HoLEP and Cystolitholapaxy

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Surgeon wants to remove bladder stones with the Holmium laser and then perform HoLEP on the way out (meaning as a single procedure). I'm worried about length of surgery as a risk factor for incontinence. I know that there is a journal article indicating that 30 percent experience incontinence following the procedure but that most recover from it in 3 - 6 months achieving "excellent results." Has anyone here actually had HoLEP and Cystolitholapaxy and, if so, how did it work out? Thanks in advance for sharing your experience.

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  • Posted

    Can you give the reference to the article? 30% sounds like very high for HoLEP. Even TURP produces less complications and incontinence rate. Timing is not important because stone destruction has nothing to do with prostate partial removal. HoLEP is the fastest method of removal piece by piece. Of course total heating of the prostate and bladder nerve bundles can result in permanent damage. What is the size of your prostate? If it's small enough (<60 cc) maybe it's better postpone your BPH treatment for a later time and less invasive method. If it's large, I would follow your Uro advice.

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  • Posted

    Thanks for your reply. Here is a link to a summary of the article:

    https://pubmed.ncbi.nlm.nih.gov/27637344/

    My prostate size is just under 150 so the options seem to be HoLEP, simple open prostectomy, aquablation, and no treatment. The first two can deal with bladder stones and prostate tissue removal as one procedure. I don't know about aquablation but suspect that the water jets can't deal with stones. I've lurked here for years without posting and have benefited from jimjames self cath posts. I can self cath fairly well when needed with the Coloplast Flex Coude Pro so no treatment may be a realistic option. Unfortunatley, there doesn't seem to be anything I can do to about bladder stones.

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    • Posted

      I had Holep done 4 months ago. I had no incontinence issues whatsoever.

      I am planning a detailed post on my experience in about a month.

      Best to find a very experienced surgeon. Mine has done over 1000 procedures.

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    • Posted

      Hi, Vincent,

      My prostate size was 120 cc until about 3 weeks ago, and I have bladder stones. I also had a large median lobe. About 3 1/2 weeks ago, I had a Focused Laser Ablation (FLA) done in Houston, TX. Dr. Karamanian removed about 45% of my prostate, including tissue along my urethra and much of the median lobe tissue. When I've healed up from this in about 3 months, I will have the bladder stones removed. Both my urologist and Dr. Karamanian agreed that this would make my bladder stones much easier to remove. For 4 1/2 years prior to FLA, I was doing CIC. As I'm healing from FLA now, I still CIC, but it certainly is much easier. I have had no pain or discomfort from FLA. I did check into having HoLEP done at the Mayo Clinic 4 years ago, but decided against it.

      Stebrunner

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    • Posted

      Thank you for the information on FLA and the strategy of doing it ahead of stone removal. I didn't know that FLA could treat larger prostates. I've become very uneasy about HoLEP and incontinence. The surgeon points to a 1 percent issue; however, I see the website of a HoLEP surgeon in Oklahoma who describes the 1 percent as referring to severe incontinence. The website goes on to refer to 5 - 10 percent as not severe but requiring patients to wear a diaper whenever in public and that is a permanent condition. I hadn't heard that before and the surgeon claims to have done more than 300 HoLEP procedures.

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    • Posted

      Not sure if moderator allows Dr names but his name is Christopher DiBlasio in Long Island, NY.

      He didn't do bladder neck sparing because I also have severe long term chronic prostatitis and he felt it was important to remove as much tissue as possible to treat that based on his prior experience.

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  • Edited

    Thanks to those that posted in response to this post and also those that PM'd me. I'm likely to avoid HoLEP for now due to these posts and the information I collected below which focuses on HoLEP incontinence information and raises questions in my mind about this procedure and how it is being marketed. I wonder if some of the knowledgeable participants here can reveal where I am confused.

    1. It seems that many HoLEP surgeons claim to "follow the data (apparently a couple of studies) " and report 1% as the rate of permanent incontinence after HoLEP. However, the HoLEP surgeon at the link immediately below seems to share more information than most:

    https://www.oklahomaholep.com/holep-information/

    The following quote is especially revealing.

    "Only 1% of men experience severe incontinence permanently. (Severe incontinence refers to poor urinary control and continual usage of a pad or Depends to manage.) 5-10% of men experience mild levels of incontinence permanently. Mild incontinence refers to light leakage that occurs on occasion. It is not a lot of leakage but it is enough that men often wear a light pad for protection when they go into public."

    I'm not convinced that knowing you need to wear a diaper permanently is all that different from having to wear a diaper permanently because you don't know for sure when you will need it. 5-10% is a lot different from 1%. Perhaps this surgeon is more inept than others or perhaps just more honest.

    1. The 2015 article at the link immediately below crowned HoLEP as the gold standard.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4446381/

    A search of the article for the word "incontinence" turns up "not found." It's curious that the issue is not mentioned. It's doubly curious when considered in light of a talk given by HoLEP surgeon Humphreys (Mayo Clinic; Phoenix) during 2020:

    https://grandroundsinurology.com/treating-bph-comparing-holep-rezum-urolift-and-aquablation/

    At 20:30, Humphreys says "when I talk about HoLEP, people say well what about the incontinence, incontinence." The "people" Humpheys refers to are urologists. If they always raise this issue, I'm especially bothered by it not being mentioned in a paper that claims HoLEP is the new gold standard.

    1. In 2016, a urologist disputed that HoLEP was the new gold standard in the writeup at the link immediately below:

    http://www.journal-ina.com/article.asp?issn=2394-2916;year=2016;volume=3;issue=2;spage=68;epage=69;aulast=Pujari

    The issue of incontinence is addressed as follows:

    "There is a higher incidence of stress urinary incontinence after HoLEP (10-15%) as compared to TURP, especially in patients with larger prostates (>100 g). Surgical technique of HoLEP tends to induce a higher rate of incontinence than does TURP with the condition lasting longer. The duration of postoperative incontinence is usually 3-6 months. Some surgeons reported permanent incontinence."

    1. To bolster his case that incontinence post-HoLEP is not really an issue, Humphreys (see the link above at 21:08) cites Hazem M. Elmansy, Ahmed Kotb, and Mostafa M. Elhilali (a Canadian study). This study reports a 1% permanent incontinence rate which matches a study that preceded it. However, Humphreys' slide indicates that this study also found "0.5% (half of one percent) leaking at 3 months." In contrast, the link immediately below leads to a talk given by Humphreys' colleague, HoLEP surgeon Cheney (Mayo Clinic, Phoenix) during 2019.

    https://grandroundsinurology.com/treating-bph-comparing-holep-rezum-and-urolift/

    At 13:16 Cheney states "I tell my patients that about a third of you will be leaking at 3 months."

    .5% and 33% are very different; perhaps too different to be explained by differences in the samples. I'd guess that Cheney is a capable surgeon relative to his Canadian counterparts.

    1. I notice that articles published by HoLEP surgeons often disclose "no conflicts of interest." I suppose this means they haven't recently received compensation from the laser manufacturer. By all accounts, HoLEP is a very difficult procedure to learn and seems to often constitute a dominant part of HoLEP surgeons' work as urologists. In such cases, the success of HoLEP and HoLEP marketing is important to the trained surgeon's career. Since when Is "career" self interest not a conflict of interest?

    Am I the only poster here that is skeptical of the "excellent results" characterization and 1% permanent incontinence figure that is being used to market HoLEP? I know that some here recommend HoLEP but know that others here and elsewhere have regrets due to incontinence. I vaguely recall a post some time back here (oldbuzzard I believe) along the lines of "for every excellent HoLEP result, there is a guy wearing a diaper for the rest of his life." I'm beginning to suspect that there may be more truth to this than not and some efforts have been made to conceal it or at least not investigate it too much.

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  • Posted

    Hi, Vincent,

    Thanks for posting your research information on possible incontinence following HoLEP. Dr. Humphries is the urologist I consulted with at the Mayo Clinic. Nice enough guy, and I'm sure he's capable with the laser. However, I felt uncomfortable with my odds of complications. When comparing treatment options, I really had to take note of who had the optimum results. My prostate was over 100 cc, and I had a large median lobe. Those factors always increased the odds of unwanted side effects.

    As I mentioned in an earlier post, I went with FLA at the end of April. I'm now 2 1/2 months out, and I'm pleased with my progress. Prior to FLA I was CICing 6 times per day. Now it's 2 times per day. My natural voids keep increasing. It looks like I may be able to stop CIC in the future. My bladder stones will be removed in August.

    Hope you're doing well.

    Stebrunner

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    • Posted

      Thanks for your message, Stebrunner. I am very pleased to hear of your progress with FLA and hope you will keep us posted going forward with further progress and stone removal. I should mention that I certainly meant no disrespect toward any urologist mentioned in my "research" post. But I know it's very easy to convince oneself that what's being recommended is in the patient's best interest when one's career and pocketbook are involved. Moreover, it appears to me that the high volume centers see a patient six weeks after HoLEP for an exit meeting and refer those that complain about incontinence at that point to a physical therapist for Kegel exercise training -- the surgeons typically never see the patient again after that and don't actually know how things turned out. Sure hope FLA gives the kind of results for you that those here hope for.

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    • Posted

      Hi, Vincent,

      I wanted to report that I'm now 3 months post FLA, and earlier this week, Dr. Karamanian told me I can go off CIC now. However, I will still need to CIC once in a while to check my PVR--though I might buy a used scanner for this. It's been a 4 1/2 year slog to get this far!

      Since my surgery I've been logging my NV volumes and my PVRs. My NVs have increased, and I had one this week of 350 ml. My PVRs have dropped from about 300 - 350 to the 70 - 120 range. My sexual function has been maintained. In 3 weeks my bladder stones will be removed.

      Dr. Karamaian and Nurse Donnie do an amazing job of following up with patients following FLA. I have emailed weekly reports of my progress, and they have called me several times to see how things are going. This is the best follow up I've ever experienced from an medical team!

      Stebrunner

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    • Posted

      Hi Stebrunner -- Thanks for the update on behalf of myself and others here now as well as future readers. I'm sure keeping my fingers crossed for you on the FLA outcome and the upcoming stone removal. Please continue to update going forward. I doubt if there is any other way that any of us could get this kind of information. Vincent

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