UH Urology Institute - January 2017
EHUD GNESSIN, MD
Urologist at University Hospitals Cleveland Medical Center and UH Urology Institute; Clinical Assistant Professor, Urology, Case Western Reserve University School of Medicine
Benign prostatic hyperplasia (BPH) is common as men get older—about half of men over age 60 experience it, and 90% of men age 80 or over have BPH symptoms. When symptoms for BPH worsen, such as urinating more often at night or experiencing a complete blockage of urine, surgery becomes an option.
The gold standard surgical treatment for BPH traditionally has been transurethral resection of the prostate (TURP). During TURP, the section of the prostate that blocks urine flow is removed. Although effective, TURP has its side effects, said Ehud Gnessin, MD, urologist at University Hospitals Cleveland Medical Center, Urology Institute and Clinical Assistant Professor, Urology, Case Western Reserve University School of Medicine. The procedure is limited to prostates of about 100 grams in size; erectile dysfunction also is possible. For prostates larger than 100 grams, the other common option is an open prostatectomy, which involves opening the bladder and enucleating the BPH tissue. However, these patients often need a catheter for up to 5 days, and there’s more bleeding as well as a longer recovery period.
For men with an enlarged prostate, the holmium laser enucleation of the prostate (HoLEP) is a minimally invasive treatment option now available at University Hospitals Cleveland Medical Center. In this procedure, a holmium laser is used to separate the prostate gland tissue from the prostate capsule, which allows for complete resection of the benign tissue. “With the HoLEP, you go through the urethra without an incision,” Dr. Gnessin said. He likens the surgical approach to “peeling an orange from the inside”. Performing HoLEP is technically demanding, which has limited the number of surgeons who perform it, Dr. Gnessin said. There are only a few dozen surgeons who perform HoLEP in the U.S.; since 2011, Dr. Gnessin has performed more than 500 HoLEP procedures in the U.S. and in Israel. Dr. Gnessin returned to the U.S. in 2016 to join University Hospitals and offers the HoLEP procedure to patients.
The HoLEP approach has several advantages over other surgical approaches. It can be used in prostates of any size; it also has a much lower retreatment rate compared with TURP—0.1% to 1% for HoLEP versus 6% to 10% with TURP. The chance for erectile dysfunction is zero with HoLEP. “With HoLEP, the penetration depth of the laser is 0.4 mm. The nerve that is responsible for erections goes outside the prostate capsule and the laser energy never reaches the depth of the nerve, so there’s less erectile dysfunction after surgery,” Dr. Gnessin said.
The recovery time with HoLEP is shorter than other modalities; some patients go home the same day, and others only have an overnight hospital stay - both options shorten the amount of time a patient uses a catheter.
Another advantage with HoLEP is less bleeding; in fact, most patients can continue blood thinners when they have to get the procedure done.
Randomized controlled trials have found that HoLEP is more efficient and has fewer side effects than other approaches.
Patients who search for BPH treatments online may come across treatment with a green light laser. Although both HoLEP and the green light laser go through the urethra, the latter only ablates the tissue, and there is no tissue available for pathology exam. Other problem is the high retreatment rate with the green light in the rate of at least 15% in larger prostates” Dr. Gnessin said. Many of the referrals that Dr. Gnessin has received thus far for HoLEP have come from primary care physicians and other urologists.