If there is an inguinal hernia: One of the common complaints in elderly male patients with benign prostatic enlargement is inguinal hernia. Inguinal hernia is due to incomplete emptying of the bladder. Patients have to constantly strain to urinate. As a result, inguinal hernia develops. If the patient also has an inguinal hernia, prostate surgery should be performed first. If hernia surgery is performed first, the hernia will recur.

Who should not have laser prostate surgery?

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. Laser prostate surgery can also be performed on those who use blood thinners, but if possible, it is better to perform these patients under appropriate conditions. If necessary, blood thinners are changed and surgery is planned under appropriate conditions.
• Patients who have had prostate surgery before: The HOLEP method is performed in patients who have had a previous prostate surgery and whose prostate cannot be completely removed, but if the remaining piece is very small and this method is costly to the patient, the remaining small pieces can be removed with other methods (such as TUR). Prior surgery is not a definite obstacle. We have patients who are like this and have done successfully. The presence of complaints in patients who have had prostate surgery before does not necessarily indicate that the prostate remains and that good surgery cannot be performed. Patients with bladder neck stenosis or urethral stenosis due to previous surgery may also have complaints such as prostate enlargement. These conditions should be distinguished and surgery should be planned accordingly.
• Patients who cannot be positioned for surgery: Operations such as TUR, HOLEP, plasmatinetics are difficult for technical reasons in patients who have problems in their 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.
• Prostate cancer: Laser surgery is not performed on patients with prostate cancer. The surgical methods are different in patients with BPH and prostate cancer. If prostate cancer is present, the entire prostate must be removed. However, if the patient has an enlarged prostate, there is no need to remove the entire prostate. Only the benign growing parts of the prostate (prostate adenoma) are separated from the prostate capsule and removed. However, if the prostate cancer has advanced and radical prostatectomy cannot be performed, laser prostate surgery can be performed for these patients for palliative purposes (to relieve the patients).

In summary; HOLEP surgery is applied to patients with prostate enlargement who cannot benefit from drug treatment, in cases where the bladder is not fully emptied, those with bladder stones and diverticulum, inguinal hernia, and patients who develop disorders in the upper urinary system. The results are a very successful treatment method. We mainly perform HOLEP surgery on our patients who need surgery.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY