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

It's a shame you have to go thru this DL but scar tissue is a side effect that does sometimes happen with HoLEP. You're not the first person here who had it. Sad you had that bad luck. Hopefully though, with his vast experience, Dr Das has dealt with this with HoLEP and will know the best way to address it and minimize recurrence. Please keep us posted. We're pulling for you.

Blayneb,

Thanks again for ur support! According to dr das, the chance of scar formation after holep is 5%.

Yeah it's low DL and I still have incontinence after now 13.5 months when probably 98% resolve in a year so we're both outliers it seems. Just the last few weeks however I've really noticed some significant improvement so I am really hoping I'm nearing the end. I only leak now during more harsh stress episodes (snow shoveling or sudden lifting are recent examples) and even when those occur, the amount I leak is much less (drops vs squirts). Fingers crossed for both of us!

I had the very same thing DL with the flow rate reductions you mentioned. It was a urethral stricture and I was also told by the surgeon that it happens in 5% of cases. I had further surgery to clear the stricture 18 months ago and my flow rate remains excellent. I hope this helps.

Blayneb
It is great news that ur incontinence keep improving. 13.5 months is indeed a very long time. I prefer to have incontinence than blockage.

Guest,
sincere thanks for sharing ur experience. This is a very positive data point. I don’t mind another surgery . According to my research on the internet, blockage recurrence is a common event. So very concerned. 18 months out still excellent is good news to me. Thanks for posting.

Phillip

From internet research and confirmed by my local urologist, dialators consisting several tubes with increasing diameter are used to treat urethra stricture.

I Am also very curious what surgery was used on our “Guest poster”.

Hello Guest,

I would appreciate information on if catheter was used after urethra stricture clearing surgery. If yes, for how long?

Yeah DL, even though the incontinence is vexing, when I see what you're going through I guess I should count myself rather lucky. Everything's relative! Based on everything I've seen here though I feel confident you'll eventually come out fine. Know that's little solace now, but have faith.

Judging from my symptoms, I most likely am suffering from urethra stricture after Holep, possibly caused by the instrument used to do HoLEP or the 5 days of catheterization.

Below is the best description of urethral stricture that I have come across.
Source ： urologyhealth.org/urologic-conditions/urethral-stricture-disease

What is Urethral Stricture Disease?
The urethra's main job in males and females is to pass urine outside the body. This thin tube also has an important role in ejaculation for men. When a scar from swelling, injury or infection blocks or slows the flow of urine in this tube, it is called a urethral stricture. Some people feel pain with a urethral stricture.
What Happens under Normal Conditions?
The bladder empties through the urethra and out of the body (called voiding). The female urethra is much shorter than the male's. In males, urine must travel a longer distance from the bladder through the penis.
In males, the first 1" to 2" of the urethra that urine passes through is called the posterior urethra. The posterior urethra includes:
the bladder neck (the opening of the bladder)
the prostatic urethra (the part of the urethra by the prostate) 
the membranous urethra
a muscle called the external urinary sphincter
Strictures that happen in the first 1" to 2" of the urethra that urine passes through are called posterior strictures.
In males, the final 9" to 10" of the urethra is called the anterior urethra. The anterior urethra includes:
the bulbar urethra (under the scrotum and perineum- the area between the scrotum and anus)
the penile urethra (along the bottom of the penis)
the meatus (the exit at the tip of the penis)
Strictures that happen in the last 9" to 10" of the urethra that urine passes through are called anterior strictures. 


Causes
Men are more likely to have a urethral disease or injury because of their longer urethra. For this reason, strictures are more common in men. They are rare in women and in infants.
Stricture (narrowing of the urethra) can happen at any point from the bladder to the tip of the penis. This narrowing restricts or slows the flow of urine in. Some common causes are:
trauma to the urethra
infection such as a sexually transmitted disease
damage from surgical tools
conditions that cause swelling
In most cases, no cause can be found.
In adults, urethral strictures are most often due to:
injury from a fall onto the scrotum or perineum
prostate surgery
kidney stone removal
urinary catheterization
other surgical tools
Posterior Urethral Stricture
Posterior urethral strictures happen in the first 1" to 2" of the urethra. This kind of stricture is due to an injury linked to a pelvic fracture (e.g., motor vehicle or industrial accident). In these cases the urethra is disrupted, or completely cut and separated. Urine cannot pass. A catheter must be placed either through the abdomen into the bladder (suprapubic tube), or through the penis into the bladder. This lets urine drain until the stricture can be fixed.
Anterior Urethral Stricture
Anterior urethral strictures happen in last 9" to 10" of the urethra. This kind of stricture is caused by:
trauma from a straddle injury (from falls onto objects where the legs are on either side)
direct trauma to the penis
catheterization

Symptoms
Simply put, the urethra is like a garden hose. When there is a kink or narrowing along the hose, no matter how short or long, the flow is reduced. When a stricture is narrow enough to decrease urine flow, you will have symptoms. Problems with urinating, UTIs, and swelling or infections of the prostate may occur. Severe blockage that lasts a long time can damage the kidneys.
Some signs are:
bloody or dark urine
blood in semen
slow or decreased urine stream
urine stream spraying
pain with urinating
abdominal pain
urethral leaking
UTIs in men
swelling of the penis
loss of bladder control

Diagnosis
There are several tests to determine if you have a urethral stricture including:
physical exam
urethral imaging (X-rays or ultrasound)
urethroscopy (to see the inside of the urethra)
retrograde urethrogram
Urethroscopy
The doctor gently places a small, bendable, lubricated scope ( a small viewing instrument) into the urethra. It is moved up to the stricture. This lets the doctor see the narrowed area. This is done in the office and helps your doctor decide how to treat the stricture.
Retrograde Urethrogram
This test is used to see how many strictures there are, and their position, length and severity. This is done as an outpatient X-ray procedure. Retrograde in this case means "against the flow" of urine. Contrast dye (fluid that can be seen on an X-ray) is inserted into the urethra at the tip of the penis. No needles or catheters are used. The dye lets the doctor see the entire urethra and outlines the narrowed area. It can be combined with an antegrade urethrogram (antegrade means "with the flow" of urine). Dye inserted from below fills the urethra up to the injured area. Dye inserted from above fills the bladder and the urethra down to the stricture. These tests together let the doctor find the gap to plan for surgery.
Also, if you have trauma to the urethra, you may have this X-ray procedure after emergency treatment. Contrast dye can be injected through the catheter that was placed for healing.

Prevention
Avoid injury to the urethra and pelvis.
Be careful with self-catheterization
Use lubricating jelly liberally
Use the smallest possible catheter needed for the shortest time
Avoid sexually transmitted infections.
Gonorrhea was once the most common cause of strictures.
Antibiotics have helped to prevent this.
Chlamydia is now the more common cause.
Infection can be prevented with condom use, or by avoiding sex with infected partners.
If a problem occurs, take the right antibiotics early. Urethral strictures are not contagious, but sexually transmitted infections are.

Treatment
There are many options depending on the size of the blockage and how much scar tissue is involved.
Treatments include:
dilation – enlarging the stricture with gradual stretching
urethrotomy – cutting the stricture with a laser or knife through a scope
open surgery – surgical removal of the stricture with reconnection and reconstruction, possibly with grafts (urethroplasty)
There are no available drugs to help treat strictures.
Without treatment, you will continue to have problems with voiding. Urinary and/or testicular infections and stones could develop. Also, there is a risk of urinary retention (when you can't pass urine), which could lead to an enlarged bladder and kidney problems.
This is usually performed in the urologist's office with local anesthesia. The stricture is stretched using larger and larger dilators called "sounds." A special balloon on a catheter can also stretch the tissue. But this stretching is not really a cure and needs to be repeated regularly. If the stricture comes back too quickly, you may be taught how to insert a catheter from time to time to prevent it from coming back. Side effects include bleeding and infection. Sometimes a "false passage" or second urethral channel may form from the stretching.
This uses a special scope that is moved along the urethra until the stricture is found.
A knife blade or laser at the end of the cystoscope is used to cut the stricture and create a gap. A catheter may be placed into the urethra to hold the gap open and let it heal. The suggested time to leave a catheter tube draining is based on the length of the stricture.
Many reconstructive procedures have been used to treat strictures, and some involve 1 or 2 operations. In all cases, the choice of repair is based on the location and length of the stricture and how serious it is. No single repair is right for all cases. The 2 main types are anastomotic urethroplasty and substitution urethroplasty.

Anastomotic Urethroplasty
This method is usually reserved for short urethral strictures. In this case, a cut is made between the scrotum and rectum. The urethra can then be reconnected after removing the stricture. This is usually performed as an outpatient procedure or with a short hospital stay. A small, soft catheter is left in the penis for 10 to 21 days. It is then removed after an X-ray is taken to make sure the repair has healed.

Substitution Urethroplasty
When the stricture is long, tissue can be transferred to replace the section that had the stricture. In difficult cases, substitution repairs may need to be done in stages. These repairs should be done by a urologist experienced with these surgeries. Overall the success rates are very good. The 3 kinds of substitution procedures are:
Free graft
Skin flap
Staged
Free Graft
This method replaces or enlarges a section of the urethra using your own tissue. The tissue may be skin (taken from the shaft of the penis) or, more often, buccal mucosa (taken from inside the cheek). After surgery, you may need a short hospital stay and use a catheter for 2 or 3 weeks.
Skin Flap
With this surgery, flaps of skin are rotated from the penis to create the new section of the urethra. This is needed when a graft needs to be long, and the stricture is severe. These procedures are complex and should be done by a surgeon with plastic surgery experience. After surgery, you may need a short hospital stay and use a catheter for 2 or 3 weeks.
Staged
This method is used when local tissue will not work for a free graft or a skin flap.
First stage – The underside of the urethra is opened, which shows the full length of the stricture. A graft is secured to the opened urethra. The graft heals and matures for 3 months to a year. During that time, you will urinate through a new opening behind the stricture. This may mean that you have to sit down to urinate while the graft heals.
Second stage – Several months after the graft around the urethra has healed, and it is soft and flexible, the graft is formed into a tube. The urethra then returns to normal. A small, soft catheter is left in the penis for 10 to 21 days.

After Treatment
Because urethral strictures can come back after surgery, you should be followed by a urologist. After the catheter is removed, your doctor will want to check you with physical exams and X-rays as needed. Sometimes the doctor performs urethroscopy to check the repair. In some patients, the stricture may return but may not need additional treatment. But if it causes obstruction, it can be treated with urethrotomy or dilation. Repeat open surgery may be needed for serious strictures that come back.

More Information
Questions to Ask Your Doctor
What symptoms should I tell you or your office about?
What are the pros and cons of each treatment option?
Is there anything I can do to prevent the stricture from coming back?
What problems could occur during or after surgery?
How long will follow-up care be needed?

My urologist Dr. Das called to schedule corrective surgery to remove blockage occurred after holep. I asked about Catheter time and hospital stay. He said if the blockage is urethra stricture, overnight hospital stay and 72 hours Catheter whereas if it is bladder neck stenosis 24 hours Catheter, not sure about hospital stay.

Thanks Phillip for ur support!