Holmium Laser Enucleation of the prostate


Holmium Laser Enucleation of the Prostate, otherwise known as HoLEP, is a surgical technique for the treatment of urinary symptoms due to benign enlargement of the prostate (BPH). It is the only laser technique recommended by NICE (National Institute for Health and Clinical Excellence) for the treatment of BPH in the UK outside of clinical trials, and is recommended for men with prostates of any size. NICE recommends that HoLEP should be performed by a surgeon specialising in the technique.

History

HoLEP was developed by two New Zealand Urologists, Peter Gilling and Mark Fraundorfer, in the 1990′s. Since then it has been extensively researched and a large number of published clinical trials support it as the new “Gold Standard” for treating BPH. Mr Aho trained with Messrs Gilling and Fraundorfer for a year and has been performing HoLEP since 2002. He is the most experienced HoLEP surgeon in the UK with experience of more than 1,300 HoLEP procedures.

What does HoLEP involve? 

HoLEP is normally done under general anaesthetic. The prostate is approached internally (endoscopically), through the urethra, without any cuts on the skin. The Holmium laser is used to peel out the obstructive core of the prostate in its entirety. This leads to maximal relief of prostate obstruction and a man will usually only require one HoLEP procedure in his lifetime as it is very unlikely that the prostate will regrow after HoLEP (0.7% need a re-operation up to 10yr after HoLEP (1) compared to 10-15% after TURP, and more after greenlight laser surgery).

HOLEP SPIRE CAMBRIDGE LEA

Diagram showing the complete removal of the obstructive inner part of the prostate that is achieved with HoLEP

After HoLEP, the area of the prostate that is removed is sent for microscopic analysis. Cancer that would otherwise be undetected is found in 8%. 

Advantages of HoLEP compared to TURP

HoLEP was developed to improve the effectiveness, safety and durability of surgery for BPH. The main advantages of HoLEP over Transurethral Resection of the Prostate (TURP) which has been in use for the past 80 years include:

  • More of the obstructing prostate tissue is removed, leading to better relief of prostate obstruction, symptoms and urinary flow rate
  • Less blood loss
  • Shorter hospital stay. 90% of men stay just 1 night in hospital after HoLEP, whereas the average hospital stay after TURP in the UK is 3 days
  • More durable. The need for redo prostate surgery is 15% for TURP compared to 0.7% for HoLEP within the first 10 years of surgery. The benefits of HoLEP can be expected to last a lifetime
  • Unlike TURP, HoLEP is suitable for men with any size prostate. Mr Aho has successfully performed HoLEP on men with prostate volumes up to 650g.
  • HoLEP is more effective at treating men who are in urinary retention. At 5 years after surgery, 98% of men who had been catheter dependent before HoLEP remained catheter-free compared to 70% of men who had TURP (Mr Aho’s own data)
  • Can be used in men who have bleeding disorders or are on blood thinners (eg. Aspirin, clopidogrel and warfarin.

Advantages of HoLEP compared to Greenlight Vaporisation

  • More of the obstructing prostate tissue is removed, leading to better relief of prostate obstruction, symptoms and urinary flow rate
  • More durable. The need for redo prostate surgery has been reported at up to 20% for Greenlight compared to 0.7% for HoLEP within the first 10 years of surgery. The benefits of HoLEP can be expected to last a lifetime.
  • Unlike Greenlight, HoLEP is suitable for men with any size prostate. Mr Aho has successfully performed HoLEP on men with prostate volumes up to 650g.
  • HoLEP is more effective at treating men who are in urinary retention. At 6 months after surgery, 99% of men who had been catheter dependent before HoLEP were catheter-free compared to 74% of men who had Greenlight vaporisation.
  • Unlike Greenlight, HoLEP removes prostate tissue in a way that allows it to be examined like a biopsy. In 8% of men who have HoLEP, unsuspected prostate cancer is diagnosed. In some of these men the incidental prostate cancer is significant and cancer treatment is recommended. Greenlight vaporisation does not allow tissue sampling.

What does research show about HOLEP?

HoLEP is one of the most extensively researched procedures for BPH.  16 HoLEP randomised trials (the highest quality of clinical trial) have been published up to Dec 2014. (2) The clinical trials comparing it to the previous “gold standard” of TURP, consistently show advantages for HoLEP that include: Less bleeding, fewer blood transfusions, shorter time with a catheter in place after surgery, and shorter hospital stay (90% of men having HoLEP are able to leave the hospital without a catheter the day after surgery, and in some cases there is no need to stay in hospital overnight). Meta-analyses which are studies analysing the results of large numbers of randomised trials, suggest that HoLEP relieves urinary symptoms and improves urinary flow rates more effectively than all other endoscopic procedures for BPH (3). The average symptom score improvement after HoLEP is 70-80% and flow rate improvements of up to 600% have been reported. (4) Recent studies have shown that HoLEP is extremely effective at treating men in urinary retention (5). 98% of men with catheters before surgery are freed from their catheter dependence after HoLEP. This compares to 70% with green light laser and TURP surgery. (6) Unlike all other endoscopic procedures for BPH, HoLEP is suitable for men with any size prostate. (7+8)

Insured Patients

Simply visit your GP and ask them to refer you to Mr Tev Aho at Spire Cambridge Lea hospital. Your GP will write a letter of referral and then either you or your GP can contact us to arrange your first out-patient appointment on 01223 266929

Self Pay Patients
You’ll need a GP referral letter to bring to your first appointment. Simply call us on 01223 266929 to request a guide price or to discuss your personal situation or email info@spirecambridge.com


References
1.Holmium laser enucleation of the prostate: long-term durability of clinical outcomes and complication rates during 10 years of followup.
Elmansy HM, Kotb A, Elhilali MM. J Urol. 2011 Nov;186(5):1972-6. Reoperation rate due to regrowth of the prostate after HoLEP is 0.7% at up to10 years after surgery
2. Holmium laser enucleation of the prostate: a paradigm shift in benign prostatic hyperplasia surgery. Aho TF. Ther Adv Urol. 2013 Oct;5(5):245-53. HoLEP literature review
3.  A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update.Cornu JN, Ahyai S, Bachmann A, de la Rosette J, Gilling P, Gratzke C, McVary K, Novara G, Woo H, Madersbacher S.Eur Urol. 2014 Jun 24. ReviewMeta-analysis showing superior results for HoLEP compared to TURP and green light laser vaporisation
4 Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial.Kuntz RM, Lehrich K, Ahyai SA.Eur Urol. 2008 Jan;53(1):160-6.HoLEP achieves equivalent flow rate improvement to open prostate removal
5.Holmium Laser Enucleation and Photoselective Vaporization of the Prostate for Patients with Benign Prostatic Hyperplasia and Chronic Urinary Retention.Jaeger CD, Mitchell CR, Mynderse LA, Krambeck AE.BJU Int. 2014 Feb 19.HoLEP is very effective at relieving urinary retention
6.Holmium Laser Enucleation and Photoselective Vaporization of the Prostate for Patients with Benign Prostatic Hyperplasia and Chronic Urinary Retention.Jaeger CD, Mitchell CR, Mynderse LA, Krambeck AE.BJU Int. 2014 Feb 19.HoLEP is more successful than green light vaporisation for relieving urinary retention
7Holmium laser bladder neck incision versus holmium enucleation of the prostate as outpatient procedures for prostates less than 40 grams: a randomized trial.Aho TF, Gilling PJ, Kennett KM, Westenberg AM, Fraundorfer MR, Frampton CM.J Urol. 2005 Jul;174(1):210-4.HoLEP is effective for small prostates and can be done as a day surgery procedure
8.Holmium laser enucleation of the prostate for prostates larger than 175 grams.Krambeck AE, Handa SE, Lingeman JE.J Endourol. 2010 Mar;24(3):433-7. HoLEP is safe and effective for men with very large prostates. There is no size limit for HoLEP



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About Mr Tev Aho

Mr Aho moved from New Zealand to the UK to be the Clinical Fellow in Uro-oncology at Cambridge University Hospitals NHS Foundation Trust (CUH) in 2003. The following year he was appointed as a Consultant Urological Surgeon. During his training in NZ he spent a year learning Holmium Laser Enucleation of the Prostate (HoLEP) from the urologists who invented it.

In 2004, Mr Aho introduced HoLEP at CUH where it rapidly became, and remains, the treatment of choice for the majority men seeking a surgical treatment for urinary symptoms or retention. CUH was one of the first centres in the UK to offer HoLEP.

Mr Aho is the most experienced HoLEP surgeon in the UK, and has performed more than 1,200 procedures. He is frequently invited to lecture on HoLEP in the UK and abroad and has convened 10 annual HoLEP courses at CUH, where hundreds of delegates have learned how to perform HoLEP. He has demonstrated live laser prostate surgery (including the world’s first thulium laser enucleation of the prostate) on more than 25 occasions at conferences throughout the world. He also has experience with other forms of benign prostate surgery including laser vaporisation and the minimally invasive urolift procedure. This means he is able to offer a truly bespoke approach for men with bothersome urinary symptoms or urinary retention

Mr Aho is committed to surgical training and was the founding President of the UK Holmium User Group (HUG). He designed and implemented the national HUG Training Programme for HoLEP (a model which is now used internationally), and has mentored many surgeons in HoLEP. He was the Urology Training Programme Director in the East of England for 5 years until 2014 and is now on the Urology Specialist Advisory Committee which is responsible for urological training in the UK.

Mr Aho has been involved in HoLEP research from its earliest days, and has published and presented widely on the subject.

Click here to learn more about Mr Aho 

Click here for detailed information and patient testimonials for HoLEP  

© Spire Healthcare Group plc (2016)