Holmium laser prostate surgery

TREATMENTS for Prostate Problems

Holmium green laser for prostate

Also known as holmium laser enucleation of the prostate (HoLEP), this treatment is ideal for cases of benign prostate hyperplasia in which there is blockage of urinary flow and best of all, without open surgery and with much more recovery fast.

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Holmium green laser for prostate

Table of content

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What is HBP

Introduction to prostate problems

Prostate enlargement due to BPH causes obstruction of urinary flow from the bladder and greatly limits the quality of life of millions of men around the world, producing feelings of shame and in advanced cases, erectile dysfunction (ED) and urinary overflow incontinence.

próstata sana

HBP enlarged prostate

It is important to understand that benign prostatic hyperplasia is not a malignant or cancerous condition, but with the passage of time, it tends to progressively worsen until it completely obstructs the passage of urine through the urethra. It is common to find cases of patients who go to the doctor when the disease has advanced enough, being able to have solved the problem in the initial phases through medication or surgery.

However, the methods to treat benign prostatic hyperplasia are becoming more and more new. Currently, surgical techniques have been perfected and it is no longer necessary to perform open surgery (with which it was necessary to open the patient’s skin to access the prostate), but laparotomy is capable of removing a large amount of prostate volume with minimal side effects and, within this field, Holmium laser surgery is positioning itself as the ideal method.

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Innovative technology

What is Holmium laser prostatic enuacleation?

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This medical procedure is a variant of laser surgery used to treat one of the most common male conditions in advanced ages: benign prostatic hyperplasia or BPH.

Holmium laser enucleation of the prostate began to be developed in the 1990s in the United States as a faster, more effective and cheaper alternative compared to other traditional endoscopic techniques such as transurethral resection of the prostate (TURP) and prostate vaporization by laser.

However, it was not until the 2000s that Holmium laser enucleation of the prostate became relevant around the world and seems to remain that way for a long time given the large number of benefits achieved in terms of reduction of prostate volume, recovery postoperative, improvement in urinary function and minimal damage to the erectile function of the penis.

How does Holmium laser surgery for BPH work?

Unlike conventional surgery that involved cutting portions of the prostate with a scalpel and with a higher risk of bleeding and longer healing time (and recovery), Holmium laser surgery has shown optimal performance in cutting and removing prostate tissue because the energy wave is controlled and emitted very carefully, thus avoiding dissecting more tissue than necessary and limiting blood loss.

The laser automatically cuts and seals the blood vessels that may have been separated and in this way, bleeding is minimal and tissue healing takes place more quickly.

When a surgeon operates with a scalpel, it is difficult to control how much tissue is separating. This complicates the work of the surgeon, who occasionally cuts healthy tissue next to the diseased tissue, but the worst occurs when within the healthy tissue there are nerves that supply the penis. This causes (among other things) erection problems and urinary incontinence in some cases when nerves to the bladder sphincter (which keeps it closed) are accidentally cut.

But why is a laser more accurate than a scalpel or any other solid cutting element? For two basic reasons:

A The laser can change its intensity in terms of cutting depending on the wavelength it emits. This means that the laser can cut as much as it is configured and this is positive because it can be adjusted so that it increases its cutting power in the ideal places and accidents do not occur.

B The laser can change the cutting perimeter, from very small to very deep. The scalpel cannot change in size and is therefore more likely to injure healthy tissues such as nerves that are close to the prostate gland.

"Enlarged prostate due to BPH causes obstruction of urinary flow from the bladder and greatly limits the quality of life of millions of men around the world."

Summary of treatment

What is laser prostate anucleation?

It is a minimally invasive surgical and endoscopic treatment that is indicated when the prostate gland is excessively enlarged. The laser very precisely cuts hypertrophic tissue. Remember to visit us at our Andromedi centres in Madrid, Seville or Tenerife for more information.

When is this treatment indicated?

This treatment is indicated in severe cases of benign prostate hyperplasia, a chronic condition characterized by a non-cancerous increase in the size of this male gland, especially when there is urinary obstruction and conservative treatments were ineffective.

Main advantages

The main advantages of this treatment compared to conventional or open surgery is that it is safer with the same level of effectiveness, there is less risk of bleeding and developing erectile dysfunction or infections, recovery is faster and there are no scars on the skin.

Type of anethesia and duration of surgery

The anesthesia used is of a general type but it can be replaced with spinal anesthesia if the patient has any special condition. The surgery usually takes about an hour and the minimum hospital stay is 24 hours.

What does this treatment consist of?

It consists of introducing an instrument known as a resectoscope with one end capable of emitting waves of concentrated energy in the form of a laser, which is used to cut the prostate tissue, through the urethra of the penis. In the end, the surgeon removes the tissue pieces and the surgery is complete.

What are the results?

The results of this surgery are usually quite positive, in more than 90% of the cases favorable results are obtained in terms of the reduction of the prostate volume and the improvement of the obstructive symptoms of the urine.

Treatment procedure

In which cases is this treatment indicated?

The pathology that finds the best results after prostate surgery with the Holmium laser is benign prostatic hyperplasia or BPH.

This disease has a high prevalence in men over 60 years of age (40%) and is the main cause of urination problems. The big problem with this pathology is that it does not develop and remains stable but tends to worsen over time, producing total obstruction of the urine in the most severe cases.

inflamación de la próstata

BPH enlarged prostate type 2

Among patients with benign hyperplasia-type prostatic pathology, those who best adapt to the characteristics of Holmium laser surgery (or laser prostate enucleation) are those men with:

Which patients CANNOT receive Holmium laser treatment?

Although the vast majority of patients with benign prostatic hyperplasia are perfect candidates for Holmium laser prostatic enucleation (HoLEP), there are some patients with special conditions who must opt for other surgical procedures.

These patients correspond to:

Las prostatectomías
Las prostatectomías

Las prostatectomías son cirugías complejas que requieren un alto nivel de precisión técnica ya que se realiza una extirpación total (o casi total) de la próstata y los tejidos que la rondan, como algunos ganglios linfáticos o las vesículas seminales si existe diseminación de células cancerígenas en esta zona, pero el gran dilema son las estructuras no implicadas en el cáncer que podrían ser lesionadas con la intervención como los nervios eréctiles.

Las prostatectomías
Las prostatectomías

Las prostatectomías son cirugías complejas que requieren un alto nivel de precisión técnica ya que se realiza una extirpación total (o casi total) de la próstata y los tejidos que la rondan, como algunos ganglios linfáticos o las vesículas seminales si existe diseminación de células cancerígenas en esta zona, pero el gran dilema son las estructuras no implicadas en el cáncer que podrían ser lesionadas con la intervención como los nervios eréctiles.

VER VÍDEO: Próstata inflamada o grande ¿cual es un PSA normal?

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Main advantages

Advantages of the green Holmium laser over other treatments

Safe procedure

This surgical treatment has a minimal risk of producing side effects precisely because of its main advantage: it is a medical device of the highest technology and precision that emits laser energy to cut the enlarged prostate tissue and stop the benign growth of the prostate without the need to use conventional instruments such as the scalpels of traditional surgery, with which there is a greater probability of accidentally injuring the nerves of the penis and healthy tissue.

The rate of complications derived from this technique is very low and the majority of operated patients show a notable improvement in their urine flow.

próstata sana

Healthy prostate

inflamación de la próstata

Prostate with inflammation

Efficient procedure

Holmium laser prostate enucleation is a unique technique that does not require new treatment sessions. The reduction of the prostate volume due to the extraction of the hyperplastic tissue is immediate and therefore, the bladder begins to experience a frank decrease in the tension necessary to expel urine.

No incisions or scars

This type of prostate operation is characterized as a special endoscopic procedure that uses a device called a prostate laser resectoscope to separate and remove the tissue removed from the patient’s body without even making a surgical wound.

For this reason, Holmium laser prostate surgery has so many positive aspects, and one of them is that it does not leave scars or marks on the skin. It is almost impossible to distinguish between an operated patient and one who has not yet received this treatment with the naked eye.

Low risk of bleeding

Bleeding is one of the most frequent types of side effects in almost all surgeries, but among all the surgical procedures that produce the least blood loss are those that use lasers to cut the tissue, and this procedure is one of them.

When the laser separates the tissue, it also seals the severed blood vessels and the bleeding stops. However, it is possible to show some blood in the urine for a few days but this disappears on its own while the tissue recovers.

Low risk of erectile dysfunction

Since the enucleation technique treats the enlarged prostate from the inside and not from the outer capsule, the likelihood of damaging the delicate nerves leading to the penis is very small and therefore the risk of erectile dysfunction is minimal.

Helps in the diagnosis of prostate cancer

A prostate adenoma is a type of injury to the prostate tissue that can be related to cancer. There is not enough evidence to confirm the hypothesis that benign prostatic hyperplasia (BPH) promotes the appearance of cancer, however, when Holmium laser surgery is performed, it is possible to subject the extracted tissue to certain analyzes (biopsies) to check if there are cancer cells or not.

Therefore, Holmium laser enucleation of the prostate can, in addition to being a therapeutic method, part of a diagnostic method.

Quick recovery

The recovery of the patient subjected to this intervention is usually very short, so in a few weeks it is possible to return normally to all the usual activities such as work or exercise (obviously, complying with all the medical indications to prevent relapses).

Short stay in hospital

The timeor elapsed since hospital admission and medical discharge rarely exceeds 48 hours, so the patient can return home promptly to continue rest.

For some patients, long hospital stays often weaken, exhaust, and even depress them.

No more medicines for BPH

There are certain medications to treat prostate growth but they tend to have many undesirable side effects such as hair loss and breast development (gynecomastia), among others. With Holmium laser surgery, the patient can experience an improvement in the typical signs of an enlarged prostate without depending on drug treatment.

"La hiperplasia benigna de próstata (HBP) es un padecimiento que no se desarrolla repentinamente sino que puede tardar varios años (incluso décadas) en manifestarse clínicamente".

Surgical procedure

What does Holmium laser enucleation consist of?

Preparation for surgery

It is essential that the patient knows as many aspects of the surgery as possible for two basic reasons:

A The patient knows the risks involved in the intervention and avoids developing them as much as possible by fully complying with all medical indications, postoperative care and monitoring the pathology.

B The safety and peace of mind of the patient during all phases of the procedure is key. Many patients develop excessive anxiety and worry about treatments even as safe as this one, Holmium laser enucleation of the prostate (HoLEP).

Before surgery, the patient must attend several preoperative consultations that will serve to examine the general state of health and anticipate any possible complications if the patient suffers from chronic diseases or significant pathological conditions (for example, a diabetic and hypertensive patient).

Surgical complications are very rare, fortunately, but should be prevented as much as possible.

Preoperative consultations include:

Before surgery, the urologist will likely order an imaging test known as cystoscopy, which involves inserting a catheter with a camera at the end through the urethra to evaluate the urinary tract and bladder.

In addition, in some patients another imaging test called urodynamics is indicated, which allows evaluating the functioning of the urinary tract through the temporary placement of pressure “sensors” in this conduit. The urodynamic test helps predict how and to what extent Holmium laser surgery might reduce signs of urinary obstruction.

Other indications prior to surgery include:

During Holmium laser surgery (HoLEP)

Upon entering our operating room in Madrid, Seville or the Canary Islands, the patient receives a dose of general anesthesia, which implies that the patient “falls asleep” throughout the surgical procedure. This ensures that the surgery is completely painless and that surgeons can operate without fear of the patient moving or waking up.

It is possible that, along with the anesthetic dose, a dose of antibiotic will be applied. It is important to understand that the prostate is an organ closely related to the urinary tract (from where the surgery will be done), which can usually carry bacteria.our

1 The patient is placed on his back, on top of a specialized surgical bed that also supports his legs so that the surgeon can operate in the genitourinary area in a comfortable and precise way.

2 The surgeon in charge of the operation inserts a resectoscope into the urethra, through the urinary meatus located at the tip of the penis. The resectoscope is a special instrument that has a high definition video camera at its end that helps to visualize the internal structure of the urethra and prostate and in this way to know exactly the site (or sites) of cut with the laser.

3 The resectoscope also houses a site through which the Holmium laser can be emitted. This laser separates the enlarged parts of the prostate gland capsule and occludes (closes) blood vessels that may have been cut.

4 Tissue that separates from the healthy prostate is pushed into the urinary bladder, where it is stored until a forceps is inserted to grasp and suction it.

5 When all of the enlarged prostate tissue has been removed and the cut blood vessels have stopped bleeding, the resectoscope is removed and the surgeon inserts a bladder catheter (or Foley catheter) to drain the urine in the days after surgery and prevent scar tissue from forming urethral obstruction points.

Postoperative care

After leaving the operating room, the patient must stay at least one night in hospital to monitor their vital signs, wait for the effect of anesthesia to wear off, and examine for bleeding through the urethra or severe pain.

Regarding bleeding, some blood loss from the urethra is likely to occur after surgery, but in the vast majority of cases, this normal bleeding lasts less than 12 hours unless the patient has clotting problems. If the bleeding is very large, blood transfusions are indicated to replace the lost fluid, but this is even more rare.

It is also normal that there are traces of clotted blood inside the urinary catheter and for this, the surgeon injects physiological solution into the duct to prevent clots from obstructing the flow of urine.

Other information of interest to the patient and post-surgery care with Holmium laser for the prostate are:

When should I call the doctor?

Complications are rare and infrequent but they can happen. It is advisable to call your doctor if any of the following conditions occur after surgery.

What kind of anesthesia is used?

For this type of surgical intervention, the patient must receive general anesthesia, which implies being unconscious during the entire procedure. However, in some patients with certain risk factors, general anesthesia can be substituted with epidural anesthesia.

Epidural anesthesia is placed on the lower back and blocks all types of pain from the waist down (including the pelvic area where the prostate operation is performed).

An anesthesiology specialist will be in the operating room collaborating with the surgeons throughout the process.

How long does the recovery take?

Almost all men undergoing this treatment require between one and two weeks of physical rest before they can return to work and other daily activities.

However, if the job isVery strenuous and involves long work hours, lifting large amounts of weight, or is simply physically demanding, recovery time can be up to four weeks.

During recovery, it is ideal for the patient to take light walks to promote recovery and prevent a sedentary lifestyle from complicating the state of health.

Results and analysis

What are the results of this treatment?

The improvement rate for this treatment is over 90%, which is quite positive when compared to other surgical procedures or simply not undergoing any treatment and seeing how urinary function deteriorates more and more.

After surgery, the patient should visit a doctor again to examine the urinary flow rate and the condition of the bladder. This is how the effectiveness of the surgery is measured (and based on other clinical parameters). These consultations take place 6 weeks and 6 months after Holmium laser surgery.

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The time of improvement depends directly on the degree of obstruction of the urinary flow by the prostatic hypertrophy and not on the surgery itself. For this reason, early detection of benign prostate hypertrophy is so important and avoiding waiting too long before solving the problem.

Risk Factors

Problems of the prostate: Causes, symptoms and diagnosis

According to the European Association of Urology, benign prostatic hyperplasia (BPH) is a chronic disease that develops slowly and is related to the non-cancerous increase in prostate size, thus producing signs of urinary obstruction such as:

BPH occurs when testosterone levels decline due to the natural aging process and the cells of the prostate become “more sensitive” to the little circulating hormone. This phenomenon is known as hyperplasia (enlargement).

The diagnosis of this disease is made through a medical interview, a physical examination that includes digital rectal examination and blood tests to measure the levels of prostate specific antigen. More specialized tests may also be done to evaluate the prostate.

Treatment of BPH depends on how advanced the disease is. In the initial stages, the treatment corresponds to drugs, but if the gland is very hypertrophic and complicates urinary function, surgery is recommended as the definitive therapeutic option.

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FAQ - Questions

Frequently asked questions at the Andromedi centres in Madrid, Seville and Tenerife

Can I have sex after surgery?

Sexual abstinence (including intercourse and masturbation) is recommended for up to four weeks after surgery to avoid injury and urethral bleeding.

What is prostate specific antigen or PSA?

Prostate specific antigen is a tumor marker for pathologies of the prostate gland. Elevated levels indicate malignant hyperplastic processes such as prostate cancer. If the doctor notices that the levels of this substance are very high, he may indicate certain special studies such as a tissue biopsy to rule out neoplastic processes or cancer.

Importantly, prostate cancer can behave like benign prostate hyperplasia and emulate its symptoms (a disease with a good prognosis if treated early). This occurs because both pathologies have similar symptoms such as difficulty urinating and usually appear in advanced ages (after the fifth or sixth decade of life).

Is it normal to feel some pain after prostate surgery with this technique?

Yes, it is normal and this occurs because hot urine can irritate the insertion sites of surgical devices such as lasers through the urethral wall and produce uncomfortable sensations such as pain, burning and even “internal itching”.

Certain medications may be prescribed to reduce urethral irritation and discomfort. The patient must consume abundant amounts of liquid and thus urinate more to purge the urinary tract of traces of blood.

How long after surgery can you experience complete improvement in urinary function?

Some urinary symptoms such as increased frequency of urination, feeling of urgency to urinate, and having to get up several times during the night to go to the bathroom may be experienced for a few months after Holmium laser prostate enucleation surgery. (HoLEP) because the bladder (the reservoir of urine) has to get used to the fact that it can empty completely without the resistance produced by the enlarged prostate gland.

In some cases, the introduction of instruments through the urethra (such as the resectoscope with the Holmium laser) can weaken the voluntary control of urination by forcibly dilating the muscles responsible for producing or against rrestract this action. Kegel exercises are positive for improving this condition.

Author

Dr. Natalio Cruz


Natalio Cruz MD, with 25 years of medical experience, has been until 2016 Head of the Andrology Unit in the Urology Service of the Virgen del Rocío Hospital in Seville, National Coordinator of Andrology in the Spanish Association of Urology (AEU) and General Secretary in the ESSM, positions that he has narrowed to focus squarely on this exciting project of offering a high-level private medical consultation in Seville, Madrid and Tenerife.

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Andromedi Clinic of Urology and Sexual Medicine

Thank you all for your comments and suggestions, we are happy to be of use in the medical and scientific dissemination around Urology and Sexual Medicine.

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