HoLEP Surgery

What Is Benign Prostate Enlargement and Why Does It Occur?

We are talking about a chestnut-sized gland found only in men, located just below the bladder, that produces various fluids for the reproductive system. A channel that allows us to pass urine runs through the very center of this gland. This structure, which quietly performs its function during youth, gradually begins to grow under the influence of advancing age and hormonal changes in the body. This enlargement, caused by an increase in the number of cells, is referred to medically as “benign” because it does not contain cancer cells.

The problem is that, while this gland can grow outward, it can also grow toward the narrow urinary channel running through it, creating the main problem. You can think of the urinary tract as a water pipe and this gland as a mandarin orange surrounding that pipe. As the mandarin grows, it compresses the pipe inside it. As a result of this compression, urine can no longer flow freely through the narrowed channel, and a series of complaints begins that can make everyday life considerably more difficult. Although this condition is a natural part of aging, it is a health problem that must be addressed when it reduces quality of life.

What Symptoms Indicate Prostate Enlargement?

When the urinary channel narrows, the bladder must contract much harder than normal and exert extra effort to expel the fluid inside. This excessive effort causes the bladder to become tired over time and send various signals. These signals gradually begin to restrict daily life. Constantly thinking about rest stops when taking a bus journey or being unable to sleep through the night are among the most typical manifestations of this condition.

The most common complaints are:

• Frequent urination
• Waking up at night
• Reduced urine stream strength
• Intermittent urination
• A split urine stream
• A feeling of incomplete emptying
• A sudden urge to urinate
• Urinary incontinence
• Dribbling after urination

These symptoms do not appear suddenly; they develop gradually over months or even years. A slight reduction in urine stream strength that is initially ignored can eventually progress to a situation in which nighttime trips to the bathroom completely disrupt sleep. When these symptoms occur, consulting a specialist is very important to understand how far the condition has progressed.

What Happens to the Body If Prostate Enlargement Is Left Untreated?

It is a major misconception to view this problem merely as a difficulty experienced in the bathroom or a condition that compromises everyday comfort. If this obstructive enlargement is left untreated, permanent and irreversible damage to the urinary tract may develop over time. As the narrowing of the urinary channel persists, the bladder cannot expel all the urine it contains. This stagnant urine that remains inside creates an excellent breeding ground for bacteria and leads to persistent, resistant urinary tract infections.

Furthermore, minerals in urine that cannot be completely emptied settle over time, paving the way for large stones to form in the bladder. As the condition progresses further, urine that cannot leave the bladder begins to back up toward the kidneys. When the kidneys remain under constant pressure, they may lose their filtering function, and this can silently progress to kidney failure. In addition, suddenly developing a complete blockage one day, becoming entirely unable to urinate, and requiring a urinary catheter in the emergency department is one of the most common crisis scenarios in untreated cases.

What Is HoLEP Surgery and What Is Its Basic Principle?

To understand the basic principle of HoLEP surgery, we can return to the mandarin orange example. The aim of the operation is to completely peel away and remove the fruit portion (the enlarged tissue) that blocks the urinary passage from the outer peel (the capsule). No incision is made in the body for this procedure. Entry is achieved entirely through the natural urinary passage using very thin instruments equipped with a camera.

Once inside, the enlarged inner tissue is separated from the outer capsule with millimetric precision using the fine tip of the holmium laser. These large pieces of tissue, completely peeled away from the capsule, are pushed intact into the bladder. The greatest strength of this method is that, despite being a closed procedure, it allows complete clearance without leaving excess tissue behind, just as in open surgery.

How Does the Laser Technology Used in HoLEP Surgery Work?

The medical use of the holmium laser is a true marvel of engineering. The most distinctive feature of this laser is the remarkable affinity of its rays for water molecules. A very large proportion of the tissues in the human body also consists of water. The moment the laser beam touches the tissue, it heats the water inside within fractions of a second, causing it to vaporize suddenly. This vaporization creates microscopic explosions on the tissue surface that are too small to see with the naked eye, along with a vapor bubble. The surgeon uses the natural pushing force created by this vapor bubble to peel the enlarged tissue away from the capsule.

Another remarkable feature of this laser is its safety boundary. The laser energy can affect only a depth of less than half a millimeter within the tissue. Because the energy does not penetrate deeper, it causes absolutely no damage to the sensitive structures running just outside the prostate wall, the nerves controlling sexual function, or the muscles that enable us to hold urine. In addition, while cutting the tissue, the laser simultaneously heats and instantly seals the small blood vessels in the area. This results in very little bleeding.

How Does HoLEP Surgery Differ from Traditional Prostate Operations?

Traditional methods used for many years were essentially divided into two categories. The first was a closed procedure (TURP) in which the prostate was shaved away from the inside in small pieces using electrical energy, and the second was open surgery performed through an abdominal incision for large prostates. HoLEP is a technology that combines the best aspects of both methods while eliminating their drawbacks.

Although open surgery allowed the tissue inside to be removed completely, it required a large surgical scar on the abdomen, a high risk of bleeding, a lengthy hospital stay, and catheter use lasting several days. With the traditional closed method, however, the tissue could not be removed completely; only enough tissue could be shaved away to create a tunnel inside. This created a risk of the condition recurring years later. HoLEP, although a closed operation, provides clearance as thorough as open surgery. There are no stitches, bleeding is almost nonexistent, and patients generally have their catheters removed and return home the following day.

Why Should HoLEP Be Preferred in Patients with Large Prostates?

There is a generally accepted principle in medicine: when the prostate exceeds a certain weight (usually around 80–100 grams), the success of traditional closed tissue-resection procedures decreases and their risks increase. As the operation takes longer, the amount of irrigation fluid absorbed by the body can reach dangerous levels. For this reason, open surgery used to be the only option for large volumes of tissue.

HoLEP, however, is a size-independent surgical procedure. Whether the tissue weighs 100 grams or 200 grams, it can be safely treated using the same closed method, without any incision and with a very low risk of bleeding. Thanks to the power of the laser, even large volumes of tissue can be separated from the capsule and removed from the body within a short time. This offers tremendous relief for patients who do not want to experience the stress of major surgery.

Can People Taking Blood Thinners Undergo HoLEP Surgery?

The use of blood thinners is quite common among older men because of cardiovascular disease, heart rhythm disorders, or coronary stents. Having to stop these medications for several days before older types of surgery exposed these patients to potentially fatal risks such as heart attacks or embolism.

Thanks to the excellent vessel-sealing properties of the laser used in HoLEP surgery, bleeding control is highly successful. This allows the operation to be performed safely even in patients for whom stopping medication poses a significant medical risk. In most cases, coordination with physicians from the relevant specialties allows blood thinners to be paused only briefly, or surgery may even be performed without stopping them at all.

What Tests and Preparations Are Performed Before HoLEP Surgery?

As with any surgical procedure, a detailed assessment of the body is carried out before the operation. The patient’s general health, urinary tract anatomy, and prostate size are carefully examined. Existing medical conditions and medications are reviewed together with the anesthesiologist.

The standard tests required before surgery are:

• Blood count tests
• PSA level measurement
• Urinalysis
• Urine culture
• Uroflowmetry (urine flow rate test)
• Urinary tract ultrasonography
• Kidney function tests
• Electrocardiography (ECG)

Each of these tests is essential for planning the operation in the safest possible way, tailored to the individual patient.

How Does HoLEP Surgery Proceed Step by Step?

The operation is generally performed under general anesthesia, with the patient fully asleep, or under spinal anesthesia, which numbs only the body below the waist. The procedure begins entirely through the natural passage, with a very thin tube equipped with a camera (an endoscope) inserted into the urethra. While the interior is irrigated with a special saline-like fluid, a very clear, magnified image is obtained.

The laser fiber is activated, and the enlarged tissue is carefully peeled away from its capsule. Bleeding capillaries are immediately sealed with the laser. Once the peeling process is complete, this large, intact piece of tissue is placed inside the bladder. A remarkable device called a “morcellator” is then introduced through the same passage. This device draws the tissue inside the bladder into itself by suction, cuts it into very small pieces, and collects it in an external container. After all the tissue has been cleared, a temporary catheter is placed in the urinary passage, and the procedure is completed.

What Happens to the Prostate Tissue Removed During HoLEP?

With some older laser techniques, the tissue was burned and vaporized inside the body, leaving no pieces available for examination. One of the greatest advantages of HoLEP is that, instead of burning and destroying the tissue, it removes all of it in pieces.

Not a single gram of the tissue removed using the morcellator is wasted or thrown away. All the removed pieces are placed in special containers and sent to the pathology laboratory. There, specialists examine them cell by cell under a microscope. This means that even if a hidden prostate cancer cell is present deep within the tissue, having gone undetected in all preoperative tests, it can be identified early, allowing a life-saving diagnosis.

What Are the Hospital Stay and Recovery Process Like After HoLEP Surgery?

The operation takes an average of 1 to 1.5 hours, depending on the size of the tissue. After the operation, patients generally stay in the hospital for just one night as a precaution. Because bleeding during surgery is almost zero, the systems used to irrigate the catheter are often switched off the following morning.

The need for a catheter, which lasts 4–5 days or longer with traditional operations, is much shorter with HoLEP surgery. If everything is satisfactory during the checks the next morning, the urinary catheter is removed. Once the patient demonstrates the ability to urinate independently with a strong stream after catheter removal, the discharge process begins. Leaving the hospital and returning home is generally comfortable, and people can resume simple daily routines within a few days.

What Should Be Expected During Recovery at Home After HoLEP?

Upon returning home, patients immediately notice that their urine stream has become remarkably stronger, as it was years earlier. However, it should be remembered that there is a large wound surface inside where the tissue was separated with the laser. This surface needs approximately 4 to 6 weeks to form a scab, heal completely, and become covered with a smooth new lining.

During these weeks of recovery, feeling mild burning or stinging during urination is entirely natural. In particular, slight pale pink bleeding or small clots at the beginning or very end of urination should not cause concern; this is a sign that the healing scabs inside are shedding. A sudden urge to urinate may occur while the bladder adjusts to the new, wider space. Drinking plenty of water during this period helps flush and cleanse the urinary tract naturally, considerably accelerating recovery.

Can Urinary Incontinence Occur After HoLEP?

One of the greatest concerns about the operation is the fear of permanent urinary incontinence. Because this surgery is performed in a safe area far from the main muscles responsible for urinary control (the sphincter), the likelihood of causing permanent damage to these muscles is almost nonexistent.

However, the enlarged tissue has acted as a “plug” in the urinary passage for many years, and the muscles responsible for urinary control have become less active over time by relying on this plug. When the plug is suddenly removed through surgery, the high-pressure flow may initially catch these less active muscles off guard. For this reason, temporary leakage of a few drops of urine may occur during the first weeks when coughing, laughing, or standing up suddenly. This is entirely temporary and resolves on its own within a few weeks as the muscles responsible for urinary control adapt to the new situation. Specific exercises that strengthen the pelvic floor muscles are very helpful in accelerating this adjustment process.

What Are the Effects of HoLEP Surgery on Sexual Life?

Another issue men understandably wonder about is the effect of the operation on sexual potency and sexual life. The very fine nerves and blood vessels responsible for erections run just outside the capsule, surrounding it like a network. Because the laser energy does not penetrate deeply into the tissue, no heat or energy reaches this sensitive nerve network outside. Therefore, this operation never harms erectile ability or sexual desire; preoperative functions are fully preserved.

The only important change to be aware of concerns the way ejaculation occurs. Because the urinary passage is greatly relieved and widened, the semen released during sexual intercourse flows backward into the widened bladder rather than outward. This semen is then eliminated from the body unnoticed with the next urination. Patients continue to experience the same orgasmic sensation and sexual pleasure; only the fluid released outward dries up. This is not a medical problem or disease but a natural consequence of the anatomical widening.

Does Prostate Disease Recur After HoLEP?

It is a known fact that, 5–10 years after older closed resection operations (TURP), tissue regrows in some patients, creating the same obstruction and requiring a second operation. This happens because the older method only creates a channel inside, leaving a very large amount of tissue behind.

With the HoLEP method, however, the enlarged tissue is completely cleared along its natural boundaries, much like separating the inside of an orange from its peel. Because no tissue remains that could regrow and cause an obstruction, the likelihood of this condition recurring and requiring another operation during the rest of the patient’s life is almost nonexistent. A person who undergoes this operation completely eliminates this health problem from their life.

Can Bladder Stones Be Treated at the Same Time as HoLEP?

Bladder stones are very common in people who cannot empty their bladder completely because of an obstruction, as urine stagnates inside. The holmium laser is one of the most powerful stone-fragmenting tools known in medicine.

If the patient also has one or more stones in the bladder, these can be pulverized and cleared within seconds during the operation, without any additional incision, through the same camera-equipped instrument and using the same laser system. The patient does not need a second operation or a different device for this procedure; it is possible to resolve both problems in a single session.

What Should the Diet Be Like After HoLEP Surgery?

During the first weeks after returning home, regular bowel movements are crucial for reducing pressure on the urinary tract. Because constipation causes straining on the toilet, it may trigger minor bleeding in the healing tissues. For this reason, attention should be paid to diet.

The recommended foods and beverages are:

• Water
• Various soups
• Boiled vegetables
• Fresh fruit
• Whole-grain breads
• Dishes prepared with olive oil
• Yogurt
• Kefir

On the other hand, temporarily avoiding foods that may irritate the healing wound surface makes the recovery process much more comfortable.

Items to avoid are:

• Hot spices
• Carbonated drinks
• Alcohol
• Caffeinated coffee
• Excessively salty foods
• Processed fermented sausages and other sausages

What Daily Activities Require Caution After HoLEP?

Although the return to daily life is very quick, it should not be forgotten that internal healing is still ongoing, and strenuous movements that place unnecessary pressure on the body should be avoided. During the first month, certain physical restrictions are recommended to allow the tissues to rest and form healthy scabs.

Activities to avoid are:

• Heavy lifting
• Excessive straining on the toilet
• Sitting on hard surfaces for prolonged periods
• Cycling
• Riding a motorcycle
• Strenuous exercises such as weightlifting or sit-ups
• Hot tub baths or saunas