HoLEP (Holmium Laser)
Urologists have long been known for innovation and for introducing new technologies that are first applied within the field of Urology but then expand into other medical specialties. The use of surgical lasers and robotic surgery are two excellent examples. Lasers can vaporize prostate tissue to mimic the gold standard procedure for BPH – the TURP (trans-urethral resection of the prostate). One such example is the Green Light Laser. However, the most common use of lasers in Urology is for treating kidney stones, and the most common laser used for this purpose is the Holmium Laser.
Many treatments can be applied to the average-sized prostate. However, the large prostate is a special circumstance. The TURP tends to be bloodier and complication-prone here, and less aggressive treatments such as the Green Light Laser and office procedures drop off in efficacy with larger prostates. In the past, large prostates were treated by taking advantage of the fact that they can be thought of as two components, the outer tissue called the capsule and the inner enlarged tissue called the adenoma. In essence, the adenoma is a benign tumor that grows with time. If one can get into the space between the capsule and the adenoma, there is little blood loss, and the enlargement can be shelled out such that only the capsule remains. In such a case, BPH relief is dramatic and almost permanent.
In the past, this space was accessed by making an incision in the lower abdomen, but two new minimally invasive techniques have largely replaced open surgery for this problem – the robotic simple prostatectomy and the HoLEP. Robotic surgery mimics open surgery. Small ports are placed in the abdomen, and the space between the adenoma and capsule is accessed, and the adenoma is removed whole. With HoLEP, this space is accessed by cutting the adenoma in several pieces and then accessing this space using the blunt end of a scope inserted through the penis and using the same Holmium laser typically used for kidney stone treatment to cauterize bleeding and establish this plane. With HoLEP, the adenoma is ground up and sucked out of the bladder in tiny pieces (morcellation).
HoLEP and Robotic Simple Prostatectomy are excellent procedures and are the procedures of choice for large prostates to treat BPH. Which one is superior is a common debate with no clear winner. HoLEP may have a higher scarring or stricture rate, and robotic surgery requires very small port incisions. Both mandate an overnight stay, have similar catheter times, and work very well. However, both procedures have a high learning curve and are not widely offered in some locales. Aquablation is a device that has emerged to capture those patients not offered HoLEP or robotic simple prostatectomy but at the expense of higher hemorrhage rates.
Dr. Engel has performed hundreds of robotic simple prostatectomies and thus offers this to his patients when treatment is needed and the prostate is very large.