Endoscopic Laser Enucleation of Prostate

Laser enucleation of prostate adenoma, commonly known as THULEP or HOLEP depending on whether you use laser energy given by thulium or holmium, is a surgical procedure used to treat benign prostatic hypertrophy (BPH), a condition in which the prostate becomes enlarged and can cause urinary problems. This guide will provide a comprehensive overview of the procedure, including its purposes, pre-operative preparation, surgical process, postoperative period, and associated risks.

Purpose of LASER enucleation of the prostate

THULEP or HOLEP are primarily used to relieve symptoms associated with benign prostatic hypertrophy, including:

Reduced urinary flow: An enlarged prostate can compress the urethra, reducing urinary flow and causing difficulty urinating;
Frequent and urgent urination: BPH can cause an increase in urinary frequency and a sudden urge to urinate;
Urinary retention: In some cases, an enlarged prostate can lead to a complete inability to urinate, causing a condition known as urinary retention.

Pre-operative preparation:

Before THULEP or HOLEP, the patient will undergo a series of diagnostic tests and preparations, which may include:

Physical examinations and laboratory tests: These may include blood tests, including PSA, urinalysis, and kidney function assessments.
Urological evaluation: The patient will undergo a comprehensive urological examination, including a digital rectal exam (DRE) and, in some cases, a prostate ultrasound.
Discontinuation of anticoagulant medications: If the patient takes anticoagulant or antiplatelet drugs, the dose may need to be stopped or adjusted under the doctor's supervision.

Surgical steps:

Enucleation of prostate adenoma is performed using an instrument called an endoscope inserted through the urethra to the prostate. The surgical process includes the following steps:

Anesthesia: enucleation can be performed using general anesthesia or spinal anesthesia, depending on the patient's and surgeon's preference;
Insertion of the operating instrument: the endoscope is inserted into the urethra and guided to the prostate;
Removal of prostate tissue: using the laser fiber attached to the endoscope, the surgeon enucleates the excess prostate tissue in a single block, pushing and releasing it inside the bladder; unlike TURP or ATV, thanks to the use of lasers, blood loss is minimal, and often the procedure is bloodless;
Extraction of the adenoma from the bladder: an instrument is used that sucks by grinding the adenomatous tissue that is drained to the outside and collected for histological examination; in the absence of the morcellator, a small incision just above the pubis can also be eradicated to extract the adenoma.

Post-operative period:

After the procedure, the patient will be monitored by medical staff and receive appropriate postoperative care. This may include:

Monitoring: The patient will be monitored closely to check for any post-operative complications, such as bleeding;
Pain management: the patient may receive pain medication, if necessary, to relieve any discomfort after the procedure;
Catheter: It is common for the patient to be left with a urinary catheter for 1-2 days after the procedure to allow urine to drain, control bleeding, and promote healing; after removal of the bladder catheter, the patient can be discharged after resumption of spontaneous urination; sometimes monitoring extends for 24 hours;
Discharge and Follow-up: at discharge, a post-operative visit will be scheduled to discuss the histological examination of the removed prostate tissue and verify a correct emptying of the bladder.

Risks associated with prostate adenoma enucleation:

Although the procedure is considered safer and more effective than other procedures for treating prostatic hypertrophy, there are some associated risks and complications, including:

Bleeding: Bleeding during or after the procedure may require blood transfusions or additional interventions to control it;
Infection: there is a risk of infection of the urinary tract or the prostate itself;
Retrograde ejaculation: Some men may experience retrograde ejaculation, where semen enters the bladder instead of being expelled through the urethra during orgasm; this side effect does not pose any danger;
Erectile dysfunction: Although rare, endoscopic enucleation of prostate adenoma can cause erectile dysfunction in some patients.

Risks associated with non-performing endoscopic enucleation of prostate adenoma

Not performing the procedure when it is indicated can result in several risks and complications associated with untreated benign prostatic hypertrophy (BPH). Here are some of the key risks:

Worsening urinary symptoms: Without treatment, symptoms associated with benign prostatic hypertrophy tend to worsen over time. These symptoms, as already mentioned on this site, include difficulty in initiating urination, weak urinary flow, frequent and urgent urination, the feeling of incomplete emptying of the bladder, and frequent nocturnal awakenings to urinate. Worsening symptoms can significantly reduce quality of life and lead to problems such as acute urinary retention;
Acute urinary retention: Without treatment, an enlarged prostate can progress to a complete inability to urinate, known as acute urinary retention. This condition requires emergency medical intervention and can lead to serious complications, such as kidney damage, severe urinary infections, and other bladder-related complications;
Urinary tract infections: The buildup of urine in the bladder due to reduced urinary flow increases the risk of developing urinary tract infections. These infections, as is well known, can cause painful and unpleasant symptoms, such as burning during urination, urinary urgency, frequent urination, and sometimes fever and pelvic pain;
Kidney damage: The buildup of urine in the bladder due to untreated prostatic hypertrophy can increase pressure on the upper urinary tract, including the kidneys. Over time, this can lead to kidney damage, kidney failure, and other serious kidney complications;
Sexual complications: Untreated benign prostatic hypertrophy can adversely affect sexual function. It can cause problems such as erectile dysfunction, painful ejaculation, and reduced libido.

Conclusions:

Endoscopic LASER enucleation of prostate adenoma is considered a minimally invasive procedure for treating the symptoms of benign prostatic hypertrophy and improving the quality of life of patients suffering from this condition. However, as with any surgery, patients need to understand the risks and benefits of the procedure and discuss their options with their doctor before making an informed decision.

Not treating benign prostatic hypertrophy with enucleation or other treatment options can lead to a range of urinary and general problems that can have a significant impact on the patient's quality of life and overall health. It is essential to consult a doctor to evaluate treatment options and determine the best treatment plan to manage the condition effectively.