HoLEP Surgery Provides Relief from Frequent Urination Caused by BPH

For years, Richard M. (who asked that his full last name not be used) simply accepted that waking up multiple times a night to use the bathroom, or constantly scouting for rest stops on road trips, was just "a normal part of aging" for men. But for about 15 years, these frequent urges chipped away at his daily comfort and peace of mind.

“There was this one business lunch when the third time I excused myself from the table to use the restroom, a guy who was a little older than me casually said, ‘They have medications for that,’” recalls Richard, 75. It was a casual comment, but it stuck with him.

Still, it wasn’t until a routine PSA (prostate-specific antigen) test, which is used to screen for prostate cancer, showed a slightly elevated level that Richard’s primary care provider referred him to a urologist. During that visit, the urologist first had Richard urinate, and then performed a simple ultrasound scan of his bladder.

“He told me my bladder was half full, which I couldn’t believe because I’d just peed as much as I could,” says Richard, a retired advertising executive who lives in Bridgewater, Conn. “That was the first time I realized something was wrong. The doctor wanted more tests and I went home feeling uneasy.”

To get a clearer picture, his urologist sent him for a different type of ultrasound. When the results came back, Richard said he was “shocked” by the diagnosis: severely enlarged prostate, also known as benign prostatic hyperplasia, or BPH.

Richard's experience is far from unique. BPH is common, affecting about 70% of men between age 60 and 69; that number jumps to 80% for men older than 70. Some men with BPH do not have any signs, but for many, it causes symptoms like the ones Richard was experiencing.

The prostate is a gland that surrounds the urethra, a tube that carries urine out of the body. As men age, the cells within the prostate grow, spurred on by a hormone called dihydrotestosterone. This growth can create pressure against the urethra, obstructing the flow of urine—acting like a kink in a hose—and leading to incomplete bladder emptying.

Richard’s urologist referred him to Daniel Kellner, MD, a Yale Medicine urologist who has performed more than 1500 of a particular kind of minimally invasive BPH surgery called HoLEP (holmium laser enucleation of the prostate).

“I promptly got on the computer and began researching HoLEP and Dr. Kellner. I learned that the HoLEP procedure was invented in New Zealand in the 1990s and had been making its way around the world,” Richard says. “It requires extensive training so it’s expansion has been slow. I read stories about people having to travel all over the United States looking for this procedure, and I was lucky to have it right here in Connecticut.”

When Richard met with Dr. Kellner in February to discuss his options, he learned that while lifestyle changes and medications are usually the first steps for treating BPH, for significantly enlarged prostates like his, surgery frequently offers the most effective solution.

“For years, the traditional approach to treat a large prostate was an open surgery called a simple prostatectomy, which is associated with a lot of bleeding, longer hospital stays, longer time using a catheter, and a higher rate of needing a blood transfusion,” Dr. Kellner says. “With HoLEP, there’s very little bleeding, no incision, and patients, for the most part, go home the same day and have the catheter removed that day or the next.”

With HoLEP, a laser removes excess prostate tissue surrounding the urethra through a process known as enucleation, which means surgically separating the tissue from the organ without causing damage.

“You can think of it like hollowing out an orange,” explains Jason Lee, MD, one of three Yale Medicine urologists who is fellowship-trained in performing procedures like HoLEP. “We take the inner part of the orange out and we leave the outer peel part intact. And after we remove that tissue, the patient has better urine flow.”

Based on the imaging tests Richard provided, Dr. Kellner determined he would be an ideal patient for HoLEP. While a frequent need to urinate is a main symptom of BPH, if left untreated it can also lead to serious health problems, including damage to the kidney, bladder stones, and urinary retention (the complete inability to urinate, accompanied by pain and swelling in the lower abdomen).

Richard didn’t have to think long about whether to pursue surgery.

“We scheduled a time and I was all in. My wife was so grateful that I had found a path that could fix my bladder issue and improve my quality of life,” Richard says. “When you can’t drive very far without stopping to find a restroom, or need to get up multiple times a night, your spouse shares your discomfort.”

The day of surgery in late March, Richard admits he was nervous. “I had only been hospitalized a few times in my life, and both were emergencies. This was my first time voluntarily going in for an operation,” he says. However, his fears were assuaged once he arrived at Yale New Haven Hospital. “Each member of Dr. Kellner’s team made me feel I was in great hands,” he says.

Most HoLEP procedures, Dr. Kellner says, take 45 minutes to a few hours to complete, depending on the prostate size. Rich was put under general anesthesia, and he did not need any pain medication after the surgery.

During the procedure, Dr. Kellner inserted an endoscope (a thin tube with a light and a camera at the tip) into Richard’s urethra. He guided the holmium laser through the endoscope and used it to separate excess tissue from the prostate, pushing it into Richard’s bladder. A second endoscope was then used to suction out the removed prostate tissue. Finally, a catheter was inserted to flush the bladder with sterile fluid and let it drain.

Richard recalls waking up feeling a bit groggy, but otherwise fine. He went home that afternoon and removed the catheter himself the next day. After the surgery, it’s normal to experience light bleeding. “I had been prepared for a little mess and wore some underwear pads. Over the next few weeks, the blood drips on the pads got less and less and by the third week, I quit using them,” he says.

Sometimes, men may experience temporary incontinence following the procedure and are therefore encouraged to practice pelvic floor exercises (such as Kegels) before and after the surgery to strengthen the muscles supporting the bladder and urethra. Richard says he did Kegels and never experienced any urinary leakage.

“For those who do have incontinence, it’s not like they’re leaking constantly. It’s more like if you bend over to tie your shoe, there might be a few drips that come out,” Dr. Kellner says. “But most patients who have this get better in six to 12 weeks. The chance of any long-term problems is about 2%.”

Another possible side effect is retrograde ejaculation, where little to no semen exits during an orgasm. “This can be troublesome to some patients, and we can tailor the operation to preserve ejaculation but it really depends on each patient’s anatomy,” Dr. Kellner explains.

One of the most significant advantages of HoLEP, according to Dr. Kellner, is the permanence of its results.

“The prostate tissue does grow back, but it does so very slowly and because we are able to remove so much of it, the chance of someone needing another procedure is probably about 1%,” he says. “We can’t say the same thing about other BPH procedures and we find we are doing a lot of HoLEP surgeries on patients who had other types of surgery that didn’t last.”

As for Richard, he says he’s thrilled with the results. “I now go to the bathroom like I did when I was 19. I get up once a night, just to pee lightly, not like before when I thought I was going to explode,” he says. “I can go hours without having to use the bathroom, even though I am hydrating. The experience has been truly life changing. It wasn’t until the problem was fixed that I realized what I was unnecessarily living with.”

Dr. Kellner echoes the impact on patients' lives: "I've had patients describe it almost as like their world is bigger, because now they're not living from bathroom to bathroom. A lot of people start to map out where bathrooms are, they know where the bathrooms are everywhere they go, and after HoLEP, they don't have to think about that anymore."