Experiences with Holmium Laser Enucleation of the Prostate, HoLEP, Laser Surgery

Oh DL, so glad you found a urologist to remove it for you. Why take a chance? This way, in the unlikely event any complications present, you'll have someone there who is knowledgeable. Yes, the nurses at Jefferson are top notch and the care there was excellent. Glad you had the same good experience with them that I did. Thanks for the explanation on the zones. I was not aware of this. I have never been sure just how much tissue Dr Das removed from me but I know this, I just had my yearly physical with my Primary Care MD and my PSA is now 2! This is down from a high of 24 just before I had my HoLEP done by Dr Das last December. This tells me he must have removed a significant amount of tissue since the sheer size of my prostate was the sole reason for my super high pre-surgical PSA (all of my biopsies including one done post-op by Dr Das showed no cancer). Hope all goes well with the catheter removal. Please keep us posted on your progress. It may take a little time, but once the catheter is removed you should be peeing like a fire hose! The first time my wife heard me in the bathroom after the surgery she said: "What's that noise?" I said, "That's me peeing!" She said "OMG, sounds like Niagara Falls!"  ;)   Wishing you the best.

Thanks for the information about the transitional zone. I have wondered about how much is removed.

I wonder if the 3 days of having a catheter is because he does not take too much tissue around the bladder neck. In that case there would be more swelling.

Keep us up to date on your recovery.

Have time to explain why removing less tissue around the bladder neck will cause more swelling?

Also there were a lot of 2mmx3mm snow flake shape blood clots in the urine. This surprised me as I thought the enucleation method is to peel off a big piece of overgrown tissue at one time as oppose to TURP or GLL. If it is s clean break of the tissue from the capsule, there should be flakes flowing around.

I now know (a bit too late) the best time to remove the catheter is when the urine color returns to normal. The nurse prediction is so accurate, surprised me.

I like Das and the Jefferson hospital support nurses. The only short coming is there isn’t much reading material to tell the patient what to expect. Fortunately, thanks to u, I read Gilling’s website and were informed/

You were right that with the catheter sitting on a hard surface was very comfortable . Obviously, waking up after holep with the catheter in place was the most awful experience of the surgery. With the catheter in place, Sitting on the car seat and travelled from PA to NJ, was really punishably uncomfortable. I suffered sharp pain whenever the car hitter bumps, holes or on uneven road surface. the catheter transmitted and amplified the dreadful vibrations to the bladder.

I am guessing that when the remainder of the tissue swells it does not have as much space to expand into cutting off urine flow.

Just a guess.

Your prostate is very tender. It does get better!

Incontinence After HoLEP
Why some have no incontinence after HoLEP and some do have? How is incontinence related to how much internal sphincter has been removed? Below is my personal opinion.

I had an enlarged prostate (about 40 gram) with a moderately enlarged medium lobe causing severe BPH symptoms with IPSS over 30. After HoLEP, I don’t have incontinence (day 6 after holep).

(This website can not post pictures, so I will use links instead.)

First, we have to understand which part of the prostate will be removed by HoLEP. Please look at
Figure 7 (Diagrammatic representation of BPH with the enlarged prostate transition zone causing obstruction of the prostatic urethra and the secondry changes in the bladder leading to hypertrophy of the detrusor muscle.) of
ncbi.nlm.nih.gov/books/NBK279008/

HoLEP removes only the transition zone (TZ). The normal TZ in the left diagram is small and surround only a small length of the prostatic urethra whereas for the enlarged TZ, it surrounds the entire length of the prostatic urethra.

Also notice how the bladder neck where the internal sphincter is located is distorted and narrowed by the TZ enlargement. A portion of The enlarged prostate resides in the TZ and another portion is in the peripheral zone (PZ). HoLEP does not remove the PZ. Notice now the bladder’s detrusor muscle is thicken reducing its volume. Thicker wall could decrease elasticity. Therefore there is s danger if treatment is procrastinated.

The pictures in the following sites show how bad the bladder neck is distorted and narrowed. The distortion blocked off the entrance to the prostatic urethra. If only the TZ is removed, the blockage at the bladder neck remains. To clear the blockage, part or all the internal sphincter has to be removed. Obviously, If more sphincter tissue is removed, the wider is the bladder neck opening resulting in stronger urine stream or Qmax. Also obviously, if the prostate is so large that the bladder neck is greatly distorted then all the internal sphincter has to be removed to clear the blockage. Thus, how large the prostate is matters as larger prostate has a bigger probability to distort the bladder neck in such a way that requires more internal sphincter to be removed. The internal sphincter is the first valve that control urine flow. If one loses that valve there is a greater chance of incontinence.

Sites showing enlarged prostates.
1) thenationonlineng.net/enlarged-prostate-lower-back-pain-frequent-urination-way/
2) epainassist.com/pelvic-pain/prostate/enlarged-prostate-in-young-men
3) hifuprostateservices.com/enlarged-prostate-bph/

An other factor is the operation time during which the metal tube endoscope pierces through the external sphincter, which is the second valve controlling urine flow. Larger prostrate requires longer operation time and longer operation time has a greater chance to injure the external sphincter causing it to be weaken. My 40 gram prostate took 1hr and 35min.

I remember that Blayneb had 150g prostate and Buster had 215g, both had suffered about 9 months of incontinence. From the above discussion, it seems that Dr. Kimberly(?) removed Buster’s internal sphincter completely is understandable.

I found a local urologist who was willing to remove my catheter installed by Jefferson hospital.
The nurse removed my catheter.

I insisted to have two ultrasound done to check my residual urine in bladder after urination, PVR. The urologist suggested that he could inject saline thru the catheter to confirm urine was being expelled. I said no and explained to him I had that done in Jefferson before catheter removal. In that test, I void without problem. However, after the catheter was removed, I could void only a small amount leaving 550cc of urine in the baldder. The only true test is, after catheter removal, I voide, then check residual urine in bladder.

The first PVR was 112cc and the second PVR was 15cc. This urologist seemed to have outdated ultrasound equipment than Jefferson. Nonetheless, I was satisfied that I could void naturally and didn’t have to worry about having to to to ER because of bladder overflow.

The technique is extremely simple just like what is shown in YouTube videos. There are two ways: (1) insert a 10mm syringe into the balloon port, the pressure of the balloon will push its liquid into the syringe collapsing the balloon, or (2) just cut the input port exposing the balloon to air, then all the liquid in the balloon will leak out collapsing the balloon.

After the ballon collapsed, the catheter was out and I didn’t even realized it. No pain.

More:
I am not peeing like a horse, but the stream is noticeably stronger. Also void hesitation is gone. I am satisfied with the result, so far.

Accrording to Dr. Das, he normally removes 40% of the internal sphincter as opposed to 60% by Dr. Miller and 100% by Dr. K.

It seems that I could have a stronger stream if Dr. Das were to remove more internal sphincter which could have resulted in having incontinence.

Whether the removed internal sphincter can regrow back to its original size is an interesting question and can only be amswered by cystoscopy at a later date.

Very glad things are going well for you DL! Perhaps you still have some swelling etc. from the procedure which might go down with some more time and recovery post-catheter removal. I know my flow did not occur super strong right off the bat and took a few days. In any event, sounds like you're on the right track.

I am really jealous of your continence as I still experience pretty much daily light stress incontinence when I am very active. I just live with it and frankly have pretty much accepted that it may never go away. I guess time will tell. I continue to do kegels and will just have to see.

Thanks Blayneb for ur well wishes. What u said makes sense. Now I remember the improvement continues over time and peaks at about month 3 or so.

I hope ur incontinence is now substantially improved than the earlier days. I have not seen any paper that states it can not be completely eliminated. Perhaps the last few % will take a much longer time to heal.

Yeah DL, I hold out hope. Also wondering, are you still seeing blood? I had blood in my urine (and clots off and on) for 3 to 4 months post-op. Just wondering if you're still seeing blood. Obviously my procedure was quite extensive due to the size and shape of my prostate, so blood for that long was not too much of a surprise, but for you I would think it will be much less.

Indeed, Blayneb is right. Qmax and IPSS each reaches peak performance at month 3 whereas PVR and QoL each reaches peak performance at month 12 , but PVR and QoL at month 3 the performance is near peak performance.

See table 3 and fig 2 of
ncbi.nlm.nih.gov/pmc/articles/PMC4871390/#!po=40.9091

Blayneb,
Blood was almost gone and no clots on day 5. Today is day 6, only very slight pink color on tissue paper. It appears after urination, not in urine itself. It seems that a wund was torn open during urination.

It seems that the recovery time is very nonlinear with prostate size.
I expect in ur case the recovery time would be longer but not that long. I believe it could be an outlier. Just bad luck.

It was Dr. Krambeck not Kimberly who performed holep on Buster.